Introduction
It is estimated that approximately half a million (476,000) Australians act as informal family carers for a family member or friend with a mental illness [
1], with numbers in the United Kingdom (UK) and United States (US) estimated at 5 million and 43.5 million respectively [
2,
3]. The significant role such carers play in providing unpaid emotional, social, financial and health care support for people with a mental illness is increasingly recognised internationally [
4‐
6], as is the need to provide appropriate support to sustain their caregiving capacity [
4,
7‐
9].
Internationally, family carers have been found to experience poor physical and mental health, with the caring role a direct contributor to such health deficits [
2,
4,
7‐
10]. A UK survey of 1007 family carers for instance - among whom 26% cared for someone with a mental health problem - found that almost one third (30%) rated their own health as only fair or poor. Approximately half (49%) said they had a longstanding physical complaint of some description, while one fifth (21%) reported they had to restrict their activities in the 2 weeks before interview because of a health problem. Almost one quarter (24%) reported their caring responsibilities had affected their health in one or more ways at least a little of the time-most often worry, depression and tiredness; with 14% indicating they had smoked, drank alcohol or used drugs more as a result of their caring responsibilities [
10].
Research which has focused on carers of people with a mental health problem specifically similarly suggests a health burden associated with the caregiving role. In an Australian survey of 756 carers of people with a mental illness for instance, 71% of participants perceived their health deteriorated as a direct result of assuming their caring role [
11]. A nationally representative Australian household survey (
n = 8841) reported that, in comparison to non-carers, family carers of a relative with any mental health condition (
n = 1309) were more likely to experience both a mental health condition at some point in their lifetime as well as recently elevated levels of distress [
12]. Further, 31% of carers reported that they had been unable to provide care for between 1 and 7 days in the last month due to their own health problems; with 13% unable to care for greater than 7 days [
12]. Such findings suggest a need to develop strategies to improve the physical health of carers for their own benefit, and to ensure their continued capacity to provide informal care to people with a mental illness.
Much of the research examining the health consequences of caring for someone with a mental illness has focused on the impact on carers’ mental well-being with little previous research exploring the impact on physical health. A related body of literature- carers of people with neurodegenerative disorders such as dementia- however, has drawn attention to the poor physical health carers are also likely to experience. A recent survey in Japan for instance, of family carers of people with Alzheimer’s disease (
n = 1302) and non-caregivers (
n = 53,758), found that carers had relatively poorer health and greater comorbid risk than non-caregivers across a majority of health outcome measures, including: greater depression, more frequent insomnia, anxiety, hypertension, pain, and diabetes, higher rates of smoking and alcohol consumption; and poorer health-related quality of life scores, with respect to both mental and physical health domains [
13]. Additionally, US studies of carers of people with Alzheimer’s disease have reported higher coronary heart disease risk and higher blood pressure relative to non-carer controls [
14], and higher smoking rates where 40% of carers were current smokers [
15]; compared to 15% of adults among the general population [
16].
The studies above suggest a high prevalence of potentially modifiable health risk behaviours among dementia carers, with implications for an increased risk of preventable chronic diseases such as cardiovascular disease, cancer and diabetes [
17,
18]. Among the general population, the four leading modifiable chronic disease risk factors are: inadequate fruit and vegetable consumption, inadequate physical activity, harmful alcohol consumption, and tobacco smoking [
18]. Fruit and vegetable consumption, as opposed to nutrition more broadly, is implicated as one of the four leading modifiable chronic disease risk behaviours due to the association with the development of a number of chronic diseases including: ischemic heart disease; stroke; diabetes mellitus; and cancer [
19‐
24]. Limited research to date has explored the prevalence of such health risk behaviours among carers of people with a broad range of mental illness. In Australia, a recent study of 42 carers of young people with psychosis suggested that this sub-group of carers may also be at high risk for chronic disease and especially so for the development of type 2 diabetes, with 79% of carers overweight and one-third with hypertension, and 24% being daily smokers [
25]. Despite the potential implications however for an increased chronic disease risk for carers and the possible need for targeted preventive efforts, there has to date been a lack of similar research among carers of people with a broader range of mental illness to identify either the prevalence of health risk behaviours or carers’ interest in risk behaviour change. Given existing knowledge gaps, the present exploratory study was undertaken with a sample of carers of people with mental illness and aimed to:
1)
Examine the prevalence of health risk behaviours (inadequate fruit and vegetable consumption, inadequate physical activity, harmful alcohol consumption, and tobacco smoking)
2)
Assess interest in improving health risk behaviours
3)
Explore possible associations of sociodemographic characteristics with health risk behaviour status, and interest in changing risk behaviours.
Discussion
This is the first study to explore the prevalence of four major health risk behaviours and interest in improving them among carers of people with a mental illness. The prevalence of risk identified across the behaviours examined was substantial, being greatest for inadequate fruit and/or vegetable consumption (74.8%), followed by inadequate physical activity (57.6%), harmful chronic and/or binge alcohol consumption (36.3%) and smoking (11.8%). Carers who were previously or never married, in the workforce, and male, were more likely to be at risk for insufficient fruit and vegetable consumption, physical activity and harmful alcohol consumption respectively. Most carers who reported being smokers or being at risk of inadequate physical activity or fruit and vegetable consumption were interested in improving that behaviour, whereas less than half of carers at risk of harmful alcohol consumption expressed interest in doing so. Participants who were currently in the workforce were more likely to express interest in improving their alcohol consumption.
Results suggest carers of people with a mental illness may not experience a higher prevalence of chronic disease risk behaviours compared to the general adult population, with the exception of harmful alcohol consumption. Similarly high levels of risk for inadequate fruit and vegetable consumption as identified among the present carer sample have also been found among the general Australian population: a 2011–12 survey of adults (aged 18 years and above) indicating over 70% consumed inadequate fruit and over 90% consumed inadequate vegetables [
39]. Also reflective of similar levels of risk to those identified among the present carer sample, data from recent surveys of the general adult population indicate just over half (52%) to engage in inadequate physical activity [
40] and 12% to be smokers [
41]. Such comparisons with general population figures however must be made cautiously, given the skewed demographic profile of carers in the present study (predominantly female and aged over 54 years). However, when the alcohol consumption of the present carer sample is compared to a general Australian population sample of similar age profile (55–64 years), while the prevalence of harmful chronic alcohol consumption is closely comparable (19.3% vs. 20%), the prevalence of harmful binge alcohol consumption among the present carer sample (34.1%) is notably higher than among the general population sample (21%) [
41].
It is difficult to directly compare the prevalence of risk behaviours identified in the present carer sample to the limited previous research involving carers for a number of reasons including the different countries across which such research has been conducted and the differences in characteristics of carers including the nature of the mental health conditions of those being cared for [
13,
15,
25,
42]. In comparison to a recent Australian study however, involving 42 carers of young people with psychosis and where the same approach to the classification of risks was used [
25], carers in the present study had a lower prevalence of smoking (11.8% vs 24%) and higher likelihood of engaging in inadequate physical activity (57.6% vs 31%).
Comparison of the findings of this study with respect to factors associated with chronic disease risk among carers of people with a mental health condition, is similarly fundamentally limited by an absence of previous carer research. One recent Australian study examined health and well-being more broadly among carers of elderly family members with a disability, and found a greater decline in carer health and wellbeing for those in the workforce as compared to those who were not, a finding which might be seen to bear some relation to that in the present study where carers in the workforce were more likely to engage in inadequate physical activity than those not in the workforce [
43].
A number of findings in the present study relating to associations with risk behaviours however do appear to reflect findings among general population samples. Among the Australian general population for instance, males are more likely than females to consume alcohol harmfully [
44]. Similarly, general population research conducted in the US [
45,
46] and UK [
47,
48] suggests poorer nutrition among single or previously married people compared to married people.
Finally it is difficult to explain the only association with interest in change found in the present study. It might be speculated that, given the significant impact harmful alcohol use can have on work-related factors such as absenteeism [
49], that those carers in the workforce may have experienced/noticed such negative impacts of excessive alcohol consumption on their work attendance or performance and so have been motived to change. Future research however would be required to examine such possible explanations.
A need exists for further research to confirm or otherwise the generalisability of these findings. If confirmed, the findings suggest that carers generally, and those caring for people with a mental illness represent a key group at risk of chronic disease and may require risk reduction programs particularly tailored to their caring roles/context [
7]. Some research suggests that carers may require tailored support to address their risk behaviours, as their capacity to do so might be negatively impacted by factors such as: a personal reduction in the prioritisation of their health and wellbeing when compared to the people they care for [
50,
51]; time, transport and financial constraints on seeking professional support to address risk behaviours [
7]; or a neglect of their own physical wellbeing by health professionals when attending appointments with the person they care for [
51]. Such support may also need to take account of the fluctuation and unpredictable nature of the caring input that might be required at a particular point in time [
50,
52,
53]. Therefore, given the current findings of interest in changing at risk behaviours, and the potential for carers to experience a reduced capacity to address their health risk behaviours, interventions tailored to the circumstances and needs of carers are required. No evidence has been reported that describes the effectiveness of such interventions. Further research is therefore required to explore interventions to improve and support carer health risk behaviours.
A range of services are available to carers of people with a mental illness in Australia [
26,
54‐
56]. Support services are free of charge and most offer individual counselling and/or group meetings aimed at providing emotional, educational, and practical (e.g. attending mental health service care planning meetings with carers) support for carers of people with a mental illness [
26,
54,
55]. Such support services are often provided face to face and as such, rural and remote carers may experience disadvantage in access. However, online forums moderated by mental health professionals are also available nationwide for carers to provide and receive support from other carers [
56]. Such support services may represent appropriate contexts in which interventions to improve carer health risk behaviours may be delivered. It is unknown if such services currently provide support for health risk behaviours; a potential avenue for further investigation.
The need to support all domains of carer well-being, including their physical health, has also been recognised in a number of national and international policy documents and surveys [
4,
7,
8,
57]. The need to identify evidence-based strategies to support carers and to assist them in maintaining their health risk behaviours is further reinforced by recent estimates that the cost to replace informal care with paid care in Australia would exceed AUD$60 billion [
58]. Further, data from the Australian Bureau of Statistics suggests that disability care needs for people with mental and behavioural disorders will more than double by the year 2031 [
59].
Limitations
The results of this research should be considered in the context of the following limitations. This study had a small sample (
N = 144), with a low response rate (< 38%), drawn from members of a carer support organisation within one regional health district in Australia. All participating carers were affiliated with a carer support organisation, the majority experienced socio-economic disadvantage and resided in regional areas. As such the experiences of these carers may not be representative of all carers of people with a mental illness, suggesting a need for caution when interpreting findings; although the socio-economic and geographic characteristics of participants are largely consistent with characteristics of carers in Australia [
60]. The self-report data may be prone to recall and social desirability biases [
61]; perhaps most likely resulting in an under-estimation of engagement in risk behaviours and over-estimation of perceived interest in behaviour change. Some evidence does suggest however that older adults’ recall of their health behaviours is reliable [
62].
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