Assessing the association between the COVID-19-related experiences and the mental health of primary caregivers and Its association with child neurobehavioral development

Abstract

Background: In Uganda, strict lockdown measures during the COVID-19 pandemic exacerbated existing societal problems, including poverty, food insecurity, and the burden of disease. These unexpected effects of the pandemic led to increased stress levels among Ugandans, particularly caregivers of young children, who faced increased caregiving responsibilities without adequate social support. This is particularly concerning as caregivers' mental health is closely linked to child developmental outcomes, yet this topic remains severely understudied in Uganda. This study aimed to assess the association between COVID-19-related experiences with mental health among caregivers and how the mental health of caregivers, in turn, is associated with child behavioral and cognitive outcomes. Method: We conducted a COVID-19 sub-study within an ongoing randomized trial of iron supplementation in children with malaria and iron deficiency (Optimizing Iron Status in Malaria-Endemic Areas, OptiM) at Mulago Hospital in Kampala and Jinja Regional Referral Hospital in Uganda. The sub-study enrolled caregivers of 100 children aged 6–48 months, newly enrolled in OptiM between October 2022 and April 2023. Eighty-five of the children had iron deficiency and malaria at baseline, and 15 children were community controls without iron deficiency or malaria. The sub-study used an internally designed COVID-19 survey to capture the different COVID-19-related experiences among caregivers. The survey was developed based on existing COVID-19 experience surveys, including the COVID Experiences (COVEX) questionnaire and the Performance Monitoring for Action (PMA) COVID-19 survey, but the questions were tailored to the Ugandan context through pilot testing. The sub-study collected data on caregivers' depression and anxiety using the Hopkins Symptom Checklist (HSCL-25) and the Center for Epidemiologic Studies Depression Scale (CESD-20) at baseline and at 6 and 12 months follow-up. Child behavioral and cognitive outcomes were already being assessed in OptiM using the Behavior Rating Inventory of Executive Function (BRIEF), Child Behavior Checklist (CBCL), Behavioral Rating Scale (BRS), and Mullen Scales of Early Learning (MSEL) at baseline and at 12 months follow up. The CBCL was additionally administered at the 6-month follow-up for children with malaria and iron deficiency. The first manuscript evaluated the relationship between adverse COVID-19 experiences and caregivers' depression and anxiety. The second manuscript investigated how these symptoms of depression and anxiety in caregivers were associated with child behavioral outcomes. The third manuscript investigated the link between caregivers' depression and anxiety and child cognitive functions. For all manuscripts, associations were assessed over the 12-month follow-up period. We also explored whether there were changes in these associations across the study visits (baseline, 6 months, or 12 months) and/or the child’s malaria and iron deficiency status at enrollment. All associations were analyzed using mixed-effects models with random intercepts, adjusting for relevant covariates. Results: In the first manuscript, which included 100 caregivers of young children, we found that certain COVID-19-related experiences—such as changes in living situations (locations or household members), food insecurity, and limited access to healthcare or daycare—were associated with depression and anxiety among caregivers. Greater food insecurity, in particular, showed consistent and longitudinal associations with increased symptoms of depression and anxiety over the 12-month period (HSCL-25: β = 3.04, 95% CI [0.85, 5.24]; CESD-25: β = 1.99, 95% CI [0.30, 3.68]). The second manuscript, which included 100 caregiver-child pairs, found that caregivers' depression and anxiety were associated with child behavioral outcomes both cross-sectionally and longitudinally. Specifically, higher levels of caregiver depression and anxiety were consistently linked to greater difficulties in emotional regulation (HSCL-25: β = 0.04, 95% CI [0.01, 0.06]; CESD-20: β = 0.04, 95% CI [0.01, 0.06]) and working memory (HSCL-25: β = 0.06, 95% CI [0.01, 0.10]) in children over the 12-month follow-up period. Lastly, the third manuscript evaluated the associations between caregivers' depression and anxiety and child cognitive development. It found no meaningful associations with cognitive outcomes, except for a cross-sectional inverse association between caregivers' depression, measured by CESD-20, and child expressive language scores (β = -0.01, 95% CI [-0.03, -0.00]) at baseline. We did not detect significant mediation effects of children having malaria or iron status at enrollment on the associations found in all manuscripts. Conclusions: This research provides valuable evidence on the link between caregiver mental health during COVID-19 and child neurobehavioral outcomes in low-income settings. The findings suggest that more adverse experiences during COVID-19 are associated with higher levels of depression and anxiety among caregivers, which, in turn, are linked to disturbances in emotional and behavioral development in children. However, no significant long-term association was found between caregiver mental health and cognitive functions in children. Further research is needed to explore the long-term effects on various domains of child development and to identify mechanisms to provide adequate support for vulnerable families during crises in low-income settings.