- Email: [email protected]
General health perception, depression and quality of life in geriatric grandmothers providing care for grandchildren
Accepted Manuscript Title: GENERAL HEALTH PERCEPTION, DEPRESSION and QUALITY of LIFE in GERIATRIC GRANDMOTHERS PROVIDING CARE FOR GRANDCHILDREN Authors: BEKTAS MURAT YALCIN, HASAN PIRDAL, ESAT VELI KARAKOC, ERKAN MELIH SAHIN, ONUR OZTURK, MUSTAFA UNAL PII: DOI: Reference:
S0167-4943(18)30172-9 https://doi.org/10.1016/j.archger.2018.08.009 AGG 3735
To appear in:
Archives of Gerontology and Geriatrics
Received date: Revised date: Accepted date:
18-6-2018 17-8-2018 18-8-2018
Please cite this article as: YALCIN BM, PIRDAL H, VELI KARAKOC E, MELIH SAHIN E, OZTURK O, UNAL M, GENERAL HEALTH PERCEPTION, DEPRESSION and QUALITY of LIFE in GERIATRIC GRANDMOTHERS PROVIDING CARE FOR GRANDCHILDREN, Archives of Gerontology and Geriatrics (2018), https://doi.org/10.1016/j.archger.2018.08.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
GENERAL HEALTH PERCEPTION, DEPRESSION and QUALITY of LIFE in GERIATRIC GRANDMOTHERS PROVIDING CARE FOR GRANDCHILDREN Running Title: Depression, quality of life and general health perception in
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grandchild-caring grandmothers
BEKTAS MURAT YALCIN1, HASAN PIRDAL2, ESAT VELI KARAKOC3, ERKAN
Prof. Dr. Ondokuz Mayis University Medical School Department of Family
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1
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MELIH SAHIN4, ONUR OZTURK5, MUSTAFA UNAL6
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Practice, MD, Samsun/ Turkey
Family Physician, MD, Medical Park Hospital, Department of Family
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Medicine, Izmir, Turkey
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3
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2 Family Physician, MD, Tekkeköy Family Health Center, Samsun/Turkey
Prof. Dr. 18 Mart University Medical School Department of Family Practice,
Family Physician, MD, Asarcık Family Health Center, Samsun
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5
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MD, Canakkale/ Turkey
6
Dr. Faculty Member, PhD. Ondokuz Mayis University Medical School
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Department of Family Practice, MD, Samsun/ Turkey
Word Count: 3381 Tables: 5 Figures: 0
Correspondence: Prof. Dr. Bektas Murat YALCIN Ondokuz Mayıs University Medical Faculty Department of Family Medicine Kurupelit/Samsun Gsm: 05324811841
Tel: 0362 3121919-3464
Highlights
Eleven percent of geriatric grandmothers provided caregiver services
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for grandchildren in our study population
Physical and mental quality of life, perception of health and
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Email: [email protected].
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depression results were better among grandparents caring for
Custodial grandmothers had the lowest quality of life, health
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grandchildren.
perception and depression levels among the entire study population
Three important aspects, socio-economic (being single or widowed, a
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(in both the control and study groups).
low education level, and low monthly income), demographic
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(increasing age, a higher number of children and grandchildren, and presence of chronic diseases), and features of grandchild care (lower ages among grandchildren, total hours spent caregiving per week, and total hours of night-time caregiving) are capable of affecting depression, quality of life, and health perception levels among caregiver grandmothers.
ABSTRACT Aim/Background: To investigate levels of depression, quality of life, general health perception, and factors affecting these in grandmothers providing care for their grandchildren.
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Material/Method: One hundred two family physicians from four cities (Samsun, Amasya, Canakkale, and Izmir) in Turkey investigated 2859
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women older than 65 years on their patient lists. Of these, 282 (9.8%) had spent at least 50 hours caring for their grandchildren in the previous three months, and these were selected as the study group, while the remaining
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2563 (89.6%) were enrolled as the control group. After all participants’
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demographic variables had been investigated, they completed the Beck
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Depression Inventory (BDI), Self-Function 12 (Mental and physical component score) (SF-12), and the Visual Analog Scale of EQ-5D (VAS).
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The participants in the study group also completed a questionnaire
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investigating features of their grandchild care. Results: The study group (with the exception of custodial grandmothers) better
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scored
on
the
SF-12
(PSC=50.60±6.96
vs
48.24±8.12),
(MCS=49.70±7.77 vs 45.48±7.61), VAS (60.44±23.5 vs 54.16±19.5), and
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BDI (13.97±0.3 vs 19.49±0.2) compared to the control group (p<0.0001 for all). Age, monthly income, mean length of education, duration of care, mean hours spent caregiving per week, being a custodial grandmother, presence of more than one chronic disease, and caring for more than one
grandchild at a time were identified as factors affecting SF-12, VAS and BID in the study group. Conclusion: Grandchild care positively affected the grandmothers’ quality of life, depression levels, and general health perception, with the exception
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of custodial grandmothers
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Key words: Geriatric, Grandmothers, Grandchildren, Babysitter, Custodial,
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Primary Care
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1.INTRODUCTION
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Significant changes have occurred in the traditional nuclear family worldwide in recent years (1, 2). Social problems (increasing divorce rates,
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single parent families, teenage pregnancies, etc.) and economic difficulties
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(unemployment or low income, and lack of social support services) oblige families to seek more support from their parents in terms of child care (3).
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Many grandparents today play a vital economic and social role as a social buffer in providing support for their grandchildren. In the U.S.A, more than seven million grandparents were living in the same household with at least
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one grandchild under the age of 18 in 2010. One in 10 American children (7.5 million) was living in a household with at least one grandparent (5). The Turkish Statistical Institute (TUIK) estimates that 7.4% of all children in Turkey aged 0-5 years had been cared for by their grandparents (6).
While most of the support provided by grandparents may be limited to the economic level, support also varies depending on the nature of the problems the family faces. Grandparents mainly care for their grandchildren as babysitters during the day, while the parents are working. However, some grandchildren live with their grandparents in the same household on
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a permanent basis (co-residential), and in some cases (such as parental substance abuse, incarceration, or death) grandparents become their
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grandchildren’s legal custodians (7). Whatever the role of the grandparents in terms of caregiving for grandchildren, the role may be a highly
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demanding one, and many unavoidable positive or adverse changes can
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affect grandparents’ quality of physical and psychological life (8).
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Theoretically, both negative and positive effects on grandparent caregivers’
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quality of life are plausible on the basis of role strain (9) and role
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enhancement (10) theories. Role strain arises or increases when role obligations exceed one’s physical and psychological resources, thus
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affecting one’s health (11). According to the role strain theory, much stress deriving from the grandparental role, such as intensive caregiving for
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grandchildren, may adversely affect physical and psychological quality of life. Some studies have reported that taking care of grandchildren is a
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stressful activity and therefore contributes to increased depression or distress (12-14). Above all, caring for grandchildren places a strain on grandmothers’ limited economic resources (meeting the feeding or clothing needs or educational costs of a fast-growing child). Insomnia, which can be caused by very young babies, heightened physical fatigue due to the
difficulty of child care, or providing emotional support for a growing, emotionally traumatized child, are some of the factors that may exacerbate the grandmaternal burden (15). Many grandmothers may also provide care for another chronic patient in the home, or may themselves have illnesses which limit their physical capacities. Many grandmothers also report feeling
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restricted in their social lives and activities (16).
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Role enhancement refers to the psychological benefits of discharging multiple roles (17). Caregiver grandparents report feeling closer to their
grandchildren and enjoying time spent with them (18). Caring for a
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grandchild may also lead to a more active lifestyle, healthier meals, or a
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reduction in smoking. Some grandparents feel that caring for their
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grandchildren makes them healthier and more active (19). Recent studies provide some clues regarding various factors
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involved in negative or positive outcomes in terms of grandparental health (20). First, although only a small percentage of grandparents act as
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custodians, the role is a more demanding one than babysitting, and adverse
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effects are more frequent in this grandparental group (21). While the negative effects of caring for grandchildren can be seen in both sexes, the main burden seems to lie with grandmothers (22). Another important factor
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may be the grandmother’s age. The balance between caregiving demands and deteriorating grandmaternal resources (economic, physical and psychological) may be more easily compromised in the geriatric population (8). Finally, the nature of the problems faced by grandmothers who look
after their own grandchildren varies in different societies and cultural groups and depending on the nature of the care provided. To the best of our knowledge, there have been no previous studies of this subject in Turkish society. Our study had several aims. The first was to investigate the proportion of geriatric grandmothers providing care for
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their grandchildren in four different Turkish cities. A second aim was to examine the effect of grandchild care on grandparental quality of life and
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depression levels. Finally, we examined several factors which might affect
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quality of life and depression in grandmothers caring for grandchildren.
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2.MATERIALS and METHODS
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2.1. Study Design
This descriptive and analytic study included only geriatric (≥65 years)
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women. It was performed between 1 March and 1 September, 2017, in four
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different cities in Turkey (Izmir, Canakkale, Amasya, and Samsun). Once a common study protocol had been prepared by the main research group,
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power analyses were computed to determine the minimum numbers of Family Health Centers and participants required to represent each urban
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city center. The study was described to all primary care physicians in these cities by the research group through local research networks. Seventy-six Family Health Centers (a total of 102 primary care physicians) agreed to participate. After providing verbal consent, 2563 women (89.6% of a total of 2859 individuals) over 65 completed a questionnaire investigating their
socio-demographic features while visiting these Family Health Centers. Seventy-two patients (2.8%) who refused to participate, and 224 (8.7%) who were receiving antidepressant medication, or with a severe medical disease capable of affect their quality of health (severe diabetes mellitus with complications, rheumatoid arthritis, etc.) were excluded from the
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study. These excluded subjects included 33 (1.2%) grandmothers caring for at least one grandchild. All the remaining participants completed the SF-
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12 (Self-Function 12 version 2), a Visual Analog Score (VAS) for general
health, and the Beck Depression Inventory. Subjects reporting personally
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caring for at least one grandchild for at least 50 hours in the previous three
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months during the study period (1 March to 1 September, 2017) were
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enrolled as the study group (n=282, 11%). The grandmothers in the study
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group were also divided into three subgroups (babysitters, co-residential,
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and custodial), according to the type of care provided. The first subgroup consisted of grandparents caring personally for at least one non-resident
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grandchild (babysitters) (n=263, 75.8%). In the second group, the grandchild lived in the same household as the grandmother on a permanent
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basis for some reason (the child’s family also living with the grandparents or working in other cities, etc.) (n=48, 16.8%). In the third group, the
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grandparents had custodial rights, and the grandchild had lived in the same household as the grandparent on a permanent basis for at least three months (n=21, 7.4%). The remaining 2281 (89%) subjects were recruited as the control group. The participants in the study group completed a specially prepared questionnaire investigating details of the care they
provided for their grandchildren. These data were then compared between the two groups. 2.2. Tools 2.2.1. General Questionnaire
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This item was prepared by the research group in order to investigate
various social and economic factors. Subjects were asked about their age,
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marital status, current occupation, annual income, and mean length of
education. All participants were also asked whether they owned their homes
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or rented them. Health status was investigated on the basis of
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hospitalization numbers and visits to physicians in the previous two years.
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The questionnaire also inquired into chronic diseases, as well as total
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numbers of children and grandchildren, and whether subjects had cared for their grandchildren previously. The participants in the study group were also
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asked some questions not put to the control group. These involved care-
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related details such as the number of grandchildren cared for in the previous three months, time spent caring for grandchildren per week, whether
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grandmothers also cared for grandchildren at night, responsibilities in terms of grandchild care, and problems encountered.
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2.2.2. The Beck Depression Inventory (BDI)
This is 21-item, self-report rating inventory measures characteristic
attitudes and symptoms of depression (24). The BDI has been developed in different forms, including several computerized forms and a card form. Internal consistency for the BDI ranges from .73 to .92 with a mean value
of .86. The BDI demonstrates high internal consistency, with alpha coefficients of .86 and .81 for psychiatric and non-psychiatric populations respectively. There is no standard cut-off point for depression, although the total results from the BDI are correlated with one another. 2.2.3. SF-12 v 2 (Self-Function 12 version 2)
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This scale was developed from SF-36 as a short, valid alternative to
it, for use in large surveys of general and specific populations (25). SF-12
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is preferable to other, longer versions of measures of quality of life, and for use among the elderly because it is short (fewer questions make it easier
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to answer) and does not include work-related questions. The scale was
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subsequently modified after 10 years of research, to produce the 2.0
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version (SF-12 v 2). Although the number of questions remained
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unchanged, these were abbreviated and simplified.
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In order to be able to interpret the results of SF-12, the subject has to answer every question. Each answer is calculated from a special table in
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order to determine basic values for mental and physical components. Finally, these two components are added with different constant numbers
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in order to determine Mental Component Summary (MCS) and Physical Component Summary (PCS) scores.
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2.2.4. EQ-5D-5 Visual Analog Scale
The visual analogue scale is the second part of the EQ-5D-5
questionnaire and indicates health status on the day of the interview on a 20 cm vertical scale with end points of 0 and 100. Notes at the both ends of the scale explain that the bottom rate (0) corresponds to "the worst
possible health status” and that a score of 100 indicates “the best possible health status” (26). 2.3. Statistical Methods All analyses were performed on SPSS version 15 (Chicago IL) and
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Minitab version 15 software. Several parametric and non-parametric analytic techniques, including the Chi-square and Independent samples t-
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tests were used. Several independent factors were investigated between
the study and control groups using binary logistic regression models. A p
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value of <0.05 was regarded as significant.
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2.4. Ethics
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Approval for the study was granted by the Canakkale University
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(COMU) Ethical Committee. The Turkish Ministry of Health Public Health
settings.
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3. RESULTS
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Institute gave permission for this study to be conducted in primary care
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A total of 2563 women were included in the study. A comparison of various sociodemographic factors, including mean numbers of children and grandchildren, between the study and control groups is presented in Table
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1. The members of the control group were approximately five years older than the study group (p<0.001), had been educated for two years more (p<0.001), were less likely to live in rented accommodation (p<0.001), and had lower monthly income levels (p<0.001). They also had more children
(p=0.036)
and
grandchildren
(p<0.001),
the
mean
number
of
grandchildren they had cared for in the past was higher (p<0.001), and they had paid fewer visits to physicians in the preceding two years (p<0.001) compared to the study group.
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The study group members provided care for 69.44±56.23 months (min=3.52, max=276). The mean age of their grandchildren was
hours
a
week
providing
care.
Two
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74.42±59.95 months (min=12, max=180), and they spent 87.64±57.5 hundred
fifty-three
(89.7%)
grandmothers cared for one grandchild, while 29 (10.3%) cared for two or Ninety-three
grandmothers
(32.7%)
also
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more.
reported
providing
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nocturnal care, with a mean value of 28.16±12.4 hours of night-time care
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for a week.
Mean scale scores were 49.58±7.54 for SF-12 PSC, 47.52±7.25 for
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SF-12 MCS, 56.53±21.3 for EQ-5D-VAS, and 17.22±11.18 for BDI in the entire study population (the study and control groups together). The study
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group had higher SF-12 PSC, SF-12 MCS, and EQ-5D-VAS scores (p<0.001
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for all) and lower BDI scores (p<0.001). A comparison between mean SF12 (PSC and MCS), VAS and BDI scores in the control and study groups is
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presented in Table 2. Relations between mean SF-12 MSC, SF-12 PSC, EQ-5D-VAS, and BDI
scores, and variables such as mean age, monthly income, numbers of children and grandchildren, age of grandchildren, mean time spent caring for grandchildren to date, hours spent caring for grandchildren care per
week, and hours of day- and night-time care per week are presented in Table 3. Relations between mean SF-12 PSC, SF-12 MCS, EQ-5D-VAS, and BDI scores within the study group depending on care-giver status (babysitter,
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co-residential, or custodial), presence of chronic disease (none, one, or more than one), marital status (single, widow/divorced, or married),
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occupation (housewife, employed, unemployed, or retired) and number of
grandchildren cared for at one time (one or more than one) are analyzed in Table 4. This analysis revealed that although the mean scores of the co-
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residential and baby-sitter subgroups were not statistically different,
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custodial grandmothers scored lower on SF-12 (PSC and MCS) and higher
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on the BDI compared to the other two groups (p<0.001). In addition,
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presence of a chronic disease (compared with no chronic disease) and a
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higher number of grandchildren cared for at a time had an effect on SF-12 PSC, SF-12 MCS, EQ-5D-VAS, and BDI scores.
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The linear regression models for SF-12 (MCS, PSC), VAS and BDI with
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several independent variables (age, mean length of education, mean monthly income, mean number of children and grandchildren, mean number of grandchildren cared for to date, the mean age of the
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grandchildren receiving care, mean time spent on grandchild care to date, mean length of care per week, and mean length of day- and night-time care) are presented in Table 4.
Binary
logistic
regression
models
were
established
in
which
membership of the study or control group was adopted as a dependent variable, together with various independent variables. In the final model, age, and mean SF-12 MSC, SF-12 PSC, EQ-5D VAS, and BDI scores were selected as independent variables. According to this model, caring for
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grandchildren results in better MCS (OR: 1.057, Min: 1.024 Max: 1087 95% CI), PSC (OR: 1.040, Min: 1.005 Max: 1063 95% CI), VAS (OR: 1.087, Min:
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1.057 Max: 1.109 95% CI), and BDI (OR: 1.027, Min: 1.008 Max: 1052
95% CI) (p<0.001 for all) scores in women over 65. This model is presented
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at Table 5
4. DISCUSSION To the best of our knowledge, ours is the only research to date on this subject in Turkey. The findings elicited are significant. First, according to our data, 11% of geriatric grandmothers provided caregiver services for
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grandchildren among our study population (including those grandmothers excluded from the study in the first draft). This is higher than the figure of
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7% previously reported by the TUIK (6). Interestingly, although our study
population was older than 65, the TUIK investigated the overall level of grandchild care provided by all grandmothers. This may be due to the
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increasing mean age at motherhood in Turkish society, meaning that
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grandparents also tend to have grandchildren later in life.
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Our study also revealed that in terms of physical and mental quality
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of life, perception of health and depression results were better among
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grandparents caring for grandchildren (with the exception of custodial grandmothers) than among those who did not provide care services. Our
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results are in agreement with other studies reporting no evidence that
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caring for grandchildren has dramatic and widespread adverse effects on grandparental quality of life or depression (20, 27). However social factors may be involved here, as in some eastern and Mediterranean cultures
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grandmothers have a more positive perception of and greater willingness to undertake grandchild care, and their quality of life and depression levels may be less vulnerable in consequence (28). This factor has also been confirmed in studies from the USA, especially among grandmothers with Afro-American or Latin ethnicity (29).
Our study also concentrated on factors that might impact on depression, quality of life (MCS and PSC), and health perception levels among
caregiver
grandmothers.
Previous
research
suggests
that
grandmothers who discharge intensive caregiving roles are often the most disadvantaged and have the poorest health (22). We investigated this by
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dividing those grandmothers whose grandchildren were permanently resident in the home on a continuous basis into custodial and co-residential
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subgroups. Although the co-residential grandmothers had similar results to the babysitter grandmothers (whose grandchildren were not permanently
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resident in the home), the custodial group had the lowest quality of life
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(MCS and PSC), health perception and depression levels among the entire
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study population (in both the control and study groups). Our finding that a
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grandchild living permanently with the grandmother may not represent a
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risk factor for the grandmother’s quality of life, health perception, or depression is an important one. The triangular emotional relationship
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between grandmother, grandchildren and parents seems to be a more important factor. Previous studies have shown that custodial grandmothers
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may experience severe life crises which may exacerbate their burden, such as their children being subjected to criminal investigations (imprisonment),
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severe health problems (cancer etc.), drug addiction, or the loss of one of the parents (through divorce, etc.) (30, 31). They may also experience conflicts with their own children, and also with their grandchildren (32). Their relationships with their grandchildren may also be more problematic since these children may experience separation trauma from a parent (33).
Several grandparents in our co-residential subgroup stated either that their grandchildren were living with their own parents together in the same household or that their children were working in other cities and frequently visited. In both these cases, the emotional triangle between grandmothers, grandchildren and parents may be less stressful and problematic than in
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the case of custodial grandparents.
Our study findings also revealed three important aspects capable of
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affecting depression, quality of life (MCS and PSC), and health perception
levels among caregiver grandmothers. These may be classified as socio-
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economic (being single or widowed, a low education level, and low monthly
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income), demographic (increasing age, a higher number of children and
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grandchildren, presence of chronic diseases), and features of grandchild
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care (lower ages among grandchildren, total hours of caregiving per week,
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and total hours of night-time caregiving), based on linear regression models and correlations. Linear regression models in the study group investigating
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the factors affecting SF-12 MCS, SF-12 PSC, VAS, and BDI produced very high R2 values. These values indicate that the variables in these models can
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explain 63%, 70%, 74.8%, and 65% of the changes in these four scale scores, respectively, which underlines the power of these models.
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Regression analysis also confirmed that greater age (OR=1.004 min=0.885, max=0.1018, 95% CI) is a particularly important factor in terms of MCS (r=-0.387), PSC (r=-0.339), VAS (r=-0.386), and BID (r=0,421) scores. It seems that with increasing age, grandmothers’ physical and psychological resources available for caregiving decrease. Although a weak correlation
was observed between increasing age and monthly income (r=-0.188), there was strong relation between grandmothers’ economic capacity and quality of life perception of health and depression. To the best of our knowledge, this is the first study to report detailed analytic and demographic features from four cities in Turkey in the context
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of this research subject. However, our study also has a number of
limitations. First, the nature of childcare is very complex, and it is therefore
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very difficult to measure the content of such care. We attempted to meet this difficulty by calculating the total weekly length of childcare provided by
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the grandparents. However, this method may not reflect the intensity of
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stress and burdens imposed on grandmothers. In order to classify the work
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load involved in grandchild care, Hughes et al. (2007) suggested a minimum
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requirement of 50 hours per year (20). However, this may not accurately
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reflect the intensity or burden of childcare. Second, our results do not indicate the long-term effects of grandchild care on grandmothers’ quality
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of life, depression levels, and general health perceptions. Additionally, the classification of co-residential and custodial grandmothers
may be
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problematic in our study population. In Turkish society, grandmothers may tend to care for their grandchildren under all circumstances (whether they
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possess custodial rights or not). Although we took great care while classifying the grandmothers, some may nevertheless have been assigned to inappropriate groups.
4.1. Conclusion With the exception of the custodial subgroup, grandmothers who provided care for their grandchildren had a better quality of life (in physical and mental terms), lower depression rates, and better general health scores. Studies involving different populations and more detailed data are
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now required in order to better understand the relationship between
grandparents and grandchild care. These studies should involve the social
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and psychological characteristics of grandmothers, grandchildren and
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parents.
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Appendix: We would like to express our sincere gratitude to all the primary
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care physicians who took part in this study as interviewers.
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E,
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J,
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J.
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Moen P, Robison J, Dempster-McClain D. Caregiving and
women’s wellbeing: a life course approach. J Health Hum Behav. 1995;36(3):259–273. PMID: 7594358 Pruchno RA, McKenney D. Psychological well-being of Black and
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White grandmothers raising grandchildren: Examination of a two-
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Waldrop DP, Weber JA. From grandparent to caregiver: The
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stress and satisfaction of raising grandchildren. Fam Soc. 2001;
Hughes ME, Waite LJ, LaPierre TA, Luo Y. All in the family: The
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82(5):461–472.
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impact of caring for grandchildren on grandparents’ health. J Gerontol
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B Psychol. Sci. Soc. Sci. 2007;62(2):108-119. PMID: 17379680 Sands RG, Goldberg-Glen RS. Factors associated with stress
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among grandparents raising their grandchildren. Fam Relation. 2000; 49(1):97-105.
Blustein J, Chan S, Guanais FC. Elevated depressive symptoms
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among caregiving grandparents. Health Serv Res. 2004;39(6 pt
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Beck AT, Ward CH, Mendelson M, Mock J., & Erbaugh, J. An
inventory for measuring depression. Arc. Gen. Psych; 1961; 4, 561571. PMID: 13688369
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Beck Depression Inventory: Twenty-five years of evaluation. Clin. Psychol. Rev;1988; 8(1), 77-100. 25.
Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health
Survey:construction of scales and preliminary tests of reliability and
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validity. Med Care. 1996;34(3):220-33. PMID: 8628042
The EuroQol Group (1990). EuroQol-a new facility for the
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measurement of health-related quality of life. Health Policy, 1990; 16(3):199-208.
Gessa Di G, Glaser K, Tinker A. The impact for grandchildren on
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the health of grandparents in Europe: A life course approach. Soc Sci
Ling Xu, Tang F, Li LW, Dong XQ. Grandparent caregiving and
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psychological well-being among Chinese American older adults-the roles of caregiving burden and pressure. J. Gerotol.A Biol Sci Med Sci.
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2017; 72(Suppl_1):56-62. PMID: 28575256 Rao S, Goodman Mr. Grandparents raising grandchildren in a
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US-Mexico border community. Qual Health Res. 2007; 17 (8): 111736. PMID:17928483
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Carr GF, Hayslip B Jr, Gray J. The role of caregiver burden in
understanding African American custodial grandmothers. Geriatr Nurs. 2012;33(5):366-74. PMID: 22595336
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Dowdell EB. Grandmother caregivers and caregiver burden.
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Sprang G, Choi M, Eslinger JG, Whitt-Woosley AL. The pathway
to grandparenting stress: trauma, relational conflict, and emotional well-being. Aging Ment Health. 2015;19(4):315-24. PMID:25056651 33.
Crowther MR, Huang CH, Allen RS. Rewards and unique
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importance of future planning. Aging Ment Health. 2015; 19(9): 844-
A
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ED
M
A
N
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SC R
52. PMID: 25345592.
TABLE 1: Comparison of various sociodemographic features between the study and control groups Variables
Age (mean)
Study Group
Control Group
(n=282)
(n=2281)
66.19±6.8
71.19±5.5
p
t=20.345
Mean length of education 8.8±1.2 (years)
10.2±1.0
t=4.729. p<0.0001
SC R
Occupation
IP T
p<0.0001
124 (44%)
1022 (44.8%)
x2=172.401
Employed
36 (12.8%)
349 (15.3%)
p<0.0001
Unemployed
61 (21.6%)
625 (27.4%)
Retired
61 (21.6%)
285 (12.5%)
N
the
1298 (91.5%)
x2=79.182
21. 8.8%
p<0.0001
0 (0%)
70 (3.1%)
x2=.212.
78 (27.4%)
710 (31.1%)
p<0.0001
204 (72.3%)
1501 (65.8%)
223 (78.9%)
Yes
59. (21.1%)
Marital Status Single
PT
Divorced/Widow
ED
No
Married
A
by
M
Home owned grandparent?
U
Housewife
CC E
Income (per month, Turkish lira [TL])
t=2.005
2257±541
2214±521
p=0.125
3.91±1.9
t=2.056 p=0.036
5.9±6.1
t=14.839. p<0.001
(3.4 $= 1 TL)
A
Mean number of children Mean number grandchildren
3.75±1.9
of 4.7±4.2
Mean number of grandchildren previously 1.65±1.9 cared for by grandmothers
t=113.747 3.75±1.9
P<0.001
Hospitalized in previous two years
the 53. 19%
x2=1.874
41. 18%
P=0.08
Visits to doctors in the 5.5±1.25 previous two years
6.8±1.87
t=10.047 P<0.001
(mean) x2=213.754 48 (13.3%)
114 (5.0%)
CVD*
75 (26.7%)
543 (23.8%)
COPD†
19 (6.7%)
144 (6.3%)
DM‡
14 (5%)
171 (7.5%)
Muscular/skeletal problems
59 (20%)
627 (27.5%)
20 (7%)
257 (11.3%)
48 (16.6%)
425 (18.6%)
More than two diseases
U
Others
P<0.001
SC R
None
IP T
Chronic diseases
A
†Chronic obstructive pulmonary diseases
N
*Cardio vascular diseases (including hypertension, hyperlipidemia, mild cerebrovascular diseases, etc.)
A
CC E
PT
ED
M
‡Diabetes mellitus (including types 1 and 2)
TABLE 2: Comparison of mean SF-12 PSC, SF-12 MCS, VAS, and BDI scores between the control and study groups Study Group
Control Group
t, p
SF-12 PSC*
50.60±6.96
48.24±8.12
10.392. p<0.0001
SF-12 MCS**
49.70±7.77
45.48±7.61
12.254. p<0.0001
EQ-5D-VAS†
60.44±23.5
54.16±19.5
7.008. p<0.0001
BDI‡
13.97±0.3
19.49±0.2
**Mental Component Summary
A
CC E
PT
ED
Beck Depression Inventory
M
A
Visual Analog Score for General Health
N
SC R
U
*Physical Component Summary
IP T
Inventory
12.560. p<0.001
I N U SC R
TABLE 3: Correlations between mean SF-12 MCS, SF-12 PSC, EQ-5D VAS, and BDI scores and different variables in the study group. 1.
2.
1
Age (years)
2
3
4
-0.247
0.220
0.123
p<0.001
p<0.001
p<0.001
Monthly income (TL)
-0.188
Mean number grandchildren
of
of
CC E
5.
Mean number children
6.
Age of grandchildren (months)
Duration grandchild (months)
A
7.
8.
9.
ED
4.
Mean length of education (years)
PT
3.
of care
Time spent caring per week (hours) Mean hours spent for night-time care per week
10. SF-12 MSC*
6
7
8
9
10
11
12
13
-0.154
-0.160
-0.208
-0.367
-0.464
-0.387
-0.339
-0.386
0.421
p=0.004
p=0.003
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
-0.293
-0.206
-0.156
-0.249
-0.108
-0.150
0.357
0.412
0.241
-0.308
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
0.224
0.011
0.224
0.125
-0.193
0.193
0.174
0.204
-0.215
0.197
p<0.001
P=0.768
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
0.569
0.123
0.162
-0.118
0.124
-0.366
-0.348
-0.372
0.437
p<0.001
p<0.001
p<0.001
p<0.001
P=0.018
p<0.001
p<0.001
p<0.001
p<0.001
0.093
0.025
-0.051
0.403
0.312
-0.125
0.205
0.350
p=0.012
p=0.442
p=0.119
p<0.001
p<0.001
p=0.002
p<0.001
p<0.001
0.820
-0.099
0.403
0.312
-0.125
-0.205
0.350
p<0.001
p=0.010
p<0.001
p<0.001
p=0.002
p<0.001
p<0.001
-0.082
0.332
0.315
-0.237
0.215
0.442
P=0.014
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
0.312
-0.237
0.328
-0.102
-0.280
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
0.105
0.117
0.102
0.088
P=0.091
p=0.063
P=0.074
p=0.886
0.778
0.698
-0.668
M
p=0.015
5
A
Variables
I N U SC R
11. SF-12 PSC **
EQ-5D-VAS †
A
12.
M
13. BDI ‡
*Mental Component Summary **Physical Component Summary, †Visual Analog Score for General Health, ‡Beck Depression Inventory
A
CC E
PT
ED
††
p<0.001
p<0.001
p<0.001
0.596
-0.789
p<0.001
p<0.001 -0.671 p<0.001
I N U SC R
TABLE 4: Relations between mean SF-12 MCS, SF-12 PSC, EQ-5D VAS and BDI scores and several variables in the
Mean SF-12 MCS*
ED
Score
Care-giving Status
43.76±7.16
PT
Custodial Co-residential Babysitter
CC E
Chronic Disease
P
M
Variables
A
study group
F=10.239. p<0.001
Mean
P
Mean
p
Mean
SF-12 PSC**
EQ-5D VAS†
BDI‡
Score
Score
Score
42.90±8.16
F=11.542. p<0.001
54.86±13.3
F=10.801. p<0.001
22.17±0.5
48.16±9.01
49.65±5.87
59.93±23.5
13.97±0.3
50.92±1.18
49.98±6.71
61.10±19.8
13.01±0.1
p
F=10.650. p<0.001
None
50.45±1.89
F=9.821
50.01±5.78
F=10.523
62.25±20.1
F=10.124
11.02±0.4
F=9.054
>1
47.79±2.73
P=0.007
46.12±1.91
p=0.003
58.14±13.7
p<0.001
13.07±0.8
p=0.012
A
1
46.97±3.03
45.09±2.31
56.07±17.4
15.06±0.9
Marital Status Single
48.85±1.02
F=1.247
47.12±1.52
F=1.024
59.47±12.7
F=0.937
13.79±0.2
F=1.007
Widow/divorced
49.02±2.07
p=0.354
46.87±1.02
p=0.784
58.79±11.0
p=0.127
12.95±0.8
p=0.248
Married
48.73±1.93
47.89±1.03
58.09±17.6
13.54±0.6
Occupation Housewife
47.55±1.08
F=1.754
46.37±2.04
F=2.009
59.27±2.21
F=2.397
12.97±0.7
F=0.987
I 48.25±2.02
Unemployed
48.12±1.27
p=0.291
47.91±3.81
48.96±1.95 1 45.01±2.62
ED
>1
p=0.102
58.92±3.87
PT CC E
13.01±0.6
46.09±3.10
59.07±4.02
12.07±0.1
47.07±1.08
57.96±4.27
13.09±0.8
p=0.248
49.27±3.32
F=10.325
58.71±1.14
F=11.017
13.55±2.9
t=12.258
p<0.001
45.02±2.94
p<0.001
53.25±9.21
p<0.001
17.87.±3.8
p<0.001
*Mental Component Summary **Physical Component Summary. †Visual Analog Score for General Health. ‡Beck Depression Inventory
A
p=0.059
F=9.987
M
Number of grandchild cared for at a time
47.01±1.07
A
Retired
N U SC R
Employed
I N U SC R
TABLE 4: Linear regression models for SF-12 MCS and PSC, VAS, and BID with different independent variables SF-12 MCS
SF-12-PSC Stan dard ized Coe fficie nts
B
Std. Erro r
Beta
Constant
1.72 7
1.91 6
Age
.058
.020
Mean length of education (years)
.032
Mean monthly income
.280
Mean number of children
t
p
Unstandardize d coefficients
B
.368
ED
.901
Stand ardize d Coeffic ients
t
p
Std. Erro r
1.185
1.21 1
BID
Unstandardize d coefficients
B
Std.E rror
1.238
.36 8
143.3 55
16.27 7
Stand ardize d Coeffic ients
t
p
Unstandardiz ed coefficients
B
Std. Erro r
8.807
.0001
52.73 0
6.46 3
Standardiz ed Coefficient s
t
p
8.158
.00 01
.004
-.128
.204
-.257
-2.397
.00 1
.357
.172
.091
2.076
.039
.259
.059
.211
4.401
.00 01
.270
6.21 5
.0001
.198
.110
.481
4.115
.00 01
-.599
.042
-.566
14.419
.0001
.086
.018
.198
4.734
.00 01
.089
.127
3.12 6
.002
-.532
.209
-.207
-2.126
.00 2
-3.302
.989
-.126
-3.338
.001
-.404
.322
-.049
1.255
.21 0
.966
.119
.421
8.12 6
.0001
.657
.314
.391
5.154
.00 01
-7.075
1.092
-.335
-6.478
.0001
2.360
.427
.276
5.523
.00 01
Mean number of grandchildr en
.087
.064
.092
.901
.177
-.175
.214
-.101
1.144
.17 7
1.701
.544
.194
3.124
.002
.725
.229
.212
3.161
.00 2
Mean number of grandchildr
.484
.092
.218
.901
.368
.397
.137
.231
1.274
.36 8
-4.111
.799
-.191
-5.146
.0001
1.699
.306
.217
5.556
.00 01
PT
2.89 3
.005
CC E A
.133
VAS
A
Unstandardi zed coefficients
M
Models
I N U SC R
en cared for to date .002
.002
.405
5.45 2
.0001
-.102
.084
.507
6.175
.00 01
-.167
.020
-.556
-8.291
.0001
-.016
.009
-.134
1.880
.06 1
Time spent caring for grandchildr en to date
1.72 7
.002
.055
.838
.403
1.031
.067
-.079
-.957
.40 3
.170
.019
.557
9.036
.0001
.041
.008
.325
5.144
.00 01
Mean time spent caring for grandchildr en per week
.014
.001
.476
11.7 27
.0001
Mean duration of day-time care
.066
.009
1.00 5
7.29 2
Mean duration of night-time care
.067
1.11 9
8.40 9
DurbinWatson
1.969
1.906
1.924
1.931
0.798
0.844
0.814
0.806
0.636
0.703
0.748
0.650
M -.210
.027
-.476
-12.102
.00 01
.172
.010
.622
16.942
.0001
-.018
.004
-.165
4.252
.00 01
.0001
.107
.014
1.271
8.147
.00 01
-.737
.074
-1.222
-9.915
.0001
.341
.032
1.399
10.63 9
.00 01
.0001
.294
.075
1.307
7.147
.00 01
-.718
.066
-1.306
10.890
.0001
.292
.028
1.356
10.43 0
.00 01
ED
PT
CC E
.008
A
Age of the grandchildr en cared for
A
R
R2
A ED
PT
CC E A
M
N U SC R
I
Table 5: Binary logistic regression model applied between the study and control groups S.E
Wald
df
Sig
Exp (B)
95.0% C.I. for EXP (B)
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Constant
6.986
0.736
90.116
1
0.0001
1081.2
Age
-0.106
0.209
109.889
1
0.0001
1.004
0.885
0.1018
MCS*
0.254
0.587
25.2458
1
0.0001
1.057
1.024
1.087
PCS**
0.754
0.329
62.287
1
0.007
1.040
1.005
1.063
VAS†
0.296
0.637
25.739
1
0.001
BDI‡
-0.601
0.273
42.178
1
0.001
SC R
IP T
B
1.087
1.057
1.109
1.027
1.008
1.052
U
STEP
N
*Mental Component Summary **Physical Component Summary,
A
CC E
PT
ED
M
A
Analog Score for General Health, ‡Beck Depression Inventory
†Visual
S0167-4943(18)30172-9 https://doi.org/10.1016/j.archger.2018.08.009 AGG 3735
To appear in:
Archives of Gerontology and Geriatrics
Received date: Revised date: Accepted date:
18-6-2018 17-8-2018 18-8-2018
Please cite this article as: YALCIN BM, PIRDAL H, VELI KARAKOC E, MELIH SAHIN E, OZTURK O, UNAL M, GENERAL HEALTH PERCEPTION, DEPRESSION and QUALITY of LIFE in GERIATRIC GRANDMOTHERS PROVIDING CARE FOR GRANDCHILDREN, Archives of Gerontology and Geriatrics (2018), https://doi.org/10.1016/j.archger.2018.08.009 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
GENERAL HEALTH PERCEPTION, DEPRESSION and QUALITY of LIFE in GERIATRIC GRANDMOTHERS PROVIDING CARE FOR GRANDCHILDREN Running Title: Depression, quality of life and general health perception in
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grandchild-caring grandmothers
BEKTAS MURAT YALCIN1, HASAN PIRDAL2, ESAT VELI KARAKOC3, ERKAN
Prof. Dr. Ondokuz Mayis University Medical School Department of Family
U
1
SC R
MELIH SAHIN4, ONUR OZTURK5, MUSTAFA UNAL6
N
Practice, MD, Samsun/ Turkey
Family Physician, MD, Medical Park Hospital, Department of Family
4
ED
Medicine, Izmir, Turkey
M
3
A
2 Family Physician, MD, Tekkeköy Family Health Center, Samsun/Turkey
Prof. Dr. 18 Mart University Medical School Department of Family Practice,
Family Physician, MD, Asarcık Family Health Center, Samsun
CC E
5
PT
MD, Canakkale/ Turkey
6
Dr. Faculty Member, PhD. Ondokuz Mayis University Medical School
A
Department of Family Practice, MD, Samsun/ Turkey
Word Count: 3381 Tables: 5 Figures: 0
Correspondence: Prof. Dr. Bektas Murat YALCIN Ondokuz Mayıs University Medical Faculty Department of Family Medicine Kurupelit/Samsun Gsm: 05324811841
Tel: 0362 3121919-3464
Highlights
Eleven percent of geriatric grandmothers provided caregiver services
U
for grandchildren in our study population
Physical and mental quality of life, perception of health and
N
SC R
IP T
Email: [email protected].
A
depression results were better among grandparents caring for
Custodial grandmothers had the lowest quality of life, health
ED
M
grandchildren.
perception and depression levels among the entire study population
Three important aspects, socio-economic (being single or widowed, a
CC E
PT
(in both the control and study groups).
low education level, and low monthly income), demographic
A
(increasing age, a higher number of children and grandchildren, and presence of chronic diseases), and features of grandchild care (lower ages among grandchildren, total hours spent caregiving per week, and total hours of night-time caregiving) are capable of affecting depression, quality of life, and health perception levels among caregiver grandmothers.
ABSTRACT Aim/Background: To investigate levels of depression, quality of life, general health perception, and factors affecting these in grandmothers providing care for their grandchildren.
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Material/Method: One hundred two family physicians from four cities (Samsun, Amasya, Canakkale, and Izmir) in Turkey investigated 2859
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women older than 65 years on their patient lists. Of these, 282 (9.8%) had spent at least 50 hours caring for their grandchildren in the previous three months, and these were selected as the study group, while the remaining
N
U
2563 (89.6%) were enrolled as the control group. After all participants’
A
demographic variables had been investigated, they completed the Beck
M
Depression Inventory (BDI), Self-Function 12 (Mental and physical component score) (SF-12), and the Visual Analog Scale of EQ-5D (VAS).
ED
The participants in the study group also completed a questionnaire
PT
investigating features of their grandchild care. Results: The study group (with the exception of custodial grandmothers) better
CC E
scored
on
the
SF-12
(PSC=50.60±6.96
vs
48.24±8.12),
(MCS=49.70±7.77 vs 45.48±7.61), VAS (60.44±23.5 vs 54.16±19.5), and
A
BDI (13.97±0.3 vs 19.49±0.2) compared to the control group (p<0.0001 for all). Age, monthly income, mean length of education, duration of care, mean hours spent caregiving per week, being a custodial grandmother, presence of more than one chronic disease, and caring for more than one
grandchild at a time were identified as factors affecting SF-12, VAS and BID in the study group. Conclusion: Grandchild care positively affected the grandmothers’ quality of life, depression levels, and general health perception, with the exception
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of custodial grandmothers
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Key words: Geriatric, Grandmothers, Grandchildren, Babysitter, Custodial,
U
Primary Care
A
N
1.INTRODUCTION
M
Significant changes have occurred in the traditional nuclear family worldwide in recent years (1, 2). Social problems (increasing divorce rates,
ED
single parent families, teenage pregnancies, etc.) and economic difficulties
PT
(unemployment or low income, and lack of social support services) oblige families to seek more support from their parents in terms of child care (3).
CC E
Many grandparents today play a vital economic and social role as a social buffer in providing support for their grandchildren. In the U.S.A, more than seven million grandparents were living in the same household with at least
A
one grandchild under the age of 18 in 2010. One in 10 American children (7.5 million) was living in a household with at least one grandparent (5). The Turkish Statistical Institute (TUIK) estimates that 7.4% of all children in Turkey aged 0-5 years had been cared for by their grandparents (6).
While most of the support provided by grandparents may be limited to the economic level, support also varies depending on the nature of the problems the family faces. Grandparents mainly care for their grandchildren as babysitters during the day, while the parents are working. However, some grandchildren live with their grandparents in the same household on
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a permanent basis (co-residential), and in some cases (such as parental substance abuse, incarceration, or death) grandparents become their
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grandchildren’s legal custodians (7). Whatever the role of the grandparents in terms of caregiving for grandchildren, the role may be a highly
U
demanding one, and many unavoidable positive or adverse changes can
N
affect grandparents’ quality of physical and psychological life (8).
A
Theoretically, both negative and positive effects on grandparent caregivers’
M
quality of life are plausible on the basis of role strain (9) and role
ED
enhancement (10) theories. Role strain arises or increases when role obligations exceed one’s physical and psychological resources, thus
PT
affecting one’s health (11). According to the role strain theory, much stress deriving from the grandparental role, such as intensive caregiving for
CC E
grandchildren, may adversely affect physical and psychological quality of life. Some studies have reported that taking care of grandchildren is a
A
stressful activity and therefore contributes to increased depression or distress (12-14). Above all, caring for grandchildren places a strain on grandmothers’ limited economic resources (meeting the feeding or clothing needs or educational costs of a fast-growing child). Insomnia, which can be caused by very young babies, heightened physical fatigue due to the
difficulty of child care, or providing emotional support for a growing, emotionally traumatized child, are some of the factors that may exacerbate the grandmaternal burden (15). Many grandmothers may also provide care for another chronic patient in the home, or may themselves have illnesses which limit their physical capacities. Many grandmothers also report feeling
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restricted in their social lives and activities (16).
SC R
Role enhancement refers to the psychological benefits of discharging multiple roles (17). Caregiver grandparents report feeling closer to their
grandchildren and enjoying time spent with them (18). Caring for a
U
grandchild may also lead to a more active lifestyle, healthier meals, or a
N
reduction in smoking. Some grandparents feel that caring for their
M
A
grandchildren makes them healthier and more active (19). Recent studies provide some clues regarding various factors
ED
involved in negative or positive outcomes in terms of grandparental health (20). First, although only a small percentage of grandparents act as
PT
custodians, the role is a more demanding one than babysitting, and adverse
CC E
effects are more frequent in this grandparental group (21). While the negative effects of caring for grandchildren can be seen in both sexes, the main burden seems to lie with grandmothers (22). Another important factor
A
may be the grandmother’s age. The balance between caregiving demands and deteriorating grandmaternal resources (economic, physical and psychological) may be more easily compromised in the geriatric population (8). Finally, the nature of the problems faced by grandmothers who look
after their own grandchildren varies in different societies and cultural groups and depending on the nature of the care provided. To the best of our knowledge, there have been no previous studies of this subject in Turkish society. Our study had several aims. The first was to investigate the proportion of geriatric grandmothers providing care for
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their grandchildren in four different Turkish cities. A second aim was to examine the effect of grandchild care on grandparental quality of life and
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depression levels. Finally, we examined several factors which might affect
U
quality of life and depression in grandmothers caring for grandchildren.
A
N
2.MATERIALS and METHODS
M
2.1. Study Design
This descriptive and analytic study included only geriatric (≥65 years)
ED
women. It was performed between 1 March and 1 September, 2017, in four
PT
different cities in Turkey (Izmir, Canakkale, Amasya, and Samsun). Once a common study protocol had been prepared by the main research group,
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power analyses were computed to determine the minimum numbers of Family Health Centers and participants required to represent each urban
A
city center. The study was described to all primary care physicians in these cities by the research group through local research networks. Seventy-six Family Health Centers (a total of 102 primary care physicians) agreed to participate. After providing verbal consent, 2563 women (89.6% of a total of 2859 individuals) over 65 completed a questionnaire investigating their
socio-demographic features while visiting these Family Health Centers. Seventy-two patients (2.8%) who refused to participate, and 224 (8.7%) who were receiving antidepressant medication, or with a severe medical disease capable of affect their quality of health (severe diabetes mellitus with complications, rheumatoid arthritis, etc.) were excluded from the
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study. These excluded subjects included 33 (1.2%) grandmothers caring for at least one grandchild. All the remaining participants completed the SF-
SC R
12 (Self-Function 12 version 2), a Visual Analog Score (VAS) for general
health, and the Beck Depression Inventory. Subjects reporting personally
U
caring for at least one grandchild for at least 50 hours in the previous three
N
months during the study period (1 March to 1 September, 2017) were
A
enrolled as the study group (n=282, 11%). The grandmothers in the study
M
group were also divided into three subgroups (babysitters, co-residential,
ED
and custodial), according to the type of care provided. The first subgroup consisted of grandparents caring personally for at least one non-resident
PT
grandchild (babysitters) (n=263, 75.8%). In the second group, the grandchild lived in the same household as the grandmother on a permanent
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basis for some reason (the child’s family also living with the grandparents or working in other cities, etc.) (n=48, 16.8%). In the third group, the
A
grandparents had custodial rights, and the grandchild had lived in the same household as the grandparent on a permanent basis for at least three months (n=21, 7.4%). The remaining 2281 (89%) subjects were recruited as the control group. The participants in the study group completed a specially prepared questionnaire investigating details of the care they
provided for their grandchildren. These data were then compared between the two groups. 2.2. Tools 2.2.1. General Questionnaire
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This item was prepared by the research group in order to investigate
various social and economic factors. Subjects were asked about their age,
SC R
marital status, current occupation, annual income, and mean length of
education. All participants were also asked whether they owned their homes
U
or rented them. Health status was investigated on the basis of
N
hospitalization numbers and visits to physicians in the previous two years.
A
The questionnaire also inquired into chronic diseases, as well as total
M
numbers of children and grandchildren, and whether subjects had cared for their grandchildren previously. The participants in the study group were also
ED
asked some questions not put to the control group. These involved care-
PT
related details such as the number of grandchildren cared for in the previous three months, time spent caring for grandchildren per week, whether
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grandmothers also cared for grandchildren at night, responsibilities in terms of grandchild care, and problems encountered.
A
2.2.2. The Beck Depression Inventory (BDI)
This is 21-item, self-report rating inventory measures characteristic
attitudes and symptoms of depression (24). The BDI has been developed in different forms, including several computerized forms and a card form. Internal consistency for the BDI ranges from .73 to .92 with a mean value
of .86. The BDI demonstrates high internal consistency, with alpha coefficients of .86 and .81 for psychiatric and non-psychiatric populations respectively. There is no standard cut-off point for depression, although the total results from the BDI are correlated with one another. 2.2.3. SF-12 v 2 (Self-Function 12 version 2)
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This scale was developed from SF-36 as a short, valid alternative to
it, for use in large surveys of general and specific populations (25). SF-12
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is preferable to other, longer versions of measures of quality of life, and for use among the elderly because it is short (fewer questions make it easier
U
to answer) and does not include work-related questions. The scale was
N
subsequently modified after 10 years of research, to produce the 2.0
A
version (SF-12 v 2). Although the number of questions remained
M
unchanged, these were abbreviated and simplified.
ED
In order to be able to interpret the results of SF-12, the subject has to answer every question. Each answer is calculated from a special table in
PT
order to determine basic values for mental and physical components. Finally, these two components are added with different constant numbers
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in order to determine Mental Component Summary (MCS) and Physical Component Summary (PCS) scores.
A
2.2.4. EQ-5D-5 Visual Analog Scale
The visual analogue scale is the second part of the EQ-5D-5
questionnaire and indicates health status on the day of the interview on a 20 cm vertical scale with end points of 0 and 100. Notes at the both ends of the scale explain that the bottom rate (0) corresponds to "the worst
possible health status” and that a score of 100 indicates “the best possible health status” (26). 2.3. Statistical Methods All analyses were performed on SPSS version 15 (Chicago IL) and
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Minitab version 15 software. Several parametric and non-parametric analytic techniques, including the Chi-square and Independent samples t-
SC R
tests were used. Several independent factors were investigated between
the study and control groups using binary logistic regression models. A p
U
value of <0.05 was regarded as significant.
N
2.4. Ethics
A
Approval for the study was granted by the Canakkale University
M
(COMU) Ethical Committee. The Turkish Ministry of Health Public Health
settings.
PT
3. RESULTS
ED
Institute gave permission for this study to be conducted in primary care
CC E
A total of 2563 women were included in the study. A comparison of various sociodemographic factors, including mean numbers of children and grandchildren, between the study and control groups is presented in Table
A
1. The members of the control group were approximately five years older than the study group (p<0.001), had been educated for two years more (p<0.001), were less likely to live in rented accommodation (p<0.001), and had lower monthly income levels (p<0.001). They also had more children
(p=0.036)
and
grandchildren
(p<0.001),
the
mean
number
of
grandchildren they had cared for in the past was higher (p<0.001), and they had paid fewer visits to physicians in the preceding two years (p<0.001) compared to the study group.
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The study group members provided care for 69.44±56.23 months (min=3.52, max=276). The mean age of their grandchildren was
hours
a
week
providing
care.
Two
SC R
74.42±59.95 months (min=12, max=180), and they spent 87.64±57.5 hundred
fifty-three
(89.7%)
grandmothers cared for one grandchild, while 29 (10.3%) cared for two or Ninety-three
grandmothers
(32.7%)
also
U
more.
reported
providing
N
nocturnal care, with a mean value of 28.16±12.4 hours of night-time care
M
A
for a week.
Mean scale scores were 49.58±7.54 for SF-12 PSC, 47.52±7.25 for
ED
SF-12 MCS, 56.53±21.3 for EQ-5D-VAS, and 17.22±11.18 for BDI in the entire study population (the study and control groups together). The study
PT
group had higher SF-12 PSC, SF-12 MCS, and EQ-5D-VAS scores (p<0.001
CC E
for all) and lower BDI scores (p<0.001). A comparison between mean SF12 (PSC and MCS), VAS and BDI scores in the control and study groups is
A
presented in Table 2. Relations between mean SF-12 MSC, SF-12 PSC, EQ-5D-VAS, and BDI
scores, and variables such as mean age, monthly income, numbers of children and grandchildren, age of grandchildren, mean time spent caring for grandchildren to date, hours spent caring for grandchildren care per
week, and hours of day- and night-time care per week are presented in Table 3. Relations between mean SF-12 PSC, SF-12 MCS, EQ-5D-VAS, and BDI scores within the study group depending on care-giver status (babysitter,
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co-residential, or custodial), presence of chronic disease (none, one, or more than one), marital status (single, widow/divorced, or married),
SC R
occupation (housewife, employed, unemployed, or retired) and number of
grandchildren cared for at one time (one or more than one) are analyzed in Table 4. This analysis revealed that although the mean scores of the co-
U
residential and baby-sitter subgroups were not statistically different,
N
custodial grandmothers scored lower on SF-12 (PSC and MCS) and higher
A
on the BDI compared to the other two groups (p<0.001). In addition,
M
presence of a chronic disease (compared with no chronic disease) and a
ED
higher number of grandchildren cared for at a time had an effect on SF-12 PSC, SF-12 MCS, EQ-5D-VAS, and BDI scores.
PT
The linear regression models for SF-12 (MCS, PSC), VAS and BDI with
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several independent variables (age, mean length of education, mean monthly income, mean number of children and grandchildren, mean number of grandchildren cared for to date, the mean age of the
A
grandchildren receiving care, mean time spent on grandchild care to date, mean length of care per week, and mean length of day- and night-time care) are presented in Table 4.
Binary
logistic
regression
models
were
established
in
which
membership of the study or control group was adopted as a dependent variable, together with various independent variables. In the final model, age, and mean SF-12 MSC, SF-12 PSC, EQ-5D VAS, and BDI scores were selected as independent variables. According to this model, caring for
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grandchildren results in better MCS (OR: 1.057, Min: 1.024 Max: 1087 95% CI), PSC (OR: 1.040, Min: 1.005 Max: 1063 95% CI), VAS (OR: 1.087, Min:
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1.057 Max: 1.109 95% CI), and BDI (OR: 1.027, Min: 1.008 Max: 1052
95% CI) (p<0.001 for all) scores in women over 65. This model is presented
A
CC E
PT
ED
M
A
N
U
at Table 5
4. DISCUSSION To the best of our knowledge, ours is the only research to date on this subject in Turkey. The findings elicited are significant. First, according to our data, 11% of geriatric grandmothers provided caregiver services for
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grandchildren among our study population (including those grandmothers excluded from the study in the first draft). This is higher than the figure of
SC R
7% previously reported by the TUIK (6). Interestingly, although our study
population was older than 65, the TUIK investigated the overall level of grandchild care provided by all grandmothers. This may be due to the
U
increasing mean age at motherhood in Turkish society, meaning that
N
grandparents also tend to have grandchildren later in life.
A
Our study also revealed that in terms of physical and mental quality
M
of life, perception of health and depression results were better among
ED
grandparents caring for grandchildren (with the exception of custodial grandmothers) than among those who did not provide care services. Our
PT
results are in agreement with other studies reporting no evidence that
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caring for grandchildren has dramatic and widespread adverse effects on grandparental quality of life or depression (20, 27). However social factors may be involved here, as in some eastern and Mediterranean cultures
A
grandmothers have a more positive perception of and greater willingness to undertake grandchild care, and their quality of life and depression levels may be less vulnerable in consequence (28). This factor has also been confirmed in studies from the USA, especially among grandmothers with Afro-American or Latin ethnicity (29).
Our study also concentrated on factors that might impact on depression, quality of life (MCS and PSC), and health perception levels among
caregiver
grandmothers.
Previous
research
suggests
that
grandmothers who discharge intensive caregiving roles are often the most disadvantaged and have the poorest health (22). We investigated this by
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dividing those grandmothers whose grandchildren were permanently resident in the home on a continuous basis into custodial and co-residential
SC R
subgroups. Although the co-residential grandmothers had similar results to the babysitter grandmothers (whose grandchildren were not permanently
U
resident in the home), the custodial group had the lowest quality of life
N
(MCS and PSC), health perception and depression levels among the entire
A
study population (in both the control and study groups). Our finding that a
M
grandchild living permanently with the grandmother may not represent a
ED
risk factor for the grandmother’s quality of life, health perception, or depression is an important one. The triangular emotional relationship
PT
between grandmother, grandchildren and parents seems to be a more important factor. Previous studies have shown that custodial grandmothers
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may experience severe life crises which may exacerbate their burden, such as their children being subjected to criminal investigations (imprisonment),
A
severe health problems (cancer etc.), drug addiction, or the loss of one of the parents (through divorce, etc.) (30, 31). They may also experience conflicts with their own children, and also with their grandchildren (32). Their relationships with their grandchildren may also be more problematic since these children may experience separation trauma from a parent (33).
Several grandparents in our co-residential subgroup stated either that their grandchildren were living with their own parents together in the same household or that their children were working in other cities and frequently visited. In both these cases, the emotional triangle between grandmothers, grandchildren and parents may be less stressful and problematic than in
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the case of custodial grandparents.
Our study findings also revealed three important aspects capable of
SC R
affecting depression, quality of life (MCS and PSC), and health perception
levels among caregiver grandmothers. These may be classified as socio-
U
economic (being single or widowed, a low education level, and low monthly
N
income), demographic (increasing age, a higher number of children and
A
grandchildren, presence of chronic diseases), and features of grandchild
M
care (lower ages among grandchildren, total hours of caregiving per week,
ED
and total hours of night-time caregiving), based on linear regression models and correlations. Linear regression models in the study group investigating
PT
the factors affecting SF-12 MCS, SF-12 PSC, VAS, and BDI produced very high R2 values. These values indicate that the variables in these models can
CC E
explain 63%, 70%, 74.8%, and 65% of the changes in these four scale scores, respectively, which underlines the power of these models.
A
Regression analysis also confirmed that greater age (OR=1.004 min=0.885, max=0.1018, 95% CI) is a particularly important factor in terms of MCS (r=-0.387), PSC (r=-0.339), VAS (r=-0.386), and BID (r=0,421) scores. It seems that with increasing age, grandmothers’ physical and psychological resources available for caregiving decrease. Although a weak correlation
was observed between increasing age and monthly income (r=-0.188), there was strong relation between grandmothers’ economic capacity and quality of life perception of health and depression. To the best of our knowledge, this is the first study to report detailed analytic and demographic features from four cities in Turkey in the context
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of this research subject. However, our study also has a number of
limitations. First, the nature of childcare is very complex, and it is therefore
SC R
very difficult to measure the content of such care. We attempted to meet this difficulty by calculating the total weekly length of childcare provided by
U
the grandparents. However, this method may not reflect the intensity of
N
stress and burdens imposed on grandmothers. In order to classify the work
A
load involved in grandchild care, Hughes et al. (2007) suggested a minimum
M
requirement of 50 hours per year (20). However, this may not accurately
ED
reflect the intensity or burden of childcare. Second, our results do not indicate the long-term effects of grandchild care on grandmothers’ quality
PT
of life, depression levels, and general health perceptions. Additionally, the classification of co-residential and custodial grandmothers
may be
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problematic in our study population. In Turkish society, grandmothers may tend to care for their grandchildren under all circumstances (whether they
A
possess custodial rights or not). Although we took great care while classifying the grandmothers, some may nevertheless have been assigned to inappropriate groups.
4.1. Conclusion With the exception of the custodial subgroup, grandmothers who provided care for their grandchildren had a better quality of life (in physical and mental terms), lower depression rates, and better general health scores. Studies involving different populations and more detailed data are
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now required in order to better understand the relationship between
grandparents and grandchild care. These studies should involve the social
SC R
and psychological characteristics of grandmothers, grandchildren and
U
parents.
N
Appendix: We would like to express our sincere gratitude to all the primary
A
CC E
PT
ED
M
A
care physicians who took part in this study as interviewers.
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TABLE 1: Comparison of various sociodemographic features between the study and control groups Variables
Age (mean)
Study Group
Control Group
(n=282)
(n=2281)
66.19±6.8
71.19±5.5
p
t=20.345
Mean length of education 8.8±1.2 (years)
10.2±1.0
t=4.729. p<0.0001
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Occupation
IP T
p<0.0001
124 (44%)
1022 (44.8%)
x2=172.401
Employed
36 (12.8%)
349 (15.3%)
p<0.0001
Unemployed
61 (21.6%)
625 (27.4%)
Retired
61 (21.6%)
285 (12.5%)
N
the
1298 (91.5%)
x2=79.182
21. 8.8%
p<0.0001
0 (0%)
70 (3.1%)
x2=.212.
78 (27.4%)
710 (31.1%)
p<0.0001
204 (72.3%)
1501 (65.8%)
223 (78.9%)
Yes
59. (21.1%)
Marital Status Single
PT
Divorced/Widow
ED
No
Married
A
by
M
Home owned grandparent?
U
Housewife
CC E
Income (per month, Turkish lira [TL])
t=2.005
2257±541
2214±521
p=0.125
3.91±1.9
t=2.056 p=0.036
5.9±6.1
t=14.839. p<0.001
(3.4 $= 1 TL)
A
Mean number of children Mean number grandchildren
3.75±1.9
of 4.7±4.2
Mean number of grandchildren previously 1.65±1.9 cared for by grandmothers
t=113.747 3.75±1.9
P<0.001
Hospitalized in previous two years
the 53. 19%
x2=1.874
41. 18%
P=0.08
Visits to doctors in the 5.5±1.25 previous two years
6.8±1.87
t=10.047 P<0.001
(mean) x2=213.754 48 (13.3%)
114 (5.0%)
CVD*
75 (26.7%)
543 (23.8%)
COPD†
19 (6.7%)
144 (6.3%)
DM‡
14 (5%)
171 (7.5%)
Muscular/skeletal problems
59 (20%)
627 (27.5%)
20 (7%)
257 (11.3%)
48 (16.6%)
425 (18.6%)
More than two diseases
U
Others
P<0.001
SC R
None
IP T
Chronic diseases
A
†Chronic obstructive pulmonary diseases
N
*Cardio vascular diseases (including hypertension, hyperlipidemia, mild cerebrovascular diseases, etc.)
A
CC E
PT
ED
M
‡Diabetes mellitus (including types 1 and 2)
TABLE 2: Comparison of mean SF-12 PSC, SF-12 MCS, VAS, and BDI scores between the control and study groups Study Group
Control Group
t, p
SF-12 PSC*
50.60±6.96
48.24±8.12
10.392. p<0.0001
SF-12 MCS**
49.70±7.77
45.48±7.61
12.254. p<0.0001
EQ-5D-VAS†
60.44±23.5
54.16±19.5
7.008. p<0.0001
BDI‡
13.97±0.3
19.49±0.2
**Mental Component Summary
A
CC E
PT
ED
Beck Depression Inventory
M
A
Visual Analog Score for General Health
N
SC R
U
*Physical Component Summary
IP T
Inventory
12.560. p<0.001
I N U SC R
TABLE 3: Correlations between mean SF-12 MCS, SF-12 PSC, EQ-5D VAS, and BDI scores and different variables in the study group. 1.
2.
1
Age (years)
2
3
4
-0.247
0.220
0.123
p<0.001
p<0.001
p<0.001
Monthly income (TL)
-0.188
Mean number grandchildren
of
of
CC E
5.
Mean number children
6.
Age of grandchildren (months)
Duration grandchild (months)
A
7.
8.
9.
ED
4.
Mean length of education (years)
PT
3.
of care
Time spent caring per week (hours) Mean hours spent for night-time care per week
10. SF-12 MSC*
6
7
8
9
10
11
12
13
-0.154
-0.160
-0.208
-0.367
-0.464
-0.387
-0.339
-0.386
0.421
p=0.004
p=0.003
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
-0.293
-0.206
-0.156
-0.249
-0.108
-0.150
0.357
0.412
0.241
-0.308
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
0.224
0.011
0.224
0.125
-0.193
0.193
0.174
0.204
-0.215
0.197
p<0.001
P=0.768
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
0.569
0.123
0.162
-0.118
0.124
-0.366
-0.348
-0.372
0.437
p<0.001
p<0.001
p<0.001
p<0.001
P=0.018
p<0.001
p<0.001
p<0.001
p<0.001
0.093
0.025
-0.051
0.403
0.312
-0.125
0.205
0.350
p=0.012
p=0.442
p=0.119
p<0.001
p<0.001
p=0.002
p<0.001
p<0.001
0.820
-0.099
0.403
0.312
-0.125
-0.205
0.350
p<0.001
p=0.010
p<0.001
p<0.001
p=0.002
p<0.001
p<0.001
-0.082
0.332
0.315
-0.237
0.215
0.442
P=0.014
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
0.312
-0.237
0.328
-0.102
-0.280
p<0.001
p<0.001
p<0.001
p<0.001
p<0.001
0.105
0.117
0.102
0.088
P=0.091
p=0.063
P=0.074
p=0.886
0.778
0.698
-0.668
M
p=0.015
5
A
Variables
I N U SC R
11. SF-12 PSC **
EQ-5D-VAS †
A
12.
M
13. BDI ‡
*Mental Component Summary **Physical Component Summary, †Visual Analog Score for General Health, ‡Beck Depression Inventory
A
CC E
PT
ED
††
p<0.001
p<0.001
p<0.001
0.596
-0.789
p<0.001
p<0.001 -0.671 p<0.001
I N U SC R
TABLE 4: Relations between mean SF-12 MCS, SF-12 PSC, EQ-5D VAS and BDI scores and several variables in the
Mean SF-12 MCS*
ED
Score
Care-giving Status
43.76±7.16
PT
Custodial Co-residential Babysitter
CC E
Chronic Disease
P
M
Variables
A
study group
F=10.239. p<0.001
Mean
P
Mean
p
Mean
SF-12 PSC**
EQ-5D VAS†
BDI‡
Score
Score
Score
42.90±8.16
F=11.542. p<0.001
54.86±13.3
F=10.801. p<0.001
22.17±0.5
48.16±9.01
49.65±5.87
59.93±23.5
13.97±0.3
50.92±1.18
49.98±6.71
61.10±19.8
13.01±0.1
p
F=10.650. p<0.001
None
50.45±1.89
F=9.821
50.01±5.78
F=10.523
62.25±20.1
F=10.124
11.02±0.4
F=9.054
>1
47.79±2.73
P=0.007
46.12±1.91
p=0.003
58.14±13.7
p<0.001
13.07±0.8
p=0.012
A
1
46.97±3.03
45.09±2.31
56.07±17.4
15.06±0.9
Marital Status Single
48.85±1.02
F=1.247
47.12±1.52
F=1.024
59.47±12.7
F=0.937
13.79±0.2
F=1.007
Widow/divorced
49.02±2.07
p=0.354
46.87±1.02
p=0.784
58.79±11.0
p=0.127
12.95±0.8
p=0.248
Married
48.73±1.93
47.89±1.03
58.09±17.6
13.54±0.6
Occupation Housewife
47.55±1.08
F=1.754
46.37±2.04
F=2.009
59.27±2.21
F=2.397
12.97±0.7
F=0.987
I 48.25±2.02
Unemployed
48.12±1.27
p=0.291
47.91±3.81
48.96±1.95 1 45.01±2.62
ED
>1
p=0.102
58.92±3.87
PT CC E
13.01±0.6
46.09±3.10
59.07±4.02
12.07±0.1
47.07±1.08
57.96±4.27
13.09±0.8
p=0.248
49.27±3.32
F=10.325
58.71±1.14
F=11.017
13.55±2.9
t=12.258
p<0.001
45.02±2.94
p<0.001
53.25±9.21
p<0.001
17.87.±3.8
p<0.001
*Mental Component Summary **Physical Component Summary. †Visual Analog Score for General Health. ‡Beck Depression Inventory
A
p=0.059
F=9.987
M
Number of grandchild cared for at a time
47.01±1.07
A
Retired
N U SC R
Employed
I N U SC R
TABLE 4: Linear regression models for SF-12 MCS and PSC, VAS, and BID with different independent variables SF-12 MCS
SF-12-PSC Stan dard ized Coe fficie nts
B
Std. Erro r
Beta
Constant
1.72 7
1.91 6
Age
.058
.020
Mean length of education (years)
.032
Mean monthly income
.280
Mean number of children
t
p
Unstandardize d coefficients
B
.368
ED
.901
Stand ardize d Coeffic ients
t
p
Std. Erro r
1.185
1.21 1
BID
Unstandardize d coefficients
B
Std.E rror
1.238
.36 8
143.3 55
16.27 7
Stand ardize d Coeffic ients
t
p
Unstandardiz ed coefficients
B
Std. Erro r
8.807
.0001
52.73 0
6.46 3
Standardiz ed Coefficient s
t
p
8.158
.00 01
.004
-.128
.204
-.257
-2.397
.00 1
.357
.172
.091
2.076
.039
.259
.059
.211
4.401
.00 01
.270
6.21 5
.0001
.198
.110
.481
4.115
.00 01
-.599
.042
-.566
14.419
.0001
.086
.018
.198
4.734
.00 01
.089
.127
3.12 6
.002
-.532
.209
-.207
-2.126
.00 2
-3.302
.989
-.126
-3.338
.001
-.404
.322
-.049
1.255
.21 0
.966
.119
.421
8.12 6
.0001
.657
.314
.391
5.154
.00 01
-7.075
1.092
-.335
-6.478
.0001
2.360
.427
.276
5.523
.00 01
Mean number of grandchildr en
.087
.064
.092
.901
.177
-.175
.214
-.101
1.144
.17 7
1.701
.544
.194
3.124
.002
.725
.229
.212
3.161
.00 2
Mean number of grandchildr
.484
.092
.218
.901
.368
.397
.137
.231
1.274
.36 8
-4.111
.799
-.191
-5.146
.0001
1.699
.306
.217
5.556
.00 01
PT
2.89 3
.005
CC E A
.133
VAS
A
Unstandardi zed coefficients
M
Models
I N U SC R
en cared for to date .002
.002
.405
5.45 2
.0001
-.102
.084
.507
6.175
.00 01
-.167
.020
-.556
-8.291
.0001
-.016
.009
-.134
1.880
.06 1
Time spent caring for grandchildr en to date
1.72 7
.002
.055
.838
.403
1.031
.067
-.079
-.957
.40 3
.170
.019
.557
9.036
.0001
.041
.008
.325
5.144
.00 01
Mean time spent caring for grandchildr en per week
.014
.001
.476
11.7 27
.0001
Mean duration of day-time care
.066
.009
1.00 5
7.29 2
Mean duration of night-time care
.067
1.11 9
8.40 9
DurbinWatson
1.969
1.906
1.924
1.931
0.798
0.844
0.814
0.806
0.636
0.703
0.748
0.650
M -.210
.027
-.476
-12.102
.00 01
.172
.010
.622
16.942
.0001
-.018
.004
-.165
4.252
.00 01
.0001
.107
.014
1.271
8.147
.00 01
-.737
.074
-1.222
-9.915
.0001
.341
.032
1.399
10.63 9
.00 01
.0001
.294
.075
1.307
7.147
.00 01
-.718
.066
-1.306
10.890
.0001
.292
.028
1.356
10.43 0
.00 01
ED
PT
CC E
.008
A
Age of the grandchildr en cared for
A
R
R2
A ED
PT
CC E A
M
N U SC R
I
Table 5: Binary logistic regression model applied between the study and control groups S.E
Wald
df
Sig
Exp (B)
95.0% C.I. for EXP (B)
Lower
Upper
Lower
Upper
Lower
Upper
Lower
Upper
Constant
6.986
0.736
90.116
1
0.0001
1081.2
Age
-0.106
0.209
109.889
1
0.0001
1.004
0.885
0.1018
MCS*
0.254
0.587
25.2458
1
0.0001
1.057
1.024
1.087
PCS**
0.754
0.329
62.287
1
0.007
1.040
1.005
1.063
VAS†
0.296
0.637
25.739
1
0.001
BDI‡
-0.601
0.273
42.178
1
0.001
SC R
IP T
B
1.087
1.057
1.109
1.027
1.008
1.052
U
STEP
N
*Mental Component Summary **Physical Component Summary,
A
CC E
PT
ED
M
A
Analog Score for General Health, ‡Beck Depression Inventory
†Visual