JFOA Journal

Introduction

COVID-19 was declared a pandemic in March 2020 and a nationwide emergency in the United States (US), with about 102 million infections and 1.1 million deaths by January 2023 [1]. While mass quarantine measures helped mitigate the public health crisis, they also had indirect negative effects on socioeconomic status, psychological wellbeing, and family functioning. Stay-athome orders, business and school closures, and social-distancing practices disrupted family routines. As a result, parents struggled with new working arrangements, parenting challenges, such as childcare, assisting their child with schoolwork or homeschooling, and restrictions on extracurricular activities [2-4]. Parents also worried about family health, finances, job security, and uncertainty about restrictions from local and national authorities [4-6].

Several studies have established the association between COVID-19 disruptions and worsening levels of anxiety, depression, loneliness, and worry [7-10]. Additionally, parents report higher levels of COVID-19 induced stress in comparison to adults without children, and these levels likely worsened with school closures [11,12].

Reports on mental health during the pandemic are mixed. While some studies reflect worsening of mental health concerns in the general population during the pandemic [9,13,14], others suggest improvement or no change in those levels over time [13,15]. Although cross-sectional studies have indicated how COVID-19 disruptions impact the psychological wellbeing of parents, the variations in COVID-19 exposure and impact over time during the pandemic are less understood [6,16]. Hence, our study presents a longitudinal analysis of the direct and indirect effects of COVID-19 among parents of school-aged children. Since COVID-19 impact on parents of school-aged children is further compounded by demographic and social determinants of health (SDoH), such as race [17], ethnicity [17], parental sex [18], family income [19,20], education, etc., we also examined those associations [15].

Methods

This longitudinal study received local institutional review board approval. Eligible parents met the following criteria: (a) English-speaking, (b) had at least one child aged 8-17 years and (c) the child was attending school in-person before the pandemic.

Recruitment

Due to the constraints of the pandemic, participants were initially recruited using a pay per click Facebook advertisement campaign. The advertisements were published on Facebook from May 13 to July 1, 2020, and targeted parents of school-aged children [21,22]. The marketing team utilized a zip-code targeted approach to increase the ethnic and socioeconomic diversity of the sample. An internet-based recruitment method was chosen to adapt to the challenges of in-person recruitment during the pandemic. Consent was implied by completion of an anonymous online survey. Facebook advertisements were linked to an electronic REDCap survey, which offered participants a chance to win a $100 gift card for completion of measures. Questions at the beginning of the REDCap survey determined parents’ eligibility for participation. REDCap automatically directed eligible parents to complete the T1 survey. Parents completing the T1 survey were given the option to participate in future research. Those who agreed to further share their experiences provided their contact information. Parents digitally completed the initial (T1) survey between May 2020 to July 2020 and reported on their experience from the start of the pandemic. Follow-up (T2) surveys were sent digitally between November 2020 and January 2021 and asked parents to report on their experience since the last survey.

Measures

Demographic characteristics. Data were collected from parents about themselves and their partners, including number of children, sex at birth, race, ethnicity, marital status, geographic location, income, employment status, and occupation. Parents also reported on the participating child’s age, grade, sex, race, and ethnicity.

COVID-19 Exposure and Family Impact Scale (CEFIS). This validated caregiver report measure assessed exposure as well as direct and indirect impact of the COVID-19 pandemic on families [23]. Part 1 of CEFIS assesses exposure to COVID-19 and events such as school closures, stay at home orders, changes in employment, and missing family functions using 25 yes/ no questions. A total exposure score within the range of 0-25 is generated by adding scores from Part 1 responses. Part 2 consists of 12 items and measures the impact of COVID-19, such as effects on parenting, ability to care for children, and physical well-being. The first ten items, rated on a modified five-point scale (to include a midpoint response for no change), indicated the degree to which COVID-19 affected each area of functioning, while the last two items assessed parental and child distress on a 10-point scale. Higher overall cumulative scores indicated greater exposure to COVID-19 stressors and more negative impact.  

Statistical analysis

Data were analyzed using IBM SPSS, version 28 for Windows. Cases with missing data were excluded from analysis. Descriptive statistics were used to describe parents’ demographic characteristics and individual CEFIS items. Paired samples t-tests were used to examine changes over the two timepoints (T1 and T2) for parent-reported distress. Gender differences in parents’ CEFIS responses were examined using independent samples t-tests. Pearson’s correlation coefficients were used to examine the relationship between demographic/social determinants of health (SDoH) variables (number of children, parent sex, race, ethnicity, marital status, socioeconomic status, and education) and CEFIS exposure and impact scores. One-way ANOVAs were used to assess if there were any differences in parents’ CEFIS exposure and impact scores based on their race and geographical locations. The US states were divided into four regions: Northeast, Midwest, South, and West [24]. Parents (n=140) based internationally and who did not report on their geographical locations were excluded from the one-way ANOVA.

Attrition analyses were conducted using Chi-square and/or independent sample t-tests to assess completion of both T1 and T2 surveys. Afterwards, sensitivity analyses assessed group differences between parents who completed measures at both timepoints with those who only completed measures at T1 and any effects on study findings.

Results

Sample characteristics

A total of 912 parents completed the screening questionnaire. Of those, 843 parents met eligibility criteria. Eighty percent (n=673) of eligible parents enrolled in the study and 69% (n=580) completed all T1 surveys and 232 (27%) completed T2 surveys.

Parents’ characteristics at T1 and T2 are described in Table 1. At both timepoints, participants were mostly mothers (T1: 94%, n=546; T2: 94%, n=219) and White (T1: 89%, n=517; T2: 92%, n=211). Half of the parents reported an annual income prior to COVID-19 of greater than $100,000 (T1: 50%, n=287; T2: 47.3%, n=108). About a quarter (T1: 24.8%, n=143; T2: 22.1%, n=51) reported being unemployed. Most families were from the Midwest, likely due to the ad being shared on the institution’s Facebook page; however, all 50 states in the United States (US) were represented.

Table 1: Demographic Characteristics.

Attrition Analysis

Due to the attrition rate of 60%, we conducted sensitivity analyses to compare the characteristics of parents who completed the measures at both timepoints versus parents who completed only T1 measures. Chi-squared tests examined group differences for sex, race, ethnicity, marital status, and employment, and no significant associations were observed. There were significant results for the independent sample t-tests examining family income and education, which suggested higher attrition among parents with lower family income (t(664) = -2.19, p = .03) and lower education level (t(661) = -1.96, p = .05).

The mean overall CEFIS exposure and impact scores were also compared for parents who completed the surveys at both timepoints versus parents who completed only T1 surveys, using independent sample t-tests; however no significant associations were indicated. This was followed by chi-squared tests for the 25 yes/no questions on CEFIS exposure. No significant differences were indicated in responses between the two timepoints. Parents reporting decreased ability to care for their child (t(497) = -2.16, p = .03) and to care for older adults (t(424) = -2.03, p = .04) at T1 were less likely to participate at T2.

COVID-19 Exposure and Impact

Time 1: The mean CEFIS exposure for parents was 8.0 (SD = 2.51, n = 580), on a scale of 0 to 25. Only 16.4% (n = 95) of participants reported experiencing direct exposure to COVID-19, and an even smaller proportion (1.0%, n = 6) reported COVID-19 related deaths. The CEFIS exposure scores included mostly indirect exposures related to the virus, such as closure of schools and daycares (99.5%, n = 577), stay-at-home orders (96.6%, n = 560), disruption in education (94.3%, n = 547), missing important events (87.1%, n = 505), and inability to visit and care for family members (79.1%, n = 459). Parents reported a mean impact score at T1 of 46.94 (SD = 10.35, n = 580). In particular, parents reported their anxiety levels (M = 4.15), mood (M = 3.97), and their ability to care for older adults (M = 3.88) were impacted by the pandemic.

Time 2: At T2, the mean CEFIS exposure score for parents (n = 232) was 7.81 (SD = 3.31). Parental reports included stay-at-home orders (65.4%), school closures (71.9%), disruption in education (78.0%), missing important events (86.6%), and inability to visit family members (74.1%). However, over one-half (54.7%) of parents reported that either they or a close family member experienced direct exposure to COVID-19 since T1 and 4.3% reported a family member had died from COVID-19. Mean parent reported CEFIS impact score at T2 was 49.29 (SD = 8.66, n = 232) on a scale of 0 to 60. Difficulty caring for older adults (M = 3.84), anxiety levels (M = 4.34), and mood (M = 4.17) continued to be highly impacted, and sleep (M = 3.82) was an additional domain experiencing significant impact.

Longitudinal Analyses. Although the paired samples t-test showed no significant change in overall CEFIS exposure scores from T1 to T2, (t(df = 231) = 1.50, p = .07), there were statistically significant differences in the individual items comprising the CEFIS exposure score. At T2, families reported fewer stay at home orders (t(df = 230) = 9.74, p < .001) fewer school closures (t(df = 230) = 9.19, p < .001), less disruption to their child’s education (t(df = 231) = 5.16, p < .001), and fewer family members with cut work hours (t(df = 230) = 3.43, p < .001) or temporarily stopping work (t(df = 231) = 3.75, p < .001). Parents completing T2 measures also reported significantly more direct exposure to COVID-19 (t(df = 230) = -9.46, p < .001), more family members with COVID-19 symptoms (t(df = 229) = -5.50, p < .001), more family members hospitalized for COVID-19 (t(df = 227) = -3.22, p = .001), more family members treated in an intensive care unit for COVID-19 (t(df = 229) = -2.33, p = .02), and more exposure to COVID-19 related death (t(df = 228) = -2.13, p = .02). Additionally, at T2, parents reported more difficulty getting household essentials (t(df = 231) = -3.07, p = .002), more quarantines due to COVID-19 exposure (t(df = 231) = -4.83, p < .001), more essential workers in the family (t(df = 231) = -3.07, p = .002), and more family members losing their permanent job (t(df = 228) = -2.08, p = .04). There was no statistical difference between T1 and T2 reports of missing important events (t(df = 231) = 1.18, p = .12) or any other exposure indicators. Table 2 shows individual item responses to the exposure questions across both timepoints.

Table 2: CEFIS Exposure Responses.

A paired samples t-test revealed a significant increase in the CEFIS impact score from T1 to T2 (t(df = 231) = -2.84, p = .005). At T2, parents reported worsened impact on parenting ability (t(df = 227) = -3.36, p < .001), exercise practices (t(df = 230) = -1.96, p = .026), and changes in their mood (t(df = 223) = -2.70, p = .004), in addition to already high levels of impact on other domains. Changes in CEFIS exposure and CEFIS impact reports over the two timepoints are illustrated in Figures 1 and 2 respectively.

Figure 1: Percent change in CEFIS exposure over time.

Figure 2: Change in CEFIS impact over time.