Work as a Root Cause of Home Health Workers’ Poor Health

In the December issue of AJPH, Sterling et al. report on data from the Behavioral Risk Factor Surveillance System highlighting the physical and mental health burden borne by home health workers (HHWs), defined in their study as home health and personal care aides.¹ They were able to accomplish this important work because information on industry and occupation was available for the subset of data they used. Their analysis showed that HHWs’ levels of self-reported mental and physical ill health were higher than those of other aides and health care support workers who provide care in institutional settings. Creating options for elderly and disabled individuals to remain living independently at home is an important public health objective; the Sterling et al. findings¹ and others call attention to the importance of creating good-quality jobs as a necessary component of good-quality in-home care.

Aides in homes and institutions are essential workers and are predominantly female, low-wage immigrants and workers of color.² Although the care tasks performed by aides in the two settings are similar, the social, economic, and environmental organization of home care differs substantially from institution-based care.^2,3 To understand what drives greater ill health among HHWs, it is important to examine how work is organized in the home care industry and the risks that arise when the workplace is a private home. Unpacking “work” as a determinant of health is essential for the development of effective public health interventions.

An extensive literature describes fragmentation in the home care industry,² which manifests in a wide range of state-specific policy models and organizations financing and providing home care. This literature also describes aides’ persistent low wages, driven largely by the limited reimbursement rates set by the Centers for Medicare & Medicaid Services.² Less well understood, however, is the origin of these low wages, which are rooted in racist policies and structures that drive many health inequities.³ The Fair Labor Standards Act of 1938, a cornerstone of the “New Deal,” was designed to protect workers through a minimum wage and other benefits. However, politicians from southern states refused to support a law that required Blacks doing the same job as Whites to earn the same wages.

The compromise allowing passage of the Fair Labor Standards Act was to exempt jobs typically held by Blacks from labor protections. An example is domestic service, the main occupation of Black women. In 1974, Congress revised the Fair Labor Standards Act to expand coverage to domestic service workers. One year later, however, the Department of Labor reinterpreted the 1974 amendment to exempt HHWs, including employees of for-profit businesses, by reclassifying them as companions (similar to babysitters). This amendment, known as the “companionship rule,” remained until the US Supreme Court overturned it in 2015, finally requiring HHWs to be paid the federal minimum wage.

Although no longer sanctioned by federal law, home care work continues to be viewed by many as akin to babysitting, with significant consequences for HHWs’ conditions of work.³ HHWs are frequently hired part time on an hourly basis with inconsistent hours and timetables, including overnight work for which they may not be fully compensated. Many HHWs have no employment benefits such as paid sick or family leave or vacation time. Moreover, as Sterling et al. found,¹ they have limited access to health care.²

These labor policies and working conditions produce a range of occupational hazards and health outcomes that have been previously described and are summarized in Box 1.^3–10 However, less well studied are the complex and urgent mental health hazards of home health work, which are strikingly highlighted by Sterling et al.¹ HHWs value the intrinsic rewards and meaning of their relationships with clients; however, these same relationships, as well as those with clients’ families, can also result in a wide array of challenging emotional demands. Stressors include being asked to do tasks outside of one’s job duties; clients’ personalities, dementia, and mental health issues; dysfunctional dynamics in a client’s family; aides’ work–family conflicts; and client deaths.^4–9 Notably, verbal abuse and physical abuse are regular occurrences in these relationships,¹⁰ and, in the home work environment, aides navigate all hazards alone.

BOX 1—

Examples of Work-Related Hazards Associated With Home Care Work

Hazard Class	Home Care Hazard Examples
Biomechanical/Ergonomic	• Lifting/transferring/mobilizing clients • Moving equipment/furniture • House cleaning tasks • Laundry
Chemical	• Cleaning and disinfecting agents • Pesticides • Second-hand smoke from client or others in household (cigarettes, cannabis, vaping)
Biological	• Bloodborne pathogens • Respiratory and other infection hazards • Pests (bed bugs, dust mites, cockroaches, mice, rats)
Safety	• Slip/trip/fall hazards inside and outside the home • Unsafe neighborhoods • Car accidents, travel-related injuries • Unrestrained, aggressive pets • Client smoking during portable oxygen use • Improperly stored or disposed sharp medical devices (needles, lancets) • Unsafe electrical/gas connections
Psychosocial	• Working in isolation, no on-site work support • Relational stressors involving clients, their families, or aides’ families • Physical and verbal aggression/abuse • Client death • Lack of respect and social recognition • Unpredictable work schedules, part-time work, low pay, limited benefits
Physical	• Heat stress as a result of inadequate cooling • Urban noise pollution

Note. Some hazards are unique to home care (relative to institution-based care); others present specific challenges because home care aides work alone.

The lived experience related to home care labor layers further stress on top of these day-to-day emotional demands. The case of client death—a common feature of home care work—is particularly illustrative. Client death can create grief symptoms among HHWs as well as a range of emotional responses. A client’s death also leads to a loss of work. In some situations, the emotional impact of the death can result in aides being out of work for longer than they would want, further amplifying financial stress.⁸ Across diverse worker populations, unpredictable work schedules are associated with multiple forms of psychological distress, and poverty is a well-known cause of poor mental health.¹¹ Finally, because of our societal devaluation of care work, some aides experience a long-term, wearing dissonance between the felt importance of their work and its low societal recognition.^5,7

These poor conditions and hazards of work disrupt the lives of HHWs and result in high turnover in the industry overall. High turnover makes it difficult to train the workforce, including in terms of safety. Economic and work organizational factors represent health risks in themselves and intensify the risks from specific job hazards. They also are structural obstacles to professionalizing the workforce even as the need for more workers with more training and ability to deliver more specialized services becomes increasingly urgent as our population ages rapidly.^2,3

Ongoing studies that document the burden and specific work-related determinants of health are important, but we already have enough data to take action, especially to meet HHWs’ training needs and to provide improved job-based support.^12,13 Intervention efficacy studies need to further explore multilevel approaches that ensure decent wages and work hours, opportunities for job advancement, and reductions in work-related hazards.

Congress is currently debating a massive infrastructure bill that could include President Biden’s proposed American Jobs Plan, which would expand funding for home care while improving workers’ wages and working hours. If the bill is passed, adequate enforcement of labor standards will be essential. Implementation research can improve dissemination of programs, including through HHW unions, home care agencies, worker and elder advocacy and service organizations, and other community-based public health programs. It will be challenging to reach many HHWs with intervention programs owing to the large number of workers who are employed by small agencies or individual families, and therefore the role of labor unions, worker centers, and community-based medical and public health providers in disseminating programs will also be vital.

The work of Sterling et al.¹ and the context presented here point to important directions for future public health research. These insights into health inequities among HHWs were possible only because the Behavioral Risk Factor Surveillance System data set included information on respondents’ industry and occupation. However, many national surveillance systems and population-based medical investigations do not capture participants’ industry and occupation, let alone other dimensions of work that determine health. The absence of such measures contributes to poor recognition of the influence of work on health and of important employment-related pathways for improving structural health inequities. An essential first step is to embrace the critical role that good-quality employment can play in addressing structural barriers to good health and equity.