COVID in BIPOC Communities: What's Happening? Now What?

In mid-May the Centers for Disease Control and Prevention declared that fully vaccinated people don't need to wear masks or “social distance” indoors in most cases. The new guidance has been greeted as a major milestone on the return to normalcy - and we hope it is. We also know that just as the COVID-19 crisis didn’t strike communities equally across lines of race and ethnicity, recovery from the pandemic will be much longer and harder for some communities, and the children in them, than for others.

Watch this conversation about some of the physical and, especially, the mental health impacts of the COVID-19 pandemic on Black, Indigenous, and Other People of Color and communities. Some 15 months in, what underreported challenges has COVID fueled in vulnerable communities of color? How are the children in those communities faring? How do we get to a new, healthier “normal”? As always, we took your comments and questions. Also check out the Action Guide full of related resources!

EmbraceRace: Welcome, everybody. Here are our guests!

We're really, really delighted to have Dr. Ashley Clawson, an Assistant Professor of Psychology at Oklahoma State University and a member of the Center for Pediatric Psychology, the Stephenson Cancer Center and the Health Promotion Research Center. Dr. Clawson received her PhD in clinical psychology, specializing in pediatric psychology. Dr. Clawson's laboratory, the Child and Family Health Promotion Lab is a pediatric psychology lab dedicated to promoting health equity for all children and families. Ashley, it's great to have you.

We have a second Ashley, Dr. Ashley B. Cole, who is an enrolled role tribal member of the Citizen Potawatomi Nation of Oklahoma. Dr. Cole earned her PhD in Clinical Psychology. She is currently an Assistant Professor in the Department of Psychology at Oklahoma State and an affiliate of the Health Promotion Research Center and the Stephenson Cancer Center at the University of Oklahoma Health Sciences Center. Dr. Cole's research examines health inequities, and health behaviors among American Indian/Alaska Native (AI/AN) populations. Ashley, welcome. Great to have you.

And we have Cara Nwankwo, who is a third-year clinical psychology doctoral student at Oklahoma State University specializing in pediatric psychology. Cara is a graduate student in the Child and Family Health Promotion Lab, and an active leader in the lab's mission to promote health equity and reduce health disparities among kids, families, adolescents, and young adults. Thank you for being here, Cara.

Thank you all. We start where we typically do start, which is give us some insight each of you.

Ashley Clawson, give us some insight into what's your personal investment in the work that you do? How do you come to this work?

Dr. Ashley Clawson: Absolutely. And to get started, I'll note my pronouns are she/her. I'm a cisgendered heterosexual White female. That's such a big question. And even though you told me ahead of time, here we go. I got my PhD in clinical psychology and specializing in pediatric psychology, and that might be new to some. For us, the specialization is supporting kids who have medical conditions, whether it's asthma or sickle cell disease or cancer or now COVID et cetera, and supporting their families. And in graduate school, I worked at St. Jude and also attending graduate school in a city that was predominantly Black and there I was able to see clear health disparities and again, clinical work and collaborating on research with Black families and adolescents. And from there, that's where my passion sort of really, I think blossomed. And then for the rest of my career, just focused on trying to get more experience in my training with working with BIPOC families, both clinically and in my research. And that's what I do now. Oh, and I have a two and a half year old. How could I forget that.

EmbraceRace: Thank you, Ashley.

Ashley Cole, can you tell us a little of your story?

Dr. Ashley B. Cole: Sure. First if it's okay, I'd like to introduce myself in Potawatomi. *Introduces herself in Potawatomi* So hello, good evening. My name is Ashley Cole. I'm learning how to speak Potawatomi. So thank you for letting me practice that. I'm, as Andrew mentioned, an enrolled member of the Citizen Potawatomi Nation. I was born and raised in Oklahoma. And when I was young, though, my family moved away from our tribal lands. And so I wasn't really connected with my tribe. I didn't grow up traditionally. But we moved back when I was a teenager. I started kind of reconnecting with my tribe and really forming interests in my graduate work. I did a lot of suicide prevention with tribal populations in Oklahoma. And then since then I have just sort of broadened to more general health and health inequities and health behaviors in American Indian and Alaska Native populations. The project we'll talk about today is both near and dear to my heart, both personally and professionally.

EmbraceRace: Thank you Ashley.

And Cara, how do you come to this work?

Cara Nwankwo: Yeah. My name is Cara Nwankwo, like you mentioned and my pronouns are she and her. I am a biracial cisgender female. Growing up, I primarily lived in both Black and White communities. And I remember, I think as early as elementary school, when I started to notice differences between those communities. And in high school, I really started to see how these differences impacted mental health and knew that I wanted to figure out a way to be a part of the solution. And that's when I came to find psychology, and specifically pediatric psychology, and felt that it was a perfect avenue to kind of use my God-given talents and passions, and really be a part of that change. Another huge component is representation. We know that mental health is still stigmatized in communities of color, and I've been fortunate enough to have many mentors, women of color in psychology. And I just want to be that for the next generation. And I think that that's what drives me to do the work that I do now.

EmbraceRace: Great. Thank you so much.

And you all launched a study this past summer, six months into COVID, looking at the health status in particular with BIPOC families. Can you tell us about this study?

Dr. Ashley Clawson: Absolutely. When thinking about this project, as we all were noticing and seeing what was happening with COVID, there are clear disparities that were being shown across racial lines. In introducing this project, I want to introduce sort of two things that we think about a lot. And one is a Social-Ecological approach to thinking about kids and families and how they're doing. And that just means that when thinking about children's mental health, they don't live in vacuums. Kids live within families and they are in peer systems, in school systems and live in different neighborhoods, in different states. And for some of us, we live in the United States. In the research that we did here and that we do with my lab and in collaboration with Dr. Cole's lab, we really try to think systemically and understand what are all the different influences that affect kids and families across these different levels, and understanding that the different systems influence kids and how they're doing in their mental health. That's going to influence parent mental health. And in the same way, parent mental health is going to influence kids.

And that's true in terms of when we think of neighborhoods, what neighborhood you're in is going to impact what schools you're in and that's going to impact how kids are doing. We take this multilevel sort of approach to understanding all of these influences and also think about that with kids, we can't take a static picture. We have to understand kids development across time. We think about life course and thinking about how early experiences in childhood are going to impact a child's development across time. And also thinking about intergenerational factors that contribute to kid and families' well-being, in terms of intergenerational wealth but also intergenerational trauma and how these factors also have to be considered when we're thinking about how are kids and families doing now in COVID. We have to really zoom out and take this broader picture.

The next quick concept I wanted to introduce was the one that's on the slide here. And the reason we wanted to talk about it now is because as we learned, yes, there are clear disparities for families. And one approach for intervention is equality. And that being that everyone gets the same intervention. Everybody gets a bike. Well, the difficulty with that approach is (and our goal is optimal health) is when we do an equality approach, some people aren't even able to get on the bike and otherwise we see all these barriers where the bike is not meeting people's needs. No one is really reaching optimal health. What we'll talk about more is an equity approach where everyone gets a bike. Everybody gets support to reach optimal health, but it's really more nuanced and more specific and understanding that all of us have different needs and we need to support the different needs of kids and families for them to be able to reach optimal health. And on that, Cara will talk about the study more specifically, but that's just sort of in general, where we're coming from.

Cara Nwankwo: Like Dr. Clawson mentioned, we have already had this focus on child and family health, specifically health disparities, fighting for health equity. And we have a specific interest in families with children with asthma. And so prior to the pandemic, we know that generally BIPOC community health outcomes were less than ideal. And this is due to drivers of health or social determinants of health. And these are really the environmental and contextual conditions that influence our physical health and social health and psychological wellbeing. These are the conditions where we live, where we work, go to school, where we get healthcare, food, resources, all of that impacts our health. And some families have access to like grade A conditions and some families don't and that all affects their health.

I know you all did a webinar earlier in the pandemic, really looking at the rates of COVID within different communities. And we saw pretty early on that the pandemic was affecting communities of color differently, where they were having higher rates of infection and mortality. And we noticed that there was no research specifically focused on understanding how the pandemic was affecting the mental health and the drivers of mental health within these communities. And given our lab's focus in asthma, and COVID being a respiratory virus, we also recognize that the pandemic may have especially big impacts on BIPOC families, and especially those families who have children with asthma. And so we decided to launch an online study about a year ago now. It started June, 2020 where we were really interested in understanding the changes of the social determinants of health. Perceived changes in income, parental employment, food security, mental health and medical care during COVID-19.

And more specifically, we wanted to understand the psychosocial impacts. "Is your family worried about getting COVID? Is your family now worried about finances due to COVID?" And so we assess these things across four groups. We had a non-Hispanic White parents of children who have asthma, and non-Hispanic White parents of children who do not have asthma. And then BIPOC parents of children who have asthma and BIPOC parents with children who do not have asthma. Throughout the course of the study that we ran last summer, we had about over 300 families participate. And Dr. Clawson, will talk a little bit more about our results.

EmbraceRace: I just want to pause just for a moment to underscore the importance of, or one big takeaway from what you've all said and this sort of the reference to the social ecological model and the reference to social determinants of health, especially because even with respect to COVID where I think probably the media have done a better job than they typically do of bringing attention to these systemic factors. These factors outside the control, certainly beyond behavior. We are society, as many have noted, that tends to emphasize individual responsibility and individual behavior.

"Why are some groups more likely to get sick? Because they're not wearing mask. They're just not doing what they're supposed to be doing." And what your work is doing is saying, not that the behavior doesn't matter of course, but that even behavior itself is situated in systems and that there are non-behavioral factors that affect certainly how groups do. I just wanted to underline that because it's huge.

And another thing to underline, looking at asthma in particular, you all had told us that there's an incredible percentage of folks that have asthma.

What are the statistics on children with asthma in this country, and specifically BIPOC children?

Dr. Ashley Clawson: Sure. I'm happy to. Overall, asthma is the most common chronic medical condition among kids. Nationally it's about 7%. But with asthma, we see the same patterns that we see with COVID and that's that there are clear racial disparities and a lot of the same social determinants of health that impact COVID risk also impact pediatric asthma. Where kids are living. If they're living in housing that has mold, or has other exposure to allergens, et cetera, or pollutants, air pollution, exposure to early poverty and crime. These things all work together to put kids at risk for asthma, but also other health conditions. And we see that, for example some of the highest rates of pediatric asthma we see are among Black youth, Indigenous youth and Puerto Rican youth.

EmbraceRace: Can you give us a sense of what those numbers are for those high incidents of asthma populations?

Dr. Ashley Clawson: Sure. It depends whether we're looking at prevalence or incidence, which is sort of new onset asthma. But if we look at nationally, let's say about 7% of kids, which is not a small number, have asthma. We see higher rates among, let's say for example, Black youth. And it ranges by study, where it might be at 10 to 15%. And then also, again, like I said, it's higher in Indigenous youth and Puerto Rican youth.

And something I also want to note is it's not just that kids have asthma and that there's these disparities by whole groups where Black youth in general are more likely to have asthma than their non-Hispanic White counterparts, but it's also that their asthma outcomes differ. If they have asthma, they are going to the emergency more often or they're having more disease and poor outcomes associated with their asthma, or they're dying from asthma at a higher rate than their White counterparts. It's not just having it. It's that the outcomes are less good because of the social conditions surrounding being a BIPOC youth in the United States.

EmbraceRace: 7% and double that for some groups.

Dr. Ashley Clawson: And then that will vary by geographic region too.

EmbraceRace: Can we hear about the results of the online study you conducted?

Dr. Ashley Clawson: Sure. As Cara said and Dr. Cole is going to bring us back with some specific information about Indigenous communities, but for the study given we already knew that there were disparities in asthma because of these social drivers of health and then disparities broadly with BIPOC families. That's why we sort of had these four groups where we're looking at the intersection of child health, asthma and their ethnic and racial identity. For our reference group, we wanted to compare groups, but we kind of needed a reference group. For us, that was non-Hispanic White families with healthy children. Because we conceptualize that for those families, they had the most privileged and likely resources and wouldn't have the stress of having a child with a respiratory condition. We looked at the differences between groups thinking about that as our comparison group and social drivers of health, child mental health, and parent mental health.

When we looked at the social drivers of health, what we saw is that our BIPOC families with healthy kids and our BIPOC families with kids with asthma reported that they experienced more discrimination day-to-day than the non-Hispanic White families with healthy children. And this didn't just occur in their day-to-day life. This happened in healthcare settings. When they were trying to seek medical care, they were being discriminated against. But it didn't end there. What we also saw in our pattern of results is what we conceptualized as a pattern consistent with systemic racism. And that's that for our families, our BIPOC families, those with and without asthma, with the worst pattern being for our BIPOC families with kids with asthma, they let us know that during the pandemic, they had more food insecurity because of the pandemic. They had more income loss because of the pandemic. They were having trouble paying their bills. They were having trouble buying food, and they were having trouble accessing the care that they needed medically. And for us, that's a pattern of systemic racism. And I know we'll talk more about what does this mean.

Dr. Ashley Clawson: But I can, real quick, for child mental health, are kids being affected during the pandemic? Kids are amazingly resilient, but the answer is yes, yes they are. Which kids? Our BIPOC kids, whether they had asthma or not, reported that they're worrying more about their health and their family's health. They're worrying more about their family's loss of income. They're worried more about loss of education. They're worried more about just COVID in general, compared to non-Hispanic White, healthy children. Now kids with asthma, non-Hispanic White kids with asthma, they reported some COVID related distress too. But it was a little different in that they were more generally just worried kind of about COVID, but our BIPOC kids, they were worried about COVID and they were worried about the fact that their family were losing resources and they were more worried about were they and their family going to be okay.

I think that's an important distinction. And then lastly how are parents doing? Our parents were largely incredibly resilient. But some important differences did come up and that's that our BIPOC families, BIPOC families with healthy kids and BIPOC families with kids with asthma and our non-Hispanic White kids with asthma said that they were very worried about income losses during the pandemic compared to non-Hispanic White families with healthy kids. Why is this important? Because kids live in systems and if parents are anxious and worried about finances, that's going to have an impact on their own mental health more broadly, but we also know that it affects child mental health. Those are sort of just bullet pointed mains. And I'm happy to talk more, but we saw differences in all areas with our BIPOC families with kids with asthma having the worst outcomes.

EmbraceRace: Part of what I'm hearing Ashley is two senses in which these outcomes tend to be sort of systemically linked. One is that they are cumulative. You have disadvantages and advantages tending to accumulate together. And part of the reason that's true is because they are in fact linked in many cases. The same sorts of underlying factors that might cause a vulnerability over here are likely to cause it over here as well. And so the same people tend to show the same pattern of outcomes. One thing I wonder, and we have a big question really about both long-term impacts and about solutions, and especially community based solutions. Just starting from the long-term effects, a premise as we noted for this topic and this webinar was that much of the country is moving on.

The vaccines are here. Most adults who want to be vaccinated have been vaccinated at least once and so on, and for a lot of people and entire communities, it's, "Thank goodness that's over. I can get out again," and obviously that's wonderful for those communities. I think a lot of us appreciate intellectually that some of these impacts after 15, 16 months of this country being in crisis around this pandemic, will be long-term at the societal level. But I suspect that we're less clear on what the long-term impacts will be for people and communities.

What are some of the long-term impacts for people and communities? The sorts of problems two years from now, we'll see the residue, if not more than that... Can you give us some idea of what should be looking out for?

Dr. Ashley Clawson: Absolutely. As many amazing scholars smarter than I am have said, we are in a syndemic where it's an intersection of the pandemic and racism. The pandemic has just widened inequities that are already there. And if we don't do something about it, then these are only going to get wider and lead to even larger disparities between our BIPOC and racially minoritized families and non-Hispanic White families. We know that children and caregivers' exposure to discrimination has long-term impacts on mental and physical health. And it's gotten worse during the pandemic. If we don't do something, those impacts are going to be even worse.

If we don't do something about the fact that certain families are being exposed to higher stress because of income loss, higher stress because of loss of social support and being worried about being able to take care of their families, those things are going to, as we know from other literature impact child and parent mental health, though we are at a different stage of the pandemic, if we do nothing, these families will falter even more. And these are already families that have been largely prohibited and oppressed. And we have obligation to stand up now and say, things have to be done. I think I loosely answered your question, Andrew, and then I just sort of went this way. Feel free to redirect me.

EmbraceRace: A fuller answer would take more time than we have I know. I wonder if in your answers you could give us some sense, including what, Ashley Cole you're doing work on American Indians and Alaska Natives. That's already a very diverse group we know, but if there's some particular things that you want to highlight that you're aware of on the solution side, that will be wonderful.

Can you give us a sense of what American Indians and Alaska Natives communities are doing in response to this? Just as the impacts and the effects of different communities are somewhat different, the solutions are surely different as well.

Dr. Ashley B. Cole: Sure. I can speak a little bit to that. One of the multilevel solutions that has kind of come into play is increased funding and support. The government has issued several COVID relief bills specific to tribal communities. And so in terms of tribal sovereignty, those funds get sent to each individual tribe. And they decide how to use those funds. And many tribes, I can speak mostly for tribes in Oklahoma, but also tribes across the country, have used those funds to support their citizens. Through opening vaccination clinics, through giving additional funds for education, for elder care. A big thing in tribal communities is we don't want to lose our elders who are some of the knowledge keepers, some of them who know traditional languages, as I introduced myself earlier. Sometimes those languages get lost.

So, really giving increased support across generations and at different levels to help keep community members going. And one thing that I do kind of want to point out and I'm sort of back channeling a little bit and then coming back, is that American Indian/Alaska Natives in particular were at greater risk depending on the numbers you see, but anywhere from one to three to four times higher rates of contracting COVID, being hospitalized for more severe symptoms related to COVID, and also mortality. And so sort of thinking about in the community level, tribes, a lot of them are leading the way and vaccinations and taking care of their tribal members and not just specific to tribal members. A lot of the tribal communities and health care organizations have opened up vaccination clinics to all community members, regardless of tribal enrollment status.

I think those are just a few examples and kind of thinking about this syndemic that Dr. Clawson mentioned where a lot of tribal communities initially received fewer resources, less PPE, less funding. Tribal members were contracting rates of COVID at higher rates. And then kind of turn that around. The CDC recently released a graphic showing that vaccination rates across ethnicity and race and American Indian/Alaska Natives have the highest rate of vaccinations so far. I think we can kind of use this also as an opportunity to learn from what are communities doing who maybe don't have that individual mindset, who have more of that communal mindset: "Let's take care of each other." I kind of derailed, I'm sorry if I didn't answer your question Andrew.

EmbraceRace: I'm thinking about the distinction, the kinds of solutions and the circumstances of people on tribal territories. At least physical territory versus the members of tribal nations who are not, or people who may be unenrolled for that matter but aren't in tribal territory. Do we know anything about the distinction and how people are doing?

Dr. Ashley B. Cole: Yeah, that's a good question. I actually saw an article that came out today that said that we really don't know a lot because it's an issue in terms of if you're a tribal citizen where you get health care. You might go get healthcare at Indian Health care Services, IHS. You might receive healthcare from a tribal clinic. There's urban tribal clinics, or you might have insurance and receive healthcare from the hospital. There is concerns in terms of the data. We're not really sure. It's hard to track essentially where folks are getting healthcare and especially if they're, for example, they might have a specific condition, they might have asthma where they need to go see a specialist and then they're referred out of the tribal health care system. It's hard to track and that's a good point though, Andrew, it is going to vary by geographic location. And if someone lives in close proximity or lives on a reservation near a healthcare facility versus how far away they are, if they're further away.

EmbraceRace: Yeah. I'm thinking about how early on when we started tracking or not tracking race ethnicity data, for example, in the States, and there's still huge gaps in what we know by race ethnicity. And that was true for so long. And that's 50 States who are doing it differently in a hodgepodge of ways. Over 500 tribal nations that the USA government recognizes. I just can't imagine and many of them are really under-resourced. The state of the data must be really, really challenging.

Cara, what's your thinking? What can you tell us?

Cara Nwankwo: We are talking a lot about these multi-level influences and so it makes sense that the solutions or the interventions will also be multilevel. There is a lot of information that we looked at. There's a lot of things going on to address, but I wanted to focus in, on mental health, on specifically child mental health of Black youth. And so when we're looking at this, taking it from the societal standpoint, are there universal laws that are in place and policies to continuously fund community mental health centers? Are there universal mental health screenings in schools and are doctor's offices really trained to meet families where they're at? Are we critically looking at the laws that are already in place that are discriminatory and how can we change those to be more equitable for all people?

And then at the community level, what supports are already available in your community? Are there funding for community mental health programs, funding for school-based psychological services, again, wanting to meet families where they're at? Is there a school psychologist that can pull a kiddo aside and do some brief intervention if they're noticing that they're struggling with something?

And then taking it a step further in to the family level. Parents and many adults on this call, I'm sure we all have people young people that are in our lives, whether it be kids or family members that we have influence over, are we doing mental health check-ins with them? Are mental health conversations a regular part of your household and a norm in your household, especially for Black and Brown children? Are you having conversations with them about their identity, about their racial identity, about what that looks like living here in America? Those types of conversations are known to help foster self-esteem and a sense of pride in who they are, which is linked to positive mental health outcomes.

Kids generally learn through observation. And so as an adult in the household, are you setting a good example of self-care? Are you engaging in family value based activities, whether that be family meal times or physical activity, going to the park, seeking social intangible support from your other family members and community family members. Again, we know that social support is super big and important in Black and Brown communities and it's linked to improved outcomes.

And then on the personal level thinking about the kids, are they engaging in their own value based activities? We know that things are beginning to open up a little bit more. Are they hanging out with their friends, either virtually or in person, whichever way is safe for them? Are they engaging in their own things that bring them joy? Are they learning ways to check in with their own mental health and kind of noticing changes in that? And if they are, do they have people around them that they feel comfortable reaching out to for support? Do they have access to mental health mobile applications or books, or even engaging in therapy? These are just some of the ideas that we've come up with to support child mental health at the different levels. And we put together this graphic that is huge with lots of recommendations across all levels for a lot of the findings that we found in our paper. And we're not going to show that today, but we will link it either where this EmbraceRace webinar will be or on our lab website. This is just a little snippet of what a multi-level intervention may look like to support child mental health.

EmbraceRace: Thank you so much. Here's a question that came in.

"My Black Indigenous grandchild whose family is working class and who attends a majority White middle upper class school demonstrated a higher preoccupation with following COVID rules than her White counterparts and other middle-class children. School did not directly attend to that."

We saw this as well, just even in our own family. BIPOC kids who don't feel invulnerable, who might have more experience with other members of the community falling ill to COVID or to other things. Did this come up in your study?

Dr. Ashley Clawson: It absolutely was in that kids were, they were in sort of in general reporting more distress and worry about COVID, but also at higher rates than the White kids, they were specifically worried about the health of their family. They were specifically worried about whether they would have enough money and food. I think kids are definitely more aware and hear what's going on and from our study and what this caregiver said, yes, they noticed, they noticed and they are hearing my community, my family is more at risk and are worried about additional things that indeed do contribute to health in their own life.

EmbraceRace: I'm thinking about your training in pediatric psychology and what we've learned about the increasing integration of what we know about adverse childhood experiences into medical practice, including very much with pediatricians, and the long-term effects of those adverse experiences. I think about the kids who came of age during 9/11 or during the Reagan years or during Vietnam, or during the Great Depression. These are major events that shaped the mental apparatus of entire generations.

From your platforms as pediatric psychologists, are we going to see a generational impact or long-term effects for kids of a certain age having gone through COVID-19?

Cara Nwankwo: I think that I can't speak to say for sure, but I definitely think that there are going to be some long-term effects for kids, but we do know that kids are resilient. We know that there are things that we've found in research, whether it be mentorship or community resources that can really change the trajectory of these impacts or the negative trajectory of what's going on. I think that yes, things could be bad, but also we have the knowledge and the resources to change that, it just needs to be kind of put into place.

EmbraceRace: I wonder if there might actually be some positive impacts with respect to empathy, for example. As we've all stressed, the impacts are very different by race, class, geography, all sorts of things. Still it's hard to think of something else that's happened in this country that's affected people in some meaningful way as widely as this one. A lot of people being home and being so broadly affected, it means that a lot more people are aware for example, of the differential racial impacts of this then who would have known even about the recession of 2008 and 2009 for example. The response to George Floyd.

Is it plausible to think that there might be some kids of relative privilege, whatever their racial identity, who might actually have some greater awareness now than they would otherwise have had about the racial and class impacts of something like this? I'm looking for a silver lining.

Dr. Ashley Clawson: We already heard about some resilience. I think I absolutely agree with Cara that this is a stressor. There's no way around, it's been a stressor for all of us and more for some, but I think the importance of resilience and being a turning point, as Cara mentioned, is critical. And that they're not set trajectories. There's so much and so much space we have to promote that resilience and that silver lining Andrew and that hope. And it's us taking action at all the levels that Cara talked about. Talk critically and evaluating and saying, "These are the racist policies." Creating anti-racist policies and supports across the board and communities at our national level.

But there's also this incredible thing that's just called ordinary magic. This is again by someone that is smarter than me. I didn't come up with it, but it's small things we can do that support resilience in kids who've been exposed to extreme stressors such as child abuse and neglect. And that with these supports, with having warm adult loving relationships in their life, with having people that show them that they care, giving them the space to talk, that those things make huge differences and the trajectories of kids. Now is the time to take action, and I think that hopefully this prompts more of us to take responsibility and action to make changes across all system levels, but also know that we can do small things for all the kids in our lives to show them that we care, we see them, we care and just being there to be that warm supportive person and these small things add up for kids. And we know that these small things make a difference to help kids be resilient in the face of all kinds of stressors, but it's our responsibility, not theirs.

EmbraceRace: There are also major differences in the numbers of people getting COVID vaccines by race and ethnicity as was mention. What relationship might you see if any, between access to, and or willingness to getting a vaccine and mental health in different communities?

Dr. Ashley B. Cole: I think that definitely plays a role. And I think taking into context historical experiences. There have been documented many examples of racism and terrible care by medical professionals and researchers to certain communities of color. I think just having that in mind in terms of medical mistrust and how that might contribute to some people's, particularly individuals who identify as BIPOC, it might contribute to their hesitancy about getting the vaccine or about really sort of questioning the medical information that's coming out. I think that probably plays a role.

And I've also sort of on the flip side of that seem some really amazing public health campaigns by for example, Indigenous doctors, Black physicians who have said, "These are the reasons I'm getting the vaccine and here's why," and really trying to shift that narrative. But I do think that historical mistrust is something to keep in mind. And it's an important consideration.

EmbraceRace: The new CDC guidelines regarding masks seem to completely invisibilize small and elementary children who are not vaccinated. The National Nurses United urges the CDC to revise its "dangerous guidelines." Can you speak to how this is going to impact poor and working class BIPOC communities?

Dr. Ashley Clawson: And I can fully appreciate that. The question being, will this, could this, the new CDC mask guidance have particular harmful or maybe unintended consequences for BIPOC communities and children? I think the answer has to be yes. Because I think there are still inequities that are making it where not all communities have the same access to vaccines. Kids in general, they're not eligible to vaccines, but if the adults in the community don't have access to the vaccines, then more adults in the community are at risk for being infected with the virus.

I think for some communities, this takes away a level of protection without having the resources or if I may go back to my diagram, the right "bike" to support optimal health for that community. And it's assuming that one policy is going to be a good fit for promoting health in all communities, but that's not what we've seen in. And therefore we don't see any reason why this would be different, that we're trying to do a one size fits all. And I don't think that is going to be likely the support optimal health for our BIPOC communities.

Dr. Ashley B. Cole: It makes me think of some of the reasons that we kind of discussed a little bit earlier, but some of the social determinants of health of why BIPOC individuals, adults in particular, are at more risk for getting COVID. A big piece of that is employment where they're employed or potentially overly employed as essential workers in places like healthcare facilities, grocery stores, public transportation, interacting with a lot of people and then thinking about yeah, their kids at home, how does that affect them? And that's not the same level of protection as someone who can fully work from home or work remotely and stay home with them. And, yeah, I think I agree with Dr. Clawson that, that one size fits all policy is probably going to have some negative impacts down the road. And it's hard to know what exactly what those will be, but it seems likely.

EmbraceRace: "How can we best support ourselves and our children through time? The more love the better. How can we best love ourselves and our children?"

Are you seeing any self care strategies for families that you can recommend in addition to what you've already said. Or what do you do with your family?

Dr. Ashley Clawson: I can jump in. And I will say what we also did is we did a work on an action guide that provides lots of resources for parents, for healthcare providers, for educators. We have lots of resources for evidence-based or screeners that we've research tells us work where you can do screeners of assessing your own mental health, or if worried about your children, screeners for assessing mental health. Lists of apps for how do you find out about which therapies work? How do I find a therapist and other resources? How to do anti-racist training. All these kinds of different things.

But coming back to your other question. What do we do? We take it day by day. I think we try to give ourselves grace as some days are better than others. I think we do a lot of value based activities in terms of things that are important to us and our North star. We really enjoy being outside spending time together. Giving social support and seeking it is very important for us. I think a big thing, and Cara mentioned this is knowing that, there are self-help resources out there that we can talk about. Melissa knows this. I'm a huge proponent for acceptance and commitment therapy. There's self-help books out there on that. And you can do therapy for your child or your family if you're concerned. And I do acceptance and commitment therapy strategies on myself. My husband and I downloaded the book and we do it together. There's specific stuff for acceptance and commitment therapy as it relates to parenting. And I think for everybody it's different and for community strengths, I think that's another thing. That is a big part for many of us. Cara and Dr. Cole, did you want to elaborate?

Cara Nwankwo: I just wanted to add, in addition to all of those things that Dr. Clawson just talked about, I do that, but I also started going to my own therapist during this time. I realized that it was a tough time for me being a Black woman and living in Oklahoma with the pandemic and all the racism and everything going on in the media and in America and really noticed that I needed some extra support. And I think that it's important for me to be open about this, because like I mentioned earlier, it's very stigmatized in my community, being a Black woman and also being a Nigerian American woman, even more so stigmatized within that community.

And I think that the more people I can be open about it if they're comfortable to help encourage that, it's okay if you need some additional help, it's okay if you want to see somebody and talk about what's going on, because it's tough. It's been a rough 15, 16 months for everybody. And there are people out there that are there to support you through that. And so that's one way that I've been engaging in self-care during this time.

EmbraceRace: Cara, we're just at time, but I wanted to squeeze in one more question actually for you. We know that as you said, there is in many communities, such stigma against getting mental health support. I think you do some volunteering and other things in clinical settings. I don't remember if you do it in mental health settings, but I know that you're very much in proximity to community members, frontline folks who are working with community.

Is there a loosening and easing of some of the stigma against mental health support in light of what we see and the demands on people?

Cara Nwankwo: I think so. I like to think that this is outside of my little bubble, but I do think that the stigma across different communities of color is becoming less for forgetting mental health treatment and support. It's becoming much more normalized. And I think with the increase of people of color in this field and clinical work and clinical settings and in research has really helped with that. I've had clients say, "I was relieved when I saw a person of color was going to be my therapist." And those messages to me are just so important because I know that by me doing the work that I'm doing, it's helping other people and making them feel a little bit more comfortable. "Oh, she looks like me or she might understand things a little bit differently." And so I'm hoping that as we continue to increase representation within this field, it's just going to become less stigmatized.

EmbraceRace: Thank you. I just have to say, you mentioned you are Nigerian American, some folks will know that Nigerian Americans are the most highly formally educated group of people in this country. And having known of you, peers and folks younger, who talk about the pressure of achieving and how one is to achieve, not to say, of course that everyone in the Nigerian American community follows scriptures in this way. But we're so glad to have had you hear, Cara will be rooting for all of you and certainly Cara, as you finish your doctoral program and go on to mentor that next generation.

Thank you so much for doing this work. Not only the survey, but for all that, you're all doing. That's an immense contribution. Thank you for spending some time and sharing your insights and wisdom.

Related Resources

COVID-19 Impacts on Families of Color and Families of Children With Asthma, Journal of Pediatric Psychology, by Ashley H Clawson, PhD, Cara N Nwankwo, BA, Alexandra L Blair, BS, Morgan Pepper-Davis, BS, Nicole M Ruppe, MS, Ashley B Cole, PhD

Want to Support the Wellbeing and Health of Children and Families? Start here. An Action Guide by Drs Ashley Clawson, Dr. Ashley Cole and Cara N. Nwankwo for EmbraceRace