Landscape Study of Prenatal-Age 3 Services and Supports in Mecklenburg County

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Landscape Study of Prenatal-Age 3
Services & Supports in
Mecklenburg County
Assessing Strengths, Needs, and Gaps: Informing Mecklenburg
County’s Systems of Support for Families with Young Children
Laura Marie Armstrong
Stephanie Potochnick
Ariana Shahinfar
Joseph Kangmennaang
Eric Delmelle
Ryan Kilmer

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ACKNOWLEDGMENTS
A special thanks to Smart Start of Mecklenburg County for funding this project and providing
guidance to this effort as well as connections with the prenatal to age 3 (PN-3) community
broadly. We particularly thank Jennifer Stamp, Chief Strategy Officer for Smart Start of
Mecklenburg County, for her expertise, guidance, support, and efforts - her time and insights
were critical to this work.
By funding this project, Smart Start of Mecklenburg County also provided valuable research
opportunities for UNC Charlotte undergraduate and graduate students to advance their skills.
Thank you for helping invest in our students. Accordingly, we offer our thanks to the dedicated
undergraduate, graduate, and post-graduate research assistants for their support on this project.
They were an integral part of the research team and worked largely voluntarily to have the
chance to learn new research skills and to share their valuable perspectives and knowledge.
Listed in alphabetical order, they are:
● Cecily Basquin
● Nitika Bhatta
● Casey Denbow
● Jocelyn Davis
● Corinne Guy
● Jodie Lisenbee
● Davena Mgbeokwere
● Emily Mikkelsen
● Ian Mikkelsen
● Gisselle Rios Palomares
● Hector Samani
● Paul Scholes
● Mariah Seymore
● Anna Sherrill
● Marley Tarlton
We are grateful for the parents, service providers, and administrators who offered their time and
shared their experiences and insights. The inclusion of parent and service provider voices is
essential in any effort made to improve Mecklenburg County’s PN-3 system of services.
Lastly, thank you to the Early Childhood Education (ECE) Executive Committee members for
their feedback and comments to ensure this report is useful and applicable to their efforts to
enhance the community’s systems and supports for families with young children. We also
appreciate their support in providing access to different data sources and helping us connect with
parents in the community.

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TABLE OF CONTENTS
Executive Summary……………………………………………………………………………….4
Project Description…………………………………………………………...……………………7
Method………...………………………………………………………………………………......9
Overview of Mecklenburg County’s Young Children (age 0-3) & Families…………………..…16
Landscape Analysis of Prenatal to Age 3 Services in Mecklenburg County....………….………21
Lessons from Prenatal to Age 3 Parents & Service Providers…………………………………….37
Stakeholder Generated Recommendations: Strengthening Systems of Care for Families with
Young Children…………………………………………………………………………………..60
Conclusion & Next Steps…...………………………………………………………………...….66
References………………………………………..…………………………………………..…..68
Appendix A: Data Sources Used to Create PN-3 Service Inventory...................………………...70
Appendix B: Parent Focus Group Questions & Service Provider Interview Questions.....……….73

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EXECUTIVE SUMMARY
The goal of the current project was to provide a comprehensive, baseline inventory of family
services and supports in Mecklenburg County for families expecting a child and for families with
a child between birth and age 3 years old (i.e., PN-3). We sought to identify gaps and
opportunities in service access and referral processes, provide recommendations for improving
family utilization of relevant services, and support County efforts to build capacity to address the
needs of families with young children, particularly those from underserved and marginalized
communities.
Through a mixed-methods approach that relied on partnership-based research principles, we
worked with community stakeholders to build-out a landscape of services. To create a baseline
inventory of PN-3 services, we compiled and carefully reviewed lists of known community
partners and resources, generated in part by reports and recommendations provided by Smart
Start and the Early Childhood Education (ECE) Executive Committee, as well as new and longstanding
connections with community researchers and local service providers. We also used
readily available administrative records (e.g., NC DHHS childcare facilities) and other data
sources (e.g., US Census data, IRS-tax data, Reference USA), along with web searches,
electronic surveys, and phone calls to obtain additional information. The baseline inventory of
services was then used to create maps of prenatal and early childhood services and supports to
visualize the broad landscape of services available in Mecklenburg County and the potential
coverage gaps, including geographic, sociodemographic, and racial/ethnic gaps. Finally, we
conducted virtual and in-person focus groups with expectant parents and parents of young
children aged 3 years old and under, with a focus on parents of color and those who reside in
neighborhoods where household income tends to fall below 200% of the federal poverty line. We
also conducted virtual interviews with service providers who represented the focal areas of the
project, including pediatrics, early intervention, prenatal care, childcare, literacy support, home
visiting, and nutrition services.
Our baseline inventory of services included 1,246 programs spanning three broad domains:
health, early care and education, and food/tangible support services. Within the inventory, these
services are further classified by the target of the support – child versus parent – as well as the
specific area (e.g., prenatal, literacy, childcare). When services were mapped by domain and
overlaid with sociodemographic characteristics, the nature of the service landscape, including
relative strengths and gaps, were illustrated. For example, within the health domain, we found
that pediatric services and child behavioral health services were primarily located in the uptown
core and south Charlotte, with considerably fewer of these services available in areas with higher
concentrations of childhood poverty. Within the early care and education domain, we found that
childcare appears to be available throughout Mecklenburg County, but parents and service
providers reported that factors such as affordability, wait time, and cultural responsiveness

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impact family access and utilization of childcare for their young children. In contrast, Early Head
Start (EHS) and home visiting programs were found to be relatively scarce in Mecklenburg
County, with 9 EHS programs and 3 home visiting programs identified by this study.
During our focus groups and interviews, key themes emerged related to parents’ strengths
(tenacity, investment in children, and support for one another) and challenges (financial strain,
and specifically, the lack of affordable housing, limited insurance coverage, inadequate play
spaces for children, uncertainty about child health and development, and unmet mental health
needs among parents).
This project also revealed several important factors that can facilitate or impede family service
access. These factors include:
Communication and logistical concerns
o Lack of communication about resources
o Barriers related to time, childcare, transportation, distance/geography, and
affordability of services
Service policies and procedures
o Stringent eligibility criteria
o Services requiring diagnosis or developmental delay inhibit preventive action
o Confusion and misunderstandings regarding eligibility
o Inefficiencies in referral processes
o Long wait times to receive services
Family experiences with services
o Relationship with providers
o Attention to family needs, preferences, and values
o Culturally sensitive and relevant care, including degree of cultural alignment
o Stigmatization, stereotyping, and systemic discrimination and racism
Programmatic strengths and challenges
o Intra-agency communication
o Nimble in adjusting to family needs
o Diverse staff
o Relationships with families
o Workforce challenges – pay, quality, diversity

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Based on the contributions of parents and service providers, recommendations are provided to
enhance family access and utilization of services, as well as strengthen systems of care for
families with young children in Mecklenburg County. Recommendations are organized into three
overarching areas, and each area consists of multiple components:
1) Implement collaborative and comprehensive PN-3 service models for meeting the diverse
needs of families
a. Improve inter-agency communication and collaboration
b. Address basic needs and build a social and economic safety net for families
c. Increase access to affordable childcare options
d. Utilize a multigenerational, whole-family approach to quality care that is
responsive to parent needs and preferences
e. Invest in quality behavioral health support for children and families
2) Strengthen outreach efforts and access to quality services
a. Enhance outreach
b. Investigate the feasibility of creating and sustaining a searchable community
database of PN-3 services accessible to parents and providers
c. Develop a community presence
d. Build evaluation capacity
e. Increase home visiting services
3) Foster culturally sensitive and responsive care necessary for building trust
a. Build a workforce that mirrors the cultural backgrounds of the families served
b. Develop trusted partners to help families navigate the systems and prepare for the
future
c. Build community trust and strengthen relationships with families
While these results and recommendations can inform important steps toward building stronger
and more equitable systems of care, continued collaboration, creative thinking, and persistent
action will be necessary to develop momentum in addressing the deeply rooted and longstanding
inequities in our community. It is also critical that actions are guided by data, including
and most importantly, the perspectives and insights of the families who are most impacted by
these decisions.

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PROJECT DESCRIPTION
“That statement - ‘it takes a village’ - it really does, if you want a successful child and not just
a statistic.”
-Charlotte Parent and Focus Group Participant
Families need a village of support to promote healthy child development for their young
children. For low-income and racial/ethnic minority families, in particular, multiple unmet health
needs are apparent from children’s conception through their early child development years. For
instance, within Mecklenburg County, access to prenatal care has been declining over the past
decade, with only 64% of expectant mothers receiving adequate prenatal care according to recent
data (UNC Charlotte Urban Institute, 2021). Moreover, the infant mortality rate for Black infants
is nearly double that for infants overall (9.4 vs. 5.1; NC Dept. of Health & Human Services,
2018). Such issues are evident on a national scale as well: 44% of U.S. children under age 3 live
in low-income families (Koball & Jiang, 2018), and 14.5% of children under age 6 live in
families facing food insecurity (USDA, 2020). These inequities are more pronounced for
racial/ethnic minority groups and families headed by a single mother. In combination, these risk
factors and conditions are associated with a lack of regular pediatric care, missed well-child
visits, and greater use of emergency care services (Ma et al., 2008), as well as increased risk for
family conflict, parent mental health and substance use problems, and child maltreatment (U.S.
Dept. of Health & Human Services, 2021).
To optimally support infant and young children’s health and development, families require a
comprehensive and well-coordinated prenatal to age 3 (PN-3) system of care that reflects the
multiple contexts within which they are embedded. Yet, families face considerable barriers in
navigating a complicated and often disparate set of family and early childhood services to
address the physical and social-emotional needs of their young child, which in turn reduce their
capacity to utilize available services.
It is critical that families and communities have a system of care to cultivate young children’s
healthy development that is available, accessible, and attuned to the needs, strengths, and
diverse sociocultural contexts within which families are embedded.

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This project’s overarching goal was to provide a comprehensive, baseline inventory of
family services and supports in Mecklenburg County for families with children from the
prenatal period through age 3.
We used an integrated, mixed-methods approach – in collaboration with Smart Start and
community stakeholders – to determine the availability, accessibility, and opportunities/needs of
families rearing young children in the context of socioeconomic disadvantage. We addressed the
following three interrelated aims:
Aim 1. Create a baseline PN-3 service inventory. To identify PN-3 service availability
and gaps, a comprehensive list of county-wide PN-3 services was compiled for both
children and parents across three broad domains of services: health, early care and
education, and food and tangible supports.
Aim 2. Conduct a landscape analysis of PN-3 services and accessibility: To identify
underserved populations and neighborhoods, we created a broad profile of
Mecklenburg’s PN-3 population and mapped the PN-3 service inventory landscape
(collected in Aim 1), overlaid with socio-demographic and transportation data to identify
accessibility gaps.
Aim 3. Engage parents and service providers to learn their perspectives on PN-3 services.
To identify parents’ PN-3 preferences and overall PN-3 system opportunities and
barriers, we (a) conducted focus groups with parents from low-income households across
Mecklenburg County to empower the voices of parents who experience socioeconomic
disadvantage, and (b) interviewed service providers from different domains of service
(e.g., pediatrics, literacy, childcare, food/nutrition support).
With these three aims, we identified gaps and opportunities in PN-3 service accessibility and
familial engagement across multiple sectors. The study’s findings and recommendations will
guide and support Mecklenburg County’s efforts to build a comprehensive PN-3 system of care
for families with young children, particularly those from communities that have traditionally
been underserved and marginalized.

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METHOD
Employing a partnership-based approach, we worked in collaboration with Smart Start and other
community stakeholders to conduct a broad, comprehensive landscape analysis of Mecklenburg
County’s PN-3 system. Aim 1 involved the creation of a baseline inventory of PN-3 services
from multiple sources (e.g., tax data, administrative records, community reports) that was used to
inform Aims 2 and 3. Aim 2 involved the identification of underserved families and
neighborhoods to target for support by combining our baseline inventory with different data
sources (e.g., micro- and macro-level Census data) and using statistical and spatial analysis
techniques to (a) describe the characteristics of PN-3 families in Mecklenburg County and (b)
map the PN-3 service landscape overlaid with sociodemographic, neighborhood and
transportation data to identify any accessibility challenges. Aim 3 involved the collection of
parent and provider perspectives by conducting parent focus groups (6 focus groups; 40 total
participants) and service provider interviews (12 providers) to learn their perspectives on service
use opportunities and barriers. In combination, these three interrelated aims identified different
PN-3 system strengths and areas for improvement.
Below we describe our approach and data used for each aim in detail.
Aim 1. Create a baseline PN-3 service inventory
Overview. Our goal was to develop a comprehensive list of PN-3 services in Mecklenburg
County. Thus, we collected data about the program point of service, that is, where the service is
typically provided or
received. For some
services this was
straightforward because
there was a single
service offered in a
single agency at a single
location. However, the
service landscape
becomes more complex
when there is an
umbrella organization
with multiple locations
and different services
provided at each location. This complexity is illustrated by the figure above and highlights that
for umbrella organizations that have multiple locations and provide multiple services at each
location, we collected data on each service provided at each location. That way, with unique

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addresses for each service provided, we could map the PN-3 service landscape for different types
of services. For some services, the point of service is families’ homes (e.g., home visiting
services), and for other services families receive care at different locations spread throughout the
community (e.g., mobile clinics). We include such services in our list because they reflect
important resources in the system of care for young children and families, but the address in
these cases is the office location where the service is housed or the address provided for taxidentification
purposes rather than the site where families are served. Thus, the accessibility
maps for these services require a different interpretation, as noted when we present the results.
Data Specifics. Because PN-3 services are provided by a complex network of organizations and
systems at all levels of government (federal, state, and local), the nonprofit sector, the private
sector, and faith-based organizations, no one dataset or report contains a comprehensive list of all
PN-3 organizations or services in Mecklenburg County. Therefore, to create a comprehensive
index of PN-3 services, we used multiple data sources and a snowball sampling approach such
that each data source was used to identify additional data sources until we reached saturation.
We started with several PN-3 service lists of known community partners, as well as resources
provided by Smart Start of Mecklenburg County and members of the Early Childhood Education
(ECE) Executive Committee. We expanded upon this list by examining reports from these
agencies and collecting (when feasible) internal administrative data from community
stakeholders (e.g., Child Care Resources Inc.). Additionally, we used readily available
administrative records (e.g., IRS-tax records) and other data sources (e.g., community reports) to
identify organizations and businesses in Mecklenburg County, many of which provided PN-3
services that were not included in our other data sources. These lists, however, were broad and
also captured organizations and businesses that did not provide PN-3 services. To narrow these
lists down to only organizations and businesses that provide PN-3 services, we conducted websearches,
cross-checked across data sources, and made follow-up phone calls as needed. Lastly,
because publicly available data for faith-based organizations (an important PN-3 support) are
more limited, we created and administered an electronic survey to faith-based organizations.
Appendix A provides more details about data sources used to create the baseline PN-3 Service
Inventory.
As we collected data, we learned of new programs and services through our interviews with
service providers and meetings with stakeholders, and thus, we continued to expand our
inventory using an iterative process. We also mapped the PN-3 data we collected to identify
potential geographic data collection gaps and worked with relevant stakeholders to ensure these
gaps were valid and not a reflection of missed programs. By using this collaborative, crosschecking
approach, which included verifying our lists with different stakeholders and drawing
from multiple data sources, we compiled a comprehensive list of PN-3 services.

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Overall, employing multiple strategies and data sources, including stakeholder guidance,
yielded a strong, comprehensive list of government, nonprofit, and private PN-3 services
for both children and parents across three broad domains of services – health, early care
and education, and food and tangible supports – that we mapped using geographic
information system (GIS) techniques and software.
Aim 2. Conduct a landscape analysis of PN-3 services and accessibility
Overview. Using our PN-3 service inventory, US Census data, and varying statistical and
geographic information systems (GIS) mapping techniques, we identified the general
characteristics of Mecklenburg County’s young (ages 0-3 years) children and families, as well as
the geographic factors shaping their PN-3 service access. We used both individual-level (or
micro-level; IPUMS, 2020) and neighborhood-level (or macro-level; U.S. Census, 2020) US
Census American Community Survey (ACS) data—the US Census Bureau’s premier source of
population and local community data (U.S. Census, 2020). Because of the sensitive nature of
these data, detailed geographic information is often suppressed. Thus, to obtain a comprehensive
picture of both PN-3 families and their neighborhoods, we used a combination of individual- and
neighborhood-level data.
Data Specifics. Below we describe the individual- and neighborhood-level U.S. census data used.
Then, we describe how each was used to identify the characteristics of Mecklenburg County’s
PN-3 families and to map their PN-3 service accessibility.
Individual-Level ACS Data. These data allow us to identify the population of children
aged 0-3 for Mecklenburg County, and we can provide details about their demographic
(e.g., race/ethnicity) and familial characteristics (e.g., socioeconomic resources), as well
as some public-benefit service use (e.g., Medicaid enrollment). This age-specific
demographic and familial detail is not available in the more typically used macro-level
census data (e.g., tract- or zip-code level), which report out limited information for
children aged 0-5. Following best practices for using ACS data to examine small
geographies and sub-populations, we use the most recent 5-year ACS estimates (2013-
2018), 1 which (compared to the 1- and 3-year estimates) have a smaller margin of error
(+/-3%) and best capture population trends. Notwithstanding their benefits, a key
1
At the time of data collection, the 2018 5-year estimates (2013-2018) were the most recently available. The results
of these data, however, are likely to be similar to the 2020 estimates (forthcoming 2022 or later; see the following
press release: https://www.census.gov/programs-surveys/acs/news/data-releases/2020/release.html). That is because
the 5-year estimate design of the ACS purposely overlaps data years to capture general trends in the population. For
instance, the 2020 5-year estimates will include several of the same data years used for the 2018 estimates (2016,
2017, 2018). Thus, although Mecklenburg County has grown in size since 2018, unless the nature of this growth
differs dramatically from prior year growth, the 2018 and 2020 estimates will provide similar pictures of
Mecklenburg County’s population demographics.

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limitation of these individual-level census data is that they only identify the county where
an individual lives, not their specific neighborhood (e.g., zip-code or census tract).
Neighborhood-Level ACS Data. We used tract-level US Census data to identify
neighborhood variation in service accessibility. We again followed best practices for
using ACS data to examine small geographies and used the most recent 5-year ACS tractlevel
estimates (2015-2019) 2 to identify the demographic and economic characteristics of
the 233 different tracts that make-up Mecklenburg County. Unlike the individual-level
ACS data, however, the tract-level data only report information for children aged 0-5
years. Thus, we used this subgroup (aged 0 to 5) to proxy our subgroup of interest:
children aged 0-3.
In combination, we used the individual- and neighborhood-level US census data overlaid with
our PN-3 service database to describe the PN-3 family population, to assess their PN-3
geographic service accessibility, and to identify focal points (e.g., sub-populations and
neighborhoods of interest) for further examination via our aim 3 efforts (focus groups and
interviews). With the individual-level ACS data, we used summary statistics to determine the
overall demographic characteristics (e.g., race/ethnicity, family composition) of PN-3 families
whose household income falls below 200% of the Federal Poverty Line (FPL, i.e., low-income
households). Overlaying the neighborhood-level ACS data with our PN-3 database, we used
geographic information systems (GIS) and mapping techniques (e.g., hot-spot analysis) to
identify different geographic barriers to and facilitators of service access. For instance, we
mapped the overall PN-3 service database distribution with different indicators of accessibility
(e.g., average distance and time traveled for each census block) to assess if certain
neighborhoods faced more access barriers, and we assessed whether these barriers differed based
on the economic and racial make-up of the aged 0-5 child population in a neighborhood.
Aim 3. Engage parents and service providers to learn their perspectives on PN-3 services
Overview. To contextualize the data from prior aims and obtain more in-depth information on
parent perspectives and experiences related to PN-3 service access and utilization in
Mecklenburg County, we conducted (a) focus groups with PN-3 parents and (b) in-depth
interviews with PN-3 service providers and administrators. The focus groups and interviews
were designed to be complementary in nature and to reach diverse sets of providers and parents.
2
Tract-level data are released before the individual-level US census ACS data. The individual-level 2015-2019
estimates were not available at the time of data collection but (as noted in the prior footnote) data trends are not
likely to differ significantly across subsequent data years.

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The figure below highlights the complementary nature of topics covered, enabling us to identify
key synergies and differences between the responses provided by service providers and parents.
Please refer to Appendix B for a complete list of the questions asked in the semi-structured focus
group and interview formats.
Parent Focus Groups
Topics Covered
Service Provider Interviews
• Charlotte Background: Context for
raising young children
• Family Context: Strengths,
challenges, & needs
• PN-3 Services: Access, utilization,
barriers, & facilitators
• Cultural Relevance: Positive &
negative experiences
• Suggested PN-3 Improvements
• Agency Background: Services
provided & families served
• Families Served: Strengths,
challenges, & needs
• Program Services: Accessibility,
barriers, gaps, & opportunities
• Cultural Relevance: Service cultural
sensitivity, responsiveness
• Suggested PN-3 Improvements
Data Specifics. Below we describe the focus group and interview data collection process in
detail. Then, we outline how we analyzed the data.
PN-3 Parent Focus Groups. We partnered with local agencies to recruit families for the
focus groups from specific sub-populations (e.g., Black and Hispanic/Latino families)
and neighborhoods (e.g., where household income tends to fall below 200% of the federal
poverty line) identified in Aim 2. As illustrated in the figure above and by the questions
asked in the focus groups (see Appendix B), these groups were used as a mechanism to
examine individual-, family-, and community-level factors that influence service access
and utilization, as well as to identify barriers, strategies, and opportunities for engaging
parents from historically marginalized and under-served backgrounds in services to
support the health and development of their young child.
We conducted 6 focus groups with parents – 3 in English only, 1 in English and Spanish,
and 2 in Spanish only. Each focus group consisted of 3 - 16 participants. Based on parent

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needs and preferences, we conducted three focus groups in-person (composed of
primarily Black parents and caregivers residing in low-income neighborhoods on the
west side of Charlotte and in low-income neighborhoods just outside the city center) and
three virtually (composed primarily of U.S. and foreign-born Hispanic/Latino families).
Groups included mothers, fathers, grandparents, and other adults representing kinship
caregiving arrangements. Parents were either pregnant and/or had a child who was age 3
or younger (in a few cases, the youngest child was slightly older than 3). Most parents
were raising children of multiple ages. The focus groups lasted approximately 90
minutes, and they were conducted by a faculty research team member and/or a facilitator
from partner organizations using a semi-structured protocol (see Appendix B). Each
group included at least one note-taker, and all focus groups were recorded.
PN-3 Service Administrator & Provider Interviews. Based on data collected for Aims 1
and 2, as well as community partner guidance, we conducted 12 interviews via video
conferencing with PN-3 service providers and administrators that spanned our three focal
domains: health (pediatrics, prenatal, home visiting), early care and education (childcare,
literacy), and food/tangible support services (e.g., WIC). We ensured that organization
representatives contacted for an interview could capture a range of developmental
periods, sociodemographic characteristics, and geographic locations. These contacts were
facilitated by Dr. Ariana Shahinfar, who has strong and long-standing connections with
community agencies and leaders. The interviews lasted approximately 60 minutes and
were conducted by a faculty research team member using a semi-structured protocol (see
Appendix B). Each interview was recorded and transcribed for analysis.

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The figure below highlights the diverse range of parents and providers we were able to reach.
PN-3 Parent & Service Provider Sample
Parent Focus Groups
(N = 6 sessions; 40 parents)
•Racial/Ethnic Background:
•Mostly Black (non-Hispanic) &
Hispanic/Latino (U.S.-born & foreignborn)
parents
•Some White (non-Hispanic) parents
•Economic & Educational Background:
•Low-income neighborhoods
•Diverse education range: HS degree to
Graduate education
•Family Background:
•Mostly mothers or female caregivers but
some fathers & grandparents
•Single- and two-parent households
Service Provider Interviews
(N = 12)
•Health:
•Pediatrics
•Early Intervention
•Prenatal Care
•Early Care & Education:
•Childcare
•Literacy
•Home Visiting & Parent Education
•Food & Tangible Support:
•Prenatal & young child nutrition services
To facilitate more timely analysis of the focus group and interview data, we had the focus group
facilitator and notetaker(s) deliberate after each meeting to identify major themes that arose. For
the service provider interviews, the interviewer took notes and summarized key themes after
each interview. We then used a team of 10 diverse researchers (team faculty members and
undergraduate and graduate students) to listen to each of the focus group and interview session
recordings to confirm and identify additional major themes. We deliberated as a team and crosschecked
theme findings to maximize the consistency between the theme findings and what
participants expressed in each of the sessions. Though the project’s funding and timeline did not
allow for more time-intensive and rigorous qualitative analysis (e.g., transcription and multi-step
coding using qualitative software), our team’s deliberation process ensures that this report
highlights key themes raised by parents and providers that can be used to improve the current
PN-3 system.

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OVERVIEW OF MECKLENBURG COUNTY’S
YOUNG CHILDREN (AGE 0-3) & FAMILIES
Mecklenburg County’s PN-3 system of care must adapt to growing and changing population
demographics. In the past decade, the Charlotte metro area has experienced rapid population
growth—nearly 20%, 5th highest in the nation (Chemtob & Off, 2020). Young Hispanic/Latino
families, in particular, are a main driver of this change. As a consequence, the racial/ethnic
composition of Mecklenburg County’s young child population is becoming more diverse. For
instance, today, 21% of young children aged 0 to 3 in Mecklenburg County are Hispanic/Latino,
compared to less than 2% in 1990 (author calculations; Ruggles et al., 2021)
Given these demographic shifts, we provide a description of Mecklenburg County’s aged 0 to 3
child population and their demographic and familial characteristics. Overall, we find that young
children are more racially/ethnically diverse than the population as a whole. Unfortunately, 41%
of all young children in Mecklenburg County live in families in which the household income is
at or below 200% of the federal poverty line (i.e., low-income households); non-Hispanic Black
and Hispanic/Latino children make up the vast majority of these young children. At the same
time, we find that young children who live in low-income households have families with diverse
characteristics—i.e., varying parent education levels, family structure/composition, and parent
employment.
These findings suggest that a mix of different PN-3 services may be needed to address the
developmental needs of Mecklenburg County’s young child population, especially for those
living in low-income households.
The Racial and Ethnic Diversity of the Age 0-3 Child Population
Young children aged 0 to 3 make-up a sizable share of Mecklenburg County’s total population.
According to the most recent micro-level U.S. Census estimates (Ruggles et al., 2021), 5.4% of
Mecklenburg County’s total population is age 3 or younger; this translates to 58,867 children
who are between 0 and 3 years old in Mecklenburg County. Moreover, the young children are
changing the face of Mecklenburg County, given that they are more racially/ethnically diverse
than the population as a whole.
This diversification is driven by Hispanic/Latino children. As shown in the figure below,
Hispanics/Latinos make-up 14% of the total population, but 21% of the young child population.
That means that more than one-in-five young children in Mecklenburg County are
Hispanic/Latino. Non-Hispanic White and Black children, however, still make up larger shares
of the young child population, 37% of whom are non-Hispanic White and 29% of whom are non-

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Hispanic Black. The remaining 13% consist of Asian or Pacific Islander, American Indian or
Alaska Native, and multi-racial children.
Finally, the racial/ethnic diversification of Mecklenburg County’s young child population is
likely to continue because the racial/ethnic composition of all 14,398 new births in Mecklenburg
County in 2019 (NC Vital Statistics, 2019) is similar to that of the age 0-3 child population.
Notably, Hispanic/Latino children continue to make up a sizable share of the population,
accounting for 22% of all new births.
The Prevalence and Diversity of Age 0-3 Children and Families in Need
Raising young children requires financial resources to invest in and support child development.
However, as shown in the figure to the right,
41% of young children (aged 0-3 years) in
Mecklenburg County live in households where
economic resources are highly strained. In other
words, approximately 24,136 young children in
Mecklenburg County live in families where the
household income is at or below 200% of the
federal poverty level (FPL), which for a family
of four means that their family makes $53,000 or
less (U.S. DHHS 2021). Furthermore, 21%
(approximately 12,362 young children in
Mecklenburg County) face even greater financial

18
strain as they live in families in which the household income is at or below 100% of the FPL; for
a family of four, this equates to a household income of $26,500 or less. In comparison, the
median household income in Mecklenburg County for families living above 200% of the FPL is
nearly $100,000 for a family of four (ACS/IPUMS, 2018).
Although Mecklenburg County’s young child population is racially/ethnically diverse, those in
need are not. The figure below shows the racial/ethnic economic disparities among Mecklenburg
County’s age 0-3 population. Non-Hispanic Black and Hispanic/Latino children make up nearly
80% of young children living in households with financial need. Among children living at or
below 200% FPL, for instance, 41% are non-Hispanic Black and 37% are Hispanic/Latino.
Despite their limited racial/ethnic diversity, young children living at or below 200% FPL in
Mecklenburg County are diverse with respect to familial characteristics. Each of the familial
characteristics examined below (i.e., parent educational attainment, family composition, and
parental employment) are strong predictors of young children’s health and well-being and
highlight critical areas that Mecklenburg County’s PN-3 system of care should address.
Overall, we consistently find that children living in low-income households have more diverse
familial characteristics than children in higher-income households. For instance, as shown in the
figure below, the share of parents with a four-year college degree or more is substantially higher
among young children living in higher versus lower-income households (79% vs. 15%). Yet, it is
particularly noteworthy that among young children living in low-income households, 15% of
their parents have at least a four-year college degree, meaning that nearly one-in-six of these
young children come from families in which at least one of their parents is college-educated. In

19
contrast, nearly one-in-five (22%) young children live in families in which neither parent has a
high school degree. These disparities are alarming given that research consistently finds that
parents with higher educational attainment nurture more favorable child development outcomes.
Thus, to promote the healthy development of all young children, Mecklenburg County’s PN-3
system must address these educational resource disparities—disparities both between children in
higher versus lower income households and disparities among children in low-income
households.
Additionally, Mecklenburg County’s PN-3 system must be responsive to and supportive of
young children’s diverse familial structures and parental employment, which again vary more
widely for children living in lower- versus higher-income households. For instance, the figure
below illustrates that although the majority of young children in higher- and lower-income
households live in a family with two parents, the share is substantially higher for children in
higher-income households (88% vs. 56%, respectively). In contrast, a more sizable share of
children from low-income households live in a single-parent family, compared to children from
higher-income households (39% vs. 11%, respectively).
In that same figure (displayed on the next page), similar variation is observed in parent
employment. Most young children in both higher and lower-income households are likely to
have both parents employed (67% and 47%, respectively) or at least one parent employed (31%
and 36%, respectively). However, a much larger share of young children in lower-income

20
households have no parent employed, compared to those from higher-income households (17%
vs. 2%, respectively).
These differences in family structure and parent employment are important because they suggest
that PN-3 resources and needs may differ both between and among children in higher and lowerincome
households. For instance, research consistently shows that children in single- versus twoparent
families face more hardships (e.g., financial, food, and socio-emotional) that can hinder
child development. Consequently, even if services and supports only target young children living
in lower-income households, the marked individual differences among these families suggest
that different PN-3 supports may be needed (i.e., supports targeting young children living in
single-parent versus two-parent families).
In sum, this demographic overview of Mecklenburg County’s age 0-3 child population
demonstrates that this young child population is widely diverse in racial/ethnic and
socioeconomic composition, as well as key family characteristics associated with young
children’s health and development. The complex challenge for Mecklenburg County’s PN-3
system is that it needs to respond to this diversity and ensure that it promotes the healthy
development of all young children by meeting their unique child development and family
support needs.

21
LANDSCAPE ANALYSIS OF PRENATAL TO AGE 3
SERVICES IN MECKLENBURG COUNTY
The landscape analysis of prenatal to age 3 (PN-3) services is divided into two sections. In the
first section, we provide a broad overview of the baseline service inventory and how the range of
services, resources, and supports for families with young children were categorized. In the
second section, we provide additional detail about each domain, including how the service
categories were defined, as well as the types and number of services in each category. In
addition, we discuss our findings based on the visualization of the service landscape using a
combination of statistical and geographic information systems (GIS) techniques. These
visualizations and their interpretation are provided for each service category.
Baseline Prenatal to Age 3 (PN-3) Service Inventory
The baseline prenatal to age 3 (PN-3) service inventory was created to capture the range of
resources, services, and supports available in Mecklenburg County for families expecting a baby,
as well as families with a young child aged 3 or younger. As such, we developed a
comprehensive database of Mecklenburg County’s PN-3 system that reflects three key domains
of services for children, parents, and families: (1) Health Services, (2) Early Care and Education
Services, and (3) Food & Tangible Supports. Within the database, services are further classified
by the target of the support (child or parent), as well as the specific service category (e.g.,
prenatal services, literacy, childcare). Each row of the database includes the name of the
organization, the address for the organization, coordinates indicating latitude and longitude, and
the type of services provided at that location (with 0 = service not offered and 1 = service
offered). The complete database can be accessed with permission from Smart Start.
The figure below illustrates the three broad domains that we captured, as well as the total number
of services about which we collected information noted in parentheses. These values specify the
total number of services; this value differs from the total number of organizations because many
organizations provide multiple services, sometimes at different locations. These data reflect each
unique service location, i.e., the point of program service.

22
PN-3 Service Inventory: Domains & Categories of Service
(N=1,246 services)
Health
(n=520)
Child
Pediatric (n=128)
Early Intervention (n=40)
Behavioral Health (n=92)
Parent
Prenatal Care (n=94)
Health Care (n=106)
Mental Health (n=60)
Early Care &
Education
(n=628)
Child
Literacy (n=52)
Child Care (n=448)
Early Head Start (n=9)
Parent
Parent Education (n=116)
Home Visiting (n=3)
Nutrition/Food &
Tangible
Supports
(n=98)
Family
Nutrition/Food (n=65)
Tangible Needs (n=33)
Analysis of the Prenatal to Age 3 (PN-3) Service Landscape
In the sections below, we describe the database components and the service landscape for each of
service categories within the three broad PN-3 domains: Health, Early Care & Education, and
Nutrition/Food & Tangible Supports. We describe these domains for children and parents
separately and provide example services for each category. In addition, we present a
visualization of the service landscape for several service categories to help assess
sociodemographic and geographic influences on Mecklenburg County’s PN-3 service landscape.
For this report, we present two maps per service category that aide interpretation of the findings:
a scatter map with sociodemographic data and a density map.
Scatter map with sociodemographic data: This map shows each point of service for a
given service category in Mecklenburg County. The zones on the map represent each
census tract in the county. The scatter map is overlaid with sociodemographic
information for each census tract detailing the percent of young children aged 0-5 years
living in families in which the household income is at or below 100% of the federal
poverty line (FPL). The 0-5 age range was the best available proxy of the 0-3 population
in the county. The census tracts that contain no sociodemographic data due to the CLT
Airport and warehouse locations are denoted with diagonal lines.

23
Density map: The density map illustrates the points of service (similar to the scatter map),
as well as the probability of access to a particular service point. The areas of the map in
darker purple indicate that there is a higher probability of being able to access a given
service, whereas the lighter areas denote a lower probability of access.
Health Services
The Health Services domain includes resources and supports focused on physical,
developmental, and behavioral health for expectant parents and for families with young children
between birth and 3 years of age.
Child
Health services that children are likely to need between birth and 3 years of age were categorized
as follows: pediatric care, early intervention, and behavioral health support.
Pediatric care was defined as services that focus on the child’s physical health and well-being
and involve preventive care, as well as the diagnosis and treatment of infections, injuries, and
diseases. This type of care can include a range of services, and therefore, in the database we
captured pediatric and family medicine practices, urgent care for children, immunization clinics,
pediatric dentistry, and specialty care (e.g., gastroenterology, neurology, cardiology,
developmental and behavioral pediatrics). At 128 points of service, pediatric care comprised
almost half (48%) of child health services.
As shown in Map A below, pediatric services were primarily located within the uptown core and
south Charlotte, with a few service points in the northeast part of the city and the northern part of
the County. Importantly, there were few pediatric services in areas with higher rates of young
children living in families whose household income is at or below 100% of the federal poverty
line. Pediatric services were also limited in the periphery of the county and north of the uptown
core. In addition, Map B illustrates similar findings and demonstrates that the probability of
being able to access pediatric care is higher in the uptown core (around zip codes 28209, 28207
and 28203) and in south Charlotte compared to areas North, East, and West of the uptown core.

24
PN-3 Pediatric Care Landscape in Mecklenburg County
A: Scatter Map with Sociodemographic Data B: Density Map
Note. Map A is comprised of two components: a scatter map and sociodemographic data. The scatter map plots each pediatric care point of service
for Mecklenburg County, as indicated by the black dots. The zones represent each census tract in the county, and the zones with diagonal lines
denote census tracts where there are no data due to the CLT Airport and warehouse locations. The scatter map is overlaid with sociodemographic
information detailing the percent of young children aged 0-5 years living in poverty. The 0-5 age range was the best available proxy of the 0-3
population in the county. The census tracts in darker blue indicate a higher percentage of children living in families where the household income is
at or below 100% of the federal poverty line (FPL), whereas the lighter tracts indicate a lower percentage of children living in families whose
household income is at or below 100% of the FPL. Map B is a density map that illustrates the points of service, as well as the probability of access
to a pediatric service point. The areas of the map in darker purple indicate that there is a higher probability of being able to access pediatric care in
that areas, whereas the lighter areas denote a lower probability of being able to assess pediatric care.

25
Early Intervention (EI) services are services and supports available to children aged 3 years and
younger who have a documented developmental delay or disability. EI is usually provided in the
child’s home and consists of a range of services depending on the needs of the child and family.
EI can include speech therapy, physical therapy, occupational therapy, and interventions to
support cognitive development and problem-solving skills. In the database, we have also
included services specifically designed for children with a diagnosis of Autism Spectrum
Disorder, such as Applied Behavior Analysis (ABA), within the EI category. Also, given the
focus on Mecklenburg County, we only included EI organizations with a physical address in the
county. However, it should be noted that there are EI sites located in neighboring counties that
serve families in Mecklenburg County. As such, the EI sites captured within the database may
underestimate the number of EI programs that serve families in Mecklenburg County.
The service database includes 40 points of service for EI. Given that EI services are typically
delivered in the child’s home, we have not presented maps of the EI service landscape, but we do
provide the address for organizational contact for each EI service within the database. However,
it is worth noting that family access to EI services is likely impacted by the physical location of
the organization because EI providers may experience more difficulties reaching families who
reside further away from the main service location. Moreover, when EI providers have
expanding caseloads and have to travel further distances to provide in-home services, this places
a heavy burden on the providers themselves, possibly contributing to greater burnout, provider
stress, and turnover, all of which have negative repercussions for families in need of services.
Child behavioral health is the final category within child health services. Behavioral health
services for young children can encompass a wide range of practices. However, effective
behavioral health treatment for families with young children focuses on strengthening the parentchild
relationship, fostering positive family interactions, and shaping parenting practices and
behavior so that parents can help children to (a) experience, manage, and express a full range of
emotions, (b) form close relationships, and (c) explore the environment and learn. These
capacities contribute to healthy social, emotional, and behavioral development among young
children and are best accomplished within the context of a warm and sensitive caregiving
environment. Within the database, we included behavioral health providers who implement
evidence-based treatments for families with young children, including Parent-Child Interaction
Therapy (PCIT), Attachment and Biobehavioral Catch-Up (ABC), Triple P Positive Parenting
Program, Child-Parent Psychotherapy (CPP), and Trauma Focused-Cognitive Behavioral
Therapy (TF-CBT). We also included providers and agencies that clearly stated their ability to
provide therapeutic services for infants and toddlers, as well as those that provide support for
specific issues that may be particularly salient for young children, such as an Autism Spectrum
Disorder diagnosis or the loss of a parent. It is worth noting that in the case of autism services,
for example, a particular organization may be coded as providing both EI and child behavioral
health services. There are 92 child behavioral health points of service included in the database.

Maps A and B, shown below, use the same approach as described for pediatric care and
demonstrate a similar trend wherein child behavioral health services are primarily located within
the uptown core and south Charlotte, with a few additional service points in north Charlotte. In
addition, the probability of access was higher in the uptown core and Northeast Charlotte, near
the university area, compared to other areas in Mecklenburg County. Importantly, census tracts
with higher concentrations of children living in households at or below 100% of the FPL had
fewer child behavioral health services. Furthermore, behavioral health services for young
children were particularly scarce in Northwest, West, and East Charlotte.
26

PN-3 Child Behavioral Health Landscape in Mecklenburg County
A: Scatter Map with Sociodemographic Data B: Density Map
27

28
Parent
The health services that expectant parents and parents of young children are likely to need were
categorized as follows: prenatal, health, and mental health care.
Prenatal care was defined as services that focus on the physical health of the expectant mother
and unborn baby, with the goal of improving the likelihood of a healthy pregnancy and birth, as
well as promoting the growth and development of the fetus. This type of care can include a range
of services, and therefore, in the database we included obstetric and midwife practices, family
planning and reproductive health organizations, doula services, and birthing and lactation
support, as well as physical therapy and chiropractic services focused on serving women during
pregnancy. There are 94 points of service for prenatal care included in the database.
As illustrated below, Maps A and B, demonstrate similar trends wherein prenatal care sites are
located throughout Mecklenburg County, but the probability of being able to access prenatal
services was greater within the uptown core compared to other areas of Mecklenburg County. It
is also noteworthy that prenatal services were scarce north of the uptown core and in West
Charlotte.

PN-3 Prenatal Care Landscape in Mecklenburg County
A: Scatter Map B: Density Map
29

30
Parent health care was defined as services that focus on the physical health and well-being of
expectant parents and parents with young children, and it included prenatal care, general
preventive care, and women’s health care, as well as the diagnosis and treatment of infections,
injuries, and diseases. Given the focus of this project on PN-3 services, this category overlapped
substantially with the Prenatal Care category. The primary difference was that some of the
services in this category were focused on low-cost and free health care services that may not
have involved prenatal care. There were 106 points of service included in the database for parent
health care. Given the overlap with Prenatal Care, we omitted these maps from the report.
Parent mental health services were dedicated to serving the mental health needs of parents or
expectant parents. Given the focus on PN-3 services, the points of service included in the
database captured mental health services for which the primary focus was the pregnancy and
postpartum period or where the core aspects of treatment involved the transition to parenthood,
women’s health, and family/parenting-related issues for those with young children. In other
words, we were selective in how parent mental health services were captured, and we did not
include all possible counseling or mental health services for adults. Using these parameters, there
were 60 points of service for parent mental health included in the database. Given the
circumscribed nature of this service category, we omitted these maps from the report.
Early Care and Education Services
The Early Care and Education domain includes resources and supports associated with keeping
young children healthy and safe, nurturing secure attachment relationships between children and
caregivers, promoting children’s cognitive, language, and social-emotional development, and
fostering family well-being.
Child
Early care and education services that children are likely to need between birth and 3 years of
age were categorized as follows: literacy support, child care, and Early Head Start.
Literacy Support was defined as any program that encourages parents to read with their young
children. Most of the literacy support services included in the database are national programs that
partner with sites in Mecklenburg County. For example, the Reach Out and Read program is run
in partnership with local pediatric and child care sites. In Mecklenburg County, 37 pediatric care
sites and 5 child care sites have the Reach Out and Read program. Therefore, a given pediatric
care site may be a point of service for both literacy support and for pediatric services. In addition
to national programs, Mecklenburg Count also has a few local programs that are dedicated
exclusively to literacy among young children, such as Promising Pages. In total, there are 52
points of service for young children’s literacy support in the database, and the majority (81%)
reflect sites (pediatric and child care) that have partnered with the Reach Out and Read national
program.

As illustrated below, Maps A and B demonstrate similar trends wherein literacy sites are located
throughout most of Mecklenburg County, but the probability of being able to access literacy
support is greater within the central and southern areas of Mecklenburg County compared to
other areas in the county. Literacy supports are limited in the northern areas of the county.
31

PN-3 Literacy Support Landscape in Mecklenburg County
A: Scatter Map B: Density Map
32

33
Child Care sites included center- and family-based care available for children between birth and
3 years of age. Some of the sites allowed children within this full age range, and other sites only
allowed children of certain ages within this range. In total, there are 448 child care sites in the
database, and of these sites, 285 (63%) are 4- or 5-star sites. Child care is one of the few services
for young children that has a quality indicator, and therefore we used this information to better
understand the service landscape.
As illustrated in the child care scatter and density plots shown below, child care sites were
generally located throughout Mecklenburg County. Notably, high quality care (i.e., 4- and 5-star)
was present within neighborhoods with higher concentrations of young children living in
families where the household income was at or below 100% of the FPL. The probability of
access to child care of all qualities (i.e., not just 4- and 5-star sites) was higher in the uptown core
and areas just east and west of uptown, compared to other areas of Mecklenburg County. Child
care sites appeared more scarce in the periphery of the county, particularly the areas in the
eastern, western, and northern periphery of Mecklenburg County. Taken together, our landscape
analysis suggests that, in general, child care of high quality is available throughout Mecklenburg
County. However, factors such as affordability (e.g., the acceptance of child care subsidies), wait
time, and cultural sensitivity and responsiveness may impact family access and utilization of
child care (these factors are raised by parents and direct service providers in the report’s next
section).

PN-3 Child Care Landscape in Mecklenburg County
A: Scatter Map with Sociodemographic Data
B: Density Map
(4- & 5-star sites only)
(all sites)
34

35
Early Head Start is a federal program for families from low-income households designed to
promote the development of infants and toddlers, as well as help parents meet their goals for
housing, employment, education, and financial stability. Early Head Start serves pregnant
women and children under the age of 3 through home- and center-based programming. There are
9 Early Head Start programs in the database. Given the relatively small number of programs
offered, we have omitted these maps from the report. However, the majority of Early Head Start
programs are located in the center of Charlotte (in or around the uptown core) and directly west.
Parent
The early care and education services that expectant parents and parents of young children are
likely to need were categorized as follows: parent education and home visiting.
Parent education included a wide range of services and supports that focus on educating and
empowering parents of young children. The services included in the database range from the
Centering Pregnancy program at Atrium Health NorthPark OB/GYN to the program for single
parents at COS Kids to agencies that offer the Resource Parent Curriculum. There is some
overlap between the services in this category and those found in the Child Behavioral Health and
Parent Mental Health categories. In total, there are 116 parent education programs in the service
database. Given the substantial overlap with other categories, we did not include these maps.
Home visiting was defined as evidence-based programs in which trained professionals regularly
meet with expectant parents or families with young children who want support with developing
parenting skills, promoting early learning and healthy child development, and building a strong
parent-child relationship. Home visitors assess family strengths and needs, and they tailor
support accordingly, often connecting families to other resources and services, as needed. In the
database, there are 3 home visiting programs listed. These maps are not included given the
limited number of home visiting programs in Mecklenburg County and the fact that the service is
provided within the child’s home.
Nutrition/Food & Tangible Support Services
The Nutrition/Food and Tangible Support domain includes services that can benefit the whole
family but are geared toward families with young children. For Nutrition/Food, we included
lactation supports, the WIC program, and a number of faith-based and non-profit organizations
that help to provide food for families with young children. We identified 65 nutrition/food
programs. For Tangible Support, we included organizations that provide items relevant for
families with young children, included baby clothes and furniture, diapers, and other supplies
needed for raising infants and toddlers. There are 33 services listed in the database.
It is important to note that these numbers – for nutrition/food and tangible support – likely
underestimate support in this domain because our data on faith-based communities were more

36
limited. At the same time, we were deliberate in our efforts to capture supports focused on
families with young children specifically, rather than the broad spectrum of support that might be
offered to older children, adolescents, and adults in need of assistance.
The Value and Potential of the PN-3 Baseline Service Inventory: Database &
Mapping Components
Developing this PN-3 baseline database was a prime objective of the current project, with the
goal of providing a snapshot of PN-3 services and supports to inform the discussions and
decisions of community leaders and early childhood stakeholders. As noted in the preceding
content, the database and its associated maps help to identify areas in the county in which
families may have more limited access to a host of PN-3 services. Across domains, there are
clear patterns such that many services and supports tend to be clustered in and around uptown
Charlotte and in south Charlotte, which tends to be home to families from higher income
backgrounds. Areas north of the city and around Mecklenburg County’s periphery tend to have
less ready access to services. This is important information for leaders and stakeholders in
Mecklenburg County as they seek to develop equitable, accessible systems of care for expectant
families and those with young children.
Beyond that clear and immediate benefit, by creating a baseline database of PN-3 services, this
project lays an important foundation upon which future projects can build. For instance,
subsequent efforts could revise and expand the database to cover additional types of services
guided by input from parents and community stakeholders (e.g., income supports, faith-based
services, housing support). In addition, the database provides critical content that could be used
to create an interactive web-based interface that parents and providers can use to locate different
PN-3 services. Given the time-intensive nature of maintaining a service database such as this,
there could also be a mechanism for parents and agencies to provide updates on services in the
community as they expand, end, or change.

37
LESSONS FROM PRENATAL TO AGE 3
PARENTS & SERVICE PROVIDERS
Lessons from the service provider interviews and the parent/caregiver focus groups are organized
into four sections. First, we provide a broad portrait of Mecklenburg County families who are
raising young children, using themes generated from the service provider interviews and
parent/caregiver focus groups. This portrait outlines the strengths, needs, and challenges that
families face as they raise their young children (aged 0-3 years) in Mecklenburg County. Second,
we describe the factors that facilitate or serve as a barrier to accessing services that may benefit
the health and development of their young child and family. Third, drawing from the service
provider interviews, we delineate programmatic strengths and challenges that may affect
families’ experiences with the services and supports offered in Mecklenburg County. Fourth and
finally, we provide targeted strategies and recommendations, many of which were directly
suggested by the parents and service providers, for strengthening the system of care for families
with young children in Mecklenburg County.
Portrait of Families
Family Strengths
During the parent focus groups and the service provider interviews, participants described
multiple strengths that help families raise young children in Charlotte. We use the term parent
broadly to describe biological parents, grandparents, adoptive parents, foster parents, and other
caregivers or guardians who are raising young children.
Tenacity
In the context of this project, tenacity was described as the determination to keep going even
when facing various obstacles. Across focus groups, parents described how they had to fight
through red tape and barriers to get their children services. Parents described spending hours
searching online and making phone
calls in an effort to access needed “I’ve learned you have to stay on top of it
services. This level of
until you get an answer, and even then, when
resourcefulness and persistence in you get an answer, if that’s not
navigating child and family systems accommodating you and your child, you keep
that were found to be complicated pushing through until you get what you need
was required to access services that because they’re not just gonna hand it to
were perceived as easily available you.”- Focus Group Participant
for White children. Consistent with
what we heard from parents, service providers also shared that parents are “not easily knocked

38
down,” such that even when they encounter hardships, such as car trouble and job loss, they
handle these challenges and persevere.
At the same time, this level of effort in pursuit of services took a meaningful toll on parents; they
described being exhausted by the burden of having to advocate tirelessly for their children
without community supports, only to receive “the bare minimum.”
Investment in Children
It was clear across focus groups and interviews that parents’ investment in their children was
another critical strength for
families. This theme also ties
back to the strength of tenacity
and gives purpose to the
persistence seen among parents
in their efforts to build a better
life for their family, to carry on
when facing adversity, and to
access services for their young
children. Parents’ investment in
“[The parents we serve] are fiercely passionate and
protective of their children. Those are things we
don’t always recognize. … [In our organization],
we try to really build upon that ‘superpower,’ and
add resources and add skills and add to rather than
take away from the things they have done to survive
where they are.” - Service Provider
their children was evidenced in various ways, including spending quality time with their
children, being present for school and other events, and fighting for their children’s rights and
equal treatment. Parents described the enjoyment that comes with engaging with their child(ren)
in everyday activities, such as playing outside, going to the park, and going to the grocery store,
as well as being able to provide new experiences, such as visiting the zoo. One mother reported
that her knowledge of child development supported her ability to use games (e.g., Uno) to teach
her children reading, math, and a host of other pre-academic skills. Parents also highlighted the
importance of being “present as much as you can” whether at in-person events or by
communicating with teachers and providers via phone and email.
Parents’ investment in their children’s health and well-being was also evident in their
descriptions of the ways (and sheer amount of time) they advocated on their children’s behalf.
Parents reported spending months and sometimes years fighting for services within healthcare
and educational contexts. One mother reported the extensive process that she went through to
access a helmet for her infant child, which included cutting all her child’s hair off so that the
doctor had a better view of the unevenness of her infant’s skull development, as well as making
repeated phone calls and appointments with the physician when she was told that the flatness of
her infant’s head was below the threshold typically required for a helmet.
Service providers, too, described the substantial investment made by our community’s parents
with young children. Across service provider interviews, parents were described as “wanting

39
what’s best for their child” and “being open to learning about [ways they can give more to their
children].” The following quote further demonstrates these strengths:
“The biggest strength I see is that parents are invested in their children. Even…cases that we
see [that are mandated] through Child Protective Services, when we can get into a family’s
home and talk to them about their child, their whole demeanor changes. Their focus is on
their children. Their ability to get the resources they need maybe needing additional support,
but parents just want the best for their children. They may not always know how to get that,
and there may be things that are interfering with that, but consistently, the strengths that I’ve
seen in families is that they are invested in and want the best for their children.” - Service
Provider
Supporting One Another
Families who are especially skilled at accessing and providing support reportedly fared better
than those who were more isolated. Parents and service providers described important variability
in support with respect to the number of supportive others in their network(s) and their comfort
with seeking out support during times of need, as well as the quality of support provided by
others, particularly when the support came from older relatives such as grandparents. Parents
shared poignant examples of spouses and partners working together to care for young children,
particularly in the context of the COVID-19 pandemic. As one case in point, a mother described
how she and her partner worked opposite shifts so that there would always be someone at home
with their children to help with caregiving and virtual schooling, while balancing their needs for
employment. Other parents, particularly single mothers, described creating a buddy system with
another single mom so that they could help each other. One mother gave the example of meeting
another mom in a Facebook group and, over the course of two years, they have established a
relationship so that when one of them needs a babysitter or has to run errands, the other will
watch the children for a few hours. This mom also shared that they provide social support to one
another and that they spend time talking and “venting” to each other.
As parents shared their experiences of
support, it became evident that there were
meaningful individual differences across
parents in their comfort and ability to
reach out to others for help. While some
parents reported being able to reach out to
several people within their networks,
including their own parents, siblings,
employers, co-workers, and neighbors,
"With our Hispanic community...they bond
instantly in our group. So everyone, after the
first session, they trade phone numbers, and
usually by session 3 or 4, they're all coming
to the group with each other. They've taken a
ride with each other to the group...a great
sense of community in that population."
other parents expressed that they had no one to rely on, other than themselves. Cultural factors
may also play a role here, as a service provider shared the quote above regarding observations of

40
Hispanic/Latino families served by the agency. Across service provider interviews, there seemed
to be a theme that Hispanic/Latino families prioritize supporting one another and building
community, and that the agencies that serve these families place a special emphasis on fostering
social connectedness and a sense of belonging among families. In contrast, there were other
parents who shared that they moved to Mecklenburg County from other states and even
countries, and that they did not have any family or people who they considered a source of
support – these parents said that they had to “go it alone.” In addition to factors related to
culture, decisions to live in Mecklenburg County and duration of residence, parents also
mentioned that gender and personality differences play an important role in comfort with support
seeking. A father in one of the focus groups highlighted this by saying, “[My wife] just knows a
lot, so when it comes down to finding programs ... it’s not really that hard for her, but if I … was
a single father without her communication, I wouldn’t be as successful and it’s for multiple
reasons. One may be because I’m a man but also because I don’t talk to people. I’m not a
sociable person.”
Parents also discussed the advantages of having an extended family network to help with
childcare, advice, and support. However, parents described that their own parents were often
their only source of information and their primary model for parenting. In turn, “they do what
their parents did” even when the parenting practices may not reflect optimal methods of child
rearing. For example, one parent noted, “prior generations didn’t have the right knowledge
because no one taught them...so this creates a toxic cycle that continues.” Other parents
discussed how grandparents help with their children but have limited financial resources and, in
some instances, cannot qualify for available assistance.
In summary, families in Mecklenburg County have considerable individual and interpersonal
strengths from which to draw as they navigate the systems of care in place for young children. At
the same time, these strengths can take a considerable toll on parents when their needs, values,
and preferences are not prioritized within early care and support systems.
Needs & Challenges
There are multiple factors and conditions that can influence and interfere with service utilization
for families with young children (birth to age 3 years) in Mecklenburg County. Some influences
include those reflecting domains that are external to the family but have meaningful implications
for everyday life (e.g., financial insecurity, the physical/built environment, the healthcare
system), while others represent domains that fall more directly within the family sphere (e.g.,
caregiving knowledge and practices, child behavior, and parent mental health). Identifying the
needs and challenges that fall across these domains of influence is critical for enhancing
understanding of service utilization (and the lack thereof) because they reflect the broader
ecological constraints that families face as they work to navigate the systems of care for their
children.

41
The sections below detail the specific factors that emerged from parent focus groups and service
provider interviews that undermine parents’ capacity to support the health and development of
their young child(ren). These concerns are complex and multifaceted, spanning varied sectors
and systems, as reflected by the following quote on the pervasiveness of socioeconomic factors
for families:
“Poverty is key and critical, and an influencer on all of the other [determinants of
health]. Poverty relates to all of them.” – Service Provider
Financial Strain
Economic instability and financial stress emerged as the most salient challenges facing parents
with young children in Mecklenburg County. In
fact, within the focus groups, multiple parents
noted that Charlotte is one of the fastest growing
cities in the U.S. but ranked as the least
economically mobile, illustrating parents' feelings
of being left behind amid the rapid growth. As
such, parents stated that they needed financial
“If people are trying to eat [and]
survive, they have to focus on that
[first]. Then, Charlotte can focus on
making sure parents have
resources.”- Focus Group Participant
stability before they could focus on children’s health and access to community resources and
supports. This sentiment was highlighted by these words from one of our focus group parents:
“Parents have to work multiple jobs to survive and afford housing. Child development
is at the bottom of the list.” – Focus Group Participant
The financial strain that parents discussed focused on three main areas, including being unable to
meet their family's basic needs, not having access to a financial safety net, and being uninsured
or underinsured. These areas are described in more detail below.
Parents explained how they were unable to meet their family’s basic needs for housing, food,
and transportation. They shared how these challenges with “making ends meet” diminished their
own capacity for health and wellness, and had widespread implications for the family, as
children “internalize the stress” that their parents feel. The quotes below center on the
challenges with finding affordable housing.
“Affordable housing is like $1000 for a 2 bedroom and ‘no’ you can’t even let your kids go
outside.”
“Gentrification is huge in Charlotte…prices have [risen] and [they] are building new
apartments, pushing people out. People can’t afford [it and] homelessness, joblessness [are
the] result. They rebuild houses in the neighborhood but [the houses are] unaffordable, so
where are folks going to go. It’s sad.”

42
While housing was not a domain of focus for the current, specific effort, service providers also
mentioned that affordable housing was one of the most critical issues facing parents, as
illustrated by the following quote from a service provider interview: “Single parents and parents
in general are paying what I pay in a mortgage in rent. It's just hard to find affordable housing.
If there's Section 8 housing, it's hard to get it … and it might be in a place [that’s] not safe.”
Another salient issue related to housing was racial and socioeconomic discrimination, wherein
landlords reportedly do not adhere to the law and ask for families for extra rent or to pay for 1-2
months up front. Given the need for housing, parents can feel as though they do not have a
choice or any recourse other than to pay the amounts specified. Discrimination was a pervasive
concern for families in Mecklenburg County and will also be described in the section on Factors
Influencing Family Service Access.
Along with the struggle to provide for their family’s basic needs, parents and service providers
shared that not having access to a financial safety net compounded the challenges that families
face. Parents described being in a predicament where they make too much money to qualify for
financial assistance, but they do not have enough income to support raising a family in
Mecklenburg County. These issues are exemplified in the quote below.
“We go through the hardships to make it easier for [our children], and you should be
able to rely on the community for those areas that you fall short in. You would think
that’s the whole process of assistance versus [having] to... do so much with that little
bit of income in order for them to assist you.” – Focus Group Participant
A related issue highlighted by the quote below was that parents have very little protection or
available resources from which to draw when they encounter unexpected stressors, such as car
trouble, sickness/injury, or job loss.
“One thing happens and financially, they get behind. It could be a car issue or they're
sick for a week, and so they lose a week's worth of wages. I think it's those little gaps
that keep parents barely above survival. So one thing happens, and they get under
financially.” – Service Provider

43
Limited Insurance Coverage
A lack of health insurance and perceptions of limited coverage offered through Medicaid were
additional issues that contributed to the hardships faced by families raising young children in
Mecklenburg
County. As
shown in the
figure to the
right, children
from
households that
fall at or below
200% of the
Federal
Poverty Level
(FPL; i.e., lowincome)
are
likely to have
public
insurance, but
almost half of
parents in these
households are
uninsured. As noted by a service provider, this means that “[Parents] send their kids to the
doctor, but they themselves do not go in part because they have more limited health care access
than their children.” The quotes below reflect parent perceptions of how being uninsured or
underinsured affects how they are treated within medical settings.
“The minute you say you don’t have insurance, you get pushed to the bottom; they can’t
prioritize you.”
“They kick you out of the hospital after 3 days. They push you out. Even with the C-section.
They give you 3 days. That’s all your insurance is gonna cover unless you have personal
insurance.”
Children’s ability to be insured under Medicaid was perceived positively because it allowed
families to access needed services, particularly for children with chronic health conditions who
have diverse and often more intensive needs. However, parents also reported that having public
insurance could contribute to delays in service access and more complications if Medicaid
denied the claim or deemed the service to be unwarranted. As one example, the parents of a child
with special needs explained, “We utilize a lot of services. Both of our kids are autistic, so they

44
have to have certain therapies...The barrier to the feeding therapy is we have Medicaid, and
Medicaid would not approve [feeding therapy] for him because he does not have medical need.
It’s not [a] health issue…it’s a sensory thing.”
Inadequate Play Spaces for Children
Across focus groups, parents discussed the lack of safe and well-kept spaces for their children to
play, as highlighted by a parent who said, “You have to take that drive, if you want to enjoy a
decent outside area.” Parents described how they spent hours searching online for fun activities
and community events that their family could explore on the weekends. During the focus groups,
parents often shared child-friendly activities and the location of recreational facilities with each
other. Parents were eager to learn about play spaces for children, even if it meant traveling 30
minutes or more by car. As evident
by the sharing of information during
the focus groups, limitations in the
physical/built environment for these
families meant that parents were not
sure where to go for outdoor play
areas or that they traveled to other
communities to access well cared for
recreational areas, as illustrated by
this quote from a parent to the right.
“During summer, we get on 485 and go up to
Huntersville where they have the spray grounds.
They got all the nice toys for kids to play with; they
have the shade. [The] spray ground on Beatties Ford
Rd, it’s torn up. It’s not where kids can go to enjoy
themselves without getting sunburned or there’s no
shelter, no benches there for the kids to sit down, for
the parents to sit down. But when you drive them to
Huntersville, there’s more stuff there.”
Furthermore, parents who had grown up in Mecklenburg County reminisced about their
experiences as a child and the easy accessibility of community centers and neighbors with an
open-door policy when children needed after-school support. Parents discussed how their work
hours often are not aligned with the hours of childcare centers and, therefore, the lack of
community support through organized centers and informal networks (e.g., trusted
neighbors) was a notable concern for families. As illustrated by the quotes below, parents
expressed a need for affordable and convenient care that operated beyond the typical hours of
school and childcare, where children would be safe, welcomed, and nurtured.
“A community garden [would be nice] …instead of throwing up an ABC store, throw up a
little community corner where young boys can go play basketball and get a decent meal, a
shower.”
“[Children] used to be able to go play basketball and it was open to everyone…They don’t
let them do that anymore or they charge for access. They want you to pay. That’s okay, but
[they] need to make it affordable to the kids in the communities where they are located… kids
have nowhere to go, so they end up going to the street”

45
Parents and service providers explained that there are still community centers, but they now
charge a fee for access because they are contracted out by different agencies to provide specific
services, such as sports, health, and fitness activities. A parent shared, “[Community centers]
would give parents comfort because [they would] know that the child is there and safe. There are
so many of these centers all over Charlotte, but they aren’t doing anything to reach out to kids.”
Uncertainty about Child Health and Development
Parents and service providers discussed the importance of building parents’ knowledge across
five broad areas: effective caregiving
techniques, managing child behavior,
understanding typical and atypical patterns of
development, addressing children’s socialemotional
needs, and navigating the educational
system. Parents and service providers discussed
the need for greater parent education in
effective caregiving techniques across different
“[The] challenge with parenting is we
don’t know if we are meeting the mark.
We need training on how best we can
help our children, so we don’t repeat
patterns. We just do what our parents
did but don’t know what works.”
child age points, as highlighted by the quote from a father to the right. During this focus group
discussion, a parent suggested, “We need to go to school for everything else, so why not
parent[ing]?”
Across focus groups, parents offered multiple examples of how they were unsure how to
manage child behavior. The behavioral challenges shared by parents ranged from common
child rearing problems, such as children’s refusal to take a bath or go to bed to more disruptive
types of behavior, such as slamming doors and “acting out”.
Another related theme discussed within the focus groups and interviews reflected the limitations
in parents’ understanding of typical and
“For a lot of parents, they don't have any
atypical patterns of development. This
experience in that world [referring to child
was particularly salient for families with
children diagnosed with chronic health development], and I don’t think the U.S. is
conditions, as one mother shared the great [at] helping parents when they are
striking differences in the process of released [from the hospital with] their
recognizing the signs of autism for her infant.” - Service Provider
first child versus her second child. This
mother provided the following recommendation: “[it’s important to have] the pediatrician
recognize early because sometimes parents don’t know what to look for…especially in
disenfranchised communities…because with our second we knew what to look for so I was like,
‘Oh yeah, he has [autism]. We’re going to go [to the Developmental and Behavioral
Pediatrician].’ But a lot of parents don’t know what to look for so I think our pediatricians really
have to aid in that and educating parents [about] what to look for and how to do the early

46
developmental screenings.” This theme of enhancing parents’ understanding of development is
closely related to parents’ ability to advocate effectively for their child within healthcare and
educational settings, especially in circumstances where parents feel dismissed, misunderstood, or
at worse discriminated against due to the intersectionality of identities that have been historically
marginalized (e.g., Black, poor, female, mother).
Across focus groups, parents vividly described how the adversities faced by their children had
downstream consequences for their children’s’ social-emotional health. The quote below, from a
mother in one of the focus groups, illustrates this perspective.
“Just because she’s not autistic, it doesn’t mean that she doesn’t have emotional or different
mental things that she needs to talk about. She doesn’t have a two-parent household. She
doesn’t have a father figure, and she doesn’t have any siblings to interact with.”
Parents also recognized how their own stress impacted their children’s well-being, as one mother
reported that her child “internalizes” the stress at home. However, parents described feeling
helpless when it comes to addressing their child(ren)’s social-emotional needs, as illustrated
by this quote from a mother in a focus group, “It’s a battle with my child every day…it’s hard to
explain and understand her level and her behavior and why she’s acting this way.” Parents
indicated a desire to seek counseling for themselves and for their child, but the barriers to
accessing behavioral health services (as described in a later section) deterred them.
Consistent with family strengths related to investment in their children, it was clear across focus
groups and interviews that parents want advice and knowledge about parenting and child
development and that they are receptive to new information. These sentiments are reflected in
the following quotes from two service providers:
“All caregivers want to do everything they can for their child, but they don’t have all the nice
toys…with the bells and whistles. They don’t have all the things that maybe they think they
need, but I think a strength is…a willingness for parents to [hear about the power of] early
relationships."
“We have families that are very receptive to coming in, and they really have a lot of
questions about how they can improve their health, and so it’s very refreshing to talk to
someone who wants to lose weight, get better health. They’re concerned about their children,
and we can tell them the smallest of things to do as far as [nutrition and exercise are
concerned] and you can see the results in 3-6 months a lot of times...That’s one of the most
rewarding parts of counseling, that I love, is seeing results in such a short period of time.”

47
Unmet Mental Health Needs Among Parents
Throughout the focus groups, parents discussed their own difficulties with mental health. The
daily hassles and hardships they face, in combination with limited support and significant
barriers to help-seeking, often resulted in parents neglecting their mental health. Service
providers also shared that many of the parents they serve have experienced “significant trauma.”
Likewise, parents discussed their need for “mental, physical, and emotional help” and that,
although the focus tends to be on supporting mothers, fathers need just as much help. In fact, the
salience of the need for supportive and mental health services for parents was conveyed verbally
and nonverbally, as several parents shed tears while they described stressful circumstances
related to their efforts to care for their young children.
Taken together, these results indicate that parents of young children must navigate multiple
challenges related to financial strain, discrimination, limited insurance coverage, inadequate play
spaces and community supports, uncertainty about child health and development, and unmet
mental health needs. These challenges are part of the broader ecology in which families reside
and can interfere with their ability to access services that would support the well-being of their
young children.
Factors Influencing Family Service Access
Parents and service providers described several factors that more directly influence parents’
ability to access services, supports, and resources offered in Mecklenburg County for families
with young children. The factors detailed in this section fall into three main categories: (1)
communication and logistical concerns, (2) service policies and procedures, and (3) family
experiences when accessing services.
Communication and Logistical Concerns
Across focus groups and interviews, participants reported that word of mouth was the primary
way by which families find out about resources. In fact, 10 of the 12 service providers who
were interviewed specifically mentioned “word of mouth” as the primary way that families find
them and their specific program or service. For the two service providers who did not mention
word of mouth, this type of communication was not relevant because they do not receive clients
that way.
While word of mouth can be an effective way of locating services for some families, it
compounds the disadvantages faced by families from low-income households or those who do
not have a local network of social connections. Moreover, it places the onus on parents to discern
the types and characteristics of available services and assess their alignment with their child or
family’s need, adding to the burdens they shoulder. This was highlighted by a mother in one of
the focus groups who, when asked how she finds services that her children need, stated, “I spend
hours on-line. I call people. I go to the doctor’s office and ask them questions about how they’d

48
treat certain situations.” In a similar vein, parents shared their struggles with finding childcare,
and they recounted using Google or calling upwards of 12 different childcare sites to determine
whether they had openings, would take the childcare voucher, and were a good fit for their
family.
Service providers can also have trouble locating appropriate services for families, as underscored
by the following quote about efforts to support parents’ access to mental health services: “A lot
of parents have been through significant trauma, so I try to suggest trauma focused cognitive
behavioral therapy, but as you probably know, there’s a gamut of professionalism, and it’s hard
[because] I don’t personally know a lot of therapists… I want to refer them to somebody that’s
effective…I don’t necessarily have a [go-to] agency. Sometimes we just sit in front of a laptop
and go through whatever we can find.” During this same interview, the service provider also
commented that insurance coverage can be a limiting factor when trying to help parents access
mental health services.
Overall, the lack of communication about resources in the community emerged as a crucial
barrier for parents in their pursuit of services, as described by the following quote from a parent
in a focus group:
“We need resources. [We need to know] what opportunities are out there. [Resources] need
to [be] present[ed] in a way so you learn and know about them. The resources are being kept
back for a certain group of people. If [we] know about a resource, we’ll use it, but they are
not made available.”
During the focus groups, it was evident that a few parents had extensive knowledge of the
resources available in Mecklenburg County. In the words of one mother: “I learn about new
resources every day.” However, the majority of parents described more limited awareness of
services and supports. At times the focus groups briefly turned into a space where parents were
able to support one another in providing tips and strategies for accessing needed resources.
Among parents with greater awareness and use of services, they reported that one person or
agency served to “bridge the gap” between their family and a wealth of other services. Parents
discussed how misinformation gets circulated within their
networks and with providers, and they do not always get the right
answers, so they have to keep asking and searching for resources.
In an interview, a service provider offered a complementary
perspective by explaining that families want what is best for their
“What you reach for
is informed by what
you know.”
children, but they may not always know what that is. If there is better communication about what
is available, then families can make informed decisions about what services they want. The quote
above from this service provider gets to the crux of the issue.

49
Parents also described many logistical factors that interfered with their ability to access services.
The most frequently cited barriers were related to time, childcare, transportation,
distance/geographic, and affordability of services. In fact, one parent who moved to
Mecklenburg County from another state explained, “Everything is so far apart here. I’m used to
15 minutes here, 5 minutes there. I literally drive 25 minutes and sometimes 2 hours to take my
child somewhere.” The interconnectedness among barriers is further highlighted by the
following quote from a service provider:
“Some of the biggest issues [for families are] proximity and transportation. … We’re not a
neighborhood clinic... [which] makes it hard if we want families to come back to us [for
follow-up] because there is a concern… That puts a lot of stress on our families to think
through missing an entire day of work to bring their kid here. Maybe they’re taking two buses
to get here, or maybe they have to find a ride from a friend because maybe they don’t have
access to their own car, and then they miss a day of work. And for many of our families,
missing a day of work is hard. It’s food on the table. It’s a potential threat of losing your
job."
Consistent with the sentiment expressed by this service provider, parents in the focus groups also
explained that the competing demands of employment and caring for their family made it
difficult to access resources. As a case in point, one mother shared, “If I need to take time off
from my job I can’t. The daycare is not affordable, or too far away. So many barriers inbetween.
You don’t even have the time, even if there was a resource.” Parents also described
how the timing of events limited their ability to be engaged in child-related activities, as
illustrated by the quote below.
“[The school system] discourages parents from getting involved. Parent meetings are during
the day when parents can’t get off work. They need to talk to the parents, not just the ones
who show up. [It’s] not that [absent parents] don’t want to be involved, [they] just can’t at
that time.” – Focus Group Participant
One mother shared that she made the purposeful decision not to seek employment to ensure that
her children are able to access the services they need. Parents discussed not being able to take
time off work to utilize resources, and even if they were able to access a particular service for
personal or family support during non-work hours, they would have no one to care for their
children. These issues were again brought to the fore in the context of a focus group discussion
about parent mental health, as a mother offered, “I would love to go to counseling. My job
provides resources for counseling, but what am I supposed to do with my child during that time?
It’s just me and my kid in Charlotte.” Across focus groups, parents talked about their desire for a
“one-stop shop” that would have more flexible hours of operation and where they could apply
for and access a range of services, while their children are cared for on-site.

50
Although barriers related to lack of time and childcare were broadly discussed as impediments to
accessing services, distance or geographic constraints more clearly emerged as a primary
deterrent to accessing child behavioral health services. Across focus groups, parents
expressed a desire to seek “counseling” services for their children but found that child therapists
are located too far away from their communities. Parents frequently commented that they could
not drive to Park Avenue for counseling services. In fact, parent perceptions of limited access to
child behavioral health services were consistent with our landscape analysis demonstrating that
these services are primarily located within the uptown core and south Charlotte, with a few
additional service points in North Charlotte. In addition, the probability of access was higher in
the uptown core and North East Charlotte, near the university area, compared to other areas in
Mecklenburg County. Of particular relevance for this study, behavioral health services for young
children were scarce in Northwest, West, and East Charlotte, and these are areas with higher
concentrations of young children living in households at or below 100% of the FPL. It would
appear that the County needs more child-focused behavioral health providers, and that concerted
efforts are needed to locate them in areas and neighborhoods that have been underserved.
In addition, the central barrier for childcare - discussed by both parents and service
providers - was affordability. Parents described that childcare was “so expensive” that they
could barely afford to pay housing and food costs. For some parents, it was more cost effective
to leave their job and care for their baby full-time, rather than pay for childcare. Another parent
described her experiences of having to decide between childcare options that are close but not
affordable versus traveling 20-30 minutes to more affordable childcare options, and how these
types of tradeoffs can lead parents to overlook more important factors related to the quality of the
childcare sites, with respect to “health, safety, and educational” experiences. These sentiments
are further exemplified by the quote below from a service provider.
"Families cannot afford the cost of quality [childcare]. We don’t expect families to
afford the cost of public education. That is a public good. Our society doesn’t yet see
childcare as a public good - this is the problem.”
In sum, parents and service providers revealed that word of mouth was the primary way that
parents learned about services for children from birth to 3 years old in Mecklenburg County.
However, this type of communication about resources tended to benefit those with a wider social
network and specific personal characteristics (e.g., gender, personality, culture), leading to the
majority of families with whom we spoke being largely unaware of the services, supports, and
resources offered in the county. Parents and service providers alike described how locating and
accessing services requires considerable legwork, further compounding the burden placed on
parents who already face a variety of challenges and disadvantages. When parents were highly
knowledgeable about local resources, it was often because they had experience navigating the
system due to the needs of a child with a chronic condition or they were connected with a person

51
or agency that served as a gateway to other services. Nevertheless, even when parents were
aware of and desired to access services, they faced multiple and intersecting constraints,
including barriers related to time, childcare, transportation, distance/geography, and
affordability.
Service Policies and Procedures
Parents described eligibility requirements for accessing services to be too stringent or unclear.
A common theme that was echoed across parent
focus groups, and reflected in the quote to the right,
was that “if you make a little bit of money, there are
no resources.” Parents described difficulties with
obtaining assistance (e.g., food, income, childcare,
housing subsidies) because they work full-time, and
“I gotta quit my full-time job to
meet your requirements to get
assistance … That's the real
dilemma.” – Focus Group Participant
in turn, their income falls just above the established cut-offs for assistance programs. This
concern regarding stringent eligibility requirements was particularly salient for mothers
seeking childcare assistance, as mothers described how they wanted to seek employment but
were unable to do so effectively without consistent childcare; however, they were not able to
qualify for childcare assistance unless they were employed.
Another key area in which eligibility requirements appeared to hinder service access is when
parents are seeking resources for developmental concerns. Prevention is hampered by
eligibility criteria that require a diagnosis or developmental delay to be present prior to
accessing services. As evidenced by the quote below from a service provider interview, parents
and service providers wondered where children who are known to be “at risk” for behavioral or
developmental problems (because for example, they have experienced a high number of adverse
childhood experiences [ACEs] or they have sub-threshold concerns) fit into the system.
“The 0-3 ranges can be hard because a lot of pediatricians [consider] the range of normality
[to be] huge in that age [range]. Developmentally, kids can be anywhere [within] a one-year
spectrum and … their behavior is not a disability [yet], so I think that becomes really hard
with some of our parents to find some way to get [their children] assessed…Parents say that
their pediatricians will not diagnose, or [that the parent must] wait a couple years [before a
developmental assessment can be conducted]. [It] becomes really tricky in our [program]
because we want to assist these kids but sometimes, we’re not sure how to [manage their
behaviors].”
If these children and families could access services sooner, there would be an opportunity to
prevent developmental problems rather than offer intervention. Working to prevent problems and
promote healthy development from the start is not only more humane, it is also less costly and
more likely to be effective (Cowen, 1994).

52
There also appeared to be substantial confusion among parents over eligibility requirements,
as highlighted by the quotes below from parents and service providers.
“[We receive] conflicting information from pediatricians, grandmother, whoever…we are
constantly having to navigate misinformation.” -Focus Group Participant
“Working moms a lot of times don’t realize they’re eligible… A lot of people don’t realize
that you can have a full-time job and still be eligible for [our] program. A lot of folks think
that ‘I have to be unemployed in order to qualify for the program’, but if you fall within that
185% poverty level, you’re still eligible.” - Service Provider
Misunderstandings regarding eligibility are of particular concern for Hispanic/Latino
immigrant families due to inconsistencies between local and federal policies, as well as fear
of deportation. Service provider interviews emphasized that immigrants, particularly
unauthorized immigrants, are either officially excluded from public services (e.g., public charge,
undocumented must pay out-of-state tuition, rather than
in-state) or there is confusion about their eligibility for
services. The quote from a service provider to the right
demonstrates that local resources, such as those offered
through the county health department and childcare
services, are often available to families regardless of
legal status, but because federal and state restrictions
are often more punitive and stringent, immigrants are
fearful and confused about their ability to access
“[We] need to help families
understand that just because the
services are located within the
County Health Department,
citizenship or documentation is
not required for services.”
services. Hispanic/Latino immigrants can also be hesitant to use public services and resources
because they worry it might hinder their ability to legalize their status or become citizens in the
future. The service provider quote below raises points that were echoed by representatives from a
number of different agencies and further demonstrates that many families do not realize that they
are eligible for services even if they do not have documentation.
“For families that are new to our country/our culture, the healthcare system is a brand-new
experience. They don’t realize they need to come in for well checks, prenatal care, etc. Many
don’t realize they are eligible for care, even if they don’t have documentation. Just by asking
someone for some of the typical things we ask patients (e.g., social security numbers), we
scare off potential patients. There is always a way around these questions, but families don’t
know that.”

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Parents also described inefficiencies with the referral process and long wait times as barriers
to service access and utilization. Across parents and service providers, doctors could be
perceived as a stumbling block rather than a partner in children’s care when it comes to children
being referred for or gaining access to additional services, either because pediatricians adhered to
a “wait and see” approach for monitoring developmental concerns or because the pediatrician
and the parent disagreed about the nature of the problem and the need for services. Service
providers offered that parents can seek out developmental screenings and services on their own,
but many parents are not aware that they can self-refer. In addition, parents expressed frustration
about the lag time between completing the intake process and receipt of service. One mother
shared her experience, which is illustrated below.
“I really need help with my son to help him with his speech. [We’ve] gone through the
application process and everything, and we’re still waiting. I don’t know when it’s going to
happen. It’s been almost 3 to 4 months now. They’re saying they haven’t found any person
[to come to our house] yet. It’s like [providers] are limited around this area.”
Another parent described a 6-month wait for an initial appointment to access in-home behavioral
health services. In this case, the parent talked with the family pediatrician, who then gave the
parent a list of four therapists who provide in-home services. Unfortunately, given the wait for an
appointment and the rapid pace of infant and early childhood development, this parent was
concerned that they will have missed an important opportunity for behavioral intervention.
Taken together, results from focus groups and interviews revealed that service policies and
procedures contribute to families’ difficulties when trying to access resources for their young
child(ren). Specifically, parents and even service providers described eligibility requirements for
programs as too stringent, confusing, and inconsistent. Throughout focus groups, parents
reiterated that programs that were supposed to alleviate their financial strain increased their
stress because parents did not make enough money to address their basic needs, and yet they
made too much money to qualify for assistance programs. In addition, mothers emphasized the
competing forces at play in their efforts to seek employment without consistent childcare, given
the requirement that parents must be employed before they can qualify for childcare assistance.
Focus group and interview participants also conveyed that the prerequisite of having a
documented diagnosis or developmental delay before accessing certain services directly inhibits
prevention efforts. Parents and service providers underscored that children and families fall
through the cracks with policies such as these and, by the time children enter elementary school,
they are significantly behind. It was clear from our discussions that children who are at-risk for
problems or exhibit sub-threshold concerns could reap considerable benefits from preventive
services. Along with stringent eligibility requirements, there also seemed to be substantial
confusion and misunderstanding among parents regarding their eligibility for services, and this
was reported to be a particularly salient issue for Hispanic/Latino immigrants who must navigate

54
local, state, and federal policies that often do not align. Finally, parents and service providers
voiced concerns about inefficient referral processes and long wait times to access services.
Healthcare settings were identified as a key context where families reported salient obstacles to
accessing the services their child needed.
Family Experiences When Accessing Services
Parents and service providers alike emphasized how relationship building was the vital
component that influences families’
experience with and likelihood of continuing
to access services in the future. In almost
every interview, service providers talked
about the importance of building
relationships and interacting with families in
a caring and supportive way, illustrated by
the quote to the right. Likewise,
"We overwhelm families with love when
they walk through the door. People don't
want to ask for help. So, we build
relationships with people - build
communication and make them feel
welcome." -Service Provider
relationships are also what allow parents to locate services (e.g., word-of-mouth) and feel
connected to organizations. Foundational to this notion is that the goal of virtually every service
for young children is to help families build strong and secure attachment relationships between
parents and children. When there is a sense of understanding and trust between the family and
staff at an organization, parents feel at ease and welcomed. Building these relationships with
service providers can also instill in parents a sense of hope in being able to reclaim important
aspects of their identity and a sense of confidence in their ability to establish a strong relationship
with their child, as well as help their child to feel safe and loved, while nurturing healthy
development. These themes are illustrated by the following quote from a parent:
“Low and behold, [Director of childcare site] came through out of 12 facilities. And she was
welcoming. From [helping with] the car seat to her walking and almost potty trained at 2,
[Director of childcare site] was such a big help, not just for me but for the family. [I was]
able to go back to work… it [allowed me to be a better] parent by having somewhere secure
for my child to go.”
Parents and service providers discussed multiple ways that trust can be developed between
families and agencies. Parents stated that they are more likely to access services when they
perceived the organization to be helpful in meeting a need identified by the family. A related
concern was the extent to which the organization attends to family preferences and values in
service delivery. In fact, families might appear to have similar needs but meeting those needs
effectively often requires an understanding of how a particular family will feel supported and
tailoring service delivery in an individualized way that aligns with the family’s strengths, needs,
preferences, and values. This sentiment is communicated in the service provider quote below.

55
“How do we meet families where they are, and cobble together that system of support that
needs to wrap around a child and family according to needs, and according to preferences …
and create that construct of support? It’s not the same [for every family]. I think about
‘equity’ or ‘equitable,’ but that doesn’t mean ‘the same’ for all children and families,
because we really have to honor different perspectives and different wants and needs, but we
don’t want income to drive access…or culture to limit access.” – Service Provider
Attention to family preferences and values also necessitates that services are culturally
sensitive and relevant. Parents also described wanting a “safe-haven” to discuss racial and
cultural issues, share experiences with discrimination, and feel as though all aspects of their
identity were respected and welcomed. Importantly, a lack of cultural alignment between
providers and families was discussed as a central barrier to accessing services, as illustrated in
the following quotes from parents:
“[You] need someone to talk with who you relate to. I went to a therapist but they [didn’t]
understand where you come from or understand what it means to be your color or to go
through what you go through. It was a waste of time and cost of daycare.”
“It is very hard to take suggestions about parenting in general when you are struggling. It’s
even harder when you have someone in a professional role and maybe your culture and their
culture have a long history of oppression. It is very challenging.”
Although cultural alignment can be difficult to achieve due to myriad factors (e.g., workforce
development), the quote below demonstrates how its occurrence can effect change and have
meaningful benefits for children and families.
“We've diversified our staff over the last several years to the point where recently, I watched
a treatment session, and this little girl was like, ‘Look at me! I'm a Black girl, this is my
Black baby doll, and my therapist is Black!’ And I just thought, that is huge. For this little
girl, that made a big difference, especially when her foster mom was White, and she was in
the process of transitioning back to her biological mom. So, to have a therapist to help her to
navigate through that, that she could relate to, was huge." –Service provider

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Factors associated with cultural sensitivity and relevance can be especially salient for
Hispanic/Latino families whose cultural diversity might be overlooked. The figure below – even
with groups combined into categories (e.g., South American) for the purposes of display –
illustrates how Hispanic/Latino children in Mecklenburg County are quite diverse, and even
more diverse in terms of country of heritage than Hispanic/Latino children nationally.
Some service providers in Mecklenburg County are uniquely well-equipped to provide culturally
relevant services for Hispanic/Latino families, which can be demonstrated in many ways. As one
service provider shared, “We understand the Latinx community and their diversity. We know
different food terms across countries of origin.” Other service providers discussed being
intentional about the books and images used at the organization so that diverse experiences and
authors are centered. In addition, some providers shared changes to their service protocols to
better understand the cultural beliefs and values that families bring, including the following:
“When I start every interview I ask, ‘What are some of the cultural beliefs you feel strongly
about?’ That way I don't offend anyone, because I've noticed that lots of things we do here in the
U.S. are not done in South American or Latin American countries.”
The final themes that emerged from focus groups and interviews related to negative experiences
with services involving stigmatization, stereotyping, and systemic discrimination and
racism. We believe these topics are important to include given their pervasiveness in family
descriptions of factors that impede service utilization. However, we want to acknowledge that

57
these experiences can be difficult to read and may contribute to a range of emotions, including
anger, sadness, guilt, disappointment, shock, and the like. For those who have experienced
racialized trauma, these descriptions may contribute to significant discomfort and reexperiencing
of past events.
Parents expressed a sense of fear in working with service providers because they worried that
sharing information or asking certain questions would lead to the involvement of Child
Protective Services or negative repercussions related to immigration. One parent voiced a
concern about asking questions about common caregiving challenges for fear that a social
worker would show up at her door and claim she was not caring for her child appropriately.
Service providers also voiced concerns about what happens when family issues are handled by
local agencies. In fact, service providers offered that anecdotally, children in Black families are
more likely to be put in foster care when there is an allegation of maltreatment, whereas children
in White families are often places with grandparents and other relatives. In addition, service
providers disclosed recent instances in which immigrant parents without legal documentation
had their children taken into protective custody because the parents were afraid to reveal who
maltreated their child because that person might face deportation.
Across focus groups, parents shared experiences of stigmatization and stereotyping in the
context of their interactions with doctors, teachers, and other providers. Parents described the
misperceptions that others have of them (e.g., “angry Black mom”, “a single-mom just looking
for a handout”, “poor and uneducated”). When describing her efforts to access specific medical
services for her child, one mother stated, “I don’t want to be the angry Black mom, but they treat
me like [I’m] dumb. ‘No, I didn’t go to school for it, but I know because I spend 24/7 with my
child, so I know.’ [Doctors] don’t believe me. It’s hard, you have to fight for it.” They also
discussed how they actively counter others’ attempts to label their children as “bad children”.
Parents also reported being weary of race- and income-based questions on application forms
because there was no information provided about how the data would be used, and parents
surmised that it could be used to reinforce negative stereotypes.
Parents and service providers identified systemic discrimination and racism as a pervasive
barrier that affects family experiences across settings and contexts. As mentioned earlier in the
report, mothers recounted their efforts to fight through red tape and advocate for services that
were perceived as easily available for White children. The discrimination was manifested at
multiple levels, from poorer quality service or ineligibility for services due to being insured by
Medicaid to interpersonal dynamics with doctors and other professionals who did not take
parents’ concerns seriously. These issues were highlighted by a parent in a focus group who said,
“If you’re on Medicaid, you can’t get anything. It labels you. I don’t get the same services,
assessments, and treatment [as someone with private insurance].”

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In sum, family experiences with services are anchored in the strength of the relationship between
the family and the service providers. Building relationships and attending to family-identified
needs, values, and preferences were highlighted time and again as the core facilitators of family
service access and utilization. The ability to do this well relies upon the program’s capacity for
culturally sensitive and relevant care, for which there is marked variability across agencies.
Programmatic Strengths & Challenges
Programmatic Strengths
During service provider interviews, two key strengths emerged with respect to organizational
capacity to address family needs and preferences. The first strength was intra-agency
communication. Service providers discussed how
they work well together as a team and try to create a
supportive work environment within the
organization because this is how they can better
serve families. This sentiment was reflected in the
following quote from a service provider, "We mirror
the relationship-building we are trying to support
our families in building." Service providers shared
“We have a very strong teamwork
philosophy within our agency. We
work really well to meet the needs of
families. Every person that works at
our agency, they want to do what’s
best for families. And that’s huge.”
multiple examples of how agency staff “band together to get the job done.” The quote from the
service provider above effectively sums up this strength.
The second, but related, strength shared my many service providers was how they were
“nimble” and could quickly adjust to family needs. This was particularly salient during the
pandemic when organizations needed to adjust course and shift programming efforts to address
the increasing needs and stress of families.
Programmatic Challenges
The main programmatic challenge that was echoed across service provider interviews was
workforce development. Service providers, particularly administrators, expressed frustration
regarding their ability to recruit staff due to issues surrounding compensation. These concerns
and their interconnections were highlighted in the quote below.
"Our childcare staff are abysmally compensated. Right now, we’re having a childcare
staffing crisis because other, lower wage employers – retail stores, coffee shops, Amazon
delivery – are paying more [than what one could earn in the childcare industry], while
families can’t afford to pay more [for childcare]. So, we have this dilemma…parents can’t
afford to pay more for childcare, childcare program operators can’t charge more for
childcare and stay in business, and childcare professionals can’t earn less. This is our
common challenge.” – Service Provider

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Along with challenges associated with pay, service providers also described related difficulties in
hiring and retaining high quality staff, as reflected in the following quote:
“[It is] difficult to find teachers, especially qualified teachers. We want our teachers to look
at what we do as not just a job. We want them to see this as a profession that they can move
up in; that they're committed to; that they'll continue to be educated on. – Service Provider
Service providers shared that as the adversities that young children and families face continue to
rise, organizations need providers who are
We're also looking for teachers that are
knowledgeable about the effects of early
willing to become trauma-informed. We’re
trauma and adversity on child development
looking for teachers that are interested in
and who can empathically meet the complex
creating a relationship with children. It’s a
needs of families. This desire for greater
lot about self-regulation, not just what’s
education among staff, as well as a possible
important academically.” – Service Provider
shift in the ways that agency staff may view
their roles and responsibilities is highlighted in the quote to the right.
The final challenge that emerged as a central theme across service provider interviews was the
diversification of program staff, which directly relates to an organization’s capacity to provide
the culturally sensitive and relevant care that families are seeking. Concerns related to an
organization’s ability to serve diverse families are described in the service provider quote below.
“Even the families that we see [who] are mandated to go to resources, [no one is] taking into
consideration - Is this a cultural match between the family and the therapist? Is the family
getting what they need from this therapist? They’re just being referred to therapists." –Service
Provider
Service providers expressed their desire to be able to serve diverse families, cultures, and
communities, but this was not able to be fully actualized because of constraints related to
workforce development. As highlighted by a service provider, “All families should be able to
choose what is best for their families that reflects their needs, their culture.” Importantly, there
was variability across organizations in their ability to serve diverse families effectively, as some
organizations were particularly skilled and well-equipped to serve families from specific
ethnic/cultural backgrounds. However, even service providers at these organizations noted that
they face challenges in their efforts to serve families from other cultural contexts.
Overall, it was evident across the service providers that we interviewed that they are invested in
building strong relationships with families and providing effective care that is aligned with
family values, needs, and preferences, and that is evidence-based and culturally responsive. At
the same time, programs face substantial challenges with funding and workforce issues that can
interfere with their ability to fully realize their vision.

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Stakeholder Generated Recommendations:
Strengthening Systems of Care for Families with Young Children
“Let’s not reinvent the wheel, let’s reinforce the wheel that already exists"
-Service Provider
Recommendations generated by participant stakeholders reflected 3 main categories:
(1) Implement collaborative and comprehensive PN-3 service models for meeting the
diverse needs of families
a. Improve inter-agency communication and collaboration. Service providers and parents
discussed how access to services is improved when organizations work together on an
inter-agency level. Organizations and programs serve families most effectively when
providers communicate well within and across organizations. During the interviews,
service providers discussed how they strive to make “warm hand-offs” when they refer
families to other services, so that families feel comfortable and know where they are
going. Parents are more likely to engage in services when agency processes are
demystified, and when families know what to expect when they enroll in a new
service.
b. Address basic needs and build a social and economic safety net for families. Parents are
not able to effectively attend to and address the developmental needs of their young
children when their family’s basic needs continue to go unmet. Parents poignantly
described the severe economic hardships they encounter in their efforts to “survive” in
Mecklenburg County. Both parents and service providers described the critical need for
safe and affordable housing for families with young children. In addition, families need a
safety net so that typical challenges (e.g., sickness, car trouble, household repairs) do not
upend a family’s entire livelihood. Parents and service providers shared several ideas,
including the recommendation that systems facilitate opportunities for parents to support
(social, instrumental, tangible) and learn from each other. One particularly innovative
idea was that families could team up with one other to provide financial assistance in the
form of a no-interest loan for a community member facing unexpected economic
hardship. Another idea that was raised in several focus groups was that parents, and
especially single mothers, would benefit from “buddy systems” to cultivate instrumental
and social support. Along with offering an avenue for social connection (an area of need
identified by many parents), a buddy could also assist with common challenges that
parents of young children have to navigate, such as auxiliary childcare, transportation
help, circumscribed food or financial needs, advice, and emotional support. Finally, there
is a clear need to provide financial assistance for those families with incomes above

61
100% of the federal poverty line but below the median income for Mecklenburg County.
These families face considerable economic strain, and yet they do not qualify for federal
assistance programs.
c. Increase access to affordable childcare options. As conveyed by a service provider,
childcare should be viewed as a public good in the same way as public education. Across
focus groups, parents discussed their need for high quality, affordable, and easily
accessible childcare. Service providers also highlighted that childcare should be
culturally responsive and align with parent and family preferences. This type of care is
fundamental to the well-being of the community but continues to be under-valued and
under-funded. Parents shared that even with steady employment, they could barely afford
childcare costs, food, and housing. Consequently, many parents were faced with the
dilemma of quitting their job to stay home with their young child full-time, or trying to
work and pay for childcare while barely making ends meet. Another central issue that
emerged is the requirement that parents must be working to receive childcare assistance.
This requirement further disadvantages parents who need consistent and reliable
childcare while they are seeking employment. Furthermore, some parents reported that,
once they received childcare assistance, it was difficult to locate sites that would accept
the subsidy.
d. Utilize a multigenerational, whole-family approach to quality care that is responsive to
parent needs and preferences. Service implementation for young children should be
oriented to support and strengthen families more broadly, rather than narrowly focus on
the needs of an identified child or parent. Efforts to support the family would consist of
articulating strategies for identifying the strengths and needs of the whole family (e.g.,
parents, infant, siblings, grandparents), addressing the family and each member therein as
part of the care plan, and communicating steps for how the care plan would be
implemented in a coordinated way that builds on family strengths and accounts for the
constraints of the community context in which the family lives (Kilmer et al., 2010).
Consistent with this approach, flexible or blended funding streams would be needed to
support elements of a care plan that would not be considered a “medical” necessity and
that may not be traditionally aligned with the identified service domain, but would
strengthen family well-being and stability. As one example, access to safe and affordable
housing may not be viewed as a medical necessity within the context of pediatric care,
but it is a critical factor that determines whether a family can meet a toddler’s needs for
security, exploration, and structure. Although a pediatrician would not be responsible for
obtaining housing, there may be funding streams that allow pediatricians or even
consultants within pediatric practices to take an active role in helping the family work
with targeted community agencies to obtain the support the family needs. Another way to
implement family-focused services would be to create more community centers in which

62
many services and programs are co-located (or providers come and use space). Parents
voiced their desire for such “one-stop shops”, with more flexible hours of operation and
safe spaces for their children to play and be cared for, while parents address personal and
family needs.
A critical element of a family-focused approach to care should be the support of
prevention strategies for children who are at-risk for developmental delays. Medical
necessity (i.e., a documented diagnosis or disability) should not drive access to care.
Parents and service providers consistently expressed their frustration with a “wait and
see” approach for children’s developmental outcomes, especially when preventive care is
well-established as one of the most effective ways of safeguarding children’s healthy
development. As such, developmental services and supports should be encouraged and
made available to families when children are at elevated risk for developmental or
behavioral health difficulties or are already experiencing subthreshold concerns.
e. Invest in quality behavioral health support for children and families. Families need
access to behavioral health services that are of high quality and are located within their
neighborhoods and communities. Across focus groups, parents repeatedly discussed their
desire for services to address children’s normative misbehavior and parenting challenges
(e.g., struggles with bath time and bedtime), as well as more problematic behavioral and
social-emotional health difficulties. However, parent report and our mapping analyses
demonstrated that the majority of behavioral health services that address the needs of
families with young children are located in south Charlotte, a relatively advantaged area
compared to other regions of the county. Therefore, behavioral health services are not
accessible for families most in need. Between birth and 5 years old, children are rapidly
developing the capacity for self-regulation, in part due to caregiver support that nurtures
children’s healthy social and emotional skills (Bendezú et al., 2018). Family access to
behavioral health services is critical during this timeframe, and parents have expressed
their strong desire for this type of support.
(2) Strengthen outreach efforts and access to quality services.
a. Enhance outreach. Parents and service providers consistently described how they
primarily learned about services and supports through word-of-mouth. The lack of
awareness about programs available for families with young children was a salient issue
echoed across focus groups and interviews. However, focus group participants shared
multiple, creative avenues for reaching parents through concerted efforts to provide them
with resource lists at natural child- and family-serving locations, such as healthcare
settings (especially maternity centers in hospitals and pediatric offices), childcare centers,
toy stores, and grocery stores. Parents also offered that it could be useful to leverage

63
social media to communicate with parents of young children, as well as have information
that is applicable to the child’s current and future developmental stages. Parents and
service providers agreed that pediatricians should play a critical role in this process, and
that it may be valuable to enhance the capacity of pediatricians to connect parents with
services. Overall, parents wanted resources to be advertised in a variety of ways, before
services were needed, rather than having to rely on word-of-mouth to learn about what
resources are available to support young children’s health and development.
b. Investigate the feasibility of creating and sustaining a searchable community database
of PN-3 services accessible to parents and providers. Parents consistently expressed
their desire for one place/website that listed all of the PN-3 services and events. Thus, we
recommend investigating the feasibility of creating an interactive web-based interface
that parents and providers could use to locate different PN-3 services. Such a web-based
interface could build off the PN-3 baseline database created via the landscape analysis
that resulted in this report, but would require that this database be expanded to
incorporate additional services (e.g., faith-based organizations) and to provide more
detail about the programs/services provided (e.g., waitlist information/wait time,
eligibility requirements). Such a web-based interface would also need to be regularly
updated and would require a user-friendly design that made it accessible to parents of all
backgrounds (e.g., with language translation). Because such a system would require
extensive up-front and longer-term sustainability costs, we recommend that the County
investigate the feasibility of creating such a system by (1) identifying best practices for
creating external facing (i.e., for parent/community use) searchable service platforms, (2)
determining which organization/agency in Mecklenburg County is best situated to house
and sustain such a system (e.g., an agency that has both the capacity and parents’ trust),
and (3) assessing short- and longer-term costs.
c. Develop a community presence. During focus groups, parents (particularly Black
parents) shared that they felt ignored by the larger community, and they wondered
whether resources were intentionally being withheld from minoritized populations.
Parents said that they wanted program representatives to “show-up” in the community
and, for example, attend community dances, festivals, and events. Parents also suggested
that agencies could even go in person to families’ homes and provide free supplies (e.g.,
diapers, books) for young children and families while introducing the family to their
services.
d. Build evaluation capacity. It is imperative that, as a community, we grow our ability to
collect, track, and use meaningful data. Information is needed not only to guide welltargeted
decision making and resource allocation related to our local programs and
systems, but to understand our community’s services and programs, who they are

64
serving, and how they are working (e.g., Kilmer & Cook, 2021). We need data about
program processes and outcomes to inform feedback and improvements to our programs,
services, and systems (Kilmer & Cook, 2021). Recent publications by the National
Academies of Science, Engineering, and Medicine [National Academies] describe
strategies for using science to guide practice and policy, highlight the importance of twogeneration
approaches to reducing poverty and achieving health equity, and underscore
the salience of state and local policy for advancing health and behavioral health equity
(see National Academies, 2019a, 2019b, 2019c).
e. Increase home visiting services. Parents conveyed their strong interest in having access
to home-visiting services during pregnancy and after they return home from the hospital
with their baby. They were clear about their preference for free and universal home
visiting, in which community nurses come to the home to check on expectant mothers
and those who had recently given birth. Parents explained the importance of an actual
visit to the home and not just a phone call, as the parents most in need are the least likely
to answer the phone. They also expressed a desire for the home visiting to involve a
collaborative process between the nurse and the family for decisions regarding the
frequency of visits and duration of service. Parents offered that home visitors are
uniquely well-positioned to support the needs of the whole family and serve as a critical
point of connection for families to community resources.
(3) Foster culturally sensitive and responsive care necessary for building trust
a. Build a workforce that mirrors the cultural backgrounds of the families served.
As one parent asserted: “For parents to be more open and accept information, it has to
be publicized by people who speak their language or advocate for that community.” In
that vein, there is a clear need for trusted Black and Brown leaders and people with
similar experiences (to the targeted parent populations) to reach out and educate parents.
To that end, it is critically important to enhance the bilingual and multicultural workforce
to meet the needs of our increasingly diverse community.
b. Develop trusted partners to help families navigate the systems and prepare for the
future. Parents and service providers expressed a clear desire for family navigation
services (beginning in pregnancy) that would help to connect families with the many
resources available in the community. If families could be reached sooner, providers
could emphasize the importance of building strong attachment relationships with their
infants, and there would be an opportunity to prevent developmental problems rather than
offer intervention. Across interviews and focus groups, stakeholders echoed the need to
switch from a reactionary mindset or approach to one in which our community invests in
prevention and promotion strategies, including education for families regarding how to

65
best support their young child’s healthy development. Systems of care should help
families connect to trusted partners who can convey information and help promote access
to resources that strengthen family well-being.
c. Build community trust and strengthen relationships with families. At the system and
organizational levels, it is necessary to enhance relationships with families and to foster a
collaborative model of care in which they can readily access and receive the services and
supports they need. To do so, it is necessary to remove barriers to services (e.g.,
paperwork requirements when documentation is actually not necessary), follow through
with committed services and programming, facilitate bridges to other resources when
necessary, and create contexts within which parents have the opportunity to build a sense
of community and grow their social networks (such as support networks among parents
with shared experiences).

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CONCLUSION & NEXT STEPS
In summary, this project sought to provide a landscape analysis of services and supports for
families with young children (prenatal to age 3 years) in Mecklenburg County. This report
describes the creation of a baseline inventory of PN-3 services and the results of the landscape
analysis, including the identification of 1,246 programs within Mecklenburg County that serve
expectant parents and families with young children aged 3 years old and under. Furthermore, the
nature of the service landscape, as well as relative strengths and gaps in coverage were illustrated
by service maps overlaid with sociodemographic characteristics. These analyses demonstrated
that there are relatively few child behavioral health, home visiting, and Early Head Start services.
Also, PN-3 services were generally located in the uptown core and in south Charlotte, areas
where families tend to have greater economic advantage. However, childcare sites were the
notable exception, as they were located across Mecklenburg County, and the key barriers to child
care access, as identified by parents and service providers, were affordability, cultural
responsiveness, and wait time.
Along with the creation of a baseline PN-3 service inventory and the maps of prenatal and early
childhood services and supports, this report also summarized the perspectives of parents and
service providers to shed light on the factors and conditions that influence service utilization for
families with young children. Key themes emerged related to parents’ strengths (tenacity,
investment in children, and supporting one another) and challenges (financial strain, and
specifically, the lack of affordable housing, limited insurance coverage, inadequate play spaces
for children, uncertainty about child health and development, and unmet mental health needs
among parents) related to raising young children in Mecklenburg County. This project also
detailed several important factors that can facilitate or impede family service access, including
communication and logistical concerns, service policies and procedures, family experiences with
services, and programmatic strengths and challenges. Based on the insights offered by parents
and service providers during focus groups and interviews, this report provided several
recommendations to address the challenges faced by parents, improve family enrollment and
engagement in relevant services, and support the County’s efforts to strengthen the systems of
care for families with young children, particularly those from underserved and marginalized
communities. These recommendations include:
(1) Implementing collaborative and comprehensive PN-3 service models for meeting the
diverse needs of families
a. Improving inter-agency communication and collaboration
b. Addressing basic needs and building a social and economic safety net for families
c. Increasing access to affordable childcare options
d. Utilizing a multigenerational, whole-family approach to quality care that is
responsive to parent needs and preferences

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e. Investing in quality behavioral health support for children and families
(2) Strengthening outreach efforts and access to quality services
a. Enhancing outreach
b. Investigating the feasibility of creating and sustaining a searchable community
database of PN-3 services accessible to parents and providers
c. Developing a community presence
d. Building evaluation capacity
e. Increasing home visiting services
(3) Fostering culturally sensitive and responsive care necessary for building trust
a. Building a workforce that mirrors the cultural backgrounds of the families served
b. Developing trusted partners to help families navigate the systems and prepare for
the future
c. Building community trust and strengthening relationships with families
Guided by the results and recommendations from this landscape analysis, there are several
avenues for next steps that would build the County’s capacity to address the needs of families
with young children, such as:
(1) Compiling additional information on the services and supports provided by faith-based
organizations in Mecklenburg County.
(2) Continuing discussions with families, possibly using interviews and surveys to gather
specific information on needs and preferences.
(3) Expanding data collection with families, including those who are not connected to
services and, possibly, families with a wider range of household incomes than those
represented in this report.
(4) Examining policies and enrollment data that impact service access, availability, and
utilization for specific service categories.
(5) Expanding the scope of this work to include information on services for families with
children up to 5 years old, as this age represents an important sensitive period with
respect to brain development and is also the point at which families become connected
with the structures and sets of services provided by entry into the public school system.

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REFERENCES
Bendezú, J. J., Cole, P. M., Tan, P. Z., Armstrong, L. M., Reitz, E. B., & Wolf, R. M. (2018).
Child language and parenting antecedents and externalizing outcomes of emotion
regulation pathways across early childhood: A person-centered approach. Development
and psychopathology, 30(4), 1253-1268.
Chemtob, D. & Off, G. (2020). “Charlotte growth pushes it pas San Francisco to become 15 th
biggest city in the US.” Charlotte News and Observer. May 21, 2020.
Cowen, E. L. (1994). The enhancement of psychological wellness: Challenges and opportunities.
American Journal of Community Psychology, 22, 149-179.
IPUMS/Ruggles S, Flood S, Foster S, et al. (2020). IPUMS-USA Version 11.0. IPUMS, 2018;
2020. https://doi.org/10.18128/D010.V11.0
Kilmer, R.P., & Cook, J.R. (Eds.). (2021). The practice of evaluation: Partnership approaches
for community change. Thousand Oaks, CA: Sage Publications. Print ISBN:
9781506368009, 150636800X
Kilmer, R.P., Cook, J.R., & Palamaro Munsell, E. (2010). Moving from principles to practice:
Recommended policy changes to promote family-centered care. American Journal of
Community Psychology, 46, 332-341. DOI 10.1007/s10464-010-9350-9
Koball, H., & Jiang, Y. (2018). Basic Facts about Low-Income Children: Children under 9
Years, 2016. New York: National Center for Children in Poverty, Columbia University
Mailman School of Public Health.
Ma, C. T., Gee, L., & Kushel, M. B. (2008). Associations between housing instability and food
insecurity with health care access in low-income children. Ambulatory Pediatrics, 8(1),
50–57. http://dx.doi.org/10.1016/j.ambp.2007.08.004
National Academies of Sciences, Engineering, and Medicine (2019a). A roadmap to reducing
child poverty. Washington, DC: The National Academies Press.
National Academies of Sciences, Engineering, and Medicine (2019b). The promise of
adolescence: Realizing opportunity for all youth. Washington, DC: The National
Academies Press.
National Academies of Sciences, Engineering, and Medicine (2019c). Vibrant and healthy kids:
Aligning science, practice, and policy to advance health equity. Washington, DC: The
National Academies Press.
North Carolina Department of Health and Human Services (NCDHHS). (2019). Basic
Automated Birth Yearbook North Carolina Residents, 2019. Retrieved from
https://schs.dph.ncdhhs.gov/data/vital/babybook/2019.htm on 11/1/2021.

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North Carolina Department of Health and Human Services (NCDHHS). (2018). North Carolina
Infant Mortality Report. Retrieved from:
https://schs.dph.ncdhhs.gov/data/vital/ims/2018/2018rpt.html on 2/15/2021.
UNC Charlotte Urban Institute. (2021). Charlotte/Mecklenburg Quality of Life Explorer:
Prenatal care. Retrieved from: https://mcmap.org/qol/#56/ on 2/12/2021
U.S. Census. (2020). American Community Survey. Washington, DC.
U.S. Department of Agriculture (USDA). (2020). Food security status of U.S. Households in
2019. Retrieved from: https://www.ers.usda.gov/topics/food-nutrition-assistance/foodsecurity-in-the-us/key-statistics-graphics.aspx#householdtype
on 2/13/2021.
U.S. Department of Health & Human Services. (2021). U.S. Federal Poverty Guidelines Used to
Determine Financial Eligibility for Certain Federal Programs. Retrieved from
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on 2/13/2021.
U.S. Department of Health & Human Services, Administration for Children and Families,
Administration on Children, Youth and Families, Children’s Bureau. (2021). Child
Maltreatment 2019. Retrieved from https://www.acf.hhs.gov/cb/research-datatechnology/statistics-research/child-maltreatment
on 2/13/2021.

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APPENDIX A
Data Sources Used to Create PN-3 Service Inventory
Below we describe the different categories of data that we used to create the service inventory.
Because each category includes multiple sources of data, it is not possible to list every source of
data. Instead, as is typical with snowball sampling, we describe each data category broadly and
provide key examples.
Stakeholder Guidance & Internal Data Sources. We created an initial list of widely known early
childhood services. We then searched relevant websites for publicly available administrative
records and submitted data requests. The table below lists the sources of information by domain.
Domain
Sources of Information
Health Services - Child
Pediatric Atrium
Novant
Tryon Medical Group
Mecklenburg County Health Department
Early Intervention CDSA & NC ITP
CMARC – Commonly Used Resources list
Smart Start
NPIDB.org
Behavioral Health NC Child Treatment Program – Provider Roster
Health Services - Adult
Prenatal Atrium
Novant
Tryon Medical Group
Mecklenburg County Health Department
Adolescent Pregnancy Resource list (developed for
separate project)
Mind Body Baby NC
Health Care Same as above
Mental Health
Early Care & Education
Literacy Pediatric practices with Reach out and Read
Smart Start
Childcare Child Care Resources, Inc.
NC DHHS website
Early Head Start Head Start: Early Childhood Learning & Knowledge
Center

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Parent Education NC Child Treatment Program – Provider Roster
Home Visiting MIECHV report
Food & Tangible Supports
Nutrition/Food WIC
SNAP
Tangible Needs
Across Domains Aunt Bertha
NC211.org
Mind Body Baby NC
CMARC – Commonly Used Resources list
Adolescent Pregnancy Resource list (developed for
separate project)
Mecklenburg County Community Resource Guide
Fun4charlottekids.com
CharlotteParent.com
Moms Moving Forward (freedom communities)
Publicly Available Administrative Data Records. We used the following publicly available
administrative records:
● NCDHHS Data – childcare sites & government services
● 501(c)3 Non-profit IRS Tax Data 3 - non-profit organizations that submit tax filings
● Reference USA Database – private businesses
Although these data do not capture every single government program, business or non-profit in
Mecklenburg County, they are comprehensive. Each data source provided a useful list of
organizations in the County from which we worked to determine (via web-searches, phone calls,
and data cross-checking) which ones provided PN-3 services. We then used the final lists
generated from each data source to fill any PN-3 service gaps not captured in our other data
sources.
Self-Collected Data. Lastly, we used web-searches, an electronic survey for faith-based
organizations, phone calls, stakeholder document archives (e.g., past reports, resource lists), and
3
Available through the National Center for Charitable Statistics Data Archives (Urban Institute, 2020),
these data capture the names and addresses of all tax-exempt, tax-filing 501(c)(3) nonprofits in the
county; their primary category of service (e.g., health care, education, human services) via the National
Taxonomy of Exempt Entities (NTEE) code; and, for most nonprofits (i.e., those with $25,000+ in gross
receipts), their general financial status (e.g., assets, expenses, charitable receipt).

other field work techniques to fill remaining known gaps in services and supports and to identify
potential gaps of which we were unaware. We gathered and reviewed reports and resource lists
in the following categories: birth statistics (Baby Book), child abuse/maltreatment (CFPPT
presentations, NC Child Welfare data), childcare (CCRI), children with special healthcare needs
(Taming the Octopus), health and early childhood (CHA, EC Action Plan, YPI), home visiting
(HVPE, NC-MIECHV), food insecurity, dental resources, free and low-cost clinics, United Way
Community Partners list, and NC state reports (ECAP, NCECF). Finally, we met with local
stakeholders and researchers who are conducting research in related areas to share information
and resources. These areas included infant mortality (Dr. Taylor), child maltreatment (Dr. Boyd),
and home visiting services (Drs. Lanier and Ansong).
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APPENDIX B
Parent Focus Group Questions
Introduction
1. How would you describe Charlotte in terms of a place to raise young children?
a. What makes it easy to raise young children in this community?
b. What makes it hard for families with young children in this community?
2. What is one strength that you feel like you have in your own family (or that you think
families in Charlotte need) that really makes a difference in raising young children?
Family Needs
3. What is your family most in need of (or what do families most need) to help ensure your
child’s healthy development and well-being?
4. What steps have you taken to address these needs?
a. What are the main services, programs, and supports that you use or have used to
address these needs?
b. What services (programs, supports) do you rely on? What’s helpful about these
services (do they meet your child’s needs)?
c. What prompted you to use these services over others that might be available in the
community? How did you decide to use these?
5. How do you typically find resources/services for your child/family?
a. How did you know where to go to get help?
b. Who did you seek advice from? Did anyone help you connect with the service?
c. Why did you choose (name) for care/support? Was there another place that you
would have preferred?
d. What are the best ways to learn about the options that families have for this type
of service?
6. Thinking about all of the services/supports a family might need to raise a young child, is
there anything you needed (or currently need) that you did not have or could not access?
a. What did you need? What got in the way of accessing this service?
b. What challenges have you faced in trying to find help?
c. What would make it easier for you to find the help or support that you need to
raise your young child?

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7. What makes it hard to find help or access the services that your child needs?
a. What barriers have you encountered that prevented you from enrolling in services
and supports your child needed?
b. What challenges have arisen after you enrolled your child in a service or
program? How were these challenges addressed?
c. Can you tell me about any gaps in the system or places where the system breaks
down?
8. What tips would you give to other parents in finding what they need?
Culturally Sensitive and Relevant Services
9. Has your family’s background, like your culture, race, or income, influenced your ability
to get help for your child or access services your child needed? [Can you tell me about
that?]
10. Have you ever felt like the way someone interacted with your family was due to them not
understanding your background?
a. How did that experience affect your engagement with those services?
b. Did you continue using those services or participating in those programs?
11. How important is it to feel understood by the people helping your child?
a. Can you describe a time you felt welcomed, understood, or valued by someone
who helped your family?
b. What made you feel welcomed, understood, or valued?
Improvements to Services
12. What could be done differently to better support your family in obtaining services for
your child? [If unclear, can clarify that we are focused on what the systems or programs
can do differently.]
13. What would make you feel more comfortable and likely to seek services and supports for
your child?
14. What would a community that supports families with young children look like? [Possible
follow-up: What would be its guiding values?]
15. How could the local services, programs, and supports be improved so that they, too,
could help you realize your hopes (aspirations, values, goals) for your child?

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Service Provider Interview Questions
Provider & Agency Background
1. Introductory Question: Could you tell me how you came to be a [position] with [agency
name]?
2. What types of services/programs do you/your organization provide for pregnant women
and families with young children (age 0-3)?
Background on Charlotte Families: Needs, Strengths & Challenges
3. What do you see as the most important determinants of health and wellness for
clients/patients you serve?
4. What are the common strengths or resources that you see among the families and young
children that you serve?
5. What are the common challenges or needs that you see among the families and young
children that you serve?
For administrator, also ask: What interventions or investments have you or your team
made to address these identified challenges/needs?
Overview of Agency Program Accessibility
6. How do families find you?
a. What makes it easy to access your service?
b. What makes it hard?
7. Where do you find that families are most likely to “fall through the cracks” or be unable
to access your service(s)? What gaps do you see?
Agency Strengths & Challenges
8. What do you see as the key strengths of your agency?
a. What does your organization do particularly well?
b. Why do families choose your service over others that might be available in the
community?
9. What challenges do you face in providing this service?
10. What concerns do you have about access, availability, or quality of this service?

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Cultural Relevance & Sensitivity of Services Provided
11. Do you feel that the care you provide is culturally sensitive? What leads you to feel that
way? Please say a bit more.
For administrator, also ask: How are staff trained regarding culturally sensitive care?
12. How do you think a family’s background, like their culture, race, or income, influence
their ability to access your service? What about engagement in services once enrolled?
13. As you think about the systems and services we’re discussing, have you seen families
discriminated against? Can you tell me about this?
Ways to Improve Services: Provider Services & Broader PN-3 System Services
14. What tips would you give to parents for accessing a service like yours?
15. What would make families more comfortable and likely to seek your service?
16. What resources, services, or programs do you wish families had access to?
17. What could be done to better support families who are trying to find help or access this
service for their young child?
a. Do you have any recommendations for local policy or practice that could begin to
build a more equitable and coordinated system of care?
b. If we wanted to optimally support families with young children, what would need
to be different? What would that look like? [Possible follow-up: What would be
its guiding values?]
Care Coordination
18. Do you routinely partner with other agencies for referrals? If so, who are your main
partners?
a. Are there certain services that you find more difficult than others to locate for
referrals?
b. How do you follow-up after the referral?