Allogeneic blood or marrow transplantation using haploidentical grandchildren donors and post-transplant cyclophosphamide-based graft-versus-host disease prophylaxis.

BACKGROUND: High-dose post-transplant cyclophosphamide allows safe and effective use of allografts from haploidentical relatives (siblings, parents and children) in patients undergoing allogeneic blood or marrow transplant (alloBMT). More recently, second- and third-degree relatives have also been shown to be safe allograft donors. An increasing number of older patients undergoing alloBMT have been receiving allografts from haploidentical donors. However, older patients are more likely to have older siblings and children, and older donor age is associated with worse outcomes. OBJECTIVE: In the current study, we report the safety and utility of grandchildren as haploidentical donors and compared with children as donors in patients undergoing alloBMT. METHODS: We compared characteristics and outcomes of alloBMT patients aged 55 years and older with children older than 30 years as donors (C group; n = 276) and those with grandchildren as donors (GC group; n = 40). Because many important baseline characteristics predict outcomes after alloBMT, we performed propensity score matched analysis based on recipient age, alloBMT year, disease, graft source and haematopoietic cell transplantation comorbidity index (HCT-CI). RESULTS: The median age of recipients was 67 years (range 55-79) in the C group and 73 years (range 57-78) in the GC group. More than 70% of recipients in the GC group were older than 70 years, compared with 27% in the C group. The median donor age was 37 years (range 31-52) in the C group and 20 years (range 14-34) in the GC group. More patients in the GC group had HCT-CI scores ≥3 than in the C group (32.5% vs. 23%, p = 0.27). Two-year overall survival did not differ between the two groups (GC 62% vs. C 60%, hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.53-1.75, p = 0.90) despite recipients of allografts from grandchildren being older. The 2-year RFS was 55% in the C group compared with 50% in the GC group (HR 1.05, 95% CI 0.62-1.77, p = 0.85). Non-relapse mortality subdistribution [SD] (SDHR 1.36, 95% 0.70-2.63, p = 0.36), relapse (SDHR 0.72, 95% CI 0.33-1.58, p = 0.42) or relapse-free survival (HR 1.05, 95% CI 0.62-1.77, p = 0.85). Propensity score matching analysis showed no significant differences in 2-year overall survival (GC 64% vs. C 53%; HR 0.77, 95% CI 0.42-1.42, p = 0.40), non-relapse mortality (SDHR 1.26, 95% 0.66-2.41, p = 0.48), relapse (SDHR 0.57, 95% CI 0.21-1.52, p = 0.26) or relapse-free survival (HR 0.94, 95% CI 0.57-1.54, p = 0.81). CONCLUSION: Our results indicate that outcomes of alloBMT patients with grandchild donors are similar to those with child donors, despite recipients' older age and higher comorbidities in the GC group. Grandchildren should be considered when selecting a donor for older alloBMT recipients.

Barriers and enablers to promoting grandchildren's physical activity and reducing screen time: a qualitative study with Australian grandparents.

BACKGROUND: With an increasing number of grandparents providing care to their grandchildren, calls have been made for these caregivers to be considered important stakeholders in encouraging children's engagement in health-promoting behaviors, such as physical activity. Understanding the perspectives of grandparents who provide care is crucial to informing efforts that aim to increase children's physical activity, yet little is understood about their perceptions of specific barriers and enablers to promoting children's physical activity and reducing screen time. The present study sought to explore these perceptions. METHODS: Semi-structured focus groups and individual interviews were conducted with grandparents who reported providing care to a grandchild aged 3 to 14 years. A total of 20 grandparents were sampled (mean age = 67.8 years). Data were subjected to reflexive thematic analysis. RESULTS: Key reported barriers to physical activity included (i) the effort (physical and logistical) and financial cost associated with organizing physical activities, (ii) grandparents' age and mobility issues (e.g., due to injury or illness), (iii) caring for children of different ages (e.g., older children having different physical activity interests than younger children), and (iv) a local environment that is not conducive to physical activity (e.g., lack of appropriate facilities). Barriers to reducing screen time included (i) parents sending children to care with electronic devices and (ii) children's fear of missing out on social connection that occurs electronically. Strategies and enablers of physical activity included (i) integrating activity into caregiving routines (e.g., walking the dog), (ii) involving grandchildren in decision making (e.g., asking them in which physical activities they wish to engage), (iii) encouraging grandchildren to engage in activity with other children, and (iv) creating a physical and social environment that supports activity (e.g., owning play equipment). A common strategy for reducing screen time was the creation of a home environment that is not conducive to this activity (e.g., removing electronic devices from view). CONCLUSIONS: Findings suggest that grandparents may benefit from resources that assist them to identify activities that are inexpensive and require minimal effort to organize. Activities that account for grandparents' age and health status, as well as any environmental barriers, are likely to be well-received.

The contributions of grandparents to preadolescent grandchildren's social skills in rural Malaysia.

This study aimed to generate localized knowledge by investigating the perceptions and experiences of preadolescent grandchildren and grandparents regarding grandparenting and intergenerational interactions and how these processes were related to the social skills of preadolescents from three ethnic groups in Malaysia. Using a concurrent quantitative-qualitative mixed method research design, Chinese, Malay, and Indian preadolescents (N = 465; ages 9-12 years old; M = 10.27 years; SD = 1.03) from rural areas in Malaysia completed a self-administered quantitative survey; furthermore, 25 grandparents participated in one-on-one interviews. Survey findings showed that preadolescent grandchildren who reported higher grandparental warmth and support had greater social skills, mediated by positive grandparent-grandchildren (GP-GC) relationships. The GP-GC relationship and preadolescent social skills association was stronger for skipped generation compared to three-generation households. Interview findings revealed that grandparents expressed unconditional love and autonomy support in their grandparenting roles by guiding and encouraging their preadolescent grandchildren to make decisions. The GP-GC interactions served as a dynamic force in promoting preadolescents' social skills. By employing a decolonized approach and drawing on the lived experiences of grandparents from three ethnic backgrounds in rural Malaysia, the study provided an understanding of grandparenting practices and their general implications across the three ethnic groups. The interview responses highlighted both commonalities and specificities in grandparenting practices and relationship dynamics shaped by religious, class, and sociocultural dimensions in rural Malaysia.

Experiences of primary health care nurses regarding the promotion of sexual reproductive health communication with grandparents in Tshwane District, Gauteng Province.

A qualitative, descriptive contextual design study was conducted to explore and describe the experiences of primary health care nurses regarding the promotion of sexual reproductive health communication with grandparents in Tshwane District, Gauteng Province. A non-probability, purposive sampling was used to select 12 Primary Health care nurses based in the Primary health care facilities within Tshwane District. An in-depth interview was used to collect data and Giorgio's five (5) steps were followed during data analysis. Ethical consideration was adhered to by ensuring confidentiality, anonymity, and privacy. All participants signed the consent form to indicate their willingness to participate in the study. Findings of the study revealed the following themes: Primary health care nurses (PHCNs) experiences of sexual and reproductive health communication, and PHCNs experiences of factors facilitating sexual reproductive health (SRH) communication. From the findings it can then be concluded that PHCNs understand facilitating factors to promote open communication with grandparents regarding SRH.

Une étude contextuelle qualitative et descriptive a été menée pour explorer et décrire les expériences des infirmières de soins de santé primaires concernant la promotion de la communication sur la santé sexuelle et reproductive avec les grands-parents dans le district de Tshwane, province de Gauteng. Un échantillonnage non probabiliste et raisonné a été utilisé pour sélectionner 12 infirmières de soins de santé primaires basées dans les établissements de soins de santé primaires du district de Tshwane. Un entretien approfondi a été utilisé pour collecter les données et les cinq (5) étapes de Giorgio ont été suivies lors de l'analyse des données. Des considérations éthiques ont été respectées en garantissant la confidentialité, l'anonymat et la vie privée. Tous les participants ont signé le formulaire de consentement pour indiquer leur volonté de participer à l'étude. Les résultats de l'étude ont révélé les thèmes suivants : les expériences des infirmières de soins de santé primaires (PHCN) en matière de communication sur la santé sexuelle et reproductive, et les expériences des PHCN sur les facteurs facilitant la communication sur la santé sexuelle et reproductive (SSR). À partir des résultats, on peut alors conclure que les PHCN comprennent les facteurs facilitant la promotion d'une communication ouverte avec les grands-parents concernant la SSR.

Latent profile analysis of depression and its influencing factors in older adults raising grandchildren in China.

OBJECTIVE: To explore the latent profile of depression in older adults raising grandchildren in China, and to analyze the differences in the characteristics of the different profiles of the population and the factors influencing them. METHODS: This study utilized the 2018 China Health and Retirement Longitudinal Study (CHARLS). Through a cross-sectional study, the latent profile analysis was used to analyze the potential classification of depression among older adults raising grandchildren, and using ordered multi-categorical logistic regression analyses to assess the effects of each factor on their different classifications. RESULTS: The 1271 older adults raising grandchildren with depression symptoms were divided into three categories: low-level depression (55.4%), moderate-level depression (31.2%), and high-level depression (13.4%). Ordered multi-categorical Logistic results showed: Gender, marital status, pension insurance, physical health status, life satisfaction, and IADL were predictors of latent profile classification of depression symptoms in older adults raising grandchildren (P < 0.05). CONCLUSIONS: In the future of primary care, it will be more meaningful to provide targeted interventions for different subgroups of depression in older adults raising grandchildren.

Making a way out of no way: The importance of improving financial instability among African American kinship care families.

Close attention should be given to the increased reliance on kinship care to provide out-of-home care for vulnerable children and youth because although these families have various strengths, they also frequently face financial instability and experience material hardship. Living in poverty and experiencing material hardship are linked to an array of negative outcomes, including physical and mental health problems, elevated parental stress, and children's academic difficulties and social and behavioral problems. This study examined African American families who are providing informal kinship care with the aim of developing a nuanced understanding of the financial characteristics, challenges, and coping strategies of these families. Data for this study were obtained from two sources: (1) an exploratory sequential mixed-method pilot study and (2) the National Financial Capability Study. It was found that most caregivers in the pilot reported their family resources were only seldom or sometimes adequate to cover their household's basic needs. Some caregivers reported being unaware of public benefits and community resources available for kinship care families, and they had difficulties navigating the system. Additionally, family members' love and support for each other helped them to cope with financial instability. Using a nationally representative dataset, predicted probabilities for three types of financial instability were higher among households with demographic characteristics of kinship care families including difficulty covering expenses, having income that exceeds expenses, and having emergency savings. Implications for practice, policy, and future research are discussed.

Grandparenting and life satisfaction of the aged in rural areas: A study in Kalia Upazila of Narail District.

In rural Bangladesh, older adults generally enjoy their role as grandparents and spend their leisure and inactive periods (non-involvement in income-generating activities) with their grandchildren. The life satisfaction of the older adults partly lies in their role-playing as grandparents. The aim of this study was to examine the impact of caring for grandchildren on the life satisfaction of the older adults in rural areas. A survey method was used to conduct the study, and the age of the participants was 60 years and above. Four Mohollas of Kalia Upazilla of Narail district were selected purposively, and 253 older adults (123 male & 130 female) were chosen by using a purposive sampling technique. An interview schedule (containing both open and close-ended questions) was used to collect data in the months of November and December 2018. The findings showed that activities with grandchildren and caregiving roles depended on the age structure, and families with more household income were found to enhance the life satisfaction with grandparenting. There was a significant association between the life satisfaction of older adults and their grandparenting role. By identifying some dimensions of family involvement and socio-demographic conditions, this research aims to provide a deeper understanding of the dynamics of how grandparenting impacts the life satisfaction of older adults in rural areas of Bangladesh. The results might help to minimize the shortfalls of policy regarding the well-being of the older adults by focusing on their social and psychological needs. This will ensure aging is in place for everyone.

Exploring self-care practices of African American informal kinship caregivers.

African American caregivers providing informal kinship care are vulnerable to chronic stress. Research has indicated stress increases individuals' risk for many adverse physical and mental health outcomes, including cardiovascular disease, Alzheimer's disease and depression. Given the adverse outcomes related to stress, identifying mechanisms to help these caregivers lower and manage their stress is critical to their overall health and well-being. This pilot qualitative study aimed to explore the self-care practices of 12 African Americans providing informal kinship care using a phenomenological approach. Three themes emerged: (a) behaviours to manage stress levels, (b) support network reminding caregivers to take care of themselves and (c) prioritizing my own needs. Specifically, our findings indicate that some caregivers have high-stress levels and engage in maladaptive coping behaviours. The children they cared for reminded them to take care of themselves by attending doctors' appointments or getting their nails done. Nevertheless, some caregivers prioritized their needs by participating in positive self-care behaviours, such as listening to jazz and gospel music and exercising. Prevention and intervention programs that focus on improving caregivers' health should consider the role of self-care practices.

A Comparative Study of Prevalence and Associated Factors of Social Support Among Chinese Shidu Parents and Non-Shidu Parents.

The number of parents in China who have lost their only child, referred to as shidu parents, currently exceeds one million and is increasing by approximately 76,000 annually. Shidu parents face a unique challenge in long-term care, primarily stemming from the sudden and tragic loss of their only child, which leads to a substantial decrease in their social support network. A multi-stage, stratified, and cluster sampling method was employed across various economic belts. Linear regression analysis was utilized to examine factors associated with the social support status of shidu and non-shidu parents. The level of social support decreases as the severity of depression increases. Shidu parents with grandchildren tend to have good social support. The city of Hangzhou exhibits relatively high levels of social support. Married individuals typically report higher levels of social support. It is recommended to prioritize shidu parents without grandchildren as a primary focus for government and societal support. Key recommendations include strengthening social skills training and developing social support networks. Drive economic development, particularly in relatively underdeveloped regions. Strengthen social organizations and community development. Enhancing access to support services, leveraging technology, and encouraging volunteerism for non-married parents.

Grandchildren as Caregivers: Adding a New Layer to the Sandwich Generation.

Although 10% of family caregivers are grandchildren, only a few studies have examined the experience of grandchildren who provide care to grandparents. The current study examined the caregiving processes and outcomes of grandchild caregivers to grandparents. Participants were (N = 5,778) adults identified as a caregiver, including 311 adult grandchildren. Analyses showed that although caregivers to grandparents did not differ significantly from other family caregivers in terms of depression, grandchildren did differ on a variety of demographic and caregiving context variables. A hierarchical binary logistic regression showed that providing personal care and helping with household tasks contribute to the equation, however, grandchild status did not uniquely contribute to the equation after other elements of the caregiving and personal contexts were entered. Post-hoc analyses identified additional predictors within the group of grandchild caregivers. The current study is an important starting point in understanding the experiences of grandchildren caregivers.

Who cares? The grandmother kinship carers shouldering the burden within a gendered care economy.

It is estimated that around half of all kinship carers in the UK are grandparents. International studies show that when broken down by gender, these carers are predominantly grandmothers. However, there is little research exploring the gender dimensions of kinship carers' experiences. Drawing on data from qualitative interviews with 27 grandparent kinship carers, this article highlights the gendered context in which the grandparents we spoke to found themselves. The grandparents - the majority of whom were grandmothers - described lives filled with multiple unpaid caring commitments and demands. We discuss the ways that gender norms, roles and stereotypes, alongside economic models and policies that invisiblise women's care work, shaped the experiences of the grandmothers who took part in our research. We argue that, despite their undeniable determination and commitment to love, nurture and care for their grandchildren in very difficult circumstances, and the money they are saving the state in doing so, grandmother kinship carers are penalized in multiple ways. Economically, emotionally, socially, physically and practically, grandmother kinship carers are unsupported and undervalued. We need a social, economic and cultural shift around the value of care and a redistribution of care work across genders. The situations of grandmother kinship carers need to be part of this shift, so that grandmothers who care for their grandchildren are no longer penalized, and all kinship carers are properly supported and valued.

Is Caring for Grandchildren Good for Grandparents' Health? Evidence From a Fourteen-wave Nationwide Survey in Japan.

BACKGROUND: Enhanced female labor force participation is raising the importance of grandparents' caring for their grandchildren. However, previous studies have reported mixed results of the association between grandchild care and grandparents' health. METHODS: Longitudinal data of 33,204 individuals born between 1946 and 1955 were collected from a 14-wave nationwide panel survey conducted from 2005 to 2018. We examined how caring for at least one co-residing grandchild aged <6 years was associated with grandparents' psychological distress (defined by five or higher Kessler 6 score) and poor self-rated health in pooled cross-sectional, fixed-effects, and 3-year follow-up logistic models. RESULTS: While pooled cross-sectional models showed a positive association between grandchild care and grandparents' health, the fixed-effects or follow-up logistic models did not find any significant association between them. In the case of grandmothers, the odds ratio of reporting psychological distress in response to caring for grandchildren was 0.98 (95% confidence interval [CI], 0.89-1.08) and 1.04 (95% CI, 0.85-1.27) observed from fixed-effects and 3-year follow-up models, respectively, compared to 0.86 (95% CI, 0.81-0.91) in the pooled cross-sectional model. Similar patterns were observed for self-rated health for grandmothers, while grandfathers' health outcomes were not sensitive to grandchild care. These results contrasted with those of caring for parents, which had almost consistently a negative association with grandparents' health. CONCLUSION: The results suggest that caring for grandchildren does not have a beneficial or detrimental effect on grandparents' health.

The effects of received grandmothers' affection on adult grandchildren's health behaviors using affection exchange theory.

BACKGROUND: Affection exchange theory (AET) explains the value of received affection for overall wellbeing in family relationships. However, this study extends prior work by investigating AET in grandmother-grandchild relationships and grandchildren's individual well-being. This study seeks to understand the relationships between adult grandchildren's received grandmother affection and health-related behaviors such as diet, exercise, substance abuse, and sleep. METHODS: This cross-sectional study included 229 university student participants. Multiple regression analyses were performed to analyze received grandmother affection and grandchildren's health behaviors. RESULTS: Using cross-sectional survey methods, it was found that grandchildren's reports of received memories and humor, and celebratory affection influenced grandchildren's dietary behaviors. Received love and esteem, memories and humor, and celebratory affection was also associated with grandchildren's exercise behaviors. CONCLUSIONS: Grandchildren who receive grandmother affection may be likely to engage in the well-being process by engaging in health behaviors, while those who are not receiving affection might suffer the health consequences in adulthood. These findings support the assumption of affection exchange theory that received family affection, in this case, grandmother affection leads to positive health outcomes such as enhanced dietary and exercise behaviors among grandchildren.

Process-Outcome Relationships and Solution-Based Goal-Setting Interventions With Grandparent Caregivers.

The present study examines the impact of change processes on outcomes in a solution-based thinking and goal-setting intervention for grandparents raising their grandchildren. We found that across the 6 program sessions there was stability and/or increases in the salience of hypothesized change processes, i.e., hopefulness about the future, solution-based thinking, positive thoughts about one's grandchild, multiple indicators of decisional personal goal-setting regarding one's own well-being and grandchild relationship quality. Indicators of change processes were for the most part, related to both post-program outcomes as well as to pre-post program outcome difference scores. Regression analyses suggested that change processes in many cases partially mediated pre-post primary program outcome scores. These data suggest that how grandmother caregivers think about themselves and their grandchildren and their approach to setting personal goals are key change processes explaining the impact of a solution-based, goal-setting intervention on them.

Stepping Up and Stepping In: Exploring the Role of Nurses in Supporting Grandparents Raising Grandchildren.

This study focused on the experiences of grandparents raising grandchildren in rural, Prince Edward Island, Canada. Termed grand-families, there are numerous reasons why grandparents must step up and step in to care for their grandchildren. Often these reasons are related to their adult children's struggles with mental illness and substance use disorders. Adopting Clandinin and Connelly's approach to narrative inquiry, we present findings from the conversational interviews conducted with 12 grandparents raising their grandchildren. Interview data were analyzed through the narrative dimensions of time, place, and relationship. Findings are presented as rich narratives which illuminate the evolution and storied experiences of grand-families. Particularly revealing are the challenges grandparents face as they navigate various systems, including health care, that do not acknowledge the uniqueness of their family form. Nurses work with grand-families across varied clinical settings. Grounded within the philosophy of Patient and Family Centered Care and family nursing theory, this article offers recommendations for supportive interventions that nurses can implement when caring for grand-families across clinical settings. This study has the potential to facilitate the development of evidence-based supports and services, which are responsive to the needs, realities, and complexities of grand-families.

Needs of Grandparents Raising Grandchildren: A Qualitative Study.

This study identified custodial grandparents' perception of sources of stress that may affect their health and better understand their needs. Findings from this qualitative study are based on thematic analysis of interviews with 10 custodial grandparents. The following themes emerged: 1) grandparents' stress from perceived lack of readiness to care for grandchildren; 2) need for effective communication between and among family members; 3) sufficiency of financial and legal resources; 4) access to community resources, and 5) raising grandchildren reenergizes and revitalizes grandparents' physical and mental health. These findings provide insight into the stressful aspects of the role of raising grandchildren. Understanding stressors affecting custodial grandparents and their grandchildren will help school nurses, social workers, teachers, school administrators and other professionals collaborate to address their challenges.

The Role of Social Services in Reunified Custodial Grandfamilies.

Social services, including the child welfare system, are often heavily involved in situations where children are returned to the care of their parents, after being raised in kinship care by their grandparents. While previous research has highlighted custodial grandparents' service needs and the challenges they experience when accessing services and working with social service professionals, few studies have examined social services in the context of reunifying grandfamilies. Informed by bioecological theory, the aim of this qualitative study was to examine custodial grandmothers' perceptions of the role of social services in the process of their grandchildren being reunified with a biological parent. Semi-structured, in-depth interviews were conducted with a purposeful sample of 16 custodial grandmothers whose grandchildren had experienced reunification. Findings from a grounded theory analysis revealed grandmothers' perceptions that having a strong connection with a responsive caseworker facilitated successful reunification, as did ongoing efforts to address the parental issues that had resulted in the grandmother assuming a custodial role. Unfortunately, grandmothers also perceived barriers to successful reunification. These included having their perspectives dismissed by caseworkers and judges as well as the child welfare system prioritizing reunification, often to the perceived detriment of their grandchildren. Implications for policy and practice with reunifying grandfamilies are addressed.

Grandparents' Mental Health and Lived Experiences while Raising Their Grandchildren at the Forefront of COVID-19 in Saudi Arabia.

Understanding grandparents' lived experiences and healthy aging is essential to designing efficient, effective, and safe services to support a family structure in which grandparents care for their grandchildren. However, no study to date has explored this concept in an Arab and Muslim country during a pandemic. The purpose of this study was to examine grandparents' experiences raising their grandchildren to provide recommendations for needed mental health interventions during and after COVID-19. We used a phenomenological approach to gain a detailed and in-depth understanding of the lived experiences of 15 grandparents caring for their grandchildren. This study shows the need for support service interventions (support groups, health professional support, and respite care) for grandparents in Saudi Arabia, especially during global crises like COVID-19, that enhance social distance and social isolation. Raising grandchildren affects the physical, mental, and social wellbeing of the grandparents.

Support and Satisfaction: Perspectives of Older Grandparent Caregivers About Faith-Based Communities.

Older grandparents raising adolescent grandchildren are a hidden caregiving population. Religion serves as a protective factor for many older adult caregivers. The caregiving and religion literature often excludes exploration of caregivers' satisfaction with social support provided by faith-based communities. Nineteen older grandparents raising adolescent grandchildren participated in in-depth qualitative interviews regarding the lived experiences of their social support and satisfaction woth faith-based communities. Research questions were: (1) describe, if any, what types of support you receive from church or religious groups? and (2) how satisfied are you with the support from church or religious groups? The diverse sample of grandparents were White (n = 10), Black/African American (n = 7), Native American (n = 1), and Filipino (n = 1). Respondents were primarily married (58%), white/nonHispanic (53%), grandmothers (84%), with some college education or college graduate (79%). Older grandparent caregivers identified key people, situational circumstances, and tangible goods that enhanced their wellbeing and posed opportunities for more support. Five themes characterizing social support and satisfaction with older grandparent caregivers' perspectives of their faith-based communities were emotional support, activities and resources, stopped attending church, attended church but did not seek support, and mixed satisfaction with religious support. Implications are presented for social work education and social work practice.

Depressive Symptoms and Suicidality of Those Raised in Kincare: A Peer Comparison Study.

The rate at which children are raised in kincare has steadily been on the rise. Prior research indicates that this group of individuals are at an increased risk of mental health problems. The current study examined the suicidality and depressive symptoms of adults who were raised in kincare compared to those raised by their parents. There were a total of 1,486 participants, 171 of whom were adults raised in kincare, and 1,315 who were raised by one or both of their parents. Participants completed a measure of suicide risk and reported symptoms of depression and anhedonia.Those raised in kincare scored significantly higher on the measures of anhedonia and suicide risk. However, there were no differences in general depressive symptoms. Further analyses found that more frequent attendance of religious activities and higher levels of household income acted as protective factors. These findings suggest kincare is associated with adverse mental health outcomes.