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Child Health Status and Parental Employment
Karen A. Kuhlthau, PhD;
James M. Perrin, MD
Arch Pediatr Adolesc Med. 2001;155:1346-1350.
ABSTRACT
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Objective To understand the relationship between several measures of child health
status and the employment of parents.
Design A cross-sectional study using 1994 National Health Interview Survey
on Disability data.
Participants A nationally representative sample of children and their parents.
Outcome Measures Maternal and paternal employment (measured separately).
Intervention We use a series of logistic regression models with maternal
and paternal employment as the dependent variables and the health status of
the child with the poorest health status in the family as the primary independent
variable. Models additionally include sociodemographic correlates of employment.
Results Having a child with poor health status, as measured by general reported
health, hospitalizations, activity limitations, and chronic condition or disability
status, is associated with reduced employment of mothers and fathers. For
example, the odds ratios of being employed for having a child with an activity
limitation are 0.75 for mothers (95% confidence interval, 0.67-0.85) and 0.66
for fathers (95% confidence interval, 0.53-0.82).
Conclusions Having a child with poor health status is associated with reduced maternal
and paternal employment. Further studies are needed to determine whether poor
child health status causes reductions in parental labor force participation.
If such a causal relationship exists, it has important implications for social
policy, employment policy, and clinical anticipatory guidance.
INTRODUCTION
THE EPIDEMIOLOGY of childhood chronic conditions has changed considerably
in the past 3 decades. Improved medical and surgical technologies and access
to these technologies during the last few decades have notably changed survival
rates.1, 2, 3, 4, 5
Several childhood conditions have increasing prevalence (eg, acquired immunodeficiency
syndrome, asthma, and attention-deficit/hyperactivity disorder),6, 7, 8, 9, 10, 11
and the prevalence of activity-limiting chronic conditions doubled between
1960 and 1981 and tripled by the mid 1990s.12, 13
Child health status, especially chronic illness, may have an important effect
on parental employment. Recent trends in employment and family structure make
this a timely issue. In recent years, labor force participation of mothers
who have children younger than 6 years doubled.14
A rise in the divorce rate and the rate of childbearing outside marriage has
lead to increases in single-parent families.15
Concurrent with these changes, opportunities to care for children with
chronic conditions in the home have expanded.16
Medicaid home and community care waivers provide additional services to keep
children out of institutional facilities and in the home or community, without
requiring families to "spend down" to Medicaid eligibility levels.17 Increasing cost-consciousness among insurers and
health care providers has led to shorter hospital stays and a reduction in
institutionalization. Several legal changes, such as the Education for All
Handicapped Children Act,18 the Individuals
With Disabilities Education Act,19 and the
Americans With Disabilities Act,20 enhance
the civil rights of children with disabilities and support some parents' desires
to keep children at home.
Major public programs make assumptions about the impact that having
a child with a chronic condition has on the family, yet few data are available
to support these assumptions. For example, the Supplemental Security Income
program supplies a cash benefit to children who meet income and disability
criteria. One justification for the cash benefit is that having a child with
a disability reduces labor force participation of family members, although
recent reviews of the child and adolescent Supplemental Security Income program
have disputed the extent of its effect.21 Families,
clinicians, and employers could benefit from increased information about how
child health status affects employment.
Previous studies22, 23, 24, 25, 26
of the relationship of maternal labor force participation and child health
status have used small and unrepresentative samples. These studies generally
find decreased labor force participation of mothers when the family includes
a child with a chronic health condition. A study27
of single mothers found poor child health status had a net association with
maternal employment. One study28 that used
nationally representative but old (1972) data found a 10% decrease in maternal
employment among white families with a chronically ill child. A second nationally
representative study29 that used recent data
found that children with conditions likely to require substantial parental
care had increased odds of having fewer than 2 parents working (for 2-parent
households) and no parent working (for single-parent households). No known
studies examine paternal employment or compare different measures of child
health status to parental employment.
We examined a nationally representative sample survey of households
using the 1994 National Health Interview Survey on Disability (NHIS-D).30 The NHIS-D has rich data on child disability. We
used the 1994 NHIS-D data rather than a more recent NHIS survey because the
NHIS-D has richer data on child health status. We hypothesized that having
a child with poor health status would be associated with reduced parental
employment and that measures of health status that imply greater caregiving
requirements by parents would have a stronger relationship with employment
than other measures. We further hypothesized that married parents would have
a stronger association between child health status and parental employment
because the second adult can provide health insurance and income in 2-parent
families.
SUBJECTS AND METHODS
DATA SOURCE
The 1994 NHIS-D provides the most comprehensive national survey on disability
ever undertaken in this country.30 The US Bureau
of the Census conducted the field operations for the survey. The noninterview
rate was 5.9%.31 The survey uses a multistage
sample designed to represent the civilian noninstitutionalized population
of the United States.
SAMPLE
We included all families with children and adolescents younger than
18 years and a parent 18 years or older living in the household as the base
sample. We then merged information on each child with the parent's information
using the household identifier and information on the relationships of the
household members with that of the respondent. Parenthood is determined by
self-reporting and likely includes biological, adoptive, and stepparents.
We excluded parents younger than 18 years and parents who are not coresidents
in the household. We had difficulty identifying parent-child pairs in some
households with extended families (eg, a grandparent as the primary respondent
with 2 sisters living in the same household, each of whom had children). Within
a family, we used the health information of the child with the poorest health
status for each measure (see the "Variable Description" section) and created
2 separate analysis groups for fathers and mothers.
VARIABLE DESCRIPTION
Employment
The NHIS-D records whether adults worked for pay at a job or business
in the past 2 weeks. We coded parents who currently had a job as employed
and other parents as not employed.
Sociodemographic
We chose commonly used covariates of employment to include in our logistic
regression models. Parental demographic characteristics include self-identified
race (white, African American, and other), ethnicity (Hispanic/Latino vs not),
age, and educational level. Family characteristics included the number of
children in the household (continuous variable), the age of the child with
the poorest health status (when  2 children had equal health status, we
randomly choose one of the children to measure child's age), and marital status
of the parent. We further examined whether the parent lived in a central city,
a noncentral city urban area, or a rural area.
Child Health
Child and adolescent health status measures include parent's report
of the child's general health status (excellent, very good, good, fair, poor)
and whether the child had any functional limitation. The functional limitation
questions queried whether the child was limited in play activities compared
with children of a similar age and whether the child was limited in school
activity (for children aged 5-17 years). We also examined whether the child
was identified as having a chronic condition using a consequences-based criterion.
This definition was based on the conceptual work of Stein and colleagues32 and operationalized in NHIS data to correspond with
the items on the Questionnaire for Identifying Children With Chronic Conditions.33 We included one measure of health care utilization,
whether the child was hospitalized (this includes children hospitalized for
a variety of reasons), since hospitalization may be associated with unique
time demands of parents.
DATA ANALYSIS
We examined means and frequencies for all dependent and independent
variables from the 2 populations. We used logistic regression to determine
the relationships between sociodemographic characteristics, child health status,
and parental employment. We used separate models for fathers and mothers,
married and unmarried parents, and each of the 4 measures of health status.
This approach resulted in 12 logistic regression models that examined associations
with maternal employment and 12 with paternal employment. We chose to stratify
analyses by the marital status of the parent because of the large increase
in single-parent families and because we anticipated a greater effect on parental
employment if the family had 2 coresident parents available to share earning
and caregiving roles. Each regression includes the age of the child whose
health status is measured, parent's age, parent's education, whether the parent
is married (in the model of all women and all men only), race and ethnicity,
urban residence, and the number of children in the household. We built models
by examining the relationships of the covariates and health status measures
with parental employment separately. We then combined these 2 types of variables
into 1 model. We included all of the covariates regardless of whether they
were statistically significant. All analyses were weighted using weights supplied
by NHIS-D, and the regression models were corrected for the sampling structure
using statistical software.34 This project
received approval from the Massachusetts General Hospital Institutional Review
Board.
RESULTS
Table 1 gives weighted means
and percentages for dependent and independent variables for the sample of
mothers and fathers separately. The child health status figures are worse
than national figures because we use the child with the worst health status
for each measure. Still, in general, these children have excellent health
status. There is substantial overlap between the measures of health status,
with agreement among all 4 health status measures for about 80% of each sample.
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Table 1. Employment, Sociodemographic, and Child Health Characteristics
of Households With Children Younger Than 18 Years*
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Table 2 gives the results
of 12 logistic regression models for maternal employment. Each number shows
the odds ratio (OR) for the health status measure from a separate regression
that controlled for other predictors of employment. The results for these
covariates (not shown) generally follow expected findings. The ORs for child
health status are all statistically significant (P<.05),
and all indicate that poor child health status is associated with reduced
maternal labor force participation for all mothers. For married women, the
same general pattern holds. For unmarried women, the general health status
measure, chronic condition status, and activity limitations are statistically
significant.
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Table 2. Association of Child Health Status and Maternal Employment
by Maternal Marital Status*
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Table 3 gives the results
of the parallel 12 logistic regression models for fathers. For the sample
of all fathers, the same general relationship holds as for mothers; that is,
ORs for child health status measures are consistently lower than 1.0 and are
statistically significant in all cases. There is no consistent pattern of
ORs for married or unmarried fathers. Married fathers are less likely to be
employed if they have a child who had poor general health status, who was
hospitalized, or who has an activity limitation. Unmarried fathers are less
likely to be employed if they have a child with worse general health status,
a chronic condition or disability, or an activity limitation. The ORs for
the analyses of paternal employment are consistently smaller than those for
maternal employment.
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Table 3. Association of Child Health Status and Paternal Employment
by Paternal Marital Status*
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COMMENT
These analyses show that poor child health status as measured by activity
limitations, hospitalizations, general health status, and disability or chronic
condition status is associated with reduced maternal and paternal employment.
Among all mothers and all fathers, each of the 4 measures of health status
is associated with a statistically significant decrease in parental employment.
The measure of activity limitation has the strongest association among mothers
(OR, 0.75). Hospitalizations have the strongest association among fathers
(OR, 0.58). In general, indicators of a condition with more potential for
an effect on the family (activity limitations and hospitalizations) have lower
ORs than the measures that are more broad (general health status and the measure
of chronic condition or disability). This finding suggests that there may
be a relationship between the caregiving responsibilities associated with
different health status measures and parental employment.
There may be a slightly greater association of child health status on
employment for married mothers compared with unmarried mothers. (Analyses
of all mothers that include the interaction of marital status and child health
status confirm this [data not shown].) This is consistent with the hypothesis
that married mothers will have increased options to choose employment because
of the presence of another potential wage earner in the household. Among fathers,
the differences between married and unmarried fathers are less clear.
The primary limitation of this study is the use of cross-sectional data,
which only measure associations. Our hypotheses infer that the primary directionality
is that of child health status influencing parental employment, although the
reverse could operate in some circumstances. In particular, having parents
who are not employed will on average reduce family income, which may in turn
have a detrimental effect on child health status. A second limitation is that
the reference time for the employment question was 2 weeks. Although the question
specifies that temporary breaks (eg, a vacation) are not considered as lack
of labor force participation, parents who are reacting to an immediate child
health issue may report that they are not employed even if they are taking
a temporary leave. Third, several potential confounding factors may explain
the results. Most important, parents who are ill may be less likely to be
employed and more likely to have a child with poor health status.
Further studies are needed to determine whether poor child health status
causes reductions in parental labor force participation. If such a causal
relationship exists, it has important implications for social policy, employment
policy, and clinical anticipatory guidance.
AUTHOR INFORMATION
Accepted for publication July 14, 2001.
Presented at the annual meeting of the Ambulatory Pediatric Association,
New Orleans, La, May 4, 1998.
What This Study Adds
Previous studies have shown an association between child health status
and maternal employment status. This study finds that this relationship is
robust across multiple measures of child health status. It also finds an association
between paternal employment and child health status. Clinicians should be
aware of the implications of health conditions on both children and their
families. Further studies are needed to determine whether poor child health
status causes reductions in parental labor force participation. If such a
causal relationship exists, social policies might support income supplements
to parents of children with poor health status, employers might design flexible
work schedules or sick-leave policies to allow parents to work if their child
is sick, and clinicians might inform families when they provide anticipatory
guidance.
From the Center for Child and Adolescent Health Policy, MassGeneral
Hospital for Children, and the Department of Pediatrics, Harvard Medical School,
Boston, Mass.
Corresponding author and reprints: Karen A. Kuhlthau, PhD, Center
for Child and Adolescent Health Policy, MassGeneral Hospital for Children,
50 Staniford St, Suite 901, Boston, MA 02114 (e-mail: kkuhlthau{at}partners.org).
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