This research examined whether raising a grandchild suppresses or elevates preventive health behavior based on the duration of time spent in that role. The results supported our hypothesis that contradictory pressures faced by caregiving grandmothers—time constraints and concern for the long-term well-being of the grandchild—differentially influence prevention, suppressing preventive behaviors among those transitioning into the caregiving role and enhancing preventive health behavior among long-term caregivers. Grandmothers who recently began raising a grandchild were less likely to report receipt of influenza vaccination, cholesterol screening, and Pap tests, but not breast self-exam or mammography. In view of our hypothesis that time constraints are the primary cause of the reduction in preventive health behavior, it is not surprising that grandmother caregivers did not report a reduction in breast self-exams, as this behavior requires minimal time and effort. In addition, it is worth noting that the pattern of mammography utilization, although not statistically significant, does reflect our hypothesized outcome. It is possible that, due to the high levels of media attention surrounding breast cancer awareness and prevention, grandmother caregivers are particularly motivated to make time for preventive behaviors linked to breast cancer, a motivation that is not present (or at least not as strong) for the other preventive behaviors measured in this study.
We found little evidence to support the hypothesis that emotional and financial strain mediates the suppression of health behaviors caused by the transition into care. Thus, even grandparents and grandchildren in households traditionally seen as stable (and therefore not generally targeted by state and federal programs) may be at adverse risk if lower use of health screening results in greater prevalence of disease and disability among caregiving grandparents.
Our results also show that grandmothers who had been raising a grandchild for at least 2 years were more likely to receive an influenza vaccination and to report monthly breast self-exams. This supports our hypothesis that long-term caregivers would be motivated to maintain a healthy lifestyle, thus compensating for the negative influence of time constraints. However, this seems to be the case only for preventive services that require minimal effort; those services that are most likely to require a doctor's visit are not affected. Only for influenza vaccination does increased use of preventive services among long-term grandmother caregivers partially offset the decreased use among grandmothers who recently began raising a grandchild; for cholesterol and Pap tests, grandmothers raising grandchildren do not appear to experience an increase in preventive service use following the transition into care.
The Centers for Disease Control and Prevention recommends that all persons older than age 50, particularly those with chronic conditions, receive annual influenza vaccinations (Fiore et al., 2007
). Taking into consideration the fact that grandmothers who recently began raising a grandchild are particularly vulnerable to influenza-related complications and hospitalizations due to the higher levels of chronic conditions seen in this group, their lower receipt of influenza vaccination as compared to that of grandmothers not raising a grandchild is especially troubling. Compounding this situation is the fact that the majority of grandparent care households include at least one child of preschool age (Mutchler, Lee, & Baker, 2006
), another age group at increased risk of influenza-related complications (Fiore et al., 2007
). In fact, the Centers for Disease Control and Prevention recommends that everyone who either lives with or cares for a child younger than age 5 receive annual influenza vaccination (Fiore et al., 2007
). So, grandmothers raising grandchildren who do not receive annual influenza vaccination not only are placing themselves at risk, but also are placing their grandchildren at risk both through the possibility of exposure to the influenza virus and through the possibility of being unable to provide care for the grandchild.
Low receipt of cholesterol screening and Pap tests among grandmothers who recently began raising a grandchild is equally troubling. Routine cholesterol screening is recommended for all women in this age group and is an important tool in identifying a person's risk of coronary heart disease (National Cholesterol Education Program, 2001
; U.S. Preventive Services Task Force, 2006
). Similarly, a Pap test is recommended for women in this age group at least every 2 to 3 years; the importance of the Pap test in early detection of cervical cancer has been well established (Etzioni et al., 2003
; Smith, Cokkinides, & Eyre, 2007
; Wingo et al., 2003
). Missing even one recommended screening, either for cholesterol or cancer, might delay both diagnosis and treatment of a serious health problem. Even if the grandmother's preventive service use returns to normal levels after an adjustment period, the consequences of a delay in treatment may be severe.
Readers should also interpret our results within the context of several limitations of our study. First, our sample of grandmothers raising grandchildren, although nationally representative, was relatively small. Consequently, we accepted results that were marginally significant. Given the high cost of missed Pap tests, we feel that even trend-level significance is worthy of discussion and warrants further investigation, though this effect should be interpreted with caution. In addition, given the constraints of the data, we are not as yet able to follow one group of caregivers across time. Therefore, our conclusions about the timing of role adoption are necessarily comparative across sets of grandparents with different time exposures, when it would be more precise to examine fluctuations in health behaviors along the continuum of the caregiving career. It is quite possible that our results for long-term caregivers would differ if we had focused on one group of caregivers across multiple time points.
Our study is also limited by the fact that we could not identify a specific point in time at which the grandmother began raising a grandchild. Therefore, it is possible that some grandmothers who recently began raising a grandchild reported receiving preventive care before the grandchild entered the household. Although this measurement is necessary to capture the effects of the recency of care, it may limit the extent to which we can capture behavioral changes among grandmothers who recently began raising a grandchild. Furthermore, this study is not able to make a direct link between decreases in preventive behavior and concrete health outcomes; we can only make assumptions about the influence of altered preventive behavior on the health and well-being of grandmother caregivers.
Future research should focus on the long-term consequences of poor health behavior during the transition into raising a grandchild for grandmothers, as well as for grandfathers. Does low receipt of preventive services during the transition into raising a grandchild lead directly to poor health outcomes among grandparents raising grandchildren? If so, are grandparents who experience poor health outcomes likely to transition out of the caregiving role as a result? As more waves of the HRS become available, it will be possible to track the health and caregiving trajectories of grandparent caregivers by following one group of caregivers past the transition into care and into the adaptation phase. Therefore, it will be possible to directly assess the sequential nature of our hypotheses. Furthermore, it will be important to determine if the influence of raising a grandchild on preventive behavior is unique or if other caregivers (such as spousal/parental caregivers or new parents) experience similar outcomes.
Increased illness, hospitalization, and in severe cases mortality have direct costs for all older adults. However, within the population of grandparents raising grandchildren, the indirect costs may be as, if not more, severe. Grandparents often raise grandchildren in cases when there is no other viable alternative; many cite parental substance abuse or imprisonment as primary reasons they begin raising a grandchild (Jendrek, 1994
; Johnson & Waldfogel, 2002
). If a grandparent cannot provide care because of a serious health problem, the grandchild may be temporarily or permanently placed back in the care of a parent or may be placed in the foster care system. Even if grandparents raising grandchildren return home, they may be deemed an unsuitable placement for children if severe health problems persist.
Support groups targeted toward grandparents raising grandchildren could be an important tool in keeping grandparent caregivers informed on the importance of health maintenance. In fact, the positive health behavior observed among long-term caregivers may be due in part to participation in these support groups, either through direct health interventions or through a broader influence on adaptation to the caregiving role. During the transition into care, overwhelmed grandparent caregivers may lose sight of the fact that their health maintenance may directly influence the future of their grandchild, instead regarding proper self-care as selfish or expendable. Reinforcing the view that positive health behaviors can delay deterioration of the grandparent's health (and in turn diminish the possibility that the grandparent will become unable to provide care due to health concerns) may go far to help many grandparent caregivers realize the importance of their own health and well-being. In addition, support groups that have additional resources may want to organize health fairs or plan field trips to community health fairs. These health fairs often offer influenza vaccination and cholesterol screening at minimal or no cost to the recipient. As these preventive services seem to be the ones most negatively influenced by caring for a grandchild, increasing access through measures such as those described may help new grandparent caregivers avoid a lapse in proper health behavior.