American Indian/Alaskan Native grandparents raising grandchildren: findings from the census 2000 supplementary survey.

Fuller-Thomson, Esme ; Minkler, Meredith

Social workers increasingly serve families in which grandparents are raising their grandchildren. Many grandparents have found raising a grandchild a rewarding experience (Bahr, 1994; Giarrusso, Silverstein, & Feng, 2000; Minkler & Roe, 1993), and the outcomes for the grandchildren often are positive (Solomon & Marx, 1995). However, grandparent caregivers are significantly more likely to be living in poverty (Bryson & Casper, 1999; Harden, Clark, & Maguire, 1997), to be depressed (Fuller-Thomson & Minkler, 2001; Strawbridge, Wallhagen, Shema, & Kaplan, 1997), to have limitations in their activities of daily living (Minkler & Fuller-Thomson, 1999), to have higher rates of heart disease (Lee, Colditz, Berkman, & Kawachi, 2003) and to have poorer self-rated health (Marx & Solomon, 2000) than their non-caregiving peers.

Between 1970 and 1997, the number of children under age 18 living in grandparent-headed households increased by 76 percent (Lugaila, 1998). By 2001 there were more than 2,400,000 grandparents raising their grandchildren in the United States (U.S. Census Bureau, 2002a). The cross-sectional nature of census data tends to underestimate the extent of the phenomenon. Earlier research indicated, for example, that more than one in 10 U.S. grandparents had raised a grandchild for six months or more at some point in their lives (Fuller-Thomson, Minkler, & Driver, 1997). Grandparent involvement in child rearing and surrogate parenting has been shown to be considerably more common among many communities of color than among white communities (Simmons & Dye, 2003; Szinovacz, 1998), with groups such as African Americans and American Indians/Alaskan Natives (AI/AN) having a well-documented history of such involvement (compare Bahr, 1994; Hunter & Taylor, 1998; Shomaker, 1989;Weibel-Orlando, 1997).

To date, no nationally representative studies have documented the prevalence and profile of grandparent caregiving in AI/AN families. An accurate assessment of the extent of such caregiving, as well as of the health, social, and financial issues facing this population, is critical to enhancing outreach efforts and effective practice with AI/AN grandparent caregivers and their families. We used the American Community Survey/Census 2000 Supplementary Survey (C2SS) data collected from 890,000 households (U.S. Census Bureau, 2003) to address this gap in the literature. We also investigated whether AI/AN grandparent caregivers were comparable to or more disadvantaged than their non-caregiving AI/AN peers with respect to poverty and health issues.

Several qualitative studies have suggested that grandparents play a particularly important caregiving role in AI/AN families (Bahr, 1994; Shomaker, 1989;Weibel-Orlando, 1997). Canadian data have supported these findings, showing much higher rates of grandparent caregiving among Native Canadians than among the general population (Fuller-Thomson, in press).

This article presents some historical context and contemporary sociocultural and other factors that help explain the higher rates of grandparent caregiving in AI/AN communities. Study methods and findings including the prevalence of grandparent caregiving among the AI/AN population age 45 and older are presented along with a profile comparing AI/AN grandparent caregivers in this age group with their non-caregiving AI/AN peers.

BACKGROUND

Without some familiarity with the experiences of AI/AN (Williamson & Ellison, 1996), it is difficult for practitioners to understand the context in which grandparent caregivers are raising their grandchildren. Although we present some historical facts and dominant views relevant to many American Indian and Alaskan Natives, we emphasize that there is no monolithic "Native American" reality (Gross, 1995). But there is a general consensus among the Native population that to be Indian is to believe that "everything is alive ... [and] that we are all related" (Couture, 1991, p. 61). To deal effectively with AI/ AN clients, social workers need to consider the diversity in the belief systems of the more than 550 federally recognized tribes (U.S. Department of the Interior, Bureau of Indian Affairs, 2002). Furthermore, within each tribe or tribal organization there remains a great deal of variation in cultural orientation and individual experience (Weaver, 1999). We emphasize that the diverse realities experienced by grandparent caregivers have been influenced not only by the historical and societal context in which they live, but also by the distinct cultural traditions of each tribe and the unique family and personal biographies they encompass.

Elders have traditionally been revered in AI/AN cultures, and their roles as wise advisers and keepers of the cultural legacy contribute to their esteemed status (Weibel-Orlando, 1997). Historically, grandparents have played a key socialization role and provided physical care and training for their grandchildren in a wide range of tribes. This phenomenon was well documented in early anthropological work among the Apache (Bahr, 1994) and Navajo (Shomaker, 1989) and more recently by a number of AI/AN scholars (compare Duran & Duran, 1995; Fredericks & Hodge, 1999). Extensive care provision by grandparents freed mothers to gather food and provide for their families (Bahr); grandchildren in turn provided assistance to grandparents (Shomaker). Weibel-Orlando highlighted the key caregiving roles of many grandparents in contemporary AI/AN communities, stressing in particular that some grandparents actively solicit caregiving responsibilities for grandchildren to enhance the children's exposure to traditional ways, and others undertake care of grandchildren because of family crises.

AI/AN communities and family structure have been heavily affected by historical circumstances, including forced relocation to reservations and removal of large numbers of children from American Indian families (Herring, 1989). Discriminatory policies that promoted removal of AI/AN children from family homes had a particularly deleterious effect on family functioning: Residential schools followed a policy of forced acculturation, prohibiting use of native language and cultural practices (Hogan & Siu, 1988; Matheson, 1996).As residential schools declined in importance, more and more AI/AN children were removed by child welfare agencies. By the early 1970s, 25 percent to 35 percent of all American Indian children were placed in foster or adoptive homes or institutions (Hogan & Siu; Matheson), the majority of which were outside their community.To address some of these injustices, the Indian Child Welfare Act of 1978 (ICWA) (P.L. 95-608) emphasized the importance of culturally similar placement for children removed from the parental home by child welfare agencies (Matheson). Preference is given to extended family members when placement decisions are made (Matheson), thus increasing the number of children in the care of AI/AN grandparents.

Grandparents' assumption of caregiving in AI/ AN communities also occurs in response to high adult morbidity and mortality, substance abuse, and a dramatic increase in female incarceration. Although the birth rate for American Indian teenagers has declined markedly in the past decade, it remains 50 percent higher than that of white teenagers (Sexuality Information and Education Council of the United States, 2002). Particularly for very young teenage parents, grandparents have often undertaken the care of the grandchild to facilitate the teenagers' continued education. The pooling of limited resources across generations and the rise in women's employment outside the home and off the reservation also have played a major role in the assumption of caregiving by grandparents. Thus, children often are left in the care of an on-reserve grandparent while the parent moves to urban areas in search of work (Weibel-Orlando, 1997).With many reservations having unemployment rates above 50 percent and correspondingly high poverty levels, work opportunities on-site are limited (Brzuzy, Stromwall, Sharp, Wilson, & Segal, 2000).

A growing body of qualitative literature is helpful in fleshing out the experience of grandparent caregivers and their families in AI/AN communities. Bahr's (1994) qualitative study of Apache grandparent caregivers emphasized the importance of such caregiving as a sign of the strength and resilience of AI/AN society despite almost insurmountable odds. She suggested that grandmothers were "caretaker of last resort, ... [devoting] extraordinary effort and personal sacrifice to performing the grandmother role" (p. 234). Emphasizing that many AI/AN grandparents experienced deep satisfaction in raising their grandchildren, Bahr also noted the substantial financial, emotional, and physical costs involved. Several grandmothers in her study were in such severe financial need that they could not always buy adequate food for their grandchildren. Such economic deprivation also has been observed in ethnographic studies of grandparent caregivers in other underserved racial and ethnic groups (Burnette, 1999;Joslin, 2002; Minkler & Roe, 1993). However, as with other racial and ethnic groups, without a random sample comparison of caregiving and non-caregiving AI/AN, it is unclear whether these levels of financial insecurity and health problems are greater than or similar to those experienced in the wider AI/AN community. As noted earlier, quantitative research in the general population suggests that grandparent caregivers are significantly more likely than their non-caregiving peers to have physical limitations and clinically relevant levels of depressive symptoms as well as a substantially greater likelihood of low income (Fuller-Thomson & Minkler, 2001; Strawbridge et al., 1997), but this has not been documented in the AI/AN community using nationally representative data.

AI/ANs, in qualitative studies, appear to share with other grandparent caregivers a number of vulnerability factors in health and poverty status. Yet, their unique historical contexts and realities, overlaid by tribal differences and similarities, make an exploration of their particular situation as grandparent caregivers worthy of investigation using nationally representative data.

DESIGN AND METHOD

The American Community Survey/Census 2000 Supplementary Survey (C2SS) used approximately a 0.6 percent sample of the U.S. population. The overall response rate was 95.4 percent. (See U.S. Census Bureau, 2002b, for details). This study focused on the experience of American Indian or Alaska Native grandparent caregivers age 45 and older (n = 319), of whom 222 claimed AI/AN solely as their race. These grandparent caregivers were compared and contrasted with 5,956 AI/AN respondents age 45 and older, who reported that they were not caregivers to grandchildren. Unfortunately, the C2SS did not ask respondents if they were grandparents. Thus, we cannot be sure that all age peers in the "non-caregiving" category are grandparents. Age 45 was selected as a cut off for two reasons: (1)The majority of Americans of color are grandparents by age 45 (Szinovacz, 1998), and (2) only one in six of the M/AN grandparent caregivers in the C2SS was younger than 45.

Measures

Several measures included in the C2SS held special relevance for this study and were operationalized as follows. Using the census definition of overcrowding, this variable was defined as more household members than rooms.

Individuals who responded "not at all" or "not well" to the question "How well does this person speak English?" were classified as speaking little or no English. For the variable race, respondents were allowed to enter multiple races. If an individual entered only AI/AN, he or she was classified as single-race AI/AN.

Household income was based on a summation of income for all household members from the following sources: wages, salary, commissions, bonuses or tips from all jobs; self-employment income; interest, dividends, net rental income, royalty income or income from estates and trusts; social security or railroad retirement; Supplemental Security Income (SSI); public assistance or welfare payments from the state or local welfare office; retirement, survivor, or disability pensions; and other sources of income received regularly such as veteran's payments, unemployment compensation, child support, or alimony. The census calculated the household's poverty line status using household size and household income data.

The variable functional disability was defined as whether a respondent had a condition that substantially limited one or more basic physical activities such as walking, climbing stairs, reaching, lifting, or carrying. Limitations in activities of daily living indicated whether a respondent reported difficulty dressing, bathing, or getting around inside the home because of a physical, mental, or emotional condition lasting six months or more. Severe vision or hearing problem was defined as whether the respondent had a long-lasting condition such as blindness, deafness, or a severe vision or hearing impairment.

Receipt of food stamps was determined by the response to the following question: "At any time in the past 12 months, did anyone in this household receive food stamps?"

Analysis

To compare the prevalence of grandparent caregiving among AI/ANs age 45 and older with that of other ethnic and racial groups, we used the Public Use Microdata Set, a one-in-three sample of the full C2SS. The prevalence of grandparent caregiving among respondents age 45 and older was determined for four mutually exclusive racial groups (AI/AN, African American, Hispanic white, and non-Hispanic white). Subsequent analyses focused solely on the AI/AN community were conducted with the full C2SS, which provided a larger sample of this subpopulation and allowed us to include individuals who reported AI/AN as well as another racial heritage. Using chi-square tests for categorical variables (for example, gender and marital status) and independent t tests for ratio level variables (for example, age and household income), AI/ANs age 45 and older who were raising their grandchildren were compared and contrasted with AI/AN peers who were not raising grandchildren.

RESULTS

When mutually exclusive racial and ethnic categories were considered, the overall prevalence of grandparent caregiving was comparable in AI/AN and African American communities (5.8 percent and 6.0 percent, respectively), somewhat lower among Hispanic white communities (4.1 percent), and much lower among non-Hispanic white communities (1.3 percent).

In the United States in 2000, an estimated 1,159,000 individuals 45 and older claimed either sole or partial AI or AN heritage. Of these individuals approximately 53,000 were grandparent caregivers.

Two-thirds of the grandparent caregivers solely claimed AI/AN heritage and 31 percent lived on Indian reservations. Slightly more than one-half of the grandparent caregivers were living in skipped-generation households in which neither the grandchild's parent nor others of the grandparent's children (for example, middle-generation members) were coresident. The majority of coresident middle-generation members were adults. One in seven AI/AN grandparent caregivers had at least one of their own children under age 18 living in their household in addition to their underage grandchildren. Almost one-half (47 percent) of the AI/AN caregiving grandparents had been providing care for five years or longer, with an additional 19 percent serving in this role for three to four years. Almost two-thirds (63 percent) of the AI/ AN caregiving grandparents were raising only one child, one-quarter (26 percent) were raising two grandchildren, and 11 percent were raising three or more grandchildren. Seven percent of AI/AN caregiving grandparents were raising a grandchild with a disability.

When we compared AI/AN caregiving grandparents age 45 and older with AI/ANs of the same age who were not raising grandchildren, substantial differences were observed (Table 1). Grandparent caregivers were far more likely than non-caregivers to be female and to have not completed high school. The caregivers were slightly less likely to be widowed or divorced and were more likely to be out of the labor force than were non-caregivers. Grandparent caregivers were three times more likely than non-caregivers to live in overcrowded quarters. Grandparent caregivers were more than twice as likely to be unable to communicate in English as their peers who were not raising grandchildren. AI/ ANs raising their grandchildren were significantly more likely than non-caregivers to report sole AI/ AN ethnicity, to live on an Indian reservation, and to be out of the labor force.

The average household income for caregivers was lower than that for non-caregivers although this difference did not reach statistical significance. Grandparent caregivers, however, had more than twice the likelihood of living in poverty as their non-caregiving peers, with more than one-third of the former living in poverty. Furthermore, caregiving AI/ANs, compared with their noncaregiving peers, had higher rates of functional limitations (for example, problems walking, climbing stairs, reaching, lifting, or carrying) and of severe chronic hearing or vision problems.

Grandparent caregivers were more likely than their peers to receive public assistance and food stamps. Analysis (not shown) restricted to grandparent caregivers who were living below the poverty line indicated that although these individuals were eligible for benefits many failed to receive them. The majority of grandparent caregivers in poverty were receiving free or reduced lunch programs in the schools for their grandchildren (77 percent) or food stamps (60 percent); however, only one-quarter were receiving public assistance (26 percent). Despite this low percentage of eligible grandparent caregivers receiving such aid, grandparent caregivers comprised one in five of all AI/ ANs age 45 and older receiving public assistance. Finally, although grandparent caregivers were significantly more likely to be receiving SSI than their non-caregiving peers (9.1 percent compared with 6.0 percent), the fact that more than one-third of caregivers were living below the poverty line suggests that many more may have been eligible for SSI benefits.

DISCUSSION

With the exception of a few helpful ethnographic studies (Bahr, 1994; Shomaker, 1989; Weibel-Orlando, 1997), there has been little research on AI/ AN grandparent caregivers. This study documents that AI/ANs age 45 and older were raising their grandchildren at rates comparable to African Americans, and at much higher rates than Hispanic or non-Hispanic white Americans. The burgeoning of research on African American grandparent caregivers (for example, Hunter & Taylor, 1998;Joslin, 2002; Minkler & Fuller-Thomson, in press; Minkler & Roe, 1993) has provided much needed insight into the problems faced by caregiving grandparents as well as creative programming and policies. The high prevalence and the economic and health vulnerability of the AI/AN population apparent in our study suggests the importance of similar focused research on this population.

The findings from our study reveal a portrait of many AI/AN caregivers raising grandchildren in the context of extreme poverty, activity limitations, and linfited access to resources and services. Furthermore, care is provided over an extended period of time with almost half of AI/AN grandparents providing care for five or more years. For the more than one in three caregivers raising two or more children, this role may be even more difficult.

One-third of Al/AN grandparent caregivers were living below the poverty line with an additional 21 percent living near poverty. The high rates of poverty found among AI/AN grandparent caregivers reflect in large part the far higher poverty rates of AI/ANs in general compared with the total U.S. population. As noted earlier, very high unemployment rates on reservations are coupled with the fact that many AI/AN older adults have been disadvantaged by poor-quality education both on and off reservations (American Association of Retired Persons Minority Affairs, 1995), which in turn influences earning potential and exacerbates the problems posed by low income.

Our finding that only one-quarter of AI/AN grandparent caregivers who were living in poverty were receiving public assistance was particularly troubling. The present data set did not enable us to determine the reasons for the low rates of access to public assistance among older AI/ANs. Other studies, however, have documented similar problems in terms of access to other forms of government support, including health care. Crabtree and Leaffe (1996) suggested that AI/AN elders "are among the most vulnerable and the most underserved older adults in America" (p. 274). Social workers should be aware that many of their poorer AI/AN grandparent caregiving clients are not receiving public assistance and other services for which they are eligible. As suggested in the following section, culturally sensitive outreach to this population and assistance in obtaining such services should be provided.

The census data do not provide information on how grandparent caregivers cope on such limited incomes in the absence of sufficient government assistance. Bahr's (1994) qualitative study of Apache grandparent caregivers on a reservation is instructive; Bahr describes low-income grandparents using the barter economy, hunting and gathering, doing seasonal labor, and making and selling traditional crafts to provide for their grandchildren. Information on comparable coping strategies among other AI/AN grandparent caregiver samples, as well as on the reasons for low rates of access to public assistance, would be helpful to social workers attempting to aid such caregivers. Information also is needed on the extent to which eligible AI/AN grandparents may be receiving foster care payments for the grandchildren in their care. These rates tend to he higher than public assistance rates and could be an important albeit inadequate source of support in impoverished AI/AN grandparent-headed households.

With almost one-third of AI/AN grandparent caregivers living on reservations, the challenges of providing adequate services are substantial. Geographic isolation and lack of transportation have been identified as serious impediments to regular medical care (American Association of Retired Persons Minority Affairs, 1995; Friedsam, Haug, Rust, & Lake, 2003). In addition, as Friedsam and colleagues observed, non-tribal agency employees may erroneously assume that tribal members are "taken care of" by the Indian Health Service (IHS) and therefore may not advocate strongly on their behalf for health and medical services. Qualitative research is helpful in illuminating the difficulties experienced by rural AI/AN grandparent carergivers in obtaining services. One of the Apache participants in Bahr's (1994) study, for example, described how she would hitchhike to the offices twice monthly to obtain food stamp benefits for which she was eligible.

Many AI/ANs also face problems with literacy that inhibit their ability to apply for public assistance and to respond to requests for written documentation from government officials (Brzuzy et al., 2000). Improving access to financial assistance through verbal documentation has been recommended (Brzuzy et al.) along with more aggressive outreach programs (American Association of Retired Persons, Minority Affairs, 1995). The utility of hiring tribal benefits counselors at American Indian clinics also has been shown to increase enrollment in Medicaid, Medicare, and other relevant programs substantially (Friedsam et al., 2003). In keeping with earlier qualitative research suggesting that grandparent caregiving was particularly common among more traditional AI/ANs, the grandparent caregivers in this study were more likely than their non-caregiving peers to report sole AI/AN ethnicity, to live on reservations, and to not speak English. These findings further underscore the importance of recruiting to the field of social work increasing numbers of AI/ANs who speak one or more native languages and are conversant with tribal customs and beliefs and able to work effectively in outreach and services provision to this population.

Finally, our findings concerning the physical health status of AI/AN grandparent caregivers suggest important avenues for social work and related provider intervention. That more than one in three caregivers had functional limitations and almost one in five had a severe chronic vision or hearing problem is of particular concern, given the fact that most grandparents assume caregiving when their grandchildren are infants or preschoolers (Fuller-Thomson et al., 1997), who typically require high levels of energy and attention.

The high rates of physical and severe sensory limitations experienced by AI/AN grandparent caregivers also are troubling. For example, approximately 40 percent of AI/ANs live in areas covered by the IHS, and this population receives the lowest federal health care dollar allocation of any group in the nation with per capita spending of $1,382 compared with $3,261 for individuals not covered by the IHS ("Unmet health care needs of Native Americans" 1998). Furthermore, AI/AN grandparent caregivers who need knee replacement and other specialty care covered by the IHS may be unable to obtain such costly treatments in a timely way because of rationing in the system in their local areas ("Unmet health care needs of Native Americans"). Social workers conversant with IHS's direct service provisions may be in a better position to help advocate for timely care for affected grandparent caregivers, and in particular to ensure that they are not simply placed on an "unmet needs" list ("Unmet health care needs of Native Americans").

Brzuzy and her colleagues (2000) suggested that social workers actively refer AI/ANs with disabilities to the SSI or Social Security Disability Insurance programs, which have fewer restrictions and sanctions than the Temporary Assistance for Needy Families program. Advocating for respite services for grandparent caregivers living with a disability also is an important social work role.

It should be recalled that, as in the larger U.S. grandparent caregiver population (Minkler & Fuller-Thomson, 1999), AI/AN caregivers did not have higher rates of limitations in the most basic activities of daily living (for example, dressing, bathing) than their non-caregiving peers. It is probable that grandparents with this level of functional impairment would either not undertake caregiving responsibility or would be more likely to relinquish such care to other family members or, as a last resort, to foster care.

By focusing solely on AI/ANs, we determined that grandparent caregivers were disadvantaged even in comparison with their non-caregiving AI/AN peers. The financial and health disadvantage of older AI/ANs when compared with their white counterparts has been well documented (American Association of Retired Persons, MinorityAffairs, 1995). Yet, as our study suggests, among the most vulnerable groups of AI/ANs may well be those who provide care for their grandchildren.

Although we were limited to cross-sectional data, a life course theoretical perspective provided insight into several findings of this study, including the very high poverty rates experienced by AI/AN grandparent caregivers and their frequently poor access to health and social services. The long history of grandparent caregiving in AI/AN communities, reflecting both traditional values and oppressive social forces (for example, the frequent forced removal of offspring from their parents), also helped us put into context the relatively high prevalence of such caregiving observed in this study. Because this research involved a secondary analysis of census data, we did not have the opportunity to explore whether the grandparent or the grandchild's parent had experienced residential schools or out-of-home placements as youths. Further research is needed to understand the interplay of these factors and grandparent caregiving.

In their interventions with AI/AN grandparents and their grandchildren, social workers must be aware of the all-too-common context of caregiving: extreme poverty, ill-health, overcrowded conditions, and limited resources. Social workers need to work actively to help grandparents gain access to the range of services for which they are eligible. Awareness of these circumstances would make targeted outreach and other interventions more helpful and appropriate as our profession works to assist one of the most vulnerable groups in U.S. society--AI/AN grandparents raising their grandchildren.

Table 1: Comparison of Grandparent Caregivers and Non-Grandparent
Caregivers in the American Indian/Alaskan Native Population Age 45
and Older

 Grandparent Caregivers
 Weighted N = 52,727
Variable Unweighted N = 319

Female (%) 72.0
Age
 M 56.4
 SD 7.6
Education (%)
 Did not complete high school 38.4
 High school graduate
 (including GED) 27.9
 Some college 22.8
 College degree or more 10.9
Marital status (%)
 Married 58.8
 Widowed 9.5
 Divorced 12.1
 Separated 8.2
 Never married 11.4
Employment status (ages 45-64)
 (%)
 Employed (including Armed
 Forces) 54.2
 Unemployed 2.5
 Not in labor force 43.3
Number in household
 M 4.3
 SD 1.7
Overcrowded households (%) 16.0
Speaks little or no English (%) 7.1
Single race AI/AN (%) 65.6
Living on Indian reservation (%) 30.8
Household income
 M $45,783
 SD $44,356
Household income (median) $32,000
Poverty index (a) (%)
 <100 34.1
 100-149 10.3
 150-199 11.0
 >200 44.5
Functional limitations (%) 36.3
Limitations in activities of
 daily living (%) 6.9
Severe vision and hearing
 problems (%) 18.6
Received SSI (%) 9.1
Received public assistance (%) 12.6
Received food stamps (%) 30.2

 Non-Grandparent Caregivers
 Weighted N = 1,105,811
Variable Unweighted N = 5,956 p

Female (%) 52.4 <.0001
Age
 M 57.8 .03
 SD 10.8
Education (%)
 Did not complete high school 28.8
 High school graduate
 (including GED) 25.9
 Some college 28.6
 College degree or more 16.7 <.001
Marital status (%)
 Married 56.4
 Widowed 13.9
 Divorced 18.6
 Separated 4.0
 Never married 7.2 <.0001
Employment status (ages 45-64)
 (%)
 Employed (including Armed
 Forces) 62.4
 Unemployed 3.9
 Not in labor force 33.7 <.0001
Number in household
 M 2.5 <.0001
 SD 1.5
Overcrowded households (%) 4.8 <.0001
Speaks little or no English (%) 3.0 <.0001
Single race AI/AN (%) 47.8 <.0001
Living on Indian reservation (%) 21.2 .0001
Household income
 M $49,723 NS
 SD $58,112
Household income (median) $35,340
Poverty index (a) (%)
 <100 14.8
 100-149 10.9
 150-199 9.9
 >200 64.5 <.0001
Functional limitations (%) 27.6 .001
Limitations in activities of
 daily living (%) 8.1 NS
Severe vision and hearing
 problems (%) 13.0 .006
Received SSI (%) 6.0 .04
Received public assistance (%) 2.3 <.0001
Received food stamps (%) 9.4 <.0001

Notes: p values were generated by chi-square tests for all categorical
variables and independent t tests for ratio level variables. From
Census 2000 Supplementary Survey

AI/AN = American Indian/Alaskan Native. NS = not significant.

(a) Percentages may not add to 100% due to rounding.

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Esme Fuller-Thomson, PhD, MSW, is associate professor, Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON M5S 1A1, Canada; e-mail: esme.fuller.thomson@utoronto.ca. Meredith Minkler, DrPH, is professor, Health and Social Behavior, School of Public Health, University of California, Berkeley. Address correspondence to Dr. Esme Fuller-Thomson. The authors gratefully acknowledge the following individuals for their contributions and assistance: Ban Cheah, Leanne McCormack, Lisa Strohschein, and the anonymous reviewers. They are grateful as well to Ken Bryson and Mai Weismantle for their encouragement and assistance and to the U.S. Census Bureau for providing access to this rich and unique data set. This research is part of a larger study made possible by a grant from the Retirement Research Foundation, and the authors gratefully acknowledge the foundation for its belief in and support of this work.

Original manuscript received February 26, 2003

Final revision received January 12, 2004

Accepted April 14, 2004