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Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

Open AccessPublished:December 21, 2022DOI:https://doi.org/10.1016/j.jamda.2022.12.017

      Abstract

      Objectives

      To examine the prevalence of coping behaviors during the first 2 waves of the COVID-19 pandemic among caregivers of assisted living residents and variation in these behaviors by caregiver gender and mental health.

      Design

      Cross-sectional and longitudinal survey.

      Setting and Participants

      Family/friend caregivers of assisted living residents in Alberta and British Columbia.

      Methods

      A web-based survey, conducted twice (October 28, 2020 to March 31, 2021 and July 12, 2021 to September 7, 2021) on the same cohort obtained data on caregiver sociodemographic characteristics, anxiety and depressive symptoms, and coping behaviors [seeking counselling, starting a psychotropic drug (sedative, anxiolytic, antidepressant), starting or increasing alcohol, tobacco and/or cannabis consumption] during pandemic waves 1 and 2. Descriptive analyses and multivariable (modified) Poisson regression models identified caregiver correlates of each coping behavior.

      Results

      Among the 673 caregivers surveyed at baseline, most were women (77%), White (90%) and age ≥55 years (81%). Alcohol (16.5%) and psychotropic drug (13.3%) use were the most prevalent coping behaviors reported during the initial wave, followed by smoking and/or cannabis use (8.0%), and counseling (7.4%). Among the longitudinal sample (n = 386), only alcohol use showed a significantly lower prevalence during the second wave (11.7% vs 15.1%, P = .02). During both waves, coping behaviors did not vary significantly by gender, however, psychotropic drug and substance use were significantly more prevalent among caregivers with baseline anxiety and depressive symptoms, including in models adjusted for confounders [eg, anxiety: adjusted risk ratio = 3.87 (95% CI 2.50-6.00] for psychotropic use, 1.87 (1.28-2.73) for alcohol use, 2.21 (1.26-3.88) for smoking/cannabis use).

      Conclusions and Implications

      Assisted living caregivers experiencing anxiety or depressive symptoms during the pandemic were more likely to engage in drug and substance use, potentially maladaptive responses. Public health and assisted living home initiatives that identify caregiver mental health needs and provide targeted support during crises are required to mitigate declines in their health.

      Keywords

      Family and friend caregivers of older adults residing in congregate care settings experienced significant emotional distress during the COVID-19 pandemic.
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      and lower staffing and service levels in assisted living relative to nursing homes.
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      ,
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      • Strain L.A.
      • et al.
      High rates of hospital admission among older residents in assisted living facilities: Opportunities for intervention and impact on acute care.
      These and other features of assisted living contribute to the extensive roles assumed by caregivers in this setting,
      • Kemp C.L.
      #MoreThanAVisitor: Families as "Essential" care partners during COVID-19.
      ,
      • Gaugler J.E.
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      Reimagining family involvement in residential long-term care.
      ,
      • Zimmerman S.
      • Sloane P.D.
      • Katz P.R.
      • et al.
      The need to include assisted living in responding to the COVID-19 pandemic.
      ,
      • Strain L.A.
      • Maxwell C.J.
      • Wanless D.
      • Gilbart E.
      Designated assisted living (DAL) and long-term care (LTC) in Alberta: Selected highlights from the Alberta Continuing Care Epidemiological Studies (ACCESS). Edmonton, AB: ACCES Research Group, University of Alberta, 2011.
      ,
      • Port C.L.
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      • Williams C.S.
      • et al.
      Families filling the gap: Comparing family involvement for assisted living and nursing home residents with dementia.
      roles that were significantly hampered by pandemic-related restrictions.
      The caregiving and personal stressors and consequent adverse mental health outcomes
      • Anderson S.
      • Parmar J.
      • Dobbs B.
      • Tian P.G.J.
      A tale of two solitudes: Loneliness and anxiety of family caregivers caring in community homes and congregate care.
      ,
      • Lane N.
      • Hoben M.
      • Amuah J.E.
      • et al.
      Prevalence and correlates of anxiety and depression in caregivers to assisted living residents during COVID-19: a cross-sectional study.
      experienced by assisted living caregivers during the pandemic may have led to new or altered coping behaviors, including seeking counseling, starting a psychotropic medication, and increased substance use.
      • Dozois D.J.A.
      Mental Health Research Canada
      Anxiety and depression in Canada during the COVID-19 pandemic: A national survey.
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      • Schmidt R.A.
      • Genois R.
      • Jin J.
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      The early impact of COVID-19 on the incidence, prevalence, and severity of alcohol use and other drugs: A systematic review.
      In the general population, studies have shown positive associations between anxiety and/or depressive symptoms and increased alcohol and cannabis use early in the pandemic
      • Dozois D.J.A.
      Mental Health Research Canada
      Anxiety and depression in Canada during the COVID-19 pandemic: A national survey.
      ,
      • Schmidt R.A.
      • Genois R.
      • Jin J.
      • et al.
      The early impact of COVID-19 on the incidence, prevalence, and severity of alcohol use and other drugs: A systematic review.
      ,
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report. May 2021.
      as well as persistence in these symptoms and behaviors over time.
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report 2: Spotlight on gender and household size. May 2021.
      ,
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report 3: Spotlight on income, employment, access. September 2021.
      Research has also revealed sociodemographic differences in the prevalence of mental health symptoms and substance use during COVID-19, with higher levels of both noted among younger adults and those facing financial stressors,
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report 3: Spotlight on income, employment, access. September 2021.
      • Varin M.
      • Hill MacEachern K.
      • Hussain N.
      • Baker M.M.
      Measuring self-reported change in alcohol and cannabis consumption during the second wave of the COVID-19 pandemic in Canada.
      • Zajacova A.
      • Jehn A.
      • Stackhouse M.
      • et al.
      Changes in health behaviours during early COVID-19 and socio-demographic disparities: A cross-sectional analysis.
      Statistics Canada
      Survey on COVID-19 and mental health, September to December 2020.
      and an increased likelihood for depressive and anxiety symptoms among women. Some, but not all,
      • Schmidt R.A.
      • Genois R.
      • Jin J.
      • et al.
      The early impact of COVID-19 on the incidence, prevalence, and severity of alcohol use and other drugs: A systematic review.
      ,
      • Zajacova A.
      • Jehn A.
      • Stackhouse M.
      • et al.
      Changes in health behaviours during early COVID-19 and socio-demographic disparities: A cross-sectional analysis.
      studies showed a higher prevalence of cannabis and problematic substance use among men.
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
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      ,
      • Varin M.
      • Hill MacEachern K.
      • Hussain N.
      • Baker M.M.
      Measuring self-reported change in alcohol and cannabis consumption during the second wave of the COVID-19 pandemic in Canada.
      ,
      Statistics Canada
      Survey on COVID-19 and mental health, September to December 2020.
      Comparable data on caregivers, especially of assisted living residents, are scarce. A web-based cross-sectional survey of 5011 adults (including 1362 unpaid caregivers) in the United States showed that caregivers were more likely than noncaregivers to report adverse mental health symptoms (anxiety and depressive symptoms, suicidal ideation) and starting or increasing alcohol or drug use to cope with COVID-19-related stress.
      • Czeisler M.É.
      • Drane A.
      • Winnay S.S.
      • et al.
      Mental health, substance use, and suicidal ideation among unpaid caregivers of adults in the United States during the COVID-19 pandemic: Relationships to age, race/ethnicity, employment, and caregiver intensity.
      Given their extensive roles in resident care, caregivers of assisted living residents may have faced additional and/or unique pandemic-related stressors, placing them at particular risk for adverse mental health outcomes.
      • Lane N.
      • Hoben M.
      • Amuah J.E.
      • et al.
      Prevalence and correlates of anxiety and depression in caregivers to assisted living residents during COVID-19: a cross-sectional study.
      Empirical data on the coping behaviors adopted by assisted living caregivers are needed so that appropriate mitigation efforts and resources are mobilized to optimize their health
      • Varin M.
      • Hill MacEachern K.
      • Hussain N.
      • Baker M.M.
      Measuring self-reported change in alcohol and cannabis consumption during the second wave of the COVID-19 pandemic in Canada.
      and that of their care recipients.
      This study sought to examine the prevalence of coping behaviors among caregivers of assisted living residents during the first 2 waves of the COVID-19 pandemic and variation in these behaviors by caregiver gender and mental health (anxiety and depressive symptoms). Based on previous literature,
      • Dozois D.J.A.
      Mental Health Research Canada
      Anxiety and depression in Canada during the COVID-19 pandemic: A national survey.
      ,
      • Schmidt R.A.
      • Genois R.
      • Jin J.
      • et al.
      The early impact of COVID-19 on the incidence, prevalence, and severity of alcohol use and other drugs: A systematic review.
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report. May 2021.
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report 2: Spotlight on gender and household size. May 2021.
      ,
      • Varin M.
      • Hill MacEachern K.
      • Hussain N.
      • Baker M.M.
      Measuring self-reported change in alcohol and cannabis consumption during the second wave of the COVID-19 pandemic in Canada.
      ,
      Statistics Canada
      Survey on COVID-19 and mental health, September to December 2020.
      ,
      • Czeisler M.É.
      • Drane A.
      • Winnay S.S.
      • et al.
      Mental health, substance use, and suicidal ideation among unpaid caregivers of adults in the United States during the COVID-19 pandemic: Relationships to age, race/ethnicity, employment, and caregiver intensity.
      we hypothesized that the presence of mental health symptoms would independently increase caregiver risk of new psychotropic drug use and new or increased alcohol, smoking, and/or cannabis use and that psychotropic drug use would be more prevalent among women while substance use would be more prevalent among men.

      Methods

      This study received ethics approval by the Health Research Ethics Board at the University of Alberta (Pro00101048), University of Calgary Conjoint Health Research Ethics Board (REB20-1544), Human Research Ethics Board at the University of British Columbia (H20-01732) and University of Waterloo Human Research Ethics Committee (ORE#42494).
      It is reported per STROBE guidelines (Supplementary Table 1).
      • von Elm E.
      • Altman D.G.
      • Egger M.
      • et al.
      The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies.

      Study Design, Setting, and Sample

      We examined cross-sectional and longitudinal survey data from the COVCARES-AB/BC (COVID-19 and Caregivers of Assisted living Residents: their Experiences and Support needs) cohort study, conducted in Alberta and British Columbia, Canada. Both provinces initiated “essential visitors” policies in assisted living in mid-March 2020, allowing a single caregiver to enter for end-of-life visits or to assist with feeding or mobility.
      North American Observatory on Health Systems and Policies
      North American COVID-19 policy response monitor: Alberta, 2020.
      Individual homes may have imposed more stringent bans on visitors during peak pandemic waves.
      We invited all eligible assisted living homes in both provinces (163 in Alberta, 137 in British Columbia) to participate in COVCARES-AB/BC (Supplementary Table 2). Consenting homes distributed study materials and an open web-based survey link to all caregivers via their internal email list and/or in-person for caregivers visiting the home. This survey link was also distributed via social media, websites, email lists, and newsletters affiliated with our government/caregiver stakeholder partners. Those who identified as the primary adult caregiver (ie, age 18+ years and most informed/involved in care) of a resident age 65+ years living in the home for 3+ months prior to March 1, 2020, were eligible to participate.
      The caregiver survey was administered online at baseline (October 28, 2020 to March 31, 2021) and follow-up (July 12, 2021 to September 7, 2021) by the University of Waterloo Survey Research Centre. All baseline respondents, excluding those of residents who passed away before wave 2 (n = 9) or who requested no further contact (n = 4), were eligible to complete the follow-up survey. Each respondent was emailed a unique survey link to permit linkage of their survey responses. Participants received a $25 coffee gift card for survey completion.

      Measures

      Survey items included standardized validated measures used in a study of assisted living residents and caregivers in Alberta
      • Strain L.A.
      • Maxwell C.J.
      • Wanless D.
      • Gilbart E.
      Designated assisted living (DAL) and long-term care (LTC) in Alberta: Selected highlights from the Alberta Continuing Care Epidemiological Studies (ACCESS). Edmonton, AB: ACCES Research Group, University of Alberta, 2011.
      ,
      • Hogan D.B.
      • Amuah J.E.
      • Strain L.A.
      • et al.
      High rates of hospital admission among older residents in assisted living facilities: Opportunities for intervention and impact on acute care.
      and/or by the Canadian Longitudinal Study on Aging.
      • Wister A.
      • Li L.
      • Mitchell B.
      • et al.
      Levels of depression and anxiety among informal caregivers during the COVID-19 pandemic: A study based on the Canadian Longitudinal Study on Aging.
      ,
      • Raina P.
      • Wolfson C.
      • Griffith L.
      • et al.
      A longitudinal analysis of the impact of the COVID-19 pandemic on the mental health of middle-aged and older adults from the Canadian Longitudinal Study on Aging.
      Measures captured caregiver sociodemographic characteristics, physical and mental health, social support, engagement in resident activities and care, and pandemic-related loss of employment and income (and concern level).

      Anxiety, Depressive Symptoms, and Reported Health Change (Baseline and Follow-up Surveys)

      Caregiver anxiety was assessed with the 7-item Generalized Anxiety Disorder scale (GAD-7),
      • Spitzer R.L.
      • Kroenke K.
      • Williams J.B.
      • Löwe B.
      A brief measure for assessing generalized anxiety disorder: The GAD-7.
      ,
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.
      • et al.
      Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.
      with 7 items reflecting how often (in last 2 weeks) respondents were bothered by feelings of distress and worry. We used a cut-point of ≥8 to define a clinically significant anxiety disorder (sensitivity 92%, specificity 70%).
      • Johnson S.U.
      • Ulvenes P.G.
      • Øktedalen T.
      • Hoffart A.
      Psychometric properties of the General Anxiety Disorder 7-Item (GAD-7) scale in a heterogeneous psychiatric sample.
      Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale, Short Form (CES-D10)
      • Andresen E.M.
      • Malmgren J.A.
      • Carter W.B.
      • Patrick D.L.
      Screening for depression in well older adults: Evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale).
      consisting of 10 items capturing how often (in past week) respondents experienced signs or symptoms of depression. We used a cut-point of ≥10 to identify clinically significant depressive symptoms (sensitivity 89%, specificity 47% for major depressive disorder).
      • Björgvinsson T.
      • Kertz S.J.
      • Bigda-Peyton J.S.
      • et al.
      Psychometric properties of the CES-D-10 in a psychiatric sample.
      Both instruments have been extensively used in caregiver studies.
      • Wister A.
      • Li L.
      • Mitchell B.
      • et al.
      Levels of depression and anxiety among informal caregivers during the COVID-19 pandemic: A study based on the Canadian Longitudinal Study on Aging.
      ,
      • Raina P.
      • Wolfson C.
      • Griffith L.
      • et al.
      A longitudinal analysis of the impact of the COVID-19 pandemic on the mental health of middle-aged and older adults from the Canadian Longitudinal Study on Aging.
      ,
      • Andresen E.M.
      • Byers K.
      • Friary J.
      • et al.
      Performance of the 10-item Center for Epidemiologic Studies Depression scale for caregiving research.
      Consistent with scale development,
      • Spitzer R.L.
      • Kroenke K.
      • Williams J.B.
      • Löwe B.
      A brief measure for assessing generalized anxiety disorder: The GAD-7.
      ,
      • Kroenke K.
      • Spitzer R.L.
      • Williams J.B.
      • et al.
      Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection.
      ,
      • Andresen E.M.
      • Malmgren J.A.
      • Carter W.B.
      • Patrick D.L.
      Screening for depression in well older adults: Evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale).
      respondents with missing values for only 1 item were assigned the mean of their other item responses before totaling their scale score. The terms ‘anxiety’ and ‘depressive symptoms’ when used in the text, indicate significant symptomatology.
      Caregiver reported change in health was assessed at the time of the survey relative to 3 months before March 1, 2020 (baseline survey) and relative to June 2020 (follow-up survey) and examined as a 3-level variable (somewhat/much better now; same; somewhat/much worse and a binary variable (worse yes/no)).

      Coping Behaviors (Baseline and Follow-up Surveys)

      At baseline, caregivers were asked to “indicate what, if any, of the following they used during the 3 months after March 1, 2020 because of their experiences during the COVID-19 pandemic: (1) sought counseling services; (2) started an over-the-counter drug to help with sleep; (3) started a prescription drug to help with anxiety or depression; (4) started to consume or increased use of alcohol; (5) started to smoke cigarettes or increased smoking level; and (6) started to consume or increased use of cannabis.” At follow-up, these same items were asked for the period October 1, 2020 to February 28, 2021 (ie, concurrent with second pandemic wave) (Supplementary Figure 1). To address smaller cells, all drug measures were combined as new antipsychotic use, and cigarette smoking or cannabis use were combined.

      Covariates

      Baseline characteristics included caregiver age, gender, marital status, relationship to resident, ethnic/cultural identity, highest education, prepandemic household income, change in employment status, and income reduction (combined with level of concern) during the 3 months post-March 1, 2020, number of chronic conditions, self-rated health, and perceived emotional/informational social support. The latter was assessed using the relevant subscale of the RAND Medical Outcomes Study—Social Support Survey (MOS-SSS).
      • Sherbourne C.D.
      • Stewart A.L.
      The MOS social support survey.

      Analyses

      Baseline sample

      We examined the distribution of caregiver characteristics, including mental health symptoms and coping behaviors, overall and by gender. Bivariate associations between caregiver baseline mental health and reported worsening health, and their coping behaviors were examined employing χ2 or Fisher exact tests, where appropriate.
      Separate unadjusted and adjusted Poisson regression models, modified for binary outcomes,
      • Zou G.
      A modified poisson regression approach to prospective studies with binary data.
      examined the associations between caregiver mental health, reported worsening of health, and gender with each of the 4 coping behaviors. These models allow for a direct estimation of risk ratios as odds ratios (from logistic regression) may lead to an overestimate of the risk ratio for some associations. Adjusted models included a limited number of relevant confounders (age, ethnic/cultural identity, income reduction/concern, education)
      • Zajacova A.
      • Jehn A.
      • Stackhouse M.
      • et al.
      Changes in health behaviours during early COVID-19 and socio-demographic disparities: A cross-sectional analysis.
      ,
      • Czeisler M.É.
      • Drane A.
      • Winnay S.S.
      • et al.
      Mental health, substance use, and suicidal ideation among unpaid caregivers of adults in the United States during the COVID-19 pandemic: Relationships to age, race/ethnicity, employment, and caregiver intensity.
      given sample size restrictions. We assessed whether accounting for clustering of caregivers within assisted living homes affected model estimates by including a robust sandwich variance estimator.
      • Zou G.Y.
      • Donner A.
      Extension of the modified Poisson regression model to prospective studies with correlated binary data.
      As we found no meaningful home-level clustering, we have reported final models without this adjustment.

      Longitudinal sample

      Prevalence estimates for caregiver coping behaviors, mental health symptoms, and worsening health at the 2 time points, were compared using the McNemar test. For this longitudinal sample, we also examined bivariate associations between their baseline mental health/health measures and coping behaviors reported during both pandemic waves.

      Missing data

      For most baseline characteristics, including coping behaviors, the proportion of total respondents with missing values was small (eg, <1%-2%). Missing values were more common for anxiety and depressive symptoms (75 and 54 respondents with 2+ missing items for the GAD-7 and CES-D10, respectively). Differences between those missing (vs not missing) mental health items were described previously.
      • Lane N.
      • Hoben M.
      • Amuah J.E.
      • et al.
      Prevalence and correlates of anxiety and depression in caregivers to assisted living residents during COVID-19: a cross-sectional study.
      At follow-up, missing values were rare but more common for the mental health measures (44 and 32 respondents with 2+ missing items for the GAD-7 and CES-D10, respectively). We explored the nature of missing data by conducting the Little MCAR test.
      • Little R.J.A.
      A test of missing completely at random for multivariate data with missing values.
      As this test was nonsignificant for all our measures (indicating that data were missing completely at random) and given the low level of missing data overall, we did not pursue multiple imputation.

      Secondary Analyses

      For caregivers in the longitudinal sample, adjusted (modified)
      • Zou G.
      A modified poisson regression approach to prospective studies with binary data.
      Poisson regression models were conducted to examine associations between their mental health/health measures (assessed at baseline and follow-up) with each of the coping behaviors reported during the second pandemic wave.
      All analyses were 2-tailed with statistical significance defined as P ≤ .05. SAS v 9.4 (SAS Institute Inc) was used to conduct all analyses.

      Results

      Baseline Sample

      There were 673 caregivers (associated with 134 assisted living homes; 81.1% supporting residents in Alberta) who completed the baseline survey. About two-thirds were affiliated with urban or large assisted living homes with approximately equal distribution by ownership status. As our recruitment strategy prevents us from identifying the total number of caregivers informed of the open survey link, it is not possible to derive contact, cooperation, or response rates at baseline.
      Respondents were primarily women, married, White, age ≥55 years, and a daughter of the resident [79% (417 out of 528)] (Table 1). Relative to men, women were significantly more likely to be <65 years, not married, and White. They were also more likely (P < .10) to report a pandemic-related change in employment status and fair/poor self-rated health.
      Table 1Distribution of Assisted Living Caregiver Characteristics, Overall and by Gender (Total Baseline Sample, n = 673)
      CharacteristicsOverall (n = 673) Column % (n)Gender
      Women (76.8%; 515/671) Column % (n)Men
      Includes 4 caregivers who responded ‘prefer not to answer’ to item on gender (1 of these noted ‘prefer to self-describe’ but their response did not make sense as they were referring to their care recipient - so coded with ‘prefer not to answer’).
      (23.2%; 156/671) Column % (n)
      Sociodemographic
       Province (facility located)
      Alberta81.1 (546)81.9 (422)78.2 (122)
      British Columbia18.9 (127)18.1 (93)21.8 (34)
       Age
      P < .001.
      18-44 y6.4 (43)7.6 (39)2.6 (4)
      45-54 y12.2 (82)12.2 (63)12.2 (19)
      55-64 y42.3 (284)45.1 (232)33.3 (52)
      65+ y39.1 (262)35.2 (181)51.9 (81)
       Marital status
      P < .05.
      Married/common-law83.1 (555)81.1 (415)89.7 (140)
      Other16.9 (113)19.0 (97)10.3 (16)
       Relationship to resident
      P < .05.
      Spouse/parent5.8 (39)4.9 (25)9.0 (14)
      Daughter/son (including in-law)78.5 (528)81.0 (417)69.9 (109)
      Sibling7.3 (49)6.0 (31)11.5 (18)
      Friend/neighbor/other8.5 (57)8.2 (42)9.6 (15)
       Ethnic/cultural identity
      P < .05.
      White89.9 (598)91.4 (467)85.1 (131)
      Other than White10.1 (67)8.6 (44)14.9 (23)
       Highest education
      University31.0 (205)30.8 (156)31.6 (49)
      College/trade42.5 (281)43.0 (218)40.7 (63)
      High school or less26.6 (176)26.2 (133)27.7 (43)
       Household income (prior to March 1, 2020)
      >$100,00027.3 (184)25.4 (131)34.0 (53)
      $80,000-$99,00015.0 (101)14.6 (75)16.7 (26)
      $50,000-$79,00023.8 (160)25.4 (131)18.6 (29)
      <$50,00020.2 (136)20.2 (104)20.5 (32)
      Missing13.7 (92)14.4 (74)10.3 (16)
       Income reduction (3 mo post March 1, 2020) and level of concern
      No73.4 (494)74.0 (381)71.2 (111)
      Yes, not concerned4.5 (30)4.5 (23)4.5 (7)
      Yes, somewhat concerned14.1 (95)13.4 (69)16.7 (26)
      Yes, very/extremely concerned8.0 (54)8.2 (42)7.7 (12)
       Change in employment status (3 mo post March 1, 2020)
      P < .10.
      No84.0 (562)82.7 (424)88.5 (138)
      Yes16.0 (107)17.4 (89)11.5 (18)
      Health and social well-being
       No of chronic conditions
      None43.1 (288)44.6 (229)37.8 (59)
      1-241.6 (279)41.1 (211)43.0 (67)
      3+11.7 (78)10.7 (55)14.7 (23)
      Don't know/prefer not to answer3.7 (25)3.5 (18)4.5 (7)
       Self-rated health
      P < .10.
      Excellent16.9 (113)18.1 (93)12.9 (20)
      Very good40.5 (271)38.3 (197)47.1 (73)
      Good31.8 (213)31.5 (162)32.9 (51)
      Fair/poor10.9 (73)12.1 (62)7.1 (11)
       Change in health (vs 3 mo pre-March 1, 2020)
      Better now9.8 (66)9.5 (49)10.9 (17)
      Same61.3 (411)59.7 (307)66.0 (103)
      Worse28.9 (194)30.7 (158)23.1 (36)
       Clinically significant anxiety disorder
      P < .05.
      Present28.6 (171)31.2 (143)20.1 (28)
      Not present71.4 (427)68.8 (315)79.9 (111)
       Depressive symptoms
      P < .01.
      Present38.8 (240)42.1 (199)28.3 (41)
      Not present61.2 (379)57.9 (274)71.7 (104)
       Emotional/informational social support
      High78.0 (493)79.1 (382)74.3 (110)
      Low22.0 (139)20.9 (101)25.7 (38)
      Includes 4 caregivers who responded ‘prefer not to answer’ to item on gender (1 of these noted ‘prefer to self-describe’ but their response did not make sense as they were referring to their care recipient - so coded with ‘prefer not to answer’).
      P < .001.
      P < .05.
      § P < .10.
      P < .01.
      At baseline, 28.9% of caregivers reported worse health (compared with 3 months prior to March 1, 2020) and 28.6% and 38.8% exhibited anxiety and depressive symptoms, respectively. Mental health symptoms were significantly more prevalent among women than men. All 3 measures were strongly associated with each other (eg, of caregivers with anxiety, 85.6% had depressive symptoms vs 18.6% among those without anxiety, P < .0001; of those with anxiety, 55.6% reported worsening health vs 19.0% among those without anxiety; P < .0001).
      During the initial pandemic wave, 16.5% of caregivers reported they started to consume or increased their use of alcohol, 13.3% started a psychotropic drug, 8.0% started or increased cigarette smoking and/or cannabis use, and 7.4% sought counseling services. All coping behaviors were significantly more prevalent among caregivers with anxiety, depressive symptoms, and worse health, except for seeking counseling among those with anxiety (Figure 1 and Supplementary Table 3). None of these behaviors varied significantly by caregiver gender.
      Figure thumbnail gr1
      Fig. 1Assisted living caregiver reported coping behaviors during the initial wave of the COVID-19 pandemic, among those with clinically significant anxiety disorder, depressive symptoms, self-reported worse health, compared with total and gender-specific prevalence (total baseline sample, n = 673).
      The strong positive associations between caregiver baseline mental health symptoms, reported poorer health and coping behaviors remained robust in adjusted models. For example, among caregivers with (vs without) anxiety, the adjusted risk ratio (95% confidence interval) was 3.87 (2.50-6.00) for starting a psychotropic drug; 1.87 (1.28-2.73) for new or increased alcohol use; and, 2.21 (1.26-3.88) for new or increased cigarette and/or cannabis use (Table 2). The corresponding adjusted models for depressive symptoms and poorer health are shown in Supplementary Tables 4 and 5, respectively.
      Table 2Unadjusted and Adjusted Associations Between Assisted Living Caregiver Anxiety, Other Characteristics and Select Coping Behaviors (Total Baseline Sample, n = 673)
      Caregiver CharacteristicsCaregiver Coping Response
      Sought Counseling ServicesStarted OTC Product for Sleep and/or Prescription Drug for Anxiety/DepressionStarted to Consume or Increased Use of AlcoholStarted or Increased Smoking and/or Cannabis use
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in the Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in the Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in the Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in the Table.
      Risk Ratio (95% CI)
      Clinically significant anxiety disorder1.70 (0.98-2.96)
      P < .10.
      1.36 (0.73-2.51)4.27 (2.82-6.45)3.87 (2.50-6.00)1.85 (1.29-2.64)1.87 (1.28-2.73)2.97 (1.73-5.08)2.21 (1.26-3.88)
       Age (65+ y =ref group)
      18-44 y3.89 (1.60-9.48)2.82 (1.16-6.86)1.72 (0.89-3.34)0.96 (0.48-1.94)2.53 (1.41-4.56)1.98 (1.06-3.71)6.12 (2.83-13.21)4.43 (1.92-10.19)
      45-54 y2.28 (0.95-5.47)
      P < .10.
      2.00 (0.80-5.04)1.47 (0.84-2.57)1.21 (0.68-2.14)2.16 (1.29-3.61)1.88 (1.10-3.20)2.28 (0.95-5.47)
      P < .10.
      2.38 (0.93-6.09)
      P < .10.
      55-64 y1.93 (0.96-3.87)
      P < .10.
      1.66 (0.80-3.45)0.92 (0.58-1.46)0.74 (0.47-1.18)1.52 (0.99-2.34)
      P < .10.
      1.39 (0.91-2.11)1.93 (0.96-3.87)
      P < .10.
      1.90 (0.96-3.79)
      P < .10.
       Gender
      Woman1.83 (0.84-3.98)1.48 (0.66-3.33)1.27 (0.77-2.09)1.09 (0.68-1.76)0.97 (0.65-1.45)0.77 (0.51-1.15)0.85 (0.47-1.52)0.61 (0.34-1.11)
       Ethnic/cultural identity
      Other than White1.25 (0.55-2.84)1.08 (0.45-2.58)0.42 (0.16-1.12)
      P < .10.
      0.40 (0.13-1.27)0.33 (0.13-0.88)0.39 (0.15-1.03)
      P < .10.
      1.84 (0.94-3.60)
      P < .10.
      2.12 (1.07-4.19)
       Income reduction (3 mo post March 1, 2020) and level of concern (No = ref group)
      Yes, not/somewhat concerned1.37 (0.71-2.66)1.21 (0.61-2.40)1.11 (0.66-1.86)1.31 (0.78-2.19)0.77 (0.47-1.28)0.68 (0.40-1.16)1.06 (0.52-2.15)0.78 (0.35-1.73)
      Yes, very/extremely concerned2.10 (0.97-4.53)
      P < .10.
      1.90 (0.84-4.30)2.66 (1.65-4.28)1.43 (0.81-2.55)1.51 (0.91-2.52)0.83 (0.44-1.55)3.10 (1.67-5.76)1.42 (0.69-2.92)
       Highest education (university = ref group)
      College/trade0.72 (0.40-1.29)0.75 (0.42-1.34)1.11 (0.68-1.83)0.92 (0.56-1.51)0.83 (0.56-1.21)0.77 (0.52-1.13)1.99 (1.02-3.88)2.10 (1.03-4.28)
      High school or Less0.39 (0.17-0.90)0.49 (0.21-1.14)
      P < .10.
      1.48 (0.89-2.46)1.30 (0.79-2.13)0.66 (0.41-1.05)
      P < .10.
      0.58 (0.36-0.96)1.28 (0.58-2.82)1.57 (0.66-3.72)
       Missing values for ≥1 model variablesn=88n=88n=88n=88
      OTC, over-the-counter.
      Bolded estimates are statistically significant at the threshold P < .05.
      Adjusted for all covariates listed in the Table.
      P < .10.
      Relatively younger caregivers were significantly more likely to have sought counseling services, started or increased alcohol consumption and cigarette smoking and/or cannabis use during this initial wave. Caregivers with a reported ethnic/cultural identity other than White were less likely to have started or increased alcohol use but more likely to have started or increased cigarette smoking and/or cannabis use. Relative to caregivers with a university degree, those with high school or less education were less likely to have sought counseling and report new or increased alcohol use while those with a college or trade level of education were significantly more likely to report new or increased use of cigarettes and/or cannabis.

      Longitudinal Sample

      At follow-up, the response rate was 60.2% (longitudinal sample = 386). Caregivers who responded to both surveys were more likely to be age 65+ years, identify as other than White, have a university degree, chronic conditions, and initiated a psychotropic but were less likely to be extremely concerned about income loss (Supplementary Table 6). They did not vary in mental health/health measures from those responding at baseline only.
      Among coping behaviors, only the prevalence of new/increased alcohol use varied significantly across pandemic waves with a lower prevalence reported during the second (11.7%) compared with the initial wave (15.1%) (Figure 2). Prevalence estimates for anxiety, depressive symptoms, and worsening health were all significantly lower at follow-up compared with baseline.
      Figure thumbnail gr2
      Fig. 2Assisted living caregiver reported coping behaviors during the initial and second waves of the COVID-19 pandemic and health characteristics∗ at baseline and follow-up. ∗Among longitudinal caregiver sample, anxiety was significantly higher among women than men at baseline (30.5% vs 19.4%) and follow-up (25.3% vs 9.6%); depressive symptoms were significantly higher among women at follow-up (36.3% vs 22.4%) and higher (but not statistically significant) at baseline (40.9% vs 31.2%). Reported worsening of health did not vary significantly by gender at either time point.
      Caregivers with anxiety and/or depressive symptoms at baseline were significantly more likely to report starting a psychotropic drug and new or increased alcohol, cigarette, and/or cannabis use during both the initial (Figure 3, A) and second (Figure 3, B) waves. Baseline depressive symptoms were significantly associated with seeking counseling during both waves. Worsening health at baseline showed less pronounced and consistent associations with coping behaviors during both waves. Gender was not significantly associated with coping behaviors at either wave. In adjusted models, the positive associations between caregiver mental health symptoms (assessed either at baseline or follow-up) and their coping behaviors during the second pandemic wave largely remained statistically significant (Secondary analyses, Supplementary Table 7).
      Figure thumbnail gr3
      Fig. 3Assisted living caregiver reported coping behaviors during the (A) initial and (B) second waves of the COVID-19 pandemic, among those with baseline clinically significant anxiety disorder, depressive symptoms, self-reported worse health, compared with total and gender-specific prevalence (longitudinal sample, n = 386).

      Discussion

      Among assisted living caregivers in 2 Canadian provinces, 16.5% started or increased alcohol use and 13.3% initiated a psychotropic drug to help cope with the initial pandemic wave. A smaller proportion reported new or increased smoking and/or cannabis use (8.0%) and seeking counseling (7.4%). During the second wave, the prevalence of most coping behaviors did not change except for a significantly lower prevalence of alcohol use. Anxiety and depressive symptoms were common among caregivers at baseline but were less prevalent by follow-up. During both waves, the prevalence of psychotropic and substance use was 2 to 4 times higher among caregivers with mental health symptoms. Contrary to our hypothesis none of the coping behaviors at either wave varied by caregiver gender.
      Research on coping strategies used by caregivers during COVID-19 is limited and largely restricted to community-based care. Our study is unique in exploring coping behaviors among caregivers to older adults in assisted living (an especially neglected and vulnerable caregiver population) and investigating variations in these behaviors over time (across 2 pandemic waves) and by assisted living caregiver mental and overall health. Similar to our findings, caregivers of community-residing persons with dementia, who exhibited depression tended to have more dysfunctional coping strategies.
      • Bussè C.
      • Barnini T.
      • Zucca M.
      • et al.
      Depression, anxiety and sleep alterations in caregivers of persons with dementia after 1-year of COVID-19 pandemic.
      Caregivers of community-residing adults in the United States showed overall higher levels of starting or increasing drug or alcohol use, compared with noncaregivers.
      • Czeisler M.É.
      • Drane A.
      • Winnay S.S.
      • et al.
      Mental health, substance use, and suicidal ideation among unpaid caregivers of adults in the United States during the COVID-19 pandemic: Relationships to age, race/ethnicity, employment, and caregiver intensity.
      Increased alcohol consumption in our baseline sample was 16.5%, compared with 13% reported in the general population of middle age and older Canadian adults, for whom depression and anxiety were also predictors of potentially worrisome alcohol use.
      • McMillan J.M.
      • Hogan D.B.
      • Zimmer C.
      • et al.
      Predictors of reported alcohol intake during the first and second waves of the COVID-19 pandemic in Canada among middle-aged and older adults: Results from the Canadian Longitudinal Study on Aging (CLSA).
      Our findings contribute to an improved awareness of the similarities and differences in pandemic-related mental health stressors and coping support needs among assisted living caregivers relative to caregivers in other settings.
      Although baseline depressive symptoms were associated with seeking counseling during both pandemic waves, this was not true for anxiety. Few caregivers reported seeking counseling at either wave despite having anxiety and depressive symptoms. This finding along with the increased substance use noted in our study and by others
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report. May 2021.
      ,
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report 2: Spotlight on gender and household size. May 2021.
      suggests many used self-medication to cope with pandemic and caregiver related stressors given a reduced availability and/or accessibility to needed mental health services during peak waves. In a small Canadian study, caregivers of persons with dementia reported that this inability to connect with resources would have a lasting impact on their own health.
      • Flemons K.
      • McGhan G.
      • McCaughey D.
      Family caregiving for people living with dementia during COVID-19: A thematic analysis.
      As older caregivers and those with lower education were less likely to seek counseling in our study, this gap in accessing services may be more pronounced for especially vulnerable caregivers.
      The absence of a gender difference in coping behaviors was unexpected given previous studies among the general population
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report 2: Spotlight on gender and household size. May 2021.
      ,
      • Varin M.
      • Hill MacEachern K.
      • Hussain N.
      • Baker M.M.
      Measuring self-reported change in alcohol and cannabis consumption during the second wave of the COVID-19 pandemic in Canada.
      ,
      Statistics Canada
      Survey on COVID-19 and mental health, September to December 2020.
      ,
      • McMillan J.M.
      • Hogan D.B.
      • Zimmer C.
      • et al.
      Predictors of reported alcohol intake during the first and second waves of the COVID-19 pandemic in Canada among middle-aged and older adults: Results from the Canadian Longitudinal Study on Aging (CLSA).
      and the higher prevalence of mental health symptoms among women in our study. However, our findings are consistent with a US study of adult caregivers.
      • Czeisler M.É.
      • Drane A.
      • Winnay S.S.
      • et al.
      Mental health, substance use, and suicidal ideation among unpaid caregivers of adults in the United States during the COVID-19 pandemic: Relationships to age, race/ethnicity, employment, and caregiver intensity.
      Canadian studies show that women were more likely to report experiencing stressors in response to the pandemic,
      • De Rubeis V.
      • Anderson L.N.
      • Khattar J.
      • et al.
      Stressors and perceived consequences of the COVID-19 pandemic among older adults: A cross-sectional study using data from the Canadian Longitudinal Study on Aging.
      and women with depression or anxiety had increased binge drinking.
      • McMillan J.M.
      • Hogan D.B.
      • Zimmer C.
      • et al.
      Predictors of reported alcohol intake during the first and second waves of the COVID-19 pandemic in Canada among middle-aged and older adults: Results from the Canadian Longitudinal Study on Aging (CLSA).
      We did observe some age differences in coping behaviors wherein younger caregivers were more likely to report starting or increasing alcohol, smoking, and/or cannabis use. These differences may reflect a greater tendency for younger adults to report more negative experiences during the pandemic,
      • De Rubeis V.
      • Anderson L.N.
      • Khattar J.
      • et al.
      Stressors and perceived consequences of the COVID-19 pandemic among older adults: A cross-sectional study using data from the Canadian Longitudinal Study on Aging.
      including a higher prevalence of anxiety
      • Lane N.
      • Hoben M.
      • Amuah J.E.
      • et al.
      Prevalence and correlates of anxiety and depression in caregivers to assisted living residents during COVID-19: a cross-sectional study.
      and multiple stresses related to care of parents and children and job loss.
      Mental Health Commission of Canada and Canadian Centre on Substance Use and Addiction
      Mental health and substance use during COVID-19: Summary report 3: Spotlight on income, employment, access. September 2021.
      • Varin M.
      • Hill MacEachern K.
      • Hussain N.
      • Baker M.M.
      Measuring self-reported change in alcohol and cannabis consumption during the second wave of the COVID-19 pandemic in Canada.
      • Zajacova A.
      • Jehn A.
      • Stackhouse M.
      • et al.
      Changes in health behaviours during early COVID-19 and socio-demographic disparities: A cross-sectional analysis.
      Statistics Canada
      Survey on COVID-19 and mental health, September to December 2020.
      Strengths of this study include the use of comprehensive primary data incorporating validated mental health measures, our longitudinal design, and large sample of adult assisted living caregivers of all ages from 2 Canadian provinces. Our focus on caregivers of older residents in assisted living addresses an important knowledge gap in current COVID-19 research. By examining both positive and potentially maladaptive behaviors we provide a balanced overview of coping strategies in this caregiver population.
      There are some limitations to consider. Self-reported survey data has the potential for recall bias (a concern given the relatively long period for baseline data collection) and social desirability bias (particularly for questions on substance use). The analytic sample included largely White, English-speaking women with disproportionately high socioeconomic status. There is the potential for selection bias given our recruitment strategy and use of open-survey link at baseline. The exclusion of caregivers from diverse cultures and the likelihood that some who declined participation did so because of stressors limits the generalizability of our results and may have resulted in an underestimation of mental health symptoms and coping behaviors. Our 60.2% response rate at follow-up likely resulted in lower power for some analyses. We did not employ validated scales for our coping behaviors and some behaviors (eg, physical activity, dietary changes, screen time) were not investigated. Finally, by anchoring coping behaviors to salient time frames to enhance accuracy of reporting, we cannot be sure of the direction of reported associations or whether an initially reported behavior was maintained, reduced, or discontinued over follow-up.

      Conclusions and Implications

      Assisted living caregivers experiencing anxiety or depressive symptoms during the pandemic were more likely to engage in drug and substance use as coping strategies. Enhanced awareness of caregiver mental health needs during crises coupled with increased availability and accessibility of counseling services and financial resources are needed to mitigate declines in their health.

      Acknowledgments

      We thank our family/friend caregiver participants, family caregiver organizations [Caregivers Alberta, Family Caregivers of British Columbia], the participating assisted living homes, and government partners [Alberta Health, Alberta Health Services, Government of British Columbia, Vancouver Coastal Health] for their meaningful contributions to this research. We also thank the Survey Research Centre at the University of Waterloo for the expert administration of the COVCARES-AB/BC baseline and follow-up web surveys and Hana Dampf for her assistance with figure presentation.

      Supplementary Data

      Figure thumbnail fx1
      Supplementary Fig. 1Timing of baseline and follow-up caregiver surveys relative to time frames for reported coping behaviors.
      Supplementary Table 1STROBE Guidelines for Reporting Observational Studies
      Item NoRecommendationPage No
      Title and abstract1(a) Indicate the study’s design with a commonly used term in the title or the abstract2
      (b) Provide in the abstract an informative and balanced summary of what was done and what was found2
      Introduction
       Background/rationale2Explain the scientific background and rationale for the investigation being reported4-5
       Objectives3State specific objectives, including any prespecified hypotheses5
      Methods
       Study design4Present key elements of study design early in the paper5
       Setting5Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection5-6
       Participants6(a) Cohort study—Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up

      Case-control study—Give the eligibility criteria, and the sources and methods of case ascertainment and control selection. Give the rationale for the choice of cases and controls

      Cross-sectional study—Give the eligibility criteria, and the sources and methods of selection of participants
      5-6 and Supplementary Table 2
      (b) Cohort study—For matched studies, give matching criteria and number of exposed and unexposed

      Case-control study—For matched studies, give matching criteria and the number of controls per case
      n/a
       Variables7Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable6-7
       Data sources/measurement8
      Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
      For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group6-7
       Bias9Describe any efforts to address potential sources of bias6,8-9
       Study size10Explain how the study size was arrived atn/a
       Quantitative variables11Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why6-7
       Statistical methods12(a) Describe all statistical methods, including those used to control for confounding8-9
      (b) Describe any methods used to examine subgroups and interactionsn/a
      (c) Explain how missing data were addressed8
      (d) Cohort study—If applicable, explain how loss to follow-up was addressed

      Case-control study—If applicable, explain how matching of cases and controls was addressed

      Cross-sectional study—If applicable, describe analytical methods taking account of sampling strategy
      9
      (e) Describe any sensitivity analysesn/a
      Results
       Participants13
      Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
      (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analyzed9,11
      (b) Give reasons for non-participation at each stageNot collected but differences between responders/non-responders in Supplementary Table 6
      (c) Consider use of a flow diagram
       Descriptive data14
      Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
      (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders9-11
      (b) Indicate number of participants with missing data for each variable of interest8-9
      (c) Cohort study—Summaries follow-up time (eg, average and total amount)Supplementary Figure 1
       Outcome data15
      Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
      Cohort study—Report numbers of outcome events or summary measures over time11
      Case-control study—Report numbers in each exposure category, or summary measures of exposure
      Cross-sectional study—Report numbers of outcome events or summary measures9-10
       Main results16(a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they were included10
      (b) Report category boundaries when continuous variables were categorizedn/a
      (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period
       Other analyses17Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses11
      Discussion
       Key results18Summarize key results with reference to study objectives12
       Limitations19Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias13
       Interpretation20Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence14
       Generalizability21Discuss the generalizability (external validity) of the study results13
      Other information
       Funding22Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is basedTitle pg and Cover Letter
      An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.
      Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.
      Supplementary Table 2Description of Assisted Living in Alberta and British Columbia, Canada and COVCARES-AB/BC Study Eligibility Criteria
      AlbertaBC
      • In Alberta, there are publicly subsidized and private pay assisted living operators.
      • Publicly funded (subsidized) assisted living in Alberta is known as designated SL.
      • Under the Supportive Living Accommodation Licensing Act, SL must be licensed for resident safety and security and also comply with Accommodation Standards; designated SL must further comply with the Continuing Care Health Service Standards.
      • Designated SL is composed of 3 progressive levels of support moving from the lowest level of support available (SL3) to higher levels of support (SL4 and SL4-Dementia)
        • o
          SL3 is for individuals who are medically and physically stable and can move independently or move with limited assistance. Health care aides are available on site 24 h/d and other health care services are scheduled and provided by home care.
        • o
          SL4 is for individuals with more complex health needs and who might require assistance with eating and transfers. It has health care aides and a licensed practical nurse available 24 h/d, and other care needs (eg, rehabilitation therapy) are contracted through home care.
        • o
          SL 4D is like SL4 but is specifically for individuals with moderate to severe dementia.
      • Further details about designated SL in Alberta can be found here:
      https://www.albertahealthservices.ca/cc/Page15490.aspx

      https://www.albertahealthservices.ca/cc/page15328.aspx
      • In BC, there are publicly subsidized and private pay assisted living operators.
      • Under the Community Care and Assisted Living Act (which sets minimum health and safety requirements), all publicly subsidized and private pay assisted living operators that meet the definition of an assisted living residence under the Act are required to be registered with the provincial assisted living registrar.
      • Publicly subsidized assisted living services provide housing, hospitality, and 1 or 2 personal assistance services (prescribed services) for adults who can live independently and make decisions on their own behalf but require a supportive environment due to physical and functional health challenges.
        • o
          Eligibility require resident to be able to make decisions on their own behalf or who has a spouse willing to live with the resident and is willing/able to make decisions on their behalf.
        • o
          If the resident requires 3 or more personal assistance services they are not eligible for publicly subsidized assisted living.
      • BC does not differentiate various levels of assisted living depending on individual care needs.
      • Further details about assisted living in BC can be found here:
      https://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/care-options-and-cost/assisted-living

      https://www2.gov.bc.ca/gov/content/health/accessing-health-care/finding-assisted-living-or-residential-care/residential-care-facilities/finding-a-residential-care-facility

        COVCARES-AB/BC Study Eligibility Criteria

      • (1)
        Assisted living Homes (Alberta and BC): Eligibility criteria included homes that were licensed and publicly subsidized (termed designated supportive living in Alberta), in operation for at least 6 months, not primarily serving psychiatric clients and with a minimum number of residents age 65+ y (4 for small, 10 for large homes, based on median bed-size).
      • (2)
        Caregivers of assisted living residents (Alberta and BC): Eligibility criteria included those who identified as the primary adult caregiver (ie, age 18+ y and most informed/involved in care) of a resident age 65+ y living in the home for 3+ mo prior to March 1, 2020.
      BC, British Columbia; SL, supportive living.
      Supplementary Table 3Distribution of Assisted Living Caregiver Coping Behaviors, Overall and by Reported Change in Health, Presence of Clinically Significant Anxiety Disorder and Depressive Symptoms [Distribution Shown as Column % (n); Total Baseline Sample, n = 673]
      Coping ResponseOverall (n = 673)Change in HealthClinically Significant Anxiety DisorderDepressive Symptoms
      Worse (28.9%; 194/671)Same (61.3%; 411/671)Better (9.8%; 66/671)Present (28.6%; 171/598)Absent (71.4%; 427/598)Present (38.8%; 240/619)Absent (61.2%; 379/619)
      Sought counseling services
       Yes7.4 (49)12.0 (23)
      P < .01.
      4.9 (20)9.4 (6)11.2 (19)
      P < .10.
      6.6 (28)12.2 (29)
      P < .001.
      4.8 (18)
       No92.6 (612)88.0 (169)95.1 (384)90.6 (58)88.8 (150)93.4 (396)87.8 (208)95.2 (359)
      Started OTC drug product for sleep
       Yes9.4 (62)19.7 (37)
      P < .0001.
      4.9 (20)7.8 (5)22.5 (38)
      P < .0001.
      4.5 (19)20.3 (48)
      P < .0001.
      3.2 (12)
       No90.6 (599)80.7 (155)95.1 (384)92.2 (59)77.5 (131)95.5 (405)79.8 (189)96.8 (365)
      Started prescription drug to help with anxiety/depression
       Yes6.2 (41)13.5 (26)
      P < .0001.
      3.0 (12)4.7 (3)14.2 (24)
      P < .0001.
      3.3 (14)14.4 (34)
      P < .0001.
      1.6 (6)
       No93.8 (620)86.5 (166)97.0 (392)95.3 (61)85.8 (145)96.7 (410)85.7 (203)98.4 (371)
      Started OTC product for sleep and/or prescription drug for anxiety/depression
       Yes13.3 (88)28.1 (54)
      P < .0001.
      6.7 (27)10.9 (7)30.2 (51)
      P < .0001.
      7.1 (30)29.1 (69)
      P < .0001.
      4.2 (16)
       No86.7 (573)71.9 (138)93.3 (377)89.1 (57)69.8 (118)92.9 (394)70.9 (168)95.8 (361)
      Started to consume or increased use of alcohol
       Yes16.5 (109)22.4 (43)
      P < .05.
      13.6 (55)17.2 (11)24.9 (42)
      P < .001.
      13.4 (57)24.9 (59)
      P < .0001.
      12.2 (46)
       No83.5 (552)77.6 (149)86.4 (349)82.8 (53)75.2 (127)86.6 (367)75.1 (178)87.8 (331)
      Started or increased smoking
       Yes4.7 (31)6.8 (13)4.2 (17)1.6 (1)7.7 (13)
      P < .10.
      4.0 (17)6.8 (16)
      P < .10.
      3.7 (14)
       No95.3 (630)93.2 (179)95.8 (387)98.4 (63)92.3 (156)96.0 (407)93.3 (221)96.3 (363)
      Started or increased cannabis use
       Yes4.2 (28)8.3 (16)
      P < .01.
      2.5 (10)3.1 (2)9.5 (16)
      P < .0001.
      1.9 (8)8.4 (20)
      P < .001.
      2.1 (8)
       No95.8 (633)91.7 (176)97.5 (394)96.9 (62)90.5 (153)98.1 (416)91.6 (217)97.9 (369)
      Started or increased smoking and/or cannabis use
       Yes8.0 (53)12.5 (24)
      P < .05.
      6.4 (26)4.7 (3)15.4 (26)
      P < .0001.
      5.2 (22)13.5 (32)
      P < .001.
      5.3 (20)
       No92.0 (608)87.5 (168)93.6 (378)95.3 (61)84.6 (143)94.8 (402)86.5 (205)94.7 (357)
      OTC, over-the-counter.
      P < .01.
      P < .10.
      P < .001.
      § P < .0001.
      P < .05.
      Supplementary Table 4Unadjusted and Adjusted Associations Between Assisted Living Caregiver Depressive Symptoms, Other Characteristics, and Select Coping Behaviors (Total Baseline Sample, n = 673)
      Caregiver CharacteristicsCaregiver Coping Response
      Sought Counseling ServicesStarted OTC Product for Sleep and/or Prescription Drug for Anxiety/DepressionStarted to Consume or Increased Use of AlcoholStarted or Increased Smoking and/or Cannabis Use
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in Table.
      Risk Ratio (95% CI)
      Depressive symptoms2.56 (1.46-4.51)2.18 (1.21-3.94)6.86 (4.08-11.53)6.13 (3.63-10.35)2.04 (1.44-2.89)2.03 (1.42-2.88)2.55 (1.49-4.34)2.04 (1.17-3.55)
      Age (65+ y = ref group)
       18-44 y3.89 (1.60-9.48)2.53 (1.01-6.31)1.72 (0.89-3.34)1.27 (0.68-2.39)2.53 (1.41-4.56)2.33 (1.30-4.16)6.12 (2.83-13.21)5.16 (2.30-11.55)
       45-54 y2.28 (0.95-5.47)
      P < .10.
      2.11 (0.84-5.29)1.47 (0.84-2.57)1.33 (0.75-2.35)2.16 (1.29-3.61)2.17 (1.31-3.59)2.28 (0.95-5.47)
      P < .10.
      2.17 (0.87-5.41)
      P < .10.
       55-64 y1.93 (0.96-3.87)
      P < .10.
      1.68 (0.80-3.55)0.92 (0.58-1.46)0.82 (0.52-1.28)1.52 (0.99-2.34)
      P < .10.
      1.54 (1.01-2.34)1.93 (0.96-3.87)
      P < .10.
      1.89 (0.97-3.68)
      P < .10.
      Gender
       Woman1.83 (0.84-3.98)1.64 (0.69-3.89)1.27 (0.77-2.09)1.04 (0.65-1.68)0.97 (0.65-1.45)0.82 (0.54-1.24)0.85 (0.47-1.52)0.60 (0.34-1.07)
      P < .10.
      Ethnic/cultural identity
       Other than White1.25 (0.55-2.84)1.33 (0.60-2.91)0.42 (0.16-1.12)
      P < .10.
      0.35 (0.11-1.15)
      P < .10.
      0.33 (0.13-0.88)0.36 (0.14-0.93)1.84 (0.94-3.60)
      P < .10.
      1.99 (1.07-3.71)
      Income reduction (3 mo post March 1, 2020) and level of concern (No = ref group)
       Yes, not/somewhat concerned1.37 (0.71-2.66)1.08 (0.54-2.18)1.11 (0.66-1.86)1.17 (0.71-1.93)0.77 (0.47-1.28)0.62 (0.38-1.04)
      P < .10.
      1.06 (0.52-2.15)0.82 (0.41-1.66)
       Yes, very/extremely concerned2.10 (0.97-4.53)
      P < .10.
      1.31 (0.59-2.91)2.66 (1.65-4.28)1.49 (0.92-2.41)1.51 (0.91-2.52)0.96 (0.58-1.57)3.10 (1.67-5.76)1.48 (0.75-2.93)
      Highest education (University = ref group)
       College/trade0.72 (0.40-1.29)0.70 (0.39-1.26)1.11 (0.68-1.83)0.99 (0.62-1.56)0.83 (0.56-1.21)0.78 (0.53-1.13)1.99 (1.02-3.88)2.07 (1.05-4.08)
       High school or Less0.39 (0.17-0.90)0.41 (0.17-1.00)1.48 (0.89-2.46)1.39 (0.86-2.27)0.66 (0.41-1.05)
      P < .10.
      0.64 (0.40-1.04)
      P < .10.
      1.28 (0.58-2.82)1.75 (0.76-4.04)
      Missing values for ≥1 model variablesn=68n=68n=68n=68
      OTC, over-the-counter.
      Bolded estimates are statistically significant at the threshold P < .05.
      Adjusted for all covariates listed in Table.
      P < .10.
      Supplementary Table 5Unadjusted and Adjusted Associations Between Assisted Living Caregiver Health Change, Other Characteristics, and Select Coping Behaviors (Total Baseline Sample, n = 673)
      Caregiver CharacteristicsCaregiver Coping Response
      Sought Counseling ServicesStarted OTC Product for Sleep and/or Prescription Drug for Anxiety/DepressionStarted to Consume or Increased Use of AlcoholStarted or Increased Smoking and/or Cannabis Use
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in Table.
      Risk Ratio (95% CI)
      Unadjusted Risk Ratio (95% CI)Adjusted
      Adjusted for all covariates listed in Table.
      Risk Ratio (95% CI)
      Health (now vs 3 mo before March 1, 2020), same = ref
       Better1.89 (0.79-4.54)1.73 (0.73-4.07)1.64 (0.74-3.60)1.79 (0.82-3.89)1.26 (0.70-2.28)1.33 (0.72-2.44)0.73 (0.23-2.34)0.55 (0.19-1.55)
       Worse2.42 (1.36-4.30)2.07 (1.17-3.66)4.21 (2.74-6.46)4.10 (2.65-6.35)1.65 (1.15-2.36)1.69 (1.20-2.38)1.94 (1.15-3.29)1.52 (0.90-2.56)
      Age (65+ y = ref group)
       18-44 y3.89 (1.60-9.48)2.56 (1.08-6.07)1.72 (0.89-3.34)1.42 (0.70-2.85)2.53 (1.41-4.56)2.44 (1.37-4.35)6.12 (2.83-13.21)5.95 (2.70-13.11)
       45-54 y2.28 (0.95-5.47)
      P < .10.
      1.80 (0.71-4.53)1.47 (0.84-2.57)1.29 (0.75-2.21)2.16 (1.29-3.61)2.18 (1.31-3.60)2.28 (0.95-5.47)
      P < .10.
      2.05 (0.83-5.04)
       55-64 y1.93 (0.96-3.87)
      P < .10.
      1.63 (0.81-3.30)0.92 (0.58-1.46)0.80 (0.51-1.24)1.52 (0.99-2.34)
      P < .10.
      1.57 (1.04-2.38)1.93 (0.96-3.87)
      P < .10.
      1.89 (0.97-3.69)
      P < .10.
      Gender
       Woman1.83 (0.84-3.98)1.54 (0.69-3.41)1.27 (0.77-2.09)1.02 (0.64-1.63)0.97 (0.65-1.45)0.78 (0.53-1.16)0.85 (0.47-1.52)0.63 (0.36-1.10)
      Ethnic/cultural identity
       Other than White1.25 (0.55-2.84)1.02 (0.46-2.28)0.42 (0.16-1.12)
      P < .10.
      0.38 (0.14-1.05)
      P < .10.
      0.33 (0.13-0.88)0.29 (0.11-0.77)1.84 (0.94-3.60)
      P < .10.
      1.79 (0.96-3.36)
      P < .10.
      Income reduction (3 mo post March 1, 2020) and level of concern (No = ref group)
       Yes, not/somewhat concerned1.37 (0.71-2.66)1.12 (0.59-2.14)1.11 (0.66-1.86)1.01 (0.62-1.63)0.77 (0.47-1.28)0.63 (0.39-1.02)
      P < .10.
      1.06 (0.52-2.15)0.82 (0.42-1.60)
       Yes, very/extremely concerned2.10 (0.97-4.53)
      P < .10.
      1.64 (0.75-3.55)2.66 (1.65-4.28)2.03 (1.22-3.40)1.51 (0.91-2.52)1.20 (0.73-1.96)3.10 (1.67-5.76)1.84 (0.94-3.61)
      P < .10.
      Highest Education (University = ref group)
       College/trade0.72 (0.40-1.29)0.66 (0.37-1.17)1.11 (0.68-1.83)0.95 (0.58-1.54)0.83 (0.56-1.21)0.77 (0.53-1.12)1.99 (1.02-3.88)2.00 (1.02-3.95)
       High school or less0.39 (0.17-0.90)0.42 (0.18-0.96)1.48 (0.89-2.46)1.43 (0.88-2.32)0.66 (0.41-1.05)
      P < .10.
      0.65 (0.41-1.03)
      P < .10.
      1.28 (0.58-2.82)1.57 (0.70-3.56)
      Missing values for ≥1 model variablesn = 24n = 24n = 24n = 24
      OTC, over-the-counter.
      Bolded estimates are statistically significant at the threshold P < .05.
      Adjusted for all covariates listed in Table.
      P < .10.
      Supplementary Table 6Distribution of Assisted Living Caregiver Characteristics, Overall and by Participation in Baseline Only vs Baseline and Follow-Up Surveys [Distribution Shown as Column % (n)]
      CharacteristicsOverall (n = 673)Survey Participation
      Baseline Only (n = 287)Baseline and Follow-Up (n = 386)
      Sociodemographic
       Province (facility located)
      Alberta81.1 (546)81.5 (234)80.8 (312)
      British Columbia18.9 (127)18.5 (53)19.2 (74)
       Age
      P < .10.
      18-44 y6.4 (43)8.1 (23)5.2 (20)
      45-54 y12.2 (82)14.4 (41)10.6 (41)
      55-64 y42.3 (284)43.2 (123)41.7 (161)
      65+ y39.1 (262)34.4 (98)42.5 (164)
       Gender
      Women76.8 (515)73.7 (210)79.0 (305)
      Men
      Includes 4 caregivers who responded ‘prefer not to answer’ to item on sex (1 of these noted ‘prefer to self-describe’ but their response did not make sense as they were referring to their care recipient - so coded with ‘prefer not to answer’).
      23.2 (156)26.3 (75)21.0 (81)
       Marital status
      Married/common-law83.1 (555)82.4 (234)83.6 (321)
      Other16.9 (113)17.6 (50)16.4 (63)
       Relationship to resident
      Spouse/parent5.8 (39)5.2 (15)6.2 (24)
      Daughter/son (including in-law)78.5 (528)80.1 (230)77.2 (298)
      Sibling7.3 (49)6.3 (18)8.0 (31)
      Friend/neighbor /other8.5 (57)8.4 (24)8.6 (33)
       Ethnic/cultural identity
      P < .01.
      White89.9 (598)93.6 (263)87.2 (335)
      Other than White10.1 (67)6.4 (18)12.8 (49)
       Highest education
      P < .05.
      University31.0 (205)25.8 (72)34.7 (133)
      College/trade42.5 (281)44.8 (125)40.7 (156)
      High school or less26.6 (176)29.4 (82)24.5 (94)
       Household income (prior to March 1, 2020)
      >$100,00027.3 (184)30.3 (87)25.1 (97)
      $80,000-$99,00015.0 (101)15.7 (45)14.5 (56)
      $50,000-$79,00023.8 (160)20.6 (59)26.2 (101)
      <$50,00020.2 (136)17.4 (50)22.3 (86)
      Missing13.7 (92)16.0 (46)11.9 (46)
       Income reduction (3 mo post March 1, 2020) and level of concern
      P < .05.
      No73.4 (494)74.2 (213)72.8 (281)
      Yes, not concerned4.5 (30)2.4 (7)6.0 (23)
      Yes, somewhat concerned14.1 (95)12.9 (37)15.0 (58)
      Yes, very/extremely concerned8.0 (54)10.5 (30)6.2 (24)
       Change in employment status (3 mo post March 1, 2020)
      No84.0 (562)83.8 (238)84.2 (324)
      Yes16.0 (107)16.2 (46)15.8 (61)
      Health and social well-being
       No of chronic conditions
      P < .01.
      None43.0 (288)45.4 (129)41.2 (159)
      1-241.6 (279)37.3 (106)44.8 (173)
      3+11.6 (78)10.9 (31)12.2 (47)
      Don't know/prefer not to answer3.7 (25)6.3 (18)1.8 (7)
       Self-rated health
      Excellent16.9 (113)18.9 (54)15.3 (59)
      Very good40.5 (271)42.5 (121)39.0 (150)
      Good31.8 (213)28.4 (81)34.3 (132)
      Fair/poor10.9 (73)10.2 (29)11.4 (44)
       Change in health (vs 3 mo pre March 1, 2020)
      Better now9.8 (66)11.9 (34)8.3 (32)
      Same61.3 (411)61.2 (175)61.3 (236)
      Worse28.9 (194)26.9 (77)30.4 (117)
       Clinically significant anxiety disorder
      Present28.6 (171)29.2 (72)28.2 (99)
      Not present71.4 (427)70.9 (175)71.8 (252)
       Depressive symptoms
      Present38.8 (240)38.8 (102)38.8 (138)
      Not present61.2 (379)61.2 (161)61.2 (218)
       Emotional/informational social support
      High78.0 (493)78.4 (211)77.7 (282)
      Low22.0 (139)21.6 (58)22.3 (81)
      Coping behaviors
       Sought counseling services
      Yes7.4 (49)7.9 (22)7.1 (27)
      No92.6 (612)92.1 (256)93.0 (356)
       Started OTC product for sleep and/or prescription drug for anxiety/depression
      P < .05.
      Yes13.3 (88)10.1 (28)15.7 (60)
      No86.7 (573)89.9 (250)84.3 (323)
       Started to consume or increased use of alcohol
      Yes16.5 (109)18.4 (51)15.1 (58)
      No83.5 (552)81.7 (227)84.9 (325)
       Started or increased smoking and/or cannabis use
      Yes8.0 (53)10.1 (28)6.5 (25)
      No92.0 (608)89.9 (250)93.5 (358)
      OTC, over-the-counter.
      P < .10.
      Includes 4 caregivers who responded ‘prefer not to answer’ to item on sex (1 of these noted ‘prefer to self-describe’ but their response did not make sense as they were referring to their care recipient - so coded with ‘prefer not to answer’).
      P < .01.
      § P < .05.
      Supplementary Table 7Adjusted Associations Between Assisted Living Caregiver Anxiety, Depressive Symptoms, Health Change (Assessed at Baseline vs Follow-Up) and Reported Coping Behaviors During Second Wave of COVID-19 Pandemic (Longitudinal Sample, n = 386)
      Caregiver Health CharacteristicsCaregiver Coping Response (Wave 2 – Assessed at Follow-Up)
      Sought Counseling ServicesStarted OTC Product for Sleep and/or Prescription Drug for Anxiety/DepressionStarted to Consume or Increased Use of AlcoholStarted or Increased Smoking and/or Cannabis Use
      Baseline Health

      Adjusted
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      Risk Ratio (95% CI)
      Follow-Up Health

      Adjusted
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      Risk Ratio (95% CI)
      Baseline Health

      Adjusted
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      Risk Ratio (95% CI)
      Follow-Up Health

      Adjusted
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      Risk Ratio (95% CI)
      Baseline Health

      Adjusted
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      Risk Ratio (95% CI)
      Follow-Up Health

      Adjusted
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      Risk Ratio (95% CI)
      Baseline Health

      Adjusted
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      Risk Ratio (95% CI)
      Follow-Up Health

      Adjusted
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      Risk Ratio (95% CI)
      Clinically Significant Anxiety Disorder4.03 (1.81-8.99)4.46 (1.98-10.02)3.23 (1.84-5.64)3.02 (1.77-5.13)2.50 (1.35-4.61)2.27 (1.25-4.13)2.67 (1.11-6.43)2.99 (1.19-7.52)
       Missing values for ≥1 model variablesn = 38n = 47n = 38n = 47n = 38n = 47n = 38n = 47
      Depressive symptoms9.52 (3.29-27.57)4.87 (2.13-11.15)2.56 (1.45-4.49)4.58 (2.48-8.45)1.72 (0.94-3.17)
      P < .10
      3.04 (1.67-5.52)2.15 (0.72-6.40)5.50 (2.00-15.14)
       Missing values for ≥1 model variablesn = 33n = 35n = 33n = 35n = 33n = 35n = 33n = 35
      Health Change, same/better = ref Worse3.38 (1.62-7.03)1.94 (0.83-4.55)2.06 (1.26-3.36)1.46 (0.87-2.43)1.51 (0.86-2.65)1.56 (0.85-2.86)0.87 (0.34-2.23)1.63 (0.64-4.13)
       Missing values for ≥1 model variablesn = 5n = 5n = 5n = 5n = 5n = 5n = 5n = 5
      OTC, over-the-counter.
      Bolded estimates are statistically significant at the threshold P < .05.
      Adjusted for age, gender, ethnic/cultural identity, income reduction/concern, and education.
      P < .10

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