There are more than 1.3 million child care workers in the U.S. [1
] of which 95.5% are women [2
]. In fact, child care is one of the 10 most prevalent occupations for women [2
]. While they are entrusted with our most valuable asset, our children, child care workers are among the lowest paid occupations, often having earnings below poverty level [3
]. The 2016 Occupation Outlook Handbook reports that the average pay for child care workers in the U.S. is $9.77 per hour or $20,320 annually [1
]. As low wage workers, they likely face higher rates of chronic disease and shorter life expectancies [5
]. Furthermore, low wage workers often experience challenging working conditions as demonstrated in a review by Landsbergis and colleagues who found that low wage workers were more likely to experience higher job insecurity and job strain than higher wage workers [8
Very little information is available about the health status of child care workers. The largest study with more than 2000 female child care workers in Pennsylvania found that 75% had one or more chronic health conditions and 20% had three or more conditions [9
]. However, the sample was limited to employees at Head Start, a federally-sponsored program that provides comprehensive early childhood education, health, nutrition, and parent engagement services to low-income children and their families. While Head Start programs have more standardized organizational structure and financial support compared to center-based programs, the study suggests that many of the workers were still struggling with multiple health issues. Among the few other studies with child care workers, results suggest elevated levels of emotional distress [10
], multiple health risk behaviors [11
], and increased prevalence of overweight and obesity [12
Working conditions such as long hours, high job demands, low wages, lack of health benefits, and high turn-over may be impacting the health of child care workers. A recent review by Cumming on child care workers’ well-being identified 30 studies conducted in the U.S. and abroad that help document these challenging working conditions, several of which also demonstrated how these work conditions are related to adverse effects on workers’ psychological and emotional health [13
]. Other studies have shown that the working conditions of the child care job can place workers at risk for infectious diseases, injuries, and other occupational hazards [14
]. Unfortunately, very few studies have examined the relationship between working conditions and workers’ physical and emotional health status and/or health behaviors.
The purpose of this study is to describe the health status, health behaviors, and working conditions of child care workers and to explore how income and job position may be associated. We believe considering working conditions will address an important gap in the literature about the health of child care workers. We will also discuss the implications of these results for both practice and research that might improve the health and working conditions for child care workers in the future.
This study describes health indicators on a sample of child care workers and selected contextual factors that provide insight into their work environment. Our results align with national data that child care workers are truly low wage workers. Our data also suggest that these workers exhibit many health risks such as excess weight, insufficient activity, unhealthy diet, inadequate sleep, and depressive symptoms. In addition to the hardship posed by low wages, our results confirm challenges of their working conditions such as long hours and high job demands and low job control. Also, this is the first study to explore differences in health and working conditions by household income (±$20,000) and job position (administrators vs. staff). Below, we emphasize the importance of these results in relation to existing literature, with a goal of improving future research and practice with child care workers.
The results of this study offer a valuable contribution to research into the health of child care workers, a population that has been largely ignored. Obesity (not just overweight) was an issue for the majority of child care workers in this study. Estimates from our study as well as the study by Sharma and colleagues of Head Start teachers, indicate a higher obesity prevalence among child care workers compared to the general U.S. population of adult women (66.3% and 54.5% vs. 40.4%, respectively) [12
]. Obesity, in turn, increases risk for a wide array of chronic diseases, including cancer, heart disease, diabetes, kidney disease, and arthritis [40
]. Interestingly, a greater portion of child care workers in this study appear to be sufficiently active compared to the general US population (27.8% vs. 10.7%, when applying the same cut points) [43
]. These child care workers reported dietary intake and sleep patterns that are similar to the general population, but again behaviors fall short of national recommendations for overall health. For example, child care workers in our study reported eating fruits and vegetables an average of 2.6 times per day, which is similar to the average of 2.7 servings consumed by adults nationwide [44
]; however, both groups fall short of the 3.5–4.5 cups recommended for women [37
]. Similarly, child care workers in this study reported 6.4 h of sleep per night, which is slightly less than 6.9 h of sleep per night that most US adults report; however, both are slightly below national recommendations of 7–8 h per night [38
An alarming 36.1% of participants in this study reported CES-D depression scores at or above the criteria for clinical depression, which far exceeds the national rate of depression for Americans (7.6%) and the rate among women between 40–59 years old (12.3%) [45
]. This finding corroborates previous research demonstrating elevated levels of depressive symptoms among child care workers, including one study that found depressive symptoms among a nearly a quarter (24%) of child care staff in Head Start programs in Pennsylvania [46
]. Depression and obesity often co-occur, so that our results warrant further investigation into the reasons why child care workers have high rates of both conditions, and, to explore effective ways of reducing their incidence and unhealthy impacts.
Our results also indicate that the lowest paid childcare workers are more likely to report multiple unhealthy behaviors. For example, they are more likely to be current smokers, drink more sweetened beverages, and report higher depressive symptoms. One potential explanation for this pattern of unhealthy behaviors is that lower wage workers are using food, beverages, or cigarettes as a way to cope with challenging work and/or financial conditions. While we cannot be certain of this explanation, we know that these behavioral choices contribute to poor health [48
], and there is evidence from the literature to suggest that lower income populations are more likely to engage in these behaviors [51
]. Future examinations of child care worker health behaviors would benefit from qualitative research that examines how and why these individuals are more likely to smoke or drink sweetened beverages. Then, the next generation of interventions could be tailored to the expressed needs of these individuals. For example, stress management may be a critical component of dietary and/or smoking interventions. And, interventions may need to address the underlying issues related to financial strain, either by offering assistance with finance management strategies and/or advocating for living wages.
In addition to the numerous health issues faced by child care workers, our study also highlights their challenging working conditions, including differences by job position. Consistent with existing literature, our study should serve as a call to action for addressing the child care work environment and its impact on workers’ stress and well-being [13
]. Our results indicate that administrators report higher demands and higher job control than staff. We may want to investigate ways to increase the job control of the lowest income childcare workers, which are typically staff. A qualitative study by Faulkner and colleagues with home-based and center-based child care workers found that common stressors were parental interactions, caregiving, and the failure of public perception to see child care as a profession [54
]. Child care workers also reported sleep disruptions (e.g., dreaming about children/work), and physical exhaustion. Child care work can be challenging, especially for administrators, who are the key gatekeepers to the child care setting. Although new interventions could be helpful, researchers should consider the readiness and capacity of child care administrators and staff when developing interventions so as not to add unnecessary burden to workers as part of well-intentioned initiatives.
Our study offers many lessons to help inform future child care-based interventions. Findings emphasize the importance of child care as a setting through which to target health initiatives, especially for those wanting to intervene with low-income women. Like other low wage earners, child care workers experience many risks to their health and well-being. These risks sometimes affect child care workers differently, based on their income and job position. Thus, future efforts to improve the health of child care workers will benefit from multi-level interventions that not only promote healthy behaviors, but also address underlying and interconnected issues related to living wages, health care benefits, and working conditions. Child care workers would also benefit from a coordinated approach to health that not only addresses physical inactivity and dietary behaviors, but also stress management and healthy coping skills. Additionally, it is not enough to focus only on the child care worker, we must address the directors, supervisors, and conditions under which these individuals operate, e.g., the entire work environment. Since child care centers are considered small businesses, we know that these organizations are less likely to provide worksite wellness and health promotion programs, policies, and environmental supports than larger employers [55
]. With more than one million child care workers nationwide, many of whom are women, we need to build the evidence base for effective interventions that are tailored to this important segment of the workforce.
We acknowledge several strengths and limitations of this study. A major strength of this study is its contribution to what is currently a very limited body of literature on the health of child care workers. Our study is unique in that it includes data on the child care worker, her health status and health behaviors, and her working conditions. Another strength is the use of objective measures of several physical health indicators (e.g., physical activity, weight, waist circumference, blood pressure). Study limitations are related to cross-sectional data, possible self-selection bias, self-report bias, and unmeasured factors that may impact our findings. Specifically, because our data are cross-sectional at baseline, we cannot establish temporality of our results. We expect to be able to explore changes over time in the larger study which will have multiple measures over time. Another limitation is that we cannot generalize our findings beyond the sample of child care workers in North Carolina due to potential selection bias both at the center and participant levels. Although we cannot be certain of the impact of the bias, it is plausible that volunteers willing to participate in the worksite wellness intervention trial may be healthier than who do not participate. However, upon comparing characteristics of our final sample to the workforce in North Carolina using data from the 2015 Child Care Workforce Survey [58
] we found that they appear to be similar in terms of income, education, and quality rating. While we used mostly self-report data which introduces another source of bias, we used primarily well-established instruments with sound psychometric evidence whenever available. In addition, our results may be influenced by unmeasured factors. For example, we did not measure years of work experience, but we know that in North Carolina, directors are in their positions, on average, for 6.4 years, teachers for 3.6 years, and teachers assistants for 2.5 years [58
]. So the results we report based on income and/or job position may be better understood if we knew length of time in child care. It is also likely that the relationships we discovered are due to an overlap between income and job position. We did not collect data on the relationship between administrators and staff which can contribute to high job strain if these relationships are negative or otherwise unsupportive. And, we have no information about the stress that child care workers may be under at home which will also likely influence health [59
]. These are several examples of unmeasured variables that could provide additional insights about our results and future studies should consider.
The next generation of research might benefit from considering integrated interventions that address both health promotion and occupational health and safety. The National Institute of Occupational Safety and Health (NIOSH) is advocating for “Total Worker Health” interventions that may be particularly appropriate for this group of workers and workplaces [61
]. Moreover, future research should include mixed methods studies that would explore reasons why child care workers practice unhealthy behaviors or rate work experiences as high demand/low control; as well as work with center administrators to determine who can best influence the policies and practices in place at child care centers. Promoting the health of child care workers at the workplace with health programs, policies, and environmental supports, along with higher wages, is critical.