Abstract
The purpose of this study was to examine the efficacy of an intervention to improve the health of grandmothers raising grandchildren. A pre- and post-test design was employed with 504 African American grandmother participants. The intervention included monthly home-based visitation by registered nurses (RNs) and social workers, participation in support groups and parenting classes, referrals for legal services, and early intervention services for children with special needs. The Health Risk Appraisal was used to assess health indicators and health promotion behaviors. A comparison of pre- and post-test scores indicated significant (p < .002) changes in the desired direction for a number of health indicators and health promotion behaviors, including blood pressure, annual routine cancer screenings, frequency of weekly exercise, and improved dietary intake, as well as participants’ perception of their health and life satisfaction. No improvements were observed in the proportion of participants who were obese or overweight.
Due to the large number of children raised by grandparents, nurses practicing in a variety of health care settings are likely to encounter these families. It is important, therefore, that nurses and other health care providers are knowledgeable regarding the health care issues associated with this family constellation. Between 1990 and 2000 there was a 30% increase in the number of grandparents providing primary care for their grandchildren (Hardy, 2005). Presently, it is estimated that more than 1.6 million children are being raised by grandparents in parent-absent households (U.S. Bureau of the Census, 2010). The upward trend in grandparent-headed families is attributed primarily to child neglect and abuse, parental substance abuse, incarceration, and behavioral health issues, as well the current preference to place children with relatives over nonrelatives when removed by child protective services (CPS).
A substantial body of research indicates that custodial grandmothers are at increased risk for health challenges. Results of a nationally representative study indicate that caregiving grandparents report more functional health limitations compared to their noncaregiving counterparts, even when controlling for age, race and ethnicity, economic status, education, and marital status (Minkler & Fuller-Thomson, 1999). Furthermore, many caregiving grandparents have reported the development or exacerbation of chronic diseases after accepting parental duties for their grandchildren (Haglund, 2000; Lee, Colditz, Berkman, & Kawachi, 2003; Waldrop & Weber, 2001). Although their health challenges are well documented, few interventions addressing the health of caregiving grandmothers are reported in the literature. The current study describes the efficacy of an intervention designed to enhance the health of grandmothers raising grandchildren.
Health Status of Grandmothers Raising Grandchildren
Research consistently demonstrates associations between the responsibility of raising one’s grandchildren and an increased propensity for stress, depression, and poor physical health. For instance, results of a comparative, longitudinal study showed worsened self-rated physical health and increased stress over a 2-year period among grandmothers raising grandchildren in parent-absent households compared to grandmothers living in three generation households and those who did not live with grandchildren (Musil et al., 2011). Being non-White and unemployed contributed to worse self-rated health.
The effects of caregiving duties on the exacerbation of chronic diseases, including diabetes, hypertension, and heart disease, have also been reported by custodial grandparents (Haglund, 2000; Lee et al., 2003; Waldrop & Weber, 2001). In addition to the exacerbation of chronic diseases, caregiving grandparents’ health may be compromised by exposure to acute illnesses acquired by their grandchildren. Epidemiological research indicates that raising grandchildren increases the risk for hospitalization due to influenza and pneumonia, even when controlling for socioeconomic status (Cohen, Agree, Ahmed, & Naumova, 2011).
Research has also demonstrated deficits in physical functioning among caregiving grandparents (Leder, Grinstead, & Torres, 2007; Neely-Barnes, Graff, & Washington, 2010; Whitley, Kelley, & Sipe, 2001). Researchers utilized a nationally representative sample to compare the health status of caregiving and noncaregiving grandparents (Minkler & Fuller-Thomson, 1999). Even after controlling for race, level of education, marital status and income level, they found that caregiving grandparents were more likely to be limited in their ability to do heavy tasks, walk at least six blocks, work for pay, and complete four out of five activities of daily living.
The Role of Psychological Distress
Elevated levels of stress have been linked with negative health outcomes in all subsets of the population. Particularly among older adults, stress can lead to decreased immune function and increased morbidity and mortality (Cearlock & Laude-Flaws, 1997; Fredman, Cauley, Hochberg, Ensrud, & Doros, 2010). Studies of grandparents raising grandchildren have consistently demonstrated disproportionately high levels of psychological distress. Not surprisingly, comparatively high scores of depression and anxiety among grandparent caregivers have also been reported in the literature (Blustein, Chan, & Guanais, 2004; Fuller-Thomson & Minkler, 2000a, 2000b; Musil, 2000; Musil & Ahmad, 2002; Musil et al., 2011; Musil, Warner, Zauszniewski, Wykle, & Standing, 2009).
Research findings suggest a multitude of factors that play a role in increasing stress levels of grandparents raising grandchildren. Caregiving grandmothers tend to be economically disadvantaged, which undoubtedly contributes to higher levels of stress and limited access to health services. In the United States, half a million caregiving grandparents are living in poverty, with minority grandparents experiencing the greatest economic vulnerability (U.S. Census Bureau, 2009). Among African Americans, caregiving grandparents are more likely than noncaregiving grandparents to be living in poverty and receiving public assistance (Minkler & Fuller-Thomson, 2005).
The circumstances under which grandparents assume full-time childcare responsibilities may also influence stress levels. Caregiving duties can increase gradually over a prolonged period of time or occur abruptly, giving grandparents little time to acquire the resources necessary to provide full-time care. Unsurprisingly, single-grandparent caregivers tend to report higher levels of parental stress and emotional strain and lower levels of support than married grandparent caregivers (Conway, Jones, & Speakes-Lewis, 2011; Dolbin-MacNab, 2006; Musil et al., 2011). Younger caregiving grandmothers have also reported higher levels of emotional strain than their older counterparts (Conway et al., 2011; Kelley, Whitley, Sipe, & Yorker, 2000; Kelley, Yorker, Whitley, & Sipe, 2001). It is possible that younger grandmothers experience an additional sense of loss for the personal aspirations that were sacrificed upon assuming full-time parenting responsibilities.
The increased levels of stress found among caregiving grandparents underscore the need for continuous monitoring of its impact on their health. In one study, stress was found to be the strongest predictor of depression and self-reported health problems in caregiving grandmothers (Musil & Ahmad, 2002). Consistent with these findings, other researchers found that stress was associated with lower levels of physical, social, and mental health in grandparents raising grandchildren (Leder et al., 2007).
Positive Outcomes of Caregiving
Whereas the majority of research indicates the detrimental health effects of assuming care of one’s grandchildren, some studies have observed a positive impact on both emotional and physical health. A small sample of grandmothers caring for children of substance-abusing parents expressed feelings of relief and less worry for the safety and well-being of the grandchild (Haglund, 2000). Other qualitative studies have revealed a greater sense of purpose, pride in the grandchild’s accomplishments, and love from the grandchild as sources of improved emotional health (Hayslip & Kaminski, 2005; Kelley & Damato, 1995; Waldrop & Weber, 2001). Some grandparents report a more active lifestyle and a greater sense of responsibility for maintaining their own health as the result of assuming care for their grandchildren (Butler & Zakari, 2005; Waldrop & Weber, 2001).
Preventive Health Behaviors
Despite the extant body of literature indicating an increased risk for health challenges among grandparents raising grandchildren, little is known about their preventive health care practices. In a study using a nationally representative sample of caregiving and noncaregiving grandmothers, researchers found that grandmothers who had recently begun raising a grandchild were less likely to have received an influenza vaccination, pap smear, and cholesterol screening than grandmothers not raising grandchildren, even after controlling for race and ethnicity, marital status, demographic characteristics, and socioeconomic status (Baker & Silverstein, 2008). No differences were found in self-breast exam and mammography. However, grandmothers raising a grandchild for at least 2 years were more likely to receive an influenza vaccination and perform breast self-exam than grandmothers not raising grandchildren. There were no differences found on the other three preventive behaviors. These findings suggest that the transition to full-time parenting may be the time period during which grandmothers are most at risk for ignoring preventive health behaviors. Another study that examined preventive health behaviors in caregiving grandmothers found that close to 30% had not received a mammogram or pap smear in the past year, and less than half had received a rectal or colon screening (Whitley et al., 2001).
Interventions for Caregiving Grandmothers
Although the need for research is clear, few studies have addressed interventions to improve the health of grandmothers raising grandchildren. The majority of the relevant literature is limited by small samples or a lack of outcome data. At the time of this study, only three health-related intervention studies involving caregiving grandparents were located in the literature. In a study assessing the efficacy of an interdisciplinary intervention to the improve well-being of a sample of African American grandmothers raising grandchildren, researchers found improved psychological distress, resources, social support and coping, but not physical health (Kelley, Whitely, & Sipe, 2007). Another study measured the impact of a home-based intervention on caregiving grandmothers’ health attributes; improvements were found in four out of eight self-reported health attributes (Kelley, Whitely, & Campos, 2007, 2010, 2011). Results of a pilot study to improve the nutrition and physical activity knowledge of custodial grandparents indicated improved knowledge, but changes in behavior were not assessed (Kicklighter et al., 2007).
Theoretical Model
This current study drew on the resiliency model of family stress, adjustment, and adaptation (McCubbin, Thompson, & McCubbin, 1996) to conceptualize how stressors placed on the family system can influence the health behaviors of African American grandmothers raising grandchildren. This model, which has been used extensively in nursing research, was developed to provide an understanding of how some families are able to cope effectively when faced with challenges (DeMarco, Ford-Gilboe, Friedmann, McCubbin, & McCubbin, 2000). The model considers how family demands produce change in the family system and how resources affect individual or family adaptation and well-being (e.g., physical and mental health). According to this model, family demands, if not reduced or moderated by resources, may increase the likelihood of negative outcomes, including compromised health. The intervention evaluated in the present study is directed toward positively affecting grandmothers’ adaptation by increasing knowledge regarding positive health behaviors and improving access to health resources. These resources include improved management of chronic health problems, implementation of strategies to improve health and incorporate preventive health behaviors, and referrals to health care providers, as warranted.
Purpose
The purpose of the present study was to examine the efficacy of an intervention to improve the well-being of grandmothers raising grandchildren in parent-absent homes. More specifically, we sought to determine which health indicators and health promotion behaviors can be positively impacted by a home-based nursing intervention designed to improve health in caregiving grandmothers.
Method
Design and Sampling Method
A longitudinal, pre- and post-test design was used to address the research question. The present study uses a convenience sampling method. The 504 participants were recruited from a variety of community-based organizations, including health care centers, child welfare agencies, senior centers, and schools. Participants were eligible if they were a grandmother or great grandmother raising one or more grandchildren aged 16 years or younger in a parent-absent home. Because of the small proportion (less than 2%) of participants who were non-African American, they were excluded from the current study.
Procedure
The study took place in a large U.S. Southeastern metropolitan area. All participants signed letters of informed consent that were part of the research protocol approved by the university’s institutional review board. Once the research protocol was explained to participants, no one who met the study criteria refused to participate in the project. Data collection occurred at base line before participants received intervention services and 12 months after the intervention was complete. Data were collected in the home by trained research assistants who read all survey questions aloud to account for the low educational attainment of many participants. Participants were compensated US$20 for each data collection session.
Intervention
The program involved a 12-month home-based intervention designed to improve the physical and mental health of grandmothers raising grandchildren. The intervention included monthly home-based visitation by registered nurses (RNs) and social workers, participation in support groups and parenting classes, referrals for legal services, and early intervention services for children with special needs. For the nursing component, each participant was assigned to the full-time master’s prepared nursing services coordinator or an RN who worked as a graduate research assistant (GRA). Although the nursing services coordinator had extensive experience in home health care nursing practice and supervision, most of the GRAs’ prior nursing practice was based in adult acute care settings. The GRAs typically had a minimum of 5 years of nursing experience. All GRAs underwent training on implementation of the intervention protocol. Each nurse received a protocol manual that contained modules on safe and effective home visitation, initial and continuous nursing assessment, establishing client goals, management of chronic disease conditions, and data collection guidelines.
During the initial home visit, the RNs conducted a health assessment that measured the following health indicators: height, weight, visual acuity, glucose and cholesterol blood levels, and blood pressure. In addition, participants’ preventive health behaviors and other health indicators were assessed using the Health Risk Appraisal (HRA; Hutchins, 1997). The HRA is a self-assessment of health behaviors and indicators, including current diagnosis of diabetes, hypertension, and obesity as well as use of tobacco, alcohol, and seat belts. The outcomes of these assessments were used to educate the client on their individual risk factors and to formulate strategies to reduce them. The HRA was scored via a laptop computer. Results were immediately available; however, a hard copy of the individual’s report was provided on a subsequent home visit. In addition, the RNs reviewed all prescribed and over-the-counter medications with clients and discussed their intended purpose, dosage levels, and administration schedule. The RNs and participants jointly developed goals to address any health concerns, as well as to foster health promotion. During subsequent home visits, the RNs continued to monitor blood pressure, weight, medications, diet and physical activity, and any issues related to chronic disease management. Referrals were made to primary health care providers or specialists, as necessary. In addition, the RNs provided emotional support to their clients who often felt socially isolated and overwhelmed by the demands of raising vulnerable grandchildren. Based on their individual needs, participants received monthly or bi-monthly visits. Over the 12-month time frame, participants received an average of 9.4 home visits, as well as an average of 3.9 telephone contacts to follow up on health-related issues.
Measures
The Healthier People Health Risk Appraisal (HRA) is a widely used, self-assessment tool for assessing the health risks of an individual and reporting specific modifiable risk factors that are associated with serious illness or premature death. It assesses health in four general areas: physiologic measures, behavioral factors, motor vehicle risk factors, and preventive health behaviors. Physiologic measures include cholesterol levels and current diagnosis of diabetes and hypertension. Behavioral factors include use of tobacco and alcohol, as well as time spent doing physical exercise and nutritional practices. Motor vehicle risk factors include use of seat belt devices and driving at the speed limit. Preventive health behaviors include annual screenings for cancer. Summary scores are not provided; instead, results seek to increase an individual’s knowledge about his or her risk factors and make recommendations to change modifiable risk factors specific to that individual. Researchers have studied the HRA’s reliability and validity attributes and found that, in general, research findings support the efficacy of the instrument. Reliability coefficients on the instrument have been established for cardiovascular disease and overall fitness with results ranging from .43 to .87 (Horowitz, 1996; Smith, McKinlay, & McKinlay, 1991).
Analyses
Data from 504 participants were available for analysis. Descriptive statistics were used to analyze demographic and background variables. Paired t tests were used with continuous level variables to compare pre- and post-test scores. Chi-square analyses were used to compare categorical-level variables at pre- and post-test stages. To avoid the problem of inflated error rates due to multiple analyses (21 total), the Bonferoni technique was applied for each of the analyses, with the Cronbach’s alpha set at .002 (.05 divided by 21).
Results
The mean age of participants was 56.7 years (SD = 8.9), with a range of 38 to 83. Almost one third (31%) of participants were aged 60 years and older. The caregivers included grandmothers (94.7%) and great grandmothers (5.3%). At the time of enrollment, 18.5% of participants were married, 41.1% separated or divorced, 25.2% widowed, and 15.3% single, never married. The mean length of time that participants were the primary care provider for their grandchildren was 4.2 years (SD = 3.4), with a range of one month to 17 years. The mean number of grandchildren in their care was 2.5 (SD = 1.6), with a range of 1 to 8. Regarding educational attainment, approximately half (50.9%) had less than a high school education, suggesting the sample was predominantly of lower socioeconomic status. Thirty-one percent of participants were currently employed, and the remainder was either retired (16.6%) or not working for other reasons (52.3%). All participants identified themselves as African American. Grandmothers reported the following as the main reasons the grandchildren were in their full-time care: child abuse or neglect, 78.7%; parental alcohol or drug abuse, 67%; child abandonment, 37%; child removed by child protective services (CPS), 18%; one or both parents deceased, 17%; one or both parents incarcerated, 16%; and parent with HIV disease, 3%. Many of these factors are interrelated and thus exceed 100% when totaled.
Health Risk Appraisal
Health indicators
Table 1 displays comparisons of pre- and post-test scores on health indicators. Although there were slight decreases in mean weight, the differences were not significant. Based on calculations of body mass index (ratio of weight to height), 87.7% of participants were determined to be either overweight or obese at pretest, with 86.9% overweight or obese at posttest; these proportions did not change significantly at posttest. Twenty-seven percent of participants had current diagnoses of diabetes at both pre- and post-test stages. The results of diastolic and systolic blood pressure measurements at pre- and post-test stages indicated decreases in mean diastolic and systolic blood pressure at postintervention; these findings were statistically significant (p < .002). At posttest, there was a statistically significant increase in the proportion of participants who were taking antihypertensive medications (p < .002). Compared to pretest, there was a statistically significant decrease in mean total cholesterol scores at posttest (p < .002). In response to the HRA item related to general satisfaction with life, there was a statistically significant increase in the proportion of participants who described themselves as mostly satisfied at posttest compared to pretest (p < .002). To summarize their physical health status, the grandmothers were asked to rate their overall physical health considering their age. Proportionately more participants described their health as either excellent or good at posttest when compared to pretest; this increase was statistically significant (p < .002).
Health Indicators
Health promotion behaviors
Comparisons of pre- and post-test scores on health screening and health promotion behaviors are displayed in Table 2. At posttest there were statistically significant increases in the proportions of participants who obtained annual mammograms (p < .002), performed monthly breast self-exams (p < .002), and had annual breast exams by a health care provider (p < .002). With regard to pap smears, there was a statistically significant increase at posttest in the proportion of participants who had obtained one in the past year. There was also a significant increase in the proportion of participants who had obtained a rectal or colon exam in the past year (p < .002), although approximately 11% had never received one.
Health Promotion Behaviors
With regard to health behaviors, there was a statistically significant increase in the proportion of participants who exercised at least once or twice a week at posttest compared to pretest (p < .002). Proportionately more participants reported eating foods high in fiber at posttest when compared to pretest (p < .002) and proportionately fewer reported eating foods high in cholesterol at posttest compared to pretest (p < .002); both changes were statistically significant. The proportion of participants who currently smoked cigarettes at posttest decreased significantly from pretest (p < .002). There were no statistically significant differences in the mean weekly number of alcoholic beverages consumed from pre- to post-test. With regard to motor vehicle behaviors, there was no statistically significant difference in the percentage of time participants wore seat belts. At posttest, proportionately fewer participants drove within 5 miles per hour of the speed limit compared to pretest (p < .002), thereby representing the only modifiable health risk behavior that worsened over time.
Discussion
Our findings suggest that a community-based intervention may be an effective strategy for addressing the health needs of grandmothers raising grandchildren. Although RN home visitation is likely to have contributed to improved self-care health practices, it is also possible that caregiving grandmothers benefited from participation in support groups and parenting classes, as well as case management by social workers. It is encouraging that grandmothers’ perception of their overall health improved, as did their general satisfaction with life. Participants also experienced several improved health indicators, including blood pressure and cholesterol measurements. In addition, there was an increase in the use of medications to manage hypertension. The finding, however, that more than 60% of participants were hypertensive raises serious concern; hypertension is a significant contributor to morbidity and mortality, particularly among African Americans who are at much greater risk of stroke, end-stage kidney disease, and heart disease–related death compared to Caucasians (American Heart Association, 2009).
It is disconcerting that the intervention was not effective in the area of weight loss. In the current study, the prevalence rate for overweight and obese was 87% compared to the national rate of 78% among African American women aged 20 years and older (Flegal, Carroll, Ogden, & Curtin, 2010). This finding suggests that among African American women, caregiving grandmothers may be at even greater risk for obesity. Because obesity significantly increases the risk for, and the morbidity of, diabetes, hypertension, and cardiovascular disease, it is imperative that nurses and other health care professionals prioritize weight management when addressing the health needs of African American caregiving grandmothers. Obesity likely contributes to the decreased physical functioning previously reported with custodial grandmothers (Leder et al., 2007; Neely-Barnes, & Dia, 2009; Neely-Barnes et al., 2010; Whitley et al., 2001). Furthermore, the finding that less than one fifth of participants were married raises concern regarding the availability of another adult in the household to assist in parenting responsibilities, especially with the elevated physical demands of caring for young children.
Findings of the present study indicate that addressing obesity may be one of the more difficult and complex health issues to positively impact in African American caregiving grandmothers. The considerable challenges faced by many caregiving grandmothers (e.g., economic disadvantage, emotional distress, parenting later in life) underscore the need to consider the role of social determinants in health. For instance, in one study grandmothers raising grandchildren cited limited resources, child-rearing responsibilities, and a preference for traditional cultural foods as the most common barriers to healthy eating and physical activity (Kicklighter et al., 2007). Living in lower-income areas is associated with fewer options for food shopping, fewer fresh food options, and limited recreational facilities (Capers, Baughman, & Logue, 2011).
Although a number of studies have examined the health status of grandmothers raising grandchildren, very few have used standardized measures. Instead, most studies rely on nonstandardized, self-report measures of health. The present study improves on previous methodology through use of a standardized self-report measure and several physiological measurements obtained by RNs, including glucose and cholesterol levels, and blood pressure measurements. In addition, RNs obtained height and weight measurements, thereby eliminating the need to rely on self-report to determine BMI scores.
In the present study, improvements were found in the majority of the health promotion behaviors examined. After the intervention, grandmothers were more likely to have received routine cancer screenings in the past year. Such timely screenings are important for early detection of cancer, especially in high-risk populations. The improvements reported in diet, specifically related to eating more foods high in fiber and low in fat, could be effective in future weight reduction efforts and help decrease the likelihood of developing cancer. Despite a slight decrease in the prevalence of smoking, almost a quarter of participants continued to smoke, thereby increasing their risk of cancer and cardiovascular disease.
Methodological Limitations
Several limitations may qualify the current findings. The participants were motivated to participate in an intervention to improve their well-being. In addition, they were predominantly low income and African American. Thus, our results cannot be generalized to all grandmothers raising grandchildren. With the exception of the physiological measures obtained by the RNs, self-report data served as the primary measurement of health indicators and preventive health behaviors. A lack of a comparison or control group makes it difficult to determine whether the intervention was effective or whether the improved health behaviors and indicators occurred for other reasons. Further studies should use randomized clinical trials, as well as samples that are more diverse by race, ethnicity, socioeconomic status, and geography.
Implications for Policy
Health promotion strategies have the potential to significantly decrease the morbidity and mortality associated with chronic disease in grandmother-headed families. Public policy needs to address the resources, including access to health care, available to grandmothers raising grandchildren. Although the grandchildren tend to be covered by Medicaid, many grandmothers are without health coverage due to unemployment, underemployment, financial challenges, and Medicare age requirements. Grandmothers may also lose health care coverage when they leave full-time employment to care for children with special needs. As states and localities develop and implement health care reform policies under the Patient Protection and Affordable Care Act, advocating for enacted provisions that benefit custodial grandparents is critical. Example provisions include expansion of Medicaid eligibility to 133% of federal poverty level, extended funding for the Children’s Health Insurance Program (CHIP), continued funding for closing the Medicare, Part D (prescription coverage) “donut hole” gap, and enhanced health prevention services for Medicare recipients. Full implementation of these provisions would reduce some of the structural barriers that prevent custodial grandparents, and other vulnerable family groups, from acquiring the resources necessary to achieve optimum health outcomes. The provision of preventive health services and disease management is more cost-effective than providing acute care for clients with chronic health conditions (e.g., diabetes, cardiovascular disease). Furthermore, when caregiving grandmothers incorporate preventive health behaviors, they serve as positive role models for their grandchildren.
Consideration of the informal arrangements under which many grandmothers assume care of their grandchildren is also necessary. Because most caregiving grandmothers are not “official” foster care parents, the majority do not qualify for foster care payments to subsidize the expense of housing, clothing, and feeding children. Policy makers should consider more equitable ways to provide financial support to economically disadvantaged grandmothers raising grandchildren. If grandmothers find themselves in a position where they cannot adequately provide basic resources for the grandchildren, the children become at risk for entry into the state foster care system at significant expense to the government.
Implications for Nursing Practice
The awareness of nurses and other health care professionals regarding the increased health risks of grandmothers raising grandchildren is critical for timely and effective intervention. Because grandmothers are more likely to access health care for their grandchildren than for themselves, nurses practicing in children’s health care settings should ensure that caregiving grandmothers seek primary health care for themselves as well. Given the propensity for high levels of stress in caregiving grandmothers, referrals to grandparent support groups, kinship navigator programs, mental health services, and other community programs are suggested. Caregiving grandmothers may also benefit from referrals to nutritionists and weight management programs where they can develop strategies for more healthful eating for themselves and their families. Referrals to smoking cessation programs are also important, when warranted. Because of increased vulnerability to influenza and other preventable infectious diseases, it is imperative that caregiving grandmothers and their grandchildren are fully immunized (Cohen et al., 2011).
Conclusions
Despite improvements in a number of health indicators and health promotion behaviors, the overall health of this group of caregiving grandmothers raises significant concern regarding their longevity and quality of life. With almost one third of participants aged 60 years and older, combined with high rates of obesity, diabetes, and hypertension, this group is clearly at risk for health challenges serious enough to interfere with their ability to parent. If they reach a point at which they are no longer capable of raising their grandchildren due to serious illness or death, the already vulnerable children in their care will, undoubtedly, be further traumatized. Although caregiving grandmothers demonstrate enormous commitment to the well-being of their grandchildren, it is imperative that they have the resources necessary to maintain their own health.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded in part by the Atlanta Women’s Foundation and the Jesse Parker Williams Foundation.