Prioritizing Early Childhood Educators Health: Insights for Worksite Health Promotion Efforts

Abstract

Background:

Early childhood education (ECE) educators play an instrumental role in children’s health and development but unfortunately have poor health themselves. This project examined the physical and psychological health of New York licensed ECE educators.

Methods:

A sequential, explanatory mixed methods design (quan→QUAL) consisted of a 110-item survey and semi-structured interviews to examine physical (diet, physical activity [PA], sleep, and body mass index [BMI]) and psychological health (stress and burnout). Quantitatively, multiple linear regressions tested associations between physical and psychological health, controlling for age and income, using R (v4.3.2, 2023); α < 0.05. Qualitatively, content analysis with pattern recognition for pragmatic synthesis was performed.

Results:

Survey respondents (n = 1423) and interview participants (n = 36) worked in a variety of ECE settings; 74% had overweight/obesity and 24% deemed themselves “unhealthy.” Many had poor health behaviors—low diet quality (74%), limited regular PA (28%), poor sleep quality (34%), and moderate/high stress levels (74%). Most desired changes to health behaviors but were challenged due to work environments and job demands. Work-based factors impacted both their physical and mental health and influenced their personal life. Burnout and stress were high, and feelings of underappreciation were prevalent. Higher burnout (emotional exhaustion) was significantly associated with higher BMI (β = 0.18, p < 0.01) and stress (β = 1.09, p < 0.01) and lower PA (β = 2.62, p < 0.01) and sleep (β = 0.94, p < 0.01).

Conclusion:

ECE educators are experiencing high stress/burnout, have poor health behaviors, and have high prevalence of obesity. Workplace health promotion efforts are needed to improve educators’ health and potentially that of the children in their care.

Introduction

Approximately 60% of children under 5 years of age are cared for in an early childhood education (ECE) setting for an average of 30 hours a week,¹ making the ECE setting a critical environment for the growth and development of young children. ECE educators’ relationships with children can have implications for children’s learning and socio-emotional development and serve as a catalyst for creating environments that promote health, including obesity-related behaviors (e.g., diet, physical activity [PA], sedentary behaviors).^2,3 To maximize children’s learning and growth in ECE, it’s imperative that educators’ health and well-being are supported.

Unfortunately, the ECE workforce is in poor health. They are experiencing increased levels of stress and burnout and are considered at high risk for chronic disease.^4,5 Educators report a high prevalence of overweight and obesity (73%–80%) with the majority not meeting dietary, PA, or sleep recommendations.^6,7 Economically, educators tend to earn low wages and have limited benefits, more than half are enrolled in at least one public support program (e.g., Medicaid or Supplemental Nutrition Assistance Program), and many report being food insecure.⁸ Collectively, these conditions make ECE educators vulnerable to poor health, which, in turn, may impact child health behaviors.

ECE educators are foundational to children’s health through support of their healthy development. Because children spend a large portion of their weekday waking hours under the care of ECE educators, significant behavior transmission occurs in the childcare setting.^9,10 ECE educators’ diet behaviors shape those of children similarly to parents, and some cite this influence as a key motivator for improving their own diet.^7,11–14 This modeling has also been identified in PA behaviors.^15,16 Thus, it is essential to ensure that ECE educators are healthy so that their positive influence on the development of young children’s health behaviors is maximized.

Despite the commitment for and positive impact that ECE educators have on children, they, themselves, are often overlooked. The workplace is an important influence on workers’ health and well-being. Job-related factors such as wages, hours of work, workload and stress levels, interactions with coworkers, access to paid or unpaid sick leave, and health-enhancing work environments impact the well-being of workers, their families, and their communities.¹⁷ Risk factors in the workplace can contribute to health problems previously considered unrelated to work—sleep disorders, cardiovascular disease, depression, and obesity.¹⁸ Kwon et al.’s research with the ECE workforce has identified meaningful relationships between working conditions and the psychological and physical well-being of ECE educators, suggesting a complex, multidimensional association between the work environment and ECE educator health.¹⁹ The work environment can be leveraged to reinforce a culture of health by providing a supportive built environment, adopting policies to promote workers’ health, and enhancing programs and communications about healthy lifestyle goals.²⁰ There are few intervention studies addressing the health of the ECE workforce,²¹ but no multilevel, obesity interventions in the ECE setting have been reported.³

The StayWell ECE (Staff and Youth Wellness for Early Childhood Educators) project examines the physical and psychological health and professional well-being of New York licensed ECE educators. This study utilized a sequential explanatory mixed methods approach (quan→QUAL) to gain a comprehensive understanding of NY ECE educators’ health and well-being to inform future intervention efforts. This article presents findings on educators’ health behaviors (diet, PA, stress management), health goals, and the relationship between their job and health.

Methods

Study Recruitment

An electronic survey (quan) and semi-structured interviews (QUAL) were administered to NY ECE educators in 2023. Participants were recruited via state listservs for NY licensed childcare providers and the NY Head Start collaboration office and had no preexisting relationships with researchers. Implied consent was collected at the start of the survey and concluded with an interest form to participate in a follow-up interview. This study was approved by the Institutional Review Board at Cornell University.

From the pool of interested survey respondents (n = 390, 27%), 213 were randomly selected to be contacted for interviews based on considerations for the type of ECE center (Head Start, large center, small center, family-based home center), New York State region (rural upstate, urban upstate, New York City), and self-reported perceived health (healthy, unhealthy). This led to 40 scheduled interviews (1 cancellation, 2 no shows, 1 ineligible), resulting in 36 completed interviews. Survey respondents were entered into a drawing for $100 (7 drawings), and interview participants were compensated $40 for their time.

StayWell ECE Survey (Quan)

The survey contained 110 items assessing demographic and socioeconomic characteristics, as well as physical, mental, and professional well-being. Questions used Likert scales (3- to 9-point) and dichotomous, multiple-choice, and open-ended responses. The survey was tested through cognitive interviews with ECE educators (n = 2), and minor changes to wording were made prior to distribution.²² REDCap (Research Electronic Data Capture), a Health Insurance Portability and Accountability Act–compliant electronic data capture tool hosted at Weill Cornell Medicine, was used for data collection and management.^23,24

Items inquired about the following health behaviors: frequency of consuming less than two servings of fruits, whole grains, or vegetables per day (Rapid Eating Assessment for Participants; 3 items, α = 0.77)²⁵; exercise in the past month (Behavioral Risk Factor Surveillance System; 1 item)²⁶; average hours slept per night and perceived sleep quality (Pittsburgh Sleep Quality Index; 2 items)²⁷; and perceived stress (Perceived Stress Scale; 10 items, α = 0.71).²⁸ Self-reported height and weight values were collected, which have previously been found to be accurately representative of measured height and weight,²⁹ and body mass index (BMI) was calculated.³⁰ Self-perceived health was assessed through one item; “In general, would you say your health is … (excellent, very good, good, fair, poor).” Burnout was assessed using the Maslach Burnout Inventory, which calculated three dimensions of burnout: low personal accomplishment (8 items, α = 0.75), depersonalization (5 items, α = 0.74), and emotional exhaustion (9 items, α = 0.92).³¹ Key demographic characteristics (age, race/ethnicity, education, annual household income; 5 items), food security (U.S. Department of Agriculture’s [USDA] Short Form Food Security Survey Module; 6 items; α = 0.76),³² and likelihood to leave one’s job, center, or the ECE career within the next year (Job Satisfaction and Retention Survey; 3 items, α = 0.89) were also examined.³³ At the conclusion of the survey, participants were asked an optional, open-ended question, “Is there anything you would like to share with us about educator health and wellness?”

Prior to analysis, dependent variables were tested for normal distribution (skewness and kurtosis). Descriptive statistics (frequencies, means, medians, and standard deviation scores) were calculated. Multiple linear regressions tested associations between physical, mental, and professional well-being, controlling for income, age, and ECE setting. Post hoc Bonferroni tests were conducted to correct for multiple comparisons. Analyses were conducted using R studio, version 4.1.3 (R Core Team, Vienna, Austria, 2023); significance was set at p < 0.05. For the open-ended text response, a general inductive approach was used in which responses were analyzed by five researchers who independently read responses, discussed until consensus was reached, and generated a summary of participant responses as key themes.^34,35 To validate this summary, the data were entered into ChatGPT using the prompt “Please tell me the top 10 trends in this feedback.”³⁶

Interviews (QUAL)

A semi-structured interview guide was developed by the research team using the social ecological framework and consisted of 20 interview questions with multiple probes to inquire about the providers’ health behaviors in both work and home environments, focusing on their daily routines, health behaviors and goals, and desired intervention strategies to improve health.³⁷ Only data related to health behaviors and goals are presented here. To establish content validity, experts (n = 3) in nutrition, PA, and qualitative research methodology reviewed the guide for their respective content areas as well as clarity and flow of questions. Training of research staff applied a five-phase interviewing protocol on ethics, qualitative methods, and pilot interviews and was conducted by a senior researcher (L.L.B.).³⁸ All interviews were audio-recorded with participants’ permission. Pilot interviews were conducted with two participants to establish face validity. Only a small number of minor word changes were needed; thus, these interviews were kept in the sample for analysis.

The interviews were attended by the participant and two researchers—a moderator (B.A.C.) and a notetaker (L.D., C.G., E.F.)—remotely via Zoom (Zoom Video Communications, San Jose, CA, 2022). Interviews ranged between 20 and 90 minutes, and all were audio-recorded with participants’ permission. After each interview, researchers debriefed to summarize responses for each research question, document insights, and process check (e.g., flow, what did not work well). Key findings extracted from the debrief were sent to the participants as part of member checking to further validate their responses.³⁹ Transcripts were auto-generated by Zoom, and each was verified verbatim by a research team member who listened to the audio recording while reading the corresponding transcript to correct discordances.

Analysis consisted of data reduction using steps from the rigorous and accelerated data reduction (RADaR) technique and content analysis with pattern recognition for pragmatic synthesis.⁴⁰ Pattern recognition allows for a descriptive synthesis without requiring thematic categorization.³⁴ The RADAR analysis procedure included (1) segmenting data in transcripts by interview guide question, (2) extracting data from each transcript into a Microsoft Excel database, (3) transferring tabulated data into narrative format (Microsoft Word) in preparation for coding, (4) coding data to identify patterns while retaining context, and (5) preparing narrative summaries for examination.⁴⁰ Coding was conducted by a team of analysts (one senior analyst [L.D.], two trained analysts [C.G., E.F.]) by interview guide question. To build consensus on process and content, the analysts debriefed after coding each question. All questions were double-coded, reviewed by a senior analyst, and used to compose a narrative summary. Narrative summaries were composed by an analyst and reviewed by the coding team and lead investigators. The study followed the Consolidated Criteria for Reporting Qualitative Research to ensure comprehensive reporting of the interview data.⁴¹

Results

Participant Characteristics

Survey respondents (n = 1423) were primarily women (95%), identified as White (70%), and half had a bachelor’s degree or higher (Table 1). Approximately one-third had low or very low food insecurity, and 33% were considered low-income.⁴² Participants worked primarily in four types of ECE settings: family childcare homes (32.2%), public school or large centers (18.9%), after school or small centers (18.6%), and Head Start and Early Head Start (22.3%). Overall, interview participants (n = 36) matched the larger sample with the exception that more interview participants had higher educational attainment (i.e., 80% had a bachelor’s degree or higher compared with 50%).

Table 1.

Demographics of StayWell ECE Survey Respondents (n = 1423) and Interview Participants (n = 36)

	Survey respondents		Interview participants
Demographics	n	Mean/percent	n	Mean/percent
Age, y, mean ± SD	1423	43.6 ± 12.6 Median: 44.0 (18.0, 81.0)	36	33.1 ± 8.0 Median: 32.0 (18.0, 63.0)
Gender
Male	57	4.0%	1	3.1%
Female	1350	95.1%	35	97.2%
Race^a
White	991	69.6%	27	75.0%
Black/African American	228	16.0%	7	19.4%
American Indian/Alaska Native^*	7	0.5%	1	2.8%
Asian	33	2.3%	1	2.8%
Native Hawaiian/Pacific Islander	8	0.6%	0	0.0%
Not listed	152	10.7%	0	0.0%
Food security
High	916	64.4%	24	66.7%
Low	349	24.5%	8	22.2%
Very low	158	11.1%	4	11.1%
Education
High school diploma or lower^*	212	14.9%	1	2.8%
Some college/occupational training^*	267	18.8%	2	5.6%
Associate’s degree	235	16.5%	4	11.1%
Bachelor’s degree or higher^*	705	49.5%	29	80.6%
Income
Low income (<185% FPL)^b	463	32.5%	12	33.3%
Moderate to higher income (>185% FPL)^b	788	55.4%	21	58.3%
Prefer not to answer	168	11.8%	3	8.3%

Race categories reflect all that apply response options.

Low income is categorized based on the 2021 standardized federal poverty guidelines at <185% for a household of four.⁴²

Listed percentages between survey respondents and interview participants are significantly different at p < 0.05.

ECE, early childhood education; SD, standard deviation; FPL, federal poverty level.

Survey (Quan)

Table 2 provides health characteristics for survey respondents and interview participants. Overall, 71% were considered overweight or obese, and 24% self-reported their health status as “unhealthy.” Related to health behaviors, 71% consumed <2 daily servings of whole grains, vegetables, and/or fruits (averaged across three items), while 18% consumed >16 oz of sugar-sweetened beverages daily, 29% did not exercise in the past month, 31% slept <7 hours per night and 34% rated their sleep quality as poor, and 74% experienced moderate/high levels of stress. Burnout was high, with more than half of the participants experiencing medium to high levels of emotional exhaustion (i.e., fatigue and inability to face demands of one’s job), 38% reporting medium/high levels of depersonalization (i.e., distorted self-perception and disengagement from one’s job), and 79% reporting low/medium levels of personal accomplishment (i.e., feeling unable to contribute meaningfully to their job). Furthermore, one-third intended to leave their current ECE center, while 25% intended to leave the profession. Regarding willingness to change behaviors, 85% were willing to make a positive change in their diet, PA, sleep, and/or stress management behaviors.

Table 2.

Health Characteristics of StayWell ECE Survey Respondents (n = 1423) and Interview Participants (n = 36)

	Survey respondents		Interview participants
Health behaviors and status	n	%	n	%
Diet
Eat <2 daily servings of fruit	983	69.1	25	69.4
Eat <2 daily servings of vegetables	1026	72.1	26	72.2
Eat <2 daily servings of whole grains	1007	70.8	27	75.0
Exercise
Did not exercise last month	407	28.7	11	30.6
Body mass index
Underweight	25	1.8	1	2.8
Normal	335	23.5	7	19.4
Overweight	405	28.5	8	22.2
Obese	608	42.7	20	55.5
Self-perceived health
Excellent	101	7.1	0	0
Very good	349	24.5	7	19.4
Good	626	44.0	11	30.6
Fair	304	21.3	16	44.4
Poor	43	3.0	2	5.6
Perceived stress
Low	373	26.2	7	19.4
Moderate	929	65.3	24	66.7
High	120	8.4	5	13.9
Burnout
High emotional exhaustion	775	54.6	26	72.2
High depersonalization	544	38.2	19	52.8
Low personal accomplishment	1120	78.7	30	83.3

Regarding associations between burnout and health, lower personal accomplishment (high burnout) was positively associated with higher BMI (β = 0.08, p < 0.01) and stress (β = 0.08, p < 0.01) and lower PA (β = 1.38, p < 0.01) and diet quality (β = 0.74, p < 0.01). Higher depersonalization and emotional exhaustion (high burnout) were also both positively associated with higher BMI (depersonalization: β = 0.06, p < 0.01; emotional exhaustion: β = 0.18, p < 0.01) and stress (depersonalization: β = 0.32, p < 0.001; emotional exhaustion: β = 1.09, p < 0.01) and lower PA (depersonalization: β = 0.83, p < 0.01; EE: β = 2.62, p < 0.01). Finally, higher depersonalization was associated with lower diet quality (β = 0.19, p < 0.01), and higher emotional exhaustion was associated with less sleep (β = 0.94, p < 0.01).

Lastly, 23% (n = 327) of respondents completed the open-ended question, and 10 themes were identified. Verification with ChatGPT produced no differences in overarching themes from the research team’s summary; nuances in the description of the themes were identified and merged together for the final summary presented in Table 3. These themes highlight the need for better compensation, improved working conditions, mental health support, and overall appreciation for the critical role educators play in child growth and development. Findings from the open-ended survey text informed the development of the interview guide.

Table 3.

Themes from StayWell ECE Survey Question: “Is There Anything You Would Like to Share with Us About Educator Health and Wellness?” (n = 327)

Themes	Descriptions
Insufficient pay and financial struggles	Low pay in ECE jobs that didn’t match the job’s demanding nature or cost of living made participants struggle to make ends meet. Many were forced to leave the profession or reconsider career paths.
Lack of benefits	Participants called for more health care benefits/insurance, flexibility for work–life balance, paid leave, and sick days. Many participants put off medical appointments and personal errands due to financial or time constraints.
Burnout and stress	Staff commonly felt stressed out, overwhelmed, and exhausted due to long hours, heavy workloads, the behavioral needs of children, and the lack of staffing support.
Mental health concerns	While the job could be rewarding, it was not enough to keep participants going, as many struggled with anxiety, depression, and other mental health challenges. The mental health of ECE providers needs to be a priority of employers and the larger system.
Need for health promotion support	Participants wanted wellness initiatives and health promotion support, including gym memberships, mental health days, yoga, health coaches, and health-related programs tailored to staff needs.
Underappreciation	Participants felt underappreciated and undervalued by parents and administrators; they wanted more acknowledgment and respect for their dedication and work.
Staffing shortages	Many centers were understaffed due to high turnover rates and the lack of quality staffing. The resulting heavy workloads further contributed to staff burnout and job dissatisfaction.
Challenging working conditions and environments	The job brought physical toll and emotional exhaustion, but participants perceived little support from administrators, parents, and the state. Participants noted a desire for more transparent, realistic expectations, supportive work environments, and funding.
Desire for professional growth and resources	More training and resources were needed to handle complicated scenarios in participants’ jobs, particularly in supporting children with special needs and managing behavioral challenges.
Impact on personal life	Participants’ job-related stress had negatively impacted their well-being, relationships, and quality of life, so there is a need to prioritize participants’ health and self-care.

Interviews (QUAL)

Due to the diversity of the sample—ECE center type, geographic location, and perceived health—we conducted 36 interviews to ensure representation and achieve data saturation.⁴³ Of the 36 participants, 16 were teaching staff (lead teachers n = 14, assistant teachers n = 2), and 20 were administrative staff (directors n = 15 and other staff n = 5). Interviews examined three health behavior topics—diet, PA, and stress and stress management—as well as health goals and the relationship between health and job performance (Table 4). Findings are presented below by each behavior with exemplar quotes provided in Table 5.

Table 4.

Interview Questions Inquiring About ECE Educators’ Health Behaviors

Introduction/study overview	In this interview we will explore things that make healthy behaviors, such as diet, physical activity, stress management, and sleep, easy or hard at both work and home. We’d also like to discuss things that could be helpful to ECE teachers related to healthy behaviors, such as programs, policies, and so on.(Interviewers introduced themselves, role in study, and occupation/student status)
Diet	1. To start, can you tell me about eating meals at school? - What does this look like? - How does eating at preschool support (or not) your health and nutrition goals? - If you could have it your way, how would your meals look like at your center/home? 2. Tell us how you eat at home. - What does this look like? Who do you eat with? Do you prepare meals? - How does eating at home support (or not support) your health and nutrition goals? - If you could have it your way, what would your eating habits look like at home?
Physical activity	3. Could you tell me about your activity level at school? What does this look like? - How does activity at preschool support (or not support) your health and physical activity goals? - If you could have it your way, how would your activity look like at preschool? 4. Could you tell me about your physical activity at home? What was the last physical activity you did? - How does physical activity in your personal time support (or not support) your health and activity goals? - If you could have it your way, what would your physical activity look like in your personal time?
Stress management	5. When you are stressed, what do you do to help manage it? - How does this differ between work and home? - Do you feel like you have enough tools to manage your stress? - How does stress affect your sleep? In general, how would you describe your sleep habits?
Health goals	6. What health goals do you have right now?
Job and health	7. How, if at all, do you feel your job impacts your health? - Stress, satisfaction/quality of life, burnout 8. How, if at all, does your health impact your job?

Table 5.

Interview Topics and Exemplar Quotes on ECE Teachers’ and Administrators’ Health and Health Behaviors

Diet at work
Priority on children	“Sometimes it could be sitting down and enjoying meals with them. Sometimes you’re up a bunch of times because they want more of something.” (Teacher, 163)
Need for more help	“I think if there were extra hands it wouldn’t have to be so rushed that there would be more hands to help, and it could be maybe more relaxed.” (Teacher, 621)
Fresh produce is costly	“It’s hard to provide those for yourself … It’s very costly to buy the fruits and the vegetables and the low-fat stuff.” (Teacher, 375)
Diet at home
Desire to eat earlier	“I would love to, for my health and everything else, to be eating sooner. I just can’t seem to get done what I need to get done until 7:30–8 o’clock at night. So, by the time I start making dinner it’s always late.” (Teacher, 1587)
Too tired to cook	“When I get out of here, I’m tired. The last thing I want to do is go home and go slave over a kitchen.” (Admin, 24)
Physical activity at work
Job is inherently active	“At school I am usually running around … While the kids are up. I’d say I’m pretty active, and then, in the gym, I’ll run around with them and chase them and do all that stuff.” (Teacher, 81) “When I was a teacher, I definitely had more physical activity within the classroom. I was always picking up the infants and changing their diapers, and running around with them, and going and walks on campus and all that. And I don’t do that as much anymore.” (Admin, 909)
Job-related wear and tear	“So, I have knee issues. I have SI joint issues. I back issues. Some of it is just wear and tear on my body because of being a preschool teacher and sitting on the floor…” (Teacher, 1661)
No breaks to get outside	“I would probably make an effort to leave the building and walk, to go get a cup of coffee or something like that, but just to leave and take like a break and take a walk at some point during my break, which I don’t get.” (Admin, 1736)
Need motivation or peer support	“That I could do more exercises and have a partner, or like a coach or somebody to motivate me. You know I need a lot of motivation when it comes to that. So probably more like a team effort or something. Maybe if we all did it, you know, together at work, or a few of us, anyway. Hmm! Maybe support that way.” (Teacher, 223)
Physical activity at home
Exercising is energizing	“I feel a lot better especially going into work. I feel more energized, you know, going into work and stuff like that. So, I feel like it is helping me. When I wasn’t doing it … I was more sluggish…” (Teacher, 461)
Exhaustion	“By the time you get home, and you get all those routine things done you’re just exhausted. You’re mentally, physically, and socially, emotionally exhausted and you just want to unwind, you don’t wanna go run a mile after a day’s work.” (Teacher, 375)
Stress
Job stressors	“Just the being short staff, meeting all the demands of the paperwork, dealing with all the struggles of you know the kids, and like the sadness and the hard times that you have to go through with them. And not always necessarily having support from higher-ups when you have difficulties can be very, very challenging.” (Teacher, 81)
Bringing stress home	“I bottle things up at work and then unleash it at home, and also home isn’t perfect. But home is just also bottled.. Cap is looser at home. It’s like soda. It’s a whole lot tighter at work at home. But it’s loser at home. So, I can just like explode at any time.” (Admin, 581)
Negative impacts on sleep	“It (stress) affects it (sleep) a lot, because our mind is racing when you can’t go to sleep, sometimes, you know, you got a million and one things on your mind, and that really stops you from getting the proper rest.” (Teacher, 550)
Stress management
Specialized support	“We have a behavioral management coordinator who comes in and helps us with the really challenging behaviors. But she’s also like a really, really good resource for me … She’ll suggest books that I can read, or just different strategies … And it just helps me too.” (Teacher, 81)
Doing it for the kids	“So, knowing that we’re providing a safe nurturing, environment. That to me, kind of calms me down a little bit because I’m like, okay, all this stress and all the not sleeping is worth it if the kids are benefiting, if the kids are enjoying themselves. And you know, learning and evolving…” (Admin, 1303)
Lack of time to manage stress	“I think we have enough (tools) to destress it’s just the time we don’t have enough time to actually do it.” (Teacher, 1911)
Health goals
Weight management	“I want to lose a lot more weight and feel better physically and mentally, about myself, because physically, I just I have like no energy.” (Admin, 1778) “And I know that losing those extra 15 pounds will make me feel better and make my productivity a lot better.” (Teacher, 550)
Physical activity	“Just to continue to stay active … Because I know I’m just getting older and like I said, I don’t want to slow down. I’m not ready yet.” (Teacher, 163)
Relationship between job and health
Physical environment	“And I have to sit in these little chairs that I’m sitting in talking to you right now, and I don’t like the little chairs. I don’t like getting on the floor cause it hurts my back. That’s not healthy for me. I don’t think that’s helping my health in any kind of way.” (Teacher, 223)
Impact on peers and children	“When I’m not feeling good, I’m mean. I’m there physically but mentally I’m not there, and then makes it hard to build connections with other staff members, to build relationships with the kids. I’ll get kind of snippy and have an attitude, and I’ll feel bad about that. And then I start feeling guilty.” (Teacher, 81) “So, my mood, my energy impacts the children’s function, which then kind of reverse impacts how I’m feeling about the day.” (Teacher, 608)
Job is rewarding and keeps participants going	“It’s good … when I told you like those joyous moments that you have with the kids. And every day being able to see and know that you’re making a difference in the life of a little one is always good.” (Teacher, 1587) “Even though there might be health issue, it doesn’t impact it because I love what I do… When I come in here, even though I might have a headache … I don’t let that stop me from doing what I’m doing. I do it.” (Admin, 24)

Diet

Participants aspired to have healthier dietary patterns and options but were often challenged by limited time and flexibility, school meals, lack of energy, and budget constraints. At work, participants who ate with children were busy serving children during lunch, while participants who ate lunch by themselves could not take full breaks due to understaffing and feeling consistently “pulled and pulled.” With limited time, providers could only “eat something fast, some crackers, a cheese stick, a banana.” With the challenge of limited time for meals and lack of flexibility in their eating schedules, several noted the desire to eat more frequently at work to avoid feeling “starving by the time [they] [got] home.”

Participants who ate school meals valued healthier options with more fresh produce and fewer processed foods, noting “[they] definitely feel healthier and [help] me maintain my weight.” However, school meals could have small portion sizes, high sugar content, and excessive use of canned fruit and vegetables. For participants who brought their own meals, barriers to healthy eating included the lack of time and energy to prepare one’s own meal and the high cost of fresh fruits and vegetables. These sentiments were also echoed when describing challenges to eating healthy at home.

At home, participants encountered similar challenges in healthy eating due to restraints in time, energy, and budget. Some participants ate breakfast on the run; some skipped it. While most participants had dinner at home as it felt “more relaxed” and “more enjoyable” with family, several participants wished for earlier meals and more time to prepare healthier options but were limited by work schedules. Some tried to cook healthy, balanced meals, while others opted for quick meals or ordered out due to fatigue and low energy after work. Lastly, participants expressed a desire to cut back on large dinners or frequent snacking due to feeling “starved” after work.

Physical activity

While PA levels differed based on participants’ roles, most participants hoped to increase PA levels but identified the lack of time, resources, and motivation as barriers. Many appreciated the inherent physical demand of their work (i.e., constant standing and moving in child-centered activities) since it kept them active and promoted weight management. Yet, several pointed out that the movements were “low” in intensity and could bring job-related “wear and tear” to the body. Conversely, administrators were mainly sedentary. Most sat at their desks with minimal PA, primarily limited to walking stairs for meetings or classroom check-ins. Some considered this PA level supportive of their health goals; others noted the lack of intensity. While participants wanted to spend more time outside, they found it difficult to take breaks due to the workload, citing a need for additional staff to help share responsibilities. Some also felt they lacked access to exercise facilities and physical resources. Conversely, peer support and encouragement were indicated as facilitators to boost participants’ participation in PA.

At home, participants had more diverse PA but still were limited by energy, time, weather, and physical condition. Participants engaged in various PA—walking, doing chores, taking care of their children, and home maintenance activities such as gardening. On the weekends, some chose to go to the gym or play sports, while others spent more time on social and leisure activities or resting. On the weekdays, however, many mentioned that they were too “mentally, physically, socially, and emotionally exhausted” for PA by the end of the day. Most participants wished to increase PA outside of work but faced barriers such as family responsibilities of child/family care, fatigue from “working 12 hours a day,” and unfavorable weather conditions in winter. Some cited physical limitations posed by one’s age and weight as hurdles to PA.

Stress and stress management

Most participants’ stress levels affected their lives. Participants experienced different stressors depending on their roles and used different stress relief strategies at work and home. At work, common stress relief strategies included deep breathing, taking quiet moments for themselves, stepping away from classrooms, and talking to support systems. Teachers often felt stress from children’s challenging behaviors, which could be effectively alleviated by seeking support from co-workers (e.g., behavioral management coordinator). Administrators faced stress from heavy workloads, understaffing, and high staff turnover rates, and they managed stress by focusing on getting tasks done or going into classrooms to play with children. A few shared that reminding themselves that their work had a bigger purpose and reading thank-you notes had calming effects, while others shared that they experienced stress eating.

At-home settings offered more flexibility in strategies due to fewer time constraints, greater access to resources, and the absence of professional expectations. Participants engaged in diverse stress relief activities at home, including spending time with their family and friends, playing with their pets, reading, exercising, and driving. A key difference between work and home was that they could take breaks or “walk away” from a situation when stressed. Some mentioned that professional expectations made them “bottle things up at work” and release stress at home due to limited opportunities for stress relief at work. Many participants described their sleep as poor and attributed this to stress, particularly when it was challenging to separate work from home. A common thread was that busy or worry-filled days caused participants’ “mind to race” and made it difficult to fall or stay asleep.

When asked about tools for stress management, there were mixed results as some felt they were well-equipped, and others found them lacking. Some centers offered massage chairs, treadmills, and human resources like therapists and supportive leadership, which were appreciated. Conversely, some teachers needed more support for managing children’s challenging behaviors and hoped for access to health professionals (e.g., therapists, personal trainers, dietitians) without extra costs. Participants who had access to resources wished they were more proactive or had the time to use the available tools. Others wanted resources for mindfulness, PA, healthy eating, and changes to policies that would increase pay and vacation days. Time was universally stated as a barrier, with many commenting that they were too busy to find downtime to manage stress.

Health goals

Participants shared similar health goals, with the majority identifying weight loss as their top health goal, believing it could help them “feel better,” improve productivity, and “be a healthier version of [themselves].” Others aimed to “keep blood sugar under control,” “lower blood pressure,” increase PA levels or stay active, and make healthier dietary choices such as “quitting soda.” Additional goals included establishing a “normal sleep pattern,” attending doctor appointments, and giving up unhealthy habits such as smoking.

Job impact on health

Most participants stated that their job was “the top thing” affecting their physical and mental health both positively and negatively. Physically, the job kept many active and thus positively impacted their health. Conversely, some noted that the job’s physical environment or high demands wore them down, leaving them with bodily wear and tear (e.g., joint pain, carpal tunnel) and no energy or time for recreational PA. Dietarily, there were mixed impressions on the job’s influence, with some feeling that their jobs improved diets and others considered school lunches unhealthy. Some reported that job-related stress had led to unhealthy eating patterns and weight gain, and many noted that the job’s time commitment made preparing nutritious meals difficult.

Participants experienced mixed effects on mental health. A positive work environment and “the rewarding parts of the job” (e.g., joyous moments with children, noticing that they are making a positive difference in the lives of children, reflecting on how much they love what they do) boosted mental health, but job-related stressors, such as children’s illness and supervisor expectations, were perceived to worsen their mental and physical health. A few noted needing more medication to deal with stress and anxiety from work, and some found it challenging to compartmentalize and “leave work at work,” which negatively impacted their mental health.

Health impact on job

Most providers stressed the need for good physical and mental health for optimal job performance and noted the impact that it can have on children. Health issues (e.g., joint pain, aging, and job-related wear and tear) made it difficult to maintain energy and enthusiasm to perform their best and led to missed work or shutting the center/home down. Feeling tired or stressed impacted providers’ ability to build relationships with other staff and the children because they “get kind of snippy and have an attitude.” Some indicated they consciously had to put negative moods aside to be role models since children noticed and were influenced by their behavior. Furthermore, some felt that being in good health led to more physically demanding tasks being put on their plate. Conversely, others stated that health had no impact on their work because they “love what [they] do.” Lastly, good physical health and exercise were perceived to improve educators’ mental health and positivity. Many believed reduced stress and better sleep would make them become more effective and productive, lash out less, and have more energy.

Discussion

Findings from this study illustrate that NY ECE educators have a high prevalence of obesity, have poor health behaviors, and are challenged to improve health behaviors due to work environments and job demands. These work-based factors impact both their physical and mental health and influence their home and personal life. Burnout and stress among educators were high, and a feeling of underappreciation was prevalent. A third of the sample had limited resources and/or were food insecure. Insufficient pay, financial struggles, and lack of benefits were a significant concern for educators. These fiscal concerns, in combination with their poor physical and mental health, are key contributors to many expressing their intention to leave the profession.

StayWell ECE quantitative findings support those of other studies in that the majority of ECE providers have low dietary quality and limited PA, and many are not meeting recommended sleep requirements.^6,44 Educators in this study revealed that, while they aspired to eat more healthfully, they were often challenged by limited time and flexibility, school meals, lack of energy, and budget constraints (e.g., affordability of fresh produce). Eating with the children, while a best practice for child nutrition,⁴⁵ posed challenges for educators to eat as children’s needs were prioritized and additional staff was not available. Many left work hungry, which led to large dinners or frequent snacking. Sleep quality was stated to be impacted by stress, and many believed that reduced stress and better sleep would improve their energy levels and, hence, job performance. PA was often confined to occupational PA, which was acknowledged as low intensity and contributed to physical pains. This finding was in concordance with Turvill et al., who found that a majority of ECE staff reported pain with work-related tasks and that longer ECE careers were associated with a higher a number of pain locations. Occupational PA is warrents further examinination as an area to improve resilience to work-related pain and to enhance the overall safety of PA at work.⁴⁶

Teaching is a high-demand profession, and ECE educator stress can significantly affect physical health, especially for those with limited resources.^6–8,47 One-quarter of our survey respondents reported their health status as “unhealthy.” Employees with poor or fair physical health status report lower mental health, higher perceived stress levels, and infrequent stress management activities.⁵ Insights from our qualitative data reveal that ECE educators commonly felt stressed out, overwhelmed, and exhausted due to long hours, heavy workloads, the behavioral needs of children, and being understaffed. Interview respondents felt that current stress management techniques were underutilized, insufficient, or absent from the ECE environment. Employment-related stress often leads to burnout, which manifests as emotional exhaustion, depersonalization, and low personal accomplishment. Our study found significant relationships between burnout and health, with higher burnout positively associated with obesity, stress, diet quality, and PA. High burnout and stress have extensive negative implications, including decreased mental well-being, which can exacerbate physical health and is associated with obesity in women.^48,49 Kwon et al. note that although many ECE educators report an initial sense of devotion for their job, work-related barriers and stress lead them to consider leaving the profession.⁵⁰

ECE educators’ poor health is threatening the quality of care for young children. Higher levels of educator stress have been shown to be associated with lower child engagement in the classroom and children’s social-emotional functioning.^2,51 Improvements in educators’ health have been shown to impact health behaviors in children. Esquivel et al. found that teachers who reported improvements in their own PA levels, weight control, dietary habits, skills, and knowledge about nutrition saw improvements in the Head Start PA classroom environment.⁵² Five out of six survey respondents in the current study indicated a desire to make a positive change to their health behaviors, and interviews revealed that the majority identified weight loss as their primary health goal to help them feel better, improve job performance, or be their best. While their desire to change their health behaviors was strong, the job demands, work environment, and feelings of exhaustion were significant barriers to change.

Educators in this study expressed a strong desire for wellness initiatives and health promotion support. This included both external support via counselors or fitness experts and internal support through peer and administrative support. There is evidence for the effectiveness of workplace health promotion efforts in improving dietary and PA behaviors and reductions in body weight.⁵³ Positive psychology strategies that focus on a positive work culture play a protective role against stressors, reduce burnout, and positively influence health outcomes (e.g., lower BMI and cholesterol levels).^54,55 Social support in the workplace impacts health behaviors; specifically, higher worksite social support was shown to be associated with higher PA and fruit and vegetable intake.⁵⁶ Supporting ECE workplace health promotion, focusing on both physical and mental health, is warranted and needs to be culturally relevant to the ECE setting and educator-driven. Work by Ward et al. note the potential benefit of worksite health promotion in ECE and point to the need for multilevel interventions addressing living wages, health care benefits, and working conditions, in addition to health behaviors.^21,57

This study is not without its limitations. Respondents are from one U.S. state, and while efforts were made to garner representation from a diverse set of educators representing various types of ECE settings and distinct geographic areas (New York City, upstate rural and upstate NY), these findings are limited in their generalizability. Furthermore, in the survey, we did not ask about job classification; therefore, we were unable to examine differences by job type. Differences in education level between interview participants and survey respondents may be due to selection bias, with those more highly educated selecting to participate. This study’s primary strength is its mixed methods design. Our quantitative data provided insights into the state of ECE educators’ health and health behaviors while providing an opportunity for respondents to provide open-ended text on the topic. While we did use ChatGPT to verify our open-text themes, potential bias introduced from generative artificial intelligence was likely limited due to themes being initially identified by the research team through traditional methods. The response to this survey question was high (23%, n = 327), allowing us to use the findings in the development of the interview guide. This high response rate may also suggest a high interest on the topic of ECE educator health and wellness and appreciation for focusing on the educators’ themselves. As noted by one respondent, “[I] definitely think this is a great step in recognizing ways to help our educators as it’s often seen that we invest all of our time into the children and forget about ourselves.”

The combination of quantitative and qualitative data in this study allowed for a nuanced examination of the current health status, behaviors, and needs of ECE educators. Collectively, these findings provide valuable insights into the development of targeted behavioral and policy interventions that are responsive to the ECE work environment and lived experiences of educators. It is critically important to understand educators’ perspectives and amplify their voices in national and local conversations on the topic. Health promotion efforts focused on both the physical and mental health of the ECE workforce have the potential to impact not only educators’ health and well-being but also the health and development of young children in their care.

Impact Statement

This study demonstrates that NY ECE educators have high obesity rates, poor health behaviors, and barriers from work environments and job demands to improving their health behaviors. Tailored worksite health promotion efforts are needed to enhance educators’ physical and mental health, job performance, and, in turn, children’s health and development.

Footnotes

Acknowledgments

The authors are appreciative of Patty Persell and Nora Yates for their feedback on study materials and for distributing the survey through their respective organizations and networks. The authors celebrate the career and contributions of Dr. Dianne Ward to the field of childhood obesity, particularly for her pioneering work on nutrition and PA in the childcare setting. Dianne’s impact on the field is broad and deep and reached many through her generous and thoughtful mentorship.

Authors’ Contributions

B.A.C. (student).: Conceptualization, project administration, data curation, formal analysis, methodology, investigation, and writing—original draft, review, and editing, L.D. (student).: Investigation, formal analyses, and writing—original draft, review, and editing, C.G. (student).: Formal analyses and writing—review and editing, E.F. (student).: Formal analyses and writing—review and editing, R.X. (student).: Formal analyses and writing—review and editing, L.L.B. (faculty/PI).: Conceptualization, methodology, funding acquisition, supervision, and writing—original draft, review, and editing.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the USDA or National Institutes of Health (NIH).

Funding Information

Funding was provided by USDA NIFA (NYC-199404); Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD 2T32HD087137-06) supporting B.A.C.; Cornell University, College of Human Ecology Dean’s Excellence Fellowship supporting R.X. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the NIH under Award Number UL1TR002384.

Author Disclosure Statement

The authors have no competing interests to declare.

Supplementary Material

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