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GRANDPARENTS THAT TAKE CARE OF GRANCHILDREN: ANALYSIS OF THE CARE PROFILE AND INTENSITY

ABSTRACT

Objective:

to identify the profile and intensity of the care provided by grandparents to grandchildren.

Method:

a descriptive and cross-sectional study by means of systematized random sampling, with application of a semi-structured questionnaire and execution of descriptive exploratory analysis. It was conducted in 2019 in the municipality of Triângulo Mineiro - Brazil.

Results:

a total of 392 grandparents caring for grandchildren were interviewed, mostly women (87.5%), retired (67.3%), with incomplete Elementary School (52.8%), hypertensive (71.9%) and with vision problems (69.4%). The main reason for the caregiver role was the fact that the parents had to work, and intensity of the care provided to the grandchildren was high.

Conclusion:

it is considered that the care relationship between grandparents and grandchildren is an invisible aspect to the scientific production and in the structuring of health programs, despite its impacts on older adults’ health status. The study broadens their visibility, with the need to unveil this topic so that it is possible to integrate them and strengthen public and social policies, especially in the health sector, given that it is an emerging phenomenon.

DESCRIPTORS:
Adolescent; Grandparents; Child; Caregiver; Older Adults.

RESUMO

Objetivo:

identificar o perfil e a intensidade de cuidado dos avós para com os netos.

Método:

estudo descritivo, transversal, por amostra aleatória sistematizada, utilizado questionário semiestruturado e empreendida análise exploratória descritiva. Realizado no município do Triângulo Mineiro - Brasil, 2019.

Resultados:

entrevistados 392 avós cuidadores de netos, maioria mulheres (87,5%), aposentadas (67,3%), ensino fundamental incompleto (52,8%), hipertensas (71,9%) e problemas visuais (69,4%). O motivo principal de cuidado foi pelos pais trabalharem e a intensidade de cuidado junto aos netos foi intensiva.

Conclusão:

considera-se que a relação de cuidado entre avos e netos é um aspecto invisível à produção científica e na estruturação de programas de saúde, apesar de seus impactos à condição de saúde dos idosos. O estudo amplia a visão aos mesmos sendo necessário o desvelar deste tema para que se possa efetivamente integrá-los e fortalecer políticas públicas e sociais, notadamente no setor saúde, dado ser um fenômeno emergente.

DESCRITORES:
Adolescente; Avós; Criança; Cuidador; Idosos.

RESUMEN

Objetivo:

identificar el perfil y la intensidad del cuidado que realizan los abuelos de sus nietos.

Método:

estudio descriptivo, transversal, con muestreo aleatorio sistemático, mediante cuestionario semiestructurado y análisis descriptivo exploratorio. Realizado en el municipio del Triángulo Minero - Brasil, 2019.

Resultados:

se entrevistó a 392 abuelos que cuidaban a sus nietos, la mayoría eran mujeres (87,5 %), jubiladas (67,3 %), con primaria incompleta (52,8 %), hipertensión (71,9 %) y problemas visuales (69,4 %). La principal razón para que cuiden de ellos era que los padres trabajaban y la intensidad del cuidado de los nietos era intensiva.

Conclusión:

se considera que la relación de cuidado entre abuelos y nietos es un aspecto invisible en la producción científica y en la estructuración de programas de salud, a pesar de los impactos que tiene en la condición de salud de los adultos mayores. El estudio amplía la visión sobre los mismos dado que es necesario dilucidar este tema para que puedan ser efectivamente integrados y fortalecer las políticas públicas y sociales, especialmente en el sector salud, dado que se trata de un fenómeno emergente.

DESCRIPTORES:
Adolescente; Abuelos; Niño; Cuidador; Adultos Mayores.

INTRODUCTION

The family structure underwent changes throughout the years; the new family configurations are a reality and the patriarchal model is no longer the sole reference. It is understood that new forms of families are emerging and that, regardless of composition (free union, de facto union, homosexual or recomposed), the family is the union of people through affectivity, consanguinity or interest11 Jorge JH, Lind W. Segurar a família pelas pontas: os dilemas dos avós cuidadores a tempo inteiro. Psychologica. [Internet]. 2015 [cited 2021 mar. 13]; 58(1), 7-22. Available from: https://impactum-journals.uc.pt/psychologica/article/view/1647-8606_58-1_1.
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-22 Cardoso AR, Brito LMT de. Ser avó na família contemporânea: que jeito é esse? Psico-USF. [Internet]. 2014 [cited 2021 mar. 13]; 19(3):433-441. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-82712014000300007&lng=pt&nrm=iso&tlng=pt.
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Reformulation of families is not only related to their composition structural scope, as there are role changes that promote more adaptable family relationships33 Souza FA. Voltando no tempo: o papel dos avós guardiões. V encontro científico e simpósio de educação 2015; Lins, SP.. In contemporary times, families are plural, with multiple organizations: families headed by women, directed by the older adults and which can also have grandchildren and great-grandchildren at their core, thus escaping from the typical nuclear family33 Souza FA. Voltando no tempo: o papel dos avós guardiões. V encontro científico e simpósio de educação 2015; Lins, SP.. The traditional nuclear family model consists of father, mother and child(ren). In this conception, the maternal role is the mother’s responsibility, and the family provider and protector one lies on the father11 Jorge JH, Lind W. Segurar a família pelas pontas: os dilemas dos avós cuidadores a tempo inteiro. Psychologica. [Internet]. 2015 [cited 2021 mar. 13]; 58(1), 7-22. Available from: https://impactum-journals.uc.pt/psychologica/article/view/1647-8606_58-1_1.
https://impactum-journals.uc.pt/psycholo...

2 Cardoso AR, Brito LMT de. Ser avó na família contemporânea: que jeito é esse? Psico-USF. [Internet]. 2014 [cited 2021 mar. 13]; 19(3):433-441. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-82712014000300007&lng=pt&nrm=iso&tlng=pt.
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-33 Souza FA. Voltando no tempo: o papel dos avós guardiões. V encontro científico e simpósio de educação 2015; Lins, SP..

Therefore, transformations are verified in the family models, which prove to be heterogeneous and singular at the same time33 Souza FA. Voltando no tempo: o papel dos avós guardiões. V encontro científico e simpósio de educação 2015; Lins, SP.. This plurality of family compositions and arrangements carry with them a number of challenges for the social and health public policies in order to promote equality and expanded care11 Jorge JH, Lind W. Segurar a família pelas pontas: os dilemas dos avós cuidadores a tempo inteiro. Psychologica. [Internet]. 2015 [cited 2021 mar. 13]; 58(1), 7-22. Available from: https://impactum-journals.uc.pt/psychologica/article/view/1647-8606_58-1_1.
https://impactum-journals.uc.pt/psycholo...

2 Cardoso AR, Brito LMT de. Ser avó na família contemporânea: que jeito é esse? Psico-USF. [Internet]. 2014 [cited 2021 mar. 13]; 19(3):433-441. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-82712014000300007&lng=pt&nrm=iso&tlng=pt.
https://www.scielo.br/scielo.php?script=...
-33 Souza FA. Voltando no tempo: o papel dos avós guardiões. V encontro científico e simpósio de educação 2015; Lins, SP..

With the increase in life expectancy in Brazil, there is an expansion in the aged population44 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo demográfico; 2010 [cited 2021 mar. 13]. Available from: www.ibge.gov.br.
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that exerts impacts on coexistence, connecting generations and transforming family arrangements55 Zanatta E, Arpini DM. Conhecendo a imagem, o papel e a relação avó-neto: a perspectiva de avós maternas. Estud. Pesqui. Psicol. [Internet]. 2017 [cited 2021 mar. 13]; 17(1):343-363. Available from: https://www.e-publicacoes.uerj.br/index.php/revispsi/article/view/35164/24865.
https://www.e-publicacoes.uerj.br/index....
. Currently ,it is evidenced that Brazilian families have more grandparents than in the last century and, when examining these transformations, it is important to consider that grandparents assume new roles and responsibilities in these reformulated family contexts55 Zanatta E, Arpini DM. Conhecendo a imagem, o papel e a relação avó-neto: a perspectiva de avós maternas. Estud. Pesqui. Psicol. [Internet]. 2017 [cited 2021 mar. 13]; 17(1):343-363. Available from: https://www.e-publicacoes.uerj.br/index.php/revispsi/article/view/35164/24865.
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Contemporary older adults have been assuming a relevant sociofamily role, pointing out new features in the family micro-structure. In addition to financially contributing to sustaining their families, they also take on the role of caregivers of their grandchildren. They are often even responsible for the education of children and/or pre-adolescents66 Ribeiro AN, Zucolotto MP da R. Avós cuidadoras e seus netos: uma reflexão sobre as configurações familiares. Disciplinarum Scientia. Série: Ciências Humanas [Internet]. 2015 [cited 2021 mar. 13]; 16(1):27-41. Available from: https://periodicos.ufn.edu.br/index.php/disciplinarumCH/article/view/1838.
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Caring for the grandchildren, either full- or in part-time and/or cohabiting, is a reality in several countries and especially in contemporary society22 Cardoso AR, Brito LMT de. Ser avó na família contemporânea: que jeito é esse? Psico-USF. [Internet]. 2014 [cited 2021 mar. 13]; 19(3):433-441. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-82712014000300007&lng=pt&nrm=iso&tlng=pt.
https://www.scielo.br/scielo.php?script=...
,55 Zanatta E, Arpini DM. Conhecendo a imagem, o papel e a relação avó-neto: a perspectiva de avós maternas. Estud. Pesqui. Psicol. [Internet]. 2017 [cited 2021 mar. 13]; 17(1):343-363. Available from: https://www.e-publicacoes.uerj.br/index.php/revispsi/article/view/35164/24865.
https://www.e-publicacoes.uerj.br/index....
. Such care can be related to parental situations, such as full-time work, divorce, consumption of psychoactive substances, imprisonment and death, leading grandparents to assume responsibility for the care of grandchildren and, thus, placing them in individual, intra-family and extra-family dilemmas22 Cardoso AR, Brito LMT de. Ser avó na família contemporânea: que jeito é esse? Psico-USF. [Internet]. 2014 [cited 2021 mar. 13]; 19(3):433-441. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-82712014000300007&lng=pt&nrm=iso&tlng=pt.
https://www.scielo.br/scielo.php?script=...
,55 Zanatta E, Arpini DM. Conhecendo a imagem, o papel e a relação avó-neto: a perspectiva de avós maternas. Estud. Pesqui. Psicol. [Internet]. 2017 [cited 2021 mar. 13]; 17(1):343-363. Available from: https://www.e-publicacoes.uerj.br/index.php/revispsi/article/view/35164/24865.
https://www.e-publicacoes.uerj.br/index....
-66 Ribeiro AN, Zucolotto MP da R. Avós cuidadoras e seus netos: uma reflexão sobre as configurações familiares. Disciplinarum Scientia. Série: Ciências Humanas [Internet]. 2015 [cited 2021 mar. 13]; 16(1):27-41. Available from: https://periodicos.ufn.edu.br/index.php/disciplinarumCH/article/view/1838.
https://periodicos.ufn.edu.br/index.php/...
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The studies conducted in Brazil indicate the importance of grandparents in the family nucleus, mainly due to the support offered and for expressing a feeling of satisfaction for taking care of their grandchildren33 Souza FA. Voltando no tempo: o papel dos avós guardiões. V encontro científico e simpósio de educação 2015; Lins, SP.,55 Zanatta E, Arpini DM. Conhecendo a imagem, o papel e a relação avó-neto: a perspectiva de avós maternas. Estud. Pesqui. Psicol. [Internet]. 2017 [cited 2021 mar. 13]; 17(1):343-363. Available from: https://www.e-publicacoes.uerj.br/index.php/revispsi/article/view/35164/24865.
https://www.e-publicacoes.uerj.br/index....
-66 Ribeiro AN, Zucolotto MP da R. Avós cuidadoras e seus netos: uma reflexão sobre as configurações familiares. Disciplinarum Scientia. Série: Ciências Humanas [Internet]. 2015 [cited 2021 mar. 13]; 16(1):27-41. Available from: https://periodicos.ufn.edu.br/index.php/disciplinarumCH/article/view/1838.
https://periodicos.ufn.edu.br/index.php/...
. After a literature review, there is limited evidence of national and international studies on the theme of grandparents taking care of their grandchildren, mainly with regard to intensity of the care they provide and their health perception after initiating this care. Thus, the objective of this study is to identify the profile and intensity of the care provided by grandparents to grandchildren.

METHODOLOGY

A descriptive and cross-sectional study with a quantitative approach, conducted with older adults that take care of children and/or pre-adolescents from the municipality of Uberaba-MG. 37,365 aged individuals were identified in the municipality of Uberaba, according to estimates by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE) in 2010; in addition, in the Family Health Strategy (FHS) units of the municipality, there are 27,995 registered older adults and, through a survey carried out by the Primary Care coordination in 2019, there are 1,627 grandparents who provide care to grandchildren in Uberaba-MG.

The sample was calculated based on the 1,627 older adults that take care of children and/or pre-adolescents, referring to each FHS unit of the municipality. Sample calculation considered a 95% confidence interval and 4% margin of error, observing a sample fraction of 27% of the population size, obtaining a sample of 400 grandparents. However, due to the inclusion criteria, the final sample was comprised by 392 grandparents. The participants were chosen based on a random selection from the coded list of aged individuals according to a draw generated in Excel®88 Cochran WG. Wiley series in probability and mathematical statistics; 1977.. Systematized recruitment was carried out by proportional allocation according to the number of registered aged caregivers grandchildren, in a representative and distributional way, according to the sample fraction in each FHS.

The inclusion criteria were as follows: age ≥60 years old, being a caregiver of children and/or pre-adolescents, living or not in the same family unit, with and/or without the presence of the parent(s) or adoptive parents, having the responsibility for the integral or partial care of subjects aged from zero to 13 years old, and being registered in the Basic Health Units (BHUs) from the urban area. For this study, the fact of acting as a caregiver was not characterized as a paid activity, but as a sociofamily responsibility tie. It was also adopted as a criterion to present cognitive ability to answer the test, verified from application of the Mini-Mental State Examination (MMSE) instrument, in which the cutoff point was considered according to the older adults’ schooling level: 13 for illiterate individuals, 18 for one to 11 years of study, and 26 for more than 11 years of study77 Melo DM de, Barbosa AJG. O uso do Mini Exame do Estado Mental em pesquisas com idosos no Brasil: uma revisão sistemática. Ciên. Saúde Colet. [Internet]. 2015 [cited 2021 mar. 13]; 20(12):3865-3876. Available from: https://www.scielo.br/scielo.php?script=sci_abstract&pid=S1413-81232015001203865&lng=en&nrm=iso&tlng=pt.
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Aged individuals paid for their work and those that were not found after three home visit attempts were excluded. The next older adult registered in the Family Health Strategy (FHS) was included for replacement.

Data collection took place at the homes and was organized based on an agenda of home visits prepared with the Community Health Agents (CHAs) of the FHS from the municipality, for better acceptance of the aged research participant. The interviews were conducted by duly trained interviewers and lasted a mean of 20 minutes per home unit. The data were collected from June to November 2019.

For data collection, the authors elaborated a semi-structured instrument, given the absence of validated instruments to reach care intensity, with elaboration and validation of a Likert type scale from zero to 10, in which the older adults choose, from zero (without or low intensity) to 10 (moderate to high intensity), the degree of time or energy spent in caring for their grandchildren according to their perception.

The instrument consists of categories grouped as follows: characterization of grandparents that take care of children and pre-adolescents, which intends to evaluate sociodemographic issues, health perception of the aged caregiver (better, similar or worse than most people their age), for what reasons they need to take care of their grandchildren (economic needs, work, legal and health problems, separation of children and others) and morbidities they present (arterial hypertension, vision problems, diabetes, back problems, arthritis/arthrosis).

In order to use it, the instrument’s face and content validation was performed by expert judges. The Content Validity Index was 0.93%, showing that the content of the instrument allows measuring what it proposes to measure; Cronbach’s alpha was 0.867, revealing excellent internal consistency; and the Intraclass Correlation Coefficient (ICC) was 0.87 (95% CI: 0.72-0.96), showing that there is excellent stability of the continuous variables, indicating that the instrument is suitable for use99 Polit DF, Beck CT, Hungler BP. Análise quantitativa. In: Polit DF, Beck CT, Hungler BP. Fundamentos de pesquisa em enfermagem: métodos, avaliação e utilização. 5. ed. Porto Alegre (RS): Artmed; 2004; p.167-98.

10 Alexandre NMC, Coluci MZO. Content validity in the development and adaptation processes of measurement instruments. Ciênc. Saúde Colet. [Internet]. 2011 [cited 2021 mar. 13];16(7):3061-8. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232011000800006.
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11 Matos DAS. Confiabilidade e concordância entre juízes: aplicações na área educacional. Est. Aval. Educ. [Internet]. 2014 [cited 2021 mar. 13]; 25(59):298-324, set./dez. Available from: http://www.fcc.org.br/pesquisa/publicacoes/eae/arquivos/1947/1947.pdf.
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-1212 Souza AC de, Alexandre NMC, Guirardello E de B. Propriedades psicométricas na avaliação de instrumentos: avaliação da confiabilidade e da validade. Epidemiol. Serv. Saude [Internet]. 2017 [cited 2021 mar. 13]; 26(3):649-659. Available from: https://www.scielo.br/scielo.php?pid=S2237-96222017000300649&script=sci_abstract&tlng=pt.
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An electronic Excel® spreadsheet with independent double typing was used for data organization, in order to assess inconsistencies in organization of the database. The analysis was performed resorting to the Statistica (data analysis software system) software, version 13 (2018).

A descriptive and exploratory analysis of the variables was performed, with central tendency analyses for numerical variables and absolute and relative frequency analysis for the categorical variables.

This research was approved by the Research Ethics Committee of Universidade Federal do Triângulo Mineiro, under opinion No. 3,134,416.

RESULTS

A total of 392 older adults comprised the sample. The difficulties to reach the final sample were due to incomplete data in the questionnaires.

The following was found among the participants: grandparents aged from 60 to 93 years old, with most of them aged between 60 and 69 years old (66.6%) and a mean of 67. In relation to gender, 343 (87.5%) were women. Regarding race groups, there was predominance of white-skinned individuals with 245 (62.5%), black-skinned with 77 (19.6%), brown skinned with 67 (17.1%), Asian with two (0.5%) and indigenous with one (0.3%). Regarding marital status, 199 (50.8%) were married and/or in a stable union. In terms of retirement, 264 (67.3%) were retired, 40 (10.2%) were beneficiaries of the Bolsa Família program and 26 (6.6%) received the Continuous Benefit (Benefício de Prestação Continuada, BPC). With regard to schooling level, 207 (52.8%) had incomplete Elementary School and 69 (17.6%) had completed it, 27 (6.9%) had incomplete High School and 40 (10.2%) had completed it, one (0.3%) had incomplete Higher Education and 14 (3.6%) had completed it, and 32 (8.2%) were illiterate.

Regarding morbidities, 19 conditions were mentioned. The participants were allowed to report more than one health problem. Hypertension was found in 282 (71%) of the grandparents, followed by 272 (69.4%) with vision problems, 203 (51.8%) with diabetes, 195 (49.7%) with back problems and 131 (33.4%) with arthritis/arthrosis, in addition to 314 (80%) that had two or more associated diseases.

Regarding perception of the health status (Table 1), 166 (42.3%) of the caregivers defined their health status as fair and 152 (38.8%) as good. In turn, when grouping “fair” with “bad” and very bad”, the result is 41 (52.8%). When comparing their health status to other people the same age, 213 (54.3%) believe it is similar.

Table 1
Health perception among the grandparents that take care of grandchildren. Uberaba, MG, Brazil, 2019

Regarding the number of children and/or pre-adolescents cared for by the grandparents (Table 2), adding up the percentages of male and female individuals per age cycle, it was verified that 93 (23.7%) older adults cared for one to two children in early childhood (children aged zero - two years old), 259 (67.1%) cared for one to five children in second childhood (children aged three - eight years old) and 211 (53.8%) cared for one to three pre-adolescents (nine - 13 years old).

Table 2
Number of children and pre-adolescents cared for by grandparents. Uberaba, MG, Brazil, 2019

Regarding the intensity of the care provided (Table 3), all age groups considered care as intensive (eight points or more): in early childhood, 46 (52.4%); in second childhood, 105 (44.7%); and in preadolescence, 79 (40.6%). In the current study, in case the grandparents took care of more than one grandchild in different age groups, the intensity for each group was reported.

Table 3
Intensity of the care provided by grandparents to their children and/or preadolescents. Uberaba, MG, Brazil, 2019

Regarding cohabitation with the grandparents, 74 (18.9%) and 64 (16.3%) of the older adults live in the same house with one child and/or one pre-adolescent, respectively, 19 (4.8%) grandparents do so with children, 12 (3.1%) with pre-adolescents, one (0.3%) older adult lives in the same house with a child and two (0.5%) with pre-adolescents (Table 4).

In the number of people living in the same house (including the older adults and the grandchildren, if they also share the house with their grandparents), one to 13 individuals were reported and 145 (37.1%) lived with two people, as can be seen in Table 4.

Table 4
Cohabitation Characteristics. Uberaba, MG, Brazil, 2019

With regard to the reasons why the grandparents took care of their grandchildren (Table 5), 230 (58.7%) reported doing so because the parents were working.

Table 5
Reasons for the grandparents to take care of their grandchildren. Uberaba, MG, Brazil, 2019

DISCUSSION

Aspects of care for grandchildren were addressed, in which there was predominance of female grandparents, which is also consistent with an international and national study1313 Cavalcanti JRG, Vieira KFL, Sousa DHAV de, Cardoso DB. Percepções e vivências de avós que cuidam de seus netos. Anais CIEH [Internet]. 2015 [cited 2021 mar. 13]; 2(1). Available from: https://www.editorarealize.com.br/index.php/artigo/visualizar/12622.
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-1414 Bailey JS, Letiecq BL, Visconti K, Tucker N. Rural Native and European American Custodial Grandparents: stressors, resources, and resilience. J Cross Cult Gerontol [Internet]. 2019 [access in 13 mar. 2021]; 34:131-148. Available from: https://pubmed.ncbi.nlm.nih.gov/31134463/.
https://pubmed.ncbi.nlm.nih.gov/31134463...
. A research study developed with rural American grandparents and European grandparents with grandchildren custody, which investigated the relationship of resources and stressors in grandchildren care, also presented predominance of female caregivers1414 Bailey JS, Letiecq BL, Visconti K, Tucker N. Rural Native and European American Custodial Grandparents: stressors, resources, and resilience. J Cross Cult Gerontol [Internet]. 2019 [access in 13 mar. 2021]; 34:131-148. Available from: https://pubmed.ncbi.nlm.nih.gov/31134463/.
https://pubmed.ncbi.nlm.nih.gov/31134463...
, corroborating the findings of a research study conducted in João Pessoa, Brazil, which investigated the grandparents’ perception about the experience of caring for their grandchildren, in which the caregivers were mostly women1313 Cavalcanti JRG, Vieira KFL, Sousa DHAV de, Cardoso DB. Percepções e vivências de avós que cuidam de seus netos. Anais CIEH [Internet]. 2015 [cited 2021 mar. 13]; 2(1). Available from: https://www.editorarealize.com.br/index.php/artigo/visualizar/12622.
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It is assumed that such care is essentially performed by women due to experiences such as pregnancy, birth and history that mothers are predominantly responsible for the care of children. A fact evidenced in a qualitative research study developed at the national level with seven grandparents that take care of their grandchildren every day showed that, when interviewed, a grandfather directed to his wife the care responsibility, reasserting the gender issue with regard to family care1515 Coutrim RM da E, Fiqueiredo AM de, Antônio OJ de OJ, Resende A. O papel dos avós nos cuidados com a educação e a saúde das crianças. REAe - Revista de Estudos Aplicados em Educação [Internet]. 2018 [cited 2021 mar. 13]; 3(5):101-110. Available from: https://seer.uscs.edu.br/index.php/revista_estudos_aplicados/article/view/5092.
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In terms of marital status, most of the older adults were married or in a stable union. Aged people responsible for their grandchildren and living with their partners are also found in other studies with older adults that take care of their grandchildren1414 Bailey JS, Letiecq BL, Visconti K, Tucker N. Rural Native and European American Custodial Grandparents: stressors, resources, and resilience. J Cross Cult Gerontol [Internet]. 2019 [access in 13 mar. 2021]; 34:131-148. Available from: https://pubmed.ncbi.nlm.nih.gov/31134463/.
https://pubmed.ncbi.nlm.nih.gov/31134463...
,1616 Esperança O, Leite M, Gonçalves P. Provision of care for grandchildren and their implications on Quality of Life of Grandparents. J Aging Innovation [Internet]. 2013 [cited 2021 mar. 13]; 2(3):63-81. Available from: http://journalofagingandinnovation.org/pt/tag/grandchildren/.
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-1717 Peterson TL. Changes in health perceptions among older grandparents raising adolescent grandchildren. Soc Work Public Health [Internet]. 2017 [cited 2021 mar. 13]; 32:6, 394-406. Available from: https://pubmed.ncbi.nlm.nih.gov/28613989/.
https://pubmed.ncbi.nlm.nih.gov/28613989...
. As they do not live alone, these grandparents can enjoy greater support on the part of their partners in caring for their grandchildren.

Retirees corresponded to the majority of caregivers in this research, which is consistent with other studies1414 Bailey JS, Letiecq BL, Visconti K, Tucker N. Rural Native and European American Custodial Grandparents: stressors, resources, and resilience. J Cross Cult Gerontol [Internet]. 2019 [access in 13 mar. 2021]; 34:131-148. Available from: https://pubmed.ncbi.nlm.nih.gov/31134463/.
https://pubmed.ncbi.nlm.nih.gov/31134463...
,1717 Peterson TL. Changes in health perceptions among older grandparents raising adolescent grandchildren. Soc Work Public Health [Internet]. 2017 [cited 2021 mar. 13]; 32:6, 394-406. Available from: https://pubmed.ncbi.nlm.nih.gov/28613989/.
https://pubmed.ncbi.nlm.nih.gov/28613989...

18 Triadó C, Villar F, Celdrán M, Solé C. Grandparents who provide auxiliary care for their grandchildren: satisfaction, difficulties, and impact on their health and well-being. J Intergener Relatsh [Internet]. 2014 [cited 2021 mar. 13]; 12:2, 113-127. Available from: https://psycnet.apa.org/record/2014-25593-003.
https://psycnet.apa.org/record/2014-2559...

19 Clottey EN, Scott AJ, Alfonso ML. Grandparent caregiving among rural African Americans in a community in the American South: challenges to health and wellbeing. Rural. Remote. Health [Internet]. 2015 [cited 2021 mar. 13]; 15:3313. Available from: https://pubmed.ncbi.nlm.nih.gov/26270646/.
https://pubmed.ncbi.nlm.nih.gov/26270646...
-2020 Marken DM, Howard JB. Grandparents raising grandchildren: the Influence of a late-life transition occupational engagement. Phys. Occup. Ther. Geriatr [Internet]. 2014 [cited 2021 mar. 13]; 32(4):381-396. Available from: https://www.tandfonline.com/doi/abs/10.3109/02703181.2014.965376.
https://www.tandfonline.com/doi/abs/10.3...
. A study carried out with 312 grandparents who provided ancillary care to grandchildren in Spain1818 Triadó C, Villar F, Celdrán M, Solé C. Grandparents who provide auxiliary care for their grandchildren: satisfaction, difficulties, and impact on their health and well-being. J Intergener Relatsh [Internet]. 2014 [cited 2021 mar. 13]; 12:2, 113-127. Available from: https://psycnet.apa.org/record/2014-25593-003.
https://psycnet.apa.org/record/2014-2559...
, mostly presented retired people (54.5%), with the possibility that this imposes a significant financial challenge for these individuals, as they report high costs with food, transportation, health and clothing of the grandchildren, which can generate a considerable stress factor. A research study conducted in Europe also indicates economic distress reported1414 Bailey JS, Letiecq BL, Visconti K, Tucker N. Rural Native and European American Custodial Grandparents: stressors, resources, and resilience. J Cross Cult Gerontol [Internet]. 2019 [access in 13 mar. 2021]; 34:131-148. Available from: https://pubmed.ncbi.nlm.nih.gov/31134463/.
https://pubmed.ncbi.nlm.nih.gov/31134463...
,1717 Peterson TL. Changes in health perceptions among older grandparents raising adolescent grandchildren. Soc Work Public Health [Internet]. 2017 [cited 2021 mar. 13]; 32:6, 394-406. Available from: https://pubmed.ncbi.nlm.nih.gov/28613989/.
https://pubmed.ncbi.nlm.nih.gov/28613989...
,1919 Clottey EN, Scott AJ, Alfonso ML. Grandparent caregiving among rural African Americans in a community in the American South: challenges to health and wellbeing. Rural. Remote. Health [Internet]. 2015 [cited 2021 mar. 13]; 15:3313. Available from: https://pubmed.ncbi.nlm.nih.gov/26270646/.
https://pubmed.ncbi.nlm.nih.gov/26270646...
-2020 Marken DM, Howard JB. Grandparents raising grandchildren: the Influence of a late-life transition occupational engagement. Phys. Occup. Ther. Geriatr [Internet]. 2014 [cited 2021 mar. 13]; 32(4):381-396. Available from: https://www.tandfonline.com/doi/abs/10.3109/02703181.2014.965376.
https://www.tandfonline.com/doi/abs/10.3...
.

It was verified that 16.2% of the grandparents that take care of grandchildren receive some type of income transfer benefit, whether Benefício de Prestação Continuada (BPC) or Bolsa Família (BF), programs created by the Brazilian government for people in situations of social assistance vulnerability. BPC2121 Benefício de Prestação Continuada. Constituição Federal de 1988 (art.203). Regulamentado pela Lei Orgânica da Assistência Social (LOAS). Lei nº 8.742, de 7/12/1993. Available from: http://www.planalto.gov.br/ccivil_03/leis/l8742.htm.
http://www.planalto.gov.br/ccivil_03/lei...
serves the elderly and physically disabled and Bolsa Família2222 Programa Bolsa Família. Lei n 10.836, de 9 de janeiro de 2004. Available from: http://www.planalto.gov.br/ccivil_03/_ato2004-2006/2004/lei/l10.836.htm.
http://www.planalto.gov.br/ccivil_03/_at...
assists in the care of children/adolescents, both indicating a situation of poverty or extreme poverty. This result shows the socioeconomic vulnerability presented by these grandparents and, when assuming responsibility for a grandchild, the expenses are high, causing greater financial difficulties, as pointed out by a study carried out in Tocantins, in which the grandparents present considerable financial difficulty when assuming the care of grandchildren22 Cardoso AR, Brito LMT de. Ser avó na família contemporânea: que jeito é esse? Psico-USF. [Internet]. 2014 [cited 2021 mar. 13]; 19(3):433-441. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-82712014000300007&lng=pt&nrm=iso&tlng=pt.
https://www.scielo.br/scielo.php?script=...
.

Several international studies1414 Bailey JS, Letiecq BL, Visconti K, Tucker N. Rural Native and European American Custodial Grandparents: stressors, resources, and resilience. J Cross Cult Gerontol [Internet]. 2019 [access in 13 mar. 2021]; 34:131-148. Available from: https://pubmed.ncbi.nlm.nih.gov/31134463/.
https://pubmed.ncbi.nlm.nih.gov/31134463...
,1818 Triadó C, Villar F, Celdrán M, Solé C. Grandparents who provide auxiliary care for their grandchildren: satisfaction, difficulties, and impact on their health and well-being. J Intergener Relatsh [Internet]. 2014 [cited 2021 mar. 13]; 12:2, 113-127. Available from: https://psycnet.apa.org/record/2014-25593-003.
https://psycnet.apa.org/record/2014-2559...
-1919 Clottey EN, Scott AJ, Alfonso ML. Grandparent caregiving among rural African Americans in a community in the American South: challenges to health and wellbeing. Rural. Remote. Health [Internet]. 2015 [cited 2021 mar. 13]; 15:3313. Available from: https://pubmed.ncbi.nlm.nih.gov/26270646/.
https://pubmed.ncbi.nlm.nih.gov/26270646...
,2424 Mhaka-Mutepfa M, Cumming R, Mpofu E. Grandparents fostering orphans: influences of protective factors on their health and well-being. Health Care Women Int [Internet] 2014 [cited 2021 mar. 13]; 35:7-9. Available from: https://pubmed.ncbi.nlm.nih.gov/24820960/.
https://pubmed.ncbi.nlm.nih.gov/24820960...
indicate that older adults found lack of governmental support to provide care to their grandchildren. The Brazilian programs (BPC and BF) can reduce the negative health effects and, thus, avoid economic stress.

Most of the respondents have incomplete Elementary School, which is similar to other studies (with grandparents in the caregiver role), which report the low schooling level of these aged people,66 Ribeiro AN, Zucolotto MP da R. Avós cuidadoras e seus netos: uma reflexão sobre as configurações familiares. Disciplinarum Scientia. Série: Ciências Humanas [Internet]. 2015 [cited 2021 mar. 13]; 16(1):27-41. Available from: https://periodicos.ufn.edu.br/index.php/disciplinarumCH/article/view/1838.
https://periodicos.ufn.edu.br/index.php/...
,1515 Coutrim RM da E, Fiqueiredo AM de, Antônio OJ de OJ, Resende A. O papel dos avós nos cuidados com a educação e a saúde das crianças. REAe - Revista de Estudos Aplicados em Educação [Internet]. 2018 [cited 2021 mar. 13]; 3(5):101-110. Available from: https://seer.uscs.edu.br/index.php/revista_estudos_aplicados/article/view/5092.
https://seer.uscs.edu.br/index.php/revis...
-1616 Esperança O, Leite M, Gonçalves P. Provision of care for grandchildren and their implications on Quality of Life of Grandparents. J Aging Innovation [Internet]. 2013 [cited 2021 mar. 13]; 2(3):63-81. Available from: http://journalofagingandinnovation.org/pt/tag/grandchildren/.
http://journalofagingandinnovation.org/p...
. In a study carried out in Bahia, the older adults were mostly illiterate2525 Meira SS, Vilela ABA, Casotti CA, Nascimento JC do, Andrade CB. Idosos em estado de corresidência em um município do interior da Bahia. Mundo saúde [Internet]. 2015 [cited 2021 mar. 13]; 39(2):201-209. Available from: http://bvsms.saude.gov.br/bvs/periodicos/mundo_saude_artigos/Idosos_estado_corresidencia.pdf.
http://bvsms.saude.gov.br/bvs/periodicos...
. In Brazil, people born in the 1970s or in previous decades have experienced countless difficulties to study, constituting a significant generation of individuals with low schooling levels, which can support the finding in this and other studies1414 Bailey JS, Letiecq BL, Visconti K, Tucker N. Rural Native and European American Custodial Grandparents: stressors, resources, and resilience. J Cross Cult Gerontol [Internet]. 2019 [access in 13 mar. 2021]; 34:131-148. Available from: https://pubmed.ncbi.nlm.nih.gov/31134463/.
https://pubmed.ncbi.nlm.nih.gov/31134463...
,1717 Peterson TL. Changes in health perceptions among older grandparents raising adolescent grandchildren. Soc Work Public Health [Internet]. 2017 [cited 2021 mar. 13]; 32:6, 394-406. Available from: https://pubmed.ncbi.nlm.nih.gov/28613989/.
https://pubmed.ncbi.nlm.nih.gov/28613989...
,2323 Osório NB, Neto LS, Souza JM de. A era dos avós contemporâneos na educação dos netos e relações familiares: um estudo de caso na universidade da maturidade da universidade federal do Tocantins. Revista Signos [Internet]. 2018 [cited 2021 mar. 13]; 39(1): 305-315. Available from: http://www.univates.br/revistas/index.php/signos/article/view/1837%20.
http://www.univates.br/revistas/index.ph...
,2626 Camarano AA, Kanso S, Mello JL e. Como vive o idoso brasileiro? In: Camarano, AA. os novos idosos brasileiros: muito além dos 60. Rio de Janeiro: IPEA; 2004 [cited 2021 mar. 13]. Available from: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/0191.pdf.
https://www.nescon.medicina.ufmg.br/bibl...
, as all the participants are over 60 years old and live in Brazil2626 Camarano AA, Kanso S, Mello JL e. Como vive o idoso brasileiro? In: Camarano, AA. os novos idosos brasileiros: muito além dos 60. Rio de Janeiro: IPEA; 2004 [cited 2021 mar. 13]. Available from: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/0191.pdf.
https://www.nescon.medicina.ufmg.br/bibl...
.

In terms of health perception, many considered themselves to have fair health and similar to people their age. A similar result was found in Portugal, in a research study about the impact of grandchildren care on older adults’ quality of life, in which most of the caregivers considered their health as fair and also believed to have similar health to people their age1616 Esperança O, Leite M, Gonçalves P. Provision of care for grandchildren and their implications on Quality of Life of Grandparents. J Aging Innovation [Internet]. 2013 [cited 2021 mar. 13]; 2(3):63-81. Available from: http://journalofagingandinnovation.org/pt/tag/grandchildren/.
http://journalofagingandinnovation.org/p...
.

In this study there was no significant difference between genders regarding the care receiver, which differs from a research study conducted in Portugal, where most of the children and/or pre-adolescents were female1616 Esperança O, Leite M, Gonçalves P. Provision of care for grandchildren and their implications on Quality of Life of Grandparents. J Aging Innovation [Internet]. 2013 [cited 2021 mar. 13]; 2(3):63-81. Available from: http://journalofagingandinnovation.org/pt/tag/grandchildren/.
http://journalofagingandinnovation.org/p...
.

Most of the grandchildren cared for, both children and pre-adolescents, did not live with their grandparents. Some research studies show that not all grandchildren live in the same house with their grandparents; however, with the change in family configurations, some are already doing so, and these grandparents provide an important supporting role to their grandchildren66 Ribeiro AN, Zucolotto MP da R. Avós cuidadoras e seus netos: uma reflexão sobre as configurações familiares. Disciplinarum Scientia. Série: Ciências Humanas [Internet]. 2015 [cited 2021 mar. 13]; 16(1):27-41. Available from: https://periodicos.ufn.edu.br/index.php/disciplinarumCH/article/view/1838.
https://periodicos.ufn.edu.br/index.php/...
,1515 Coutrim RM da E, Fiqueiredo AM de, Antônio OJ de OJ, Resende A. O papel dos avós nos cuidados com a educação e a saúde das crianças. REAe - Revista de Estudos Aplicados em Educação [Internet]. 2018 [cited 2021 mar. 13]; 3(5):101-110. Available from: https://seer.uscs.edu.br/index.php/revista_estudos_aplicados/article/view/5092.
https://seer.uscs.edu.br/index.php/revis...
. In a survey conducted in Tocantins, 70% of the grandparents cohabited with their grandchildren2323 Osório NB, Neto LS, Souza JM de. A era dos avós contemporâneos na educação dos netos e relações familiares: um estudo de caso na universidade da maturidade da universidade federal do Tocantins. Revista Signos [Internet]. 2018 [cited 2021 mar. 13]; 39(1): 305-315. Available from: http://www.univates.br/revistas/index.php/signos/article/view/1837%20.
http://www.univates.br/revistas/index.ph...
.

In another study, conducted in Bahia, 79.2% of the grandparents shared the house with approximately four other people, and were satisfied with this cohabitation2525 Meira SS, Vilela ABA, Casotti CA, Nascimento JC do, Andrade CB. Idosos em estado de corresidência em um município do interior da Bahia. Mundo saúde [Internet]. 2015 [cited 2021 mar. 13]; 39(2):201-209. Available from: http://bvsms.saude.gov.br/bvs/periodicos/mundo_saude_artigos/Idosos_estado_corresidencia.pdf.
http://bvsms.saude.gov.br/bvs/periodicos...
. In most cases, the generational relationship that exists between grandparents and grandchildren can occur across three generations, consisting of grandparents, parents/children and grandchildren, either cohabiting or not.

Regarding care intensity all three age groups surveyed (first and second childhood and pre-adolescence), the results show an intensity level equal to or above eight points in more than 40%, being inversely proportional to the age group (the lower the age group, the higher the care intensity).

In an American study it was observed that grandparents who provided bulky care (more than 30 hours a week) could suffer negative effects, and the lower the workload, the lower such effects2727 Minkler M, Fuller-Thomson DE. Physical and mental health status of American grandparents providing extensive childcare to their grandchildren. J Am Med Womens Assoc [Internet]. 2001 [cited 2021 mar. 13]; 56:199-205. Available from: https://pubmed.ncbi.nlm.nih.gov/11759793/.
https://pubmed.ncbi.nlm.nih.gov/11759793...
. Concomitant to this, an association between care intensity (12 hours or more) and a perception of poor health among the grandparents was detected by Spanish research study1818 Triadó C, Villar F, Celdrán M, Solé C. Grandparents who provide auxiliary care for their grandchildren: satisfaction, difficulties, and impact on their health and well-being. J Intergener Relatsh [Internet]. 2014 [cited 2021 mar. 13]; 12:2, 113-127. Available from: https://psycnet.apa.org/record/2014-25593-003.
https://psycnet.apa.org/record/2014-2559...
, causing less satisfaction in care or an increase in diagnosed morbidities.

The 1998 and 2009 British Social Attitudes (BSA) Survey data report, conducted by NatCen to analyze grandparents in Great Britain, found that most of the grandparents provide nearly 10 weekly hours of care to their grandchildren2828 Wellard S. Doing it all? Grandparents, childcare and employment: an analysis of british social attitudes survey data from 1998 and 2009. London: Grandparents Plus; 2011 [cited 2021 mar. 13]; Available from: https://www.bl.uk/collection-items/doing-it-all-grandparents-childcare-and-employment-an-analysis-of-british-social-attitudes-survey-data-from-1998-and-2009#.
https://www.bl.uk/collection-items/doing...
. In Europe, another study found a workload of 15 weekly hours of care2929 Gessa GD, Glaser K, Price D, Ribe E, Tinker A. What drives national differences in intensive grandparental childcare in Europe? J. Gerontol [Internet]. 2015 [cited 2021 mar. 13]; 71(1):141-53. Available from: https://academic.oup.com/psychsocgerontology/article/71/1/141/2604976.
https://academic.oup.com/psychsocgeronto...
.

For not finding any validated instrument (especially quantitative) to understand the intensity of the care provided by the grandparents, mainly in Brazil, there is a gap in knowledge about how they overload or not their health, quality of life and social well-being. Associated with this, there is an important number of qualitative research studies11 Jorge JH, Lind W. Segurar a família pelas pontas: os dilemas dos avós cuidadores a tempo inteiro. Psychologica. [Internet]. 2015 [cited 2021 mar. 13]; 58(1), 7-22. Available from: https://impactum-journals.uc.pt/psychologica/article/view/1647-8606_58-1_1.
https://impactum-journals.uc.pt/psycholo...
,22 Cardoso AR, Brito LMT de. Ser avó na família contemporânea: que jeito é esse? Psico-USF. [Internet]. 2014 [cited 2021 mar. 13]; 19(3):433-441. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-82712014000300007&lng=pt&nrm=iso&tlng=pt.
https://www.scielo.br/scielo.php?script=...
,1313 Cavalcanti JRG, Vieira KFL, Sousa DHAV de, Cardoso DB. Percepções e vivências de avós que cuidam de seus netos. Anais CIEH [Internet]. 2015 [cited 2021 mar. 13]; 2(1). Available from: https://www.editorarealize.com.br/index.php/artigo/visualizar/12622.
https://www.editorarealize.com.br/index....
,3030 Ribeiro PCP, Bittencourt MIG de F. Reflexões acerca dos vínculos de cuidado entre avós e netos na atualidade. Polêmica [Internet]. 2017 [cited 2021 mar. 13]; 17(4):17-29. Available from: https://www.e-publicacoes.uerj.br/index.php/polemica/article/view/34309.
https://www.e-publicacoes.uerj.br/index....
(which kept the proportions of the importance of understanding the phenomenon) that contribute a subjective view of the intensity levels of such care: understanding care metrics of grandparents and grandchildren is a need in itself, as it is a phenomenon that has been expanding and, therefore, would support the importance of social policies.

Regarding the reasons that led the grandparents to take care of their grandchildren, most have the care responsibility due to the fact that the parents need to work; this finding is in line with other research studies carried out in Brazil22 Cardoso AR, Brito LMT de. Ser avó na família contemporânea: que jeito é esse? Psico-USF. [Internet]. 2014 [cited 2021 mar. 13]; 19(3):433-441. Available from: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-82712014000300007&lng=pt&nrm=iso&tlng=pt.
https://www.scielo.br/scielo.php?script=...
,66 Ribeiro AN, Zucolotto MP da R. Avós cuidadoras e seus netos: uma reflexão sobre as configurações familiares. Disciplinarum Scientia. Série: Ciências Humanas [Internet]. 2015 [cited 2021 mar. 13]; 16(1):27-41. Available from: https://periodicos.ufn.edu.br/index.php/disciplinarumCH/article/view/1838.
https://periodicos.ufn.edu.br/index.php/...
and Europe, in which most of the grandparents also assist in the balance between professional and personal life in the family when caring for the grandchildren2929 Gessa GD, Glaser K, Price D, Ribe E, Tinker A. What drives national differences in intensive grandparental childcare in Europe? J. Gerontol [Internet]. 2015 [cited 2021 mar. 13]; 71(1):141-53. Available from: https://academic.oup.com/psychsocgerontology/article/71/1/141/2604976.
https://academic.oup.com/psychsocgeronto...
. Circumstances such as abandonment, death and drug use by the parents are recurrent in the research studies and are reasons for the older adults to assume responsibility their grandchildren1414 Bailey JS, Letiecq BL, Visconti K, Tucker N. Rural Native and European American Custodial Grandparents: stressors, resources, and resilience. J Cross Cult Gerontol [Internet]. 2019 [access in 13 mar. 2021]; 34:131-148. Available from: https://pubmed.ncbi.nlm.nih.gov/31134463/.
https://pubmed.ncbi.nlm.nih.gov/31134463...
.

Grandparents initiate such care for their grandchildren due to their parents working; certain lack of public daycare centers and full-time schools can be indicated. The absence of governmental support at this point in the life of grandchildren, grandparents and parents can lead to less health for aged caregivers1818 Triadó C, Villar F, Celdrán M, Solé C. Grandparents who provide auxiliary care for their grandchildren: satisfaction, difficulties, and impact on their health and well-being. J Intergener Relatsh [Internet]. 2014 [cited 2021 mar. 13]; 12:2, 113-127. Available from: https://psycnet.apa.org/record/2014-25593-003.
https://psycnet.apa.org/record/2014-2559...
.

The study limitations are justified by the incipient number of specific studies on the topic and by the fact that many of them are qualitative in nature, not expressing in numbers the dimension of this care, and the quantitative ones only take into account the hourly care load, not presenting a broader evaluation of intensity. There are limitations regarding the validated questionnaires and in Portuguese to evaluate this population, requiring elaboration and validation of an instrument.

Another limitation is the aged caregivers’ reach, as this information is not official due to the fact that only Primary Care and no other instance collect data on grandparents who care for their grandchildren. As future research studies, there is a perceived need to analyze joint associations and similarity groups between sociodemographic aspects, health perception, reasons and care intensity of grandparents towards grandchildren.

CONCLUSION

It is observed that, in addition to caring for their grandchildren for various reasons, those aged women still present important morbidities that can worsen if they focus only on their grandchildren and fail to adequately maintain their underlying diseases, generating sequelae and possibly difficulties managing their grandchildren with their health, taking into account that such care was reported as intensive. There are some studies on this theme, although insufficient to clarify positive impacts or not in such care; however, this study brings us closer to this reality and broadens the view on the care relationship between grandparents and grandchildren, aiming to integrate it into the theme of public and social policies, especially in health.

It is considered that the care relationship between grandparents and grandchildren is an invisible aspect to the scientific production and in the structuring of health programs, despite its impacts on older adults’ health status. Consequently, the study broadens their visibility, with the need to unveil this topic so that it possible to effectively integrate them and strengthen public and social policies, especially in the health sector, given that it is an emerging phenomenon. Given the unprecedented nature of the study at the national level, especially regarding care intensity, further studies in the area are suggested, considering the new family, economic and social compositions, asking for understanding and more research studies on grandparents who are currently caregivers.

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Edited by

Associate editor: Dra. Susanne Betiolli

Publication Dates

  • Publication in this collection
    06 Feb 2023
  • Date of issue
    2023

History

  • Received
    05 Mar 2021
  • Accepted
    27 July 2022
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