Addressing Health Equity through the Dual Language Learner's Program Assessment

Addressing Health Equity through DLLPA

April Powell: Welcome everyone. Thank you so much for standing by. And we are ready to get started. My name is April Powell, and I'm the resource program manager for the National Center on Early Childhood Health and Wellness. And I'm pleased to welcome you all to today's webinar: Addressing Health Equity through Culturally and Linguistically Responsive Health Services, Implementing the Dual Language Learner's Program Assessment, A Closer Look.

Before we begin, I have just a few housekeeping announcements. First off, all participants will be muted throughout the presentation portion of the webinar. There is a slide presentation that will be shown in the webinar system, and only the presenters will be able to change the slides. If you have a technical or content question, please type your question in the chat box. Please be aware that everyone on the webinar will be able to see your question. There's a lot that we'll be covering, so you can submit questions at anytime. Some of the questions will be answered as we're going; some will be saved for the end. And if we run out of time, we'll continue this conversation on MyPeers.

There will be polls throughout the webinar; click directly on the slide to answer the poll. If you have any questions, again, ask in the chat box, and one of us will help you. Now, you have three boxes on your screen. At the bottom you should see web link, and that feedback survey is what you'll take at the end to let us know how we did. And the DLLPA page is a resource that we'll be talking about. There are a few files to download, and we'll go over those during the webinar. So, please take the feedback survey at the end. And then ... One of the files under Files to Download is the webinar certificate. Download that and fill in your name and keep that for your own records. Lastly, this webinar is being recorded, and an archived version of the webinar -- along with the webinar slides -- will be available on ECLKC within a few weeks. So, with that, I'm going to turn it over to my esteemed colleague.

Steve Shuman: Thank you, April. I'm Steve Shuman and I'm a senior T&TA associate with the National Center on Early Childhood Health and Wellness. Welcome to this final webinar in the series called, "Implementing the Dual Language Learner's Program Assessment, A Closer Look." As the name implies, this series has allowed participants to look more closely at the DLLPA and how it can be used across all your program services and systems.

Today, we will learn more about how to use the DLLPA to assess health program practices and the importance of health equity. We will also hear about a Head Start program and their community efforts to address the unique needs of their dual-language children and families. Our sister national center's program management and physical operations, development teaching and learning, and parent and family and community engagement have all had opportunities to discuss and describe how the DLLPA can be used to support children and families for whom English is a new language.

These previous webinars, and last August's introduction to the DLLPA, are or will be archived on the Early Childhood Learning and Knowledge Center. This tool, and this series, has been spearheaded by Jennifer Amaya-Thompson, program specialist at the Office of Head Start, and the Culturally and Linguistically Responsive Practices content lead. And now, let's have a few words from Jennifer.

Jennifer Amaya: Thank you, Steve. Good afternoon, everyone. I'm thrilled to be with all of you today. I'm Jennifer Amaya, the content lead for Culture and Language at the Office of Head Start in the Office of Early Childhood Development at the Administration of Children and Families. Welcome to the fourth and final broadcast in the National Webinar Series: Implementing the Dual Language Learner's Program Assessment. Today, as Steve mentioned, we will concentrate on health equity through culturally and linguistic-responsive practices identified in the Health Services section of the DLLPA. This section highlights the health, oral health, nutrition, mental health, and other related health services that are responsive to the individual needs of diverse children and families and support each child growth and improve readiness.

Since its inception, Head Start has incorporated healthy children ready to learn as foundational to school readiness efforts. This principle is, and continues to be, a cornerstone of the program for over 50 years. Head Start Health Services, at their core, are responsive to the unique and diverse backgrounds of families in the programs and their communities. The DLLPA Services support programs as they intentionally address to talk about [inaudible] and their coordinated approaches. Families enrolled in Head Start programs they speak more than 140 languages and dialects for nearly over 300,000 Head Start children that speak at home a language that is not English. Many Head Start and Early Head Start programs to communities are more racially, ethnically, culturally, and linguistically diverse than ever before. This is an amazing opportunity. This amazing diversity means that Head Start programs are able to create opportunities and innovative health services and approaches that truly embrace and integrate the uniqueness of our children and our families.

For today's webinar, I'm excited to share that we have over 600 participants registered. This is really exciting. I also wanted to thank all of our federal partners -- the Office of Head Start National Center, the Regional T and TA staff Head Start grantees -- and many others who have been involved in the planning of the DLLPA National Webinar Series. We are grateful for the time and commitment shown by all of our partners. In putting together today's webinar, I especially want to acknowledge the Office of Head Start National Center on Early Childhood Health and Wellness and the Children's Learning Center Headset Program from Jackson, Wyoming in Region 8, and the director Lettie Liera and her staff for sharing with us their experiences and their voices from the field to demonstrate their efforts to support health equity and the implementation of the DLLPA. Steve, I can't wait to hear this Children's Learning Center journey to health equity.

For those of you who are joining for the first time, our National Webinar Series, I wanted to provide you with a brief overview of the DLLPA. The DLLPA, as Steve had mentioned, assists Head Start child care and pre-K programs to assess their management systems and services to ensure the full and effective participation of children who are dual-language learners. It also helps programs to ensure the integration of culturally and linguistic-responsive practices for all children. It is anchored in the current Head Start Program Performance Standards, which retain existing regulations and include new standards for ensuring that cultural linguistic appropriate services are included for children birth to 5. The DLLPA is also aligned with a 2007 Head Start Act requirements to support children who are dual-language learners. The tool includes research-based responsive practices for the implementation of the regulations.

Also, the OHS multicultural principles for early childhood leaders were used as a guide to develop the DLLPA. In the development of the DLLPA, we also included feedback from grantees to ensure that the voices from the field were reflected in the final version of the tool. This has been truly a comprehensive process that is responsive to supporting the needs of our Head Start program service and children who are dual language and their families.

So, when we think about the importance of the why we need to take a closer look at the implementation of the DLLPA, it's extremely necessary to remind us that just that the United States population at large hits our families represent the increasing diversity of our nation.

Once again, thank you to all of our partners for your hard work in putting together today's webinar. Later, at the end of the webinar, I will join the presentation again and provide you with some final remarks. I will share with you some of our next steps in our work to continue to ensure the full and effective participation of children who are dual-language learners. Now, let's go back to the main stage and our colleagues from the National Center on Health and Wellness. Steve?

Steve: Thank you, Jennifer. And thank you for your leadership. As I said, I am Steve Shuman. I'm a T and TA specialist. I've worked in Head Start Child Care and Public Health for over 45 years. I've always had a particular interest in equity and inclusion, especially for children with special health care needs, tribal communities, and LGBTQ families. The National Center on Early Childhood Health and Wellness is led by the American Academy of Pediatrics. And I'm joined today by two of my colleagues from the Academy. And I'm going to let them introduce themselves.

Joanne Kelly: Great. Thank you, Steve. Good afternoon, everyone. My name is Joanne Kelly, and I am the collaboration manager at the National Center on Early Childhood Health and Wellness. Our center is housed at the American Academy of Pediatrics here in the Chicago area. And that's where I am located. I've been with the Center for over seven years. And my current work as the collaboration manager revolves around building bridges between pediatric medical homes and early childhood settings such as Head Start and Child Care. I'm very happy to be here today and thank everybody for joining us.

Stephanie Womack: Hi everybody. I'm Stephanie Womack. I'm a program manager with the American Academy of Pediatrics Institute for Healthy Childhood Weight. And I work with the National Center on Early Childhood Health and Wellness on their Healthy Active Living Initiatives as well as the health equity work. And I'm happy to be here on today's webinar and happy to have you on the line.

So, like many other organizations, the National Center on Early Childhood Health and Wellness have become increasingly aware of the health-related inequities for so many of the families in our care. And today's webinar, Addressing Health Equity through Culturally and Linguistically Responsive Health Services, will hopefully highlight the importance of culturally and linguistically responsive practices when providing all types of health services, and the DLLPA. And how the DLLPA and other resources can help each of you improve those practices to really benefit all children and families in your program, especially those who are dual-language learners. So, we hope that you'll be able to walk away from today's webinar with a sense of how to better assess the cultural and linguistic responsiveness of your health and nutrition and mental health services, as well as an increased understanding of the importance of health equity.

And finally, resources that can support you in your efforts to support dual-language learners. As Jennifer mentioned, the DLLPA is an assessment tool designed to assist early childhood programs to assess their management systems, including their health services to ensure the full and effective participation of children who are dual-language learners and their family. And the DLLPA also helps programs assess their effectiveness in delivering services that are culturally and linguistically responsive to all children. So, if you've participated in previous webinars in the series, you're familiar with this tool. And today we have the opportunity to really focus in on the Health Services section.

But before we get started, we'd really like to propose a poll to find out how familiar you are with the Health Services section and have used it. So, you should see a poll open up on your screen, and just click the answer that best represents your response. [Inaudible] So, usually you'd have a visual [Inaudible].

Steve: We can ...

Joanne: I can hear you.

Stephanie: I see some.

Steve: We can hear people.

Stephanie: And yes, if you are not one of the presenters, could you please mute your line? Thank you so much. I see some responses coming in. Okay. I think we're okay to go ahead and close the poll. We've got some good responses. It looks like the majority of folks have said they haven't used the tool yet, which is okay. That's good because part of our work that we hope to do together today is to present the Health Services section of the tool and as a resource for evaluating the responsiveness and quality of your program, and especially if you are educating dual-language learners. So, there's a lot of research that shows the benefits of high-quality, early care and education programs and the role that they can play in life-long health. And with that, I'm going to turn it back over to my colleague Joanne to discuss more.

Joanne: Great. Thank you, Stephanie. So, I'd like to start today by mentioning James Heckman's work. I'm not sure if people are familiar with the research that he has done. James Heckman, he's a Nobel Prize-winning economist at the University of Chicago. And he's conducted decades of research that concludes that high-quality, early childhood programs that address health and nutrition needs result in better health outcomes throughout life. Heckman's work proves that comprehensive early childhood programming, like we do in Head Start, is cost effective, it's health-promoting, and it really is one of the best upstream solutions that can be offered to disadvantaged young children.

So, there's a quote from Professor Heckman that I wanted to share with you today. I like it a lot. He says, "The highest rate of return and early childhood development comes from investing as early as possible – from birth through age 5 -- in disadvantaged families. Starting at age 3 or 4, it's too little, too late, as it fails to recognize that skills beget skills in a complementary and dynamic way." So, I encourage everyone if you don't know Heckman's work to maybe take a little bit more of a closer look at the website that we've listed on the slide.

So, before going deeper into the Health Services section of the DLLPA, we thought that we'd back up a bit and talk about Head Start Health Services overall. From the very beginning of Head Start over 50 years ago, health services have been a critical and a fundamental aspect of the program. In fact, Head Start was implemented in large part because so many low-income children were entering school with poor health and poor nutrition.

So, the Head Start model has always been committed to the provision of high-quality health, mental health, oral health, and nutrition services. Basically, what I consider like the four pillars. Those services being provided in a developmentally, culturally, and linguistically appropriate for the families that we serve. And because we all recognize that school readiness begins with health, we know that healthy children are better able to learn and thrive as they advance throughout school and in life.

So, in regards to physical health, the Head Start performance standards direct programs to ensure that children are up to date on a number of important metrics that include well child visits, developmental and sensory screening, while also ensuring that any new or recurring health concern gets addressed and followed up. The performance standards also direct programs to promote good oral health by addressing and monitoring each child's oral health care, whether that be through preventive, or treatment, or follow-up services.

The Head Start model also includes the design and implementation of developmentally and culturally-appropriate nutrition services. The goal here is to meet the nutritional needs and the feeding requirements each child in the program, including children with special dietary needs or children with disabilities. And then lastly, the fourth pillar, is that the standards require programs to support a program-wide culture that promotes children's mental health and social/emotional well-being through the use of mental health consultants.

So, as I mentioned earlier, there's been so much research that has shown that it's these kinds of health services that we provide in the early years that appear to serve as a buffer against adverse community and societal conditions that can influence life-long health and health equity. So, to further discussion on health equity, I'm going to hand it back to my colleague Stephanie.

Stephanie: Thanks, Joanne. And as Joanne is starting to allude to, there are many factors that influence a person's ability to be healthy and experience good health. Health really starts in our homes, in our schools, our workplaces, our neighborhoods, and really the communities that surround us. And Bright Futures Guidelines, which is a resource for health care providers on pediatric health promotion and prevention, tells us that our health is also determined in part by access, and that's access to social and economic opportunities.

So, the resources and supports available in our homes and communities, that's the quality of our schools, that's the safety of our workplaces, the cleanliness of our water, food, air, and so on. So, if we go around the circle here, we're talking about things like the neighborhood and built environment. Do I have access to foods that support healthy eating patterns and safe places to be physically active? Health and health care, do I have access? Do I have access to quality health and health care? And are those environments health literate, which we'll talk more about in a little bit. Social and community context, this includes things like race and gender. Do I experience social cohesion or social isolation based on any of those things? Education. Do I have access to early childhood education and development programs? Do I have the ability to acquire language and literacy skills? And then economic stability. Am I living in poverty? Am I food insecure? Do I have the ability to provide for my family in the way that I want?

And when we look at the Head Start program, these are our families, right? We know and we've heard Head Start was designed to serve low-income families. So, that's a factor, income. We know that in fiscal year 2017 30 percent of our families identify -- 37 percent, excuse me, of our families identify themselves as Hispanic or Latino, and 29 percent were black or African-American. So, that's a factor to consider. Additionally, 29 percent of Head Start participants primarily spoke a language other than English, so that's a factor. And approximately 49,000 families served in fiscal year 2017 experienced homelessness, which is a huge factor that impacts health.

So, when we start to consider these things, it becomes more apparent that the conditions in which we live, these social determinants of health, can explain why in some part some people are healthier than others. Like I mentioned, these social determinants of health really do impact the overall health of a person. An unfavorable condition, such as poor education, or poverty, and structural racism can lead to disparities in health outcomes. A health disparity is when a particular type of health difference is closely linked with social, economic, and/or environmental disadvantage.

For example, non-Hispanic black children experience higher rates of infant mortality than non-Hispanic white children. And you can see how different race and ethnic groups compare to each other in the graph on the screen as well. Again, when you look at the demographics across Head Start programs, these are our family. Health disparities really adversely affect groups of people who have systematically experienced greater obstacles to health based on things like race or ethnic group, religion, socioeconomic status, gender, age, cognitive or physical disability, sexual or gender orientation, geographic location, and many other characteristics historically tied to discrimination or exclusion. Here's another example that shows disparities in child passenger safety where you can see American Indian and Alaskan native children die at a higher rate than any other -- almost three times higher than any other racial or ethnic group.

And these are the types of things that should cause pause for us and have us to consider the questions of why these things happen in certain communities. The underlying point here is that health disparities can be avoided, and that's why it's important to consider the culture and background of the families you serve, and gain more understanding about any unique health challenges or needs that they may face so that you can provide tailored services and education. So, let's chat.

We'd like to hear a bit more from you about the disparities that you noticed in your program or your community. And you can just use the chat box to share with the group. And we'll call up some as they come in. And again, your chat will be seen by the whole group. So, please feel free to chat there.

Steve: Looks like people are typing, Stephanie.

Stephanie: Yeah, I see some folks typing.

Steve: Access to prenatal care.

Stephanie: Yeah, I see that, oral health, good.

Steve: Food insecurity. A lack of understanding about the importance of primary teeth. Access to care. Insurance or under insurance.

Stephanie: Yeah, lots of good -- I mean, not good things -- but lots of ideas coming through in the chat. So, thank you guys for that. Lots of things to think about and consider.

Joanne: A lot of oral health and asthma I'm seeing.

Stephanie: Yeah.

Steve: Yeah, yeah. I was glad to see environmental situations like housing, and parks, and recreation. Those are also contributing factors.

Joanne: Yeah. So, Jan Cox is talking about the lack of health literacy. So, we're going to be talking more about that.

Joanne: Well ... Jan, that's a good point.

Steve: Jan must know what we're going to talk about.

Joanne: Yeah.

Stephanie: Thanks for mentioning that. That's on our list of things today. Childhood obesity, safe housing. Yes, yes, lots of things. So, thank you guys so much for chiming in on the chat today. That's really, really helpful to help inform our conversation today. We recognize that we may be introducing some new terms and concepts to some of you on today's webinar.

So, to ground our conversation, we put this image together to really help you think about some of the terms we're using, such as the social determinants of health, such as health disparities, and eventually health equity. We also hope to be able to help you see yourselves as a part of this equation, if you will, to achieving health equity.

As we noted earlier, many Head Start children and families experience these factors, the social determinants of health such as poverty, homelessness, and lack of access that may lead to health disparities. And these health disparities really can have a negative effect on healthy growth and development. And Head Start Health Services staff have a unique opportunity to really model healthy behaviors and connect children and families to health services and resources that can help mitigate some of these health disparities.

And some of the strengths that we hope to really build upon are utilizing culturally and linguistically responsive practices. If you haven't seen or heard of this book before, this is Multicultural Principles, which Jennifer mentioned earlier. And it really is the foundational document behind this work within the Head Start program. Head Start programs can really capitalize on their existing strengths when their systems and services support the cultural diversity of their families. There are 10 principles outlined in the book, some of which we will talk on more later in the presentation.

But we really want to start with this simple idea. The idea here is that every individual is influenced by their culture, either in their belief or their behavior. And culture is acquired starting at birth through repeated, daily interactions with people that are around as we grow up and as our children are growing up. And this cultural knowledge is really learned as children are starting to develop language skills, learning concepts, and experience the way that they are cared for by their parents, family members, and also their experiences within their communities and caregivers such as the [inaudible] in Head Start.

And culture is passed from generation to generation. And really, home language is a key component of a child's identity formation. And culturally and linguistically responsive practices acknowledge this fact. Research really suggests that we can become blind to our own culture because of our way of thinking and living built up over a lifetime becomes a habit. And our way of thinking and living built into these habits since childhood can lead us to think that our way of doing things is the right way or the only way. And our personal cultural backgrounds really do influence how we think, the values we hold, and the practices we use to support children's development. And to achieve Head Start goals and maximize child and family development, these principles must not be limited to the educational components of the program alone, but apply to all aspects of the program.

So, health services that incorporate culturally and linguistically responsive practices should also consider health literacy concepts. And what is health literacy? So, the U.S. Department of Health and Human Services defines health literacy as, "The degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions."

So, health literacy can affect a person's ability to use health care services, to communicate with their health care provider, to manage chronic diseases or health conditions, as well as change unhealthy or unsafe behavior. And there are many components that really contribute to the health literacy environment such as health information, as we've mentioned. We need to be able to access health information and services that are clear, concise, and relevant.

And since we are talking about language and culture today, it's also important to consider the language and cultural needs when it comes to providing health information and services to families in your program. People who provide health care or health services also need to understand the people that they are serving and really be able to confirm that the person understands that information or services that are being provided, or facilitate connections to services that can assist with any barriers that might exist, such as language.

And then there are policies and processes. Policies and processes are also important because this is what embeds health literacy components into the culture of your program. So, things to consider: Do you have a process in place to ensure that materials are available to families in their native language, or there is a process to make sure that there is a way for materials to be translated and they still make sense culturally? We will talk about this later. I believe Steve has a funny story to share. But it's important to know that not all materials can be translated word for word and still have the same meaning.

Additionally, other considerations might be: Do you have policies that support diversity and inclusion both in your workforce and family engagement practices? And are you providing training and professional development that support staff and family in improving their own health literacy? And, of course, there are the places where health care is provided, which ranges, as you know. Families are able to receive care in many different places and types and settings. And it's important to understand that as a place that does provide or facilitate the connection to health services and information, your program is a part of the landscape here.

And you may already have some ideas about where families struggle to understand certain information or access services. So, as a service provider, it's really important to work with families more directly to understand what their needs are and create a culture of open communication. And finally, the individual person is at the center here because the individual has to have the skills. They have to have the knowledge and the motivation in order to act on the information that has been provided. And a person's culture and beliefs shape their decision.

So, it's important to consider this when thinking about how you support a health literate environment. And when all of these components are considered, and there's education, there is training, and there are resources, and there are policies to support a person to take action on their health, this makes up the health literacy environment. And when the environment is inclusive of and reflective of the family, they are more likely to have an impact on behavior.

So, let's go back to our grounding image. We've talked about how social determinants of health impact a person's health and ability to be healthy and how these factors can lead to health disparities. We've also talked about the role of Head Start Health Services and the importance of those services being culturally and linguistically responsive. We've talked about how Head Start Health Services – coupled with health literacy concepts and support -- can promote health equity. And how are we defining health equity? But before we ... That's a good question. But before we dive into that, we'd like to do a quick poll to see how familiar you are with the term health equity.

So, let's bring up the poll. And it should pop up on your screen there. And you can click your response. Okay. We see some responses coming in. It looks like a majority of folks right now have heard the term and knows what it means. So, that's good. That's really good. Okay. So, I think we're holding at about that 50 percent mark of folks know what it means. So, a good range of responses. Okay. So, thanks, Robin. So, there are several definitions of health equity.

And here's the CDC definition, which states that health equity is when, "Everyone has the opportunity to be as healthy as possible." And we mentioned Bright Futures earlier, and they also have a definition. And they say that health equity is defined as, "Attainment of the highest level of health for all people." And they add a little bit of context to their definition saying, "Achieving health equity requires valuing everyone equally, with focused and ongoing societal effort to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities." And the Robert Wood Johnson Foundation defines health equity as, "Everyone has a fair and just opportunity to be as healthy as possible. And this involves removing economic and social obstacles to help, such as poverty and discrimination" And before we move on, I think it's important to make an important distinction between equity and equality.

I love this image from Robert Wood Johnson Foundation to really help us visualize equity as a concept. A health equity approach means that everyone has the basics that they need for help. And Robert Wood Johnson explains that thinking that the same approach will work universally or equality is like expecting everyone to be able to ride the same bike. And I think this image here is an example of that tailoring that we've continued to talk about in our services and that we provide to families. And I think with a better understanding of health equity and the role you play in supporting families, we hope that you're starting to see the value in tailoring services to fit the families you serve, including dual-language learners. So, with that, I'll turn it back over to Steve to walk through the Health Service section of the DLLPA. Steve?

Steve: Thank you so much Stephanie. So much great information. So, people responding in the polls and in the chat box. Let me remind folks that all of the handouts that we're mentioning today are in the Files to Download pod right underneath your slides there. They can all be downloaded right onto your computer, including this, the actual Health Program Services section of the DLLPA. And in the web link pod there is a URL that will take you to the entire DLLPA. Unlike the Management Systems sections of the DLLPA or the other Programs Services section, especially Education and Child Development Services, the Health Programs Services section is relatively short, but that doesn't make it any less critical.

As Stephanie explained about the serious impact of health disparities, and Joanne described Head Start Health Services, we are all in a unique position to help children and families overcome the barriers they may face, achieving positive, lifelong health outcomes. The eight items in the Health Programs Services section allow grantees to assess where they stand on providing culturally and linguistically-competent health services to dual-language learners. After that process, programs may want to look at resources to inform their action plans.

Let's take a look at each item and where to go for more information. The first item in this section of the DLLPA is to provide our families with easy-to-understand information about common health issues and services in their preferred language. Health education materials are most effective when they are science informed and aligned with a learner's cultural, linguistic, and developmental needs. Understanding health information makes it easier for families to take care of themselves and their children. Families are more likely to keep well child appointments and get follow-up treatment when they understand what is being asked of them and why it matters.

When families and early care and education staff have access to and can understand health information and how to use it, children are more likely to miss fewer days of school due to illness, avoid unnecessary trips to the emergency or urgent care facility, and be injured less often. For these reasons, all health information should be easy to read and given to families in their preferred language. By intentionally selecting the best information, it shows you know your families and their health needs and can help families set goals that promote health. The National Center on Early Childhood Health and Wellness developed these seven health tips for families currently available in 13 languages. And we continue to translate into additional languages.

Information can be shared program wide, such as on a bulletin board, used one at a time to support classroom curriculum, or disseminated selectively as the family establishes a specific health goal. NCECHW also developed health education materials for parents and staff available in English and Spanish on lead awareness, home safety, reducing stress, understanding depression, and responding positively to your child's behavior. These can all be found on ECLKC under Family Support and Well-Being. If you are still looking for a particular topic in another language, please contact us at Help@ecetta.info.

The next item in the DLLPA has to do with authentically partnering with families using relationship-based engagement skills. Culturally and linguistically responsive practices respect the health beliefs and linguistic needs of diverse populations. Culturally and linguistically responsive practices result in more effective partnerships with families and with staff. There we go. CLRP can help programs develop an awareness of, respect for, an appreciation of individual and cultural differences, learn accurate information about families, apply knowledge and awareness of different health beliefs and traditions, identify each family's preferred language and literacy level, provide language assistance at meetings, trainings, and program activities, and provide written translated materials for communicating health information.

So, here's another chance for you to chat. I know you like chatting. How do you obtain information about each family's beliefs and practices? So, jump into the chat box. Thank you, Sarah. I see your starting and several other people.

Stephanie: Yeah, we've got several folks chatting or trying to get in their answers there I see.

Steve: Yeah, I know there's always a delay. Through relationship building and the first few home visits. Oh, home visits are so important in both Early Head Start and in Head Start when it's possible and during enrollment, through their outcomes and assessment forms. Family goal setting. Intake. Oh, simply talking. Authentic conversations. I love that, Laurie. Thank you. A home language survey that they use in York, Pennsylvania. Thank you, Stephanie. During orientation. Lot's happening at the beginning of the year. Hopefully, it continues throughout the year.

Stephanie: Oh, motivational interviewing, Steve, that's a good one.

Steve: There you go! Yes, it is. It's one of our center's favorites. Family plan development conversations. Thank you, Ann. Okay, well people can continue typing. We thank you for this great engagement. This is what we want. Don't stop. A family map? Christina, I'd love to hear more about that. Okay. Keep typing.

So, of course, families are our best resource for learning about their cultures and their languages. But no resource can replace the specific concerns of any one family. For more general information, consider engaging culturally-specific community partners from places such as social service and faith communities to help you learn more about beliefs and practices. The ECLKC also has a number of helpful resources such as Raising Young Children in a New Country, Making It Work, Implementing Cultural Learning Experiences in American Indian and Alaskan Native Early Learning Settings, Partnering with Families of Children Who are Dual-Language Learners. And there are cultural backgrounds and various refugee and cultural groups new to the United States. This is background information about families from the Mixtec, Zapotec, and Trique indigenous peoples of Mexico, from Burma, formerly known as Myanmar -- I mean also known as Myanmar, excuse me -- Bhutan, Somalia, and Iraq. So, take advantage. And those links, again, are in the resource handout in the Trials pod.

The next item in the DLLPA Health Services section is that something that every Head Start and Early Head Start program has many opportunities to combine second or third language acquisition with the teaching of healthy habits. For instance, signs around the classroom might be both instructional and language-rich. Healthy behavior such as handwashing, tooth brushing, and well-balanced meals can also be opportunities to build literacy in more than one language.

Here's a graphic depiction of a healthy lunch in Arabic and a handwashing poster in Cherokee. Health messages for adults can also reinforce important health practices and acknowledge that staff and volunteers are also dual-language learners. And Stephanie, you've been very involved in this particular series of handouts. You want to talk more about that?

Stephanie: Sure. Thanks, Steve. Yeah, this is just another example of a resource designed for dual-language families. This specific resource was created by the Institute for Healthy Childhood Weight and is related to early and responsive feeding, which is also influenced very much by culture. So, this entire suite of resources is available in English and in Spanish and covers additional topics such as breast feeding, complimentary food introduction, as well as picky eating. The suite also includes videos that are available in English and Spanish as well. Thanks for allowing me to share that, Steve.

Steve: Thanks for creating it. So, translation changes the message from one language to another, but merely translating materials is not enough to transmit the full meaning of the message. Stephanie promised you a funny story. I won't be able to hear you laughing, but I hope you do laugh. An advertising company was hired to promote chicken to Spanish-speaking communities. Their slogan, "It takes a strong man to make a tender chicken," was translated onto Spanish billboards all over the country as, "It takes an aroused man to make him a chicken affectionate." This is not the message the client was trying to convey. [Laughing] Thank you for the laughing there. Oh, we got some laughing in the chat box, too. Thank you. I have a whole bunch of examples, but we don't have time to go through them. In Head Start and child care programs, we run the risk of giving the wrong message, possibly a harmful message, unless we engage in transcreation.

Transcreation involves taking a concept in one language and completely recreating it in another language. Programs can work closely with families, staff, and community partners to make sure that messages are not merely matched word for word, but also convey the same emotional impact and in the context of their culture of origin. A successfully trans created message in words or in pictures evokes the same emotions and carries the same implications in the target language as it does in the source language but in a way that resonates with the target audience.

Two items from the DLLPA Program Services section involve food. Engaging families around meal planning may sound like a simple strategy, but it can be quite powerful. Foods may differ from country to country, region to region, culture to culture, and family to family. But food is also a great unifier. Each of us grows up eating the food of our own culture. It becomes a part of who we are. Food is an important part of culture. Traditional recipes are passed from one generation to the next. Food is also one expression of our cultural identity. Immigrants bring the food of their countries with them. And cooking can be a way of preserving culture, a symbol of pride, and a means of coping with homesickness in new places.

Your program menus can reflect each child's cultural traditions by regularly including healthy foods they know from home and/or their countries of origin. What's Cooking? USDA mixing bowl is one of many websites that provides web ... That provides recipes and resources, sorry, to support building healthy and budget-friendly meals. What's Cooking? was developed through collaboration between the Center for Nutrition Policy and Promotion, SNAP, the Child Nutrition programs, and the Food Distribution division. The site offers household and large quantity recipes in both English and in Spanish for CACFP and National School Breakfast and Lunch program participants.

It is a rich resource of easy-to-prepare, multicultural foods. Moreover, it's user-friendly. Searchable features are designed to encourage key behaviors emphasized in the current dietary guidelines for Americans while using diverse cuisines. And we have a whole handout in the Files pod there of more recipes that you can -- and cookbooks -- that you can download and use. Not every facility is able to allow cooking on site. When it is possible, family members can bring their own recipes, speak about their food, and help children or staff prepare a special dish or meal. When this isn't possible, consider having families instruct food service personnel in shopping for our cooking items that represent their culture. The ingredients for engaging families around food do not have to be rare, unusual, or complicated. It may be as simple as mixing together items that you might not have considered before, using a new spice or condiment, or preparing common foods in a new way.

Food is just one way to involve families in bringing culture and language into your early childhood programs. Another time to chat here. How do you [inaudible] menus reflect the foods that your families enjoy? Ramona, to answer your question about whether the recipes are in English, yes, they're all translated even though they are from other countries. And while people are chatting about how their menus reflect ... I see a question, how to prevent using trans ... If a translator is not available.

You have to be really careful with health information using translation services. They don't always translate correctly. They're usually word for word. And that's why we encourage you to use community partners. Even if you don't have certified translators, use some community partners, the faith community, the social service community, the medical community that can re-look at your materials. I always suggest back translating when you're translating materials.

So, once it's translated into the new language, then have it back translated back into English and see what it is word for word. There's a story about an airline that was advertising its new leather seat. And instead of, "fly on leather," it said, "fly naked," which was not what the airline was encouraging. I have lots of these stories.

Stephanie: Steve, you just keep the stories coming. That's great.

Steve: Yeah. Unfortunately, there are many. And many of them are in advertising. But in health, we have to be really careful. So, we see a lot of people here talking to parents about menus, getting input. That's what we want to see.

Joanne: Oh, there's a call out for the brush up on Oral Health Cook's Corner.

Steve: Oh, yes! Thank you, Beth. You're not biased there, Beth. And let me say that the work that Beth and her colleagues have done on the Oral Health Cook's Corner is available in English and Spanish. So, that book of recipes is in both languages and guaranteed to be healthy. Okay, thanks for typing, and keep typing in as we move forward. The Head Start Program Performance Standards give every program a valuable strategy for improving their culturally and linguistically responsive practices. Family representation on their health services advisory committee not only informs your program of the health needs of the children in your care, but it is also an opportunity for community partners to learn and share what they know about their clients.

Weaving Connections is designed to help programs create and maintain strong health services advisory committees. The HSAC gives families a platform to express themselves. It is also an opportunity to recruit partners to both care for and represent the community in which you are located. These partners could be nurses, they could be nutrition professionals like you have at WIC, health care providers, first responders like you have at your EMT stations, firefighters, police officers, public health professionals represented by your local boards of health, and oral health professionals. So, keep looking, think out of the box, and look for people that are working with the families you care for.

So, how do you ensure that all your families are reflected in your health services advisory committee? Here's another chance to chat in the chat box. Thank you. Oh, Lettie, thank you! Glad to see you're here, Lettie. I see lots of people had other ideas about recipes while folks are typing. There's always a little delay here.

Joanne: She was just mentioning the 5-2-1-0 program.

Steve: Yep. And there ... So, we have programs that ensure there are always translators available, a range of ... Thank you, Amy. A range of community partners that work with similar populations. That's what we're really talking about. Including them in menu planning and nutrition meetings. Making sure there are interpreters. They have an in-house translator at Pam's program. Always getting parents' feedback.

Inviting members to the policy council. A great way to build leadership skills. Unusual partner like Habitat for Humanity. Thank you, Lettie. I'm sorry, what did you just say Joanne?

Joanne: No, I'm just saying I'm seeing a lot of folks inviting parents and using the parent meeting.

Steve: But I always like thinking outside of the box, so Habitat for Humanity, wonderful. Housing is always such an important issue. And they really know some important things. Okay, I think people are still typing. But Joanne, I'm going to pass the slide over to you.

Joanne: Great. Thanks, Steve. And thanks everyone for all that great sharing. So, as Steve was saying, having families involved in the [inaudible] is just one way that Head Start can engage with parents. And it's engaging with parents and community partners that's such a critical piece of health equity work. Involving parents through a variety of leadership, and civic engagement, and advocacy activities are all part of the work that we do in Head Start. But it's really these collaborative partnerships that we develop with parents that then empower them to be able to advocate for health equity within their communities.

So, the parent leadership piece of this is so important. In essence, the way I like to think about it is that Head Start can serve as a catalyst to support family members who wish to be empowered and educated on how they can address community-wide conditions, those social determinants of health that Stephanie had talked about earlier, that impact their family's health and well-being. So, while Head Start can assist family members in getting involved in health equity work, Head Start, though, as well as an organization, plays an important role in being able to be part of community networks and referral systems on the local level. It's these local networks that are important in connecting families to the services that they might need that go beyond what Head Start might be able to provide. So, it's facilitating those kinds of referrals for families like we do in Head Start that is, in essence, health equity building work. So, I'll hand it back to Steve to talk about the next item on the DLLPA tool.

Steve: Okay, thank you, Joanne. Ooh, we jumped ahead. Thank you, Joanne. I see some folks were worried that we ... They thought maybe the DLLPA was required. It's not. But being culturally and linguistically appropriate is in the DLLPA is a tool that OHS has created for you to think about your program. So, this item and the next one really address health services in a very specific way. And they build on some of the previous items we've already talked about. Now that you've established relationships with families and learned about what they need, what they feel, and what they believe, you are better prepared to communicate around any child health concerns they or staff may identify.

The Resources handout in the file below has links to resources such as culturally-appropriate positive guidance with young children, culturally-sensitive care, cultural competence and health promotion, and a guide to choosing and adapting culturally and linguistically-competent health promotion materials. Every child needs an ongoing source of continuous, accessible physical and oral health care provided by a health care professional. While skilled medical and dental care is important, linguistically-capable and culturally-competent medical and dental staff are also critical to reaching health equity. Your handout in the resources ... There are handouts in the resources below such as Head Start in the Medical Home, Culturally and Responsive Practices and Oral Health in Rural Areas from our Brush Up on Oral Health Series, and Bridging the Cultural Divide in Health Care Setting, the Essential Role of Cultural Broker Programs.

Joanne: Steve, this is Joanne. You know, as we're talking, I feel ... I'm very struck by how important and yet challenging this work around health equity and dual-language learners can be. So, my question to you is, do you have any example of how this is happening on the programmatic, on a local level, like a real-life example?

Steve: Well, thank you, Joanne, because we do. And here they are on the screen. They are the Children's Center in Jackson, Wyoming. And here is their story of how they successfully met the physical and mental health needs of their dual-language children and families. The Children's Center in Jackson has a funded enrollment of 40 center-based Head Start children and 48 home-based Early Head Start pregnant women and children. More than 95 percent of their participants identify as being of Hispanic or Latino origin and speak Spanish as their primary language at home. Jackson, Wyoming, for those that don't know, is in Teton County. It is considered a two-season community. Consequently, and unfortunately, many employers do not provide health insurance as they consider their employees to be part-time. The Children's Learning Center is a story of Head Start partnerships with the medical and mental health community to provide comprehensive services that are both individualized for children and families.

Joanne: Steve, again it's Joanne.

Steve: Yeah.

Joanne: If I may ask, how did the learning center figure out what their needs really were?

Steve: Well, it didn't happen overnight. Almost 20 years ago, Joanne, a study assessed Teton County's access to care among the uninsured and Latino immigrant population. And they came up with two findings. One was the need to increase affordable primary care services, and the other, a need for community-wide health care interpretation services that allowed access to all types of care. As a result, the Teton Free Clinic was started in 2003.

Stephanie: Wow! Steve can ... This is Stephanie. I'd like to jump in here because I used to work at a hospital system that operated our free clinic. And I was always fascinated about how they made that work. So, can you say more about what they're doing in Jackson to make that free clinic work?

Steve: Yeah. I'm so lucky. The program and their partners were so generous with their time and their information, so I do have that. The Teton Free Clinic provides free primary medical care for low-income and uninsured and medically-underserved people from all walks of life who live and/or work in the county. The clinic receives no federal funding. It is supported entirely by donations in the community and a few grants from local community foundations. TFC is currently open one evening a week and is staffed primarily by volunteer physicians, nurses, medical translation, and community volunteers. They see approximately 25 to 30 patients a week.

And this year, a new project, in conjunction with several other organizations in Teton County, including Head Start, the hospital, the public health department, farmer's markets, food security program, they started a pilot program to help diabetic patients. This new program includes subsidies to help pay for insulin, diabetes education classes, exercise and nutrition classes, education about and access to healthy food choices. So, really remarkable.

Joanne: You know, Steve, this is so remarkable. And I'm so interested in hearing about this because of the work that I do and really working to try and bridge -- build bridges between pediatric and health care settings and early childhood. But I'm also curious, what did they do about the need for having services, though, in other languages?

Steve: Well, they really worked hard. And now they have two agencies that address the need for interpretation. One is called Lavose and the other is 122. They are comprised of experienced and culturally-competent social workers, advocates, educators, and language experts. Their teams of interpreters provide interpretation in a variety of health care and social service settings. So, really across the board.

Stephanie: Thanks, Steve. This is Stephanie, again. I'm really intrigued by the ability to offer social services as well because we know those wraparound services really are critical to families. So, can you say more about how they're doing that and what's happening?

Steve: Um-hum. Sure can

Stephanie. Thanks for asking. So, not surprisingly, mental health is a major focus due to the vulnerability of the Head Start and Early Head Start population. So, the Children's Learning Center partners with the community resource center and with La Familia counseling services to provide treatment in different languages. Originally, they planned to provide group options for families seeing that as something that was more affordable, but that didn't quite work out. So, they reassessed, and they now do referrals and individual work that have turned out to be very, very successful. The partnerships allows families and children to be served through a mix of funding, including Medicaid, Medicare, private donors, and other resources.

Joanne: Steve, I'm so interested that so much came from these community partnerships that we had talked about earlier. So, I'm also wondering, did anything else happen as a result of these initial partnerships?

Steve: So, they have a long history. As I said, they go back almost 20 years. And all of these successful community partnerships have led to even more collaboration. They developed a Latino Leadership Academy and trained parents on professionalism and civic engagement. The community partners promised not to tell the parents what to do, but allow the parents to make their own decisions. Their final action plan created three groups, one to focus on health, one on education, and one on housing. One of those endeavors that was created is called First in Family. And it provides mentorships and scholarships for 11th and 12th grade high school students. And a number of its recipients are Head Start graduates now in prestigious colleges and universities. And, thank you Joanne, and Stephanie for your questions. And I see in the chat box people were really excited. I know the director Lettie Liera is on. I just can't thank you all enough at the Children's Center, your health manager, Cheri Flores, your partners Julie Angelo-Kabatzy, and Vita de Sanchez. Your hard work, your generosity, and most of all for today, your willingness to share your journey. I know it wasn't an easy one.

[Multiple women]: Thank you. Yeah, for everybody there.

Steve: So, now we'd like to know what partnerships you've developed that might address health equity issues for your families? So, jump right in there.

Stephanie: We've seen Steve from the chat folks partnering with WIC, Habitat for Humanity, AARP, Food Bank, state rep office, which is good. We're getting some local advocates there. So, that's awesome.

Steve: Local banks for financial literacy. Thank you, Leslie. Give to the Smile. Yeah. For those don't know ... Mobile dentists. Indian Health Center. In urban environments. Food banks. Pediatricians. I like to see pediatricians working with Head Start, Joanne.

Joanne: I know. I'm loving it!

Steve: Readily-qualified health centers. WIC. Please use WIC. Boys and Girls Club. More Indian Health Centers. Great. Working at the local hospital. So, folks are working with partners. You can't do it alone. Keep typing. I love so many ... I've been doing this for a long time, as I said, and I have not thought about working with Habitat for Humanity. So, I love that several of you have mentioned that. That's great. We've got insurance companies involved. Cool, good for you!

Joanne: And local community colleges. I think they often are an untapped resource. So, I like ...

Steve: Absolutely, yeah.

Stephanie: And nursing schools, especially for those providers, especially young nurses, that we don't get all of the training that we know is needed in the course work, in the curriculum. So, it's important to tap in to those folks early. So, that's good.

Steve: I saw that someone typed in a faith-based community. And I can't stress enough, particularly for newly immigrant -- immigrated families -- how strong the faith-based community can be and how the leaders in those community organizations can be helpful to you both with language, but with cultural norms and resources. Oftentimes, immigrant groups come, and the first thing they do is establish some kind of formal or informal community around faith. Dental students. Grocery stores. Yes, grocery stores. Great! When I was a Head Start director our grocery store printed information on, in those days, paper bags to link people to Head Start with messages. I'm sorry, Stephanie. I interrupted you. Go right ahead.

Stephanie: No. that's okay. I was just going to say I was looking at HUD and Section 8. And one that stood out was domestic violence shelters, especially with homelessness being an issue, and tapping families where they are and being able to connect with all of those wraparound services. Right? So, that's huge.

Joanne: I wanted to ask folks, because I'm looking at the chat, but it does go by quickly. I'm wondering if anybody -- I know -- if anybody works with advocacy groups. And I'm thinking in particular around the piece around parent leadership, advocacy skills, civic engagement. Are folks working with advocacy organizations in that realm?

Stephanie: There was one that she's working with her state rep office, which is huge. I used to do advocacy, and it's a challenge to be able to go and talk to your state reps, and your city council people, and all that. So, they can be intimidating. So, it's important to provide those skills and to let folks know these folks are here to work for you. So, you have a right to talk to them. Call them and, you know, advocate for yourself and your community. But it can be a challenge.

Steve: Leslie is working with the Mexican consulate in New Mexico. That's interesting. And yes, Natalie, you bring parents to Advocacy Day at the state capital. I did that every year. We had children -- we were close to the state capital where I worked in Massachusetts. And we actually brought kids, too. Nothing creates a commotion more at the state house than children. [Chuckles] Leticia, I'm not sure if you meant to type those numbers and letters. If you did, I don't know what it means.

Joanne: We need translation!

Steve: Yeah, there you go. Madge has, has a state rep that was a Head Start graduate and so is readily available for advocacy. That's great! We have wonderful Head Start success stories all over the country.

Stephanie: Mm-hmm, that's great.

Steve: While people are typing and before we move to the next slide, I wonder if this is a good time to see if anyone has any questions. I know some came by, we tried to address. April, Robin, and Katie were busy typing in the box -- in the chat box. But if there are questions, this is a good time to type them in because we're going to ask you about next steps. Managed care organizations. Yes. Medicaid. Actually, when they fund managed care organizations have people that can help families navigate the system. Oh, the mayor's wife! Oh, that's great. Deborah and Antonio, very nice. It also could be the mayor's husband if the mayor's a woman or same-sex couple.

Stephanie: Absolutely.

Steve: Getting second inhalers and spacers to bring to the program. Yes, Leslie, that's sometimes a challenge for children who are on Medicaid, getting that and making it happen. The health department reached out. More resources in audio and video form because our Spanish-speaking families have very low literacy. Let me say that to Grace, in the Resources file, I believe there's a link to HealthyChildren.org. That's the site that's established by the American Academy of Pediatrics. And it's designed specifically to answer parent questions on nearly every topic you can think of. And nearly every page, it's translated to English and Spanish and has an audio and print. And some of them are in video; more and more in video. Also KidsHealth.org, our colleagues at Nemours in Delaware have a wonderful site.

So, that's HealthyChildren.org and KidsHealth.org. Also, their materials are designed for parents and for staff. They have different sections in English and Spanish, audio and print. Yes, special health foundations like the Epilepsy Foundation, the boards of nursing, the boards of pharmacy. The local Allergy and Asthma Foundation, absolutely. I used them all the time when I was at the program level. Leticia's asking, "Shouldn't the managers and assistants or people in charge do surveys to know more about what parents need?" We all need to engage with parents to find out what parents need. Leslie, you used your regional health specialist. We're glad to know that.

I think things look like they're slowing down here, and people are starting to move away. We don't want to lose people because we have a little bit more to say. So, I'm going to bring ... MyPeers. Yes. Please use MyPeers. We're going to talk about that. We have another poll. Robin, could you bring up the poll about next steps? We know this isn't fast or easy work. It's a journey. But we've talked about the DLLPA and particularly the Health Programs Services section.

So, we wondered if you wouldn't mind sharing what you might be doing next. And we've given you a lot of options. And we'll bring back the chat box if your option isn't here. I'm excited to see that a lot of people are going to look at the DLLPA more closely. I'll bet, based on the first poll we did, a lot of people hadn't looked at it. It was new. And that was really part of our work this year with this series. And I'm sure Jennifer will mention that. Oh, we've got a third of the folks are going to bring it back to their health services staff and discuss it. And another -- almost more than a third -- bringing it to a management team. A few are talking about a policy counsel and HSAC. Just a few talking about it to a governing board.

And I'm happy to see, we've got at least 12 people who are going to start implementing the whole Health Program Services section as soon as possible!

Stephanie: Yay!

Joanne: Yay!

Steve: But the fact that more than 3/4 of you are going to look at the DLLPA more closely warms my heart. I don't want to step on Jennifer's toes because I know she has a big heart, and I know it's feeling very warm when she sees you saying that. So, Robin, let's close the poll and bring back the chat box. And if anybody has other next steps, please let them ... Type them in the chat box. And here we go. And we're going to have Jennifer speak. And then we'll come back for the final part of today's session. Jennifer!

Jennifer: Thank you, Steve. So, today we conclude the implementing the Dual-Language Learner's National Webinar Series. Let's reflect. In summary, I want to review the DLLPA launch and implementation support hoping to offer a springboard for the expansion and sustainability of your efforts to intentionally introduce and support the use of the DLLPA with your programs and the staff to support the full and effective participation of children who are dual-language learners and their families.

So, as Steve mentioned earlier in the beginning of the presentation, in August 2018, we were very enthusiastic to launch the DLLPA as a way to address coordinated approaches for management systems and programs services. With this introductory webinar and associated resources, we presented the nature and the scope of the program assessment. We also demonstrated how to use the tool and the results of the ratings to strengthen management systems and the program services areas.

As a result of the introductory webinar, you asked us to create the National Webinar Series to support you in your daily efforts and support you in providing high-quality services for all children and families. So, we did.

So, over the past four months and concluding with today's health equity webinar, we have approximately 5,000 people who registered to participate in the implementation of the Dual-Language Learner's Program Assessment Webinar Series. Each of these broadcasts offer explicit examples on how regional TA systems and Head Start programs are implementing the use of the DLLPA in the old programs to focus on continued quality improvement. We make sure that the voices and the journeys from our grantees were also included in each of the webinar series. This has been a truly comprehensive process that is responsive to supporting the needs of our HSAC programs serving children who are dual-language learners and their families.

If perhaps today's in this webinar was the beginning of your DLLPA journey, I encourage all of you to lean and explore the introduction of the DLLPA and the previous closer look webinars, which will be coming soon to be posted at the ECLKC.

As you move along, don't hesitate to reach out to us and identify ideas for other material, helpful work, and Head Start programs or share your experiences in the CLRP MyPeers Community. As for Head Start, we will continue to intentionally plan, implement, and move forward I will work to support diverse children and families who will directly work across the regions with specifically connected activities to support our regional TA and staff and our TA systems. We will make sure that we work with you to support the needs of our grantees' programs. We will spend time with the national centers to gather and analyze all the data that you have shared with us in the past couple of months to really move forward with the implementation of our work to continue to support diverse children and families.

So, before and in closing my remarks, I also wanted to thank all of you who are participating in today's webinar for your ongoing effort, your daily commitments, and your passion to provide high- quality services to all children. Thank you Steve, and thank you everyone who worked so hard to put together today's webinar. Thank you.

Steve: Thank you, Jennifer. I want to remind people that the National Center on Early Childhood Health and Wellness is available to answer your questions now and in the future. If you write to help at ecetta dot info, you can find our resources on the Early Childhood Learning and Knowledge Center. We also administer the health, safety, and wellness community on MyPeers. And we look forward to hearing everyone's ideas on meeting the health needs for all children and families. And before we sign off, I want to ask you to please choose the feedback survey link in the Link pod to evaluate today's session. It will open up in a new window when you select it and select "Browse To." If you do want a certificate of attendance for today's session, download it now from the Files to Download pod, along with any of the other handouts you might not have had time to download. Those, too, will open up in a new window. Robin, we'll keep this open for a few more minutes. But I want to thank you. And Joanne and Stephanie, have some last words from you?

Joanne: Just again, thank you for being with us. This is such important work. I know we all have a passion for it, and we just feel honored to be in it with you.

Stephanie: Ditto.

Steve: Okay. And you're looking for the certificate, you need to use the scroll bar on the Files pod. It says DLLPA Webinar Certificate under the Files to Download. But you do have to use the scroll bar because we have so many handouts today. Lettie, thank you very, very much for sharing your story. April, Robin, and Katie, thank you for handling things backstage. Thank you to the crew.

Steve: Yeah.

Jennifer: Thank you, Steve.

Steve: And Jennifer, and I know you're with Suzanne, thank you both. And I think we're watching people slowly sign off. I want to give them a chance to make sure they get the evaluation and the certificate. Thank you, April. If you haven't downloaded your materials yet, please do so. For those of you that were on the phone, only you'll be able to access these handouts when the email comes to you with the recording and when it's archived on ECLKC.

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