Integrating Child Health in Child Care

Ruchi Gupta, MD, MPHRuchi Gupta, MD, MPH

Steve ShumanSteve Shuman

Elsie Taveras, MD MPHElsie Taveras, MD MPH

Jonathan Finkelstein, MD MPHJonathan Finkelstein, MD MPH

Health Promotion

Health promotion education and Health promotion education and “anticipatory guidance” central to “anticipatory guidance” central to pediatric carepediatric care

Overloaded office visits, pediatricians Overloaded office visits, pediatricians increasingly interested in coordinating increasingly interested in coordinating with community partnerswith community partners

Why Child Care?

Over 60% of children < 5 y.o. (12 Over 60% of children < 5 y.o. (12 million) are in some form of child caremillion) are in some form of child care

Child care centers are increasingly seen Child care centers are increasingly seen as “early education” rather than as “early education” rather than custodial carecustodial care

The Partners

Clinicians:Clinicians: Credibility, content expertiseCredibility, content expertise Effective brief interventionsEffective brief interventions

Child Care StaffChild Care Staff Daily contact (albeit brief) with parentsDaily contact (albeit brief) with parents Trusted relationshipTrusted relationship See themselves as educatorsSee themselves as educators

Existing Linkages

Child Care Health Consultant (CCHC) for all Child Care Health Consultant (CCHC) for all licensed group day carelicensed group day care Can be physician, registered nurse, nurse Can be physician, registered nurse, nurse

practitioner or physician’s assistantpractitioner or physician’s assistant Review and approve the child care program Review and approve the child care program

health care policyhealth care policy Approve the first aid training program for staffApprove the first aid training program for staff Available for consultation as neededAvailable for consultation as needed

Main Goal

To determine the needs and potential To determine the needs and potential opportunities for health promotion opportunities for health promotion education for families and staff through education for families and staff through the child care centerthe child care center

Overview of Methods

Self-administered survey: Self-administered survey: Mailed to 160 Boston child care centersMailed to 160 Boston child care centers Mailed to 88 health consultantsMailed to 88 health consultants Given to 240 parents in 16 randomly Given to 240 parents in 16 randomly

selected centersselected centers Collaboration with Massachusetts DPHCollaboration with Massachusetts DPH Collaboration with HeadstartCollaboration with Headstart

Survey DesignChild Care Director SurveyChild Care Director Survey DomainsDomains

1.1. Unmet health needs for parents and staffUnmet health needs for parents and staff

2.2. Current child care health promotion activitiesCurrent child care health promotion activities

3.3. Barriers to providing health educationBarriers to providing health education

4.4. Opportunities for health promotion educationOpportunities for health promotion education

5.5. Health consultant’s roleHealth consultant’s role

6.6. Director and center demographicsDirector and center demographics

Survey DesignChild Care Health Consultant SurveyChild Care Health Consultant Survey DomainsDomains

1.1. Unmet health needs for parents and staffUnmet health needs for parents and staff

2.2. Barriers to providing health educationBarriers to providing health education

3.3. Opportunities for health promotion Opportunities for health promotion educationeducation

4.4. Health consultants’ current and desired Health consultants’ current and desired rolerole

5.5. Personal and professional informationPersonal and professional information

Survey Design

Parent SurveyParent Survey DomainsDomains

1.1. Unmet health needs Unmet health needs

2.2. Current sources of informationCurrent sources of information

3.3. Barriers to receiving health educationBarriers to receiving health education

4.4. Opportunities for health promotion Opportunities for health promotion educationeducation

5.5. Demographic informationDemographic information

Results - Response Rates

After 2 sets of mailings and one set of phone After 2 sets of mailings and one set of phone calls…calls…

Directors – 60% (97/160)Directors – 60% (97/160) Health Consultants – 64% (56/88)Health Consultants – 64% (56/88) Parents - 58% (138/240)Parents - 58% (138/240)

Parent Survey:Baseline Characteristics

Variable (%)Variable (%)RelationRelation: Mother: Mother 81 81

FatherFather 10 10

Grandparent/OtherGrandparent/Other 7 7

AgeAge:: <20 <20 6 6

21-3021-30 31 31

31-4031-40 41 41

41-5041-50 19 19

>50>50 3 3

Variable (%)Variable (%)RaceRace: White: White 33 33

BlackBlack 44 44 Hispanic 17Hispanic 17

Other 4 Other 4

IncomeIncome: <15,000 15: <15,000 15 15-35 4115-35 41 36-55 11 36-55 11 56-75 756-75 7 >75 22>75 22

Parent Survey:Baseline Characteristics

Variable (%)Variable (%)

EducationEducation: :

88thth Grade Grade 1 1

Some High School 4Some High School 4

High School Grad/GEDHigh School Grad/GED 20 20

Voc/Tech SchoolVoc/Tech School 4 4 Some College 35 Some College 35

College Grad 20College Grad 20

Post-Grad 15Post-Grad 15

Variable (%)Variable (%)People living in homePeople living in home:: 22 2020

3 3 3434

4 4 2424 55 22 22

Adults WorkingAdults Working: : 11 54 54

2 382 38 33 7 7

44 0 0 55 1 1

Director Survey:Baseline Characteristics

Variable Variable (%)(%)

SexSex: : Male Male 2 2 FemaleFemale

9393 EducationEducation::

School Diploma/GEDSchool Diploma/GED 4 4Associate DegreeAssociate Degree 12 12Bachelors DegreeBachelors Degree 42 42Masters DegreeMasters Degree 35 35DoctorateDoctorate 1 1OtherOther 5 5

Variable (%)Variable (%)RaceRace: White: White 52 52

BlackBlack 37 37

Hispanic 8Hispanic 8

AgeAge:: <20 <20 0 0

21-3021-30 10 10

31-4031-40 23 23

41-5041-50 26 26

>50>50 38 38

Consultant Survey:Baseline Characteristics

Variable Variable (%)(%)

Profession: Nurse/NPProfession: Nurse/NP4747

Pediatrician/FP Pediatrician/FP 5353

SexSex:: Male Male 3232

FemaleFemale5959

Variable (%)Variable (%)

RaceRace: White: White 68 68

BlackBlack 16 16

Hispanic 4Hispanic 4

Other 4Other 4

Place ofPlace of

Work:Work: Clinic 29 Clinic 29

HospitalHospital 21 21 Comm. Health Comm. Health

CenterCenter 29 29

Other 29Other 29

The need for health promotion education in child care

Descriptive analysis

Sources of Information for the parents

SourceSource Sometimes/OftenSometimes/Often

Child’s doctorChild’s doctor 69%69% Family membersFamily members 55%55% MediaMedia 55%55% Materials distributed in child careMaterials distributed in child care 41%41% Staff in child care centerStaff in child care center 41%41%

Facts about educational information received by parents

90% of the child care center directors said 90% of the child care center directors said they provide health information they provide health information

65% parents said they receive the 65% parents said they receive the informationinformation

1.8% of parents said they are satisfied with 1.8% of parents said they are satisfied with current informationcurrent information

Need for additional health education to parents

IssuesIssues ParentsParents DirectorsDirectors ConsultantsConsultants

DevelopmentDevelopment 55%55% 57%57% 42%42%

BehaviorBehavior 55%55% 74%74% 48%48%

SafetySafety 51%51% 55%55% 46%46%

NutritionNutrition 38%38% 61%61% 53%53%

Emergency Emergency managementmanagement

55%55% 39%39% 29%29%

Physical Physical activityactivity

40%40% 56%56% 42%42%

Extremely Valuable

Strategies to provide families with health education

StrategyStrategy PP DD CC

Educational session by HPEducational session by HP 74%74% 91%91% 89%89%

Handouts on health topicsHandouts on health topics 79%79% 88%88% 63%63%

Bulletin boardBulletin board 69%69% 79%79% 61%61%

Website with health infoWebsite with health info 63%63% 70%70% 44%44%

Moderately-extremely Valuable

Child Care Health Consultation: Do Physicians and Nurses

Differ?

• Descriptive analysis

• Fisher’s Exact Test used to compare physician and nurse responses to

select items

My children/patients/

friends were attending

14%

Was Asked To16%

Part of the job/neighborhood

29%

Like to give to the community

41%

What Motivated You to Become a Child Care Health Consultant (CCHC)

How significant are the following barriers/ challenges to your work as a child care

health consultant?

Barrier / ChallengeBarrier / ChallengeModerately- Moderately- extremely extremely significantsignificant

Insufficient time to do this workInsufficient time to do this work 36%36%

Lack of financial compensationLack of financial compensation 12%12%

Child care providers don’t seem to need my Child care providers don’t seem to need my helphelp

28%28%

Need clarification/ expectation of the role Need clarification/ expectation of the role 28%28%

Inadequate support form primary workplaceInadequate support form primary workplace 10%10%

Physicians Physicians NursesNurses P valueP value

RewardingRewarding 33%33% 66%66% p= 0.05p= 0.05

CompensationCompensation 0%0% 30%30% p< 0.01p< 0.01

VisitVisit 68%68% 93%93% p= 0.02p= 0.02

Physicians vs. Nurses

PhysiciansPhysicians NursesNurses P valueP value

Usefulness of health Usefulness of health education in child careeducation in child care

76%76% 70%70% p= 0.05p= 0.05

Willingness to provide Willingness to provide health educationhealth education

53%53% 83%83% p= 0.02p= 0.02

Physicians vs. Nurses

$0-$50 $50-$100 >$100

52% 39% 9%

For your activities as a health consultant, what would you consider to be a reasonable compensation rate?

Further Analysis – Health Consultants

Health Consultant predictorsHealth Consultant predictors

- profession- profession - work place- work place

- gender- gender

OutcomesOutcomes

- current and desired compensation- current and desired compensation

- current and desired roles- current and desired roles

- ability to perform intervention- ability to perform intervention

Further Analysis - Families

Predictors for select responses – chi-Predictors for select responses – chi-squared and logistic regression modelssquared and logistic regression models- Race/ethnicity- Race/ethnicity - Household income- Household income

- Center variability - Center variability - Education - Education

OutcomesOutcomes- - Currently receive information from child care Currently receive information from child care

- Select needs- Select needs- Interventions – handouts/sessions- Interventions – handouts/sessions

Further Analysis - Directors

PredictorsPredictors

- SES of children- SES of children - size of center- size of center

- age of children - age of children - education- education

- for/not-for profit- for/not-for profit - race - race OutcomesOutcomes

- current health promotion education- current health promotion education

- need for health promotion education- need for health promotion education

- possible interventions- possible interventions

Finally…

Linking the three populations (families, Linking the three populations (families, directors and consultants) from 16 centersdirectors and consultants) from 16 centers

Looking at Headstart and how it compares Looking at Headstart and how it compares to non-Headstart child care centers in to non-Headstart child care centers in BostonBoston

Conclusions

Families, child care center directors, and Families, child care center directors, and health professionals believe enhancing health professionals believe enhancing health promotion education in child care health promotion education in child care could improve child healthcould improve child health

Physicians and nurses differ significantly in Physicians and nurses differ significantly in their current and desired roles as health their current and desired roles as health consultantsconsultants

Conclusions

New models of collaboration between New models of collaboration between pediatricians and child care can pediatricians and child care can potentially improve the effectiveness potentially improve the effectiveness of health promotion education and in of health promotion education and in turn…positively impact the health and turn…positively impact the health and safety of our children.safety of our children.

Three-Way Alliance for the Child

Pediatrician

Parent

Caregiver