ST04

ORIGINAL PAPER

Deborah M. Whitley dwhitley@gsu.edu

Esme Fuller-Thomson esme.fuller.thomson@utoronto.ca

1 School of Social Work, Andrew Young School of Policy Studies, Georgia State University, P.O. Box 3993, Atlanta, GA 30302, USA

2 Factor-Inwentash Faculty of Social Work and Faculty of Medicine, University of Toronto, 246 Bloor St. W., Toronto, ON M5S 1A1, USA

© Springer Science+Business Media New York 2016

African–American Solo Grandparents Raising Grandchildren: A Representative Profile of Their Health Status

Deborah M. Whitley1 · Esme Fuller-Thomson2

Introduction

Approximately 1.3 million African–American grandparents are living with their grandchildren in the U. S.; nearly half (47.6 %) of them have primary responsibility for raising their grandchildren [1]. Further, about one-third of all grandpar- ent-headed families are raising their grandchildren without the children’s parents living in the home, and without the assistance of a spouse or significant other [2]. The total par- enting responsibility rests entirely with these grandparents, a role that may contribute to adverse physical and emotional outcomes unless deliberate efforts are made to provide safe- guards designed to meet their unique needs [3]. Social and economic challenges (e.g., poverty, substandard housing, public assistance dependency) augment African–American grandparents’ risks for adverse health conditions, which they face disproportionally in comparison to other racial groups [4]. The present study attempts to document the physical and mental health characteristics and health behaviors of a rep- resentative sample of African–American custodial grandpar- ents, who are raising their grandchildren without the support of a spouse or significant other, hereafter referred to as solo grandparents. The physical and emotional strains of raising one or more children under difficult social circumstances and with limited financial resources often negatively impact their well-being [5]. To develop effective community-based services to address grandparent caregivers’ health concerns, it is important to document the prevalence of their medical conditions and problematic health behaviors.

For this inquiry, we compare the health profile of solo grandparents with a representative sample of African– American single parents also raising their children alone. Comparing these two family groups has merit because of their similar socio-economic status, and shared life chal- lenges [6, 7].

Abstract The objective of this study is to document the health profile of 252 African-American grandparents rais- ing their grandchildren solo, compared with 1552 African- American single parents. The 2012 Behavior Risk Factor Surveillance System is used to compare the specific physi- cal and mental health profiles of these two family groups. The findings suggest solo grandparents have prevalence of many health conditions, including arthritis (50.3 %), dia- betes (20.1 %), heart attack (16.6 %) and coronary heart disease (16.6 %). Logistic regression analyses suggest that solo grandparents have much higher odds of several chronic health disorders in comparison with single parents, but this difference is largely explained by age. Although solo grandparents have good access to health care insur- ance and primary care providers, a substantial percent- age (44 %) rate their health as fair or poor. Practice inter- ventions to address African American solo grandparents’ health needs are discussed.

Keywords African American grandparents · Grandparents raising grandchildren · Health disparities · Single parents

J Community Health (2017) 42:312–323 DOI 10.1007/s10900-016-0257-8

Published online: 20 September 2016

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many face similar social and economic challenges [7, 24, 25]. While variation in age-related health outcomes between the groups is expected, the importance of highlighting simi- larities and differences in health conditions and behav- iors between the two single parenting groups gives health experts additional information about the range of services required to promote positive family health.

Theoretical Perspective

The theoretical underpinnings of this study draw upon Pearlin and colleagues’ [26, 27] perspective about the association between life stressors and physical/emotional health. Specifically, the authors postulate that unexpected life changes or role transitions are a source of emotional stress; intense, unabated stress is a primary contributor to adverse health outcomes, such as heart attacks, obesity, and diabetes [26, 27]. Grandparents faced with sudden role transition, such as becoming a surrogate parent due to child abandonment, parental illness/death, military deployment, or incarceration, experience levels of stress that do not nec- essarily dissipate with time. Additionally, economic insecu- rity, ongoing family disruptions, or raising grandchildren in need of specialty medical and other support services due to extensive physical, emotional and development problems from early life trauma and loss exacerbate stress levels for solo grandparents. While our study is not explanatory in nature, we believe a descriptive account of specific health attributes of solo grandparents provides added knowledge to support community-based health promotion options.

Methods

Data Source and Sample

As has been discussed elsewhere [28, 29], this study is a sec- ondary analysis of the 2012 Behavior Risk Factor Surveil- lance Survey (BRFSS). The BRFSS is a collaborative project of the Centers for Disease Control and Prevention (CDC) and U.S. states and territories. The survey is designed to appraise risks related to state-specific health characteristics and behav- iors for the adult population. Annually, interviewers gather standardized data by telephone from a representative sample of non-institutionalized adults, aged 18 or older who are liv- ing in households. The BRFSS uses a disproportionate strati- fied sample design, which divides all possible phone numbers into high and medium-density groups that are sampled inde- pendently [30]. Although the 2012 BRFSS includes both cel- lular phones and landlines, only respondents with landline numbers were asked a question on the number of adults in their household. We used this question to determine if the

Literature Review

Several early studies on custodial grandparents explore self-reported physical and mental health conditions [4, 5, 8–10]. Many of these studies focus predominately on the health of African–American grandmothers because of their over-representation in comparison to other ethnic-racial or gender groups. Grandparents’ reported chronic health conditions include obesity, heart disease and hypertension [10, 11]. Several studies suggest custodial grandparents have high rates of depression and are more likely to have low self-esteem and poor health [3, 12, 13]. A majority of these studies reported generalized health status as opposed to exploring specific diseases or diagnoses, thereby pro- viding an incomplete picture of grandparent caregivers’ health challenges [14–16]. However, there is a consensus among researchers that the physical and mental health of grandparents can affect their ability to provide long-term caregiving support to their grandchildren, producing a risk for further childhood trauma and life disruption [17, 18].

There is a small body of research that explores the direct association between caregiving and the health of grandparent caregivers [11, 19–21]. However, most of these studies, while informative, have limited generalizability due to their reliance upon small, convenience samples, or the sampled group does not explicitly focus on African–Americans in the U.S. Fur- thermore, early studies on grandparent-headed families give scant attention to family composition. Most studies aggre- gate grandparent households across family arrangements to include those raising their grandchildren solo with those who are sharing the caregiving burden with others, often a spouse. The current study addresses this issue by focusing only on grandparent caregivers who are raising their grandchildren solo, without live-in support from spouses or other family members. It is likely these grandparents are most vulnerable to adverse health effects since there is no one to share the caregiving tasks and responsibilities. The full physical and emotional burden of care rests on their shoulders.

Another factor in exploring the health of African–Ameri- can solo grandparents is recognizing the inclination of care- givers to delay or neglect their health care needs in order to give full attention to the multiple needs of their grandchil- dren [22]. Delays in addressing existing chronic illnesses (e.g., assessing glucose levels for those with diabetes) or keeping routine medical exams and screenings (e.g., annual mammograms) may negatively affect parenting roles and responsibilities if these delays result in an exacerbation of health problems [23]. Furthermore, insight on the use of health services by African–American custodial grandpar- ents can also inform future outreach strategies.

We use single parents as a comparison group for this study because they are also raising children without the sup- port of a spouse or significant other in the household, and

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considered included arthritis, COPD, diabetes (excluding borderline and gestational), asthma, cancer (excluding skin), heart attack, stroke, kidney disease, coronary heart disease and depression. Self-assessed health was also measured using the following question: “Would you say that your health, in general, is: excellent, very good, good, fair, poor?” Responses were recoded into excellent/very good/good health vs. fair/poor health. Finally, health-related quality of life was measured based on three questions. The first was “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?” Responses were recoded into 0, 1–7 and >7 days. The same type of question was also asked about mental health (e.g., “Now thinking about your mental health…”); response codes were changed in a similar manner as physical health. The third question was as follows: “During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?” Response codes were changed using the same categories as physical health (i.e., 0, 1–7 and >7 days).

Health Care Utilization

Access to health care coverage was assessed by the question: “Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or govern- ment plans such as Medicare, or Indian Health Service?” Access to doctors or other health professionals was based on the following two questions: “Do you have one person you think of as your personal doctor or health care provider?” Responses were recoded into yes (one or more) and no. The second question addressed cost as a barrier to accessing a health care provider: “Was there a time in the past 12 months when you needed to see a doctor but could not because of the cost?” Finally, the respondents reported the time since their last routine checkup in response to the question “About how long has it been since you last visited a doctor for a routine checkup?” [A routine checkup is a general physical exam, not one for a particular illness or injury]. Response options were “within the past 12 months”, “between 12 and 24 months”, “between 2 and 5 years”, “5 years or more”.

Health Behaviors

The 2012 BRFSS measured health behaviors [31]. The first question asked about physical activities: “During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthen- ics, golf, gardening, or walking for exercise?” Based upon self-reported weight and height, the body mass index (BMI) score, was calculated and categorized into three levels: Nei- ther Overweight nor Obese (BMI < 25), Overweight (BMI

grandparent was raising their grandchildren alone in the residence. Thus, our findings are generalizable to commu- nity-dwelling residents in 36 states who have landlines. The landline response rate for the 2012 BRFSS was 49.1 % [31]. The sample for this study was restricted to African–American adults who were living with no other adult in their household and who were raising their grandchildren or children. The unweighted sample size for the bivariate analyses included 252 African–American, non-Hispanic solo grandparents and 1552 single parents for a total of 1804 respondents. Due to missing data on age, the logistic regression analyses had a slightly smaller sample size (1766).

Measures

Parental Demographics

Background information was gathered on the parent figure in the household, including the following: gender (male vs. female); age (18–39, 40s, 50s, 60s, 70s, 80+); education level (less than high school diploma vs. greater), income range (less than $15,000, $15,000–24,999, $25,000–49,999, $50,000–74,999, $80,000 or greater) and place of residence based on metropolitan statistical area (MSA) codes.

Parental Identification

In the BRFSS, there is a module that focuses on a randomly selected child under age 18 in the household [31]. One of the questions asked about the adult respondent’s relationship to the focus child. If the adult responded “grandparent” and there was only one adult in the household, this respondent was identified as a “solo grandparent caregiver.” If the adult answered “parent,” which could include biologic, adoptive, or step and there was only one adult in the household, this respondent was categorized as a “single parent with no part- ner present in the household.”

Child Characteristics

The focus module, as described above, included questions on a focus child’s age (age <5, 5–12 years, 13–18), gender, and ethnicity. Specific questions about health status involved asthma (“Has a doctor, nurse or other health professional EVER said that the child has asthma?”) and receiving a flu shot in the past year [“During the past 12 months, has (the child) had a seasonal flu vaccination?”].

Physical and Mental Health Status

Adult respondents were asked to indicate whether a “doctor, nurse or another health professional” ever told them they had any of the following [medical conditions]?” The conditions

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heart attack (16.6 vs. 1.5 %; p < .001), stroke (11.2 vs. 2.0 %; p < .001), cardiovascular disease (12.6 vs. 2.3 %; p < .001) and kidney disease (5.3 vs. 1.6 %; p < .001). Solo grandpar- ents also report having asthma at higher rates than single parents (26.8 vs. 15.8 %; p < .001). Solo grandparents are more likely than single parents to report they have been diagnosed with depression compared to single parents, (25.4 vs. 16.8 %; p < .05).

Consistent with information on physical health condi- tions, a far higher percentage of solo grandparents rate their health as fair or poor (43.8 vs. 15.1 %; p < .001), experience more than seven days of bad physical health a month (32.5 vs. 13.2 %; p < .001), and are more likely to experience functional limitations in daily activities (23.2 vs. 11.4 %; p < .001) in comparison with single parents. Finally, the health behaviors of solo grandparents reveal worse habits than those of single parents. A greater proportion of solo grandparents had not exercised in the previous month (42.6 vs. 23.1 %; p < .001), are current, everyday smokers (26.2 vs. 13.9 %) or former smokers (28.7 vs. 8.5 %; p < .001) as compared to single parents. However, African–American solo grandparents have a lower percentage of being obese in comparison to single parents (36.4 vs. 45.8 %; p < .001), but, both groups have rates that are disturbingly high.

Health utilization characteristics are found in Table 3. More than 90 % of the solo grandparents in our sample have health care coverage compared to nearly four-fifths of single parents (92.9 vs. 78.9 %; p < .001). A larger percentage of solo grandparents also report having one or more doctors (89.9 vs. 81.2 %; p < .001). Finally, more than 90 % of solo grandparents had a routine physical checkup in the previous year, compared to just over three-fourths of single parents (p < .001).

The logistic regression analyses, presented in Table 4, give the odds of African–American solo grandparents having specific health conditions as compared to African– American single parents. Solo grandparents had signifi- cantly higher unadjusted odds of arthritis (OR 4.82; 95 % CI 3.47, 6.69), COPD (OR 4.42; 95 % CI 2.59, 7.53), dia- betes (OR 3.41; 95 % CI 2.23, 5.20), asthma (OR 1.96; 95 % CI 1.36, 2.82), cancer (OR 4.13; 95 % CI 2.35, 7.25), heart attack (OR 12.71; 95 % CI 7.20, 22.43), stroke (OR 6.31; 95 % CI 3.51, 11.35), and angina or coronary heart disease (OR 6.05; 95 % CI 3.47, 10.55) (all p < .05). In the preceding month, African–American solo grandparents had higher odds of having poor physical health days (OR 1.58; 95 % CI 1.14, 2.18), being limited in their activities due to physical or mental illness (OR 1.63; 95 % CI 1.16, 2.29), and reporting their overall health as fair or poor (OR 4.38; 95 % CI 3.14, 6.10) compared to African–American single parents. When adjusted for race, education, income, and sex, the differences between parents and grandparents persisted. However, when age was added to the model,

between 25 and 29.99) and Obese (BMI of 30 or more). The third health behavior self-identified smoking habits accord- ing to four categories: Current Smoker-Everyday, Current Smoker-Some Days, Former Smoker and Never Smoked.

Data Analysis

A descriptive analysis was used to classify the demo- graphic, physical health and mental health characteristics of African–American solo grandparents, contrasted with African–American single parents. Comparisons were made using Chi square tests undertaken in SPSS, version 21. We also conducted a series of logistic regression analyses for 13 physical health outcomes using a three-nested model. The first model compared health results for the solo grandpar- ents and the single parents with no adjustments for other characteristics. The second model added gender, education and income level; the final model included age, gender, edu- cation and income. The analyses were conducted with data weighted to address the probability of selection and nonre- sponse bias. The p-values, percentages, and odds ratios are based on weighted data. The sample sizes are presented in their un-weighted form.

Results and Discussion

The demographic characteristics of the two samples are found in Table 1. As anticipated, African–American solo grandparents are significantly older in age in comparison to single parents, (p < .001). The largest proportion of solo grandparents are in their 50s (32.7 %), while a majority of single parents are between 18 and 39 years of age (63 %; p = .001). Solo grandparents have lower socioeconomic sta- tus than single parents; almost a third of solo grandparents had not completed high school (31.2 %) versus approxi- mately one-tenth of single parents (10.5 %; p < .001). Simi- larly, one-third of solo grandparents has an annual income of less than $15,000 (30.3 %), compared to a quarter of single parents (25.5 %; p < .001). A larger percentage of solo grandparents have only one child in the household, in comparison with single parents (59.2 vs. 39.3 %; p < .001). Solo grandparents were more likely to be raising grandchil- dren age 13–18 years (56.6 %) as compared to single parents (37.0 %; p < .01). Fewer children with asthma were found in homes of solo grandparents (14.9 vs. 24.2 %; p < .05).

The physical and mental health characteristics of the two parent groups are presented in Table 2. As expected, a larger percentage of African–American solo grandparents’ report having more chronic medical conditions as compared to African–American single parents, including arthritis (50.3 vs. 17.5 %; p < .001), COPD (12.5 vs. 3.6 %; p < .001), dia- betes (20.1 vs. 6.9 %; p < .001), cancer (11.2 vs. 2.9 %),

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were threefold among the solo grandparent caregivers than the single parents. In contrast, when age was included in the analyses, solo grandparents had significantly lower odds of

the difference between solo grandparent caregivers and single parents was no longer significant for most health issues. Three exceptions existed: For heart attack, the odds

Table 1 Solo African–American grandparents and single parents: demographic characteristics (n = 1804)

Grandparent/parent demographic indicators Solo AA grandparents (n = 252) (%)

Single AA parents (n = 1552) (%)

p-value

Gender Male 16.6 12.9 0.11 Female 83.4 87.1

Age 18–39 0.6 63.3 0.001 40s 10.1 25.4 50s 32.7 10.1 60s 26.8 1.1 70s 29.2 0.1 80s 0.6

Education Did not graduate high school 31.2 10.5 0.001 Graduated high school 68.8 89.5

Income categories <15,000 30.3 25.5 0.001 15,000–24,999 40.7 27.0 25,000–49,999 16.6 25.3 50,000–74,999 8.3 12.1 75,000 or more 4.1 10.1

MSA code In the center city of an MSA 60.4 54.4 0.54 Outside the center city of an MSA 20.7 22.3 Inside a suburban county of the MSA 6.5 13.4 In an MSA that has no center city 0 1.6 Not in an MSA 12.4 9.4

Number of children in household 1 59.2 39.3 0.001 2 27.2 37.6 3 10.7 13.7 4 1.2 6.7 5+ 1.8 2.7

Gender of child Boy 51.2 48.1 0.47 Girl 48.8 51.9

Age of child <5 years 11.0 15.3 0.001 5–12 years 32.4 47.7 13–18 years 56.6 37.0

Child history of asthma Yes 14.9 24.2 0.04 No 85.1 75.8

Child flu shot in past 12 months Yes 62.7 57.7 0.56 No 37.3 42.3

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depression at some point in their lives, as compared to sin- gle parents (16.8 %). As a point of reference, the estimated lifetime prevalence of depression in adults in the U.S was 16.1 % in 2008 (last year data available) [34]. While it is believed stress is a major contributor to depression among parents [35], there may be other factors that are uniquely relevant especially for persons of color. Put simply, the issue of depression among African–American grandpar- ents, as with any persons of color, is complex. Poverty is associated with an increased risk for depression [36, 37], which concurs with the prevalence of depression among solo grandparents, who also reported lower socioeconomic and educational status in comparison with single parents. African–American solo grandparent caregivers often face the cumulative effects of lifelong poverty, poor education, low-paying jobs, precarious employment, and social mar- ginalization. Having to support young grandchildren finan- cially on limited resources is often enough to push some grandparents into poverty, thereby increasing their risk for depressive moods. Social factors associated with depression for persons of color also often include perceived personal discrimination, living in communities with few economic resources, and lack of social connectedness with peers or other significant social groups [38–40]. Expanding research that considers these perspectives may provide greater insight into the prevalence of depression among African-American solo grandparents.

From another perspective, there is extensive literature on the structural and interpersonal barriers various racial/eth- nic groups experience when trying to obtain mental health services for depression [41]. As noted, most solo grand- parents are enrolled in health care plans which should give them access to mental health services. But when services are located, the quality of care is often poorer for African– American patients in comparison to other racial groups [42– 44]. Therefore, depression and other psychological distress diagnoses may remain unresolved. Poor patient-provider interactions may exacerbate the risk for adverse mental health outcomes, leaving patients to abandon any prescribed management protocols due to lack of trust and connected- ness with the provider [45].

On a positive note, a majority of solo grandparents (61.3 %) reported experiencing “no bad days” in the previ- ous month due to psychological stress, which was similar to the physical health results. Our findings suggest adverse mental health effects is not a forgone conclusion for this family group. Rather, most solo grandparents seem to have attained an emotional balance robust enough to report a pos- itive rating of their mental health. Learning what specific coping or stress management mechanisms are used by solo grandparents that enhance their mental health perceptions is an area for future study. But it is also important to discern if African–American solo grandparents are possibly using

both arthritis and diabetes than single parents. Adjusting for race, education, income, sex and age also reduced the differ- ence between solo grandparents and single parents regard- ing past-month functional limitations, and poor physical health days to non-significance.

Physical Health

Our findings reveal African–American solo grandparents had a higher prevalence of chronic health conditions, poorer physical functioning, and longer periods of inactivity com- pared to single parents. These factors alone suggest the vul- nerable physical state solo grandparents are experiencing. Their leading diagnoses were arthritis, diabetes, asthma, and COPD. Age is a key factor for this result because many of these diagnoses are strongly age-related (e.g., arthritis, COPD). Single parents, as expected, were younger and reported fewer health challenges; their most prevalent diag- noses were arthritis and asthma, but at significantly reduced rates in comparison to solo grandparents.

The high prevalence of chronic physical conditions among solo grandparents provides some rationale as to why nearly 44 % of the grandparents rated their physical health as “fair” or “poor”, and 32.5 % rated their health as being “not good” for more than 7 days in the previous month. Depend- ing on the level of disease severity, several of the reported conditions have very debilitating effects that require spe- cialty care and management (e.g., various forms of arthri- tis, COPD). Combined with the natural aging process, a significant portion of solo grandparents are in a vulnerable physical state, and could continue to experience physical deterioration during times when their grandchildren’s devel- opmental needs will require ongoing active involvement or monitoring by an adult. For this sub-group of grandparents, there is a concern given the general understanding that poor self-rated health increases the risk of premature mortality [32]. Determining if personal physical routines, alternative treatment modalities, or social support networks have any bearing on self-ratings of health and mortality risk needs further study, especially since these and other factors may affect how African–American grandparents manage their health [33]. Interestingly, over half (56.5 %) of solo grand- parents rated their physical health as “good, very good or excellent” despite the preponderance of chronic health con- ditions. How self-rated health and mortality risk are related within this group is also unknown, but is an area of study that could have significant meaning.

Mental Health

Our results showed the prevalence of clinical depres- sion was disturbingly high among solo grandparents with approximately a quarter (25.4 %) of them diagnosed with

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Health indicators Solo AA grandparents (n = 252) (%) Single AA parents (n = 1552) (%) p-value

Arthritis Yes 50.3 17.5 0.001 No 49.7 82.5

COPD Yes 12.5 3.6 0.001 No 87.5 96.4

Ever diagnosed with diabetes (excluding borderline or gestational) Yes 20.1 6.9 0.001 No 79.9 93.1

Asthma Yes 26.8 15.8 0.001 No 73.2 84.2

Cancer (other than skin) Yes 11.2 2.9 0.001 No 88.8 97.1

Heart attack Yes 16.6 1.5 0.001 No 83.4 98.5

Stroke Yes 11.2 2.0 0.001 No 88.8 98.0

Angina or coronary heart disease Yes 12.6 2.3 0.001 No 87.4 97.7

Kidney disease Yes 5.3 1.6 0.001 No 94.7 98.4

Self-rated health Good or better health 56.2 84.9 0.001 Fair or poor health 43.8 15.1

Number of days/month physical health not good No bad days 53.0 64.1 0.001 1–7 bad days 14.5 22.7 >1 week bad days/past month 32.5 13.2

Limitations in activity in last month due to physical or mental illness No days limited 66.7 76.6 0.001 1–7 days limited 10.1 11.9 >1 week limited days/past month 23.2 11.4

Number of days mental health not good in past month No bad days 63.5 62.3 0.77 1–7 bad days 15.6 17.8 >1 week bad days/past month 21.0 19.9

Lifetime depressive disorder Yes 25.4 16.8 0.01 No 74.6 83.2

Health behaviors Any physical exercise in last month

Yes 57.4 76.9 0.001

Table 2 Solo African–American grandparents and single parents: family physical/mental health indicators (n = 1804)

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example, older grandchildren may take on some of the most physical tasks, such as doing laundry and housecleaning, while leaving less physical tasks to be performed by their grandparents. In this context, a grandparent could very well give a positive rating of their functioning, in light of the lower physical demands they face. Three in five solo grand- parents are raising only one grandchild, and the majority of these grandchildren are in their adolescent years. Routine childcare tasks may be less of an issue for them. However, there is a segment of solo grandparents (11 %) who are rais- ing grandchildren 5 years of age or younger and having the physical and emotional capacity to perform daily caregiving tasks could be a challenge for these grandparents. An area for further study is learning how these grandparents accom- modate functional limitations to complete daily caregiving duties.

Health Service Utilization

A majority of solo grandparents and single parents report having some form of health care coverage (92.9 vs. 78.9 %; p < .01). Medicare is probably the primary health plan for many grandparents since 56 % are 60+ years of age. Single parents may have greater difficulty accessing health insur- ance if they are employed where health insurance is not offered to them, or the cost is beyond their means [46]. Aligned with having health insurance, solo grandparents are more likely to have a health care provider in com- parison to single parents, (89.9 vs. 81.2 %, p < .01), and to have obtained a routine physical examination in the pre- vious year compared with single parents (92.3 vs. 75.8 %, p < .01). But as noted, the percentage of solo grandparents who rated their health as fair or poor is quite high. The literature suggests the lack of culturally-sensitive health care services may impact health outcomes in racial minor- ity groups [47]. Knowing how custodial grandparents pos- sibly delay obtaining medical services for their own health

unhealthy behaviors to address their emotional needs, which may have temporary emotional benefits, but ultimately have deleterious effects on other aspects of well-being, such as physical health. For example, consumption of alcohol, smoking, and overeating are known responses to stress. Grandparents who are practicing such forms of coping may experience some temporary relief in mental health symp- toms, but such strategies may eventually have a negative impact on their physical health [36]. Further exploration of the association among stress, coping and depression among African–American solo grandparents is essential.

Functional Limitations

Nearly one-third of the solo grandparents in our study expe- rienced functional limitations due to physical and mental health conditions. Considering the prevalence of chronic health conditions reported by solo grandparents, it is some- what surprising that more grandparents did not report dif- ficulties with their daily activities. Functional limitations include the ability to perform activities of daily living (bath- ing, dressing, preparing meals, general housekeeping) to meet personal needs. But the concept should extend to take into account the caregiving role for children. In this context, functional capacity includes being able to perform general parenting tasks such as carrying and bathing infants or small children, preparing multiple family meals on a daily basis, cleaning and mending laundry, and picking up small toys or objects from the floor, transporting children as needed. More than double the percentage of African–American solo grandparents in comparison to single parents had functional limitations extended beyond seven days in total during the preceding month (23.2 vs. 11.4 %). Not being able to per- form routine activities is particularly problematic when there are small children in the household. For some solo grandparents, older children may take on full or partial care- giving responsibilities for young children in the home. For

Health indicators Solo AA grandparents (n = 252) (%) Single AA parents (n = 1552) (%) p-value

No 42.6 23.1 BMI category Neither overweight nor obese 35.8 21.2 0.001 Overweight 27.9 33.1 Obese 36.4 45.8

Smoking status Current smoker—smokes everyday 26.2 13.9 0.001 Current smoker—smokes some days 9.1 7.1 Former smoker 28.7 8.5 Never smoked 36.0 70.5

Table 2 (continued)

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and other social institutions that are readily available to solo grandparents. Without improvements in these health behaviors, African–American solo grandparents (and single parents) are likely to live shortened lives, potentially cre- ating another phase of life trauma and disruption for their grandchildren.

Practice Implications

Many African–American solo grandparents are living under social and economic conditions where they have restricted flexibility to access a variety of support services. Although single parents also have similar environmental stressors, their younger age serves, at least for the time being, as a buffer for the physical adversities shown in the solo grand- parent group.

The constructs of race and poverty cannot be ignored when thinking about the findings from this study. Mat- thew [49] suggests resolutions addressing issues of race, poverty and health disparities should be framed within a structural context. Social and legal efforts that disincen- tivize racial bias leading to health disparities is certainly an ideal goal toward changing social norms. But concur- rent with this long-term effort, more immediate changes in practice behaviors by health professionals that are patient- centered needs consideration. Promoting patient-centered services steers away from institutional-focused strategies where “one size fits all”, and provides culturally-aware strategies that are practice readily. Patient-centered health care practices promote interpersonal respect between the patient and health care provider, and there is an acknowl- edgment of and appreciation for cultural differences in the health care setting [50]. Examples of patient-centered practices include establishing ways to make African– American grandparents and single parents feel empowered by promoting a sense of fairness and trust in the health care staff. The collaborative development of patient care plans should acknowledge the parenting challenges grand- parents face and the potential effect on their physical and emotional health. Health care institutions should consider how patients are given a voice when assessing health care services, as well as advocate for greater racial diversity among medical personnel. Many African–American solo grandparents are from a generation where they were viewed only as recipients of medical care, and not as a partner in the healing process. Changing the interactive dynamic between patient and provider could be an initial point to alter this perspective. Work towards testing and expanding patient-centered strategies across health care settings (i.e., primary care, specialty care, ancillary ser- vices), and evaluating this approach on caregiving grand- parents’ clinical outcomes and perceptions is a fruitful area of future research.

because of the time needed to raise their grandchildren [5, 48], cultural insensitivity by health care providers may add another barrier to accessing much needed health services for these caregivers.

Health Behaviors

African–American solo grandparents have a high preva- lence of negative health behaviors. Our findings suggest solo grandparents are less likely than single parents to par- ticipate in recreational physical activities (57.4 vs. 76.9 %, p < .001) and are more likely to be current smokers, either every day or some days compared to single parents (35.3 vs. 21.0 %, p < .001). However, a smaller percentage of solo grandparents are either overweight or obese as compared to single parents (64.3 vs. 78.8 %; p < .001). Physical inactivity, current smoking behavior, and obesity are known risk fac- tors for adverse health outcomes, including cardiovascular disease, diabetes, respiratory illness, and cancer. Grandchil- dren are also at risk for respiratory ailments in households where solo grandparents smoke. There is an urgent need for accessible and affordable community support services to help these families modify unhealthy behaviors, and move toward a healthy lifestyle. For example, a majority of solo grandparents are living in central cities (60.4 %), where access to safe parks and other recreational facilities may be challenging. Efforts to advocate for redirection of public resources to fund public parks, walking trails, and playgrounds in central cities are essential. Culturally sensi- tive smoking cessation and weight management programs are needed in central cities through churches, senior centers,

Table 3 Solo African–American grandparents and parents: utilization of health care services (n = 1804)

Health service utilization indicators

Solo AA grandparents (n = 252) (%)

Single AA parent (n = 1552) (%)

p-value

Have any health care coverage Yes 92.9 78.9 0.001 No 7.1 21.1

Have one or more personal doctors/health care providers Yes 89.9 81.2 0.001 No 10.1 18.8

Could not see doctor because of cost Yes 17.9 24.3 0.07 No 82.1 75.7

Length of time since last routine checkup <12 months 92.3 75.8 0.001 1–2 years 3.0 15.4 2–5 years 1.8 5.9 5+ years 3.0 2.9

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Compliance with Ethical Standards

Conflict of Interest The authors declare they have no conflict of interest.

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Conclusion

The substantial physical and mental health problems expe- rienced by African–American solo grandparents continue to be of great concern, particularly for a segment of custodial grandparents who display serious physical and mental health challenges. Our detailed findings signal the critical need for environmental and institutional health interventions to consider planned approaches to affect the health problems of solo par- enting groups in acknowledgment of their unique needs and behaviors. Health interventions that engage solo grandparents in the healing process may contribute to the long-term care and well-being of the grandchildren they are raising, creating a more stable family environment for their growth and development.

Acknowledgments Dr. Esme Fuller-Thomson gratefully acknowl- edges support from the Social Science and Humanities Research Council (SSHRC) and the Sandra Rotman Endowed Chair Fund.

Table 4 Odds ratios and 95 % confidence intervals associated with African–American solo grandparent caregiving versus African–American single parents for 13 different health outcomes (n = 1766)

Health outcome Solo grandparent versus single parents

Model 1 Model 2 Model 3

No additional adjustments Adjusted for sex, education and income

Adjusted for sex, education, income and age

Arthritis Solo grandparents 4.82 (3.47, 6.69) 4.35 (3.11, 6.09) 0.50 (0.31, 0.82) Single parents 1.00 1.00 1.00

COPD Solo grandparents 4.42 (2.59,7.53) 3.84 (2.20, 6.70) 1.40 (0.59, 3.34) Single parents 1.00 1.00 1.00

Diabetes (excluding borderline/ gestational)

Solo grandparents 3.41 (2.23, 5.20) 3.14 (2.01, 4.91) 0.35 (0.18, 0.68) Single parents 1.00 1.00 1.00

Asthma Solo grandparents 1.96 (1.36, 2.82) 1.84 (1.26, 2.68) 1.34 (0.79, 2.25) Single parents 1.00 1.00 1.00

Cancer (excluding skin cancer) Solo grandparents 4.13 (2.36, 7.25) 3.43 (1.88, 6.25) 1.24 (0.49, 3.13) Single parents 1.00 1.00 1.00

Heart attack/myocardial infarction Solo grandparents 12.71 (7.20, 22.43) 10.57 (5.74, 19.46) 3.10 (1.16, 8.26) Single parents 1.00 1.00 1.00

Stroke Solo grandparents 6.31 (3.51, 11.35) 5.86 (3.15, 10.92) 1.86 (0.70, 4.96) Single parents 1.00 1.00 1.00

Angina or coronary heart disease Solo grandparents 6.05 (3.47, 10.55) 5.00 (2.76, 9.05) 0.96 (0.38, 2.43) Single parents 1.00 1.00 1.00

Fair or poor health Solo Grandparents 4.38 (3.14, 6.10) 3.75 (2.64, 5.33) 0.97 (0.59, 1.61) Single parents 1.00 1.00 1.00

Poor mental health days for past month

Solo grandparents 0.95 (0.68, 1.32) 1.02 (0.73, 1.44) 0.88 (0.57, 1.38) Single parents 1.00 1.00 1.00

Poor physical health days for past month

Solo grandparents 1.58 (1.14, 2.18) 1.61 (1.15, 2.24) 0.75 (0.48, 1.17) Single parents 1.00 1.00 1.00

Limited in activity for past month due to physical or mental illness

Solo grandparents 1.63 (1.16, 2.29) 1.64 (1.15, 2.33) 1.01 (0.63, 1.63) Single parents 1.00 1.00 1.00

Statistically significant health outcomes are in bold. Odds ratios and confidence intervals are weighted to adjust for the probability of selection and nonresponse according to Statistics Canada data release guidelines. Source: BRFSS 2012

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