“We Were Held in Bondage”: A Case Study on Grandparents Raising Grandchildren in Skipped Generations in Rural Northern Thailand

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Introduction
Te prevalence of skipped generations is on the rise worldwide as middle-aged family members leave their hometowns and move to cities for various reasons [1,2].Demographic and health surveys (DHS) conducted in 49 countries between 1990 and 2016 revealed an increase in the proportion of children under the age of 15 years living in skipped-generation households from 1.7% to 2.4% during that period.Moreover, the number of older adults caring for their grandchildren increased from 5.4% to 6.7% [2].In the United States, over 70 million people are grandparents, and more than 10% of them live with their grandchildren, taking on the roles of both surrogate parents and caregivers [3].
Grandparents taking on the role of primary caregivers bear a multitude of responsibilities, including providing basic personal care, managing nutrition, promoting children's health and development, supporting education, and covering various expenses [4].However, many grandparents fnd themselves unprepared for this task and may consequently struggle to ofer adequate care for their grandchildren [5].Tis lack of preparation may be particularly evident in their support for children aged one to fve years old, a critical period for promoting physical-mental health, social development, and personality [6].
Te challenges faced by these grandparents can lead to high levels of stress, causing some to perceive themselves as their children's servants, resulting in negative emotional and physical health outcomes [7,8].
It is well known that grandparents play a signifcant role in caring for young children [9,10].However, parenting the second time around may have a very diferent and alienating experience compared to raising their own children due to unfamiliarity with digital technology, such as social media, and evolved parenting recommendations.Importantly, some parenting practices and approaches to supporting children's development and education may have changed since grandparents raised their children [7,11].While knowledge about parenting practices is accessible through several channels, such as textbooks, infographics, and social media, older people often lack the confdence to learn about technology.Tey also lack trust in the Internet, leading to an apprehension about online activities [12].Te costs associated with owning a computer or tablet, paying for an Internet connection, and geographic isolation have been cited as key constraints to technology usage, especially among those living below the poverty line.At the same time, the overuse of technology could have a negative impact on a child's health in terms of emotional, physical, cognitive, language, and social skills.As a result, there exists a notable barrier for older individuals to explore and embrace the wealth of parenting knowledge available through digital platforms [13][14][15][16].
A growing body of literature has extensively explored the specifc factors contributing to grandparents' challenges and negative emotional experiences when raising their grandchildren.Additionally, this literature has demonstrated that grandchildren in skipped-generation families often encounter various health and behavioral issues, including lower levels of school engagement and substantial exposure to adversity from an early age [17,18].However, as of now, no study has delved into the experiences and perspectives of grandparents in skipped-generation families in Tailand [19].Tese grandparents difer from the mainstream population, primarily due to their limited educational and economic opportunities and inequities in healthcare services [20].In order to support grandparents in caring for and promoting their grandchildren's health, it is crucial to gather information regarding their challenges, the obstacles they face, and the support they need.Tis research aimed to address this gap by exploring the perceptions and experiences of grandparents involved in the care of their grandchildren in rural Tailand.Te outcomes of this study are anticipated to contribute to the development of community health policies, aiming to enhance the quality of life for skipped-generation families and alleviate their healthcare burdens.

Methods
As part of this study, qualitative methods, in-depth interviews, and focus group discussions (FGDs) were employed to examine the grandparents' experiences of caring for their grandchildren in skipped-generation families.

Participants and Setting. Te research was conducted in
Pa-Tueng, a subdistrict in the northern region of Chiang Rai Province, Tailand.Tis location was chosen due to a signifcant trend of both internal and external migration, which played a pivotal role in the selection process.Residents in this area have notably lower levels of formal education and incomes compared to those in urban areas, primarily infuenced by factors such as geographical isolation, poverty, and limited access to education.To gain a deeper understanding of these complex experiences, participants were recruited through purposeful sampling.Coordination with the teacher from the child development center facilitated the recruitment of participants meeting specifc criteria: (1) currently acting as a grandparent responsible for raising a grandchild aged 1 to 5 years old; (2) serving as the primary caregiver, with parents being physically absent or having delegated full childcare responsibility to the grandparents, who have fulflled the role of sole caregiver for over a year; (3) profcient in communicating in the Tai language; and (4) willingness to participate in the study.
Participants who met the inclusion criteria were provided with detailed information about the purposes, risks, confdentiality, and benefts of the study before voluntarily choosing to participate.All methods adhered to the principles outlined in the Declaration of Helsinki and relevant guidelines and regulations (protocol no: EC 21001-19 COA 038/ 2021).In total, 17 grandmothers and three grandfathers were interviewed for this study.Te participant gender distribution was not balanced (male and female) as older female adults predominantly serve as primary caregivers for children in the rural Tai context.However, the data obtained indicate no signifcant diferences in the experiences between men and women.

Data Collection. Data collection took place between
June and October 2021.Te researcher scheduled an appointment at a time convenient for the participants to minimize any impact of being interviewed in an unfamiliar environment.All participants were interviewed in the meeting room of the child development center.Te researchers (SK and KM) conducted in-depth semistructured interviews.At the beginning of each interview, they gathered basic information on the participants' socioeconomic demographics through rapport questions.Te researchers then asked questions such as the following: "What is a typical day like for you as the primary caregiver for your grandchild?" "What challenges have you encountered in providing care for your grandchild, and how have you navigated or overcome them?" "At home, how do you promote the growth and development of your grandchild?" "What do you think about your grandchild's health and their health condition?"and "Would you like someone else to support you in caring for your grandchildren?" Te FGDs were deemed pertinent to capture the shared perceptions, attitudes, beliefs, and experiences of participants who shared a common background and trust.FGDs took place in a natural setting, mainly at participants' homes, with occasional sessions held in the community health 2 Health & Social Care in the Community center.Te FGDs and individual interviews, ranging from 45 to 65 minutes, were audio-recorded and transcribed with explicit permission from the participants.

Data Analysis.
Using the six steps developed by Maguire and Delahunt [21] to review the data, two authors independently analyzed the data using thematic analysis.Te frst step was to listen to the audio recording and translate it verbatim into Tai.Te transcripts were then read to gain a general understanding of the data.Afterward, the data were coded by underlining words or sentences and describing the content with codes.A code was created, patterns were found in the codes, and themes were then generated.To ensure that the data were accurate, we read the script and checked for consistency between the transcript and the theme.We analyzed the data and gave the theme a clear and understandable name after writing up our analysis.

Trustworthiness.
A number of strategies were employed to enhance the trustworthiness of the study, including credibility, prolonged engagement with participants, nonparticipant observation, verifcation of participants, and the establishment of an audit trail.Te prolonged engagement ensured constant interaction that allowed participants to set aside their prior knowledge of the phenomenon of interest and abandon ideas that did not support the data.A number of transcripts were read, and the results of the coding system were compared, resulting in the identifcation of themes and subthemes.To validate the results of the in-depth interview, an observation note was utilized, along with a discussion of how the data were interpreted to identify implicit bias.As a measure of the reliability of the data, transcripts were read multiple times and the coding system results were compared.
Te results led to the development of themes and subthemes as a measure of data trustworthiness.Te emerging themes were compared to the transcripts as a whole and individually during the writing of the manuscript.
To confrm the accuracy of the fndings and to increase trustworthiness, the fndings were shared with fve participants.Te participants are asked to refect on what they have narrated or discussed and what they have not narrated or discussed.In addition, readers were provided with as much contextual information as possible about the research fndings in order to determine the transferability of the fndings.

Results
Seventeen grandmothers and three grandfathers (n � 20), aged 44-62 years old (52 ± 5.18), participated in this study.Regarding the participants' educational backgrounds, eight had received no education, 11 had completed elementary school, and one had completed junior high school.Teir occupations were housewives, day laborers, and agricultural workers.Most of the participants had an income of less than 5,000 baht ($130 USD) per month (Table 1).
"We were held in bondage" is the overarching theme of the perceptions, attitudes, and experiences of grandparents raising children in rural areas in Tailand.Two main themes emerged from the interviews: (1) feeling of burden, divided into the following three subthemes: lack of parenting skills, worries regarding grandchildren's health and well-being, and emotional stress and fnancial/physical strain; (2) maintaining family bonds, which were further divided into the following subthemes: supporting adult children, being parents again, and becoming more loving and bonded.

Lack of Parenting Skill.
In rural areas, it is common for multigenerational families to live together.However, many grandparents in this study live only with their grandchildren due to labor-force migration, with the responsibility of raising grandchildren falling on the grandparents.However, the grandparents stated that they had forgotten the essential skills of being a parent, such as preparing infant formula, maintaining a healthy diet, and educating children.Moreover, due to a lack of knowledge and awareness about children's health, grandparents were less likely to engage in child development-related health promotion and prevention activities than parents.Te difculties were multiplied when the child was being raised without any additional support at home."I fnd it challenging to teach them because I didn't attend school, and at times, I forget the day-to-day care routines.It's been 20 years since I raised my daughter. . .It feels like Eight grandparents in this study were illiterate and had not attended school, which led to complications in caring for their children.Participants stated that they could not help their grandchild with schoolwork and could not fnd any written or teaching materials either on their cell phones or in reports.While some grandparents observed that smartphones could help them take care of their grandchildren, they apathetically passed their phones to their grandchildren instead of engaging in physical activities.

Worries regarding Grandchildren's Health and Well-
Being.Due to unsuitable environments and practices for raising children, the participants lacked confdence in caring for their grandchildren and sought assistance from close friends and family.When their grandchildren became sick, a few grandparents sought advice from the child's parents through telecommunication channels, instead of relying on nearby relatives, neighbors, or village health volunteers (VHVs).Some participants reported that the way they treated their grandchildren was not suggested by healthcare providers, and they were unaware of how to carry out appropriate care.

"If my grandchild is sick or behaves abnormally, I don't know whether that is abnormal development. I often consult my neighbors who are VHV instead of seeing the doctor. I realize it's not the right approach, but sometimes, I'm unsure of what to do."-(GF, 52 years old)
Te participants' outdated knowledge about child growth, development, and mental health is also a concern.Some grandparents reported challenges in knowing how to monitor children's physical and mental well-being and maintain appropriate behavior.Due to a lack of knowledge and outdated practices, grandparents may particularly have difculty managing their grandchildren's bad behavior and inevitably punished them.
"When the teacher or nurses informed me that my grandchild is at risk of becoming overweight.I am unsure of how to encourage her to participate in diferent activities because she tends to live quietly and avoids playing with other children.When I suggest that she go outside, she consistently refuses, leading to my frustration and occasional scolding, making it quite challenging"-(GM, 50 years old) "I fnd myself uncertain about raising children in today's world.Concerns arise regarding potential accidents during outdoor play and the negative efects when using a smartphone.I notice that they remain sedentary for an extended period while on smartphones, which does provide me with convenience for managing household tasks.Nevertheless, I am unsure about the long-term repercussions of this behavior."-(GF,58 years old)

Emotional Stress and Financial and Physical Strain.
Te participants addressed the problem of a lack of support due to generation gaps and physical problems.Stress was perceived as directly related to the responsibilities associated with child care and the participants' health conditions.

"My daughter has left her baby with me since he (grandchild) was eight months old. Now she has a new family and never comes back, providing no fnancial support. I am over 60 and have to work every day on the farm to make a living. I have knee pain, but I cannot stop working. I cannot do the best . . . but there are times when he speaks harshly and screams. I once hit him and felt guilty. I don't want him to turn out like his mom, and I don't want my grandchild to leave me, except for education purposes."-(GM, 50 years old) "I have been raising my grandchild since she was three months old because her parents separated and went to work in another place. So, I have to take care of my grandchildren. My daughter sends money to spend on raising their child, but it is not enough. . .I had received the Municipal assistance funds (20 USD per month) but it is still not enough to cover all the expenses."-(GM, 48 years old)
One grandmother was raising three grandchildren at the same time and caring for her bedridden mother, which resulted in insufcient fnancial means and limited time to rest.She faced various difculties, particularly health conditions, such as stress and depression.
"She (grandchild's mother) left when the youngest child was 18

Discussion
Tis qualitative exploratory study contributes to the international literature on grandparent caregivers' perceptions and experiences of navigating care processes for their grandchildren in the parents' absence.Te study has indicated that grandparents play a pivotal role in linking generations in Tai families.However, the grandparents in this study stated that they lacked knowledge, parenting skills, and technological literacy and acknowledged holding outof-date views on children's health and development [7,22].Tis study also demonstrated that the grandparents also perceived being in a servitude situation because, as aging grandparents, they were forced to care for their young grandchildren without adequate preparation and support.Some grandparents coped with the problem by seeking help from relatives, teachers, and community, as well as VHVs.Such support people are important considerations in the community healthcare system as they care for and provide various services to people in their communities [11].Te study fndings also demonstrated the need to address issues outside the healthcare system relevant to grandparents, such as the education of young children and fnancial burden.For example, self-help groups or local government funding systems could be employed to help grandparents who live in rural areas [23,24].
Raising their young grandchildren frequently causes health deterioration for grandparents due to the strain of the role and its associated daily tasks.In prior studies focusing on grandparents raising their grandchildren in an Asian context, it was observed that taking care of very young grandchildren creates highly stressful circumstances in skipped-generation families [4,13,22,25,26].A study carried out in Cambodia highlighted that grandparents Health & Social Care in the Community undergo signifcant complexity and stress while caring for their grandchildren.Te research revealed that receiving fnancial support, instrumental assistance, and advice from family members or neighbors regarding the child's health and available facilities played a crucial role in alleviating stress, anxiety, and mental health problems among grandparents [9].In instances where grandparents encounter challenges perceived as insurmountable, negative mental health outcomes may arise.Tese may include feelings of loss, grief, and loneliness, disruptions in social activities, changes in family relationships, heightened stress levels, and depression [27][28][29].However, our study noted that some participants found solace in Buddhist practices or beliefs, which helped them cope with distress, life risks, and unexpected negative events [30,31].
Te current study also found that some grandparents were raising multiple grandchildren with inadequate support, resulting in insufcient funds, and depression.Te responsibility for these young children diminishes the time available for self-care activities, such as exercise, medical appointments, and social interactions.Moreover, it can result in a lack of sleep and increased vulnerability to infections [32,33].Additionally, fndings indicate that grandparents in skipped-generation families tend to experience higher levels of depression compared to their peers once they assume the responsibility of caring for their grandchildren.Concerns also extend to food preparation, with worries about using poor-quality ingredients that may afect the children's health [34].
While raising grandchildren can pose a burden or diffculty for grandparents, our study identifed a growing appreciation for the roles that older individuals play as support providers for their families.In Asian cultures, there has traditionally been a strong emphasis on valuing the relationship between older and younger generations [35,36].
Grandparents who received support-whether fnancial or instrumental-from family members were the least likely to report that caring for their grandchildren was a difcult experience.Tey were willing to sacrifce the end of their lives for their family, allowing their family members to save money and ofering their grandchildren a secure environment, encouragement, and unconditional love.In the Tai cultural context, certain grandparents underscore the signifcance of beliefs and Buddhism, guiding their mindset that performing benevolent acts for family members will attract positive karma into their lives [20,28].Moreover, most of the study participants in our research expressed the hope of remaining continually with their grandchildren [25,37,38].

Limitations
Te study's fndings must be considered within the context of grandparents who live in rural areas in Tailand.Tere is potential for bias in the fndings because most of the participants had low levels of education, which may afect their experiences of caring for their grandchildren including ways to promote child's development or school tasks.Another limitation is that many of the participants were interviewed for approximately one hour, which may be too short a time for the participants to refect adequately on their caring experience.

Conclusion
Tis study is a comprehensive examination of the experiences of grandparents in skipped-generation families in rural Tailand."We were held in bondage" emerges as the theme that explains how grandparents viewed taking care of their grandchildren.Burdens were experienced when the grandparents were faced with difculties such as a lack of parenting skills, a lack of support, and physical health issues.However, grandparents also indicated feelings of bonding when raising their biological grandchildren.Te study also demonstrates how grandparents obtain support from the healthcare system, teachers, and community, which ofer recommendations on caring for young children.When reading and analyzing the narrative texts, the researchers were also surprised to discover how grandparents coped with complicated situations through alternative means, such as by drawing on Buddhism or other beliefs.
months old, and my son is in the prison . . .My husband is a construction worker and works every day for our living . . .I have also taken care of my mom since her stroke . . .I 4 Health & Social Care in the Community have a busy and hard day . . .and so much pain . . . in my whole body. . .and I feel like, if I died frst, I would end my sufering frst . . .One minute later, I question who would take care of my children and my mom . . .and Buddha said that Dhukha does not end even when we die, "So live and do it better every day.""-(GM,59 years old) ..for me parenting is not over yet . . .If I die, my husband will continue this role, and one of my adult children will get older and have grandchildren . . .
children without negative efects . . .and I want to be healthy for my grandchild . . .and I want to see them achieve in the future."-(GM,56 years old) "I can raise my grandchild the way I am.We are all doing well . . .with help from a family member, we will make it . ..Bonding . ..we were held in bondage that we produced.