Beagle Obesity Overcoming Challenges Through Nutrition

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WHITEFOORD COMMUNITY PROGRAM: CARING FOR CHILDREN IN THE CONTEXT OF FAMILY, HOME, AND COMMUNITY

Health disparities are multifactorial, Johnson said, and she prefers to approach childrens health in a very holistic manner, going into the community and caring for them in the context of everything that affects their lives. In 1994, Johnson and the late George Grimley (also of Emory University) decided that to better care for children, the two had to go where the children were. Health disparities were not a focus at the time. Rather, access to health care was the primary issue they were trying to address. They set up the Whitefoord Elementary School-Based Center, located in Southeast Atlanta, as a typical practice with pediatric primary health services for the children who attended the school and their preschool siblings. Johnson and Grimleys goal was to increase access to quality health care and thereby improve the academic achievement of the students.

Initially, students came to the clinic when they were sick, and they were treated accordingly. But after 2 or 3 months Johnson discovered that physical health really was not the greatest issue facing the children, and that their health outcomes were not entirely contingent upon whether their ear infection was treated or their asthma was controlled. Instead, the outcomes for children were centered on psychosocial, academic, and family issues. She then saw the clinic as an entry point for interactions with the families. Out of the clinic grew the Whitefoord Community Program, a community-based, community-driven organization designed to care for children in the context of everything that affects their lives, their family, their home, and their community. The program empowers residents to take charge of themselves, their children, and their community.

Community Needs

The Whitefoord Community Program is based on the needs that were identified by the families in the community. Johnson noted that it is very important to go into the community and ask questions. Sometimes there is a tendency to think we know what families, communities, and individuals need, when in fact we really do not. You need to go out and live among people to really begin to understand what their challenges are, and why they do what they do, she said.

Based on the discussions, it was clear that the mission of the program would be greater than just direct medical intervention; in fact, the mission evolved to a focus on working with families in the community to ensure that every child had the ability to succeed in school. The primary need identified was increased access to quality health care to address chronic health problems such as asthma, diabetes, and obesity in the community, as well as issues of youth violence, teen pregnancy, substance abuse, and mental health disorders. The families also wanted more affordable, high-quality early childhood education and after-school programs. Some parents said they needed adult literacy and General Educational Development (GED) instruction so that they could better teach and mentor their own children. (Prior to initiation of the program, about 50 percent of the families did not have a parent with a high school diploma.) Families also needed more direct social services in the community, including parenting support, and more importantly, counseling for the parents so they could better deal with the stresses in their own lives and thereby be better able to manage the lives of their children.

Planning and Implementation

As discussed above, the first step in planning the program was working with the community to identify and prioritize needs. The next step was to collaborate with everyone in the community who had a role in caring for childrenschools, parents, community leaders, community agencies, and potential fundersto develop programs to address each of the needs. An advisory committee was established within the schools to monitor and evaluate the effectiveness of the programs. Finally, community members were recruited to be on the board of directors to participate in governance of the organization.

The Whitefoord Community Program is run out of a series of five homes across the street from the Whitefoord Elementary School, where the first school-based health center was established. There are three major components of the program: school-based clinics, of which there are now two; a child development program that currently cares for about 75 children; and a family learning and community development center that provides GED instruction for families, and after-school programs, summer programs, and mentoring programs for children.

Services and Staffing

The in-school clinics are comprehensive and holistic. Clinic services include management of acute and chronic illnesses and injuries; routine and sports physicals; immunizations; dental care; mental health assessments and counseling, including services for adults; psychoeducational assessments and testing to identify children who are at risk for failing; and referrals to medical specialists and social services.

The clinics are staffed by medical providers, including physicians, nurse practitioners, physicians assistants, nursing assistants, a dentist and dental assistant, social workers, and mental health providers. There is also a full-time health educator, as health promotion and disease prevention is the best approach to decreasing health disparities, and administrative staff.

Funding

Funding for the Whitefoord Community Program comes from a variety of sources. Medicaid alone, Johnson noted, is not sufficient. Neither are reimbursements from private insurers. Currently, 35 to 50 percent of the funding for the center comes from a Health Resources and Services Administration (HRSA) federal grant. Medicaid and private reimbursement supply about 25 percent of the funding, philanthropy about 20 percent, and in-kind donations (e.g., clinic space, utilities, malpractice insurance) make up about 5 to 10 percent.

Programwide Accomplishments and Individual Success Stories

The Whitefoord Community Program has some impressive program-wide accomplishments. Overall, the program has increased community access to quality medical and dental care. Over 5,000 children have received medical care since the program began in 1995. The clinics are currently the medical home to about 1,000 children, but in reality, the clinics see about 1,500 to 1,600 children and adults per year. There is very strong support from the schools and community, with 95 percent clinic enrollment and utilization. Johnson believes that this speaks to the quality of their approach to caring for children. The immunization rate for 2-year-olds is about 9092 percent. The immunization rate for adolescents in the same families is also high, at 82 percent.

School attendance has improved, especially among children who have chronic diseases such as asthma. Johnson believes that performance has also been positively affected, but improvement has not yet been measured directly. Every child in the school receives health education on drug and substance abuse, violence prevention, safety, general health, and nutrition. The program goes into the classrooms and provides about 8,000 student health education encounters every year.

Children with chronic illnesses, especially asthma, have shown improved health outcomes. Eight percent of the asthma visits to the clinic are children who are asymptomatic, a result of the very aggressive approach to managing these children. The program also improved the health outcomes for the children who are overweight. Since an after-school fitness and nutrition program was implemented several years ago, about 50 percent of the children have had a reduction in their body mass index (BMI), and 40 to 50 percent of the children have had a decrease in their cholesterol level and fasting insulin level.

A very important accomplishment, Johnson said, is the increased parental involvement. The program has been able to impart to them the importance of having an active role in the lives of their children, and families are engaged even when it is difficult or stressful for them. There has also been a reduced cost to the states Medicaid program and decreased emergency room use and hospitalization of students with asthma (Adams and Johnson, 2000).

As important as these program-based figures are, Johnson likes to measure success one child and one family at a time. Among the examples she cited were the ability to detect a brain tumor in a third-grader while it was in the early stage and treatable, the early detection of a genitourinary deformity in a 9-year-old child that was successfully corrected, and early detection and intervention of children with chronic illnesses such as asthma and diabetes.

In addition, through onsite counseling and support, the program has facilitated the recovery of many emotionally troubled children. This, Johnson noted, is probably the most important aspect of the program as far as improving the outcomes for children. Unless you adjust the emotional aspect of the health of people, she said, you will not be able to make improvements in their physical health.

In meeting needs and bridging gaps, Johnson concluded, the program has been able to increase access to health care, improve health outcomes for children and their families, decrease health care costs, and improve school attendance and academic performance.

ACCOUNTABLE COMMUNITIES: HEALTHY TOGETHER

Atlanta, Georgia is divided into 25 neighborhood planning units (NPU). The NPU system was established by Mayor Jackson in 1974 to ensure that citizens, particularly those who have been historically disenfranchised, would have a voice in the structure and development of their community. Accountable Communities: Healthy Together (ACHT) is a community-based, participatory research effort that Kreuter and colleagues are conducting in NPU-V (letter V). ACHT is funded by a grant from the National Center on Minority Health and Health Disparities (NCMHD), which supports a collaboration between the NPU-V community leadership and the Georgia State Institute of Public Health, the Centers for Black Womens Wellness, the Atlanta Regional Health Forum, the Fulton County Department of Health and Wellness, and the Southside Medical Center. The ACHT program, Kreuter explained, engages the community in identifying their health issues, providing them with the methods, activities, and data to do so, and then identifying pilot programs to take action on those health problems.

The neighborhood data advisory group (NDAG), composed of local residents, developed a profile of NPU-V in 2004. The NDAG identified an unambiguous pattern of health, social, and environmental disparities in NPU-V. Examples include physical or mental disability at twice the citywide rate; high school graduation at half the citywide rate; infant mortality at two and a half times that of white infants; owner-occupied housing at half the citywide rate; overweight among women at 64.5 percent versus 44 percent among women citywide; male cancer mortality 50 percent higher than for white men in the state; diabetes prevalence 48 percent higher than a decade prior; 68 percent of households with incomes less than $25,000; and 25.4 percent of reported major crimes classified as violent versus 16.8 percent citywide.

As described in the IOM report From Neurons to Neighborhoods:

It is important to emphasize that early biological risk and insults, such as iron deficiency, often do not occur in isolation. In fact, they typically are increased among infants who also grew up in a disadvantaged environment. It can be exceedingly difficult to disentangle poor development and behavioral outcomes that are due to the biological exposure from those due to the problematic environment. (IOM, 2000, p. 206)

And in fact, Kreuter said, in NPU-V it is the environment that is the culprit.

Health Data Collection and Community Listening Sessions

NPU-V has about 16,000 residents, 94 percent of whom are African American, said Longino. As described above, the community is burdened by a disproportionate number of health, social, and economic disparities. After receiving the NCMHD grant for the community-based, participatory research program, community health workers were recruited and trained, and collection of health information for NPU-V began.

One primary source of health information was medical records from Southside Medical Center. Records were reviewed to determine the most frequent diagnoses for NPU-V residents who presented at the hospital. The data showed that the neighborhood mirrors the national pattern for disadvantaged populations, with hypertension, diabetes, asthma, and disorders of the skin, eyes, and teeth being the predominant complaints.

To help assess disparities, health indicators in NPU-V were compared with those in another Atlanta neighborhood, NPU-F. Demographic data from the year 2000 show that NPU-V was 90 percent black with 68 percent of homes having an income of less that $25,000, while NPU-F was 85 percent white with 40 percent of households earning more than $75,000. Despite the marked differences in race and income, the differences in vacant housing were less dramatic, with 88 percent of houses in NPU-V occupied, compared to 95 percent in NPU-F. However, by 2007, only 58 percent of the housing in NPU-V was occupied, with 42 percent of houses vacant.

Geographic information system (GIS) maps provided by the Georgia Department of Human Resources enabled the team to compare similar health problems in the two neighborhoods. Figures , , and compare NPU-V and NPU-F with regard to the rates of all cancer deaths for males, type II diabetes prevalence for males, and type II diabetes prevalence for females, respectively. In all three examples, the rates are higher in NPU-V. But notice the pattern, Longino said, when the incidence of breast cancer in females is compared between the neighborhoods (). The incidence of breast cancer in NPU-V appears lower. The different pattern was puzzling at first, Longino said, until it was determined that in this case, incidence reflects how many women were screened for breast cancer. The breast cancer mortality rate in females in NPU-V is 50 per 100,000, nearly twice that of NPU-F at 26 per 100,000. Clearly, low rates of screening correspond to higher rates of mortality. The question to be answered next is if this low rate of screening is due to lack of knowledge about the importance or availability of screening, lack of access or transportation to screening, lack of insurance, or a combination of all of these things.

All cancer deaths among males in Atlanta, Georgia, neighborhood planning units V and F, 19982002. SOURCE: Georgia Department of Human Resources Behavioral Risk Factor Surveillance System.

Type II diabetes prevalence among males in Atlanta, Georgia, neighborhood planning units V and F, 20022004. SOURCE: Georgia Department of Human Resources Behavioral Risk Factor Surveillance System.

Type II diabetes prevalence among females in Atlanta, Georgia, neighborhood planning units V and F, 20022004. SOURCE: Georgia Department of Human Resources Behavioral Risk Factor Surveillance System.

Breast cancer incidence among females in Atlanta, Georgia, neighborhood planning units V and F, 19992002. SOURCE: Georgia Department of Human Resources Behavioral Risk Factor Surveillance System.

Another phase of data collection was small group community listening sessions (about 15 to 20 people per group) employing perception analyzer technology. This approach is an effective alternative to focus groups. Each participant received a handheld device that he or she used to instantly and anonymously register his or her responses to questions. Everyone has an opportunity to respond, participants remain engaged throughout the presentation, and the tallied responses can be displayed in real time, spurring further discussion. Participants in the listening sessions, for example, were shown the GIS maps on breast cancer incidence and the data on mortality, described above, and were asked to provide instant feedback using the perception analyzer. Eighty percent of the participants indicated that they were not aware of the disparity.

As another example, residents were asked how many days during the previous month they would say their mental health had not been good. Twenty-six percent said that their mental health was not good for 14 days or more, which is considered to be frequent mental distress. This is consistent with the national pattern of mental health findings in disadvantaged communities. By comparison, only 12 percent of residents in a statewide survey indicated mental distress 14 days or more within a month.

Social Determinants of Health

In addition to collecting health data, the team sought to understand the social and environmental determinants of health, starting with the loss of businesses in the community. The first half of the 1900s saw a steady increase in businesses in the community, peaking at 178 businesses in NPU-V by the early 1960s. But between 1964 and 2006, the community saw an 86 percent decline in the number of local businesses, with only 26 remaining in 2006. You dont have to be an economist, Leslie said, to understand that losing 80 percent of local businesses, and therefore also local jobs, is not good for community health.

To study the social environment, the team used photovoice, a qualitative method that combines photography and grassroots social actions to better understand how residents see the conditions they live in, and to bring these graphic realities to the attention of policy makers. Leslie cited one photovoice submission from a 7th grader in NPU-V. Describing the picture she took of a boarded-up home, the girl said This is an abandoned house with lots of trash. Anybody from criminals to rapists could just walk in and make themselves at home. Ive been in the Pittsburgh community for a long time, and this house is one of the issues in our community. When I walk by this house on the way to school with my friends, it makes us worried, especially the little kids.

Another photovoice picture of a house in disrepair was used as part of a campaign entitled The Dirty Truth. The campaign was designed to spread the message about the high number of vacant properties in NPU-V, and the associated concerns including increased crime, rodents and pests, pollution, strained community services, and poor physical and mental health. This campaign also enabled the documentation and update in the percentages of vacant properties from 12 percent vacant to 42 percent vacant.

Establishing Priorities and Pilot Interventions

In August 2006 a community meeting was held to set priorities for NPU-V based on the health and social environment information collected. Participants marked ballots with what they perceived to be the two most important local health issues and social determinants of health (). Residents then voted a second time on a subset of items that received the most votes. The residents first priority health issue was mental health and depression, and they saw this as a root cause of other problems. Interestingly, the data from the Southside Medical Center presented by Longino earlier did not list mental health as one of the top 10 diagnoses stemming from hospital visits. The reason, Leslie said, is because the hospital does not screen for it. But based on their experience, the residents identified depression and mental health as a top concern for NPU-V.

NPU-V resident ballot to establish community priorities. SOURCE: Kreuter, Longino, and Leslie, 2008.

After establishing the priorities, the NCMHD grant required several pilot interventions be undertaken. The first intervention was improving access to mental health services through a clinic-based strategy designed to improve the rates of follow-up support services. The second was the Dirty Truth campaign, mentioned above. Using the photovoice method as an advocacy and community empowerment strategy, the campaign was designed to improve the environment and housing problems (factors that are known to influence depression and hopelessness) through changes in local policies and enforcement practices. Everyone Deserves to Work, the third pilot intervention, is an innovative strategy to reduce crime by providing social support and connection to services for reentry candidates (ex-offenders). It pairs previously incarcerated individuals, male and female, with a resident sponsor who is willing to help them navigate through the system of job placement, job training, and so on.

Finally, during the listening session there were repeated references to residents using the 911 system for health care. Analysis of emergency medical services (EMS) data at Grady Memorial Hospital led to a 2-year pilot grant funded by the Healthcare Georgia Foundation to determine whether a strategy to make primary care services more available to NPU-V residents would result in a decline of EMS and 911 services for nonemergency health needs.

Accomplishments and Challenges

Examples of accomplishments of the ACHT pilot interventions to date include demolition of several hazardous structures, increased access to mental health services at the Center for Black Women and Wellness, and as noted above, support from the Healthcare Georgia Foundation to address the nonemergency use of 911 and emergency services.

Challenges fall into two basic categories: community challenges and institutional (university) challenges. For the community, a key challenge has been developing trust. Other challenges include balancing differences in perspective, priorities, assumptions, values, beliefs, and language, determining who speaks for the community, and documenting intervention success. A significant challenge at the institutional level is institutional review board (IRB) approval of interventions. Recall that this is community-based participatory research. Other institutional challenges include time-consuming processes, budget issues, benefits for community health workers, documenting intervention success, and the inability to fully specify all aspects of research up front.

Leslie concluded with advice for those who undertake the community-based participatory approach, from her perspective as a community health worker and NPU-V resident. Remember that we are people, not subjects or experiments, she said. Also be aware that there is a research disparity in that the university gets all the indirect costs, which is not a partnership in the eyes of the community. Collaboration and trust are not one-time eventsthey are fragile and need constant care. The roles of social, racial, and economic determinants of health have been known for decades. Disparities cannot be resolved in 2, 5, or 10 years time, and funding support must reflect this reality.

RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH (REACH)

We must endeavor to eliminate, so far as possible, the problem elements that make a difference in health among people, Giles began, offering a quotation that could have easily been current, but in fact was written by W.E.B. Dubois over 100 years ago, in 1899, in the first systematic review of the health status of a non-Caucasian population in the United States.¹ We are still talking about those same disparities, Giles said, and while we do need to continue to document disparities, what we need now is action. We cant still be documenting these disparities 100 years from now.

The disparities are well known. Heart disease death rates are 30 percent higher for African Americans than whites, and stroke death rates are 41 percent higher. Diabetes is more prevalent among American Indians and Alaska Natives (2.3 times), African Americans (1.6 times), and Hispanics (1.5 times). Vietnamese American women have a higher cervical cancer rate than any other ethnic group (5 times non-Hispanic white women). African American infants are 2.5 times more likely to die before their first birthday.

Racial and Ethnic Approaches to Community Health (REACH) is a national program instituted by the CDC to eliminate racial and ethnic disparities in health by providing grants to support community-based interventions. Partners supporting the REACH program include the Office of Minority Health, the Office of the Assistant Secretary for Program Planning and Evaluation, the Administration on Aging at the Department of Health and Human Services, the Office of Minority Health and Health disparities at the National Institutes of Health (NIH), and the California Endowment.

REACH is about empowering community members to seek better health, Giles said. REACH communities are working toward bridging gaps between the health care system and the community; changing their social and physical environments to overcome barriers to good health; implementing strategies that fit their unique social, political, economic, and cultural circumstances; and moving beyond individuals to community- and systems-level change.

Health Disparities Can Be Overcome

The number one lesson learned, Giles said, is that disparities in health are not insurmountable and they can be overcome. In South Carolina, for example, there are REACH communities that are focused on diabetes among African American men and women. They have been able to reduce low-extremity amputations among African American men with diabetes by 36 percent and 44 percent in Charleston and Georgetown counties, respectively, over the last 8 years. These are people who otherwise would have been severely disabled from their diabetes. A second example, in Lawrence, Massachusetts, focused on Latinos with diabetes and has demonstrated a nearly 9 percent improvement in blood sugar levels, 18 percent improvement in systolic blood pressure, and 14 percent improvement in diastolic blood pressure.

A REACH community in Fulton County, Georgia, and others across the country, are conducting blood pressure and cholesterol screenings at the barber shop as young men are sitting down to get a haircut. The barber is trained to talk with them about physical activity and healthy eating. In Charlotte, North Carolina, a local farmers market was established to provide access to affordable fresh fruits and vegetables, and as an added benefit, it also helps local farmers. Survey data indicate an increase in fresh fruit and vegetable consumption among African Americans in Charlotte.

Although these examples of community-specific results are encouraging, it is important to assess the programs impact nationwide. The REACH Risk Factor Survey compares data from all REACH communities with the larger U.S. population, and larger racial/ethnic subpopulations. A survey covering 20022006 shows that cholesterol screening for Hispanics living in REACH communities is increasing, even while nationwide fewer Hispanics are being screened. And within the REACH communities, cholesterol screening of African Americans is actually greater than the national average for all races.

Today, only one out of every three people with hypertension has their blood pressure adequately treated and controlled. Nationwide, although there has been an increase in the percentage of people with hypertension who are on medication, among American Indians nationwide there has been minimal change. However, among the REACH communities the number of American Indians with hypertension who are taking medication has increased.

Finally, cigarette smoking among Asian men has historically been very high compared to the rest of the nation. But in REACH communities, the percent of Asian men who smoke is now lower than the percentage of Americans of all races who smoke. Disparities are not insurmountable, Giles reiterated, and said we need to teach other communities how to do what these communities have done so well.

Why REACH Works

Echoing the comments of other speakers, Giles said there have been a number of challenges around community-based participatory research, including time; coordinating federal and community priorities; forming successful community, academic, and governmental partnerships; ownership; power; and division of resources.

First, community-driven programs and policy development are key, said Giles. During a planning year, the community developed an action plan, which was extremely important in terms of the success of the REACH program. This participatory activity led to the empowerment of individuals within the community to take charge of their own health. It also empowers the community as a whole. In the Bronx in New York City, for example, most people in the community were not aware that there were disparities in diabetes and cardiovascular disease. When they found out, they mobilized and traveled to Albany, New York, and talked with state policy makers about creating safe places for physical activity. In Los Angeles, Califor nia, members of a REACH community worked with the city council to establish a moratorium on new fast-food restaurants in south central Los Angeles. When you mobilize communities, Giles said, they are empowered to approach policy makers about these issues.

A second key component for success is having community, academic, and governmental partnerships. All of the REACH community coalitions were required to include a state or local health department, an academic or research institution, and a community-based organization. This has not necessarily been easy, Giles said, and many of the communities struggled with this. For example, when the academic institution wants to conduct a survey and publish the results, the community members also want to see the results and be part of the analysis and interpretation. During the planning phase of the study, residents had the opportunity to have this type of important dialogue, and it helped to move the process forward and helped the communities be more comfortable with the partnerships they engaged in.

Community expertise is very valuable. Given time and guidance, the community members are really best suited to determine the types of interventions that should occur in their community. In Charleston, South Carolina, community members developed a program called Praisercize where older residents do chair aerobics to gospel music. They have become local celebrities, and now they travel around the state to county fairs demonstrating Praisercize.

Finally, relying on the communities is an important aspect. This is a very different approach for CDC, and it has been challenging for the CDC staff conducting the community-based participatory approaches. But REACH has proven to be a successful partnership, and it has been exciting to watch how the communities have grown. REACH has been able to give communities a sense of hope. They have the tools and the sense that there is something that they can do to eliminate disparities. An example of this is the Golden Girls in Charleston, who go out walking in their neighborhood every day. The idea of creating safe places for physical activity is important, as is giving communities the tools to actually make changes.

REACH-ing Further

Communities need to be aware of and understand health disparities in their daily lives, Giles continued. They need to establish interventions, and then they need to teach other communities about what worked for them. To facilitate this, REACH funds 16 Centers of Excellence in the Elimination of Health Disparities (CEED). At the centers, regional and national experts serve as mentors for other communities. These experts offer information about how to address disparities, and the centers provide small seed grants to communities to begin the discussion around disparities elimination. In addition to the centers of excellence, there are 22 action communities involved in the implementation and evaluation of established and innovative interventions ().

REACH communities in the United States. SOURCE: CDC, 2007.

Giles concluded by emphasizing that over the last 9 years, REACH communities have been able to show that disparities can be addressed and can be eliminated.

OPEN DISCUSSION

Much of the discussion that followed the presentations focused on budget issues and sustainability. We need to find creative ways to document the effectiveness of interventions, and we need to be much more politically active in terms of communicating effectively with legislatures, Kreuter said. Even programs such as SCHIP, which has demonstrated efficacy, was difficult to obtain funding for early on.

Leslie noted that as a community health worker, she has seen the disparities in her neighborhood, and said they are caused by the lack of essential services, the lack of interest from political leaders, and the lack of government identifying and providing what is needed in order to close the health gaps. Funding is badly needed, and she emphasized that the communities are not asking for a handout, but a hand up. Giles concurred with the funding issues. Kansas City, Missouri, he said, was one of the communities that REACH did not have the resources to continue to fund. Instead of discontinuing the interventions, the community mobilized and raised $400,000 to continue the work of the community. This is a real example of community empowerment and shows what can happen when the communities realize the value of what they can accomplish. But, Giles said, there does need to be more federal dollars for this type of work. There were over 200 communities applying for REACH, and CDC was only able to fund 40.

Johnson noted that there are two very important issues around sustainability. First, initial funders have unrealistic expectations that there will be results in 2 or 3 years. They need to be made to realize that this is a long-term generational approach to changing the health climate for families. Second, everyone is conducting similar work in different silos. We need to integrate and collaborate so we can use the paucity of funds more effectively, she said.

In response to a question about the costs of clinic services provided by the Whitefoord program, Johnson said that the clinics are federally qualified health centers (FQHCs), and there is a sliding fee scale, with some patients charged a zero fee. She noted that because hers is a school-based clinic, a large number of the children are seen without the parents being present. While the clinic does not follow up with the parents regarding the fee, it does make an attempt, when families come in together, to make them aware that the clinic is an FQHC, and that they are responsible for paying something.