Los consultores de salud para el cuidado infantil promueven la equidad en la salud

(En inglés)

Child Care Health Consultants Advancing Health Equity

Nydia Ntouda: We have two amazing presenters, and they will introduce themselves. Kim, take it away.

Kimberly Clear-Sandor: Thanks so much, Nydia. Hi, everybody. Welcome. We're so happy you're here spending your time with us this afternoon. As Nydia said, my name is Kim Clear-Sandor. I'm a senior training and technical assistance associate with the National Center on Health, Behavioral Health, and Safety. I'm a nurse and a family nurse practitioner and child care health consultant. But like many of you, working, bringing our health expertise and our passion for children and families and communities to our work with early childhood programs.

I'm so excited to be joined today by my colleague and friend, Ms. Mercedes Gutierrez. Mercedes, you want to say hello?

Mercedes Gutierrez: Yes. Hi, everyone. My name is Mercedes Gutierrez. I'm also a senior training and technical assistance associate working with the National Center for Health, Behavioral Health, and Safety. I am an MD, MPH. I've been in the field of Public Health and Head Start for many years, greater than 15 years, I would say. I've worked as both a health manager for Head Start programs and a child care health consultant. I'm excited to talk to you all today about this topic. We have a really, really great training here for you today.

Kimberly: Thanks, Mercedes, and all of you, I notice that many of you have been saying hi in the chat. Please do continue to say hi to each other. It's always kind of fun to network and see where folks are coming from. Our thoughts and positive energy we are sending out to all of our colleagues and families in the way of the hurricanes out there. I saw a couple of folks from Florida pop up in the chat. So happy you could join us today. You're all in our thoughts as you go through these hurricanes.

Today, we are … OK, I am a health care provider. I am a nurse. I'm a family nurse practitioner. Our topic today about equity and thinking about health and promoting health. It's humbling to think that 80% of someone's health can be linked to factors other than medical care. Where people live, where they work, where they play, where they worship all makes an impact on their health. As we think about bringing health and safety to our early childhood programs and supporting our families there, this is a really important component to keep top of mind. Next slide.

Kimberly: We've made this – usually, our quarterly webinar series are just an hour. We really felt that this topic today really needed some extra time, so that we could start to process this information together. I'm on my own journey learning about equity and social determinants of health and how I can incorporate this into my work. I am somewhere along my way out of my journey. I see where we're going I know where I started.

I invite you all to have grace with yourselves and appreciate that we're all in different places on the journey. Perhaps today is the first time we're thinking about health equity or maybe you've been well immersed in it. Wherever you are today, I hope that you feel that you can engage with the content. We welcome your questions and feedback in the chat. I hope that we can use this as a learning experience together.

To do that, we're going to start by grounding our discussion in the child care health consultant's competencies, and then really work through some shared understanding about some of the language that's out there, and what does these terms mean and what does it look like. Think about health equity, health disparities, and social determinants of health. Then we're going to spend some time thinking about how do we take that information and begin to apply it to our regular work to support the health of children and families.

It's OK to feel uncomfortable at times, know that you may, you may not. Please do chat with us. We appreciate you being open and fully present as we go through this session. As Nydia said, there is the chat box. For clarification or just to chat or make a comment about something, feel free to do it there. There's also that Q&A box. Mercedes and I try to watch that as we go through the presentation so that if there's something we can elevate in real time, we will try our best to do that. Thank you and next slide.

Let's go ahead and look at the health consultant competencies. We love to ground our work in these competencies, because they were really made to help define and help health consultants and relate the field of early childhood, understand the breadth and depth of what a child care health consultant can bring to a program. The consultants are very broad. We know that there are 50 states, and 50 states do child care health consultation a little bit differently.

We hope that the competencies are something that you can see your work in, and it helps to further articulate the work you could do, as well as expand your thinking about your professional knowledge and skills in this work. The competencies are broken into two main categories. The first is general areas of expertise, and the second is subject matter expertise. Take a look at them at some point. We always love to start our webinars grounding in this work to keep us focused on where the research and the best practice skills have been driving us as we move forward. Next slide.

Specifically, we're going to take a look at the first competency, one which talks about consultation skills. Part D, specifically says that health consultants can apply principles of health equity and cultural linguistic competence to their work with early care and education programs, including staff, children, and families. This link to the competencies is part of the links that they're putting in the chat for all of you. I know you see them on the slide, and you might want to … They're on that wonderful handout that our team makes for you. OK. Next slide.

1D, when you look at that a little further, it explains that the health consultant, health programs respond to the needs of staff, children, and families in this competent manner. It also further pushes us to look at competencies 4A and 4B. If we can go to that next slide.

4A and 4B further goes on to how health consultants work to support families, and this looks at how do we identify, design, and implement health education, how do we work with programs to build staff and family health literacy, and how do programs make linkages to community resources. How do health consultants support that linkage to community resources so that health mental health, social services needs of program staff and families can be met? Again, they're broad.

You might not see yourself in this work right off the bat, but we hope that as you go through the program, you see how the concepts that we're talking about can be applied no matter what type of your work you're doing in the center. Perhaps you're called in to discuss a child with special health care needs. Perhaps you're working with staff on implementing a new policy or procedure. I hope that as you go through the concepts and the ideas today, you can see different ways that you can apply it to these competencies in your work. Next slide, please.

Mercedes: We want to launch a poll right now to get a little bit of background from you. We're asking you to take a look at these experiences that are listed here in this poll and just click all that – I think you can select any that as many as you want that really relate to the work that you are doing with programs and families. Which of these experiences have you encountered in your work with children and families?

We want to just take a couple of seconds to allow you to make some choices here. It says it's multiple choice, but I believe you can select all that apply to you and the work that you've been doing. We're going to talk about how some of these experiences can relate to health equity. I can't see the percentages of – if they've been answering. Can you see them, Kim?

Mercedes: We have about 60% participation. I'm going to give it just a couple more seconds, trying to get to that 70% participation. I thank you all for taking a look. I know it could take a little bit of time to read all of them so … OK. I'm going to end the poll. Great. And then, Kate, are you going to share the results? OK. Great.

As you can see, it looks like 83% of the people that participated in the poll are experienced – have had the experience where you've shared some sort of health guidance, but it just was not followed at all by the family or by the program. Then the next highest percentage was that the family shared that they missed a health appointment because of work. We want you … I'm going to stop sharing. I hope that goes away for you all.

What we want you to get from today's training is that the situation that the programs and the families are encountering that cause these outcomes are not just as plain as they seem to be. There are a lot of different factors and a lot of different concepts and things that are impacting the family's life. For instance, one of the top choices there was that a family shared that they missed a health appointment because of work.

If you dig a little deeper, you might go and talk to that family and find out, well, the family really doesn't get paid time off and missing that – or missing work to take their child for the follow-up appointments or the doctor's note that's required to come back to school is really impacting that family financially, because they don't get PTO, they're missing time off, and maybe they've been already warned at work that they can't miss any more hours. Or it could be that you shared some health guidance.

And you think, “Oh, my goodness this family is just not listening to me. I told them several times that they shouldn't be doing x, y and z.” Could it be that perhaps it was explained to them in language or a level of literacy that they just did not understand? Could it be that the orders weren't clear, wasn't direct? Or maybe when you gave the program, the material to share with the family, it wasn't translated into their native language.

There are some other underlying factors that contribute to these circumstances that we experience with families and programs. Today, we want to focus in on health equity. Health equity is really defined as striving for the highest possible standard of health and behavioral health for all people. This means everybody is included in this definition. Meaning, those with different backgrounds, socioeconomic backgrounds, those with different disabilities, those of different races.

Everyone, when we achieve health equity, everyone receives the same standard and the same quality of care. To do this, we would ensure equitable access to really high quality resources. We would ensure that people are experiencing it having really positive experiences anytime they access health care systems. To achieve health equity, it at times means that we have to give special attention to those who are at greatest risk of poor health and behavioral health outcomes based on systemic and structural racism or other forms of oppression.

Health equity for us is the underlying commitment to reduce and eliminate disparities that impact children, families, and staff. I'm going to dig a little bit deeper into health disparities. When we talk about health disparities, we're talking about the differences in health outcomes and what are their root causes among different groups of people. We'll see that health disparities are inequitable and are directly related to historical and unequal distribution of resources.

They also might make you think of race immediately, so you'll see that health disparities have an underlying racial inequity as well. Anytime a health outcome is seen to a greater or lesser extent between populations, that is what we are defining as a health disparity. There are many different factors that can be associated with health disparities. It could be defined by race or ethnicity. It could be sex or sexual identity, age and disability, or socioeconomic status or geographic location, could be urban or rural.

All of these things are impacting a person's health, and it's important to realize that health disparities can be prevented, and they are actually a preventable difference in the burden of disease. When we recognize that the impact of social determinants of health have on specific populations, we can improve the health of all groups.

Today, we will explore the social determinants of health, including racism to begin to understand how these social determinants of health are impacting the health outcomes of the families and the programs that we work with. I'm going to give you a few more examples of what a health disparity might look like. We know that infant mortality rates are higher in infants of color. They are less likely to make it to their first birthday than their White counterparts.

There's also information around traffic data that shows us that compared to all other racial groups, American Indian and Alaskan Native persons have substantially higher rates of total traffic fatality– fatalities with Black persons being at the second highest rate. When I read that data point, it made me think of my family and friends. I've been in the car with family and friends that don't wear their seatbelts, and if I question them, I say, “Why are you not wearing your seatbelt?”

“Oh, well in the back seat, you don't have to wear your seat belt,” or “kids don't have to wear their seatbelt because they sit in the back, and it's safer back there,” things like that. We have certain things within our cultures that really can explain some of these things. We really want to look at some of the root causes as well. When you take a look at healthy weight of children, we see that Hispanic children are more likely to be overweight or obese compared to their white counterparts.

When we think about prior to the pandemic, we found that vaccination rates were lower among Black and Hispanic who were living below the federal poverty level. So why? Why? I'm sure you're hearing some of these things. You're like, “Well, what's the root cause of this? Why do these disparities or differences even exist at all?” We're going to try to dig a little bit deeper now and think about what could be causing some of the disparities at the root cause and the root level of this.

You may be familiar with the social determinants of health. Like Kim mentioned earlier, sometimes we think about health just very plainly as what is our physical health and what are the genetics that our family has passed down to us that impact our current physical state of health. It's so shocking to hear that statistic, that 80% of our overall health is actually driven by these social determinants of health, like the environment or the social and economic factors that are really impacting our health outcomes.

Social determinants of health are defined as conditions in the places where people live, learn, work, and play that affect a wide range of health and quality of life risks and outcomes. You'll see in this diagram the social determinants of health are broken down into five categories. Economic stability really relates to poverty. It relates to employment, food security.

When you look at education access and quality, we're speaking about the language and literacy levels of the area that you live, work, and play in, what the high school graduation rate is, and whether or not people go on to pursue higher education. We're a little bit biased, but most importantly the early childhood education availability within that area, we want to know is that available for the families that are living in that area.

Also one of the categories is health care, access, and quality. When we talk about that, we're talking about, are there hospitals around? Or are there primary care physicians that meet the needs of the community? Do you have access to those hospitals or health systems? Do those health systems or hospitals speak the same language that you speak? Additionally, are they welcoming you?

Another category that is one of the social determinants of health is the neighborhood and built environment. We're talking about the quality of the houses, the crime rates, the condition of houses, the conditions of the neighborhood. Are the playgrounds safe? Is it safe to send your children outdoors? All of that is impacting the health of the people that live in within a community. Finally, the social and community context. This really means, does it feel like a neighborhood?

Are your neighbors looking out for your children or families? Is there civic participation? Do you feel like you fit into the neighborhood? Or do you feel like you're being discriminated if you go to a store within the neighborhood? Are there high level – high rates of incarceration within the neighborhood? If you notice here on this diagram of the social determinants of health, there is a blue ring around all five of those categories.

That blue ring really is to signify the structural and systemic racism that is the root of all of that – that is the root of the social determinants of health. We know that racism has a direct impact on health. It can increase stress in the body and contribute to the development of chronic diseases, such as diabetes and hypertension. It also is a significant driver in health inequities. We're going to take a little look at racism a little bit deeper here.

Because this slide is saying that racism itself is a social determinant of health. It contributes to negative social conditions and health outcomes through discriminatory policies across multiple levels. You see the different rings that are on this slide, demonstrating the different levels of racism. For example, at the systemic level, there are policies that are put into place that can lead to racial inequities in health.

For instance, there are immigration policies or incarceration policies. At the community level, you'll see a difference in resource allocation or racially segregated schools or classes or programs within the community. At the institutional level, you can think about the hiring and promotion practices of employment. Then at the interpersonal level, think about the internalized racism that people have or the stereotypes that they might be thinking about, and the biases that they hold.

Then the intrapersonal level is really that overt discrimination and racism that people may experience. When we look at these various levels of racism, we know that they can apply to how people receive health care services. Research has demonstrated that there are differences in the way that people of color experience health care services. I'm sure you may have experienced it in your own health care, or you know someone who has had a negative experience with a provider.

Maybe you're sitting here, and you're like “No, I've never had a negative health experience with a provider.” Let's think of it in a different – let's have a different example. Maybe you're a woman, and maybe you've been treated differently because you are a woman. Imagine a situation where somebody has talked down to you because you're a woman. Now amplify that times 10 and think about how a person of color might be experiencing some of these instances of racism in their lives.

This is why it's important … This is why health care access and quality of health care access is one of the important social determinants of health that we are going to talk about today. It's because of racism that social determinants of health are disproportionately experienced. We know that Black, Indigenous, Latinx communities and other communities of color or people with disabilities or the LGBTQIA+ community have all had experience of disproportionate systemic marginalization.

Systemic marginalization is when we put people into a place where they cannot access the same resources or services as their white counterparts. Overall, systemic marginalization really disadvantages people of color or other communities and gives advantage to white people. Therefore, racial disparities in health, the health differences we see and have seen are a result of systemic and structural racism and other forms of oppression.

Systemic marginalization via policy that has disadvantaged people of color and advantaged white people has resulted in racial disparities in poverty, income, and wealth. As we share examples of different categories of the social determinants of health, think about how the role of systemic marginalization via policy carries across each of these social determinants of health, specifically health care access, neighborhood, and built environment. I'm just going to go over one of the pieces of that larger circle.

Remember the larger circle of all of the five categories of social determinants of health. We take a deeper dive into economic stability. We can see that the social determinants of health that is called economic stability includes items such as employment, food insecurity, housing, and poverty. Kim, can you share how these may impact someone's health or your health?

Kimberly: Now, you know Mercedes, I'm glad we actually get to take all that information and say, what is it? Where you at? What does it look like in action? I know going through some of the examples helps to put some of these concepts together for me.

I think when we think about economic stability and how it can impact your health, I think before your example of work and your ability to be able to take time off or whether or not you have health insurance or perhaps you do shift work, and you're working nights, that is going to in and of itself, impact your health. What is that employment – is that employment giving you a livable wage? Do you need to work two jobs? Does it provide health insurance? How much doe s– how are you doing there? Are you stressed out all the time?

Is there a long commute? Do you have access to that? A study from the National Bureau of Economic and Research shows that distinctly Black names on a resume reduces a probability of a callback despite having similar education experience or skills. I thought that was an amazing statistic. When you think about – when you think about racism as circling all of the social determinants of health.

I think, when you look at those circles of racism from the interpersonal to the big systemic level, oftentimes, you might think of racism as happening one-on-one, that it's something that you're doing to someone else. When you see how it can be so much broader and so much bigger. Then a study comes out showing that just by having a certain kind of name, there may be a bias towards you moving forward and what kind of impact does that have on your livelihood if you have the similar education experience, but you're not able to get the call back or to get an opportunity for that?

All of your employment ends up affecting everything else. Your rent, your ability to buy food, get medications, afford transportation, and all of that good stuff. There's great information about the food insecurity that happens from economic instability. In 2020, they estimated one in eight Americans were food insecure. I can't imagine what the numbers of that are. As we're in what? Going 2 and 1/2, 3rd year of our pandemic here, food insecurity is huge. It doesn't happen just by itself. It's part of the bigger system.

When we look a little bit deeper, we find that families with single parent families are more likely to face hunger, and Black and Latino children are more than twice as likely to face hunger. Again, when you're looking at someone's health with that economic stability, really impacts so many other parts.

Mercedes: Right. I want to ask you – I think some people are putting some things in the chat already. Can you all share in the chat if you've had any strategies that you've used for the programs that you work for where you were able to support food and food security for the families? I see – somebody also put one of a stat in the chat that your zip code is the biggest social determinant of health. I thought that was interesting when I learned that. I also read that too.

It's so interesting that a difference of even 5 miles can make such a difference. I actually am from Philadelphia, and that happens a lot in Philadelphia, where one neighborhood is very much different from another neighborhood but is still considered Philadelphia. But the resources and the lack of grocery stores, for example, as we talk about food insecurity, the lack of grocery stores and within a certain neighborhood really contribute to the food insecurity.

Then you'll have a bunch of corner stores that sell food that isn't as high quality as some neighborhoods. You go 5 miles, or you cross a street, there's one street called City Ave. that really is the border of a very wealthy neighborhood and the city. You'll see Wegmans and Whole Foods and all these really great grocery stores within 1 mile of each other. So a lot of these things are contributing. We have some examples.

We offer – Kyle Rodriguez said – we offer health books, which are $2 coupons that families can use at local farmers markets. If they use their SNAP benefits at the market, they get even more health books. It's NYC program. We also refer people to partner organizations. That's great. Yes. Food swamps, food deserts, grocery store disparities. We do backpack food programs every two weeks. High risk families receive food for their families, includes food for all children and families. That's so great.

Kimberly: I love that it's really highlighting the other role about the health consultant that we noted in the competencies about really being that connector to those community services, like how can we identify? What do our families and the community that our program serve need? How can we begin to be thoughtful about connecting them? I'd love to see the examples in the chat. I hope everyone is able to see the chat and follow along with some of these great ideas folks are sharing.

Mercedes: Yes. Take some notes. They're really great ideas. Another category of those five social determinants of health that we first talked about is the neighborhood and built environment. When we talked about the neighborhood and built environment, we're talking about things like the quality of housing, the access to transportation, the availability of those healthy foods that we're talking about, clean air, clean water, and then crime and violence.

The things we encounter in our built environment can either be risk factors or protective factors. For example, having no access to a bus route in the neighborhood may be a risk factor, but having a local grocery store around the corner that actually sells fresh foods and fresh vegetables is a protective factor. Both of those factors can impact your health. I'm going to ask you all in the chat could share your thoughts. What aspects of the neighborhood built environment and racism may affect asthma and asthma management?

You guys can take a minute to just think about that. Jot some notes down in the chat. What could directly impact – maybe you've encountered a family that you've given them all of the asthma education that you can, but the child is still having asthma attacks while they're in the program. Think about that. What do you think – what else is it – so it must not just stop there. What else about their life, their environment, the neighborhood, and where they live could be impacting and causing these asthma attacks for this child?

Kimberly: Yeah, Melissa said, living right next to a freeway. A lot of pollution coming off the freeway. There's housing around freeways may vary depending on how that built environment was. They could be where some of the more affordable housing is or more dense housing as well. Oh, it's flying …

[Inaudible]

Mercedes: I couldn't catch up. Those things that you guys are all saying is – they're completely right. The lead in paint, the pest, the old houses, the mold. I saw the traffic and the pollution. It could be that the family is experiencing one or many of these things. In your head, you're thinking, well they just shouldn't live there. Then you have to think about the family situation. Maybe they are unable to move because they don't have the money to move, because they need to be in a specific area to be around their support system.

There are so many different things that could be impacting this family. You have to think about these other factors before really feeling like the family is just not listening or taking your advice. We must think about the role of systemic marginalization and discrimination via policy across neighborhood and built environments. Think about redlining and the patterns and trends in health care in specific neighborhoods and think about how there are higher rates of asthma in specific neighborhoods, especially in children of color.

There is a health disparity for Black children. They are nearly two times the rate of current asthma as white children. Research shows that low income communities of color are disproportionately exposed to environmental hazards that children are particularly susceptible to. I think this is – you.

Kimberly: This is me. So thank you, Mercedes, and thank you all for contributing so much to the chat. I can already sense from all of you participation in the chat that we're in the same realm, talking about these things. We're seeing this in our work. I think that story about asthma is so great, Mercedes. Because sometimes, we don't connect. We might not connect the health condition to everything else.

From all the comments you guys put in the chat, it shows how critical it is to connect that health condition that management of asthma to everything else. The child is living in a maybe – maybe, it's something to explore and to better understand in an environment that's contributing to it. That goes well beyond the carpet that's there or the curtains that are there or perhaps their ability to change – a family's ability to change that, because it's a rental unit or something.

I love – everyone's sharing such an awareness of all the different things that can impact the health conditions. Hopefully, we're starting to connect those dots to the social determinants of health. Now what we're going to try and do is take all that good information and begin to think about, how do we move forward? How do we be good role models, champions of understanding this information and bringing it into our conversations and our work with programs and children's and families?

We're going to – we know that a lot of work is done on building relationships. In order to build relationships, we really need to think about our communication and have a good understanding about our self, as well as the people that we are working with. Next slide. We thought we'd do a fun little activity to think about our frame. When I talk about, what is your frame? I'm really talking about, what's your perspective? I always say like, “I'm a nurse.”

When I walk into an early childhood room, I put on my health and safety lens. Now, we're just going to bring it right down to the personal level, and we're going to say, almost like put it up to the mirror. What is our frame when I think about the world? What is the context I might bring to that conversation? We're going to go through a couple of different questions. As I go through the slides, I'm going to ask you to choose a picture that most closely relates to your own personal frame of reference.

You can just jot down which picture you would select. And it's … Let's just do it. Let's just do it. OK. Next slide. There we go. Here's our first picture or thought you want to jot down. Looking at all these pictures, which picture best represents where you live or where you grew up? And go ahead and just jot it on a piece of paper. It could be at the beach, a home, apartment, in a dry desert, in the mountains, in a city, on a farm, rural agriculture, maybe you're on the road. I love that RV picture. All right.

Mercedes: You think about military families are always moving, right?

Kimberly: Yeah. Excellent. I love that you're putting it in the chat. OK. Next one. Which one most closely describes or represents your family? We have – and we really realized we have not captured the entire breadth and depth of families. Just think, do you have a mother, father, and biological children? Is your family unit friends with children? Is it a single parent and child? Perhaps it's a blended family, perhaps it's a lesbian, gay, bisexual, transgender, queer family, perhaps it's multi-generational, adopted, foster, et cetera.

I know you can read all that, so … All right, next one, how does your family make decisions? I love this frame, because it's something that we might not always think about that we carry forward. Oftentimes, the family we grow up in is behaviors and approaches to life that we often carry forward and to be reminded that not everybody thinks the same way I think is so important. Everyone has an equal vote or maybe you weigh the costs and benefits or maybe there's an authority figure that makes those decisions. OK.

Mercedes: Multiple scenarios in this – maybe, it's two of them, not just one of these choices.

Kimberly: True.

Mercedes: Yeah.

Kimberly: Yeah. OK. How does your family deal with illness? We know that our approach to health, health promotion, illness, disease is all very different. Some folks might go right to the doctors. Other we have a lot of folks that research and learn on their own and bring that forward. There's holistic medications. There's self-treatments, things like that. Our last one is, how do you travel? How do you get around? How do you get to work? How do you get to appointments?

How do you get to programs, education, the places that you worship and play? How do you get around? All right. So at the end, I know you're not going to have a pretty little frame like I have on the screen. But imagine your frame and know that this is your frame. When I'm coming into a conversation, I realize that these are my experiences and these early experiences impact my beliefs and values, and how important is it as we grow from childhood to adulthood that we understand others and understand their beliefs and where they're coming from.

Because as we work together, it's not about what Kim wants. It's about what do our children and families want and how can we help them within the context of their life and the way they do things to achieve that health? It really needs to start from this common place of understanding. Next slide. What else? What else might impact your frame? I know we just looked at a couple little different pictures – where you live, how you think about health, what are some other things that may influence your frame of reference? Pop it in the chat there. We'll watch it come along.

Mercedes: Religion? Employment.

Kimberly: Deployment? I know I always say, I'm a nurse. And that's a culture in and of itself. I totally appreciate that professional kind of camaraderie.

[Inaudible]

Kimberly: Family loss, definitely. Your own health, past experiences, trauma, salary.

Mercedes: Introvert. [Inaudible] Oh, I like that. Introvert, verteverse, extroverted, yes.

Kimberly: Yeah. Very true. Weather, location, personality. There's so much. And I love that you guys are putting it in here. Because again, it just is reflecting how you own this and how you think about it in your work. For me, communication – I'm not good with silence, if you can't tell. I always have to remind myself. No matter how … I don't even like to tell anyone how old I am anymore or how long I've been doing this kind of work.

The first day I learned about communication skills in school is one of those things where it's something I revisit continually, and I continually learn. As we continue to grow as professionals, the more we pause and learn and listen and expand our thinking in this way. It helps us in our journey, and it helps us in our journey in working with children and families. We have to give ourselves grace that we need to be reminded of these things sometimes. It's very easy to slip back and fill space and not be good with silence.

But it's OK. Like that I notice it, and I kind of pull back again. As we continue to grow, it's important just that we keep moving forward and keep growing, Thank you all for being fun about that. Next slide. Again, be open. Other people's frames and in order to build those meaningful relationships, we really need to bring that understanding forward. Otherwise, it's just a barrier. How can we do it? What are some skills and things that we need to bring it forward? We can go forward to the next slide.

This is an opportunity to think about those attitudes, skills, and knowledge that you need to support successful interactions to kind of keep you in this open space where you are continually learning about the children and families. You are working with and your programs and your staff and your community partners. Some people use the term cultural and linguistic responsiveness. There are other terms out there that reflect different skills that you should bring to your communication with others.

There's a lot of words – terms such as diversity, inclusion, and belonging language and cultural humility. No matter … We're going to define, and there are different nuances to those different terminology. It's really about cultivating that humility every time you enter a conversation with others that you're open and that you're curious and you're willing to you're willing to learn. It's really towards us. We're curious about ourselves, as much as I think the frame of reference is a good idea to realize.

Sometimes when you're having conversation, oh, gosh, I didn't even realize how important eye contact was to me until somebody wasn't making eye contact, and I realized it made me feel different. It was really – that was my feeling versus somebody was just being true to their culture, which was not to give eye contact. Again, it's that humility in your own understanding as you go along as well. This is actually … Yep, do you want to say something?

Mercedes: No, I was just agreeing. I'm sorry.

Kimberly: This is actually – this little slide here is actually from the Child Care Health Consultant Skill Building Module. We do have the link on the screen, and I know it's also on your handout. If this is something that you want to explore a little bit more, you can definitely go online and check out this module. It's an interactive self-guided module that walks you through these – one, two, three, four, five different areas so that you can practice using a cultural and linguistic responsiveness and see what it looks like in the context of your work as a child care health consultant.

Next slide. We're just going to dig a little deeper into what those five topics are and what they really mean. The first one is a willingness to learn about other cultures. I think we covered that already. We know there's more than one, the one way to do things. We know that people's backgrounds and experiences really influence who they are and how they operate in the world. Approaching that with respect and openness is important, and we need to continually work on ourself with that. That self-assessment is a huge piece of it.

The other is the ability to recognize cultural bias. We've talked a lot about implicit bias and bias is language that's been flying around out there. If anyone who's ever done an implicit bias test, it's actually quite amazing. No one sees themselves as being biased. But really, no one's immune to bias. It happens. It can happen in different forms. A health consultant is working with so many different families, staff, and programs must really be aware of their own cultural beliefs and how they affect their interactions with others.

You also have to be aware of historical bias and institutional bias that may exist in the communities. May notice it. Like it might be something that you notice, and that may be a barrier to providing services or making assumptions about things as we move along. Next slide. Cross-cultural communication skills. This is really that sensitivity to different languages and communication styles. I know I talked about the eye contact before. Some people love to use body language, where the hand – you can be sitting here on a webinar.

I wish I could see all of you, but I can't keep my hands still as I sit here worlds away from all of you. This is just who we are. I get excited. I get passionate, and that's who I am. Some folks are not. Some folks may not receive that well. It's important for me that I'm aware of that. Some folks may work well telling stories. Maybe that's the most effective way to share information. Really being able to be aware of your own style but really understand those that you're working with, so that you can really approach them in a meaningful way so that they can really get the most out of whatever it is you're trying to share.

The other is that flexibility to adapt messages, and that's really, how do we incorporate those other points of views and adapt our practices so that we can be respectful to the community. Mercedes and I have talked in the past about sometimes children and infants might come to a program with a string with beads around their wrist. And this may be a cultural practice.

You might see a bracelet with beads, not knowing it's a cultural practice, and your immediate instinct is those beads could fall off and be a choking hazard, so you have a concern about it. It's important to not find out – so tell me a little bit about that bracelet. Can you share with me, what is the bracelet? Or maybe I do some research on my own and then talk to the family about it, and then figure out a way that we can move forward that respects the family's culture and beliefs and keeps everybody healthy and safe.

The last one is it's a sensitivity to power relationships. I think about that in early childhood a lot. Because teachers are caring for your children all day. They're caring for your most precious cargo, and you want to have a good relationship with them as a parent. When a teacher is sharing something with a family or the family sharing something with the teacher, be aware that there may be a power relationship there, because there is – everyone has a different role and different complex dynamics in a situation. In general, these are the five areas – I think as we think about those five areas, we can think how we can apply them to our work, so that we can live in that space to continue to learn, grow, and adapt. Next slide.

Mercedes: Someone put in the chat, “Makes me think of the Mongolian birthmark on the butt.” And I think that that's such a great example, because it actually happened to a friend of mine. She has biracial children. She is a white woman, and she took her child to a daycare that was predominantly white children, and they actually did call CPS on her. They call Child Protective Services because they believe that this dark spot on the child's butt was a form – it was an example of child abuse, that she was abusing the child.

But it is just a birthmark that goes away. Somebody also put in the chat that they'd never heard of that. It was a good to be aware of these things to help our programs and our families realize some of these things that could end up causing some sort of inequity for this family and disparity for this family. Thank you for bringing that up.

Kimberly: I love it. It's that ongoing learning. Thank you for saying that Mercedes, and even just sharing with each other those different things as well. OK. Let's think. Let's think how we're going to put together some of this social determinants of health piece with cultural responsiveness and humility and look at this scenario. We have Billy. He's a 3-year-old. He's missing his health and immunization records despite many requests and reminders.

The director is frustrated and asks the health consultant for some help. You learn the family only speaks Spanish and is new to the rural community. What are you doing next? How are you going from here? What are some of the things that you're thinking about in how you can work with this family and the program? I have experienced the situation today.

Mercedes: Wow. Iso real. I'm glad that we picked it a real life experience. Great. Find a doctor that speaks the language.

Kimberly: An interpreter. Make sure they understand what we need from them. Ruth, that says a great thing. Make sure they understand it, and how do we go about making sure they understand it? In nursing, we do a lot of patient education, and we often show people how to give themselves an injection, and then they do a teach back, and they show us that they know how to do it. How are we doing that? It's so much more.

People talk about the letter. I got the letter. It's so much more than the letter. Like how do we go we go beyond that? Build a rapport with the mom. Find someone who can translate. Do a fax for the records instead of having them get it, so get rid of the middleman? That's excellent. Someone shared they explained to the parents the importance of the immunizations and how – oops. It helps a child here, child in the States, then I served as liaison and spoke to the doctor for the parent to make sure they had an appointment and sure there's an interpreter. Awesome.

Travel to them with information and translation. Give them a ride. Sometimes they're dealing with financial housing issues that we must address first. That's a great point. Not everybody's ready to do some of those things. Because there are other more pressing stressors in their life or issues in their life that really need to be done first is great reflection. CDC has Spanish versions of the vaccination schedules. Excellent resource sharing. Appreciate that. Yeah. A lot of people are bringing up the statewide immunization registries, which I think is so important to be able to know – to tap into that. Thank you.

Anything else, Mercedes? I miss – I know it was moving kind of fast.

Mercedes: Yeah. We're moving kind of fast, but they're all definitely the points that – they're great. They're great tips that I hope you guys are taking and taking a look and watching what your colleagues are writing in the chat, because those are great examples. Especially the people that are living through these experiences right now are really sharing some really great insights how to address this. Kim, I think I think we've hit everything there on our list.

Kimberly: OK. Thank you.

Mercedes: OK. We're going to take a look at some strategies. As you think about how you can take this information that we've talked about today and really bring it back to your program, you might be right now feeling a little bit overwhelmed and thinking, “Oh, my goodness. There's so many things about the social determinants of health and health equity that I feel are out of my control.” At least, that's how I felt when I first started learning about this.

I always feel like, “What? Like, what am I supposed to do next?” We're hoping today to give you some concrete strategies of things that you can take back to your program or things that you may consider that could be strategies that you could use to support the families to help achieve better health outcomes. Click here. Taking a look at this wheel one more time and looking at the five categories of the social determinants of health.

You can – you as the child care health consultant, can work with the family, you can work with the program, or you can work with a community partner to identify the social determinants of health that are impacting the families, and then ensure that they are considered as you work with the families. When you are thinking about some strategies, think of it as either you work with the families, or you can make family strategies, or you can make program-wide strategies. If you look at the wheel, you might be thinking, OK, which ones are really targeted towards the family?

Well, you can think about the health care access and quality, the neighborhood and built environment, and that economic stability. If you want to help the family with those things, you might connect them to social services. You might help the family navigate some of those barriers within their neighborhood, whether it be the transportation or feeling unsafe. The other one was health care access and quality. You might help the family find high quality health care providers that meet both their cultural and linguistic needs.

I know a lot of people shared that as some of the strategies in that last example that we did. If you're thinking about program-wide strategies, you would take a look at education access and quality. You might say that you could support an ECE program to strive for high quality education and best practices. If you think about that social and community context, you can make a program-wide strategy where you partner with community centers to offer health services or resources.

I saw a lot of those examples when we talked about that food insecurity, the partnerships that you're forging and creating where you can provide those services really help to target some of that specific social determinants of health. Then again, the economic stability could be a program-wide initiative, where you're helping families or linking families to employment opportunities or various things like that. If the health care field has begun to incorporate some social determinants of health assessments into their work.

This makes sense, because social determinants of health are responsible for 80% of an individual's health outcomes. Taking a deeper look into these program-wide initiatives, if you're going to create a program-wide initiative, you first need to understand what is going on with the community that the program is in. You need to understand – you have to have a better understanding of what are some things that they need? They might not need everything on this wheel. it is very important to do an assessment.

And this is largely … You'll see that – I'm sorry. The Virginia Commonwealth University with funding from the Robert Wood Johnson Foundation, max life expectancies in certain areas. They found that in some cases, life expectancies differed by as much as 20 years in neighborhoods that were only 5 miles apart from each other. That was an example that somebody shared in the chat earlier as well. This is largely due to the social determinants of health and the nature of the communities and the built environments that people reside in and whether there is a strong investment in resources like hospitals or health centers or grocery stores or things like that.

This community data that you should be looking for can help you identify what are the barriers for the families that are in the programs that you work for. Health data can help programs develop specific approaches, so that you can help to ensure that families receive specific health services. And child care health consultants can use this data with their programs to consider how to address and improve health services and plan for future program years. Kim, I think this one's you.

Kimberly: Yeah. How do you get that information? I think it's wonderful to think program wide. Like if we do some reflection on, what are the needs of … Our program might serve a general geographic area. How can I learn in general what is the health? What are some of the needs and challenges in that community, so we can do program-wide intervention. One way to find some of this data is something called the County Health Rankings Model. I know it's on your resource list.

I get to geek out when I go into the County Health Ranking Model. I get kind of excited about all that they share in here, but the model or the website allows you to go in and type in your zip code, and it gives you the Health Rankings of a County there. It will dive deep into characteristics about the community where you live. It looks at four chunks – of chunks or big picture things, healthy behaviors. That's really looking at rates of cigarette use, diet and exercise, sexual activity, alcohol, and drugs.

It looks like clinical care. It looks like, how many health care providers are there? What kind of insurance do they take? Is it good quality care? It looks at socioeconomic factors. What's the access to education? How are the schools? What is the employment? What are the family and support services? Lastly, it looks at the physical environment, which looks at the air quality, housing, et cetera. You can see what they're sharing information on aligns with the social determinants of health.

It aligns with some of the discussions we had today, even about asthma. You guys talked about air quality. You talked about housing. You talked about access to health care. The data that you can dig out from here can really inform you as a health consultant about what might be some of the challenges that families could be facing. Next slide. I don't know if folks have seen that before. If anyone's using it, I would love to see in the chat. If anyone has looked at it before.

One of the things I kind of think is super cool when you go in there is that you can link to and learn about different interventions at different communities have done to address some of these different areas of social determinants of health with community partnerships. Really, if you have that kind of relationship with your program director where you could look at this information together and be able to identify what's really impacting the families that you serve, perhaps there's community partners to really make a difference in this space. OK.

Anyway, let's say you dove into your County Health Rankings, and you got some information that in your community, there's a shortage of places to buy fresh fruits and vegetables. What are some of the strategies you could consider to do program-wide? I know you guys shared a lot of nutrition stuff before, but if you could share some thoughts in the chat box about how you could go ahead and support families if there are not a lot of places to buy fresh fruits and vegetables.

Martina said she's used it before. Thank you, Martina. I couldn't see a way for that chat to fill up there. I know someone said before that they had a pantry to bring fresh food, pop-up farmer's market, a lot of that. In New York City, you can adopt a shop – encourage them to sell more fruits and vegetables. What a great idea. That's neat.

Food pantries, farmer's markets – team up with the Ag. I love that. With the Texas, with the A&M AgriLife extension in the Assist communities in starting community gardens and in the schools. We've seen that in a lot of child care programs, that they have started a child care garden. What a great opportunity to then for learning, growth, and development plus trying new different kinds of foods and vegetables and then being able to provide them to families.

YMCA has a monthly fresh fruits and vegetable giveaways and some vegetables and farmer's markets, so thank you. I know you guys shared a lot before as well on the nutrition piece, but it's just a way to take that program that community data and bring it forward. Just like you could take data on these or the health care providers in the area, so when families need them, you would be able to connect them to those services.

Mercedes: My daughter's child care does this too, where the kids help Mr. Andy in the garden. And every Friday they have the fresh bag of vegetables for all of the ECE families to take first. If they don't take it, then she goes to child care in a Salvation Army. It's within the community, so if the families within the child care center don't take the bags of fresh fruit, then it's available to the community all for free. Oh, it's really – it's great. It brings the resources directly to the family but also the resources to the community as well.

Kimberly: I love that. Thanks for sharing, Mercedes. We also found this really neat tool that we thought folks might be interested in. I know we're talking specifically about food. It's from the American Academy of Family Physicians. You have the link in your handout. It's Navigator.familydoctor.org, and it's a neighborhood navigator. If you're finding that there's an issue around housing, you could pop in your zip code, click housing, and it gives you a whole bunch of different resources.

Sometimes, it's not always easy to find the resources. I know in Connecticut, we have something called a Child Care Infoline, 211, and you can call it up, and you can get all sorts of information. It can be a little tricky to find stuff, so we thought this was a good resource to put at your fingertips so that it would at least give you a starting point to navigate some of these social determinants of health and programs in the community.

Mercedes: We talked about some of those program-wide initiatives. Now, I want to give you some tools that you can use for family-centered strategies. This assessment is a social need screening tool, and you can choose some of the questions from there, or you can do the whole assessment with a family, but it helps you identify some of the factors that the individual family's experience that could be both challenging and protective factors.

You'll see – the answers to these questions should be evaluated child by child, and then it helps you start a conversation with the family, where you can both begin to understand and strategize solutions that are really, really targeted and specific to the family. Another screening tool is the Adult Food Insecurity Screening Questions. This resource is on your resource handout, and it's from the National Recreation and Park Association.

They are just statements, or where you can ask the family is it often true, sometimes true, or never true for your household within the last 12 months. And they're really specific questions that help you understand what's happening with food in their household or food security in the household, and then it might even lead to something that's happening in the community and so to help you really develop some program-wide initiatives.

Mercedes, I love that. We can get our community data. It could tell us one thing, but it doesn't really mean that it reflects the families that are in your program. Really trying to bring it down to the family level gives you an opportunity to learn about the families so that you can support them. What a great piece of information to be able to have to kind of … Of course, it's a survey. It's not the end-all-be-all. It never beats a conversation and really learning about somebody, but it's a starting place.

We know that in some – as Mercedes mentioned before that, health systems are starting to incorporate these questions more. There was one study that showed that when the different social determinants of health were marked on a patient's tracker, the doctor was able to adjust their recommendations. For instance, a patient may move around a lot, and they need a medication. The health care provider may decide that to not give them one that gets refrigerated because it may be difficult because the person's moving from home to home to home and to go with the pill.

You could take that and extrapolate it to our work, that if we have a better understanding of some of the things that families are challenging or maybe a challenged to some different issues, that you know that going into the conversation, and you can provide more meaningful conversation and resources at that time. I love that.

Mercedes: Another great resource is from the Office of Minority Health. We talked about earlier how social determinants of health can lead to health disparities. Health disparities are experienced differently among different racial groups, different demographic backgrounds. Child care health consultants can learn about health disparities related to race and ethnicities to further inform their approach to services and their families. Once you have an understanding of the community demographics and the demographics of the families that are being served within the program you're working for, you can take the next step to really understand what the disparities that are affecting this population.

The Office of Minority Health provides this resource in which they share detailed demographic education, economic and insurance coverage of specific communities, which is another critical factor to creating these interventions that support health equity. I'm just going to bring it back to where we started with today, which was the child care health consultant competencies. As you consider what we reviewed today, think about how it supports your ability to implement the competency that involves consultation skills.

Remember, one A says that we apply the principles of health equity and cultural and linguistic competence to work with ECE programs, including staff, children, and families. And this is just a review of the competencies that we reviewed today and how all of the knowledge about health equity and social determinants of health are really fueling that conversation and our ideas that we can bring to our programs for strategies.

Have a few takeaways that we want you to gain from today. Remember to continue to learn about health equity, health disparities, the social determinants of health, and how structural racism is impacting all of that. Take time to reflect and understand your own frame, your values, your beliefs, your assumptions, your experiences, and where you come from, and reflect on that and how it is impacting your work with families.

Approach your work with humility – cultural humility to be specific – so that you can learn from the families and the staff that you work with. Continue to learn about the disparities and the social determinants of health that are specific to your community. Just like Kim said previously, if one of these websites identifies something that sounds like it's a disparity to your community but then you survey your population and you find that that's not really impacting them, make sure that you're able to adjust and adjust your strategy to what is really affecting the families within your programs. Identify these program-wide and family-specific strategies that really support positive health outcomes.

Kimberly: Thank you, Mercedes. I feel like we should pause and do questions now and then go back to the resources. I'm just going to encourage folks if they have questions, please pop it in the chat. We will answer them. We welcome them. We're really interested to hear what else do you want to know about what does this mean to where are you in your journey in thinking about this.

As you're thinking about those and typing them in the chat or the Q&A, I'm just going to go through some other resources for health consultants that may help you as you do your work. Again, today, we talked very specifically about this competency and how it could apply to your work. We have some really nice resources for health consultants that can help you even with some of your discussions and conversations with program directors and leaders.

Not everyone understands all that a health consultant can bring to a program, so having the opportunity to sit down and talk about it is really great, and we have lots of resources that the National Center has made to help you with that. Just curious if you can go to the next slide, and Olivia, if you can – Kate, if you can launch the poll. I just wondering if any of you have explored any of these resources. We have health consultant competencies, webinars. We have some online interactive – you can – is it launched? I can't tell.

You have some skill-building modules or self-directed. They're fun. They allow you to get a coach for a health consultant. We have the partnering with the health consultant and making early care and education programs healthier and safer. Those two items are actually tip sheets that I think are really great tools to use working with programs about as you can do.

I love connecting with all of you on these quarterly webinars. But we do – can feel like we're an island out there doing this work all by ourselves. We do have an online community for peer-to-peer interaction called MyPeers. It was part of the – I want to say it's in your calendar invite, or it's part of the email you get confirming your attendance there – how to access the community – and it's on your resources as well. That community is just a place to connect with other health consultants and chat and share some best practices.

Then look at this – we're down to 7% have never been – you can show the results there. I forgot just I was seeing them, but look at this. We are down to 8% have never been on the ECLKC. Woo, woo – I call that a success. That 8%, check out the ECLKC. The link is in your handout. There's a lot of resources on there, and I'm really excited to see that folks are engaging in MyPeers, and they're coming to the webinars. We're excited, and we're always happy to be with you doing these quarterly webinar series. OK. Next slide.

Mercedes: You have a question here online. It says, "Our consultations here in Kansas are usually only with ECE programs/providers. Would the adult food insecurity screening questions or social need screening tool be something that we as consultants can pass on to the program providers to be used with the families that they serve as a resource?” I think that – I mean, it's a great question. There are some – yes, you can pass that on to the program.

You can suggest that they pick one or two questions maybe to add to their enrollment packet or maybe to do these at different times, because doing these screenings one time is not really going to address the needs of the family. Things change. Things happen in life, and that your needs change from month to month. Suggesting that they incorporate some of these screening tools, whether they be quarterly or just annually, it really helps keep a pulse on what's happening within your community. It would be a great resource to share with your programs.

Kimberly: Yeah, and I mean, like I am a big believer of don't reinvent the wheel. Give me a starting place, and we can go and figure out where it best fits in that program practice. I think it's a great thing to share, and how wonderful that you could begin to have these conversations. It's a great entry to those conversations with folks too.

Is there a certification for child care health consultant consultants? Where could we find the information? I wish I had an easy answer. Every state is a little bit different. Some states do have some requirements around who can be a health consultant and what their background education, training – whether or not they need to be a health professional or not – is. There is not one uniform across the United States training. I would definitely look into your state though and find out about those regulations and if they have anything like that in place.

OK. If any more pop up, Mercedes – OK. These are the skill-building modules. I know we talked a little bit about the one using cultural competence to solve problems, but there's other ones as well like creating collaborative relationships, applying – there's a whole scenario around applying your skills to an oral health intervention. There is a module about identifying, resolving concerns. If anyone's ever walked into a program and saw a hazard right away and thought how do I bring this up? How do we have this conversation? Or can I just go back to the office and have a conversation? It's a great way to go through thinking about the daily interactions you have, communication skills – it's probably no surprise that that's on there.

Again, it's a great opportunity to reflect, do that self-work that we all need to do to think about how we're communicating with our programs, children, and families, and how we can improve those skills, and how improving those skills and bringing our cultural competence and thinking how we can be collaborative. We just continue to build trust with our programs, and then health consultants can be more and more impactful in their work. Next slide.

Yes. MyPeers. Here it is – the link, again, is in your handout. I know. This is just, again, a reminder to join. Come and say hello. Mercedes does a lot of work in there, connecting folks and chatting and sharing resources. Please, check it out, and then we can see each other in between our quarterly webinars. And then our …

Mercedes: Another question in the Q&A. Do the skill-building modules come with a certificate?

Kimberly: Yeah, they do not. They do not, Rebecca. Yeah. I think that if you have a question about certificates, it's also on the very last slide we share our info line question. If you wanted to ask about a certificate, you could always send the question to the Infoline, and they could probably more specifically share with you what they can give certificates on. That's on the website.

Our upcoming webinars for 2022 to 2023 – we have our December webinar set. I believe it's on the 15th. We're going to be talking about ways health consultants can promote staff health and wellness. Our February, May, and September are TBD's. We don't even have our topics there, so please share in your evaluations in the chat things you might want to have us bring to you. Is that it? Are we good with the questions?

Mercedes: Looks like we – will this recording be available?

Kimberly: Yes. I will go ahead and just thank all of you for being here today and for sharing with us and being so willing to take this journey with us to go through these difference areas about equity and maybe different, maybe new, maybe enhance the way you're thinking about these areas that impact health and what we can really do as health consultants moving it forward. Thank you, Mercedes, Livia, Kate, Lydia, everybody on the back end that makes all of this happen as well so that we can be here and enjoy our time together.

Mercedes: You want to drop the evaluation?

Kimberly: You got it.

Nydia: If you're done with all the questions, I can take it from here.

Kimberly: Thank you.

Nydia: Yes, thank you. Thank you so much. Thanks again to Kim Clear-Sandor and to Mercedes Gutierrez. If you have more questions, as mentioned earlier, you can go to MyPeers or you can write to help@ecetta.info. Also another reminder that the evaluation URL – it will appear when this webinar ends, so do not close the Zoom platform, or you won't be able to see the evaluation when it pops up.

Remember that after submitting the evaluation, you will see a new URL. This link will allow you to access, download, save, and print your certificates. You can subscribe to our monthly list of resources using this URL as well. You can find our resources in the health section of ECLKC, or write us, again, at health@ecetta.info. Thank you again, everyone, for your participation today, and Kate, you can close the Zoom platform.

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