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PapPartners Final Proposal
 

PapPartners Final Proposal

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    PapPartners Final Proposal PapPartners Final Proposal Document Transcript

    • I. Executive Summary The Charles B. Wang Women’s Health Clinic requests a $100,000 grant from New York Community Trust to implement an innovative, new outreach program intended to increase cervical cancer prevention among Chinese American women in the Chinatown neighborhood of New York City. This program, called Pap Partners, will educate women in our community about the risk of cervical cancer and the value of pap smears in a culturally sensitive way. The Pap Partners program will also provide women with free or low-cost pap smears and will engender a relationship between a health care professional and each woman who receives our services. Through this culturally relevant, personal approach to health care outreach and access, we hope to overcome the disparity that currently exists in cervical cancer prevention between Chinese American women and women of other ethnic backgrounds in New York City. Worldwide, cervical cancer is the second most common cancer in women. In the United States, over 11,000 women are diagnosed with cervical cancer each year and about 3,700 women die in the U.S. each year from this disease. The vast majority of these deaths could be prevented through improved cancer screening and access to health care. However, Asian Americans, in general, have among the lowest rates of cancer screening in the United States and, specifically, studies have shown that Chinese American women have significantly lower rates of Pap smear screening than woman from other ethnic groups. These screening gaps reflect the alarming fact that Asian American females are the first American population to experience cancer as the leading cause of death. New York City has one of the largest Chinese American populations anywhere in the country, but Asian women in our city are the ethnic/racial group most likely to go without a Pap test, at nearly twice the rate of white women (35% vs. 21%).Furthermore, research shows that women who do not get regular Pap tests are more likely not to receive regular mammograms either—pointing to a double burden of cancer risk in this population. Much of this risk could be easily prevented with improved screening and increased access to care. However, despite national-, state- and city-wide interventions to increase screening access, these disparities remain persistent—pointing to the need for culturally- competent, community-specific interventions. Many studies have attributed these disparities in preventive screenings to language and health care barriers and unfamiliarity with and misconceptions about cancer screening. The CDC asks that all current and future interventions and outreach to increase cervical cancer screening among Chinese American women address cost, insurance and provider barrier, provide information on places to go for low-cost screening and utilize community resources. For more than 30 years, the Charles B. Wang Community Health Center has been a leader in providing high-quality, affordable, culturally competent health-care to the Asian American community in New York City. The majority of the Center's clients are low income, uninsured or under insured Asian immigrants with nowhere else to turn for basic healthcare. In addition to providing comprehensive primary care services, the Center promotes the health of the community through
    • innovative, award winning health education and advocacy programs, and by recruiting and training bilingual health care providers. As part of a previous grant, The Charles B. Wang Health Center was able to develop education brochures in Mandarin and Cantonese to educate Chinese immigrant women to the benefits of pap smears and the danger of going without this simple preventive test. However, these materials will have a much greater impact and will lead to an increase in preventative screening if they are combined with a more vigorous and targeted outreach effort by staff of the Center. Using an interdisciplinary model of service, the Pap Partners program will address these needs by: • Directly addressing common barriers to cervical cancer screenings among Chinese immigrant women in NYC. • Creating five Pap Partners teams, each consisting of a nurse practitioner, program staff member, and bilingual community volunteer who will do outreach to the Chinatown community and will distribute 2500 copies of Chinese/English culturally competent brochures regarding cervical cancer and screening at various locations in Chinatown. • Decreasing incidence of cervical cancer among Chinese immigrant women through increased screenings and annual reminders for pap tests. • Linking Chinese immigrant women to services for cervical cancer screening. The Pap Partners program will allow our Center to reach a greater number of women in our community using culturally appropriate staff and materials, provide these women with the critical cancer prevention screenings they need. In addition, the Pap Partners program will work to develop an ongoing relationship with women in our community to ensure that they receive the care and services they need to live a healthy life. II. Statement of Need Introduction Worldwide, cervical cancer is the second most common cancer in women. Cervical cancer deaths and death rates have seen a downward trend for women born in the United States; however, cervical cancer mortality rates have increased among foreign-born women in the United States, which has influenced overall U.S. cervical cancer mortality trends. In the United States, over 11,000 women are diagnosed with cervical cancer each year and about 3,700 women die in the U.S. each year from this disease.1 The vast majority of these deaths could be prevented through improved cancer screening and access to health care.1, Routine cervical cancer screening is strongly recommended for all women, up to age 65, who are sexually active and have not had a hysterectomy.1 Papanicolaou tests (Pap smears) are recommended every 1 to 3 years for women in this population.1 However, Asian Americans, in general, have among the lowest rates of cancer screening in the United States. More specifically, Chinese American women have significantly lower rates of Pap smear screening than woman from other ethnic groups. These screening gaps reflect the alarming fact that Asian American females are the first American population to experience cancer as the leading cause of death.
    • Cervical Cancer Prevention in NYC Local statistics reflect these national trends and—strikingly—Pap smear screening in New York City is well below national targets.3 New York City is known as home to many immigrant groups, yet immigrant women in New York City are less likely to get regular Pap smears than U.S.-born women.3 New York City has one of the largest Chinese American populations anywhere in the country, but in New York City, Asian women are the most likely ethnic/racial group to go without a Pap test, at nearly twice the rate of white women (35% vs. 21%).3, Furthermore, research shows that women who do not get regular Pap tests are more likely not to receive regular mammograms—pointing to a double burden of cancer risk in this population. Much of this risk could be prevented with improved screening and increased access to care.3 Despite national-, state- and city-wide interventions to increase screening access, these disparities remain persistent—pointing to the need for culturally-competent, community- specific interventions. The Need for Cervical Cancer Prevention in Chinatown Chinatown, Manhattan—one of the largest Chinatowns in the United States—has the highest concentration of Chinese immigrants in the Western hemisphere. In Community District #3, which includes Chinatown, 60.4% of the foreign born population is from China. Of these, 37.8% are not proficient in English. Over 60% of immigrants in Chinatown speak Chinese at home.8 In this community cancer screening rates remain well below targets and the community’s cancer related death rate is higher than the rate in New York City overall. Additionally, Flushing, Queens and Sunset Park, Brooklyn—New York City’s second and third largest Chinese communities, respectively—have two of the lowest levels of cervical cancer screening in New York City.3 These neighborhoods are linked to Chinatown by both public transportation and private Chinese-speaking bus lines—allowing for access to Chinatown’s Chinese-speaking markets, restaurants, employers, health care, and various cultural services. Thus, Chinatown serves as an epicenter for New York City’s Chinese population—making it an ideal location to serve the needs of New York City’s vast Chinese population. Barriers for Chinese Immigrant Women Many studies have attributed disparities in preventive screenings to language and health care barriers as well as to unfamiliarity with and misconceptions about cancer screening. , Immigrant Chinese women are likely to be unfamiliar with English and often times materials are translated into Cantonese but not Mandarin. Additionally, the cultural concepts of traditional Chinese medicine utilize alternative prevention strategies that Western medicine does not include.11 For example, less acculturated Chinese women use traditional herbal remedies and folk practices based on Chinese medical theory. As well, Asian women are more likely to believe in the role of luck and self-care regarding their health.11 Furthermore, embarrassment during Pap tests may serve as a barrier for Chinese women.11 A recent study showed that Chinese American immigrant women have an overall average knowledge about cervical cancer and Pap tests; however, they are misinformed about risk factors for cervical cancer.14 Additionally, Chinese women are likely to consider themselves to be healthy unless they feel sick, which presents a barrier to screening because cervical cancer is asymptomatic in its early stages.11 Recent research among Chinese American immigrants has shown that women with higher prevention orientation are more likely to have had a Pap test and women with higher cervical cancer knowledge are more likely to practice screening guideline recommendations. This research points to the need for cervical cancer screening programs to be tailored to individual communities.
    • Cancer Facts and Figures. 2008. Atlanta, GA: American Cancer Society. Available at: http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf. Accessed on November 11, 2008. Seeff LC and McKenna MT. 2003. Cervical cancer mortality among foreign-born women living in the United States, 1985 to 1996. Cancer Detection and Prevention. 27: 203-208. Olson EC, Van Wye G, Kerker B, Thorpe L. Cervical Cancer Screening in New York City. NYC Vital Signs 2006, 5(3): 1–4. Coughlin SS and Uhler RJ. 2000. Breast and Cervical Cancer Screening Practices among Asian and Pacific Islander Women in the United States, 1994–1997. Cancer Epidemiology Biomarkers & Prevention. 9: 597-603. Asian American Network for Cancer Awareness, Research and Training. Available at: www.sp.ohiostate.edu/aancart/About_AANCART.htm United States Census Bureau. Census 2000 Profile. Available at: www.census.gov/PressRelease/www/20001/tables/dp_us_2000.pdf Encyclopedia of New York City. 1995. New Haven: Yale University Press. Manhattan Community District 3. 2007. New York, NY: New York City Department of City Planning. Olson EC, Van Wye G, Kerker B, Thorpe L, Frieden TR. Take Care Lower East Side. NYC Community Health Profiles, Second Edition; 2006; 27(42):1-16. Wang JH et al. 2008. Disparities in cervical cancer screening between Asian American and non- Hispanic white women. Cancer Epidemiol Biomarkers Prev. 17(8): 1968-73. Lee M. 1998. Breast and cervical cancer early detection in Chinese American women. Asian American and Pacific Islander Journal of Health. 6(2): 351-357. Cook K. Elderly Chinese immigrants at greater risk. University of Calgary Nursing. Available at: http://www.ucalgary.ca/nu/chinese/. Accessed on December 2, 2008. Jackson JC et al. 2006. Development of Cervical Cancer Control Interventions for Chinese Immigrants. J Immigr Health. 2002 July; 4(3): 147–157. Lee FL et al. 2007. Cervical cancer beliefs and Pap test screening practices among Chinese American immigrants. Oncology Nursing Forum. Available at: http://findarticles.com/p/articles/mi_6854/is_6_34/ai_n28468305. Accessed on November 13, 2008. III. Program Description The Charles B. Wang Health Center requests support in the amount of $100,000 to implement a new one year cervical cancer screening initiative for Chinese American and Chinese immigrant women in the Chinatown district of Manhattan. This new program, PapPartners, seeks to increase the number of Chinese American and Chinese immigrant women receiving annual pap smears by providing these women with culturally relevant education materials and one-on-one interactions with health professionals. This outreach is intended to motivate women to bring a friend or relative with them to each receive a free pap smear at the Charles B. Wang Women’s Health Care Clinic located on 268 Canal Street in Manhattan. The funds requested will support a full time outreach and program coordinator.
    • PapPartners is an innovative program, intended to utilize the materials and resources already available through the Charles B. Wang Health Center to extend our reach into the Chinatown community and increase utilization of cervical cancer screenings. Additionally, the CDC recommends that all current and future interventions and outreach to increase cervical cancer screening among Chinese American women address cost, decrease barriers to the health care system, and utilize community sources. As a trusted community institution in Chinatown, the Charles B. Wang Center is uniquely qualified to achieve all of these goals in a sustainable manner. Much of our initiative will be determined by community member feedback that we gather during the first phase of our program. Pap Partners will adapt as the program proceeds through the year, based on ongoing analysis of what is most beneficial to increasing the number of women in our community who are receiving annual pap smears. The PapPartners goal is to decrease the incidence of cervical cancer among Chinese immigrant women in New York City by addressing common barriers to screening in order to increase utilization of regular screenings and improve access to treatment of pre-cancerous cells by. Pap Partners objectives 1-7 cover the range of efforts the planners think initially necessary to implement the program. GOAL: Directly address common barriers to and increase utilization of cervical cancer screenings among Chinese immigrant women in NYC. 1) Assemble and conduct two 15 member focus groups of existing Charles B. Wang Health Center clients, and Chinatown community members to determine barriers to care, appropriate incentives to receive regular pap smears, program design, social marketing messages and scheduling for screenings that are convenient for community members. These groups will be assembled and convened within the first month of the program. 2) Create five Pap Partners teams, each consisting of a Nurse Practitioner, Coordinator, and bilingual Community Volunteer. The Coordinators, where possible, will be hired from the community. These teams will receive culturally and medically competent training, provided by key focus group members and program administrators. The Pap Partners teams will be assembled and trained within the first three months of the program. 3) Distribute 2500 copies of Chinese/English culturally competent brochures regarding cervical cancer and screening at various locations in Chinatown, where education about the importance of cervical cancer screenings and counseling will also be offered GOAL: Decrease incidence of cervical cancer among Chinese immigrant women through increased screenings. 100 Chinese immigrant women will be enrolled in Pap Partner Program and receive pap tests during the first year at no cost.
    • GOAL: Link Chinese women immigrant women to services for cervical cancer screening. 1) Link 100% of women with abnormal pap smears to care within Charles B. Wang Health Care Systems. 2) Project administrators will contact 100% of enrollees with follow-up tracking and annual appointments reminders 9 months after first screening 3) Provide referrals to resources within the Charles B. Wang Women’s Health Center and counseling to 100% of the women who request it on the day of their pap smear. The Pap Partner teams will also provide referrals to other community resources as needed. Methods Participants and Community Involvement: Our organization is well integrated into the local Chinese American community in Chinatown. We will recruit female bi-lingual Mandarin/Cantonese and English speakers from our existing health programs and will match these community volunteers with nurse practitioners from our Women’s Health Care Clinic in Chinatown. Each pair will be joined by a coordinator from our organization who will facilitate the team’s activities. We aim to create five teams in total. Our outreach program will take place in six phases: Start Up and Community Needs Assessment Starting in September 2009, an Administrator will be hired, who will be responsible for assembling our teams. We will assemble two focus groups of existing Charles B. Wang Health Center clients, as well as Chinatown community members, to determine barriers to care, appropriate incentives, program design, social marketing messages, and convenient scheduling for screenings. These groups will be assembled and convened within the first month of the program. These focus groups will also provide us with ideas for appropriate locations for Pap Partners' team outreach. Once the focus groups have decided on appropriate incentives for our program, the Pap Partner Administrator will work to partner with the applicable product suppliers in order to acquire those
    • incentives (examples of incentives may be movie theatre tickets, supermarket gift certificates, as well as appointments for child wellness visits.) Team Development and Training Create five Pap Partners teams, each consisting of a Nurse Practitioner, Coordinator, and bilingual Community Volunteer. These teams will receive culturally and medically competent training, provided by key focus group members and the Program Administrators. The Pap Partners teams will be assembled and trained within the first three months of the program Information and Education Outreach To serve the needs of Chinese immigrant women in Chinatown, our organization has created two Chinese/English brochures regarding cervical cancer and testing: · A Pap Test Can Save Your Life · Cervical Cancer (both in traditional and simplified Chinese) information In order to get these pamphlets into the hands of the women who need them, each team will be sent to Chinatown locations where Chinese American women often visit (as determined by our community focus groups). Pap Partner teams will table at these various locations in Chinatown, answer health questions, distribute information on women's health and recruitment materials and make appointments to enroll women into Pap Partners program on specific days/weekends. Women who make appointments will be given reminder tickets which they will be asked to bring to their appointment. This outreach will take place once a month throughout the year-long program. Our program will also buy newspaper and radio advertisements to announce the days and times of free pap smears at the Charles B. Wang Health Center. These advertisements will run monthly in the local, Chinese language papers and radio stations. As an incentive to get women to the Health Center, Pap Partner teams and newspaper/radio advertisements will explain that every woman who brings a friend or relative to the Health Center so that they can both receive screenings, will receive two free coupons/tickets for our incentives or other incentives determined by focus groups.
    • Providing Free Screenings The Charles B. Wang Health Center will provide free pap smears to all women who come to the Women’s Health Clinic on Pap Partners Days. (The exact times and dates of Pap Partners Days will be established by our community focus group.) On these days, the Pap Partners Teams and organization staff members will be at the clinic to provide informational counseling to women receiving their first pap smears. In addition, we will create a festive atmosphere in the waiting room on Pap Partners Days, including incentives and a very non-waiting room feeling. Staff members will collect tickets from those women who made their appointment through the outreach teams, and will ask to enroll information about how all other women heard about the program. The Pap Partners teams will be on hand in the waiting room to discuss any health issues with the women, and to engender a welcoming atmosphere in the room. Referral and Counseling The Pap Partner Teams will provide referrals and counseling to 100% of the women who request it on the day of their pap smear. The Pap Partner teams will also provide referrals to other community resources (such as churches, insurance information), as needed. Follow up and Sustaining Our Success Project Coordinator will call women with annual pap smear reminders, and will send reminders annually as well. Movie tickets and other incentives will be again be offered to any woman who brings a friend or relative to her next pap smear. Additionally, the Pap Partners administrators will link all women with abnormal pap smears to care within the Charles B. Wang Health Center system. Staffing The Pap Partners programs will consist of a Program Administrator and 5 Program Coordinators who will work under the administrator. Program Administrator - Wendy W. Kong
    • Wendy W. Kong is a Family Nurse Practioner from the Columbia University School of Nursing, with A Master’s in Public Health from Hunter College. In addition to her unique educational and training background, Wendy has experience leading numerous Charles B. Wang community health initiatives. In 2005, Wendy served as the assistant program coordinator of the Charles B. Wang “B” Healthy Model Care Program. Founded in March 2005, the “B” Healthy Model Care Program in collaboration with the Association of Asian Pacific Community Health Organizations (AAPCHO) and Bristol-Myers Squibb to addressed the epidemic of hepatitis B in the Asian American community. The program was designed to reduce barriers to care and provide community education and support for hepatitis B patients and their families. Culturally and linguistically-appropriate health education brochures, videos, and radio programs were developed for the program, as well as patient and family support groups. Continuing medical education seminars were offered to 150 local providers to increase awareness of hepatitis B in the Asian American community and to inform them of the latest screening, vaccination, and treatment options. In the past year, Wendy has been the program coordinator for the Charles B. Wang Community Health Center Diabetes Literacy program, which has developed an educational program for low literacy Chinese patients with diabetes. The program offers training for physicians, nurses, health educators and others on how to improve health communication and incorporate health literacy principles in development of educational materials. Patients education workshops are offered in Chinatown and Flushing on issues such as improving patient-physician communication, diet control, and blood sugar monitoring. The Health Center staff members are planning an intervention manual for health educators and other health-care providers that includes a curriculum on delivering culturally appropriate care and self management tools. The Health Center has also joined the New York City Health Department Diabetes Collaborative Care Initiative. The Health Center has developed a patient registry and is checking clinical outcomes to monitor and improve diabetes care. Currently, there are approximately 800 active patients with diabetes in our registry. Wendy has been a valued member of the Canal Street Charles B. Wang Health Center for the past six years, and will bring a variety of leadership experience within the Chinatown community as well as within the Charles B. Wang Health Center to the new Pap Partners Program. Program Coordinators– to be hired
    • Program Coordinators will include students who are currently pursuing Master’s degrees in public health and nursing, and who have demonstrated prior experience and/or continued interested in working with multi-cultural health initiatives. This is a part-time position, consisting of 20 hours a week of work. The Program Administrator and Coordinators will be responsible for assembling 5 Pap Partner Teams, each of which will consist of: - 1 Program Coordinator - 1 Nurse Practitioners- Nurse Practitioners will be members of the Charles B. Wang Women’s Health Clinic Staff. They will be paid overtime for their work with the Pap Partners project. - 1 Community Member - Each community volunteer will receive a stipend of $1,000. IV. Organizational Description For more than 30 years, the Charles B. Wang Community Health Center has been a leader in providing high-quality, affordable, culturally competent health-care to the Asian American community in New York City. The majority of the Center's clients are low income, uninsured or under insured Asian immigrants with nowhere else to turn for basic healthcare. In addition to providing comprehensive primary care services, the Center promotes the health of the community through innovative, award winning health education and advocacy programs, and by recruiting and training bilingual health care providers. Since its inception in 1971 by a group of volunteers, the Health Center has continuously expanded services to meet growing community demands and has had to relocate several times in order to obtain adequate clinical space to provide bilingual and bicultural healthcare services to the underserved Asian American community. In addition to the clinical services, the Center has also nurtured and grown a generation of health, social services and other professionals for community service through our unique training and internship programs. Many of these graduates now work in Asian American community based organization throughout the country, further spreading the impact of those volunteers who came together in 1971. The Charles B. Wang is guided by a deeply committed Board of Directors, comprised of ten dedicated members. Together, Jane T. Eng, our Chief Executive Officer, and Thomas Tsang, MD and MPH, our Chief Medical Officer, run an organization staffed by ten incredibly experience medical administrators, as well as over one hundred knowledgeable and caring health professionals, many of whom are themselves of Asian descent and reside in the communities we serve.
    • The Charles B. Wang Community Health Center’s goals are: SERVICE • Provide our patients with compassionate, professional health care through the following efforts in: ADVOCACY • Advocate on behalf of the Asian American Community, who, due to cultural, linguistic, educational, or financial barriers, lack access to basic health care services and health education. • Reach out and interact with the community and its leaders to understand and respond to community needs. • Raise national awareness of Asian American health and social needs. • Serve as a model for other community health centers. EDUCATION AND TRAINING • Disseminate up-to-date health information to the community. • Promote the practice of preventive medicine and good health habits. • Provide students and health care professionals with experience and understanding in meeting the special needs of our population. • Motivate Asian Americans to pursue health careers and become involved in the community. RESEARCH • Participate in community-based research that benefits the Asian American community. • Collect data to identify needs of our patients and community. As part of our ongoing commitment to these goals, the Charles B. Wang women's health department is a unique community based health care program serving Asian American women in New York City. The women’s health department is comprised of five obstetrician/gynecologists, 2 family health medical practitioners and three registered midwives. All of our staff members have extensive experience working with diverse communities of women.
    • In the past year, the women’s health department served 324 clients in the Chinatown community. The majority of the clients in the women’s health department are low income women who are recent immigrants. The Health Center provides a wide array of primary and specialty services, including gynecological care, family planning, pregnancy testing, prenatal and postnatal care, genetic and nutritional counseling, breast-feeding education, screening and education for HIV and STD infections, and screening and education for breast, cervical, ovarian and prostate cancers. The women's health department also sponsors many outreach and health education programs to promote and increase the community's awareness of women's health issues. V. Timeline Personnel Project Activity Measurable Outcome Time Frame · Pap Partner teams Pap Partner teams VI. Budget To be added…
    • VII. Evaluation Through an evaluation of data regarding cervical cancer screenings completed by immigrant Chinese women in Chinatown, we will be able to measure the impact of the Pap Partners intervention. The number of screenings completed during the project funding period will be compared to rates of Pap smears completed at the Charles Wang clinic over the last three years. We will be testing the hypothesis that individualized health promotion that directly addresses barriers to cervical cancer screening for this population can result in increased screenings and better access to oncological care for women whose screenings show evidence of cancer. While the overall goal of this project is to decrease cancer-related deaths among a specific population, we also intend to test our innovative model of individualized health promotion. Much of the design of our program will result from information collected during two primary focus groups. Therefore, we will be able to evaluate the impact of a consumer-created intervention, rather than a traditional health education program designed by one population for another. We will also be able to measure (and contribute to the body of medical literature regarding) the effectiveness of the interdisciplinary team model of service delivery. Binary and quantitative evaluations of our process objectives will include: 1. Focus groups Were two focus groups held within the first month? (# of focus groups) Were focus groups composed of existing Charles B. Wang Health Center clients, as well as Chinatown community members? (composition of groups) Was data collected during focus groups helpful to determine appropriate incentives, program design, social marketing messages and scheduling? (yes/no) 2. Pap Partner Team Creation Were five Pap Partners teams each consisting of a nurse practitioner, program staff member, and bilingual community volunteer created? (# of teams, composition) Did teams receive culturally and medically competent training, provided by key focus group members and program administrators? (yes/no) Were teams assembled and trained within the first three months of the program? (yes/no)
    • 3. Service Delivery Were 100 women enrolled in the Pap Partner program? (# enrolled) Did 100% of enrollees complete Pap smears within the first program year? (# Paps completed) 4. Referrals Did Pap Partners teams and staff provide referrals and counseling to 100% of the women who request it on the day of their pap smear? (%age of referrals made) Did Pap Partner teams also provide referrals to other community resources as needed? (# of other referrals made) Did Pap Partners teams link 40% of women with abnormal pap smears to care within the Charles B. Wang Health Center system? (#age linked to care) Other specific qualitative evaluation activities will consist of: New clients presenting for enrollment into the Pap Partners program will be asked how they heard about the program. This will indicate the success of our various outreach activities (flyers, advertisements, tabling, etc.) Every sixth client completing a Pap smear will be asked to undergo a verbal exit interview as they leave the clinic. This interview will include five brief questions about their experience with the medical provider and likeliness to recommend this program to a friend. This data will be collected and analyzed to inform potential program revisions. Our final evaluation will be collected into an evaluative report, not only for submission to our funder but also to serve as a mechanism for building our organizational capacity and the success of future programs. If our program is successful, we hope that it will be integrated into the regular menu of programs and services offered by the Charles B. Wang clinics.