Abstract
Introduction
Grandparents are often highly involved as secondary caregivers for their grandchildren and may influence children’s psychological and physical health outcomes. The purpose of the current review was to gather and synthesize research findings on the effects of grandparent involvement on children’s physical health outcomes.
Methods
PubMed, PsycInfo, and MedLine were searched by three independent reviewers for articles that reported on grandparent involvement and children’s health. Twenty-six articles were included for final review based on selection criteria.
Results
Relatively few studies have examined the effects of grandparent involvement on children’s health outcomes and therefore the degree of their influence remains unclear. Four categories of children’s health outcomes: disease/illness, weight, eating behaviors, and injury/safety emerged during this review. Results indicated that the majority of studies available reported a negative effect of grandparent involvement on child’s weight status. However, It is important to note that in most of these studies the effects of grandparent involvement were not a primary outcome and the amount of time grandparents spent with their grandchildren was not accounted for. Many studies in this review were qualitative studies, limiting the types of analyses that could be conducted. Additionally, few longitudinal studies have been conducted in this area.
Discussion
Based on this review, it is clear that grandparents are involved in caretaking for children across many cultures but in order to understand their role in children’s health outcomes, more systematic and longitudinal research needs to be conducted.
Keywords: grandparent, caretaking, grandchildren, health
Introduction
Over the past few decades, specific societal shifts have contributed to an increase in grandparental involvement as secondary caretakers. For one, individuals are living longer. Second, women and mothers have become much more integrated in the workforce worldwide (Alonso-Almeida, 2014). Due to their involvement in the workforce, it has become increasingly difficult for mothers to balance raising their children with work. Mothers likely depend more on extended family, particularly grandparents, to provide care for their children. Third, the number of single-parent homes has increased (Winefield & Air, 2010). Today, about 7 million (10%) grandparents live with at least one of their grandchildren (U.S. Census Bureau, 2012).
Grandparent Involvement Across Cultures
Rates of grandparent involvement seem to be consistent globally, and may be even higher in non-western societies, such as Africa, Asia, and Latin America (Aubel, 2012; Kataoka-Yahiro, Ceria, Caulfield, 2004). Although grandmothers are often actively involved in caregiving across cultures, there are some specific cross-cultural differences to consider. For example, Aubel (2012) conducted a review of the literature on the influence of grandmothers on child feeding practices during pregnancy and childhood in non-Western societies, including Asia, Africa, Latin America, and the Pacific. The findings suggested that (a) grandmothers play a critical role as guides to young women with children, and (b) grandmother social networks contribute to mother and young child rearing practices.
In the U.S., grandparents from families of ethnically diverse backgrounds tend to take on greater responsibility for their grandchildren than White grandparents (Kataoka-Yahiro, Ceria, & Caulfield, 2004). For example, one study comparing African-American to European-American grandparents found that African-American grandparents perceived themselves to play a greater role as teachers to their grandchildren than did European-American grandparents (Watson & Koblinsky, 1997). In Hispanic families, grandmothers have been found to play an important role in reinforcing cultural values (Facio, 1996), serve as a main source of support for parents (Markides, Boldt, & Ray, 1986), and a main source of knowledge for infant feeding strategies (Baughcum, Burklow, Deeks, Powers, & Whitaker, 1998).
Grandparent Influence on Child Health Outcomes
Despite the high rates of grandparent involvement in child rearing, little is known about the impact of grandparent involvement on children’s mental and physical health outcomes. For mental health outcomes, some researchers have noted that children who have grandparents involved in caretaking may have better mental health outcomes. For example, one study assessing the role of grandparents on the mental health of African-American youth found that having a grandparent in the household was associated with lower depressive symptoms and less deviant behavior (Hamilton, 2005). Another study found that in a sample of Muslim and Hindu families, children exhibited better behavioral adjustment when grandparents were involved in their care than when they were not involved (Sonuga-Barke & Mistry, 2000). For physical health outcomes, research findings are less consistent. Some studies have found that children who are cared for by grandparents have poorer health outcomes than those who are not cared for by grandparents (Pearce et al., 2001; Watanabe et al., 2011) whereas others have found the opposite to be true (Pulgaron et al., 2013). One area in which grandmothers are especially involved in is guiding feeding practices, starting with breastfeeding for infants and extending to general nutrition in childhood (Aubel, 2012). Their involvement in feeding practices may significantly affect physical health, especially in relation to obesity and associated comorbidities in their grandchildren.
The purpose of this review is to gather and synthesize research findings on the effects of grandparent involvement on children’s physical health outcomes. To our knowledge, this is the first paper to review studies of this kind. By reviewing the findings of grandparent caretaking on child health outcomes we will be able to summarize the current state of research in this area, detect gaps in the literature, and identify future directions for research on interventions for grandparents and their grandchildren.
Methods
Search Strategy
The literature search identified research studies that examined the effects of grandparent involvement on children’s health status and behaviors. Three electronic databases – PubMed, PsycInfo (EBSCO), and MedLine – were searched by three reviewers independently. Predetermined key terms were used to identify articles meeting the inclusion criteria, which is described below. For each database, the terms “grand*” and “child*” were limited to the title and abstract fields, while the term “health” was searched throughout all text. The search was not limited to U.S. samples.
Inclusion Criteria
Studies included in the current review met the following inclusion criteria: (1) publication date between January 1994 and January 2014, (2) publication in a peer-reviewed journal, (3) written in the English language, (4) population of interest included grandparents and their grandchildren (0–18 years), (5) grandparents’ role was limited to caretaking, level of involvement, responsibility, kinship care, and informal childcare (i.e. not the primary caretaker), and (6) reported data on children’s health, well-being, and safety outcomes. If it was unclear whether the grandparent was involved in caretaking or not, the article was excluded. Dissertations, review papers, conference abstracts, and articles listing grandparents as the primary or sole caretakers were also excluded. Moreover, studies that focused on mental health, cognitive functioning, and physical disabilities were also removed.
Review Process
Initially, a total of 2,982 abstracts were reviewed from all three databases. Two research assistants read each abstract and coded each one as include or exclude based on the pre-established inclusion criteria. For each database, a list of studies that were included by either research assistant was created (n = 117). Any discrepancies were reviewed by a third reviewer. Once discrepancies were addressed, the three lists were screened for duplicates across databases to ensure each study was included only once. The three compiled lists were then merged for a final review of the full text manuscript to confirm that grandparent involvement had been documented in each selected study. This resulted in a final number of 26 studies. See the Figure for details.
Figure.
Search Results. This figure illustrates the number of manuscripts that met the inclusion criteria at each stage of review and the final number included in this review paper.
Analytic Plan
We coded methodological considerations—i.e., if a longitudinal design was used, if the effect of grandparent involvement on children’s health was the primary outcome of the study, and if grandparent involvement was quantified. A summary of the eligible studies as well as information on the outcomes measured is shown in the Figure.
Results
Methodological Considerations
Six of the 26 studies reviewed included a longitudinal component and 65% reported grandparent effect on child health as a primary outcome. Of the 26 studies in this review, 13 quantified grandparent involvement to some degree. The description of grandparent involvement varied across studies with the most common report being whether the grandparent lived in the child’s house or not (n=5). One study reported whether grandparents lived in the home and if the grandparent played a “major” role in caretaking for the child (Li et al., 2013). Other divisions were made such as whether grandparent was primarily responsible for childcare (Tankskanen et al., 2013) or whether a grandparent was present or absent (Sharma et al., 2006). One investigator (Ellen et al., 1995) reported whether a grandparent lived in the home and cared for the child at least once a week. A couple of investigators (Pearce et al., 2010; Pulgaron et al., 2013) measured time-spent caretaking in hours per day.
Four main health outcomes emerged during the review: disease/illness, weight, eating behaviors, and injury/safety.
Weight
Seven studies assessed whether grandparent involvement was related to children’s weight outcomes. One of these studies found that children’s birth weight did not differ for families in which the maternal grandmother lived in the house (Cunningham et al., 2010). The other six studies reported outcomes on childhood obesity as related to grandparent involvement. Five of these studies (Li et al., 2013; Pearce et al., 2010; Polley et al., 2005; Tanskanen, 2013; Wantanabe et a., 2011) found an adverse effect (i.e., grandparent involvement was associated with higher weight in children) and only one study found a positive association between grandparent involvement and children’s weight status (Pulgaron et al., 2013).
In a sample of nearly 500 8 to 10 year old children from mainland China, Li and colleagues (2013) found that those who were cared for mainly by their grandparents or had two grandparents living in the home were over twice as likely to be overweight/obese (adjusted OR 2.03; 95 % CI 1.19–3.47) and to report higher consumption of unhealthy snacks and sugar-added drinks (B=2.13, 95 % CI 0.87–3.40) than those who were cared for mainly by their parents or another adult. However, those children who lived with one grandparent were more likely to engage in 60 minutes of moderate to vigorous physical activity (MVPA) a day compared to those who did not live with grandparents, according to mother’s report. Similar findings were reported in a large sample (n = 12,354) of three-year-old children from the United Kingdom (Pearce et al., 2010). After controlling for variables such as maternal pre-pregnancy weight, ethnicity, and child birth weight, toddlers who were in informal childcare settings (e.g., with a grandparent, neighbor, or nanny) were more likely to be overweight than those cared for only by a parent (adjusted RR = 1.15, 95% CI 1.04–1.27). Seventy-five percent of those children in informal childcare were cared for by grandparents (Pearce et al., 2010). On the other hand, Pulgaron and colleagues (2013) collected BMI data on a sample of 199 Hispanic American elementary aged children and whether or not their grandparents were involved with caretaking. Results indicated that having a grandparent involved in caretaking was associated with lower zBMI scores for children of certain Hispanic ethnic backgrounds. See the table for details on the study samples and design.
Table.
Summary of Reviewed Articles
First Author,Year |
Country of Origin |
Sample Size | Study Design | Theme | How was degree of grandparent involvement quantified? |
Longitudinal Design |
Grandparents effect on child health as a primary outcome |
---|---|---|---|---|---|---|---|
Auld, 1994 | United States | 20 | Qualitative | eating behaviors |
Did not quantify | ||
Bedri, 1995 | Sudan | -- -- | Qualitative | eating behaviors |
Did not quantify | X | |
Bezner Kerr, 2007 | Malawi | 160 | Cross-sectional | eating behaviors |
Did not quantify | ||
Bezner Kerr, 2008 | Malawi | -- -- | Qualitative | eating behaviors |
Did not quantify | X | |
Cunningham, 2010 | United States | 90000 | Ecological | weight | Maternal grandmother living in the household or not |
X | |
Douglass, 2008 | Ghana | -- -- | Qualitative | eating behaviors |
Did not quantify | ||
Ellen, 1995 | United States | 45 | Cross-sectional | disease/illness | Grandparent living in the same neighborhood or house and involvement (at least once per week) |
X | |
Ellis, 2013 | Mali | 25 | Qualitative | disease/illness | Did not quantify | ||
Fonseca, 1996 | Brazil | 650 | Case-control | disease/illness | Grandparent living in home or not |
X | |
Jingxiong, 2007 | China | 23 | Qualitative | eating behaviors |
Did not quantify | X | |
Kaplan, 2006 | United States | 44 | Qualitative | eating behaviors |
Did not quantify | ||
Leach, 2008 | United States | 307 | Qualitative | injury/safety | Did not quantify | X | |
Liu, 2013 | China | 681 | Prospective cohort |
eating behaviors |
Grandparent living in same province or not |
X | X |
Li, 2013 | China | 497 | Cross-sectional | weight |
|
X | |
Masvie, 2006 | Nepal, India | 31 | Qualitative | eating behaviors |
Did not quantify | X | |
Moestue, 2008 | India and Vietnam |
5692 | Cross sectional | eating behaviors |
Grandmother in household or not |
||
O'Neil, 2012 | United States | 2042 | Cross Sectional/ Qualitative |
injury/safety | Did not quantify | X | |
Pearce, 2010 | United Kingdom |
12354 | Cohort | weight | Quantified hours per week |
X | X |
Polley, 2005 | United States | 84 | Cohort | weight | Did not quantify | ||
Pulgaron, 2013 | United States | 199 | Cross sectional | weight | Quantified hours/days throughout the year (e.g., in an average week, weekend, summer |
X | |
Sear, 2000 | Gambia | 2018 | Cohort | disease/illness | Did not quantify | X | |
Sharma, 2006 | India | 70 | Cohort | eating behaviors |
Absent vs. present grandparent |
X | |
Schmeer, 2013 | Mexico | 4649 | Longitudinal cohort |
disease/illness | Residency status of grandparent |
X | X |
Tanskanen, 2013 | United Kingdom |
9000 | Cohort | weight | Whether grandparent is primarily responsible for childcare |
X | X |
Urita, 2013 | Japan | 838 | Cohort | disease/illness | Grandparent living in the home or not |
X | |
Watanabe, 2011 | Japan | 2114 | Cross-sectional | weight | Grandparent living in household or not |
X |
Eating Behaviors
Breastfeeding
Breastfeeding support by grandmothers has been explored by researchers in various areas of the world and the results differ by culture. In Nepal, a qualitative study of grandmothers found that grandmothers endorsed positive health feeding practices such as valuing colostrum, not using prelacteals (i.e. the practice of giving newborns foods before breastmilk “comes in”), and supporting early initiation of breastfeeding (Masvie, 2006). On the other hand, in Malawi, another qualitative study found that grandmothers felt strongly about the inadequacy of breast milk and reported encouraging mothers to introduce complementary foods early in an infant’s life (Bezner Kerr, et al., 2008). In China, having a grandparent living in the same area as parents (and presumably responsible for caretaking) was associated with shorter duration of breastfeeding in a cohort study (Liu et al., 2013).
Feeding
Results of studies assessing the role of grandparents in feeding children beyond breastfeeding were mixed. As an example, a qualitative study of three-generation families in China found that grandparents were involved in planning and preparing family meals, but engaged in unhealthy feeding strategies such as generally wanting children to eat more than parents and using food as a way to reinforce children’s behavior (Jingxiong et al., 2007). In another qualitative study conducted in the US, grandparents endorsed knowledge about the importance of healthy eating, but struggled to assist their grandchildren in eating healthy. Grandparents reported poor communication strategies and disagreement between family members as obstacles to promoting healthy eating for their grandchildren (Kaplan et al., 2006). Although most of the studies in this domain were qualitative, one cross-sectional study by Moestue & Huttly (2008) reported that grandmothers education level was positively associated with children’s nutrition in a large sample (n = 5692) of Indian and Vietnamese families. However, the presence of a grandmother in the home did not influence children’s nutrition.
Injury/Safety
Two studies examined the effects of grandparent involvement on children’s safety outcomes. A study by O’Neil et al. (2012) conducted in Indiana observed the use and misuse of car safety seats (CSS) by 284 grandparents when transporting their grandchildren in motor vehicles. Researchers found that grandparents (42.7%) were more likely to have the lower anchor straps or the seat belt anchoring the CSS to the vehicle too loose compared to parent drivers (25.5%). They were also more likely to have a child younger than thirteen years of age in the front passenger seat position. However, there was no significant difference between grandparents and parents when determining the appropriate time to turn an infant’s car seat forward facing.
In another study,Leach et al. (2008) assessed the quality of different childcare settings for 10- and 18-month-old infants in England. Scores from the Profile Safety and Health Scale which measures indoor safety of an environment (e.g. heater is protected from child’s reach) indicated lower levels of safety in grandparents’ homes for infants at 10 months compared to infants being cared for by nannies. Refer to the table for further details.
Disease/Illness
Relatively few studies have assessed the relationship between grandparent involvement and disease outcomes in youth. In one study conducted in a Japanese rural town,Urita et al. (2013) found elevated rates of Helicobacter pylori (H. pylori) transmission from grandmothers to children when the grandmother lived in the home. In a second study,Fonseca et al. (1996) assessed pneumonia outcomes in a sample of 650 children and found that having at least one grandparent living in the home was significantly associated with pneumonia in their grandchildren (OR = 1.4, 95% CI 1.03 –1.89). In a third study, Ellen, Ott, and Schwarz (1995) examined the relationship between grandparent support and proximity, and number of emergency department (ED) visits for colds. In the sample of pre-dominantly African-American mothers, mothers who reported greater support from and proximity to the grandmother or great-grandmother took their child to the ED more often than those who did not have grandmother support. A fourth study by Sear and colleagues found that involvement of maternal grandmothers was associated with lower mortality rates for children in Gambia (Sear, Mace, & McGregor, 2000). See study details in the table.
Discussion
The results from this review must be interpreted within the context of the following considerations. Grandparent involvement is a difficult construct to operationally define, and only half of the studies in this review attempted to define grandparent involvement at all. “Involvement” can be interpreted in many ways. It may be a grandparent who lives in the home and is solely responsible for the child 40 hours a week while parents are at work or a grandparent who provides occasional parenting advice as needed. There is no standard practice for those who did define involvement and standards for that definition may vary according to cultural norms and age of the child. While reading the articles included in this review, reviewers attempted to be as objective and systematic as possible. If the grandparent lived in the home or if it was described or implied that the grandparent was involved or influential, then the article was included. If some data on the grandparent (e.g., education level, grandparent BMI) was available, but there was no indication that the grandparent was involved or influential in decisions regarding the child, then the article was excluded. This distinction was difficult to make at times, especially if grandparent involvement was not the primary outcome of the manuscript.
Future research in this area will need to quantify or at least set specific guidelines for how to distinguish between children who have and those who do not have grandparents involved in their lives. These guidelines could be created by assessing the number of hours grandparents care for their grandchildren and the degree of responsibility grandparents assume during that time. Accounting for variation of involvement according to season and/or day of week (i.e. weekday versus weekend) would be important. Both the quantity and quality of care should be targeted by future researchers in order to be able to make more assertive conclusions about the role of grandparents on children’s healthcare. Moreover, most of the studies in this area referred to some included grandfathers too but the role of grandfathers specifically has not been studied.
For many studies, the effect of grandparent involvement on child health outcomes was not the main outcome of the research. Grandparent involvement was one of many potential predictors of change or a secondary outcome. Because of the manner in which these studies were designed, most did not account for the amount of time the grandparent spent with the child and therefore differences in outcomes associated with degree of grandparent involvement were unable to be tested. Research is needed to determine the direction and/or intensity of the effect of grandparent involvement on specific health outcomes. According to the available literature at this time, healthy eating habits is the health outcome most likely influenced by grandparent involvement. It will be important to conduct specific research in this area to determine the most effective way to intervene with this population.
Additionally, most of the studies in this review were qualitative, which limits the type of analyses that can be conducted. There were some cross-sectional investigations with a few being part of large national public health databases and a couple of longitudinal studies. Although grandparent involvement with children appears to peak during infancy and early childhood (Guzman, 2004), it would be important to assess group differences as children age and determine the long-term health consequences of grandparent involvement. Ideally, longitudinal research conducted on this topic would clarify the degree and direction of the effect of grandparent involvement on children’s health.
Researchers from many countries have recognized the importance of grandparents in children’s health outcomes. In fact, from the 26 studies included in this review 14 different countries are represented. The type of influence evidenced by grandparents is likely to vary by culture, which partially explains the discrepancies in the findings from the various studies reviewed. Previous studies have documented the high rate of grandparent involvement in child rearing in ethnic minority groups in the US (Kataoka-Yahiro, Ceria, & Caulfield, 2004) and in Eastern societies (Aubel, 2012; Kataoka-Yahiro, Ceria, Caulfield, 2004). It is unclear how this influence affects children’s health and if that effect is consistent among the various ethnic groups. In addition to a need for more rigorous longitudinal study designs, particular results of grandparents influence need to be replicated within and across cultures.
Conclusions and Implications
There is some evidence suggesting that grandparent involvement influences children’s health outcomes. Most of the available research in this area focuses on weight and eating behaviors, but some studies have assessed the effect of grandparent involvement on disease and safety outcomes. Overall, the direction of the effect is not clear and varies across specific health areas and cultures.
Future research in this area should be designed specifically to assess the role of grandparent involvement as a primary influence on children’s health status across time. In order to do so effectively, grandparent involvement must be operationally defined. An attempt to separate the effect of parents and grandparent caretaking must be made to understand the unique effect of grandparent care. A mixed methods approach to research in this area may be useful. Grandparents may be an under-utilized and important resource for children’s health interventions. It will be important to continue to assess the effects of grandparents’ involvement on children’s health outcomes in a systematic manner over time.
Acknowledgments
This work was partially supported by NIH Grant #1R01HL102130 SB01 from the National Heart Lung and Blood Institute.
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