An Exploratory Study Martha J. Sanders, Tim Morse BACKGROUND. Caring for ones children is among the most ubiquitous of occupations. However, few studies have examined the ergonomic risks involved in parents caring for children at home. PURPOSE. The purpose of this study was to identify the frequency, type, and severity of musculoskeletal symptoms in parents of children less than 4 years old. The study further examined the factors that contribute to musculoskeletal pain in this sample. METHODS. A convenience sample of 130 parents with children younger than 4 years old completed a seven-page survey that included questions related to the parents demographics, their musculoskeletal dis- comfort, their performance of child-care tasks with high biomechanical risks (such as carrying a child in a car seat), and parents perceived psychological strain related to caring for their children. RESULTS. Ninety-two percent (92%) of the providers were mothers. Sixty-six percent (66%) of the sample reported the presence of musculoskeletal pain. The parts of the body most affected were the low back (48%), neck (17%), upper back (16%), and shoulders (11.5%). Factors associated with musculoskeletal pain were performing child-care tasks dened as having high biomechanical risks (p = .001), the perception that caring for children is highly demanding (p = .003), and performing hobbies less than 1 hour per week (p = .04). Parents working status, age, and participation in other daily activities were not signicantly related to muscu- loskeletal discomfort. CONCLUSION. This study demonstrates the high prevalence of musculoskeletal pain in parents of children under the age of 4 years. It underscores the association between physical and psychological factors in the development of musculoskeletal discomfort. It suggests the need for occupational therapy wellness programs that focus on preventing musculoskeletal discomfort and providing support for the parenting role. Sanders, M. J., & Morse, T. (2005). The ergonomics of caring for children: An exploratory study. American Journal of Occupational Therapy, 59, 285295. M othering, one of the most universal of occupations, has received a resurgence of interest in the last several decades as women struggle to dene their roles, balance their careers with home life, and make sense of the fundamental impor- tance of this occupation (Francis-Connolly, 2000; Hochschild, 2000; Primeau, 1992, 2000). Researchers have acknowledged the stress that women experience in trying to balance multiple roles but have only recently begun to delve deeper into the tasks required of mothering and the strategies women use to orchestrate the lives of their families (Francis-Connolly; Primeau, 2000). Although qualitative studies have described mothers reports of physical and emotional strain arising from the routine tasks of lifting, carrying, and bending while caring for young chil- dren (Grifn & Price, 2000; Hochschild) few studies have quantied the physical exposures in these tasks or have documented the frequency of musculoskeletal symptoms related to caring for young children. Ergonomics has traditionally assisted industry in decreasing musculoskeletal disorders (MSDs) and associated workers compensation costs through optimizing worker and workplace interactions (Kroemer & Grandjean, 2001). Although Martha J. Sanders, MA, MSOSH, OTR/L, is Assistant Professor, Occupational Therapy, Quinnipiac University, 275 Mt. Carmel Avenue, Hamden, Connecticut 06518; martha.sanders@quinnipiac.edu Tim Morse, PhD, CPE, is Associate Professor, Ergonomic Technology Center of Connecticut, Occupational and Environmental Medicine, University of Connecticut Health Center, Farmington, Connecticut. applications for ergonomics exist in nonwork-related set- tings (Sanders, 2004), this has not been a central focus of research in the United States, possibly due to the lack of direct monetary incentives for improving ergonomics out- side the workplace. However, large Scandanavian studies have found important interactions between leisure activities and work that affect long-term physical functioning (Leino- Arjos, Solovieva, Riihimaki, Kirjonen, & Telema, 2004). Research suggests that injuries precipitated by nonwork- related tasks (including caring for children) interacts with workplace exposures to contribute to higher use of the workers compensation and private health care insurance systems (Bergqvist, Wolgast, Nilsson, & Voss, 1995). Because attribution to specically work or nonwork causes is difcult for chronic conditions such as MSDs, many workers do not le for workers compensation even for work-related MSDs but instead use sick time and tradi- tional health insurance (Azaroff, Levenstein, & Wegman, 2002; Boden, 2000; Morse, Dillon, Warren, Levenstein & Warren, 1998). Overall, given the very large numbers of persons at risk, implications exist for preventing muscu- loskeletal pain in parents (including mothers, fathers, and other family members acting as the primary caregivers for young children) in order to minimize health care costs and optimize the role of a parent. Literature Review Musculoskeletal Symptoms and Psychosocial Strain in Child-Care Workers This literature review will address the research on the fre- quency of reported pain in individuals caring for children and the ergonomic risk factors that may contribute to MSDs. Although the term ergonomic risk factors is classical- ly associated with the biomechanical or physical workplace exposures, current denitions of ergonomics address the broader organizational and psychosocial factors that may also contribute to the development of MSDs (Warren, 2004). For the purposes of this paper, the discreet compo- nent terms of ergonomics will be used. The term biome- chanical risk factors will refer to physical exposures such as working in awkward postures or lifting heavy objects (or children). The term psychosocial risk factors will refer to such individual and social factors as an individuals perceived stress, control over ones job, ability to make decisions, and social support, all of which have been associated with work- related MSDs (Karasek & Theorell, 1990; Warren; Warren, Dillon, Morse, Hall, & Warren, 2000). A paucity of literature exists relative to the biomechan- ical and psychosocial strains involved in adults caring for children in day-care centers, nursery schools, and home set- tings. Researchers rst addressed child-care work with a focus on improving the general work environment for adults caring for children in day-care settings. Studies pri- marily addressed the infectious disease, environmental, and stress-related concerns in child-care work (Bright & Calabro, 1999; Manlove, 1993). Results of the Child Care Employee Project Survey indicated that biomechanical issues were also important concerns for child-care providers across the United States. In this survey, 48% of child-care workers had experienced back strains from lifting children, 69% reported moving heavy furniture, and only 25% of the day-care centers in which the respondents worked used adult size furniture for workers (Child Care Employee Project, 1983). However, when epidemiologic studies began to address the musculoskeletal health of adult child-care workers, wide discrepancies in the frequency of musculoskeletal discom- fort were reported. Brown and Gerberich (1993) examined workplace injuries in 440 child-care workers in Minnesota and found an overall injury incidence rate of 1.94 injuries per 100 workers over a 6-year period. Low-back strain accounted for 34% of all injuries, followed by lower extremity (20%), upper extremity (12%), and injuries to multiple sites (13%). Almost 50% of all injuries were sprains, the majority caused by overexertion (34%); 49% of all back injuries were associated with lifting children. Studies conducted by Gratz and Claffey (1996) and Calabro et al. (2000) yielded much higher prevalence of musculoskeletal symptoms in child-care workers. Gratz and Claffey found that 18% of 446 early child-care workers in day-care centers and in-home day-care settings noted back pain; 30%35% noted headaches; and 23%36% noted fatigue on a weekly basis. In addition, 29% to 35% of this sample rated their jobs as stressful to very stressful. When Calabro et al. (2000) surveyed 240 child-care workers in 34 day-care centers, they found that 11.5% of child-care work- ers suffered low-back pain and 21.5% suffered falls or trips related to the job. Although these self-report surveys were conducted on nonrandom samples of child-care workers and thus must be interpreted cautiously, collectively, the outcomes indicate that both musculoskeletal and psychosocial health concerns are legitimate but not yet fully described in those caring for children on a regular basis. Musculoskeletal Symptoms and Psychosocial Strain in Parents The studies related to adult health while caring for children in day-care centers were conducted within the context of promoting workplace health, safety, and quality of work. 286 May/June 2005, Volume 59, Number 3 Without this organizing framework, the concern for par- ents musculoskeletal health relative to caring for children has been compartmentalized into niche perspectives. Medical studies have associated low-back pain and tension headaches with delivering children and lifting children. Mundt et al. (1993) studied nonoccupational lifting in a case-control study of 287 clients with symptoms of a herni- ated lumbar intervertebral disc. In 177 conrmed cases the relative risk of developing a herniated intervertebral disc was 4 times higher in cases that lifted children greater than 25 lbs from the oor using a back-bent, straight-knees pos- ture than in controls. Russell, Groves, Taub, ODowd, and Reynolds (1993) and Breen, Ransil, Groves, and Oriol (1994) examined low- back pain in new mothers as related to the use of epidural anesthesia use during delivery. Although the two studies results differed with respect to the relationship of anesthesia to low-back pain, both suggested that repetitive lifting and poor understanding of proper posture contributed to new mothers long-term low-back pain. Yamada, Yamada, Naito, Kamishima, and Yamaguchi (2003) compared the prevalence of tension headaches in Japanese women who worked part-time outside the home and those who did not work, also comparing basic fami- ly structure (wife, husband, children) to complex family structure (additional relatives or elderly parents living with them). They found a signicantly higher prevalence of ten- sion headaches in those women who did not work outside the home and who had a complex family structure (p < .05). Researchers suggested that the stress of caring for children and elderly relatives and performing housework triggered frequent tension headaches in this sample. Given that low-back pain appeared to be the most common musculoskeletal disorder related to caring for chil- dren, researchers began to more closely examine parents lifting practices and their process of choosing their methods of lifting. Grifn and Price (2000) examined lifting meth- ods in mothers, hypothesizing that choices in lifting meth- ods would be based on a myriad of contextual factors such as the equipment available, number of children, duration and frequency of the task, and ways to conserve energy. In reality, mothers used primarily one lifting method, the stoop lift method of lifting (bending at the waist with knees straight), because it was perceived to be the quickest, most efcient, and safest method for the child. Decisions were based on the childrens immediate needs rather than mothers regards for their personal health. The psychosocial strain in caring for children at home while coordinating family and household responsibilities with work demands has been further addressed. Francis- Connolly (2000) uncovered mothers feelings of incompe- tence in caring for their new babies and their feeling over- whelmed by the constant 24-hour physical and emotion- al demands of mothering. Dyck (1992) discussed the social constraints and complex social network mothers used to negotiate their child-rearing tasks. Primeau (2000) dis- cussed the unequal division of labor in traditional house- holds. Hochschild (2000) examined the emotional stresses and general fatigue women derive from rearing children and the double shifts that women undertake to manage careers and families. Researchers acknowledge the enfolding nature of mothers performance of child-care tasks that occur simultaneously with teaching children, nurturing children, and performing household tasks (Francis- Connolly; Primeau, 1998). Given that high frequencies of musculoskeletal pain have been reported in both child-care workers and parents, particularly mothers, a closer examination of the research on specic risk factors that may be contributing to MSDs is provided. Biomechanical Risk Factors in Caring for Children Owen (1994); King, Gratz, Scheuer, and Claffey (1996); and Grant, Habes, and Tepper (1995) all examined the biomechanical risk factors related to musculoskeletal dis- comfort (primarily low-back pain) in child-care workers. Owen identied the 10 tasks perceived to be the most phys- ically stressful for 27 child-care workers in ve Midwestern day-care centers. These tasks involved lifting (onto a chang- ing table or toilet, into and out of a pushcart or crib), bend- ing (to feed, play, wash hands, or clean the room), and stooping. Observations of these workers demonstrated that they used poor lifting technique throughout the day. King et al. (1996) cited similar biomechanical stressors in a work- site analysis of 125 child-care workers. These workers addi- tionally used inadequately sized furniture, sat unsupported on the oor, and reached repetitively above shoulder height. Grant et al. (1995) substantiated that child-care work- ers frequently assume awkward postures during the day. Work sampling studies indicated that 25% of workers time was spent in squatting, kneeling, or sitting on the oor. An additional 26% of their time was spent sitting on small, child-size furniture. Eighteen percent (18%) of teachers activities involved exing at the trunk greater than 20. Frequencies for these awkward postures were higher for those working with younger children. Although similar child-care tasks are performed by child-care workers and parents, important differences exist. Parents must perform all the child-care tasks mentioned previously in addition to bathing and transporting, putting children to bed and waking them, playing with children, teaching and consoling them. Household tasks of cleaning, The American Journal of Occupational Therapy 287 cooking, laundry, and shopping must also be accomplished while organizing the household schedule to meet job and community demands. Parents acting as the primary care- givers (primarily mothers as cited in the literature) report routinely multitasking to take care of children while per- forming daily chores (Esdaile & Olson, 2004; Hochschild, 2000; Pirie & Herman, 1995; Primeau, 2000). However, child-care workers must care for a larger number of children and therefore may experience higher repetition and intensi- ty of exposures than parents during their daily shift. Some researchers argue that workplace exposures are typically more intensive than environmental exposures (Kroemer & Grandjean, 2001). Effects of Employment on Women Caring for Children Finally, Hall and Gordon (1973) suggested that married women with part-time jobs are more likely to experience role overload in striving to fulll the tasks of both a mother and worker than women who are employed full-time. Greenhaus and Beutel (1985) suggested that homework conicts are exacerbated by having young children and little spousal support. Paden and Buehler (1995) found that role overload and conict between home and work creates a spillover effect that is associated with physical symptoma- tology in women who work. This role overload predicted personal and marital stress for women in a sample of 261 Midwestern couples (Hyde, Essex, Clark, & Klein, 2001). In other studies, Ratszon, Jarus, Baranes, Gilutz, and Erez (1998) found that the number of children in ones family was highly correlated with musculoskeletal pain in a group of female workers who performed varied ofce work. Vroman and MacRae (2001) found that personal nonwork stressors were higher in a sample of female grocery workers with upper-extremity pain as compared to their asymp- tomatic peers. Demand Control Model of Occupational Stress The combined effects of physically demanding and emo- tionally taxing jobs have been addressed in a model of occu- pational stress, called the Demand-Control Model (Karasek & Theorell, 1990). The Demand-Control Model suggests that work-related illnesses result from an interactive effect of jobs that are highly demanding (such as fast-paced jobs that require high physical exertions) and jobs that offer workers little control, little opportunity to make decisions, and limited opportunity to exercise their skills (termed decision latitude). Workers in such occupations are con- sidered to have high demands and low decision latitude which results in high-strain jobs according to the model. Extensive research supports that workers in high-strain jobs have a higher incidence of cardiovascular and muscu- loskeletal disease than occupations without these character- istics (Karasek & Theorell; Warren et al., 2000). Thus, according to this model, caring for children could be con- sidered a high-strain occupation (high demands, low con- trol) although no studies have specically applied parenting to this theory. In summary, the research on the musculoskeletal dis- comfort in parents caring for preschool children suggests that biomechanical exposures such as frequent lifting and bending during the daily tasks of parenting may contribute to their musculoskeletal discomfort. However, no studies have specically identied which child-care tasks may put parents at risk for developing an MSD. Although qualita- tive studies have alluded to the emotional demands required in caring for children, no studies have addressed the rela- tionship between psychosocial strain and MSDs in parents. The purpose of this study was to identify the frequency of musculoskeletal pain in parents of children under 4 years of age and delineate the specic biomechanical and psychoso- cial variables related to these symptoms. For the purposes of this study, parent refers to the mother, father, or guardian acting as the primary caregiver for the child or children in the home. The research questions were: (1) What is the frequency, type, and severity of mus- culoskeletal symptoms in parents of children 0 to < 4 years of age? (2) What biomechanical and psychosocial factors con- tribute to musculoskeletal pain in parents? Methods Survey Development A seven-page survey instrument was developed from eld observations of child-care tasks, focus-group feedback from parents of children 0 to < 4 years of age, the literature, and 20 pilot surveys. The survey underwent review by seven experts, including three occupational therapy professors (who specialized either in ergonomics, orthopedics, or pedi- atrics, all with children under 4 years of age), one social research scientist, one ergonomist, and two day-care providers with combined experience of over 25 years. Experts critiqued the survey relative to clarity, face validity, and the degree to which each survey question was critical in answering the overall research questions. The survey began with demographic questions related to childrens and parents ages and weight, marital status, family income level, and spouses level of assistance in child- care tasks. The survey addressed parents hours of sleep, hours working outside the home, hours children spent in day care and babysitting, and parents participation in 288 May/June 2005, Volume 59, Number 3 common daily activities (including exercise, housework, computer use, yard work, and hobbies). Participation in daily activities was categorized according to the frequency parents performed the activity per week (< 1 hr, 13 hrs, and > 3 hrs). The survey then addressed the following variables that may impact the development of musculoskeletal dis- comfort in a parent and location of the musculoskeletal pain. High-Risk Practices: Child-care tasks considered to be high risk were assumed to be those that result in high biomechanical stresses placed on a particular part of the body. Most practices that involve carrying, lifting, and bending place a strain on the low back that is exacerbated by repetition, prolonged duration, and weight of the child. When the child is held away from the parents body (such as when loading a child into a car seat or removing a child from a crib) the torque placed on the upper and lower back and shoulders is greatly increased. Most of these practices can be performed with less risk by maintaining proper alignment of the body, by keeping the child close to the body when lifting, and by using alternate means to carry a child for prolonged durations (e.g., backpack, front pack, stroller) (Kroemer & Grandjean, 2001; Sanders, 2004). High-risk practices were dened based on the literature (King et al., 1996; Owen, 1994), the focus group, and pilot study feedback. Focus group and pilot study feedback pro- vided additional high-risk practices related to transporting, bathing, feeding children, and performing chores with chil- dren that were not identied through prior research on child-care workers. Table 1 lists those high-risk practices as dened in the study. Parents who completed the survey identied the high- risk child-care practices they performed on a regular basis. The number of high-risk practices that parents reported was summed to form an overall high-risk practice score. The potential number of high-risk practices varied according to the age of the child. For example, parents who cared for infants could potentially perform 12 high-risk practices, whereas those caring for children 2 to < 3 years of age could potentially execute only 9 high-risk practices given fewer feeding, holding, and transporting demands. To adjust for these different possibilities, each of these age groups were divided into high-, medium-, and low-risk categories. To illustrate, for parents of children 0 to < 1 year of age, the potential number of high-risk practices was 12. Those who performed 04 practices entered the low-risk category, those who performed 58 practices entered a medium-risk category, and those who performed 912 practices entered a high-risk category. Perception of Psychological Strain: Psychological strain is postulated to arise from high-perceived occupational demands and low control over ones job or limited use of skills according to the Demand-Control Model of occupa- tional stress (Karasek & Theorell, 1990). The perceived level of psychological strain resulting caring for children was addressed in three questions related to the occupational demands of a parent, adapted from the Job Content Questionnaire (Karasek & Theorell). Questions were I have enough time to get done what I need to do, I have sufcient time during the week to perform hobbies or other activities that are meaningful to me, and Caring for my children requires a lot of physical effort. Perceived demands were scored according to a Likert scale. The values were summed for a perceived demand score that was cate- gorized as either high or low. Presence, type, and location of pain: Participants provid- ed information about the presence, type, and location of musculoskeletal discomfort through completion of a schematic drawing of the entire body. The operational def- inition was pain or discomfort lasting for either 7 days con- secutively or 20 days all together in the last 3 months that you think may be related to caring for your child or children. This denition was adapted from that used by the Connecticut Upper-Extremity Surveillance Project (Morse et al., 1998). Severity of the condition was assessed based on positive responses for visiting a medical doctor and receiv- ing a medical diagnosis. Procedure Surveys were distributed to a convenience sample of providers at malls, playgroups, playgrounds, stores, and day-care centers in Southern New England from October through December 2001. Inclusion criteria for the partici- pants were: (1) being the primary caregiving parent for the The American Journal of Occupational Therapy 289 Table 1. High-Risk Child-Care Practices (Based on Literature and Expert Opinion) Practice Carry child in car seat Carry child on one hip Carry child while bending down Lift child up to or off a changing table Lift child into or out of a crib with high sides Lift child up from the oor Stand bent over to wash child Change child on oor, crib, or playpen Open baby food jars and cans Push child on a seated toy Breast feed in an awkward position Bottle feed in an awkward position Note. Most high-risk practices entail use of the body, particularly the back or neck, in an awkward posture. An awkward posture is one that deviates from a neutral position (i.e., head upright, maintenance of vertebral curves, shoulders at ones side, elbows exed to 90, forearms not rotated, wrists straight) (Kroemer & Grandjean, 2001; Sanders, 2004). child or children, (2) having one or more children under the age of 4, and (3) willingness to complete and return the survey within the requested time period. Surveys were either completed immediately or mailed to the researcher. No attempt was made to follow-up those that were not returned. Approval by a university institution review board was obtained prior to conducting the study. Data Analysis Microsoft Excel 2000 and SPSS for Windows statistical package version 11.0 were used to tabulate and analyze data. Descriptive statistics were used to describe the sample demographics and frequency of musculoskeletal symptoms. Pearson chi-square analysis was used to compare activity, practices, and perceived demand variables between those parents with and without musculoskeletal pain. Logistic regression was used to examine the interrelationship between independent variables and the presence of muscu- loskeletal pain. Demographics One hundred and thirty surveys were completed and returned for a response rate of 82%. Table 2 summarizes the sample characteristics. The great majority of participants were married (95%) women (92%). The ages of the sample ranged from 17 years to 56 years with a mean age of 33 years. Eighty-six (66%) participants were in the 3040- year-old age category. The weight of the providers ranged from 95 pounds to 210 pounds with a mean weight of 137 lbs (SD= 27.8 lbs). The majority of participants (81%) had family incomes over $60,000 (the median family income for the same geographic region was $65,000 annually). Less than half of the sample (42%) indicated that their spouses equally assisted in caring for the children (dened as 50% of the time or greater). There were 153 children 0 to < 4 years of age reported by the sample. Twenty-one parents (16%) had more than one child under 4 years of age. The mean weight of all children was 25.7 lbs (range 8.0 lb45.0 lb; SD 8.0 lbs). Parents working status was as follows: 41 participants (31%) did not work outside the home, 43 (34%) worked part-time (less than 30 hours), and 46 (35%) worked full- time (30 hours or more). The mean number of working hours for pay was 29.6 hours (range 062 hours; SD 13.5 hours). Hours that children spent in day care were as fol- lows: 22 (17%) of the parents children were not in day care; 70 (54%) were in day care part-time (less than 30 hours) and 38 (29%) were in day care full-time (30 hours or greater). The mean number of hours children spent in day care was 21 hours per week (range 060 hrs; SD 15.6 hrs.). The differences between the mean hours parents worked for pay and the mean number of hours children were in day care could be explained by the fact that some parents worked for pay at home. Parents in the sample received an average of 6.4 hours of sleep per night (range from < 4 to > 9 hours). Results What is the frequency, type, and severity of musculoskeletal symptoms in parents of children 0 to < 4 years of age? Eighty-eight parents (66%) indicated that they had experi- enced musculoskeletal discomfort related to caring for their children. Table 3 indicates the frequency according to body part. Almost half of all parents, 62 (48%), indicated the presence of low-back pain. Over 44% of the parents indi- cated the presence of neck, upper-back, or shoulder pain. Complaints of knee, nger or wrist, and hip pain were each indicated in 10% or less of the parents. Thirty-three (25%) of all participants had visited a medical doctor due to painful symptoms. Twenty-seven parents (21%) had received a diagnosis. Diagnoses included low-back strain, sciatica, shoulder tendonitis, knee pain, neck pain, wrist tendonitis, deQuervains tendonitis, carpal tunnel syn- drome, and hip tendonitis. What factors contribute to musculoskeletal pain in parents? Parents Working Status: Table 4 provides the frequencies of reported pain according to the parents number of hours working, number of hours the children were in day care, age of the parent, age of the child, and childs percentage of the parents body weight. No clear association existed between reports of musculoskeletal pain and the number of 290 May/June 2005, Volume 59, Number 3 Table 2. Sample Demographics Demographic Variable Number Percentage Gender Female 120 92% Male 10 8% Marital status Married 124 95% Single 6 5% Percent of time spouse assists with child care Never (0%) 6 5% Occasionally (124%) 15 12% Frequently (2449%) 54 42% Always (50% or >) 55 42% Age categories of children Number Mean weight 0 to < 1 41 16.0 lbs 1 to < 2 43 26.1 lbs 2 to < 3 45 30.3 lbs 3 to < 4 24 39.8 lbs hours that a parent worked or the number of hours that children were in day care. The greatest frequency of painful symptoms (77%) occurred in the category of parents who worked part-time, between 10 and 30 hours per week. Ages of the Child and Parent: There were no statistically signicant relationships in regard to the age of the baby or the age of the parent and developing an MSD. Parents with children 0 to < 1 year of age and 1 to < 2 years of age had more musculoskeletal complaints than did parents with children 2 years of age and older. Older parents reported fewer musculoskeletal complaints. Parents 40 years of age and older had the lowest frequency of musculoskeletal com- plaints of all age categories. This category of parents also performed high-risk practices with less frequency (44%) than did parents 30 to < 40 years of age (60%) and parents 20 to < 30 years of age (66%). Daily Activities. Chi-square analyses found no signi- cant associations between reports of musculoskeletal pain and the performance of relaxation techniques, yard work, or exercise (see Table 5). A small but signicant negative asso- ciation was found between musculoskeletal pain and hob- bies (p < .05). Participants who engaged in hobbies for just 1 hour per week or greater had fewer complaints of muscu- loskeletal pain. Performance of High-Risk Child-Care Practices: Signi- cant and strong associations were found between the per- formance of high-risk child-care practices and presence of musculoskeletal pain (p = .001; CI = 59%95% had mus- culoskeletal discomfort who reported a high numbers of such tasks, compared to 133% for low numbers and 4171% for medium numbers). Those who performed more high-risk practices more frequently indicated the pres- ence of pain (see Table 6). The American Journal of Occupational Therapy 291 0 10 20 30 40 50 Low Back Neck Shoulder Knee Wrist Hip Body Locations Upper Back Fingers P e r c e n t 48 17 16 11.5 10 7 5 8 Table 3. Frequency and Percent of Pain in Parents, by Body Location Note. The actual percentages are given above the bars (N = 130). Table 4. Frequency and Percent of Musculoskeletal Pain in Parents, by Demographics Number of respondents Percentage Variable with pain with pain Hours children are in day care < 10 39 63% 1030 19 66% 30+ 28 72% Hours working outside the home < 10 29 60% 1030 27 77% 30+ 30 64% Age of child 0 to < 1 26 70% 1 to < 2 26 76% 2 to < 3 25 58% 3 to < 4 9 56% Age of parent < 2029 20 74% 3039 56 65% 40+ 10 55% Childrens weights as percentage of parents weights < 15% 17 63% 15%24% 44 70% 25%+ 16 66% Perceived Demands in Caring for Children: Similarly, a strong association was found between parents perceived demands in caring for children and presence of muscu- loskeletal pain (p = .003; CI = 65%83% for high demand, compared to 3364% for low demand). Those who indi- cated that caring for children was a highly demanding occu- pation more frequently indicated the presence of pain (see Table 6). Logistic regression demonstrated no clear relationship between complaints of musculoskeletal pain and childrens ages, parents ages, childrens weight, childrens percentage of parents weights or number of hours children were in day care, and parents work hours. The performance of high- risk child-care practices dropped below statistical signi- cance in the logistic regression (OR= 2.1, 95% CI = .96 4.59, p = .065), but high-perceived demands (OR = 2.75, CI = 1.104 6.857, p = .030) was signicantly associated with the development of musculoskeletal pain when other variables were controlled. The strongest associations between high-perceived demands and musculoskeletal pain were identied in parents with children 1 < 2 years of age (OR 20.32 , CI 2.16190.79, p = .008). This data speaks to the signicant physical and psychological stresses involved with caring for children this age. Discussion A high number of parents, primarily mothers, appear to be at-risk for developing some kind of musculoskeletal pain as a result of caring for children under 4 years of age. In this study, 66% of the sample noted the presence of muscu- loskeletal pain they felt was related to caring for their chil- dren. The parts of the body most affected were the low back (48%), neck (17%), upper back (16%), and shoulder (11.5%). The prevalence of low-back pain in our sample of parents was much higher than that previously reported in child-care workers. The ndings from this study are consis- tent with Tong et al. (2003) who found that 43.5% of mothers with children over 2 years of age with a nonphysi- cally disabling illness experienced low-back pain on a regu- lar basis. Performing high-risk practices while caring for children (including carrying a child on one hip, lifting a child from the oor, bending to wash a child, changing a child on the oor, pushing a child on a seated toy, and feeding in awk- ward positions) was associated with musculoskeletal pain in parents, as was the perception that caring for children was highly demanding. This supported the Demand-Control Model of occupational stress suggesting that psychosocial factors are equally as important concerns as biomechanical factors in the development of musculoskeletal symptoms (Karasek & Theorell, 1990; Warren, 2004; Warren et al., 2000). The psychological strain was reected in parents per- ceptions that they did not have enough time to complete what they needed to do, did not have enough time for them- selves, and the belief that caring for children was physically demanding. In fact, the performance of hobbies greater than just 1 hour per week was associated with fewer muscu- loskeletal symptoms, which supports the importance of per- forming personally meaningful activities, controlling ones time, and/or participating in an outside physical activity. The greatest impact of biomechanical and psychosocial stressors appeared to be in parents of children < 2 years old and particularly in parents with children 1 to < 2 years old. In this category, high-perceived demand and high-risk child-care practices were the most highly correlated with musculoskeletal pain. In very young children, high biome- chanical exposures presumably exist as parents frequently lift, carry, and hold the children. As children grow older, the frequency of lifting is less, but childrens weights are higher. From 1 to < 2 years of age, both high frequencies in lifting or holding and higher childrens weight (mean 26.1 lbs in this study) are experienced by parents. Further, young chil- dren are very dependent and cannot be left unattended at 292 May/June 2005, Volume 59, Number 3 Table 5. Percent and Frequency of Musculoskeletal Pain as Related to Daily Activities Performed Performed Performed < 1 hr 13 hrs > 3 hrs Activity percent (n) percent (n) percent (n) 2 Exercise 63% (36) 75% (34) 54% (14) 3.7 Relaxation 64% (66) 70% (14) 80% (4) .737 Hobbies 74% (59) 52% (17) 53% (8) 6.25* Computer 59% (35) 69% (29) 74% (20) 2.11 Housework 33% (1) 60% (21) 68% (62) 2.3 Yard Work 62% (26) 74% (40) 56% (18) 3.2 Note. Only engagement in hobbies more than 1 hour per week approached signicance as protective of musculoskeletal pain (*p < .05). Table 6. Child-Care Practices, Perceived Demand and Musculoskeletal Pain Number Percentage 95% With of Parents Condence Variables and Categories of Risk Pain (n) With Pain Intervals Number of high-risk child-care tasks Low 1 17% 1%33% Medium 26 56% 41%71% High 59 77% 59%95% Perceived demand in caring for children Low demand 19 49% 33%64% High demand 67 74% 65%83% Note. Performance of high-risk child-care activities was signicantly associat- ed with musculoskeletal pain (chi-square value 14.08, p = .001). The percep- tion that caring for children was highly demanding was signicantly associat- ed with musculoskeletal pain (chi-square value 8.97, p = .003). this age. In fact, many parents commented anecdotally that physical stresses were exacerbated by childrens crying, strug- gling, and arguing so that daily tasks became monumental. Overall, the ndings from this study are consistent with the notion that caring for children is a highly demand- ing occupation as presented by Francis-Connolly (2000), Primeau (1992, 1998, 2000), and Esdaile and Olson (2004). Although the results of the study have implications for all parents and guardians acting as the primary caregiv- er for children, this study allows us to consider these ergonomic risks within the context of motherhood and womens health given that 92% of the parents were moth- ers and that less than half of all spouses assisted with caring for children > 50% of the time. (Although it is possible that spouses performed key biomechanical tasks that may have required higher physical forces, data was not available in our study to address this point.) Francis-Connolly discussed that mothers of young children felt culturally compelled to discuss the virtues of mothering; however, in reality they felt overwhelmed by the physical exhaustion and mental stress- es of the constant attention demanded by children. Grifn and Price (2000) further described mothers feelings of helplessness and lack of control when not knowing what was wrong with their babies. This lack of control, as indi- cated in psychological strain, bore out to be an important factor in the development of MSDs in this sample. Finally, the role of part-time work in mothers develop- ment of musculoskeletal pain is not clear. Although it would be logical that those mothers who worked fewer hours per week would have more pain secondary to increased expo- sures related to caring for children (i.e., would have more hours of caring for children at home given fewer hours away at work), this was not the case. In this study those mothers who worked for pay between 10 and 30 hours per week had the highest frequency of musculoskeletal pain (77%). This is consistent with the role and task overload theories relating to dual employment of women (Greenhaus & Beutel, 1985; Hall & Gordon, 1973; Hyde, Essex, Clark, & Klein, 2001; Paden & Buehler, 1995). We did not have data con- cerning work exposures for this sample, so we cannot report on possible cumulative effects of work exposures and parental child-care tasks. Clearly, more research is needed to better understand the complex relationships and stressors among work, child rearing, and the development of muscu- loskeletal discomfort. Limitations Many limitations exist in this study. This exploratory study was a small convenience sample that was not necessarily representative of the overall population ages and socioeco- nomic status. The low power from the relatively small sam- ple raises the possibility of Type II error (not nding associ- ations where they actually exist). The self-report and cross-sectional nature of the instrument may lend towards a possible response bias such that those with pain may have been more likely to complete the survey and may have rated their activities systematically differently than those without pain. Common instrument bias may have also affected the responses to questions, with respondents giving higher risk scores if they had higher levels of symptoms. The question- naire instrument was for the most part a nonstandardized tool due to a lack of prior research in the area, and had only limited psychometric testing. Due to the cross-sectional nature of this survey, it is unclear whether the problems may be self-limiting or chronic. However, the fact that musculoskeletal pain in par- ents lasts at least through their childrens preschool years lends some evidence as to the long-lasting nature of the problem. Possibly the greatest limiting factor is the surveys inability to directly record the biomechanical practices of the respondents such as the actual postures used for lifting and carrying, the frequency of performing such tasks, and the duration of time holding children. Future studies should examine parents biomechanical and psychosocial strains in greater depth appreciating the integrated nature of these variables. Research methods relat- ed to biomechanical exposures should include direct obser- vation of child-care practices in the home addressing the fre- quency, duration, and postures used to perform child-care tasks. The nature of the psychological strain including par- ents perceptions of control, personal efcacy, and means of establishing personal support while caring for children can be further explored using interviews and standardized tests to clarify the survey information. The nature of parents workplace exposures should also be documented. Finally, the sociological and biomechanical implications for fathers as the primary caregivers for children should not be ignored. Implications for Practice This study supports the need for both wellness and inter- vention programs that focus on preventing and managing MSDs related to caring for children and providing support for the role of a parent. Occupational therapists can assist parents through educational programs regarding body mechanics, child-care equipment, environmental modica- tions, and managing parents daily routines. Body-mechanics education involves teaching parents the biomechanical principles that promote proper alignment The American Journal of Occupational Therapy 293 of the body and training them to identify tasks that may increase their risk of developing an MSD. Occupational therapists and parents together can problem solve strategies that minimize biomechanical stresses while parents perform such tasks as transporting, bathing, and feeding children. For example, when transporting an infant in a car seat, instead of carrying the car seat with one arm extended to the side of the body, a parent may hold the car seat sideways centered in front of the body using the arms to support the head and foot of the car seat. This alternative strategy pro- motes better alignment of the body and more equal distri- bution of forces across the body (Pirie & Herman, 1995; Sanders, 2004). Occupational therapists can assist parents in choosing child-care equipment that has design features that encour- age proper body alignment. For example, long handles placed on push toys or a bathtub kneel chair both allow the parent to interact with the child while minimizing biome- chanical stresses to the low back. Occupational therapists can also assist parents in arranging their home environment so as to optimize good body mechanics during tasks (e.g., adjusting the heights of changing surfaces to correspond to the parents height). These educational components have been incorporated into a group educational format for new mothers called ErgoMOMics (Maynard & Blain, 2002). In this program members analyze as a group the components of child-care tasks and demonstrate the best options for minimizing biomechanical risks. This program also addresses the restorative needs of new mothers. Finally, occupational therapists can help parents orga- nize their daily and weekly schedules in order to develop a sense of control over their lives and nd ways of engaging in activities that are personally meaningful to them. They can help parents examine the emotional stressors and psy- chological demands in their lives with the hope of nding ways to bolster their social supports and sense of efcacy in the parenting role. Educational programs for parents can be integrated into preventive and rehabilitative models of care. They can be offered as part of wellness programs for young children attending well-child clinics; they can be provided by occu- pational therapists treating children with special needs; or offered through postpartum support groups such as ErgoMOMics. Intervention programs can integrate this information into existing activities of daily living retraining programs for individuals learning to manage MSDs. 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