Navigating the caregiver’s strain: psychosocial well-being among sandwich generation caregivers in India

INTRODUCTION

Multigenerational caregiving means providing simultaneous care for family members of two generations. Most research on multigenerational caregiving has focused on the “sandwich generation”, a term coined by Miller that originally referred to women in their early 40s caring for their young children while caring for their ageing parents between the ages of 60 and 70 years old.^1,2 states that “the sandwich generation refers to individuals who, by dint of circumstances, find themselves in the position of being caregivers for their young children, and/or adult children and care for one or both of ageing parents”. It is now broadly classified as individuals caring for older adults and children at the same time.³ ‘Sandwiched’ caregiving measures only include care given to children and parents or, more broadly, to adults and children.^4,5

This generation confronts the unique challenge of balancing the needs of two distinct generations, which frequently results in a substantial burden and an overwhelming sense of responsibility.^6,7 As a consequence of their dual caregiving responsibilities, the sandwich generation is burdened by a number of factors. On the one hand, they must offer emotional and financial support to their older parents, who may be coping with health issues, retirement concerns, or the loss of a spouse, and on the other hand, parents are responsible for the daily care, upbringing, and education of their own offspring. This burden can manifest in various ways, including financial strain, emotional exhaustion, time constraints, feelings of remorse and inadequacy, and time constraints.⁸

Financially, the sandwich generation may encounter difficulties as they attempt to provide for both their parents and their own families. They may be forced to choose between paying for their children’s education, saving for their own retirement, and covering the costs of their ageing parents' healthcare and other necessities.⁹ Emotionally, the burden of caregiving duties can weigh heavily on members of the sandwich generation.^10-12 As they attempt to divide their attention between their parents and children, they may experience feelings of remorse and anxiety.^13-15 Constant anxiety regarding the well-being and contentment of both generations can result in emotional exhaustion, fatigue and poor health.^16,17

Time constraints are another significant burden that sandwich generation must contend with. Work, caregiving responsibilities, and personal obligations become a constant juggling act. A lack of personal leisure and self-care can result from their attempts to fulfil multiple roles and conflicting demands. Overall, the burden borne by sandwich generation is a complicated and difficult matter. Individuals must navigate the delicate balance between caring for their ageing parents, raising their own children, and meeting their own requirements. Recognizing and comprehending this encumbrance is crucial for providing support and resources to assist sandwich generation in overcoming its challenges.

The situation of the so-called ‘sandwich generation’ is not just a phenomenon experienced by developed countries. All societies that experience population ageing, including India, will have to face the challenges currently being experienced by developed nations. The fact that health insurance coverage in India is still negligible, the economic dependence of older adults is high, and the cost of education and childcare is on the rise all pose serious challenges to generations of individuals and couples who are expected to take care of both their children and their parents.

This issue holds significant importance for individuals and couples residing in several Indian states, where they are already grappling with the challenges posed by the sandwich generation phenomenon. As this situation is expected to become more prevalent in the coming years, numerous states will face the daunting task of addressing these complexities. These challenges will have a large impact on many aspects of society. They will affect not only the couples’ well-being but also how their children and parents are taken care of. Additionally, the physical and emotional health of these caregiving couples will be impacted.

In the Indian context, studies focused on sandwich generation and their predicaments remain scarce. Moreover, the majority of caregiving literature concentrates on spousal caregiving, overlooking the unique circumstances of sandwich generation caregivers. Additionally, every individual belonging to the sandwich generation may not have an active role in taking care of their parents, which makes it interesting to study their behaviour. Furthermore, existing research predominantly highlights women as primary caregivers, leaving the role of men and couples as relatively unexplored units of analysis. Thus, the present study focuses on the psychosocial well-being among sandwich generation caregiving couples in India. The main aim of the study was to examine the different types of burdens and look at the effect of background characteristics on the burdens experienced by the sandwich generation.

METHODS

The present study was carried out in a city that is relatively advanced in the population ageing process. Thus, the study was conducted in Mumbai city in the state of Maharashtra, which has close to 9 percent of its population aged 60 and above at present, while the overall dependency ratio in Mumbai is 44.2 percent as per Census of India, 2011. The city has also seen a rise in joint family households over the last decade; the percentage of joint family households increased from 10.6 in 2001 to 14.5 in 2011 (census 2001-2011). According to the census of India classification, the city of Mumbai is divided into a) greater Mumbai and b) greater Mumbai suburban, which comes under the jurisdiction of the greater Mumbai municipal corporation.

Study design and setting

This cross-sectional study of three-generational households was conducted in the city of Mumbai, India representing both geographical areas of greater Mumbai and greater Mumbai suburban. The study was proposed on 10^th April, 2018 and it was completed on 7^th February, 2023. The study used quantitative methods to collect data on middle-aged couples (25-59 years) residing in three-generational/sandwich generation households.

Sample size

A sample size of 300 couples from the sandwich generation(s) was calculated. From the study area, a total of 2 wards using simple random sampling (SRS) were selected for the study in such a way that the entire greater Mumbai municipal corporation area was represented. In the second stage, five census enumeration blocks (CEBs) were randomly selected from each of the two wards. From each ward, a total of 200 households were selected. A total of 300 households were selected from both wards.

From each household, couples were interviewed individually. Therefore, the primary respondents were 600 married individuals (300 men and 300 women) in the 25-59-year age group belonging to sandwich/three-generation households.

Selection of respondents

Inclusion criteria/exclusion criteria

This study selected households where sandwich/three-generation residents reside in a household. This would mean that at least one parent, along with their son/daughter and grandchild(ren), were living in the selected households. Accordingly, couples in the age group 24-59 years who have at least one dependent child (0 years and above) and one surviving older adult/parent (age 60 or above) to look after were selected as the respondents for the interview. Middle-aged couples in one-generational and two-generational households were excluded as they did not meet the selection criteria.

Tools

In the present study, the sandwiched couples were the primary respondents. A structured interview schedule was administered to the respondents (sandwich generation caregivers) comprising of a household and couple schedule (husband and wife) with subsections for questions regarding the older adults and the dependent child/children. Pilot testing of the interview schedule was performed to test its appropriateness.

Ethical considerations

The present study has received all the necessary approvals from the student research ethics committee (SREC) of the International Institute for Population Sciences. Individual respondents’ written consent was taken, and the purpose of the study was explained clearly to the respondents before the start of the interview process. Respondents had the right to skip or not answer any question(s) and could also withdraw from the interview at any point in time. The respondents were informed that the data collected would be used solely for research purposes without using any identifiers keeping in mind the anonymity of the respondents. Necessary permissions from the selected housing societies and local leaders were obtained prior to the start of the study.

Methods

To understand the effect of caregiving on health and well-being, we used the Montgomery Borgatta caregiver burden scale.¹⁸ The respondents were asked, “since you began caregiving, how has assisting or having contact with him/her affected the following aspects of your life”? The answers were coded as 1. do you have a lot less, 2. a little less, 3. the same, 4. a little more, 5. or a lot more...? This question was only asked to respondents belonging to only sandwich generation/three-generation households. The scale captured the different types of burdens experienced by sandwich caregivers:

The ‘objective burden’ contains observed infringement or interference of physical aspects of life. It contains six items: ranging from the extent of time one has for him/herself, personal privacy; time for recreation; restrictions on breaks and outings; time for individual work and daily routines; and spending time with friends and relatives.

The ‘subjective demand burden’ is the degree to which the caregiver distinguishes the care responsibilities to be overly demanding. It includes the following: manipulating the caregiver; unreasonable requests of the caregiver; taking undue advantage of the caregiver and being over demanding to the caregiver.

The ‘subjective stress burden’ is the emotional impact of the caregiving responsibilities on the caregiver. It accounts for specifically the degree of stress in the relationship with the dependent relative, tension in the caregiver’s life, nervousness, and depression due to the relationship with the dependent relative, and anxiety about things.

RESULTS

Burdens experienced by the sandwich generation

Figure 1 presents the different types of burden experienced by the sandwich generation caregivers. The three types of burden considered are objective burden, subjective demand burden and subjective stress burden. The extent of different burdens by the sandwich generation caregiver in the study sample is quite high. It can be seen that the share of those suffering from objective burden and subjective stress burden is quite high (70 percent and 66 percent, respectively). The proportion of those suffering from subjective demand burden was 42 percent.

*Chi-square test was applied to examine the association between socioeconomic and demographic characteristics and objective burden among caregivers.

The burden categories ‘moderate’ and ‘high’ were combined to address small percentages in some cells. Table 1 presents the association between background characteristics and the objective burden faced by both men and women within the sandwich generation. When considering age, no significant gender disparities in objective burden are evident. Among males aged 25-34, 33.9 percent experience moderate/high burden, while 66.7 percent of females in the same age group experience moderate/high burden. Similarly, for those aged 35-44, 30.4 percent of men experience moderate/high burden, and for women, the proportion was 64.5 percent. In the 45-59 age range, 41.8 percent of men experience moderate/high burden, with the corresponding proportion for women experiencing burden at 59.4 percent. Looking at income levels, a significant difference emerges, with 27.9 percent of poorest males experiencing moderate/high burden, while the corresponding figures for females were 57.4 percent. Religion does not show substantial gender-based variations. Among scheduled caste males, 44.4 percent experience moderate/high burden, whereas 62.8 percent of scheduled caste females report moderate/high burden. Work status highlights a noteworthy gender difference, with 64.4 percent of males who were not working experiencing low burden moderate/high burden, compared to females at 40.0 percent.

Table 2 provides the association of background characteristics with the subjective demand burden experienced by both men and women within the sandwich generation. For males aged 25-34, 16.1 percent experience a moderate/high burden, while 23.2 percent of females in the same age group experience a moderate/high burden. It can also be seen that 6.1 percent of the poorest males experience moderate/high burden, while among poorest females, the proportion that experience subjective demand burden was 20.6 percent. Hindu males and females face demand burdens of 60.9 percent and 39.1 percent, respectively, with corresponding figures for Buddhists at 87.4 percent and 12.7 percent. Among scheduled caste males, 85.7 percent experience a low demand burden, compared to 79.8 percent for females. We can also see that 48.1 percent of males with higher education report moderate/high burden, while 39.2 percent of females with higher education experience moderate/high burden. Interestingly, work status shows gender differences, with 28.6 percent of males not working experiencing moderate/high burden compared to females at 27.4 percent.

*Chi-square test was applied to examine the association between socioeconomic and demographic characteristics and objective burden among caregivers.

Table 3 shows gender differences in the relationship between background characteristics and the subjective stress burden faced by sandwich generation caregivers. It can be noted that among males aged 25-34, 54.1 percent endure moderate/high subjective stress burden. Furthermore, we see that 65.4 percent of males aged 35-44 and 56.6 percent of males aged 45-59 experienced moderate/high stress burden. Income also plays a role in determining stress burden, with higher-income males displaying lower stress. However, the reverse is true for females. Hindu males and females face significant proportions of stress, with 69 percent and 63 percent, respectively, experiencing moderate/high stress burden compared to other religious groups. Among scheduled caste males, 55.8 percent experience a low stress burden, while among scheduled caste females, 53.6 percent experience a low stress burden. This association is significant, indicating that men and women belonging to the scheduled caste category experience a lower stress burden compared to other caste categories. The table also shows that for both males and females, subjective stress burden increases with an increase in the level of education. Males with higher education report a 71.4 percent moderate/high stress burden, while females with higher secondary education report a 61.6 percent moderate/high stress burden. It can also be noted that work status minimally impacts stress burden.

*Chi-square test was applied to examine the association between socioeconomic and demographic characteristics and objective burden among caregivers.

Factors affecting burdens experienced by the sandwich generation

Table 4 shows the logistic regression results of objective burden, subjective demand burden and subjective stress burden experienced by sandwich generation caregivers. Individuals aged 35-44 have 0.879 times the odds of experiencing objective burden compared to the reference group (25-34 years old). Individuals aged 45-59 have 1.229 times higher odds of experiencing objective burden compared to the reference group (25-34 years old). Females have 1.148 times higher odds of experiencing objective burden than males. However, the difference in objective burden between the age groups and sex was not statistically significant. The results show that scheduled tribe individuals have 2.987 times higher odds of experiencing objective burden compared to scheduled caste individuals. Individuals in the poorest category have 2.134 times higher odds of experiencing objective burden compared to the reference group. Individuals in the poor category have 2.224 times higher odds of experiencing objective burden compared to the reference group. Individuals in the middle-income category have 1.673 times higher odds of experiencing objective burden compared to the reference group. Individuals in the richest category have 3.497 times higher odds of experiencing objective burden compared to the reference group. Education, religion, income and work status did not have a significant effect on the objective burden experienced by sandwich generation caregivers.

The results also show that individuals aged 35-44 have 1.993 times higher odds of experiencing subjective demand burden compared to the reference group (25-34 years old). Individuals aged 45-59 have 1.313 times higher odds of experiencing subjective demand burden compared to the reference group (25-34 years old). Females have 1.061 times higher odds of experiencing subjective demand burden than males. The difference in subjective demand burden between age groups and between males and females was not statistically significant. Individuals with higher education have 2.372 times higher odds of experiencing subjective demand burden compared to those with primary education. Buddhists have 0.474 times the odds of experiencing subjective demand burden compared to Hindus. The odds ratio was statistically significant, indicating a lower likelihood of subjective demand burden for Buddhists compared to Hindus. Individuals from other castes have 0.464 times the odds of experiencing subjective demand burden compared to scheduled caste individuals. The odds ratio is statistically significant, indicating a lower likelihood of subjective demand burden for individuals from other castes compared to scheduled caste individuals. Individuals in the middle-income category have 2.296 times higher odds of experiencing subjective demand burden compared to the reference group. Individuals in the rich category have 3.094 times higher odds of experiencing subjective demand burden compared to the reference group. Individuals in the richest category have 3.742 times higher odds of experiencing subjective demand burden compared to the reference group. Individuals who were employed have 2.009 times higher odds of experiencing subjective demand burden compared to those who are not employed.

*p≤0.1; ** p≤0.05; ***p≤0.01.

Furthermore, individuals aged 35-44 have 1.104 times higher odds of experiencing subjective stress burden compared to the reference group (25-34 years old). Individuals aged 45-59 have 0.793 times the odds of experiencing subjective stress burden compared to the reference group (25-34 years old). Females have 1.09 times higher odds of experiencing subjective stress burden than males. However, for both age and sex, the results are not significant. Individuals with secondary education have 1.348 times higher odds of experiencing subjective stress burden than those with primary education. Individuals with higher secondary education have 1.542 times higher odds of experiencing subjective stress burden compared to those with primary education. Individuals with higher education have 1.48 times higher odds of experiencing subjective stress burden compared to those with primary education. Individuals in the richest category have 2.007 times higher odds of experiencing subjective stress burden than those in the poorest category. Individuals in the middle-income category have 1.248 times higher odds of experiencing subjective stress burden than those in the poorest category. Religion, caste, and work status also did not show a significant effect on stress burden.

DISCUSSION

The present study delved into the complex realm of multigenerational caregiving, focusing on sandwich-generation caregivers in India. This unique caregiving arrangement places individuals in the challenging position of simultaneously caring for their ageing parents and their own children. The findings from this study shed light on the burdens experienced by sandwich generation caregivers and offer insights into the factors contributing to these burdens.

The study revealed that sandwich generation caregivers in India face significant burdens across various dimensions. Caregiver burden may be related to various difficulties in caring for a family member, including physical, economic, and psychosocial factors.¹⁹ The objective burden, encompassing tangible disruptions to daily life, was found to be prevalent among the caregivers. This includes limitations on personal time, privacy, recreation, and individual work. The subjective demand burden, reflecting the perceived overwhelming demands of caregiving, was also pronounced.

Moreover, the subjective stress burden, which captures the emotional toll of caregiving, emerged as a substantial concern. Caregivers report experiencing stress, tension, anxiety, and even depression due to their caregiving responsibilities.²⁰ The findings align with previous research, highlighting the challenges faced by sandwich generation caregivers globally.^12,21-23 The association of many of the selected background variables is statistically significant; age, education, religion, income, and work status were among the significant correlates. Issues related to caregiver burden may be influenced by the caregiver’s resources, socioeconomic status, social support, and health status prior to assuming the role of caregiver.²⁴

Younger caregivers experienced greater objective and demand burdens, suggesting that the caregiving challenges intensify as caregivers age. Higher education and income were associated with increased subjective demand burden, possibly due to higher expectations and greater responsibilities. The socioeconomic dimensions of caregiving burdens highlight the need for targeted support strategies. These burdens also have important implications for the well-being of sandwich generation caregivers. Financially, caregivers often find themselves caught between competing priorities, such as providing for their children’s education, their own retirement, and the healthcare needs of their ageing parents.²⁵ This financial strain can lead to difficult decisions and compromise caregivers’ own financial security.²⁶ The emotional toll is evident in the feelings of remorse, anxiety, and exhaustion reported by caregivers. Balancing the needs of two distinct generations can lead to emotional fatigue and strained relationships. Thus, this study tried to identify some relatively unexplored facets related to the burden borne by familial caregivers in the sandwich generation.

While this research has tried to explore the burdens experienced by sandwich generation caregivers in India, it has certain limitations. The research is based entirely on the household survey and even though Mumbai is one of the leading metropolitan cities in the country, the study is explorative in nature pertaining to a selective group of households, and so the results cannot be generalized to the state or country as a whole.

CONCLUSION

The study provides valuable insights into the lived experiences of sandwich generation caregivers in India and their associated burdens. The findings underscore the multifaceted challenges faced by these caregivers, encompassing objective disruptions, perceived demands, and emotional stress. Financial strain, emotional exhaustion, and time constraints are key manifestations of these burdens, impacting caregivers’ overall well-being.

It is evident that sandwich generation caregiving is not confined to developed nations; it is a phenomenon with global relevance, including countries experiencing population ageing, such as India. The unique socioeconomic context of India, with issues such as limited health insurance coverage, high economic dependence of older adults, and rising education and childcare costs, exacerbates the challenges faced by sandwich generation caregivers. The study’s findings underscore the importance of recognizing and addressing the needs of sandwich generation caregivers.

Policymakers, healthcare professionals, and support organizations must develop targeted interventions that offer financial, emotional, and practical assistance. Financial planning tools, flexible work arrangements, and respite care options could alleviate some of the burdens. Additionally, raising awareness about the challenges of sandwich generation caregiving and promoting open discussions within families and communities can contribute to a more supportive environment. The expansion of community awareness regarding both caregiver issues and caregiver services is therefore essential to meeting caregiver needs. State and local units on ageing as well as service providers could conduct marketing, outreach, and education aimed at caregivers and the broader community in collaboration. As a number of caregivers are unprepared to assume the dual role of caring for both children and older adult family members, education and training programmes for caregivers serve an essential purpose. Such programmes would be well suited to target not only the female caregiver but also other members of the household, including adult males. Initiatives that target the entire family unit and household can aid families in increasing caregiver participation and distributing caregiving responsibilities.

In conclusion, sandwich-generation caregivers in India navigate a complex landscape of caregiving responsibilities, juggling the needs of ageing parents and their own children. This study sheds light on the burdens they face and emphasizes the urgency of providing tailored support to mitigate these challenges. As population ageing continues to impact societies worldwide, understanding and addressing the concerns of sandwich generation caregivers is crucial for the well-being of individuals, families, and communities.

ACKNOWLEDGEMENTS

I would like to acknowledge the respondents who willingly took time and participated in the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of International Institute for Population Sciences. The ethical clearance certificate (Certificate number: IIPS/ACAD/SREC/IO-719/21) was approved on 06/09/2021

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