Copyright 1992 by The Cerontological Society of America The Cerontologist Vol. 32, No. 6, 752-761

This article explores the physical and emotional health status of 71 African-American grandmothers raising their grandchildren as a result of the crack cocaine involvement of the children's parents. A comparison of self-assessed health ratings with qualitative responses revealed a tendency for respondents to downplay their own health problems and symptoms. Key Words: Family caregivers, African-Americans, Caregiver burden, Extended family

The Physical and Emotional Health of Grandmothers Raising Grandchildren in the Crack Cocaine Epidemic1

The 1980s saw a dramatic increase in the number of grandparents serving as primary caregivers to their grandchildren and great-grandchildren. Approximately 3.2 million U.S. children currently live with grandparents or other relatives, up from just over 2 million in 1980. In approximately a third of these homes, neither parent is present (U.S. Bureau of the Census, 1991), suggesting that the grandparent may well be serving as the sole or primary caregiver. Although the increase in grandparent caregiving cuts across ethnic group lines, it has been particularly pronounced in the African-American community, where over 12% of children live with their grandparents, compared with 5.8% of Hispanic and 3.6% of white children (U.S. Bureau of the Census, 1991). In some predominantly black inner-city areas, these rates may be considerably higher. A recent survey of the Headstart population in Oakland, California, for example, revealed that 20% of enrolled children were in the care of grandparents (Nathan, 1990). And in one of the city's junior high schools, more than half of the 750 enrolled students are believed to live in homes with neither parent present (Gross, 1992). Grandparent caregiving provides an important area of inquiry for gerontologists for two reasons.

1 Funding for this research was provided by the San Francisco Foundation. The authors also gratefully acknowledge the instrumental roles of the Community Advisory Committee, and of Frances Saunders, Rama-Selassie Bamwell, Lisa Moore and Relda Beckley Robinson in the research process. Thanks also are due Lydia Ferrante, Gregg Thomson, Bob Freeland, and Peter Fisher for their assistance, and to the manuscript's anonymous reviewers for their helpful suggestions. Finally, our deepest appreciation is extended to the grandmother caregivers who shared their lives and experiences with us and made this research possible. 2 Professor of Community Health Education, School of Public Health, University of California, Berkeley, Ca 94720. ^Associate professor of Health Education, Department of Health Sciences, San Jose State University, San Jose, CA. 4 Senior research associate, Institute for Health Policy Studies, University of California, San Francisco.

First, although grandparents in youthful lineages may be as young as their late twenties, many are older women for whom the demands of the new role may lead to increased physical, emotional, and economic vulnerability. Second, although gerontologists have long been interested in grandparenthood as a life stage, studies in this area, as Burton and Bengtson (1985) have noted, have tended to be limited to the more tenuous and ill-defined grandparent role most prevalent in American society. With 5% of U.S. children now living with grandparents (U.S. Bureau of the Census, 1991), the nature and dynamics of more extensive grandparental roles are in need of attention. This article describes and analyzes health findings from the Grandparent Caregiver Study conducted in Oakland in 1990-1991. The research focused on African-American grandmothers, greatgrandmothers, and great-aunts who were raising young children as a result of the crack cocaine involvement of the children's parents. The study attempted to explore this experience from the perspective of grandmother caregivers themselves on the assumption that there is much older black women can tell researchers, policymakers, and practitioners about caregiving under these unique historical circumstances. Further, the study endeavored to demonstrate the utility of a research strategy that combined quantitative and qualitative methods to provide a richer and more complete picture of the health of respondents than either approach could attain in isolation. The Role of African-American Grandmother

Grandparenthood has been described as a ''contingent process" (Troll, 1985, p. 135) whose playing out is influenced by variables including ethnicity and social class (Cherlin & Furstenberg, 1986; Jackson, 1986; Kivett, 1991), geographic proximity to and ages 752

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Meredith Minkler, DrPH,2 Kathleen M. Roe, DrPH,3 and Marilyn Price, MSW4

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black grandmother (Christian, 1985; Holloway & Demetrakopoulos, 1986), relatively few empirical studies have focused specifically on this topic. As Burton and Bengtson (1985) suggest, moreover, the research in this area has looked, with few exceptions, at the "traditional" role of the black grandmother as surrogate parent or "family matriarch," ignoring the occupancy by many of a more tenuous and ill-defined grandparent role. Our own review of this literature suggests that studies of the traditional role of black grandmothers tend to focus on the grandparent's caregiving functions when the adult daughter, who is usually an adolescent, remains a member of the household. Research on the caring functions of grandmothers in low-income families, for example, documents the heavy involvement of grandmothers in both surrogate parenting and household tasks, in part as a means of freeing the young mother to finish school, get a job, or in other ways engage in "selfimprovement" activities (Brooks-Gunn & ChaseLansdale, 1991; Flaherty, 1988; Furstenberg & Crawford, 1978; Field et al., 1980; Presser, 1989; Wilson, 1989). Although the multiple functions of grandparents and other extended family members are effectively illuminated through these explorations, the emphasis is on the extended family unit, including the young mother and/or father, in negotiating and fulfilling a variety of family and work roles. In the "skipped generation" families examined in our research, the general absence of the young children's parents due to their crack cocaine involvement and the consequent full-time and often permanent nature of the caregiving role of grandmothers made for a substantively different surrogate parenting experience than that described in most accounts of the traditional black grandmother (see also Burton, 1990). In short, although historical and contemporary accounts of the black extended family and of the traditional role of the grandmother within that family anchor the current research, they remain an incomplete framework in three key respects. First, they pay little attention to those "skipped generation" families in which the extended family is comprised of grandparents and the young children in their care. Second, they tend to ignore the popularity and likely prevalence of newer, more tenuous manifestations of the grandmother role in African-American families (Burton & Bengtson, 1985). Finally, for the most part, they ignore the health status of role occupants and the potential health consequences of their extensive caregiving responsibilities.

Grandmother Caregivers: A High Health Risk Population?

Whether full-time grandmother caregiving, particularly as a result of the crack cocaine epidemic, significantly affects the health status of role occupants remains subject to debate. Miller (1991) has reported adverse health consequences of such caregiving including insomnia, back and stomach pain, and exac753

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and gender of one's grandchildren (Shanas, 1979; Tinsley & Parke, 1984), and the " o n " versus "off" timing of entry into the grandparental role (Burton & Bengtson, 1985; Troll, 1985). Yet as nurturers, grandparents are "the second line of defense," serving as a safety net for children whose parents are unable or unwilling to provide care (Kornhaber, 1985, p. 162). As Burton and Dilworth-Anderson (1991) have pointed out, although research on grandparenthood has proliferated in the last decade, grandparenthood among African-Americans remains a relatively unexplored research domain. Despite the dearth of empirical work in this area, however, one facet of grandparenthood in African-American extended families — the role of the black grandmother as surrogate parent — has long been appreciated. Conceptualizations of the historic and contemporary role of the grandmother within that family structure provide, therefore, an important framework for the present study. A number of classificatory schemes have been proposed for understanding and analyzing scholarship on the African-American family (Allen, 1978; Cibbs, 1990; Martin & Martin, 1978; Wilson, 1986). As Cibbs (1990) and Allen (1978) suggest, these schemes tend to be similar and to have overlapping categories. One of the most popular of these typologies (Martin & Martin, 1978) divides portrayals of the black extended family into two general categories: a "pathology-disorganization" perspective, which views the black family as inherently unstable, deviant, and maladaptive (Frazier, 1939; Moynihan, 1965; Rainwater, 1966), and a "strength-resiliency" perspective, which emphasizes the ability of black families to adapt and thrive despite adverse external forces (Billingsley, 1968; Hill, 1971; Stack, 1974). More recent analysts have stressed the existence of a third perspective on African-American family life, reflected in the work of Nobles (1974, 1988), Farley and Allen (1987), and others (e.g., Billingsley, 1968; Stack, 1974), who earlier were identified with the strength-resiliency perspective. Termed the cultural or "cultural variant" approach, this perspective views the African-American family as "a distinctive cultural form that has evolved in America from a fusion of elements from African culture and adaptations to slavery, segregation, rural southern culture, and urban northern ghetto life" (Cibbs, 1990, p. 328). Critical reviews of the literature in the pathologydisorganization, strength-resiliency, and cultural variant traditions are available elsewhere (Dodson, 1988; Cibbs, 1990; Martin & Martin, 1978; Taylor et al., 1990; Wilson, 1986). Of relevance here, however, is the fact that a number of analysts representing each of these diverse paradigms appear to share an appreciation — and sometimes an idealization — of the critical role of the grandmother in African-American family life. Typically absent from such accounts is much consideration of the physical and emotional health status of women occupying this role. Although a rich tradition in African-American fiction has explored and illuminated the role of the

Methods

Because this was an exploratory study, the goal of our sampling strategy was to assemble a group of grandmother caregivers that would reflect as much of the diversity of this experience as possible. Participants were identified through "open sampling," a form of theoretical sampling (Glaser & Strauss, 1967; Strauss & Corbin, 1990) aimed at uncovering as many potentially relevant patterns as possible. Such an approach does not attempt to achieve a random or representative sample, and the results obtained are not generalizable. The strength of open sampling, and its chief advantage in exploratory research, lies in its ability to capture a greater range of experiences than a similarly sized random sample is likely to achieve. Initial sampling was designed to identify differences in the caregiving experience based on age, number of dependent grandchildren, sources of financial support, marital status, and social support. Later sampling enabled comparisons based on factors such as employment, health status, and additional caregiving responsibilities. This sampling strategy allowed us to keep sampling until we had heard a wide range of stories and experiences and had begun to find recurring patterns and commonalities. These patterns were subsequently validated by participants

Background and Purpose of the Study A major aim of the Grandparent Caregiver Study was to provide an in-depth look at the physical and emotional health status of African-American grandmothers who were sole or primary caregivers for infant and preschool-age children as a consequence of the crack cocaine involvement of the children's parents. For the purposes of this research, the term grandmother was used broadly to include greatgrandmothers and great-aunts as well as biological grandmothers. Although grandfathers and other older male relatives also play an important role in caregiving, the high rates of widowhood, separation, and divorce among older black women (Chatters & Taylor, 1990) and the tendency for men to play supportive secondary rather than primary caregiver roles (Abel, 1991) led us to focus on African-American grandmothers. The decision to focus on this specific population reflects several other considerations. First, although the traditional role of the black grandmother has included that of kinkeeper and "guardian of the generations" (Frazier, 1939), sociodemographic 754

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changes, including the recent and devastating crack cocaine epidemic, have significantly altered the nature, context, and dynamics of the caregiving role. As Burton and Dilworth-Anderson (1991) have pointed out, grandmothers raising their grandchildren as a result of the drug addiction of the children's parents may have very different attitudes toward this experience than those who took in grandchildren so that their parents could migrate north or so that a young mother could finish school and get a job. The nature of the drug epidemic also means that several of a grandmother's children may be involved with crack simultaneously, effectively disrupting some of the social support from the next generation that previously had been available to help the caregiving grandmother (Minkler & Roe, in press). Finally, many of the young children being raised by grandparents in the crack epidemic have been prenatally.exposed to drugs and/or are suffering the medical or behavioral problems associated with early abuse and neglect (Coles, 1991; DeStephano Lewis, Bennett, & Hellinger Schmeder, 1989). Societal labeling of such children as a "lost generation" of "crack babies" further adds to the problems they face, particularly as they reach school age (Barth, 1991; Coles, 1991). In short, grandparent caregiving in the crack cocaine epidemic represents a quantatively and qualitatively different experience from any we have seen before. The primary aim of this article is to describe and utilize findings from the Grandparent Caregiver Study to explore the effects of grandparent caregiving under these circumstances on the physical and emotional health of grandmothers.

erbations of previously controlled chronic conditions such as hypertension and arthritis among middle-aged and older women clients seen at public hospital clinics in San Francisco. Similar anecdotal reports have been provided by physicians in other parts of the country (Minkler & Roe, in press). It is difficult, however, to tease apart the possible health consequences of grandparent caregiving under these difficult circumstances from other confounding variables and from changes associated with normal aging. Moreover, health may well be a selection factor in determining whether grandmothers take on the caregiving role in the first place. A ''healthy grandparent effect" similar to the "well worker bias" in retirement research (Haynes, McMichael, & Tyroler, 1977) would suggest that grandmothers who are ill or disabled would be less likely to take responsibility for grandchildren, leaving a pool of grandmother caregivers who are in better health overall than a random sample of age peers. On the other hand, continuing and pronounced differences in the health status of black and white Americans suggest the likelihood of health problems in black grandmother caregivers. African-Americans have both more acute and more chronic conditions than their white counterparts, and 57% of older blacks report limitations in activities of daily living as a result of chronic health problems compared with 44% of older whites (National Center for Health Statistics, 1990). Finally, the low socioeconomic status of many grandparent caregivers, including most of those in this study, and the well-documented relationship between social class and illness (Kaplan et al., 1987) suggest again the possibility of significant health vulnerability in this population. Given these realities, the importance of examining the health status of African-American grandmothers in the crack cocaine epidemic is underscored.

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The interviewing strategy also aimed to minimize possible biases introduced as a result of the crosscultural nature of the research. An initial team interview, conducted by one of the coinvestigators and an African-American graduate student, was supplemented by a shorter follow-up interview conducted 1 to 2 weeks later by the research assistant alone. We had anticipated that study participants might be more comfortable, and therefore perhaps more candid, in the second interviews, and built in checks for reliability by including many identically worded questions in the initial and follow-up questionnaires. Comparison of the data obtained in the first and second interviews, however, revealed a high degree of consistency of response and the sharing of considerable amounts of often deeply personal information and feelings in both interview sessions. The two interviews usually lasted a total of 3 or more hours, and each participant received compensation of $50. The interviews were conducted in the women's homes or in other settings of their choice and included both structured and open-ended questions. Although the physical and emotional health of the caregivers was our primary interest, data also were gathered on the women's daily routines; their social support and coping resources; circumstances surrounding the assumption of caregiving; extended family roles and functioning; the economic costs of caregiving; and attitudes and concerns about the future. Sample The median age of sample members was 53, with 42.3% of the women aged 55 and older. Nearly a quarter of the sample was married with the husband present in the household. Education ranged from 4th grade to a Master's degree, with close to two-thirds of the sample (66%) having graduated from high school (see Table 1). One-third of the participants (n = 25) were employed outside the home, with most of those women working 40 hours a week. Most respondents (86%) had assumed primary responsibility for one (25%), two (37%) or three (23%) young children. Over 80% of the women (n = 58) were raising grandchildren, while 10 respondents were caring for at least one great-grandchild and the remaining three were caring for grandnieces or grandnephews. Respondents had occupied this new role from 6 months to 5 years at the time of the interviews and at least nine (12.7%) had raised other youngsters, usually other grandchildren, under these same circumstances. Over half of the respondents (54%) had at least one of their own children still living at home; the others had been without children in the household, often for a number of years, when they assumed primary caregiving for a grandchild. Approximately a quarter of the women interviewed reported that they had lost an adult child recently to a violent and/or drugrelated death. Although sample members were geographically dispersed throughout 13 residential zip code areas in north, east, and west Oakland, 72% of the sample (n 755

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when the findings were re-presented later in the study. Our research purposefully did not seek a random sample. Demographic data from the study, however, correspond well to those of a recent large (N = 1,377) random sample of 50% of the clients attending three child health clinics in New York City (Brouard & Joslin, 1991). Eight percent of the children in that survey were in the care of grandmothers, greatgrandmothers, or great-aunts, for example, whose ages ranged from 35-77 with a median of 55. In our study, the age range was 41-79, with a median of 53. In both studies, the majority of grandmothers were caring for at least two of their grandchildren (62% and 75%, respectively). Potential respondents in the Grandparent Caregiver Study were identified through health and social service providers, a dense network of community contacts, an invitational flyer, and snowball referrals from study participants. The latter two strategies were especially effective in finding women who were without phones, were not well connected to health and social services, and were in other ways likely to be overlooked through more traditional sampling methods. Criteria for inclusion in the study were that the women be living in Oakland or within a few blocks of its borders, that they be African-American, and that at least one of the grandchildren in their care was an infant or preschool-age child for whom they had become primary caregiver as a result of the cocaine involvement of the child's parents. Of more than 100 caregivers expressing an interest in participating, 71 met all of the study criteria and were included in the sample. Those excluded from participation were grandmothers who belonged to other ethnic groups or who were raising older grandchildren they had taken in for reasons other than the crack involvement of the children's parents. Because the principal investigators were both white women, a number of steps were taken to help overcome some of the pitfalls of cross-cultural research and to increase the study's ability to accurately and sensitively document the perceptions and concerns of African-American grandparent caregivers. A research team was assembled that included a community liaison and four African-American graduate students; the team worked closely with a community advisory committee composed mainly of African-American women; and we tried to make participation in the study an empowering experience. In the latter regard, for example, participants were heavily involved in planning an elaborate luncheon celebration honoring the women, sharing initial study findings, and seekingthe participants' input on the appropriate uses of study findings. Discussions also were held with the women concerning community actions and policy changes they hoped to see, and a number of respondents began working with members of the research team on coalitions and other projects designed to help bring about such changes (see Minkler & Roe, in press, for a fuller discussion).

Table 2. Self-rated Physical and Emotional Health (n = 71) of Grandmother Caregivers at Time of Interview

Table 1. Selected Characteristics of the Grandmother Caregivers (n = 71)

Physical health

Age 40-44 45^9 50-54 55-59 60-64 65-69 70-74 75-79

11 17 13 16 6 3 3 2

(15%) (24%) (18%) (23%) ( 8%) ( 4%) ( 4%) ( 3%)

Marital status Single Married Separated Divorced Widowed

10 17 11 24 9

(14.1%) (23.9%) (15.5%) (33.8%) (12.7%)

6 ( 8%) 18 (25%) 17

(24%)

22 (31%) 8 (11%)

Number of children cared for 1 2 3 4 or more

18 26 16 11

Relationship Grandmother Great-grandmother Great-aunt

58 (82%) 10 (14%) 3 ( 4%)

Self-rated financial status Doing well Doing okay Not doing very well Doing poorly

0 9 37 25

Employment Yes No

25 (34%) 46 (66%)

(25%) (37%) (23%) (15%)

( 0%) (13%) (52%) (35%)

= 51) lived in 10 zip codes in which at least 40% of the population had annual household incomes of below $15,000 (National Planning Data Corporation, 1989). (The 1990 poverty line for a family of four was $13,359.) Hard income data were not available for all of the members of our sample, but most reported themselves to have only modest financial means, with 69% reporting that their income was inadequate to meet their current needs. Health Measures A variety of measures were used in both the first and second interviews to tap the respondents' feelings and beliefs about their physical and emotional health and well-being. Self-rated health was assessed in both interviews through the questions, "Overall, how would you rate your physical [or emotional] health: excellent, good, fair, or poor?" Such global self-rated health measures have been shown to correlate well with physician ratings and objective health indicators (Ferraro, 1980; Kaplan & Comacho, 1983; Mossey & Shapiro, 1982). Although as Gibson

%

n

%

7 31 28 5

(9.9) (43.6) (39.5) (7.0)

20 20 25 6

(28.2) (28.2) (35.2) (8.4)

(1991) has noted, the literature is contradictory on whether self-reports of health among blacks systematically contain more or less bias than those of whites, research by Anderson, Mullner, and Cornelius (1987) suggests that self-ratings accurately portray the health status of African-Americans. In addition to the global health assessment items above, Likert-scale items elicited feelings and attitudes about health. Included were such questions as "How concerned are you about your health right now?" and "Does your health ever get in the way of doing things you need or want to do?" Respondents were asked whether they had experienced any of a list of symptoms or conditions (e.g., arthritis, back or stomach pain, diabetes) over the last 6 months. To provide additional insights into emotional health status, an abbreviated version of Blackburn's Affective Balance Scale was employed (Moriwaki, 1974). The items used helped ascertain whether any of a variety of moods or feelings had been experienced in the last week, such as feeling "appreciated," "depressed or very unhappy," "lonely or remote from people," "like I couldn't get going," and "totally exhausted, even though it was still early in the day." Self-reported changes in physical and emotional health over the past year and in the period since caregiving began also were measured through global assessment items, such as "Compared with a year ago, would you say your health now is: much better, somewhat better, about the same, somewhat worse, or much worse?" Participants were asked a range of questions about their health behaviors and about changes in such behaviors as smoking, alcohol consumption, and eating patterns over the last year and since caregiving began. Finally, follow-up probing and open-ended questions in the areas of perceived health, health behaviors, and changes in health and health habits were used to provide depth and complexity to the health picture presented through more quantatively oriented questions. Findings Table 2 shows responses to the global self-rated assessment question, "Overall, how would you rate your physical health?" As the figure demonstrates, about 10% of the respondents {n = 7) rated their health as excellent, with only five reporting that they were in poor health, and the remainder rating their health as either good (43.6%) or fair (39.5%). No significant differences appeared by age or marital sta-

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Education 8th grade or less Some high school High school degree Some college College degree

Excellent Good Fair Poor

Emotional health

n

tus, but employment status did appear to make a difference, with working women significantly more likely to rate their health as excellent or good (p = < .05). When the same self-rated health question was asked at the follow-up interview conducted with participants approximately a week after the initial interview, almost identical responses were given, with over half of the sample again reporting their health to be good (39.4%; n = 28) or excellent (12.9%; n = 9) and only six women stating that it was poor. Approximately half of the study participants (n = 35) reported that they were "concerned about their health right now," with 15.5% reporting that they were "very concerned." Close to 44% of respondents (n = 31) stated that they were in pain at the time of the interview, and high proportions reported having experienced in the last 6 months stiffness or swelling (50.7%), back or stomach pain (49.3%), heart trouble (25.4%), and other physical symptoms and conditions. Despite their frequent reports of pain and other symptoms, however, fully 45% of the women (n = 32) stated that their health "never" got in the way of things they wanted or needed to do, with only eight women saying that it "frequently" got in the way. Many of the women reporting that their health never got in the way, however, qualified their response by adding statements like, "It can't — I don't let it," "I don't have the luxury of being sick," "I use my asthma pump and keep going," "I just take my medication and keep o n , " or "I bandage my leg, grab my cane, and keep going." A 65-year-old great-grandmother, working parttime at a local school and caring for two greatgrandchildren aged 1 and 2, was among those who reported that her health "never got in the way," but she, too, qualified her response, saying:

Table 3. Physical and Emotional Health of Grandmother Caregivers (n = 71) Now Compared with Before Caregiving Began and with a Year Ago

Physical health n

When asked to compare their current physical health with their health before caregiving began, close to half {n = 33) stated that there had been no change, about a fifth (n = 14) reported a change for the better, and just over a third (n = 24) said that their health was worse now (Table 3). Yet even among women reporting a worsening of what was already poor health, qualitative data frequently revealed an intense desire to convey that "I can handle things," including the added caregiving responsibilities. The response of a 48-year-old grandmother caring for three preschool-aged children illustrates this determination. Her chronic and often disabling back pain requires that she lie on the floor much of the time, yet in her words:

n

%

Now compared with before caregiving began Much better 7 (9.9) Somewhat better 7 (9.9) About the same (46.4) 33 Somewhat worse (21.1) 15 Much worse (12.7) 9

12 9 24 17 9

(16.9) (12.7) (33.8) (23.9) (12.7)

Now compared with a year ago Much better 6 Somewhat better 12 About the same 33 Somewhat worse 13 Much worse 7

11 9 30 14 7

(15.5%) (12.7%) (42.3%) (19.7%) (9.9%)

(8.5%) (16.9%) (46.4%) (18.3%) (9.9%)

Since study participants became primary caregivers for their grandchildren at different times, we also asked them to compare their physical health now with their health a year ago. As Table 3 indicates, 46.4% of the women (n = 33) reported that their health status was the same now as it had been a year ago, with approximately a quarter reporting improved health. Of the latter, six women said that their health was "much better" now, with twice that number stating that their health had improved only "somewhat." About 28% of the sample (n = 20) reported that their health was worse now than a year ago, with seven of these women saying that their health had become "much worse" in the last year. Among the quarter of the sample reporting improved overall health compared with a year ago, many attributed this to improved health behaviors as a consequence of their new caregiving responsibilities. An overweight 57-year-old reported that she had cut back from two packs a day to almost no cigarettes since taking in her two young grandchildren and had also lost 30 pounds. The weight loss, she said, was because she exercises more now, taking the grandchildren for long walks and bike rides, and because "there's no time to sit and enjoy f o o d ! " Another caregiver reported giving up smoking entirely because of the baby's respiratory problems, while a 56year-old with an infant grandson remarked: "I realized I was neglecting myself so I started seeing a doctor, losing weight, and taking care of myself, because I'm the only one he has now." Grandmother caregivers who reported that their health had deteriorated over the past year, however, also frequently cited changes in health and social behaviors as a consequence of caregiving. A 62-yearold diabetic woman commented that she had missed four medical appointments in the last year, each time because of caregiving or because the disarray and confusion in her household, with two young children and a crack-involved daughter, caused her to forget her own needs. A 44-year-old raising two toddlers reported that she and her husband "drink and smoke more than we should now" because of all of the additional responsibilities. And several older

If they don't take me out of here in an ambulance I'll care for them. I've had to almost crawl to the kitchen sometimes, but they've never gone without a meal. Vol. 32, No. 6,1992

Emotional health

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I've been blessed. Oh, sure, I've got arthritis and I had a bladder infection last week. I have high blood pressure and diabetes, I have sleepless nights, but I'm not concerned about my health. What does worry me lately is this pace I'm trying to keep up.

%

I'd like to get myself under the care of a doctor, because I'm feeling this soreness in my back. I can feel myself failing. I'd like to get some teeth in my mouth. That would help my image so much. If I could just get myself some things I need. I need glasses and don't have any . . . . Classes are available, it's just having someone to watch the baby so I can get an appointment. Although the line between physical and emotional health is a thin one, separate analyses were conducted in each of these areas. As shown in Table 2, almost three times as many women reported themselves to be in excellent emotional health as had rated their physical health to be excellent (28.2% vs. 9.9%). Many of those reporting excellent emotional health, however, qualified their rating with comments like "It has to be excellent or I'd be in a nut house" and "I guess it's excellent or how could I deal with all this?" Finally, even among those rating their emotional health as good or excellent, there were frequent reports of feeling lonely or depressed. As Table 4 reveals, 72% of the total sample reported feeling depressed at least some of the time during the past week, with 70% feeling that they "couldn't get going," 78% feeling "totally exhausted even though it was still early in the day," and 47% reporting feelings of loneliness. Although very high proportions also reported feeling appreciated (89%) and feeling that they were fulfilling their responsibilities (96%), the high percentages who reported the more negative feelings are worthy of note. Table 3 reveals how participants rated their emotional health now compared with before caregiving began and compared with a year ago. Approximately a third of the women (n = 24) reported no change, with about 30% (n = 21) suggesting that there had been a change for the better and 36% (n = 26) stating that their emotional health had worsened. Of those reporting improvement in their emotional health since caregiving began, three-quarters reported their emotional health "much better" now than before they took in the grandchildren. In contrast, the majority of those reporting worsened emotional health since caregiving began said that their emotional health was only "somewhat worse" now, with

It took me a long time to accept that that's the way she was. But I had to either accept it or go down with her. I just had to cut her loose. I still think about it a lot, feel bad about it, I still cry a lot. But there's nothing I can do. So I try to go on and do for these kids. In contrast, many of the women who reported that their emotional health was worse now than before caregiving began, or that it had worsened in the last year, stated that watching the deterioration of an adult child on crack was the main factor responsible. For such women, it wasn't caregiving per se that caused a perceived worsening of their emotional health, but rather what that caregiving stood for in terms of the problems faced by their adult children. A subgroup of women for whom caregiving itself was often particularly stressful consisted of those working women for whom the nature of their paid employment tended to mimic work at home. A 59year-old food handler in a public elementary school thus remarked, "There's kids at work and kids at home. Everywhere I go it's kids." Similarly, a nurse's aide working graveyard shift in a convalescent hospital reported that she spends the nights "changing people's diapers" only to return home to do the same for her infant grandson. A second subgroup for whom the emotional dimensions of caregiving appeared particularly stressful were those women who were combining caring for their grandchildren with service as the primary caregiver to a frail or disabled parent or other elder. Although only eight of the women in our sample fell into this "dual caregiver" category, preventing meaningful statistical comparisons, the qualitative data suggested that such women often felt "stretched to the limits" by the overwhelming nature of their responsibilities. A 41-year-old who was raising two grandchildren and a grandniece, all under age 4, and providing significant daily care to two elderly relatives reported feeling frequently depressed and exhausted:

Table 4. "Have you felt this way over the past week?"

Fulfilling your duties Appreciated Totally exhausted Depressed Couldn't get going Need break or go crazy Lonely

n

%

68 63 55 51 50 41 33

(95.8) (88.7) (77.5) (71.8) (70.4) (57.7) (46.5)

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just nine women reporting that it was "much worse." When comparing their emotional health now with a year ago (Table 3), approximately 42% of the women (n = 30) reported no change, with about 28% and 30% reporting better and worse emotional health, respectively. Of the 21 women reporting worse emotional health now than a year ago, twice as many {n = 14) reported that their emotional health was only "somewhat worse" as stated that it was "much worse" now (n = 7). Of those women reporting improvement in their emotional health since before caregiving began, many attributed this to knowing that the grandchildren were finally safe and cared for now that they were in the custody of the grandparents. For others, coming to terms with the crack addiction (and in some cases, the death) of an adult child or grandchild on drugs had resulted in improved emotional health. The case of a 61-year-old great-grandmother, who had raised her granddaughter and was now raising that granddaughter's two young children because of their mother's crack addiction, was illustrative.

grandmothers stated that they no longer took their prescription medications because they needed to "stay alert all the time" for the grandchildren. For a 76-year-old great-grandmother raising her infant great-grandson, the lack of time and of respite care, which would enable her to attend to her own medical needs, was described as taking a toll on her already poor health:

If it's not my grandchildren it's my mother. If it's not her it's my grandniece. If it's not them, it's the children's grandfather. I feel like everyone is depending on me and I have to be there for them.

Discussion The findings of the Grandparent Caregiver Study in the area of physical and emotional health underscore the utility of a research strategy that combines qualitative and quantitative methods. Although 54% of the women in our study reported themselves to be in good or excellent physical health, for example, and although close to half reported that their health "never got in the way," their qualitative responses indicated a more complex and dynamic profile. Indeed, their in-depth responses often revealed an intense desire to protect the children in their care and the newfound security of the children's living situation by downplaying their own health problems. For many of the women, fear that their grandchildren might be placed in foster care if they were unable to provide care for them appeared to contribute to the frequent discrepancies between their own global health ratings and the details they revealed throughout the interviews. Although our results cannot be generalized, they suggest a potentially rich area for further research on the validity of subjective interpretations of health status under such circumstances. As Burnette (1991, p. 175) has noted, "There is an important distinction between unconscious denial of disease and reframing the illness experience within the context of daily life." Although the women in our study admitted to a variety of health problems, some quite debilitating, for the most part they refused to dwell on them or to let them get in the way of caregiving activities. Recent research by White-Means and Thorton (1990) demonstrated that African-American caregivers for the elderly contributed significantly more hours to this activity than the German, Irish, or English ethnic groups studied. Other research has suggested that perceived caregiver burden may be less among African-American women, for whom cultural attitudes and beliefs and the nature of the extended Vol. 32, No. 6,1992

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A 56-year-old woman who reported frequently feeling depressed opened the interview by saying, "I have three children: my 2-month-old who was born on crack, my 17-month-old who's HIV + , and my 83year-old mother. All three are in diapers." A 48-yearold respondent was a caregiver across four generations. In addition to raising five of her grandchildren, she regularly provided help with bathing and other activities of daily living for her own grandmother, did all of the driving, shopping, and other instrumental activities of daily living for her mother, and had her own youngest child still at home. Although each of the above women reported that they were glad to be able to help their elderly parents, they also made clear the impact this added caregiving responsibility was having on their emotional health and their ability to cope.

family system may strongly affect interpretations of burden and strain (Young & Kahana, 1991). In our own study, participants' repeated indications that they were glad they could be there for the grandchildren and that the new caregiving role was well worth the costs similarly suggested that any negative physical or emotional effects of caregiving may be viewed as less important and troubling than might otherwise be the case. The tendency for grandmother caregivers to deemphasize their own health problems appears in keeping with the traditional and often idealized role of the strong black grandmother that pervades writings in the strength-resiliency, pathologydisorganization, and cultural variant perspectives on black family life. Yet such paradigms tend to ignore the fact that full-time caregiving, particularly under the circumstances of the crack epidemic, often is not a desired role for many contemporary black grandmothers who find themselves in this position (Burton & Dilworth-Anderson, 1991). The latter's frequently expressed preference for a more tenuous grandparental role suggests a potential for resentment and conflict that, combined with the demands of such caregiving, might be expected to adversely affect the health of role occupants. Research is needed to reexamine the relevance of existing paradigms on the traditional role of the black grandmother for grandparent caregiving within the context of the crack cocaine epidemic and other problematic sociodemographic circumstances. The far greater tendency for respondents in our study to report excellent emotional health than excellent physical health is of special interest and may suggest a greater perceived reserve of emotional strength than of physical resources. Yet the high rates of feeling depressed, lonely, or "like I couldn't get going" over the past week, together with qualitative findings of often immense stress and worry persisting over months or even years, suggest again that simple self-ratings of emotional health may present an overly optimistic picture. Studies of caregivers for the elderly have demonstrated that although such caregiving may negatively affect the physical health and economic circumstances of caregivers, the most consistent consequence is emotional strain (Brody, 1985; Cantor, 1983; George & Gwyther, 1986; Scharlach & Boyd, 1989). Without ignoring that important differences exist between caring for disabled elderly relatives and raising infant and preschool-aged grandchildren, the emotional strain reflected in both our qualitative and quantitative findings is worthy of attention. The women in our study who reported an overall decline in their emotional health status and who attributed this to the pain involved in watching the deterioration of an adult child provide an important reminder of the need to consider the physical and emotional needs of grandparent caregivers within the context of the larger family unit. As a number of the women suggested, for example, expansion and improvement of treatment programs for crack-

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involved youth may be at least as important to the emotional well-being of grandparents as direct counseling and other interventions directed at these caregivers themselves. The special needs of particular subgroups of grandparent caregivers, for example, those working in jobs that mimic their childcare responsibilities at home and those who are combining grandchild care with eldercare, merit further investigation. Research also is needed to document the prevalence of grandparent caregiving nationwide, including variations by ethnic group and social class. Clinical studies of the functional health status of grandparent caregivers and longitudinal investigations of changes in physical and emotional health and perceived caregiver burden over time also are needed. Further research attention should be focused on the role of formal and informal supports and resources that may help grandparents cope with this challenging role. Finally, the special needs of grandparents raising children who have behavioral, medical, and other problems stemming from prenatal drug exposure or early abuse and neglect deserve research attention, including intervention studies. Whether they are working outside the home, combining eldercare with grandchild caregiving, or foregoing work and other plans for mid- and late life, grandparents who are raising their infant and young grandchildren and great-grandchildren are, for the most part, forgotten caregivers. Practitioners and service providers with a middle-aged and older clientele, particularly in areas with large ethnic minority populations, should be alert to the possibility that their client population includes grandparent caregivers who may have special needs and concerns. Finally, policymakers and others who are working to support family leave and other policies and programs for providers of eldercare should broaden the focus of such efforts to include the needs of grandparent caregivers.

Geriatric Service Line Director Sheppard Pratt Health System, Inc. is an innovative and renowned organization located in suburban Baltimore, Maryland. In response to patient needs and shifting trends in healthcare delivery in the 21st Century, we recently implemented the service line model throughout the Health System. We are currently seeking an accomplished individual to lead and direct the development, growth, and management of our Geriatric service line. In this capacity, you will design and implement innovative programming, marketing and referral strategies; ensure effective fiscal management; and anticipate and meet customer needs through quality care and services. This high-visibility position reports directly to the CEO and COO and emphasizes the visionary and pragmatic components of leadership. The stewardship component will allow the director to pioneer in the development of an integrated continuum of care, thus helping shape the future of the geriatric mental health delivery system. The position requires demonstrated knowledge of gerontology and a minimum of seven years of progressively more responsible administrative and/or clinical leadership normally acquired through an M.D., Ph.D., or Master's degree in health administration, public health, business or related field. Send your resume and salary requirements to: Steven Sharfstein, M.D. President and Chief Executive Officer Sheppard Pratt Health System, Inc. 6501 N. Charles Street Towson, Maryland 21204 An equal opportunity employer.

A not-for-profit health system

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The physical and emotional health of grandmothers raising grandchildren in the crack cocaine epidemic.

This article explores the physical and emotional health status of 71 African-American grandmothers raising their grandchildren as a result of the crac...
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