A recent study found notable differences between female direct-care workers and the female workforce overall (Table 5-3) (Smith and Baughman, 2007). Black women, for example, make up a disproportionately large percentage of the female direct-care workforce relative to their presence in the female workforce overall (29 percent versus 13 percent). A second difference is that female direct-care workers are more likely to be single mothers than are female workers in general (24 percent versus 14 percent); of those who are single parents, 35 percent to 40 percent are below the poverty line (GAO, 2001b).

The education and training of the direct-care workforce is insufficient to prepare these workers to provide quality care to older adults. Although there are a number of state and federal requirements for the education and training of nurse aides, home health aides, and personal- and home-care aides, these requirements are minimal (Table 5-4). Many direct-care workers have no more than a high school education, and some have even less (Montgomery et al., 2005; Smith and Baugham, 2007). Minimum training requirements for these workers are often inadequate or non-existent, and they vary across occupational categories and settings of care as well as among states. A number of other training-program characteristics vary among states as well, including the specific qualifications that instructors are expected to have, maximum student/instructor ratios, and the required program approval and oversight processes (AARP, 2006).