Occup. Med. Vol. 49, No. 7, pp. 427-^37, 1999 Copyright C 1999 Upplncott WHHams & WHklns for SOM Printed In Great Britain. All rights reserved 0962-7480/99 Child care workers and workplace hazards in the United States: Overview of research and implications for occupational health professionals K. A. Bright* and K. Calabro* * University of Texas-Houston Health Science Center, School of Public Health, SoutJiwestjCenter for Occupational and Environmental Health, P.O. Box 20186, Houston, TX 77225, USA and ^University of Texas- Houston Health Science Center, School of Nursing, 7000 Fannin, Suite 1620, Houston, TX 77030, USA In the past, the hazards facing child care workers have largely been ignored by health and safety professionals, due in part to a lack of awareness of hazards and inconsistencies In state health and safety requirements. The aim of this paper is to provide a summary and critique of the literature on the topic of occupational hearth and safety concerns for child care workers. Twenty-seven articles pertaining to child care workers, published between 1980 and 1998, were reviewed. The job roles and tasks related to physical care, janitorial functions and participation in child recreation lead to risk of exposure to biological, physical and chemical hazards. Psychological stressors were found to contribute to high levels of job dissatisfaction and turnover. Infectious disease transmission was the major topic of focus In the literature, whereas US statistical data for illnesses and injuries for this classification of workers revealed injuries as the prominent health problem. Directions for future research are described Key words: Child care; day care workers; health and safety; occupational health. Occup. Med. Vol. 49, 427-437, 1999 Received 23 February 1999; accepted in final form 15 June 1999 INTRODUCTION According to the US Bureau of Labor statistics, the aver- age annual employment in private sector child day care facilities in 1996 was 576,600 workers. 1 The actual num- ber of child care workers is considerably higher when child care workers from public facilities and facilities with fewer than 11 employees are included. In addition, the number of child care workers is expected to increase significantly in the future. Parents are choosing child care centres over traditional babysitters or relatives to care for their children. 1 Furthermore, the US federal government's plans to expand child care block grants to serve an additional 1.15 million children will necessitate the training and development of additional child care workers. 2 Correspondence to: K. Bright, University of Texas-Houston Health Sci- ence Center, School of Nursing, 7000 Fannin, Suite 1620, Houston, TX 77030, USA. In spite of the increasing numbers of workers in this field, the health and safety concerns of child care workers have largely been ignored by health and safety profes- sionals in the United States. Child care workers confront a variety of biological, physical and chemical hazards 3 while caring for approximately 13 million children in child care centres. 4 Several factors have contributed to the relative inattention to health and safety concerns of child care workers. First, the majority of hazards facing child care workers are not addressed directly by US federal safety and health standards. Child care workers are covered under the health and safety regulations of the Blood Borne Pathogen Standard; however, Occupational Safety and Health Administration (OSHA) monitoring and inspection of public and smaller child care centres is infrequent. Second, licensing of child care facilities at the state level is inconsistent in specifying health and safety provisions for workers, although protection for the health of children is routinely addressed by the state licensing agency. For example, in the state of Alabama prior Downloaded from https://academic.oup.com/occmed/article-abstract/49/7/427/1467471 by guest on 04 April 2019
Transcript
Occup. Med. Vol. 49, No. 7, pp. 427-^37, 1999Copyright C 1999 Upplncott WHHams & WHklns for SOM
Printed In Great Britain. All rights reserved0962-7480/99
Child care workers and workplacehazards in the United States:Overview of research andimplications for occupationalhealth professionalsK. A. Bright* and K. Calabro** University of Texas-Houston Health Science Center, School of PublicHealth, SoutJiwestjCenter for Occupational and Environmental Health,P.O. Box 20186, Houston, TX 77225, USA and ^University of Texas-Houston Health Science Center, School of Nursing, 7000 Fannin, Suite1620, Houston, TX 77030, USA
In the past, the hazards facing child care workers have largely been ignored by healthand safety professionals, due in part to a lack of awareness of hazards andinconsistencies In state health and safety requirements. The aim of this paper is toprovide a summary and critique of the literature on the topic of occupational hearthand safety concerns for child care workers. Twenty-seven articles pertaining to childcare workers, published between 1980 and 1998, were reviewed. The job roles andtasks related to physical care, janitorial functions and participation in child recreationlead to risk of exposure to biological, physical and chemical hazards. Psychologicalstressors were found to contribute to high levels of job dissatisfaction and turnover.Infectious disease transmission was the major topic of focus In the literature, whereasUS statistical data for illnesses and injuries for this classification of workers revealedinjuries as the prominent health problem. Directions for future research are described
Key words: Child care; day care workers; health and safety; occupational health.
Occup. Med. Vol. 49, 427-437, 1999
Received 23 February 1999; accepted in final form 15 June 1999
INTRODUCTION
According to the US Bureau of Labor statistics, the aver-age annual employment in private sector child day carefacilities in 1996 was 576,600 workers.1 The actual num-ber of child care workers is considerably higher whenchild care workers from public facilities and facilitieswith fewer than 11 employees are included. In addition,the number of child care workers is expected to increasesignificantly in the future. Parents are choosing childcare centres over traditional babysitters or relatives tocare for their children.1 Furthermore, the US federalgovernment's plans to expand child care block grants toserve an additional 1.15 million children will necessitatethe training and development of additional child careworkers.2
Correspondence to: K. Bright, University of Texas-Houston Health Sci-ence Center, School of Nursing, 7000 Fannin, Suite 1620, Houston, TX77030, USA.
In spite of the increasing numbers of workers in thisfield, the health and safety concerns of child care workershave largely been ignored by health and safety profes-sionals in the United States. Child care workers confronta variety of biological, physical and chemical hazards3
while caring for approximately 13 million children inchild care centres.4 Several factors have contributed tothe relative inattention to health and safety concerns ofchild care workers. First, the majority of hazards facingchild care workers are not addressed directly by USfederal safety and health standards. Child care workersare covered under the health and safety regulations of theBlood Borne Pathogen Standard; however, OccupationalSafety and Health Administration (OSHA) monitoringand inspection of public and smaller child care centres isinfrequent. Second, licensing of child care facilities at thestate level is inconsistent in specifying health and safetyprovisions for workers, although protection for the healthof children is routinely addressed by the state licensingagency. For example, in the state of Alabama prior
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428 Occup. Med. Vol. 49, 1999
to employment all child care workers must have atuberculosis (TB) test or chest x-ray, and a physicianstatement of physical suitability (which is repeated everyfour years). In addition, the state requires reporting ofall worker injuries that require medical treatment. Incontrast to Alabama, the state of Texas has fewer healthprovisions for child care workers, requiring an annualtuberculosis examination and notification of any out-break of illness for children or staff that results in thefacility becoming unsafe.5 Third, responsibility for thehealth and safety of child care workers rests primarilywith the management of individual centres and workersthemselves. Placing responsibility for health and safetywith the individual centres may be problematic in thistraditionally underfunded industry since expendituresfor health and safety tend to be forfeited in order tomaintain and support general operations.6 In addition,child care workers may not have the knowledge toprotect themselves adequately. Generally, there areminimal education and training requirements for childcare workers; therefore, knowledge of health and safetyhazards should not be assumed. Moreover, this work-force is not organized to the extent that a professionalassociation or union exists to advocate for health andsafety practices.
The lack of health and safety controls and regulationsfor child care workers reveal a gap in the safety net forthis population, and serve as a barrier for health andsafety professionals to assist this population. Little sub-stantial progress appears to have been made in study-ing the health and safety issues facing this group. Nothorough review of the literature pertaining to the occu-pational health issues relevant to child care environmentshas been located. This paper provides a comprehensiveoverview of the occupational health and safety hazardsencountered by child care workers through a summaryand critique of current literature and research in thisfield.
MATERIALS AND METHODS
In October 1998, a computer-based literature search wasconducted using the following databases: Health Star,Eric, Medline, PubMed, ADI Form and the Internet.The search terms 'child care workers', 'daycare workers'and 'health and safety' were used. The search was limitedto literature published between 1980 and 1998. Approx-imately 60 citations were screened and 50 of the 60 cita-tions were reviewed further. Of the 50 articles reviewed,16 were excluded. Articles were excluded for the follow-ing reasons: they focused mainly on the child or family;they were not written in English; they were not relevantto health and safety or they were published in obscurejournals that could not be located by library services.Literature related to home day care centres, adult careproviders and programmes for disabled, chronic orlong-term care of children were also excluded. Articlesincluded in the review were directly related to the healthand safety of child care workers who worked with'healthy' children. The search terms incorporating 'child
care' or 'day care' included references to similar facilitiesreferred to as nursery schools, preschools and playgroups. International articles were included if written inEnglish. Employment statistics and population descrip-tions were obtained through Internet searches of govern-ment databases and relevant literature.
Defining the child care worker population
Information currently available indicates that child careworkers represent a vulnerable population of workersconsisting primarily of younger women of childbearingage, who are often of low educational and socioeconomicstatus. According to the 1996 US Bureau of LaborStatistics (1998), the population of child care workersconsists primarily of women, aged 18 to 40 years. Theeducational levels of child care workers vary considerablyacross the country as each state sets caregiver educationand training requirements as part of daycare licensingrequirements.7 Currently, the education and trainingrequirements range from a high school diploma orgeneral education diploma to a college degree in childdevelopment or early childhood education.1 Generally,there are large numbers of part-time workers in this fieldand the salary and wages for this occupation tend tobe low. According to the Bureau of Labor statistics, the1996 median annual earnings for full-time salaried childcare workers was $13,000 or below the poverty level fora family of four. According to the Department of Healthand Human Services the poverty level for a family offour was $15,600 per year in 1996.8
Although child care centres have not historically beenviewed as 'dangerous' work environments, the literatureavailable suggests that working in child care environ-ments may pose a significant risk of illness and injury toworkers. A combination of work role demands, environ-mental and organizational factors may contribute towork-related injuries, illness and to employee dissatisfac-tion. The specific work role, skills and job tasks of childcare workers are described by Small and Dodge9 in areview article for professional child care. The child careworker assumes several roles: caregiver, educator andtherapeutic helper that require a variety of skil)s. The jobtasks and roles described in the literature such as 'diaper-ing and toileting care, janitorial functions, first aid,and participating in child recreation' expose workers topotential health and safety hazards.3 Specifically, theAmerican Public Health Association (APHA) and theAmerican Academy of Pediatrics (AAP)7 health andsafety performance standards for child care programmesidentify the following hazards facing this worker popula-tion: infectious diseases, injuries and noninfectious dis-eases, stress and environmental exposures to hazardousmaterials (Table 1).
The literature clearly substantiates the assessmentof the potential health and safety hazards for workersidentified by the APHA and AAP. For the purposes ofthis review, the authors have further categorized thesehazards according to biological, physical, chemical andpsychological hazard criteria. In reviewing each article,the authors also used a standard format to outline key
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K. A. Bright and K. Calabro: Child care workers and workplace hazards in the USA 429
Table 1 . Occupational health hazards in child care
Undervalued workInadequate leaveWorking aloneResponsible for children's welfareInadequate trainingInadequate facilitiesFear of liability
Health hazard category
Injuries and non-Infectious diseases
Back injuriesBitesDermatitis
Environmental exposure
Art materialsFormaldehydeNoiseDisinfecting solution
Source: American Public Health Association & American Academy of Pediatrics, 1992.
elements of the articles including the type of issue,sample size, study design, outcome measures, existenceof a control group or follow-up and outcomes (Table 2).The type of studies located for the literature reviewvaried considerably ranging from review articles todescriptive and intervention studies.
DISCUSSION
Biological hazards
Infectious diseases. The majority of the studies (19 of 27)focused on infectious disease transmission, control andprevalence. Cytomegalovirus (CMV) was a subject thatreceived considerable attention. The cytomegalovirus isthe leading cause of congenital infections and contrac-tion of CMV during pregnancy carries a high risk ofsevere consequences for the foetus.10 This virus posessome concern for the child care worker population whoare primarily women of childbearing age. The major riskfactors for contraction of CMV in the daycare environ-ment are contact with the secretions and excretions ofCMV infected children. Contraction of the virus may bedue to poor hygiene following contact with infectiousagents found on toys and diaper change areas. Child careworkers who test negative for CMV infection by bloodsample are considered nonimmune. After these non-immune child care workers are exposed to the virusfound in the urine or saliva of infected children theymight contract CMV. Individuals with CMV infectionwill test positive by blood sample and are consideredinfected. Dejong et al.11 reports that in the adult popula-tion, the prevalence of antibodies of CMV ranges from40-100%. A cross-sectional study by Jackson et al.12
found that 62% of child care workers were seropositivefor CMV. In the longitudinal CMV studies by Pass etal.,10 Adler13 and Murph et al.,14 the seropositivity atenrolment into the studies ranged from 38-62.5%. Work-ers who tested seropositive at enrolment were more likelyto be older, to be employed longer in child care and to
have worked with children under the age of 2-3 years.During the periods of study, the overall seroconversionrate among seronegative daycare workers ranged from0-20% annually.10-13'14 Murph et al.14 found that themost significant risk factor for workers who seroconver-ted during the study was the rate of CMV excretion andacquisition among the children in the centres. However,Pass et al.10 reported that significant risk factors for ser-oconversion were exposure to children under the age of3 years and a greater number of hours worked (a total of20 hours per week or more). One review indicated thatrisk of transmission of the disease to child care workerscould be prevented with proper handwashing. Workereducation about the occupational hazard of contractingCMV during pregnancy was also recommended.15 Thelongitudinal studies of CMV were limited by high ratesof attrition which may have been associated with highturnover in personnel. The studies also lacked adequatecontrol groups and selection bias was identified.
Blood-borne pathogens, including AIDS, HIV,hepatitis B and C, are also infectious diseases of concernfor child care workers, although transmission of thesediseases in the child care setting has not been extensivelyreported.4'12'16 The viruses that cause these diseases arefound in blood or body fluids and are more dilute insaliva and urine. Within the child care centres biting isa possible mode of transmission of these diseases.4
According to Donowitz4 there has only been one docu-mented case of transmission of hepatitis B and nodocumented cases of transmission of hepatitis C or HTV/AIDS within a child care setting. Although the risk oftransmission or contraction of these diseases is low, theconsequences of contracting these diseases are severewith death from AIDS and chronic cirrhosis for thehepatitis B and hepatitis C viruses as possible adverseoutcomes.4
Federal law mandates the provision of training pro-grammes about protecting workers who could potentiallybe exposed to blood-borne pathogens.17 One study
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Table 2. Summaries of reviewed articles on child care workers
Study
First authority/year/target group
Health and safety Issue Measurement
Outcome measures/control group/Type of issue/n/study design follow-up
Outcomes
Results
Infectious diseases
Churchill, 199716
Day care centrepersonnel
Renaud, 199718
Day care workers,day care parents,public health nursesand others
Knowledge and attitudesregarding HIV/AIDS and Hep B.Pre-test n = 2,279, post-testn = 2,207, follow-up n = 602.312 day cares and 37 familyday cares. Pre-test/post-teststudy design.
Hepatitis A, B, C,cytomegalovlrus, varicella andmeasles, n = 360 providers from49 centres. Cross-sectionalstudy.
Faecal contamination, n = 25caregivers and n = 109 childrenin four child day care centres,Prospective longitudinal cross-over study.
Health risks for pregnant staff.Literature review.
Educational approach forcontrolling infectious diseases,discussion and methods articlefor decreasing Infection.
Knowledge vs. attitudes ofAIDS, n = 212 female child careworkers. Cross-sectional survey.
Determining feasibility of trainingin preventive health practicesfor child day care providers,n = 983 staff. Cross-sectionalsurvey.
Cytorrtegalovirus, n = 252 daycare providers in six centres.Cross-sectional study.
Infection control recommendations.
Questionnaires measuredknowledge and attitudes of policyfor HIV/AIDS and Hep B. Nocontrol group, 3 month follow-up.
Demographic and immunity historyquestionnaire. Laboratoryevaluation. No control group, nofollow-up.
Laboratory evaluation of faecalcontamination. No control group,no follow-up.
Recommendations for female childcare staff.
Reduction of Infectious diseasetransmission. No control group, nofollow-up.
Ukert scale response to surveyItems. No control group, nofollow-up.
Laboratory evaluation, demographicquestionnaire. No control group butstudy results were compared toprevious studies. No follow-up.
Providers: knowledge of childhealth and safety, training needs.Child health trainers: type, costand length of training. No controlgroup, no follow-up.
Questionnaire and lab evaluation,observation of hygienic practices.No control group, 30 monthsfollow-up.
Guidelines for infection controlprocedures and policy, recommendeducation for disease prevention.
Pre-test knowledge of hygiene in daycare was lacking. Post-test knowledgeof hygiene in day care improved.Knowledge of policy increasedsignificantly from pre-test to post-test.Attitudes changed significantly frompre-test and post-test and persistedover time.
Seroprevalance: hepatitis A = 13%,CMV = 62%. 1 % of workers showedevidence of Hep B disease, 0.5% ofworkers showed antibodies for hep Cand workers under the age of 30 weremore likely to be susceptible to measles.
All sites showed contamination.Careglvers hands and diaper changingareas greatest contamination, nodifference between cloth and paperdiapers in respect to faecalcontamination. Outbreak of diarrhoealillness led to improved hygienicpractices and decreased faecalcontamination.
Recommendations for fatigue, exposureto infectious disease, back problems,frequent urination, swollen feet andvaricose veins.
Recommended training and education,health policy adoption and enforcement.
Worker's age, work experience,education and age of children not usefulindicators for knowledge of AIDS. Ageand experience were linked to morecautious attitudes towards AIDS andpolicies.
4.8% of workers susceptible to VZV,immune status uncertain for 31 % ofworkers (by disease history).
Providers' responses: 86% of centresreported one or more persons havinghad health training; workers answeredhalf of the questions related to childhealth and safety, sanitation, foodhandling and disease prevention.Trainer's responses: 76% of coursesoffered were CPR and first aid.
Demographic variables/risk factors notsignificant for seroconverters vs. non-converters. Seroconversion rates at sixcentres ranged from 7-40%, Positiverelationship found at one centrebetween seroconversion rate andhygienic practices.
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Table 2. Continued
K. A. Bright and K. Calabro: Chid care workers and workplace hazards In the USA 431
Study
First authority/year/target group
Health and safety Issue
Type of issue/n/study design
Measurement
Outcome measures/control group/follow-up
Outcomes
Results
Van, 1991b23
Caregivers andchildren
Van, 1991a22
Caregivers andchildren
Canadian PaediatrlcSociety InfectiousDiseases andImmunizationCommittee, 199015
Children and womensusceptible to CMV
Gillespie, 199051
Day care provided to0 to 5 years;kindergarten to grade12 school personnel
Pass, 199010
Day care centreworkersAdler, 198913
Day care workers
CDC, USPHS,DHHS, 1984s0
Public health authority,children's physicians,day care personnelBlack, 198127
Child care centreworkers and children
Hadler, 198028
Persons associatedwith day care centres
Enteropathogens, observedhygienic practices, examinationof environmental contamination,n = 6 day care centres with 121children, Inanimate objectstested n = 1275, toy balls testedn = 724 and hands n = 924.Prospective longitudinal study.
Faecal contamination with clothvs. paper diaper, n = 2946environmental samples,Prospective, longitudinal,crossover study.
Cytomegalovirus, review article.
Owen, 199237
Child care workers
Lab evaluation (cultures ofinanimate objects, toy balls andhands). Availability of hygienicsupplies and hygienic practices.No control group, no follow-up.
Lab evaluation of inanimate objectsand hands, survey of diaperleakage and handwashingpractices. No control, no follow-up.
Summary of transmission, Issuesrelated to reducing exposure.
Human parvovirus B19,questionnaire n = 571 andserologic testing n = 518 In14 day care centres.Cross-sectional study.Cytomegalovlrus, n = 509workers in 32 day care centres.Cross-sectional study.
Cytomegalovlrus, n = 610 womenday care workers. Prospectivecase-control.
FaecaJ oral diseases, respiratoryillness vaccine preventable,other important diseases suchas CMV and chicken pox.Review article.
Diarrhoeal Illness in infants andtoddlers, n = 62 children inhandwashing centres, n = 54children In control group, no 'n'for workers given. Pre- andpost-test.
Hepatitis A. n = 1,098 cases ofHep A. Cross-sectional contactInvestigation based on publichealth reports, family survey,Interviews with directors.
Injuries
King, 1996M
Child care centre staffErgonomics of child care, n = 36staff from one university-basedchild care centre. Case studydesign.
Musculoskeletal disorders,n = 27 day care workers, fiveparticipating centres. Interviewand observation of child careworkers.
Age of children significant for faecalcontamination: toddlers greatest level ofcontamination. Increased diarrhoeaassociated with Increased contaminationof hands, contamination of handscorrelated with environmentalcontamination, Inconsistencies Inhygienic supplies and practices.
Faecal contamination of Inanimateobjects and hands ranged from11-46%. Contamination decreasedusing paper diapers or when clothingworn over diapers. More frequent handwashing associated with cloth diapers.Advice on limiting the spread of CMV.
Infection rate, symptom analysis,questionnaires and lab evaluations.No control group, no follow-up.
Lab evaluation: serum, saliva andurine. 2 year study period, hospitalbased control group.
Summary of epidemiology.
Laboratory evaluation of faecalspecimen, direct electronmicroscopy. Control group,follow-up 9 week study period.
Disease transmission, serologictesting. No foilow-up.
Ergonomic job analysis: Includingenvironmental, machines, physicaldemands, sensory demands.Survey of child care workersymptoms and demographics. Nocontrol group, no follow-up.
Worker perception of physicalstress of job tasks, andbiomechanical assessment ofphysical stress associated withjob tasks. No control group, nofollow-up.
Highest Infection rate = 54% forcafeteria workers; teaching personnel(Including day care workers) = 16%Pregnancy outcomes = 6 of 6 healthybabies delivered to workers.
Annual seroconversion rate = 20%,working with children < 3 years old and >20 hr/ week significant for seroconversion.Seroconversion rate = 11% per year forday care workers vs. 2% for hospitalworkers, seroprevalence associated withrace, marital status, duration ofemployment, caring for children < 2 yearsof age.
Recommend that state and localgovernments provide guidance fordisease prevention and control.
Centres with handwashing programexperienced half of the diarrhoealdisease when compared to the controlcentres. Support for properhandwashing.
Hep A outbreak 15% in child careworkers, 72% of workers with Hep Aregularly worked with Infants — fourtimes the attack rate of employees whoworked with older children.
Survey findings: workers' primaryconcern was lifting young children andphysical endurance required for olderchildren. Problem areas identifiedInclude: incorrect lifting of children, toys,supplies; inadequate work heights,frequent sitting on floor with unsupportedback, reaching above shoulder height.
Workers perceived that tasks completedmost frequently such as lifting weremost physically stressful. Lifting posturesobserved were blomechanlcaJly stressfuland exerted large compresslve andshearing forces against the lower lumbarvertebral disks.
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Table 2. Continued
Study
First authority/year/target group
Health and safety Issue Measurement
Outcome measures/control group/Type of Issue/nJstudy design follow-up
Outcomes
Results
Environmental
U, 199741
Day care centreworkers
Ruotsalainen, 199440
Female day careworkers
Psychological
Manlove, 199345
Child care workers
Kushnir, 199248
Directors of day carecentres
Whltebook: 198339
Child care workers
Whltebook, 198047
Child care workers
Evaluation of sick buildingsyndrome and respiratorysymptoms related to moisture,dampness and mould, n = 612employees (males •= 31,females = 581) In 56 centres.Cross-sectional survey withquestionnaire.
Symptoms among workersrelated to dampness In day carecentres, n = 268 female workersin 30 centres. Cross-sectionalsurvey and onsrte observation.
Factors associated with burnoutn •= 186 child care workers in 28centres. Cross-sectional study(questionnaire).
Stress and burnout in directorsof day care centres, n = 34Inexperienced directors in 169day care centres, pre-test post-test study design,psychoeducatlonal intervention.
Child care worker's health andsafety, n = 89 workers in 20states. Cross-sectional survey.
Burnout and turnover amongchild care workers, n = 95workers in 32 centres. Cross-sectional survey (telephonesurvey).
Employee perception of work-related sick building syndrome andchronic respiratory problems. Nocontrol group, no follow-up.
Employee perception of workrelated Sick Building Syndrome(SBS) and chronic respiratoryproblems. No control group, nofollow-up.
Maslach Burnout Inventory,Eysenck Personality Inventory,demographic variables,questionnaire about work roles andambiguity. National Child CareStaffing Study staff survey adaptedto measure organizationalcommitment and |ob satisfaction.No control group, no follow-up.
Variables: demographic, rate ofillness and infection, administrativepolicies, ergonomic issues andinjuries, chemical hazards, sourcesof stress, health care benefits andaccess to care. No control group,no follow-up.
Employee perception of tensionand satisfaction reason forturnover, suggestions for changesIn day care centres. No controlgroup, no follow-up.
Significant association betweendampness and sick building syndromesymptoms. Workers reported dampnessin 75% of centres. Females reportedmore work-related SBS than males;males reported more chronic respiratoryproblems than females.
Respiratory symptoms higher among theday care workers exposed to dampnesscompared to workers with low or noexposure.
Predictors of burnout: 'emotionalexhaustion', 2 of 7 variables weresignificant (work role conflict/ambiguityand organizational commitment);'depersonalization', 2 of 7 variableswere significant (work role conflict/ambiguity and staff relations); 'personalaccomplishment', 4 of 7 variables weresignificant (educationAralning, workexperience, work role conflict/ambiguityand organizational commitment).
Significant changes post-intervention for'stressors' (staff problems), overload andtoo much responsibility, role conflict andconflict with children's parents.'Resources' (assertlveness, perceivedcontrol and setf-efficacy) and 'Stresscomplaints, depression, stress work,stress home, life satisfaction, jobsatisfaction, suppressed hostility andcoping.
High rates of infection for colds, sorethroat, flu and inpetlgo. Administrativepolicies inconsistent or non-existent.Lack of adult-sized furniture identifiedimplications for hygiene, physical safetyand mental health of the staff.Respondents reported chemical hazardexposure. 96% Indicated that job wasstressful. Inadequate health carescreening and coverage. Proposal forimproving conditions within centres.
Reasons for job dissatisfaction:overwork, underpayment (Includinglimited or no medical benefits for almost50% of workers). 72% of workersIndicated unpaid time. Turnover mostfrequently attributed to low pay andunpaid overtime. Only 24% intended tomake child care a career. Staffsuggestions for improving worksituation: higher pay, more benefits,Increased job security and careermobility.
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included a training programme designed to teach childcare workers about universal precautions.18 Two invest-igators assessed workers' knowledge of transmissionof ADDS/HIV.18'19 Despite demonstrated knowledge ofHIV transmission and clarification of misconceptionsabout the disease, workers in these studies continued toexpress fears of transmission of the virus. Furtherresearch is needed to develop effective interventions thatallow workers to fulfil policies on caring for children withHIV/AIDS based on scientific facts and not irrationalfears. Regarding viral hepatitis, a 1996 study by Jacksonet al. tested for antibody prevalence of hepatitis Band hepatitis C in day care workers.12 The antibodyprevalence of these diseases was extremely low suggest-ing that these diseases were not significant occupationalhealth risks for the relatively small population studied.The demonstrated efficacy and extended protection con-ferred by the hepatitis B vaccines have resulted in wideacceptance of the vaccine and routine immunization ofchildren in the US.20 In spite of the low risk of childcare workers becoming infected with hepatitis B, risk ofexposure to blood does exist; therefore, Donowitz sug-gests that child care workers also receive the hepatitis Bvaccine.4
Child care workers infected with HIV/AIDS areexposed to various opportunistic diseases that occurroutinely in the child care environment The US PublicHealth Services Infectious Diseases Society of America(USPHS) (TDSA) have produced draft guidelines forprevention of opportunistic disease for HIV/AIDSpatients.21 The guidelines specifically address the occu-pational health concerns of child care providers. Accord-ing to the USPHS, child care providers with HTV 'areat increased risk of acquiring CMV infection, crypto-sporidiosis, and other infections (e.g., hepatitis A andgiardiasis) from children. The risk of acquiring infectioncan be diminished by good hygienic practices such ashand washing after faecal contact (e.g., during diaperchanging and after contact with urine and saliva)'.Recommendations for immunizations of persons infectedwith HIV should consider the stage of HTV infection andthe type of immunization.21
Child care centre workers that care for non-toilet-trained children are at risk for contracting enteric patho-gens. Faecal-oral contamination is responsible for avariety of infectious disease hazards within the daycaresetting. Agents commonly transmitted through the faecal-oral route include hepatitis A, cryptosporidium, giardia,shigella, campylobacter, enteroviruses and rotavirusamong others.4 Enteric infections are high among infantsand toddlers, and minimizing faecal contamination isimportant in reducing the transmission of enteropatho-gens in the daycare environment.22 Diarrhoeal outbreaksare common in child care centres22'23 although the actualincidence of diarrhoeal illness among child care workersis not documented. Enteric infections are responsible forincreasing medical costs due to physician consultation,medications and employee absenteeism.24 In the UShepatitis A vaccination has been recommended for childcare workers.4 Hepatitis A vaccines provide long-termpre-exposure prophylaxis against infection and lead to
high seroconversion rates (exceeding 95%) and are safefor use during pregnancy.25
Four studies included in the review examined diar-rhoeal illness in daycare settings. Three of the four studiesmonitored levels of faecal contamination in environ-mental sources (diaper changing areas, sleep/play areas,hands of child care workers and children's toys). Childcare workers who worked with 1-2 year olds had thegreatest exposure to enteric pathogens.23 Faecal contam-ination of hands and inanimate objects used in the workenvironment may account for one documented outbreakof Hepatitis A in a day care centre.26 The three studiesof faecal contamination were limited to assessment ofenvironmental surfaces and hands. In each study, theHawthorne effect was a major methodological limitationsince the investigators monitored the staffs' hand wash-ing and hygienic practices. Education and enforcementof handwashing and proper hygiene have been shownto prevent some of the diarrhoeal illness in day carecentres.27
Varicella-zoster virus and human parvovirus B19 aretwo viral agents that have the potential to cause adversefoetal outcomes in child care workers.4 Varicella-zoster(VZV) (commonly referred to as chicken pox) is a routineand highly contagious illness that is not usually severe inchildhood. However, child care workers who are suscept-ible to varicella often experience serious illness wheninfected with this disease.28 The incidence of varicella-zoster and the number of workers who are susceptible tothe virus is unknown. One study documented that 4.8%of workers in the study sample were susceptible to thevirus. These workers are at increased risk of infectionand complications such as pneumonia.28 With the poten-tial for severe illness and adverse foetal effects, day careworkers of child-bearing age who are susceptible andwho are exposed to varicella should be evaluated by theirhealth care provider within 24 hours of exposure.29
Proper handwashing is recommended as the preventivestrategy.16 Despite the National Health and SafetyStandard ST 71 recommendation for assessment of theneed for vaccines upon employment, a random selectionof several state licensing requirements indicated thatVZV had not been adequately addressed by the stateswithin the US.5 During a three month period in 1997there were three varicella fatalities among unvaccinatedand susceptible young women who were exposed tounvaccinated preschoolers.30 These deaths may havebeen prevented with the vaccine for VZV. Althoughvaricella vaccination has been recommended for childcare workers in the US,4 the varicella vaccine is notgenerally available in the United Kingdom.31
Human parvovirus B19 is also a childhood illness,manifest as a benign rash called erythema infectosum or'fifth disease'. The more serious consequences of thedisease are those related to the negative foetal outcomespossible when pregnant workers become infected. In thestudies reviewed, one outbreak of parvovirus B19 wasdocumented in workers within a school district that alsomaintained child care centres. Within the population ofdaycare workers, at pre-outbreak 68% of workers testedhad a previous parvovirus B19 infection. During the
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434 Occup. Med. Vol. 49, 1999
outbreak of parvovirus B19, 31% of susceptible childcare workers became infected with the virus. A study ofB19 infection in Danish pregnant women comparedinfection rates of pregnant women in the general popula-tion to nursery school teachers and found that nurseryschool teachers had a threefold increased risk of infec-tion.32 In addition, a recent study of B19 infection in theUK general population found an excess rate of foetaldeaths (averaged at 9%) occurring during the first 20weeks of gestation. Although the early weeks of gestationposed the greatest risk, the overall risk of acquiringhuman parovirus was approximately 1 in 400, and therisk of an adverse outcome of pregnancy after week 20was remote.33 The results of these studies support theexistence of the occupational risk of B19 infection in thechild care worker population. According to Donowitz,4
handwashing and decontamination of environmentalsurfaces have not been proven to be effective in reducingthe risk or preventing transmission of this virus. How-ever, until more research in this area has been con-ducted, proper handwashing and hygiene are prudent.Work exclusion policies for pregnant child care workersare not routinely recommended in the US.4 Vaccinationfor parovirus B19 is currently in the stages of develop-ment.33
The APHA and AAP have also identified several otherinfectious disease hazards such as pinworm, herpes andinfluenza. However, no research studies were located thatexamined the prevalence and impact of these diseases inday care workers. Donowitz4 provided infection controlrecommendations for personnel which emphasized theimportance of handwashing in preventing transmission.Currently, the UK Public Health Laboratory Service34
and the US Center for Disease Control35 recommendvaccination against flu for elderly and persons withweakened immune systems. Donowitz also recommendsthat all child care workers receive an influenza vaccineannually.4
Physical hazards
Injuries. The Occupational Safety and Health Admin-istration (OSHA) injury statistics for the industryclassification 'child day care services' reported 11,600work-related injuries for the period from October 1997through September 1998. A combination of sprains,strains, fractures, cuts, bruises and back injuries make upthe list of injuries included in OSHA logs during thisperiod (Table 3).1 Only two published studies havedescribed the ergonomic issues relevant to child careworkers.36'37 These researchers found that the risk ofwork-related ergonomic injury was a concern. The resultsof the job analyses indicated that injuries involving thelower back were likely to occur because of the mechanicsof lifting, bending, squatting and reaching. The lack ofadult-sized furniture for workers has also been cited ascontributing to physical discomfort and injury as wellas psychological stress. Both studies arrived at similarconclusions; recommending the purchase of adult-sizedfurniture, task and work area redesign and staff trainingon general ergonomic principles. The limitations of these
Table 3. Occupational Injuries and illness for child day care servicesleading to lost work days
Per 10,000 full-time workers
SprainsFracturesCuts/puncturesBruisesBack pain and pain except backMultiple traumatic injuriesAnd disordersAll other types
Total cases
59.810.92.4
20.015.18.3
27.6
145.9
• Statistics based on the US Bureau of Labor 1996 data for child care servicesindustry.
two studies are small sample sizes, selection bias andreliance on workers' perception of physical stress. Inaddition, the studies failed to report demographic char-acteristics and anthropometric measurements. A descrip-tion of the objective ergonomic measures that led to therecommendations for environmental changes and educa-tion would have been helpful. The APHA and the AAP7
have also identified noise and bites as occupational healthhazards in child care; however, no studies were locatedwhich documented the prevalence or impact of either ofthese hazards. Biting by children has been documentedin early childhood research literature.38
Chemical hazards
Environmental exposure. The APHA and AAP7 have iden-tified potential chemical hazards in child care settingsincluding disinfecting solutions, art materials and formal-dehyde; however, no studies were found which examinedthe health effects of these hazards. The survey of childcare workers by Whitebook39 contained self-reportedexposure to art materials (powdered paint, permanentmarkers and dry clay) that was accompanied by respirat-ory and skin irritation. Whitebook39 also identified contactwith pesticides and cleaning solutions as potential chem-ical hazards for child care workers. The APHA and AAPidentify dermatitis as an occupational health hazard inchild care centres.7
Other environmental exposures which were not identi-fied by the APHA and AAP were documented in twointernational studies of child day care centres. A Finnishstudy examined dampness and moulds in day carecentres and found that workers reported eye irritation,upper and lower respiratory symptoms and chronicrespiratory diseases.40 A second study in China exam-ined the association between dampness in centres andrespiratory illness in day care workers and found astatistically significant relationship between exposure tomoulds and dampness and the prevalence of sick-buildingsyndrome (SBS) symptoms.41 One methodological prob-lem identified in the China study may have been mis-classification bias. The environmental exposure data wasbased on subjective assessment of water damage andmould odour. This may have led to errors in the relation-ships identified between respiratory symptoms and
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K. A. Bright and K. Calabro: Chid care workers and workplace hazards In the USA 435
exposure. Although no studies were located whichfocused on sick building syndrome symptoms in childcare centres in the United States, it is estimated that10-25 million employees who work in commercial build-ings have symptoms associated with SBS.42 Since SBShas been found in child care centres in other countries, itmay be prudent to conduct studies in the United Statesto determine whether SBS is a concern.
Psychological hazards
Stress. Stress has been defined as 'the subjective mentalstate that results from exposure to a stressor'.43 Occupa-tional stressors may be attributed to a variety of exposuresincluding 'psychological factors as well as interpersonal,organizational, environmental, and physical demands'.44
Four studies in the review examined stressors associatedwith child care work including job dissatisfaction andwork conditions.39145""47 A comprehensive study by Man-love45 found that child care workers experienced psycho-logical stress triggered by interactions with children andfamilies. Psychological factors such as neurotic person-ality as well as conflict with organizational and jobdemands were correlated with staff burnout. Burnout inchild care workers is related to the high turnover ratesand low morale that have been described as a chronicproblem with this occupation.45 Whitebook47 first identi-fied a variety of stressors that impacted on the child careworkers, citing the organizational stressors of low wagesand lack of benefits, understaffing and low job satisfac-tion. In addition to these descriptive studies, a stressreduction intervention designed for less experienceddirectors of child care centres was documented. Theresults showed that with training the directors of day carecentres learned coping skills and practised stress reduc-tion in order to improve coping and well-being.46 Thesetwo surveys, the descriptive study, and the interventionare the only existing studies we were able to locate on thetopic of job burnout and stress in child care workers.Unfortunately, the existing studies have largely relied onself-reported data collected with survey instruments andpersonal interviews. Supporting observational data mayhelp to validate these results and clarify the relationshipbetween high employee turnover and job stress.
CONCLUSIONS
The US Department of Labor, Occupational Safety andHealth Statistics (OSH) 1996 injury and illness ratesindicate that there were 145 injuries and illnesses per10,000 child care service workers in 1996.1 Thus far,infectious disease transmission has been the major focusof research. Based on the available research, preventionof infectious disease transmission is a priority concernfor child care workers. Current research, however, doesnot adequately describe the prevalence, transmission andprevention of the illnesses that are potential concerns forthis population.
Limitations of the current studies of infectious dis-eases are noteworthy and include: the quality of the
studies located tended to be less than rigorous; thestudies were geographically limited thereby decreasinggeneralizability; sample sizes were small; randomized con-trols were not used and there was little effort to replicateany findings among studies. Specifically, large-scalestudies are needed to determine the magnitude of theproblem of infectious diseases and effective ways to pre-vent disease transmission.
In contrast to the number of articles related to childcare workers and infectious disease, scant literatureis available about the other occupational health con-cerns for child care workers. With the exception of two'first studies' of ergonomic issues in child care, injuriesand non-infectious diseases including back injuries anddermatitis were minimally addressed.36'37 Environmentalhazards such as noise, potentially hazardous chemicalssuch as disinfecting solutions and insecticide exposureneed to be addressed. Finally, the occurrence of sickbuilding syndrome among child care workers in the USmay deserve further investigation.
Ironically, the OSH statistics currently availableindicate that injuries are a more serious problem than ill-ness among child care workers. The majority of reportedinjuries were related to musculoskeletal injury, not infec-tious illness. The authors suspect that the incidence ofillness in this population is significantly higher than thereported statistics for at least three reasons. First, a largenumber of child care workers are employed in businesseswith fewer than 11 workers; therefore, they are excludedfrom the OSH statistics. Second, the illnesses would tendto be underreported because they would not necessarilybe attributed to the workplace. Third, it is commonlyaccepted that workers and employers underreportinjuries.48 However, the fact that there are few docu-mented illnesses should not lead to the conclusion thatemployee illness in child care settings does not have anegative financial impact on these business. In the case ofchild care workers, the accumulation of sick days due to'routine' illness may significantly impact upon job loss,productivity, turnover and increased insurance premi-ums.
Compounding many of the problems previously iden-tified with the collection and completeness of currentstatistics and available research is the well-documentedphenomenon of high employee turnover rates. The highturnover rates in this occupation could mask some ofthe problems within these centres since the 'day careworking life' of these employees tends to be shortdue to organizational factors like money and job dis-satisfaction.
The problem of employee turnover in child care cen-tres also appears to be correlated with psychologicalstressors. Although some work has been initiated in thearea of stress and child care work, the reviewed studiesshould be considered 'first studies'. There is every indi-cation that stress is a major health and human resourceconcern. More work is needed to provide the ground-work for future research addressing job burnout andstress.
A pioneer in identifying issues related to occupationalhealth and safety, Whitebook conducted surveys of child
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436 Occup.Med.Vbl. 49, 1999
care workers' concerns almost 20 years ago.39'47 Sincethis time, child care services and environments havechanged. With the national demand for more child care,there will be an increase in the number of child careworkers entering the workforce. We recommend that ahealth and safety survey of the occupational health con-cerns of child care workers be conducted. By definingthe risks to current child care workers, future researcherscan begin to assemble an agenda for addressing occupa-tional health and safety problems appropriately.
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