Health Impacts of Paid Domestic Work: A Focus on Social, Occupational, and Employment-related Health Inequities in the United States

Abstract

Domestic workers (DWers)—who are disproportionately women, people of color, and/or immigrants—labor in and are often employed informally by private households doing tasks such as adult care, child care, and housecleaning. Despite the growing size of the domestic labor force, the essential nature of the services DWers provide, and DWers’ likelihood of experiencing poor working conditions and health given their social location within their societies, remarkably little research has quantitatively investigated DWers’ health, in the United States (US) or internationally. Given these data and research gaps, this dissertation uses multiple sources of data not previously or rarely used in social epidemiologic research to advance empirical understanding of the health impacts of paid domestic work (DW). Guided by the ecosocial theory of disease distribution, I focus on US DWers during the 2010s and investigate how the work-related exposures and associated health impacts of DW are distributed among DWers, in relation to their social group membership, primary DW occupation, and employment arrangement. In the first chapter, I use exploratory latent class analysis to identify groups of DWers with distinct patterns of exposure to 21 self-reported economic, social, and physical workplace hazards. I then use multinomial logistic latent class regression to examine associations between workers’ individual, household, and occupational characteristics and latent class membership. To do so, I analyze data from the sole nationwide survey of informally employed US DWers with work-related hazards data, conducted by the National Domestic Workers Alliance, the University of Illinois Chicago Center for Urban Economic Development, and the DataCenter in 14 US cities (2011-2012; N = 2086). Latent class analysis identified four groups of DWers doing: ‘Low hazard domestic work’ (lowest exposure to all hazards), ‘Demanding care work’ (moderate exposure to pay violations and contagious illness care), ‘Strenuous cleaning work’ (high exposure to cleaning-related occupational hazards), and ‘Hazardous domestic work’ (highest exposure to all but one hazard). Covariates were strongly associated, in many cases, with latent class membership. In the second chapter, I use the same dataset to examine associations between DWers’ exposure to patterns of workplace hazards, as well as to single hazards, and their work‐related and general health. I first characterized DWers’ exposures using four approaches: single exposures, composite exposure to hazards selected a priori, classification trees, and latent class analysis. Across all four approaches, exposure was associated with increased risk of work‐related back injury, work‐related illness, and fair‐to‐poor self‐rated health in city fixed effects regression models. For back injury, the estimated risk ratio (RR) associated with heavy lifting (the single hazard with the largest RR), exposure to all three hazards selected a priori (heavy lifting, climbed to clean, worked long hours) versus none, exposure to the two hazards identified by classification trees (heavy lifting, verbally abused) versus “no heavy lifting,” and membership in the most‐ versus least-exposed latent class were, respectively, 3.4 (95% confidence interval [CI] 2.7–4.1); 6.5 (95% CI 4.8–8.7); 4.4 (95% CI 3.6–5.3), and 6.6 (95% CI 4.6–9.4). In the third chapter, I estimate the association between entering domestic work employment—informally or formally—and within-person changes in women workers’ health. To do so, I analyze 2014-2017 US Survey of Income and Program Participation panel data from 25-75-year-old women who had complete four-year follow-up and entered informally or formally employed DW during the panel (n = 226; weighted n = 891 198; ~50% non-Hispanic White women, ~50% women of color). In weighted individual fixed effects models, entering informally employed DW was associated with 11.5 (95% CI 0.7–22.2) and 5.4 (95% CI -3.4–14.3) percentage-point increases, respectively, in the probability of experiencing fair-to-poor self-rated health and work-limiting health conditions. Entering formally employed DW was not associated with health changes (Fair-to-poor self-rated health: -1.3 [95% CI -11.2–8.5]; Work-limiting conditions: -3.1 [95% CI -10.1–3.8]). Across these chapters, I find that paid DW is hazardous and harmful to workers’ health, but not uniformly so. Even among this group of inequitably exposed workers, there is stark socially structured heterogeneity in who experiences what workplace hazards and—through pathways related to these exposures and others—who experiences what health harms. At a minimum, these results suggest the importance of multi-level action that raises labor standards for DWers and ensures these standards are adequately enforced among groups of DWers unduly harmed by employer practices. These chapters also suggest ways of using available data to rigorously investigate the health impacts of DW among DWers, while calling for improved data and further research examining health inequities between DWers and others and their societal determinants.