Data
Data for this study comes from the Survey of Health, Ageing and Retirement in Europe (SHARE)[19] and the SHARE Corona Survey (SCS).[20,21] SHARE has collected data on adults > 50 years of age and their spouses since 2004 with approximately biennial follow-ups through early 2020; 28 European countries and Israel have been included in SHARE. The SCS was conducted among ongoing SHARE participants via computer-assisted telephone interviews (CATI) during the early months of the pandemic (June-August 2020) and one year later (June-August 2021).
We restricted the analytic sample to respondents > 65 years in European countries (excluding Israel) who 1) had at least one living child aged 25 years and older (we excluded those with only children under 25 years of age because they may not have completed their educational trajectory), 2) reported on their child characteristics at any of the pre-pandemic SHARE waves, and 3) had completed SHARE wave 8 (conducted between October 2019 and March 2020), from which we derived our pre-pandemic control variables. and had complete data for at least one SCS wave. After applying these inclusion criteria, we were left with an analytic sample of 17,024 respondents (see eFig. 1).
Outcome Measures
Psychosocial Outcomes
At each of the two SCS waves, participants answered the following questions, which each had binary response options: “In the last month, have you felt nervous, anxious, or on edge?”, “In the last month, have you been sad or depressed?”, “Have you had trouble sleeping recently?”. Respondents also reported on the frequency of feeling lonely; we grouped those who reported often or some of the time (vs. hardly ever or never).
We separately evaluated associations with self-reported worsened mental health as compared to the pre-pandemic period. During the first SCS wave, respondents were asked to rate whether each of the symptoms listed above (nervousness, depression, trouble sleeping, and loneliness) had worsened, improved, or had stayed the same as compared to the pre-pandemic period. We contrasted those who reported that their symptoms had worsened with those who reported that their symptoms had improved, stayed the same, or that they had not experienced that symptom.
Secondary Outcomes
Contact with children was measured at each pandemic wave with the following question: “Since the outbreak of Corona, how often did you have personal contact, that is, face to face with your own children from outside your home?”. We grouped those who responded daily, several times a week, or about once a week (vs. less often or never).
Support given to and received from children was measured with two questions at each wave: “How often did your own children help you to obtain necessities, compared to before the outbreak of Corona? Less often, about the same, or more often?”. “Compared to before the outbreak of Corona, how often did you help your own children to obtain necessities: less often, about the same, or more often?” Wording for the latter two questions shifted slightly during the second SCS wave (see Supplemental Appendix for specific question wording). We grouped those who responded less often or about the same (vs. more often).
Respondents’ COVID-19 experiences were captured with the following questions at each wave, which we evaluated as separate outcomes: “Have you or anyone close to you been tested for the Corona virus and the result was positive, meaning that the person had the Covid disease? (Yes/No)”, Have you or anyone close to you been hospitalized due to an infection from the Corona virus? (Yes/No)”, “Has anyone close to you died due to an infection from the Corona virus? (Yes/No)”.
Adult Child Socioeconomic Status
At the pre-pandemic SHARE waves, respondents reported the level of educational attainment for each of their children > 16 years of age. Levels of educational attainment were standardized across SHARE countries using the International Standard Classification of Education (ISCED-1997),[22] with values that ranged from 0 (pre-primary education) to 6 (doctoral studies). For each respondent, we calculated a binary variable contrasting those who reported that their adult children had completed a mean level of educational attainment at or above vs. below the mean level for all respondents residing in the same country. We evaluated the consistency of our results using a continuous measure of the average level of educational attainment across adult children (range: 0-6) as well as a categorical variable based on country-specific quartiles of average adult child educational attainment.
Confounders and Effect Modifiers
We considered confounders to be measures that may have influenced adult-child educational attainment and older parents’ psychosocial outcomes during the COVID-19 pandemic. These included respondent’s age, gender, educational attainment, nativity, country, marital status, parents’ level of educational attainment (for mother and father), spouse’s age (if currently married/partnered), spouse’s educational attainment (if currently married/partnered or formerly married), the total number of respondent’s living children, and the percentage of female children. All these measures were captured during pre-pandemic waves of data collection. We did not control for respondents’ pre-pandemic health, given that this may have mediated the relationship between adult child educational attainment and mental health during the pandemic.
We considered variation in associations by SCS wave, which corresponded to some of the earliest months of the pandemic (Wave 1) and the post-vaccination period (Wave 2). We also considered heterogeneity by the intensity of the COVID-19 pandemic since higher COVID intensity at the time of the interview was associated with larger declines in mental health in SHARE.[1] COVID-19 intensity was measured as the number of cases per 1,000 population averaged separately for each country during the three-month data collection period for the first SCS wave; data were obtained via Our World in Data, sourced from Johns Hopkins University.[23] We transformed this measure into a binary indicator of cases per 1000 population at or above vs. below the median across the countries included in our analyses. We focused our analysis on heterogeneity by COVID-19 intensity on the first SCS wave (June – August 2020); given the vast differences in the landscape of vaccination and treatment by the second SCS wave (June – August 2021), the meaning of “high” COVID-19 intensity may have varied substantially by this time.
Analytic Strategy
We used generalized estimating equations with a Poisson distribution and a log link to analyze the associations between adult child educational attainment and older parents’ psychosocial outcomes with data pooled across both pandemic waves. While our primary models combine all respondents, we also test for differences in associations by both the gender of the adult child and respondent given mixed prior evidence of heterogeneity in studies of pre-pandemic health outcomes.[6,10,12,14] We subsequently test whether these associations varied across study waves or country-level COVID-19 intensity (high vs. low) with stratified models as well as multiplicative interaction terms in pooled models. We used the same modeling strategy to estimate overall associations with secondary outcomes.