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Lauren A. Smith, MD, MPH, Diana Romero, PhD, MA, Pamela R. Wood, MD, Nina S. Wampler, DSc, MPH, Wendy Chavkin, MD, MPH and Paul H. Wise, MD, MPH

Lauren A. Smith and Paul H. Wise are with the Department of Pediatrics, Boston University School of Medicine, Boston, Mass. Diana Romero and Wendy Chavkin are with the Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City. Pamela R. Wood is with the Department of Pediatrics, University of Texas Health Science Center, San Antonio. Nina S. Wampler is with the Division of American Indian and Alaska Native Programs, University of Colorado Health Science Center, Denver.

Correspondence: Requests for reprints should be sent to Lauren A. Smith, MD, MPH, Boston Medical Center, Department of Pediatrics, Dowling 3 South, One Boston Medical Center Pl, Boston, MA 02118 (e-mail: lauren.smith{at}bmc.org).

	ABSTRACT

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Objectives. This study evaluated the association of chronic child illness with parental employment among individuals who have had contact with the welfare system.

Methods. Parents of children with chronic illnesses were interviewed.

Results. Current and former welfare recipients and welfare applicants were more likely than those with no contact with the welfare system to report that their children’s illnesses adversely affected their employment. Logistic regression analyses showed that current and former receipt of welfare, pending welfare application, and high rates of child health care use were predictors of unemployment.

Conclusions. Welfare recipients and applicants with chronically ill children face substantial barriers to employment, including high child health care use rates and missed work. The welfare reform reauthorization scheduled to occur later in 2002 should address the implications of chronic child illness for parental employment.

	INTRODUCTION

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The 1996 Personal Responsibility and Work Opportunity Reconciliation Act significantly changed welfare policy in the United States. The stated intent of the legislation, commonly referred to as welfare reform, was to decrease reliance on welfare and increase the economic independence of poor families. The legislation replaced the Aid to Families with Dependent Children (AFDC) program with the Temporary Assistance for Needy Families (TANF) program, eliminated entitlements to cash benefits, and imposed a 5-year time limit for benefits, work requirements, and benefit reductions or terminations for noncompliance with program provisions.¹

Parents of children with chronic conditions are likely to experience difficulties complying with these new requirements because their children’s health needs require them to take so much time away from work. Low-income parents in general, and current and former welfare recipients in particular, are more likely to have low-wage jobs that do not provide vacation or sick leave that would allow them to care for sick children.^2–5 Welfare recipients have been shown to cite child illness as a barrier to employment.^1,6–9

Anything that poses a barrier to sustained parental employment, such as chronic child illness, will undermine the intent of the welfare legislation. The law has incompletely addressed the needs of families with chronically ill children, however. Welfare agency screening for health barriers to employment is often inadequate.¹⁰ In addition, welfare recipients with chronically ill children are often unaware that work exemptions and time limit extensions based on child illness are available.¹¹ Because those targeted by the legislation are parents, understanding the implications of chronic child illness for parental employment will be important when the legislation is reauthorized later in 2002, especially given current proposals to increase the work requirement.¹²

There has been no research since the implementation of the welfare reform legislation that has specifically considered the association of clinically significant rates of chronic child illness with particular employment outcomes among parents who have had contact with the welfare system. In the present study, we sought to fill this gap by exploring the prevalence of employment barriers among a cohort of families with chronically ill children.

	METHODS

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Study Sample
A detailed description of the study sample and recruitment methods can be found in the Romero et al. article elsewhere in this issue.¹³ In brief, the study involved an initial cross-sectional investigation of 504 predominantly low-income English- or Spanish-speaking parents or primary caretakers of children aged 2 to 12 years with one of 7 chronic illnesses (asthma, diabetes, sickle-cell anemia, epilepsy, hemophilia, cerebral palsy, or cystic fibrosis). Respondents were identified during 2001 at clinical sites and welfare offices in San Antonio, Tex.

Trained interviewers approached all families, determined eligibility, and administered a structured survey in respondents’ preferred language. The survey included original and previously validated questions.¹⁴ Data were collected on child health care use, illness severity (including asthma severity as assessed with the Rosier Asthma Functional Severity Scale, described in detail elsewhere in this issue¹⁵), welfare status, current and recent employment, employment barriers, receipt of Supplemental Security Income, and demographic characteristics.

High child health care use was defined as 3 or more emergency department visits or 2 or more hospitalizations in the previous 6 months. Welfare status was defined as current (receiving TANF benefits at the time of enrollment in the study), former (had received TANF/AFDC benefits in the past), denied (had applied for TANF/AFDC and been denied benefits), pending (had pending applications), or no contact with the welfare system (had never received TANF/AFDC).

Statistical Analysis
Bivariate analyses and multivariable logistic regression analyses were performed to examine the association of welfare status with child health status, health care use, employment status, and employment issues. SAS (version 8.02, SAS Institute Inc, Cary, NC) and Epi Info (version 6.04, Centers for Disease Control and Prevention, Atlanta, Ga) were used in conducting data analyses.

The primary outcome variables included in the multivariate logistic regression models were current parental unemployment (yes, no) and work absence(s) in the previous 6 months because of child illness (yes, no). The models controlled for race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other) and parental age, educational level (less than high school, high school or greater), marital status (married, unmarried), and birthplace (United States, other). Multivariate analyses were performed to examine the association of welfare status, child health status, child health care use, and demographic variables with these 2 parental employment outcomes.

	RESULTS

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Demographic Characteristics
The majority of parents were Latino or Black, reported that they had been born in the United States, and were comfortable speaking English (Table 1). Approximately half of the respondents (55.2 %) had some previous contact with the welfare system, and 23.8% were former welfare recipients. Race/ethnicity, educational level, and marital status differed significantly among the 5 welfare groups. The majority of respondents (91.3%) were mothers; 4.2% were fathers, and 3.4% were grandparents.

Employment Issues
Rates of current and recent employment varied significantly among the 5 welfare groups (Table 3). Although the majority of respondents (74.3 %) indicated that their children’s health problems had made it difficult to find or keep a job, the degree to which the 5 groups identified this barrier differed significantly, with former recipients and denied applicants having the highest rates. Respondents also identified their own health and the health of other family members as barriers, but less frequently than they identified child health barriers.

Table 4 presents the results of regression analyses examining the association of welfare status and high rates of child health care use with unemployment and missed work after parental education, race/ethnicity, age, birthplace, marital status, and receipt of Supplemental Security Income had been controlled. Parents of children with high health care use rates were more likely to be unemployed (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.001, 2.9). High rates of child health care use were not associated with parents missing work, however.

	DISCUSSION

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Welfare recipients and applicants with chronically ill children face substantial barriers to employment related to their children’s illnesses. These barriers include high rates of child health care use and missed work. Denied applicants had the highest rates of child health barriers and work absences. We do not know why these families were denied welfare, so we cannot determine whether the rejections were related to the employment difficulties described. Because most studies of welfare recipients do not include separate data on denied applicants, the experiences of this group have rarely been explored.^16–19 The association of child illness with parental work absences and unemployment seen in this study is consistent with the findings of other studies involving large national data sets.^20,21 However, ours is the first study to link specific chronic childhood illnesses with parental employment outcomes.

The present findings are particularly relevant because parents receiving welfare are more likely to have chronically ill children than are other poor families.^4,22,23 Because it may be difficult for mothers of chronically ill children to meet the current work requirements, not to mention the proposed increased requirements, these women will be more vulnerable to benefit terminations for noncompliance.

Some states offer work exemptions and time limit extensions on the basis of parental or family member disability,²⁴ but recent research has shown that parental knowledge and use of such provisions are limited.¹¹ These exemptions are often based on such strict criteria (e.g., Supplemental Security Income disability determination) that they would not be available for many chronically ill children. Nevertheless, these children often have significant health needs requiring parental participation in their medical care. Such families may also have difficulty completing the transition from welfare to stable employment, which was the major goal of the welfare reform legislation.

There are likely to be economic and health consequences of the choices that parents of chronically ill children make when they must choose whether to miss work or miss their children’s medical appointments, and a substantial proportion of our respondents indicated that their children had missed medical appointments because they were unable to take time away from work. This finding is consistent with national data suggesting that low-income mothers in general, and former welfare recipients in particular, lack sick or vacation leave.^2–4

The economic consequences of work absences could include lost wages or, if absences occur frequently, even a lost job. On the other hand, when parents miss their children’s medical appointments, continuity and quality of care are undermined. For example, children with asthma who miss their flu shot, do not receive a peak flow meter or an asthma care plan, or do not obtain a refill for their inhaled steroids are at higher risk of increased and preventable morbidity. Missed appointments are likely to result in more reliance on emergency departments, which are not usually organized to provide the multidisciplinary approach that benefits chronically ill children.

This study also highlights the importance of child care for chronically ill children. Although we did not collect data on the availability or cost of child care, the inadequate supply of child care for current and former TANF recipients has been well documented.^25–27 The 1996 welfare legislation provided additional funding for child care subsidies, but many states have been unable to provide these subsidies to all eligible families.^27,28 If the overall supply of child care is inadequate, it is not likely that there will be a sufficient supply of specialized child care settings that can accommodate chronically ill children by providing their medications and monitoring their symptoms.

This study involved important methodological limitations. First, the sample was recruited in San Antonio, Tex, and so the findings are not necessarily generalizable to other states. Second, we relied on parental reports of child health status and employment status. However, self-reports of such information are considered valid and are collected in numerous national surveys.¹⁴

Finally, because of the cross-sectional design of the study, we cannot conclude that there is a causal relationship between chronic child illness and parental employment problems. Although we postulate that chronic child illness adversely affects parental employment, it is possible that the association we found resulted from some other cause. It is also possible that illness severity is exacerbated by parents’ employment. Inflexible work conditions can make it difficult for parents to take their children for care, and many parents have jobs that do not provide health insurance. These factors, in combination, could lead to an increase in illness severity because children are not receiving the health care they need.

Policymakers focusing on the 2002 reauthorization of the welfare legislation need to consider that welfare recipients with chronically ill children will face challenges in complying with work requirements and may need additional assistance such as subsidized child care in settings that accept chronically ill children. Efforts should be made to ensure that family resources are not further strained by the unnecessary loss of Medicaid and Food Stamp benefits, because data suggest that many eligible children and families lose these benefits when they leave welfare.^16,29–31 State and federal policymakers need to create reasonable employment and welfare policies for low-income families with chronically ill children that will help them achieve sustained employment and improved family well-being without jeopardizing their children’s health.

	Acknowledgments

 
This work was supported by funding from the National Institute of Allergy and Infectious Diseases, National Institutes of Health (grant UOI AI39769-03S1); the Robert Wood Johnson Foundation; the Maternal and Child Health Bureau, Health Resources and Services Administration; the Open Society Institute; the Ford Foundation; the Moriah Fund; the General Service Foundation; and the Office of Population Affairs, US Department of Health and Human Services.

We wish to thank Fernando Guerra, MD, MPH, William Parry, MD, James Alexander, MD, Steven Enders, and the administrators at the San Antonio Texas Works offices, without whose assistance we would not have been able to conduct this research. We would also like to thank Monica Trevino, MSW, for her coordination of the project, along with all of the dedicated interviewers, the many clinical and agency site personnel, and the children and families who participated. We offer many thanks to Heather Smith, MPH, for her assistance with data management and in preparation of the article.

Human Participant Protection
This work was approved by the institutional review boards at Boston University Medical Center, the Columbia University School of Public Health, the University of Texas Health Science Center, and CHRISTUS Santa Rosa Hospital. All participants consented to be interviewed.

	Footnotes

 
Peer Reviewed

L. A. Smith, D. Romero, P. R. Wood, W. Chavkin, and P. H. Wise contributed to the development of hypotheses, to the planning of the study, and to the preparation of the article. L. A. Smith analyzed the data and wrote the article. N. S. Wampler contributed to the data analysis.

Accepted for publication May 15, 2002.

	References

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12. Working Toward Independence. Washington, DC: US Dept of Health and Human Services, Administration for Children and Families; 2002.

13. Romero D, Chavkin W, Wise PH, Smith LA, Wood PR. Welfare to work? Impact of maternal health on employment. Am J Public Health. 2002;92:1462–1468.[Abstract/Free Full Text]

14. National Center for Health Statistics. Current estimates from the National Health Interview Survey, 1994. Vital Health Stat 10. 1995;No. 193.

15. Wood PR, Smith LA, Romero D, Bradshaw P, Wise PH, Chavkin W. Relationships between welfare status, health insurance status, and health and medical care among children with asthma. Am J Public Health. 2002;92:1446–1452.[Abstract/Free Full Text]

16. Welfare Reform: Information on Former Recipients’ Status. Washington, DC: US General Accounting Office; 1999. GAO/HEHS publication 99-48.

17. Data Available to Assess TANF’s Progress. Washington, DC: US General Accounting Office; 2001. GAO publication 01-298.

18. Loprest P. How Are Families That Left Welfare Doing? A Comparison of Early and Recent Welfare Leavers. Washington, DC: Urban Institute; 2001.

19. Prendergast M, Nagle G, Goodro B. How Are They Doing?: A Longitudinal Study of Households Leaving Welfare Under Massachusetts Reform. Boston, Mass: Massachusetts Dept of Transitional Assistance; 1999.

20. Smith LA, Hatcher JL, Wertheimer R. The association of childhood asthma with parental employment and welfare receipt. J Am Med Womens Assoc. 2002;57:11–15.

21. Kuhlthau KA, Perrin JM. Child health status and parental employment. Arch Pediatr Adolesc Med. 2001;155:1346–1350.[Abstract/Free Full Text]

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24. US Dept of Health and Human Services, Administration for Children and Families. TANF: selected provisions of state plans. Available at: http://www.acf.dhhs.gov/programs/ofa. Accessed April 14, 2000.

25. Welfare to Work: Child Care Assistance Limited; Welfare Reform May Expand Needs. Washington, DC: US General Accounting Office; 1995.

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27. Child Care: States’ Efforts to Expand Programs Under Welfare Reform. Washington, DC: US General Accounting Office; 1998. GAO/T-HEHS publication 98-148.

28. Piecyk JB, Collins A, Kreader JL. A Report of the NCCP Child Care Research Partnership: Patterns and Growth of Child Care Voucher Use by Families Connected to Cash Assistance in Illinois and Maryland. New York, NY: National Center for Children in Poverty, Columbia University; 1999.

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