Navigation Models for Early Childhood Education Providers

Pialee Roy, Ph.D.

Health and Education Research Services, Inc.

American Public Health Association (APHA) 2023

Abstract
Early Childhood Education experiences a high staff turnover rate in spite of incentive programs
intended to retain high quality teachers, (Caven, 2021, and U.S. Department of Education, 2016).
Low job satisfaction and depressive symptoms, from financial woes working more than one
minimum wage job may correlate with high staff turnover also, (Caven, 2021 and Roberts, A.M.,
Gallagher, Kathleen, C., Daro, Alexandra A., Iruka, Iheoma, U. Sarver, Susan L, 2019).
A set of logic models are derived after review of the Consumer Assessment of Health Providers
Survey by AHRQ and New Vital Signs by Pfizer, and PEDS Quality of Life inventory, and
Multicultural Assessments, informs an updated logic model for ECE provider and family
navigation to where there may be opportunity for intervention to promote health literacy and
parent health education for better parent child health outcomes for early education settings,
mental health referrals, and utilization of health coaches.

The original model from Roy (2018) describes health literacy levels of parents of young children
and their health seeking behavior as this relates to utilization of primary care, and child health
outcomes for child BMI. The results then influence a trajectory that interacts with lower parental
education, assessments, and referrals, to yield an unknown level of health seeking behavior. The
second path depicts the possible association between lower parental health literacy and high
child BMI interacting with parent education, screenings, and referrals, to yield another unknown
level of health seeking behavior. The two groups are then compared, with differences in
perception in quality of care as a possible mediating factor influencing frequency and utilization
of pediatric primary care.” The model is then updated to reflect incorporating family navigation.

The conceptual model is updated again to reflect the level of professional development seeking
of ECE teachers by comparing the trajectory of federally funded or private pay ECE. The
conceptual model is updated again to reflect the level of professional development and cultural
competence of ECE teachers by comparing the trajectory of federally funded or private pay ECE
centers. ECE teacher demographics would compare with family demographics, plus assessment
scores of level of ECE awareness for incentive programs/loan forgiveness programs/knowledge
of how to complete child assessments and evidenced based programs, instead of Health Literacy
Score could indicate who most requires a professional development intervention.

The intervention opportunity would be professional development training participation and

human resources, career growth options. Then ECE teacher or home visitors could complete a
survey about their education and wellbeing, and awareness levels of career options. Lower
education would lead to likelihood to utilize referrals to CDA scholarships and funding to earn
higher education, resulting in utilization of scholarships, loan forgiveness programs, and other
funding streams to earn a bachelors degree and correlated with job satisfaction and improved
child health outcomes.
Introduction
Increased stress from low minimum wage work in the Early Childhood Education (ECE) field
may lead to recommendations for increasing professional development to increase both
knowledge base in the field, thereby increasing eligibility for higher pay. How can minimum
wage paid ECE providers afford professional development like Child Development Associates
credentials and other Associates and Bachelors degrees and career advisement without adequate
scholarships and funding from various resources? Financial stress, low educational attainment
from low quality expectations and high staff turnover can be a risk factor for wellbeing
impacting both ECE providers and the families they serve with young children. Therefore, the
paper explores how, when, and where to assess level of Health Literacy and Health Seeking
Behavior for both ECE providers and parents of young children in center based and home
settings.

Figure 1, Health Literacy and Health Seeking Behavior Model, by Pialee Roy, Ph.D. 2018, is
updated, shown in Figures 2 and 3, to include generalizeability in nonclinical settings to
interchange various assessment to referral and resources for ECE providers and parent and
family navigation to culturally competent mental health and physical health supports in clinical
and community based settings for those who prefer health coaches and public health supports

Where the model in Figure 1 was specifically for preschool settings and families to get to
primary care, the effort is expanded in Figures 2 and 3, to the age appropriate assessment that can
be comprehensive in the nonclinical school setting to refer to both primary care, mental health
care, or behavioral health coaching, plus extracurricular activities and resources that support
community involvement and wellness for both ECE teachers, and preschool going family in the
comprehensive health and socioecological context.

Purpose
The study purpose is to provide guidance through expansion of a logic model on assessment
opportunities in the preschool setting to primary care for the three groups, teacher, parent and
preschool going child. The intervention opportunities support both ECE providers and ECE
families’ health literacy, navigation choices and health seeking behavior towards utilization of
culturally competent care in a dynamic and thriving system of care for the ECE community.
Later, how this affects opportunities for home visiting services or utilization of coaches can also
be explored.

Definitions

The ability to access, understand, and interpret health info,” (The Institute of Medicine, 2004,
p.32). Health seeking behavior for Primary care utilization / medical home, offsets overuse of
ER.

The term health literacy has been around since the 1970s and refers to the ability to complete
tasks like access, understanding, and interpreting, health information with both literacy and
numeracy skills: “wording on, medication bottles, food labels, appointment slips, discharge
instructions, informed consent documents, medical forms, insurance applications, medical bills,
and health education materials”, (Hersh, Salzman, & Snyderman, 2015).
Scholarly Significance

Early Childhood Education experiences a high staff turnover rate in spite of incentive programs
intended to retain high quality teachers, (Caven, 2021, and Roberts, A.M., Gallagher, Kathleen,
C., Daro, Alexandra A., Iruka, Iheoma, U. Sarver, Susan L, 2019 and U.S. Department of
Education, 2016). Low job satisfaction and depressive symptoms, from financial woes working
more than one minimum wage job may correlate with high staff turnover also, (Caven, 2021, et
al). How can child health excel when young children depend on both parents and teachers who
have varying health status and stress levels, as well as varying levels of health literacy and health
seeking behavior? These characteristics may impact caregiving interactions with children and
inform the environmental health offered to children in ECE settings and at home.

Literature Review

Proposed logic models are an update to an original logic model by Roy (2018) depicting a health
literacy and health seeking behavior study of parents of young children to improve child BMI
health outcomes. Chronic health issues and results of other assessments exhibited in Head Start
serving low income families and non Head Start programs serving all income families results in
varying levels of referrals to a primary care medical home. The study finds that 5 star Head Start
programs offer twice the rate of referrals as 5 star non-Head Start programs to get to the same
level of health seeking behavior to primary care and that although many families prefer
community based care, the majority like primary care visits once they attend, Roy (2018).

Study about health literacy was about adolescents and adults primarily in clinical settings rather
than the school system when the responsibility of completing assessments happened in primary
care, (Chari, Warsh, Ketterer, Hossain, Sharif, 2014; Institute of Medicine, 2004; Sharif & Blank,
2010). Later the child development assessments were expected to be completed in preschools, if
at all, (National Institute for Children’s Healthcare Quality, 2018). Lack of developmental
assessments lead to a lack of intervention opportunity. Basically, completion of assessments
allows for identifying early intervention opportunities for physical health or behavior problems,
delays, or disability support referrals (Marks and Glascoe, 2010). Therefore, with school settings
now as the primary venue responsible for completion of assessments, health navigation
opportunities exist after that for teachers, parents, children from the ECE systems to primary
care, specialty care, or other community based resources. The health provision opportunity by
health providers increases with collaboration by ECE setting completing assessments, so that
providers like interventionists, nurses, coaches, pediatricians can talk about solutions to
assessment findings.

Conceptual Framework.

The conceptual framework for the original logic model by Roy (2018) is based on the Green and
Kreuter’s 2005 Precede Proceed model for health promotion and program evaluation, and
Nutbeam’s asset and risk models from 2008.DeWalt & Hink (2009) find that parental health
literacy levels associate with children’s health status.
Demographic characteristics and parent health literacy levels that associate with lower parental
health literacy scores result in opportunity for intervention with parent and child health education
assessment for children who depend on their parents to have good health. Consequently, based
on levels of lower or higher parental education, additional assessments and referrals yield a level
of high or low parental health seeking behavior. The two groups of high or low health seeking
behavior are then compared, with differences in perception in quality of care as a possible
mediating factor influencing frequency and utilization of pediatric primary care to help attend to
children’s chronic health issues. While this model describes health seeking behavior of families
with young children, teacher, and provider choices to participate in their professional
development about health literacy and cultural competence which should be accounted for as
well. The update includes that ECE teacher’s health literacy and health seeking behavior
alongside of parents is important also. If referral to resources and health provider are consistently
to culturally competent providers that are perceived as culturally competent then the system will
thrive.

Cultural Competence

Roy (2018) suggests that nonclinical settings of preschools are an ideal opportunity to support
parental health literacy and child health assessment to determine intervention opportunity for the
level of assessments being completed, so that early intervention through referrals and access to a
pediatric primary care or other specialty care is possible.

Administered in both English and Spanish the 2018 study finds that nutritional health literacy
measured by interpretation of a nutritional facts label is lower among minority parents who are
Black or Hispanic, even when offered assessments in the preferred language. The finding
suggests that there is an assumption about preference to utilize nutritional labels or not based on
cultural standards of weight management that would possibly be associated with more familiarity
and practice with their use and facts interpretation.

Given parents’ health is associated with childhood health outcomes, these considerations of
preventable health should be culturally competent to help offset overuse of emergency rooms for
preventable concerns to support child and family health outcomes. ECE providers who
participate in training to increase their child development and parenting education knowledge
through their professional development, can measure both how many they have attended, and
opportunities to support their own health and preschool going families.

Roy (2018) shows from a CAHPS assessment that those who chose to go to primary care
actually thought the visit was good. Health literacy and health seeking behavior levels of ECE
teachers, determine opportunity for intervention utilizing a variety of assessments with
recommendations to certain kinds of providers. Based on CAHPS assessments, and surveys
about provider cultural competence, family perception of the provider’s quality of care, varying
levels of health outcomes for the three: ECE provider, parent and child results.

The logic model is updated again to incorporate the level of professional development seeking of
ECE teachers by comparing the trajectory of federally funded Head Start programs or private pay
ECE of non Head Start programs. The programs and corresponding policies, standards, and
regulations mentioned also influence the level of professional development seeking of ECE
providers depending on the star quality rating alongside of QRIS and other licensing systems.

ECE teacher demographics can then be compared with family demographics, plus assessment
scores of ECE teacher’s health status about stress, anxiety, depression. Possibly financial stress
from low pay is a factor that is a risk. Many families are earning less than half of what
kindergarten to higher grade level teachers are earning, U.S. Department of Education, (2016).

This brings about the rationale for the dire need for awareness for incentive programs/loan
forgiveness programs like T.E.A.C.H. and WAGE$ and many other models which encourage
completion of degree programs and credentialing programs to learn about knowledge of how to
complete child assessments and evidenced based child development programs, and implement
those factors to indicate which teachers most could benefit from both professional development
support when asked about levels of proficiency with child development know how. Thereby
higher rates of child development assessments, referrals, and early intervention for the preschool
attending families could result.

The model proposes to resolve health care disparities, by increasing school based health
intervention opportunities, instead of waiting for clinical settings to determine interventions,
because children are required to go to school according to policies yet, choices of where to
receive health care vary. Bringing health care to teacher, parent and child offers comprehensive
indicator opportunities for their supports.

Survey scores indicating lower levels of professional development or child development

knowledge base would lead to likelihood to utilize navigation to recommendations and referrals
to CDA scholarships and funding to earn higher education, resulting in utilization of scholarships
and pursuit of AA/BA degrees. Higher education might be afforded through loans and other
funding streams to earn associates or bachelors degrees or other other credentials resulting in
higher pay, possibly less stress, and correlated with job satisfaction and improved child health
outcomes. The opportunity for mental health support navigation for ECE teachers and parents is
ideal from a preschool setting that utilizes health assessments through health coaches and
navigators.

Suggested Assessments

The ECE teacher or home visitors could complete a survey about their education and wellbeing,
and awareness levels of career options. The intervention or support opportunity would be
professional development training participation and human resources, career growth options plus
guidance on how to support preschool going families.

(1) the Consumer Assessment of Health Providers Survey by AHRQ

(2) the New Vital Signs by Pfizer

(3) Pediatric Quality of Life Survey. PEDS QL, Tohen, M., Bowden, C., Nierenberg, A. A., &

Geddes, J. (Eds.). (2015).

(a) About my Health and Activities (b) My Feelings, (c) How I Get along with Others, and (d)
Work and Studies.

(4) Multicultural Assessments

(5) Beck’s Depression Inventory, Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck
Depression Inventory–II (BDI-II).

(6) Beck’s Anxiety Inventory, Beck, A. T., Epstein, N., Brown, G., & Steer, R. (1988). Beck
Anxiety Inventory

Survey scores indicating lower levels of professional development or child development

knowledge base would lead to likelihood to utilize navigation to recommendations and referrals
to CDA scholarships and funding to earn higher education, resulting in utilization of scholarships
and pursuit of AA/BA degrees. The higher education might be afforded through loans and other
funding streams to earn associates or bachelors degrees or other other credentials resulting in
higher pay, possibly less stress, and correlated with job satisfaction and improved child health
outcomes. The opportunity for mental health support navigation for ECE teachers and parents is
ideal from a preschool setting that utilizes health assessments through health coaches and
navigators.

Future Research
Recommended next steps include analysis of the number of completed health appointments as a
function of demographics, health literacy Levels and referrals plus college education levels and
professional development training levels. Based on stress levels, school based referrals for
teachers to primary care that lead to speciality care, counseling, coaches, and extracurricular
activities may show that our alternative model from the school based settings, helps to close the
gap in identifying teacher/family navigation opportunities to get to primary care, specialty care,
counseling, coaches and extra curricular activities without losing those families’ opportunities
for health care utilization that may choose not to go to primary care, but yet are part of public
requirements to attend education settings.
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