African american grandmothers' perceptions of caregiver concerns associated with rearing adolescent grandchildren

African American Grandmothers' Perceptions of Caregiver Concerns Associated With Rearing Adolescent Grandchildren Emma J. Brown, 1 Loretta Sweet Jemmott, 2 Freida H. Outlaw, 2 Greer Wilson? Monique Howard, 2 and Saleema Curtis 2

In 1996, grandparents were the sole providers of care for 269,000 grandchildren. Research findings indicate that grandmothers are usually the primary caretakers of grandchildren. Previous issues associated with raising grandchildren vary, but usually relate to the grandparents' health, financial concerns, or lack of social support. This qualitative descriptive study was designed to describe African American grandmothers' perceptions about the burdens of raising adolescent grandchildren. Using this approach, the researchers were able to study the richness and diversity of the grandmothers' perceptions. Data were collected from 35 grandmothers through a focus group (n = 7) and during a 4-day intervention research study (n = 28) entitled "Grandmother-Grandchild Health Promotion Program." Numerous concerns were voiced by both groups, but those stated most frequently were associated with the well-being of grandchildren (grandchildren's sexual behavior, potential drug use, and potential risk of encountering violence) and relational conflicts with adult children. Unexpected findings were the absence of stated concerns associated with the grandmothers' financial situation or health. Recommendations for intervention, clinical practice, and research are discussed. Copyright © 2000 by W.B. Saunders Company

N 1996, THERE were 785,000 Black families with grandchildren being raised by grandparents with grandparents being the sole providers of care for 269,000 grandchildren (U.S. Census Bureau, Current Population Survey, unpublished tabulations, 1997). Research findings indicate that grandmothers are the primary surrogate parents for grandchildren (Fuller-Thomson, Minkler, & Driver, 1997). In studies conducted between 1988 and 1993, single grandmothers compared to married grandparents or single grandfathers were the primary caregivers for grandchildren (Minkler, Roe, & Robertson-Beckley, 1994; Schable et al., 1995). This trend is especially evident in low-income urban communities where African American females and African American adolescents are disproportionately represented due to the impact that crack cocaine, HIV/AIDS, and incarceration have

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on their children and parents, respectively (Joslin & Brouard, 1995; Minkler & Roe, 1996). According to 1990 census data, 12% of Black children live with their grandparents, in contrast to 5.8% of

From the 1University of Central Florida, School of Nursing, Orlando, FL; the 2Center for Urban Health Research, University of Pennsylvania School of Nursing, Philadelphia, PA; and 3Greer and Company, lnc, Charlottesville, VA. Supported by a Research Supplement for Minority lnvestigator Award to grant ROMH557 from the National Institute of Mental Health. Dr. Emma J. Brown was the minority investigator conducting the study at the University of Pennsylvania in 1998 and I999. Address reprint requests to Emma J. Brown, Ph.D., R.N., C.S., University of Central Florida, School of Nursing, PO Box 162210, HPA 219, Orlando, FL 32816-2210. Copyright © 2000 by W.B. Saunders Company 0883-9417/00/1402-0003510. 00/0

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Latino and 3.6% of White children (U.S. Census Bureau, 1997). The developmental stage and tasks of adolescents and grandmothers differ significantly, although grandmothers who are raising their grandchildren are younger than in previous years (FullerThomson et al., 1997). From a social developmental perspective, after parents rear their children they usually anticipate grand-parenthood and retirement. These developmental milestones usually begin when parents are in their 50s. Traditionally, parents were not expected to establish a "new" family as primary caretakers of their grandchildren. The notion was that grandchildren spend time with their grandparents during the summer and on special occasions, and sometimes grandmothers were the baby sitters, but grandparents were not expected to be parents in the traditional sense. In contrast, the biological, social, and psychosexual stages of adolescence are ones of rapid physical change, increased interest in peer relations with numerous social activities, and heightened tendencies to experiment with different behaviors such as sex, drug use, and other risky physical activities (Graber & Brooks-Gunn, 1995; Ponton, 1997). Struggling with parenting their grandchildren while simultaneously coping with drug-addicted children predisposes grandparents to mental and physical stressors (Minkler et al., 1994). Other issues that result from raising grandchildren, which grandparents encounter include: (1) deterioration of health such as depression, insomnia, hypertension, back problems, and gastrointestinal problems; (2) social isolation; (3) financial difficulties; and (4) frustration negotiating public systems for legal support (Kelley, Yorker, & Whitley, 1997; Minkler & Roe, 1996). EPIDEMIOLOGY OF ADOLESCENTS' BEHAVIOR THAT RAISE ISSUES OF CONCERN

Adolescents' sexual behavior, drug use behavior, and predisposition to encounter violence may partially be understood in light of their developmental stage. An overview of the epidemiology of adolescents' sexual behavior, including sexually transmitted diseases (STDs), pregnancy rates, drug use, and violence is presented. The term Black is used in the section as surveillance data are reported for Blacks as a whole and not solely for African Americans. In 1995, as part of the Youth Risk Behavior Surveillance, the Centers for Disease Control and

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Prevention conducted a national school-based youth risk behavior survey among 10,904 high school students (CDC, 1996). More than 53% of the adolescents were sexually active. Black adolescents are 73.4% more likely to be sexually active than White adolescents and 24.2% more likely to have engaged in sex before the age of 13 (CDC, 1996). Gonorrhea, chlamydia, and human papilloma virus (HPV) rates are highest among adolescents 15 to 19 years old (CDC, 1997). In 1997, Black adolescents 15 to 19 years represented 45% of chlamydia cases, 78% of gonorrhea cases, and 86% of syphilis cases (CDC, 1997). Although adolescents make up less than 1% of the cumulative total AIDS cases, the long latency period between infection with HIV and the diagnosis of AIDS may mask the magnitude of the problem. An estimated 18% of AIDS cases have been reported among young adults in their 20s, many of whom were likely infected during adolescence (CDC, 1996). Each year almost 1 million adolescents experience unplanned pregnancies. Black adolescents account for about 14.8% of all unplanned pregnancies, which is significantly higher than Hispanic (12.5%) or White adolescents (4.0%) (Warren et al., 1998). Finally, findings showed that 45% of the adolescents who participated in the Youth Risk Behavior Surveillance had used marijuana during their lifetimes, whereas 7% had used cocaine. Additionally, 4.5% of the adolescents had experimented with crack cocaine (CDC, 1996). Twenty percent of the adolescents in the surveillance reported they carried a weapon such as a gun, knife, or club sometime during the 30 days preceding the survey. Male students were more likely than female students to have carried a weapon: 31.1% versus 8.3%. African American and Hispanic adolescents were more likely than their White counterparts to carry a gun: 10.6%, 10.5%, and 6.2%, respectively. Finally, 38.7% of the adolescents engaged in a physical fight 12 months before the survey (CDC, 1996). The experiences of grandmothers as surrogate parents of their grandchildren have been investigated, but these investigations have not produced in-depth information from the grandmothers' perspectives. Neither have studies been conducted that focused solely on the issues of caring for adolescent grandchildren. Therefore, the purpose of this descriptive qualitative study using grounded theory analysis (Strauss & Corbin, 1990) was to describe

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grandmothers' perceptions of issues associated with raising their adolescent grandchildren by analyzing the comments of 2 groups of grandmothers. METHOD

This qualitative descriptive study used focus group interviewing, open-ended questionnaire items, and participant observation to collect information about African American grandmothers' perceptions of the issues associated with raising adolescent grandchildren. This study was part of a larger experimental intervention study entitled, "The Grandmother-Grandchild Health Promotion Program." The Institutional Review Board of the University of Pennsylvania approved this study. Verbal informed consent was obtained from the grandmothers and facilitators, who participated in the focus groups, to audiotape the session. Written informed consent was secured from the intervention participants. Names were not used during the focus group and were omitted from the questionnaires to maintain confidentiality. The sample consisted of 35 grandmothers who either attended a focus group (n = 7) or participated in a 4-day intervention research study (n = 28). The sample was drawn from African American grandmothers who resided in a large urban northeastern city and who had formal or informal custody of at least 1 grandchild between the ages of 11 to 15 years. Grandmothers were recruited from housing developments, scatter site housing, and "section 8" housing. Notice of the study was accomplished by flyers, mail-outs, and by contact with the housing development staff. This study occurred in 3 phases. In Phase 1, data were solicited from 7 grandmothers during a focus group held at one of the housing developments. Perceptions about caregiver issues were ascertained by asking questions such as "What is it like raising an adolescent grandchild today? . . . . How stressful is it to discuss sexual issues with your grandchild?" The focus group responses were documented through field notes and audiotape. The audiotape was transcribed to ensure that the analysis process was systematic and verifiable. The purpose of the focus group was to refine the intervention by making it culturally- and ageappropriate for African American grandmothers. In Phase 2, qualitative data were collected on the questionnaires of 28 grandmothers during their participation in a 4-day intervention study held on a

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university campus. Some of the participants included additional information on the questionnaires that was unsolicited. The purpose of the intervention study was to empower grandmothers with the knowledge, skills, and confidence to teach their grandchildren strategies to reduce their risks for various diseases. In Phase 3, the responses of the participants in the 4-day intervention study were cross-validated by the 4 African American female facilitators who taught them during the intervention. The facilitators participated in an audio-taped focus group to discuss comments that the grandmothers made to them, which was in accordance with the protocol of the intervention study. Another source of crossvalidation was the debriefing questionnaires, which were completed by the facilitators at the end of the intervention study to describe their experiences. The purpose of this phase of data analyses was to determine if the grandmothers' unsolicited responses were similar to their solicited responses. The facilitators collected data by participant observation, which they documented on debriefing questionnaires. The qualitative data from Phase 1 and Phase 2 were analyzed for recurrent themes and subthemes using the line-by-line coding method (Strauss & Corbin, 1990). A predetermined sample size was generated for the intervention study. The qualitative data from this study and the focus group were analyzed at the conclusion of the intervention study. Therefore, data saturation was not used to determine when data collection would conclude. The demographic data from Phases 1 and 2 were analyzed by descriptive statistics. The sample inclusion criteria were ethnicity, being African American, a willingness to participate in the study, and being a grandmother raising a grandchild between 11 and 15 years of age. Individuals meeting these criteria were invited to participate in the focus group and intervention study. RESULTS

Grandmothers ranged in age from 44 to 83 years with a mean age of 56.4 years. Twenty-five percent were married while 75% were single (widowed 39%, divorced 18%, separated 7%, or never marfled 11%). Thirty-six percent had obtained either trade school, some college or a college degree, 28% had completed high school, and 36% had some high school education.

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While numerous issues were raised by grandmothers during the focus group and the 4-day intervention study, recurrent issues most often were those associated with the grandmothers' caregiving responsibilities and spirituality. Because the covert theme of the responses about caregiving appears burdensome, they are clustered under the theme "concern." Therefore, the focus of the findings will be the description of the 2 major themes, (1) concern, which has 4 subthemes (sexual behavior, drug use, violence, and relational conflicts) and (2) spiritual meaning, which will be illustrated by quotes from the grandmothers.

Concerns of Raising Grandchildren Sexual behavior. During the focus group the grandmothers were asked "What are some issues or concerns that you have as grandmothers raising grandchildren?" The responses varied, but most were subsumed under the concept sexual behavior. According to the grandmothers these included the potential of their grandchildren to "engage in sex or sell their bodies" prostitute themselves, "women sharing the same man (no shame)" share a man with another woman, and/or "sexually transmitted diseases and AIDS" acquiring a sexually transmitted infection including HIV. In addition, many of the grandmothers spontaneously discussed their concerns about caring for their grandchildren with the training facilitators and research staff during the 4-day intervention research study. Among other things, the grandmothers stated their concerns about not knowing how or what to say to their grandchildren to prevent them from engaging in risky sexual or drug-use behavior. The following quotes from some of the grandmothers illustrate the concern associated with ensuring the health and welfare of the grandchildren. One grandmother stated: "I needed this [information about adolescent sexual development and how to communicate with adolescents about STD/HIV and pregnancy prevention] 17 years earlier, then I would not have to raise my grandchildren and great grands on." On the last day of the intervention, the oldest grandmother (age 83 years) said to the investigator: "I really do appreciate you letting me in the study. I did not know how I was going to talk with my grandson about sex." One grandmother from the focus group stated:

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"We are having a real problem with sex. The girls are covered-up during the day and selling their bodies at night." Another grandmother agreed with the comment and then added, "Or else they are all sharing the same man and know it." Drug use. The grandmothers in the focus group also expressed their concern about the potential or actual use of alcohol and drugs by their grandchildren. They made reference to the negative consequences of drug use, which were profound. This statement from one grandmother illustrates this concern: "I love my grandchild. I'm not going to let the streets have him." A grandmother in the focus group commented, "Drug use is a problem. Drug prevention, preventing the use and selling of it is needed." Violence. Grandmothers in both the focus group and 4-day intervention study expressed their concern about the potential for their grandchildren encountering violence and "shootings." Some grandmothers exhibited proactive behavior to protect their grandchildren from either engaging in violent behavior or becoming a victim of violence. More than two thirds of the grandmothers in the 4-day intervention study would not allow their adolescent grandchildren to leave the study site and return home alone. Concern for the grandchildren's safety was among the reasons given for this behavior. For example, one grandmother stated, "I'm not giving up on him." Relational conflicts. Another recurrent concern expressed by the grandmothers was that of relational conflicts' with their adult children. These conflicts appeared to stem from the children exhibiting unacceptable behavior, which the grandmothers stated they were not taught. Another source of conflict was that of the parent(s) attempting to sabotage the grandmothers' authority. Some participants of the 4-day intervention research study discussed conflict and relationship problems with adult children, feeling hopeless about the grandchildren's behavioral problems, grandchildren's parents coming in and out of their lives, and harboring a sense of failure as expressed by one grandmother, "where did I go wrong?" These comments were typical: "I raised her and she turned out like this and now I am raising my grandchildren." "I raised them [her children] to know right from wrong." "Even if we were struggling, we always had rules

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in the house." "She comes in and tells him what he can and cannot do. So I started asking her [the child's mother] to call before coming to visit." Spiritual meaning. An additional finding that seemed intermeshed with the other findings was the apparent spirituality of the grandmothers. At the initiation of the grandmothers the focus group opened and closed with prayer. Additionally, some grandmothers in the intervention study made spiritually-related comments when discussing various topics during the study. Comments such as the following were typical: "Let go and let God," "Put it in God's hands," "I pray about it everyday," "God is always watching over us," and "God knows all, God sees all." DISCUSSION

The concept of concerns was helpful in understanding grandmothers' perceptions about raising their adolescent grandchildren, but other themes such as spirituality seemed to help them manage their worries. The latter may explain why the grandmothers did not express anxiety about their finances or health. Grandmothers were most concerned about their grandchildren's sexual behaviors, drug-use, potential of being victims of violence, and conflicts with their adult children. These concerns seem realistic given what they have observed in their immediate communities. Behaviors such as "girls covering up during the day and selling their bodies at night," overt drug trade and drug use, and exposure to violence are continuously transmitted in inner-city urban neighborhoods (Prowthrow-Stith, 1991; Wilson, 1996). Two unexpected findings from the study were that none of the grandmothers expressed concern about their financial situation or their health (Kelley et al., 1997; Minkler & Roe, 1996). They never talked about lacking money to care for their grandchildren's needs. Nor did they discuss any concerns about their inability to care for their grandchildren due to their health status. Perhaps one reason for these unexpected findings is the grandmothers' spiritual fervor. It seems that this spiritual fervor includes the belief that God is an omnipresent friend, one who is always available "to call on" and their major source of strength. Picot (1995) found a similar theme with a sample of Black caregivers. The caregivers in that study reported feeling a sense of empowerment as a result

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of their relationship with a "Supreme Being." Comments such as "put it in God's hand" and "let go and let God," clearly support the belief of the present sample that burdens can be transferred to a higher and greater source. The belief that God's help is always present may provide them with a sense of relief, support, and peace and may well explain the grandmothers' ability to cope with the many pressures they encounter rearing adolescent grandchildren. Additionally, the parental skills and experiences developed by raising their own children may pose a distinct advantage for grandmothers. Grandmothers may be able to reflect on and compare their attitudes, skills, and behaviors when they raised their children with their present attitudes, skills, and behaviors while raising their grandchildren. This reflection may be a determining factor influencing the grandmothers' desire to learn and implement new knowledge in child rearing practices with their grandchildren. For example, the grandmothers in the 4-day intervention study appeared eager to receive educational and skill building interventions, which aimed to improve their communication with their grandchildren. From information gathered from both the focus group and the unsolicited data during the 4-day intervention study, it is clear that the implications for interventions are in 2 areas. First, grandmothers need skills to help them educate their grandchildren about health and social issues such as adolescent pregnancy, STDs, HIV, and general health concerns. Second, community resources are needed to assist them in the rearing of their grandchildren.

Skill-Building Intervention Many of the grandmothers in this study felt unprepared to talk with their grandchildren about sex, pregnancy, and STDs. Although they realized the importance of talking with their grandchildren about these topics, they were embarrassed and felt ill-equipped. Hence, interventions that teach grandmothers about adolescent sexuality are needed. In addition to providing them with factual information through the use of hooks and videotapes, opportunities for the grandmothers to practice and become comfortable talking with their grandchildren about these sensitive issues are needed. The earlier these types of interventions are provided, the easier it will be for the grandmothers to assimilate into their new roles.

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Community Resources Intervention Paramount to the skill building and educational intervention is the need for community resources, services, and programs for grandmothers and grandchildren. This means that the entire community must become involved in the raising of these grandchildren. In the African American community, this is clearly the meaning of the African proverb, "It takes a whole village to raise a child." The village in this case includes a legal system that gives the grandmothers certain rights without their having to "squeal on" or abandon their children. It means having politicians and public policy makers aware of the needs of grandmothers and committed to developing legislation and public policies that give grandmothers certain parental rights. It means providing funding to community agencies so that they can provide activities and programs needed for grandmothers and grandchildren. Another place that many grandmothers go for support is the church or other religious organizations. The church and its activities may serve as a refuge and fortifier for grandmothers with strong religious and spiritual roots. In dealing with the issue of violence, it is clear that a variety of programs and services need to be designed. Grandchildren need to participate in programs and activities that will keep them busy, enhance their in-school experiences, and teach them responsible and appropriate behaviors. The use of mentors and role models, participation in after-school tutoring programs and activities, programs provided by various churches and organizations as well as various recreational, arts, music and athletic activities would provide grandchildren with productive and physical challenging outlets; thus eliminating the amount of time they would have to become involved in disruptive and potentially life-threatening activities. Moreover, with the amount of violence on television and the number of hours that they watch television, any after-school activity that replaces the television should prove beneficial. The neighborhoods where most of these grandmothers lived have much to do with their fears about violence. This is clearly shown by the findings of Schuster, Halfon, and Wood (1998) who found that mothers of newborn infants in South Central Los Angeles were fearful of their infants growing up within the local environment (10%) and fearful of the infants encountering (1) violence in and outside of gangs (39%), (2) diseases, ill-

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nesses, and health problems (17%), and (3) drugs and alcohol (15%). If mothers of African American infants harbor these fears how much greater are the fears of grandmothers of African American adolescents? Therefore, a survival strategy is for law enforcement agencies, tenants' organizations, and community groups to work together to rid communities of violence.

Implication for Clinical Practice The fact that the grandmothers in this study expressed conflictual thoughts and feelings about their children (the mother or father of their grandchildren) supports the concept of relational patterns in family system theory (Bowen, 1978; Mnnichin and Fishman, 1981). For example, the "executive functions" of child rearing may lack clearly defined parental roles for each generation in intergenerational families like the ones in this study. Boundaries are never clearly established and differentiation of function between the grandparent who has been designated as the caregiver and the parent who may come in and out of the home depending on the circumstances is never negotiated. This lack of role clarification may cause intergenerational conflicts resulting in or from 3 generational triangles in which grandparents and grandchildren cross generational fines to collide against the child's biological parent. It was evident in this study that many of the grandmothers were very unsatisfied with how their biological children had responded to their teachings. One can speculate that grandmothers may infer negative intent to the child's behavior because they are afraid the grandchild will be like his/her parent. In the clinical setting some grandparents have attributed sexual connotations to their grandchild's movements to music because they are afraid the grandchildren will be promiscuous like the parent. Understanding relational patterns allows us to theorize that when tensions are high in a family system, it is common for triangles to form in an attempt to relieve the stress in the system. In parent-absent households where the grandmother is the primary caregiver, this study and others have found that the majority of grandchildren who are living with their grandmothers are doing so because their biological parent, most likely the mother, is addicted to drugs, is HIV positive, is incarcerated, is a teenage mother, or is experiencing a combina-

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tion of several of these factors (Pearson, Hunter, Cook, Ialongo, & Kellam, 1997; Joslin & Brouard, 1995; Kelley et al., 1997). Tension, shame, fear, and guilt were just some of the negative feelings that grandmothers expressed about the lifestyles of their biological children. Crack and other drug addictions, HIV/AIDS, incarceration, child abuse and neglect, and teenage pregnancy are all behaviors that have negative social and moral connotations and are incongruent with the messages of right from wrong that they were given by their biological parents. That is, grandmothers overtly and covertly implied that they were very distressed about their children's behaviors that precipitated their being unable to care for their biological children. For this reason, it would be important to assist these grandmothers in groups or in individual therapy to examine the interactional patterns that create and sustain their destructive family relations.

hnplications f o r R e s e a l v h

Current behavioral research is scant on the implementation and evaluation of effective pregnancy prevention, STD/HIV intervention, drug use and violence prevention strategies for African American grandmothers to use with their grandchildren. An emphasis on intervening with grandmothers becomes imperative when one considers the increasing numbers of grandchildren being reared by grandmothers and in most cases, single grandmothers. As such, grandmothers have great potential for intervening effectively with their adolescent grandchildren regarding their sexual behavior, which may predispose them to STDs, unwanted pregnancy, drug use, and behavior that may lead to violence. Therefore, one important recommendation is to investigate the efficacy of providing grandmothers with the knowledge and skills to teach their grandchildren how to prevent STDs, drug addiction, and interpersonal violence. Specifically, psychiatric nurse practitioners in all settings, but especially in community and primary health care settings, need to ascertain whether the grandparents for whom they provide services are surrogate parents to their grandchildren. Comprehensive interventions that take into account those factors that increase the health risk of grandmothers should include all the previously mentioned inter-

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ventions. In addition, teaching grandmothers about social policies and how to advocate for themselves to secure funds to provide services such as respite care, is equally important. In summary, alleviating grandmothers' caregiving concerns affords an ideal interface for behavioral researchers and clinical practitioners to develop strategies to empower grandmothers to eliminate what they have identified as concerns connected with parenting their adolescent grandchildren.

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