Parents’ COVID-19 stressors and associations with self-rated health, symptoms of mental health problems, and substance use: a cross-sectional study

The coronavirus disease-2019 (COVID-19) pandemic and public health measures necessary to minimize risk led to unique challenges for parents. Studies have found that the impact of the pandemic on stress, mental health, and substance use was different, and often more pronounced, among parents or caregivers (hereinafter referred to as parents) than among nonparents (American Psychological Association 2020; Gadermann et al. 2021; Hill MacEachern et al. 2021). In two nationally representative surveys of adults in Canada conducted at the beginning of the pandemic, differences emerged between parents (of children under 18) and non-parents (Gadermann et al. 2021; Hill MacEachern et al. 2021). Parents self-reported a higher prevalence of worsening mental health since the onset of the pandemic (Gadermann et al. 2021) and of significantly increased alcohol use compared to before the pandemic (Hill MacEachern et al. 2021). However, among males, parents were less likely than non-parents to report increased cannabis use (Hill MacEachern et al. 2021). Understanding parents’ stress, mental health, and substance use during the pandemic is key to preventing and/or lessening the negative consequences not only for their own health and well-being but also, intergenerationally (Daks et al. 2020; Spinelli et al. 2020; Roos et al. 2021).

Parents have identified a range of COVID-related stressors including (but not limited to): caring for and worrying about the impacts of the pandemic on their children; lack of supports such as childcare; balancing roles and responsibilities; anxiety and worry about COVID-19; uncertainty about the future; job or income loss; mental and physical health; health care system concerns; inability to see family or friends; and relationship challenges (Brown et al. 2020; Adams et al. 2021; Alonzi et al. 2021; Gadermann et al. 2021; Roos et al. 2021). In one study, at the beginning of the pandemic, parents of non-adult children reported experiencing an average of 3.5 COVID-related stressors (Brown et al. 2020).

In an August 2020 survey involving a representative sample of parents in Germany, higher pandemic-related stress scores were correlated with worse depression, anxiety, and self- rated health (Calvano et al. 2022). These associations are informative, but greater specificity is needed to understand what pandemic stressors were associated with health and well-being problems to thereby inform prevention strategies, as well as intervention approaches to reduce impairment. Although some studies have had greater specificity, their focus was narrow. For example, researchers investigated the impacts of school closures and time spent home schooling due to the COVID-19 pandemic and noted significant, associations between these experiences and parental mental health problems and cannabis and alcohol use (marginal association) to cope with mental health symptoms (Deacon et al. 2021; Kishida et al. 2021). One U.S. study of parents conducted early in the pandemic studied the associations between a comprehensive list of pandemic-related experiences moderate-to-severe mental distress (Hart and Han 2021). Experiences associated with an increased likelihood of distress included: having been diagnosed with COVID-19; stigma or discrimination; pandemic-related income or job loss; increased anxiety, depression, loneliness; increased alcohol or substance use; and not having enough basic supplies (Hart and Han 2021). On the other hand, the same study reported that fear of COVID-19 contagion (being infected and infecting others) and worry about family members and friends were associated with a decreased likelihood of mental distress (Hart and Han 2021). A Chinese study noted that the absence of family conflict during the pandemic was associated with lowered odds of mental health problems, but two-week quarantine (personal or family member) was associated with higher odds of depression (Wu et al. 2020). Furthermore, Tsai et al. (2024) found that caregiving for children with attention deficit hyperactivity disorder (ADHD) was associated with elevated psychological distress in parents, suggesting that parents of children with psychiatric disorders may have experienced greater challenges during the pandemic.

Several important studies were conducted in the early months and first year of the COVID-19 pandemic (Brown et al. 2020; Wu et al. 2020; Adams et al. 2021; Gadermann et al. 2021; Hart and Han 2021; Hill MacEachern et al. 2021; Roos et al. 2021; Calvano et al. 2022). Compared with retrospective reports of pre-pandemic stress, parents reported considerably higher levels of stress during the first months of the pandemic (Adams et al. 2021; Calvano et al. 2022; Li et al. 2022). Some improvements were noted later in 2020, but stress levels remained above retrospective pre-pandemic reports (Adams et al. 2021). Studies beyond the first year of the pandemic are limited. One nationally representative German longitudinal study of adults living with non-adult children observed an upturn in parental stress and psychological distress during the region's second wave in March to April 2021 (Li et al. 2022). Overall, little research has examined stressors that parents had and continue to experience and their association with physical and mental health and substance use. It is essential to study parents’ stressors and associated outcomes beyond the first year, given the evolving nature of the pandemic and its ongoing impact.

Furthermore, the epidemiology of COVID-19 and measures to mitigate its effect have varied dramatically by jurisdiction. For example, in Canada, the province of Manitoba experienced four COVID-19 waves. Few people were infected early during the pandemic, the frequency and severity of cases gradually increased whereby the province experienced the nation's second highest COVID-19 death rate, surpassed only by Québec (Aboulatta et al. 2022; Government of Canada 2022). Details on the epidemiology of the disease and public health strategies in the province have been published elsewhere (Aboulatta et al. 2022; Canadian Institute for Health Information 2022).

The current study is informed by stress response theory. Under conditions of stress, the neural and neuroendocrine systems respond with adaptive defense mechanisms, which can affect several biologic systems and impair health (Selye 1950; McEwen and Stellar 1993; McEwen 1998). Acute stress and cumulative or chronic exposure to stress increasing allostatic load can lead to poor mental and physical health outcomes (McEwen and Stellar 1993; McEwen 1998). Understanding the specific stressors experienced by parents at different phases of the COVID-19 pandemic as well as the impact of individual stressors on health outcomes is important to inform public health and policy efforts to support parents not only in recovery from the COVID-19 pandemic but also in the context of future pandemics.

The objectives of the current research were to understand for two time periods: a) which COVID-19 experiences were identified as stressors by parents and b) associations between those stressors and self-rated physical and mental health, problems with mental health (depression, anxiety, and posttraumatic stress disorder), and problematic alcohol and cannabis use in Manitoba, Canada.

Table 2 presents the prevalence of socio-demographic and outcome variables in the sample. The associations between sociodemographic characteristics and the outcomes are provided in the supplementary online material. Table 3 presents the prevalence with which 27 COVID-19 experiences were identified as stressors by parents during the pandemic and in the past month. Nearly all respondents identified at least one item as stressful; fewer than 1% indicated “nothing” when asked about the entire pandemic, 10.7%, indicated “nothing” when asked about the past month. On average, parents reported 9.4 stressors during the pandemic and 4.5 stressors in the past month. The stressors most frequently identified for the pandemic were: 1) inability to spend time with family (72.3%); 2) inability to spend time with friends (67.5%); 3) worry about you (i.e., one's self) or your family getting COVID-19 (67.0%); and 4) travel restrictions (60.3%). The stressors most frequently identified for the past month of the pandemic were: 1) worry about you or your family getting COVID-19 (44.5%); 2) travel restrictions (32.3%); 3) public health restrictions (wearing masks, physical distancing, lock down, 32.0%), and 4) uncertainty about the future (30.0%).

The current study examined relationships between 27 COVID-19 stressors identified by parents and seven health outcomes in two pandemic time periods. Almost all parents identified one or more COVID-19 stressors, not only throughout the pandemic (99%), but also within the month preceding data collection (first few months of 2022; 89.3%)—evidence of the ongoing and long-lasting impact of the pandemic. Although the average number of COVID-19 stressors was higher for the pandemic (average of 9.4) than in the past month (average of 4.5), both exceeded the 3.5 pandemic-related stressors identified in a US study (Brown et al. 2020). The differences may be because the U.S. study included fewer stressors (11) and was conducted in the first few months of the pandemic. By contrast, the current analysis examined 27 stressors and was conducted about two years after confirmation of the first COVID-19 case in Manitoba, Canada.

Findings about several of the most prevalent COVID-19 stressors identified by Manitoba parents are consistent with previous research that found parents rated their pandemic-related stress highest for the following experiences: distancing from family and friends, worry about others’ health, and restrictions of outside activities (Calvano et al. 2022). In the current study, some of the most prevalent parent-reported COVID-19 stressors persisted across time periods (worry about getting COVID-19 and travel restrictions), while others varied (entire pandemic: unable to spend time with family or with friends vs. past month: public health restrictions and uncertainty about the future). These findings are important to understand within the context of the epidemiology of COVID-19 and public health measures. For instance, worry about getting COVID-19 was among the most frequently identified stressors in both time frames. This reflects the ongoing risk of contracting COVID-19. Furthermore, at the time of Wave 2 data collection for the parent cohort (February-March 2022), Manitoba was recovering from the highest infection rates the province had experienced (peaking January 7, 2022) with the emergence of the highly transmissible Omicron variant (Aboulatta et al. 2022). However, this stressor was less frequently identified in the past month than during the entire pandemic. This may be attributable to greater understanding of the disease and its treatments, vaccine eligibility for the majority of the population (age 5 years and older), lower disease severity of new variants, and habituation and stress fatigue, among other factors. Travel restrictions, one of the most frequently identified stressors for both time periods, may reflect Canadian public health orders for international travel, which were among the last to be eased and, in some cases, only after data collection was completed (Canadian Institute for Health Information 2022). Identifying not being able to spend time with family or friends as stressors during the entire pandemic but not in the past month also aligned with public health orders. During the most restrictive periods of pandemic measures, social contacts in Manitoba were limited to household members and gatherings were prohibited (Canadian Institute for Health Information 2022). By comparison, around the time of data collection restrictions on social contacts were relaxed twice in February 2022 including removal of outdoor capacity limits and allowing 50 people indoors. Most public health orders had been lifted by March 15, 2022 (Canadian Institute for Health Information 2022).

The majority of stressors were associated with one or more health and well-being outcomes; however, few were associated with problematic substance use. A dose-response trend was noted with increasing numbers of stressors associated with higher odds of fair or poor self- rated physical and symptoms of mental health problems. The most prevalent stressors were not necessarily among those with the greatest associations with health outcomes. For example, identifying travel restrictions as a stressor in either time period was not associated with any of these outcomes. Stressors positively associated with the greatest number of outcomes and time periods included: job loss or financial burden; feeling lonely or isolated; disrupted or poor sleep; uncertainty about the future; accessing health care for any reason; increased conflict in relationships; cancellation of surgeries, caregiving for children; and inability to spend time with family. Some associations were consistent with published results based on parent samples. For instance, loneliness and financial or job loss have been associated with moderate-to-severe mental distress (Hart and Han 2021). Other findings differ from earlier research: for example, in the current study, reporting worry about you or your family getting COVID-19 as a stressor during the pandemic was associated with higher odds of fair or poor self-rated mental health. However, an analysis of data collected in the U.S. in May 2020 found that fear of contracting COVID-19 and worry about family or friends had a protective relationship with moderate-to- severe mental distress (Hart and Han 2021).

Disrupted or poor sleep, feeling lonely or isolated, and uncertainty about the future were identified as stressors strongly associated with both physical and mental health outcomes, and both since the pandemic onset and in the month prior to data collection. Likewise, job loss or financial burden showed a strong association with poor mental health outcomes and problematic substance use in both pandemic phases. Given the consistency of findings related to such stressors in the literature (e.g., Brown et al. 2020; Hart and Han 2021), these are key target areas to improve support for parents. Strengthening parents’ mindfulness-based coping skills may be one avenue for helping with sleep problems (Rusch et al. 2019), loneliness (Saini et al. 2021), and uncertainty (Brown et al. 2020).

Furthermore, many of the stressors that were as associated with increased likelihood of poor mental health outcomes for parents were related to family and friends, such as caregiving for children; not being able to spend time with family; increased conflict in relationships with friends or family; missing significant life events; restrictions on visiting family members in personal care homes; visiting sick relatives; and grieving the death of a friend or family member during the pandemic. Caregiving for children and increased conflict in relationships with friends or family were also associated with increased likelihood of problematic cannabis use. Recent studies have reported that helpful strategies used by parents to manage pandemic stress also focused on family and friends, such as spending time with children, doing family activities, and spending time with friends and family virtually (Adams et al. 2021; Koepp et al. 2023). Public health and policy efforts focused on promoting positive relationships among family and friends would be imperative to address parents’ needs for pandemic recovery. Two inverse relationships emerged: identifying inability to spend time with family and inability to spend time with friends as stressors were each associated with lower odds (protective) of problematic alcohol consumption. This may reflect the social nature of alcohol use among respondents (Cook et al. 2022). This is consistent with some Australian parents’ qualitative reports that fewer (or no) opportunities for social drinking during the pandemic reduced their alcohol consumption.

Some stressors related to pandemic safety measures, such as public health restrictions, being at work with public health restrictions, adjusting to changes at one’s workplace or working virtually, and limited access to shopping and restaurants, were also associated with poor health outcomes in parents. For many of these stressors, associations were found within the past month rather than since the pandemic onset.

The stressors that were found to not be associated with any of the outcomes at either time point were: caregiving for parents; loss of recreational activities; being at school, college or university with restrictions; remote learning for school, college, or university; working from home; and travel restrictions. This suggests that in the event of future epidemics, public safety measures such as working from home, remote learning, as well as restrictions on school-based learning, recreational activities, and travel, may not have adverse consequences for parents’ physical health, mental health, and substance use.

Going forward, studies could focus on developing specific strategies and resources to assist parents in coping with pandemic-specific stressors. According to stress response theory, positive (or “low-cost”) coping responses may mitigate the adverse effects of stressors, whereas “high-cost” coping responses (e.g., risk-taking behaviour) may worsen the effects (McEwen and Stellar 1993). Some recent studies have found evidence to increase parental coping (Adams et al. 2021; Kar et al. 2023; Koepp et al. 2023; Prasetyo et al. 2024). This is an important direction for future research.

The current study contributes to the limited literature on adverse outcomes associated with COVID-19 stressors among parents. It is among the first analyses of pandemic-related stressors beyond 2021 in any population, and reports results for two reference periods. It examined a comprehensive list of COVID-19 stressors and their associations with several important health outcomes: self-rated physical and mental health, symptoms of mental health problems, and problematic alcohol and cannabis use.

The results should be interpreted in the context of several limitations; the cross- sectional nature of the analysis precludes causation inferences. There is a possibility of bidirectional relationships between stressors and dependent variables. For instance, individuals with mental health problems may be more likely to report pandemic-related stressors. The online WE Wave 2 did not require that participants live in Manitoba; consequently, some parents may have been subjected to different public health measures and COVID-19 epidemiology. The study used a community sample of parents in Manitoba which may not be representative of the population and therefore not generalizable to other populations living in other jurisdictions and for whom the COVID-19 pandemic-related experiences could be different. Due to the sample size and the rare occurrence of some experiences (used as independent and dependent variables), several models may be underpowered. This may be the case for models where larger effect sizes were noted but associations were not statistically significant (e.g., relationships between inability to spend time with a partner and self-rated health variables). The COVID-19 stressors were not derived from a validated scale; however, Cronbach's alphas of approximately 0.80 suggest good reliability of internal consistency. Aside from alcohol and cannabis, other types of substance use were not examined in the present study; future research could investigate a range of substances using, for example, the 11-item Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST-11; Lee et al. 2023).

Most Manitoba parents indicated that they experienced stressors related to the COVID-19 pandemic. For many of them, these stressful experiences were associated with poor or fair self- rated physical and mental health, mental health symptoms, and alcohol and cannabis use problems. The specific stressors associated with negative outcomes suggest areas that might be targeted for additional support, intervention, and prevention for pandemic recovery, as well as public health preparedness to mitigate declines and/or bolster parents’ health and well-being in the context of future pandemics. These areas include (but are not limited to): financial and employment support, mental health (loneliness, uncertainty about the future), healthy sleep, healthcare access, relationships (coping with conflict and not seeing family), and caregiving for children. The scope and salience of the stressors identified by parents indicate that individually- based approaches to addressing pandemic-related stressors and the associated negative health and well-being outcomes are likely insufficient. It must include consideration for enhancing protective factors across socioecological levels, including interpersonal relationships, communities, systems and society at large (Dahlberg and Krug 2021).

The authors thank the parents and adolescents who participated in the Well-being and Experiences Study and took the time to share their experiences for this work.