Abstract
This study examined gender differences in sleep outcomes among spousal caregivers of disabled partners in China and the relationship between the breadth of a care recipient’s functional disability and a caregiver’s sleep. This study used the 2020 data from the fifth wave of the China Health and Retirement Longitudinal Study (CHARLS), including 13 243 participants, of whom 1600 were caregivers for disabled spouses. The degree of disability was assessed using the Basic/Instrumental Activities of Daily Living (BADL/IADL) scale. Sleep quality and duration were measured by self-report. Statistical analyses included chi-square tests and binary logistic regression, adjusting for potential confounders such as sociodemographic characteristics, health status, and lifestyle factors. Women spousal caregivers had shorter sleep duration (OR = 1.309, 95% CI: 1.098-1.561) and poorer sleep quality (OR = 1.200, 95% CI: 1.011-1.424) versus non-caregivers, whereas no significant differences were observed among men caregivers. Analysis of the parametric relationship revealed that when the number of types of disabilities in care recipients reached 5 to 8, caregivers’ sleep duration was significantly reduced (OR = 1.238, 95% CI: 1.007-1.522); when the number reached 9 to 12, both sleep duration (OR = 1.616, 95% CI: 1.096-2.382) and sleep quality (OR = 1.774, 95% CI: 1.220-2.579) of caregivers deteriorated significantly. Caregiving for a disabled spouse impairs sleep among women. A clear graded relationship exists between care recipients' functional disability types and caregivers’ sleep problems. Support policies should consider gender differences and target women undertaking high-intensity care.
Introduction
In recent years, alongside global aging, functional disability has emerged as a significant public health challenge.1,2 The World Health Organization (WHO) defines the characteristics of disability as impairments and restrictions in individuals’ physical functions, daily activities, and social participation. 3 China is the fastest-aging and most populous country in the world, with more than 42 million disabled older adults, accounting for 16.6% of the elderly population. It is estimated that by 2030, the number of disabled older adults will exceed 77 million. 4 Studies have shown that functional disability is closely associated with significant declines in quality of life, specifically manifesting as reduced mobility, self-care ability, and social participation. 5 Therefore, people with disabilities often require long-term and continuous care support, which greatly increases caregiving costs. 6
However, the supply of resources in formal care systems is limited in many countries and cannot fully meet the care needs of the disabled population. 7 Thus, informal care, which refers to unpaid caregiving services provided by family members, relatives, or friends, has become the main form of care. 8 International data indicate that in 2020, about 53 million adults in the United States provided informal care, accounting for approximately 21% of the adult population. 9 Studies in rural China have shown that more than 70% of disabled older adults are primarily cared for by informal caregivers, with institutional care coverage rates below 2%. 10 In China, the “4-2-1” family structure and the phenomenon of empty-nest families, resulting from the one-child policy and urban–rural population migration, have led to a scarcity of available family caregiving resources. 11 This unique demographic and family structure makes spouses a key role in disability care. Several recent national studies have shown that among disabled individuals aged 50 years and above, nearly 60% receive primary care from their spouses, significantly higher than from children or other family members.10,12
A long-term and high level of caregiving burden can negatively affect caregivers’ mental health, significantly increasing the risk of depression and anxiety. 13 In addition, caregivers are more likely to face increased risks of chronic diseases such as obesity, asthma, chronic obstructive pulmonary disease, and arthritis, due to sustained physical and emotional labor. 14 Notably, gender differences among caregivers are particularly pronounced. Women caregivers are more likely to withdraw from the labor force and experience more severe physical and mental health problems. 15 Under similar caregiving intensity, the overall burden index of women caregivers is about 20% higher than that of men, and they report poorer self-rated health and quality of life. 16
As an important indicator of health, sleep insufficiency or disturbance is closely related to cardiovascular, 17 metabolic, 18 and psychological diseases. 19 For spouses undertaking long-term caregiving tasks, the need for nighttime care, psychological stress, and the cumulative effect of caregiving tasks can significantly disrupt sleep quality and sleep duration, which in turn can have a profound impact on long-term health.20,21 Nevertheless, current research still lacks sufficient attention to sleep problems among caregivers. Most studies have focused on caregiving contexts related to specific diseases, while research on the sleep of spouses caring for individuals with general functional disabilities (regardless of the underlying disease) remains scarce.22,23 Moreover, when examining the continuous or graded relationship between caregiving burden and sleep impact, current studies mostly include caregiving duration or years of caregiving in their models, and rarely consider quantitative indicators such as the types or degree of disability in care recipients. 24
Therefore, this study utilizes nationally representative data from the China Health and Retirement Longitudinal Study (CHARLS) to systematically investigate the gender differences in the impact of spousal caregiving for disabled partners on caregivers’ own sleep duration and sleep quality. In addition, this study quantifies the number of types of disabilities in care recipients and analyzes its parametric relationship with caregivers’ sleep quality and duration, aiming to provide scientific evidence for improving caregivers’ health.
Method
Study Design
This research adopts a cross-sectional design, utilizing data from the fifth wave (2020) of the CHARLS, which was publicly released on November 16, 2023. Multiple survey modules, including demographic and health information, were analyzed to assess the relationship between spousal caregiving for disabled partners and both sleep duration and sleep quality. CHARLS is an interdisciplinary survey, specifically targeting issues of population aging in China. Initiated in 2011, the study has conducted subsequent follow-ups in 2013, 2015, 2018, and 2020, covering more than 10 000 households and individuals aged 45 years or older across 28 provinces, autonomous regions, and municipalities. 25 This study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline for cross-sectional studies. 26
Sample
A total of 19 395 respondents were included in the CHARLS database (2020). Among them, 29 respondents were excluded due to incomplete health and function surveys (n = 28) and duplicate sample (n = 1), leaving 19 366 potentially eligible respondents after the initial screening. Subsequently, an additional 6123 respondents were excluded due to incomplete sleep duration and sleep quality data (n = 2091), inability to determine whether they had a spouse requiring care due to disability (n = 4025), and incorrectly filled information (n = 7). Finally, 13 243 eligible respondents were included in this study, among whom 1600 were caregivers for disabled spouses. A detailed participant selection process is shown in Figure 1.
Participants screening flowchart.
Measures
Disability
The independent variable was spousal disability status, assessed using the Activities of Daily Living scale, which includes both Basic Activities of Daily Living (BADL) and Instrumental Activities of Daily Living (IADL). The BADL items consist of dressing, bathing, eating, getting in and out of bed, toileting, and controlling urination and defecation. The IADL items include doing household chores, preparing meals, shopping, making phone calls, taking medication, and managing finances.27,28 For each activity, having difficulty or being unable to perform it was coded as 1 and classified as disabled 29 ; otherwise, it was coded as 0. The sum of these scores was used as a proxy indicator for the number of types of disabilities in the spouse. In this study, a “type” of disability is operationally defined as a reported difficulty in one of the 12 distinct functional domains (6 BADL and 6 IADL items) listed above. Thus, the “number of types of disabilities” quantifies the breadth of functional impairment across different daily activities. This measure reflects the extent of functional limitation rather than the presence of specific diagnostic disease categories or traditional disability classifications (eg, sensory, physical).
Sleep Duration and Quality
The dependent variables were sleep duration and sleep quality. According to the 2020 CHARLS questionnaire, participants were asked, “During the past month, on average, how many hours of actual sleep did you get each night?” to determine the self-reported average sleep duration over the past month. Based on the joint consensus statement from the American Academy of Sleep Medicine and the Sleep Research Society, less than 7 hours of sleep per night was defined as insufficient sleep. 30 Sleep quality was obtained using 1 question from the depression scale: “My sleep was poor” in the past week. If the answer was “rarely or never (<1 day),” sleep quality was classified as “good”; “not too often (1-2 days)” as “fair”; “sometimes or about half the time (3-4 days)” as “poor”; and “most of the time (5-7 days)” as “very poor.” This classification method is consistent with previous studies.31,32
Other Variables
Previous studies have shown that older age, 33 rural residence, 34 higher educational level, 33 social isolation, 35 smoking, 33 alcohol consumption, 33 the presence of chronic diseases, 36 and frequent internet use 37 are important risk factors for sleep disorders. Therefore, the covariates included in this analysis were: age (<60 years or ≥60 years, since the United Nations defines older adults in China as those aged ≥60 years 38 ); educational level (categorical, 5 levels); place of residence (urban, rural, urban-rural fringe); and number of chronic diseases (0, 1, 2, 3, or ≥4). In addition, lifestyle factors (alcohol consumption, smoking, and internet use) and social activities were included as binary variables.
Statistical Analysis
Data were entered and cleaned using Microsoft Excel 2016, and then imported into SPSS 25.0 (SPSS Inc., Chicago, IL, US) for statistical analysis. Frequencies and proportions were used to describe the general characteristics of the data. Stratified by gender, univariate analyses were conducted using the chi-square test. After adjusting for potential confounders, binary logistic regression was performed to examine the associations between sleep duration, sleep quality, and caregiving for disabled spouses. Furthermore, based on the number of types of disabilities in the spouse, participants were categorized into 4 groups: 0 (non-caregivers), 1 to 4, 5 to 8, and 9 to 12. Binary logistic regression was further used to analyze the parametric relationship between the number of types of disabilities and sleep duration and quality among caregivers. We further examined whether care recipients’ chronic disease categories were associated with caregivers’ sleep duration and sleep quality. Based on chronic disease information available in CHARLS, care recipients were classified into emotional and psychiatric disease, memory-related disorders (including dementia), and Parkinson’s disease. Multivariable logistic regression models were fitted using the same covariate adjustments. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to represent the risk of short sleep duration and poor sleep quality. A P value of <.05 was considered statistically significant.
Results
Sociodemographic Characteristics of Participants
A total of 13 243 participants were included in this study, among whom 1600 were caregivers for disabled spouses. The overall gender distribution was balanced, with 6624 women (50.02%) and 6619 men (49.98%). Baseline characteristics indicated that, compared to the non-caregiver group, caregivers for disabled spouses were more likely to be aged ≥60 years (68.9% vs 46.5%), reside in rural areas (73.1% vs 63.6%), have lower educational levels (70% vs 60.9%), and suffer from a higher number of chronic diseases (≥4 chronic conditions: 21.9% vs 14.9%) (Table 1).
Sociodemographic Characteristics of Participants.
Associations Between Caregiving for Disable Spouses and Sleep Outcomes
Stratified analyses by gender revealed that sleep outcomes in women caregivers were significantly affected by caregiving responsibilities. After adjusting for potential confounders such as age, place of residence, educational level, social activities, number of chronic diseases, smoking, drinking, and internet use, women caregivers had a significantly higher risk of short sleep duration (OR = 1.309, 95% CI: 1.098-1.561, P = .003) and poor sleep quality (OR = 1.200, 95% CI: 1.011-1.424, P = .037) compared to non-caregivers (Tables 2 and 3). Among men, no significant associations were observed between caregiving for disabled spouses and either sleep duration (OR = 1.127, 95% CI: 0.974-1.304, P = .109) or sleep quality (OR = 1.058, 95% CI: 0.915-1.223, P = .447).
Crude and Adjusted Odds Ratios (OR) for the Associations Between Caregiving for Disable Spouses and Sleep Deprivation.
Crude and Adjusted Odds Ratios (OR) for the Associations Between Caregiving for Disable Spouses and Sleep Quality.
Additionally, after controlling for other variables, the number of chronic diseases emerged as a significant factor affecting sleep outcomes. An increased number of chronic diseases was consistently associated with a higher risk of insufficient sleep duration and poor sleep quality in both women and men (Tables 2 and 3). Place of residence was also an important factor: women participants living in rural areas had a significantly lower risk of impaired sleep duration compared to those living in urban areas.
Association Between Spousal Functional Disability and Caregivers’ Sleep Outcomes
Compared with non-caregivers, caregivers whose spouses had a higher cumulative number of types of disabilities experienced greater risks of insufficient sleep duration and poor sleep quality. When the number of types of disabilities in the spouse reached 5 to 8, the risk of insufficient sleep duration among caregivers began to increase significantly (OR = 1.238, 95% CI: 1.007-1.522), and this risk further increased when the number reached 9 to 12 (OR = 1.616, 95% CI: 1.096-2.382). In addition, a significantly higher risk of poor sleep quality among caregivers was observed only when the number of types of disabilities in the spouse reached 9-12 (OR = 1.774, 95% CI: 1.220-2.579); no significant effect was observed when the number of types was 1 to 8. This trend is illustrated in Figure 2.
Association between the number of spousal functional disability types and caregivers’ sleep outcomes.
When caregivers were categorized according to their care recipients’ chronic disease types (emotional and psychiatric disease, memory-related disorders, and Parkinson’s disease), no statistically significant associations were observed between disease category and caregivers’ sleep duration or sleep quality after covariate adjustment. Detailed results are presented in Supplemental Tables S1 and S2.
Discussion
This study found that caring for a disabled spouse was associated with sleep quality and sleep duration among caregivers, with marked gender differences observed. After adjusting for a range of potential sociodemographic and behavioral confounders, the impact of caregiving burden on sleep quality and duration was more pronounced in women caregivers, whereas sleep indicators in men caregivers did not show significant changes. Importantly, this study is the first to identify a clear graded trend between the number of functional disability types in care recipients and sleep problems in caregivers.
Our findings demonstrate a higher risk of sleep problems among women caregivers, consistent with previous studies showing that women providing care are more vulnerable to adverse health outcomes.39,40 This phenomenon may result from multiple factors. In traditional cultural and social contexts, women often undertake more emotional labor, including ongoing emotional regulation and comforting activities, which are themselves closely related to both physical and mental health as well as sleep problems.41,42 Women may also exhibit greater physiological and psychological sensitivity to chronic caregiving stress, which can alter hypothalamic–pituitary–adrenal (HPA) axis activity, reduce cortisol secretion, and thereby increase the risk of sleep disorders. 43 In contrast, caregiving for a disabled spouse did not have a significant effect on sleep problems among men caregivers. This may be explained by greater external support obtained by men in caregiving tasks, 44 and by the fact that, due to gender norms, intimate care tasks such as bathing and incontinence management are more likely to be performed by adult daughters or professional aides.
These findings highlight the importance of sleep interventions targeted at women spousal caregivers. In the context of China’s rapidly aging population, efforts should focus on developing caregiver support systems, including increased access to external care resources, emotional support, or short-term respite services. In particular, tailored sleep management and intervention programs should be provided for women caregivers.45,46 It should be noted that some studies have shown that women caregivers may experience enhanced self-efficacy during caregiving, such as increased confidence in their own abilities, greater capacity to handle difficult situations, and higher overall caregiving satisfaction; these benefits have been associated with a lower risk of sleep disruption. 47 This suggests that caregiver interventions and support programs should aim to shift negative attitudes, promote the development of self-efficacy and well-being, and further cultivate more effective coping strategies.48,49 Future public health policies should incorporate gender differences and establish differentiated support mechanisms for caregivers.
We observed a clear upward trend in the risk of sleep quality and sleep duration problems among caregivers as the number of types of disabilities in their spouses increased. This graded relationship suggests that the complexity of caregiving tasks, as measured by the diversity of functional limitations in the care recipient, may have a cumulative impact on sleep health. Moreover, a significant negative effect on sleep duration was observed only when the number of types of disabilities in care recipients reached 5 to 8 (P < 0.05), while both sleep quality and duration were statistically significantly impaired at even higher numbers (9-12 types). This implies the existence of a threshold effect for caregiving burden: below a certain number of disability-related care demands (1-4 types), the effect may be negligible, but beyond a certain threshold (≥5 types), the risk of sleep problems rises sharply. However, due to the cross-sectional design, our results may have overlooked short-term fluctuations or periodic caregiving demands that impact caregivers’ sleep in real time. The intensity and difficulty of caregiving tasks may vary substantially in the short term, and a one-time cross-sectional survey is limited in its ability to capture these dynamics and their immediate effects, potentially underestimating the dynamic impact of caregiving on sleep health.
Previous research has drawn similar conclusions. A systematic review found that long-term, high-intensity caregiving significantly increases the risk of sleep problems among caregivers. 50 During nighttime caregiving, caregivers are frequently forced to interrupt their sleep to respond to the immediate needs of care recipients, such as assisting with toileting or turning in bed. These demands become more frequent as the number of types of disabilities increases, further disrupting the continuity and stability of caregivers’ sleep.51,52 A greater diversity of disabilities in care recipients may lead to increased skill requirements, emotional labor, and psychological stress. 53 This psychological burden can affect the caregiver’s sleep structure via sympathetic nervous system arousal, resulting in reduced sleep quality and shorter sleep duration. 54 Existing studies suggest that the physical and mental health of spousal caregivers may experience cumulative effects as caregiving burden increases and caregiving duration is prolonged.55,56 Particularly within the Chinese cultural context, the strong social norm of family caregiving obligations often leads caregivers to assume even higher intensity and broader responsibilities. 57 The clear graded trend identified in this study further confirms and strengthens these findings. This trend suggests that health and public policy makers should pay close attention to the burden associated with a greater diversity of disabilities, especially in households with spouses experiencing moderate to high levels of disability, and should develop more detailed and diversified care support systems. In practice, it is important to consider establishing targeted sleep intervention programs for high-risk caregiver groups, such as nighttime care assistance, psychological counseling, or community support services, to mitigate their long-term health risks.
Because the database only provided broad diagnostic labels, our 3 disease categories are a coarse indicator and may have masked meaningful heterogeneity within each condition. Prior work suggests that caregivers’ sleep is strongly shaped by overall caregiving burden, stress, and care intensity, which can outweigh diagnosis labels when clinical detail is limited.20,22 In neurodegenerative caregiving, night-time symptoms and care-recipient sleep disruption can be key drivers of caregivers’ sleep problems, but disease stage and symptom-level information were not available in our dataset.23,58 Future studies with richer clinical characterization, including stage, symptom severity, and night-time behaviors, alongside caregiver burden measures, may better clarify which illness characteristics matter most for caregiver sleep and inform targeted sleep support.
Limitations
This study has several limitations. First, sleep quality was assessed with a single-item measure, which lacks the multidimensional detail (eg, sleep latency, awakenings) captured by comprehensive questionnaires or objective measures. Future research should incorporate such tools, ideally within longitudinal designs. Second, while the count of disability types reflects caregiving diversity, it does not quantify the specific demands or intensity associated with each type. Future studies could refine this by weighting or grading disabilities to better characterize their relationship with sleep health. Third, generalizability is primarily to middle-aged and older adults, as the sample was drawn from individuals aged 45 and above. Future work should examine whether similar gendered patterns exist among younger caregivers, whose caregiving contexts and sleep may differ due to distinct life-stage challenges.
Conclusions
This cross-sectional study found that, compared with individuals who do not care for disabled spouses, women caregivers for disabled spouses are more likely to experience shorter sleep duration and poorer sleep quality, whereas this phenomenon was not observed among men caregivers. Moreover, as the number of types of disabilities in spouses increases, caregivers are more likely to suffer from reduced sleep duration and quality. Therefore, future efforts should focus on strengthening the social support system for caregivers and further identifying potential factors contributing to nocturnal sleep disturbances, with an emphasis on targeted psychological interventions to effectively improve caregivers’ health outcomes.
Supplemental Material
sj-docx-1-inq-10.1177_00469580261420705 – Supplemental material for Gender Differences in Sleep Deprivation and Quality Among Spousal Caregivers of Disabled Partners: A Nationwide Cross-Sectional Study
Supplemental material, sj-docx-1-inq-10.1177_00469580261420705 for Gender Differences in Sleep Deprivation and Quality Among Spousal Caregivers of Disabled Partners: A Nationwide Cross-Sectional Study by Tingyu Mu, Rixiang Xu and Qianyin Zhu in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Supplemental Material
sj-docx-2-inq-10.1177_00469580261420705 – Supplemental material for Gender Differences in Sleep Deprivation and Quality Among Spousal Caregivers of Disabled Partners: A Nationwide Cross-Sectional Study
Supplemental material, sj-docx-2-inq-10.1177_00469580261420705 for Gender Differences in Sleep Deprivation and Quality Among Spousal Caregivers of Disabled Partners: A Nationwide Cross-Sectional Study by Tingyu Mu, Rixiang Xu and Qianyin Zhu in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
Acknowledgements
We thank the CHARLS research team and all participants for their contribution.
Ethical Considerations
The Biomedical Ethics Review Committee of Peking University approved the CHARLS data collection (IRB00001052–11015).
Consent to Participate
All participants provided written informed consent at the time of participation.
Author Contributions
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Anhui Province Social Science Innovation and Development Research Project (2024CXQ028), the University Humanities and Social Sciences Research Key Program of Anhui Province (2025AHGXSK30278) and 2025 Anhui Medical University School of Medical Humanities Featured Research Team Project (2025kytd03).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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