cc  >> Good evening.  I think we're about ready to  get started.  My name is Connie Gundacker, and  I represent the Global Health  Interest Group here at the UW  School of Medicine and Public  Health.  Tonight it is my pleasure to  introduce Shiva Bidar-Sielaff,  the director of community  partnerships at UW Health and  vice chair of the Dane County  Latino Health Council.  On a national level  Ms. Bidar-Sielaff has worked  extensively on issues of equal  access to healthcare for limited  English proficient individuals,  serving on the board of National  Council on Interpreting and  Healthcare.  Ms. Bidar-Sielaff was awarded  the Dane County Public Health  Leadership Award for  multicultural healthcare in 2000  and is a 2005 recipient of the  Madison YWCA Women of  Distinction Award for her work  in fighting inequality and  eliminating racism.  Earlier this month she was  elected to serve as alder for  Madison's fifth district.  This evening she will be  discussing the influence of  culture on views of healthcare  and potentially successful  culturally competent  interventions to improve the  health and well-being of our  diverse community.  Please join me in welcoming  Ms. Bidar-Sielaff.  (applause)  >> Thank you, very much. 

 Thank you for being here on this  beautiful evening.  First sunny evening and we're  all inside, but I really  appreciate the opportunity to  talk to all of you about an  issue that I'm certainly very,  very passionate about which is  culturally competent approaches  and resources to make sure we do  provide a healthy lifestyle to  all of our children in our  community which is a much more  diverse community than many  people even think about.  So again I work at UW Health as  the director of community  partnership, and as such I have  the pleasure to work with many  of our schools and our community  organizations that provide  support to children in our  community and make the  connection between health and  the need for health education  and healthy lifestyles for our  children and families.  And I also serve as the vice  chair of the Latino Health  Council of Dane County, and I'll  talk a little bit more of the  Latino Health Council of Dane  County as an example of an  organization that is a good  partner organization in trying  to implement culturally  competent approaches and  resources.  I am a very fast speaker because  I usually only get half an hour  to speak and I have a lot of  stuff to say.  So I want to leave some time for  us to have a little bit of a  dialogue and allow you to ask  questions and for us to have  some discussion so I'm going to  speak really fast so that I can  hopefully end, I'm 10 minutes  behind, end by 7:10, 7:15 so  that we can have about 15  minutes of questions and  answers.  So forgive me if I go through  the presentation pretty fast.  So obviously the reason that  cultural competence is important  is not because it's just a buzz  word or it sounds really great  so let's do it.  It really is something that has  been studied over and over and  shows that really when people  are dealing with health issues  and approaches to how to live  their life, their culture, their  background, their ethnicity,  makes really a difference in the  way they approach things and the  way they see things.  And certainly when it comes to  health a lot of our attitudes  and behaviors towards health  have to do with our background,  our culture and what we think  needs to happen for us to have a  healthy life. 

 And there is obviously also  fears and hopes and expectations  that are based on our life  experience and our culture.  The other reason that this issue  of cultural competence is  really, really critical is  because we continue to see huge  disparities in health outcomes  in our country based on race,  ethnicity and gender, and I will  say also for the LGBT community  huge, also, disparities in  health outcomes.  So again we've come a long ways  in our country in dealing with  issues of race and racism, but  we still have a long ways to go  in dealing with disparities.  We continue to see in many  areas, and you look at every  area really of health, and we  still see that there is really  gaps and disparities based on  race and ethnicity.  And for those you who work in  the school district this sounds  very familiar because you see  the same kind of achievement  gaps that are based on race and  ethnicity in school  achievements.  So we see the same issues in  healthcare and I think it's  incumbent on all of us to make  sure that we create  institutional systems that are  supporting getting rid of those  disparities.  So the first question that  always comes up when I talk  about cultural competency is  what's culture.  And people tend to think of  culture as people like me  because I have an accent so I  must bring a different culture  to the table.  Or somebody that looks  different.  But really culture is about  every single one of us. 

 And that's the most important  thing to remember about culture  is that we all have it,  fortunately.  And we all bring it with us to  our work, to our environment,  and the children bring their  culture with them to their  school.  So when we're talking about  cultural competency we're really  talking about cross cultural  differences because you, in  whatever role you have in the  school, bring your culture with  you.  The children, the families that  you're working with, may bring a  different set of culture with  them.  So it's important to understand  that it's not just about looking  at the other person and trying  to figure out what their culture  is, it's really about also  looking inside and inward and  knowing what your culture is and  how is that influencing your  opinions, your actions and how  you're dealing with providing an  environment that is  multicultural and supports  healthy lifestyles in a very  multicultural way.  The important thing to remember  about culture and the reason  that we all have culture is  because it's about us sharing a  certain amount of beliefs and  values with another group of  individuals.  That's what makes life  interesting is to have a group  of people that you share things  with and then have another group  of people that you don't share  the same values with and that  you can learn from and have  discussions with.  So what's really important about  culture is that it provides us a  sense of security.  We like to be around people  often that we share certain  things with because when we're  around those people we know what  we're talking about and we feel  there is a sense of security and  the sense of shared values and  that we don't have to explain  ourselves.  For many of our children and  families, especially, and I'll  focus a little bit more on our  immigrant families in a moment  because they're the ones that  see the huge cultural  differences, coming into our  institutional system, and the  school being one and healthcare  facilities being the other one,  is walking into a foreign land. 

 Is really being in a system  where they do not share the same  culture.  So it's really that sense of  walking into a system in which  you don't feel that you have a  sense of belonging.  Again it's incumbent about us to  make a system become really  systems where those families do  feel like they belong.  The other important thing about  culture when we're talking about  health is that it certainly  determines what illnesses are  about and the causes of  illnesses.  This sometimes sounds very  exotic but I'll give you my  quick example.  A cold.  Now for all of us that work in  healthcare, we know that colds  are due to viruses.  And I've worked in healthcare  for a very long time, but for  me, culturally, is the change of  temperature outside.  I don't care how many years I've  worked in healthcare.  I will still say that the reason  I caught a cold is because, not  because I work in a hospital and  there is maybe if there's a lot  of people that have colds  because I didn't do that great  washing, no, it's because the  temperature changed outside. 

 So again even little things  about illness are very based on  what your cultural beliefs were,  what you were told about what  causes those illnesses.  Rituals are also part of our  culture, and again rituals  sounds like something very  exotic but can somebody tell me  what the biggest ritual in life  is?  Think about it.  You do it every day a few times.  Eating.  Food is really the biggest  ritual in life.  And it is very culturally based.  What you eat is really based on  the food that you grew up with,  what is being served in your  family, what can be served at  your home.  So it is definitely one of the  biggest issues in healthy  lifestyles is nutrition, and  that biggest issue is one that  is definitely based on the  culture of the family and that  child.  So when we talk about obesity  and nutrition, cultural  competency has to be an integral  part in dealing with obesity and  nutrition because it is  culturally based.  This is just for you a quick  picture of when we talk about  culture also the many aspects of  it. 

 There is a tendency of wanting  to think about culture as just  race, ethnicity, gender,  physical abilities, the things  that are obvious and people can  see.  But, again, there is many, many  other aspects to every one of us  in our culture that is as  important as our race,  ethnicity, our gender.  For example, our marital status,  where we grew up, what kind of  work we do, what country we are  from.  All of those things are as  important.  So it's really, again, critical  not to try to label a group just  based on one aspect of these  will but really to think about  the complexities of issues that  every single child and family  brings with them as the  complexities of our own culture  and lives.  So this is just to give you some  numbers on the aspects of  diversity in Dane County.  You can see our diversity by  race and ethnicity.  You can see, also, our diversity  by education level.  46% of people living in Dane  County have a bachelor degree  and higher.  You can see by social-economic  status. 

 Persons below poverty level,  10%.  And I know that it's been  repeated many times for those of  you who certainly work in the  school district, but our poverty  level at the school district is  a very, very high level in the  Madison school district.  And then we have linguistic  diversity, for example, as  another aspect of diversity.  About 10% of people residing in  Dane County saying that they  speak a language other than  English at home.  That doesn't mean, again, that  they do not speak English, that  means that their language of  comfort at home, both for the  child and the adults, is a  language other than English.  Here is some demographics about  immigrant populations.  One in eight people living in  the US today say that they were  born in the country other than  the US.  That's a pretty staggering  number.  One in eight persons are first  generation Americans.  And in Wisconsin one in 22 which  I think is pretty high too. 

 Residents speaking a language  other than English, again you  see the overall population for  the country, about 20% of the  population.  In Wisconsin 8% and you saw in  Dane County is about 10%.  So now getting to the specifics  of cultural competence and where  to start.  In cultural competence everybody  wants to talk about other  people.  Because it's easier, right?  It's always easier to have a  laundry list of how other people  do things and have a recipe book  about what do Latinos do and  Hmong people do.  But what people don't want to do  is take time to really look into  their own culture and why do we  do the things we do the way we  do instead of why other people  do the things they do the way  they do.    And I can tell you if you're  going to even try to start  anywhere you really need to  start with the most difficult  step which is try to first  figure out why do we do  personally the things we do,  what are our cultural values and  norms that we hold very dear and  think are very important, and  then think about your  organization and your  institution, why does that  institution do things the way  they do?  What are the values and the  culture of that organization  that drives certain ways of  doing things?  That's really the first step.  And the second step is then to  see what the families, the  children that we serve, how do  they do things and then try to  figure out where there are  differences and where we can  bridge those differences.  So as you're leaving tonight,  hopefully on your way home start  asking yourself questions about  what are your own personal  biases, what are you  assumptions, what are your hot  buttons, we all have them.  And what really bothers you, why  don't you, what are the things  that you hear sometimes that are  really set you off on wanting to  give a big speech about how life  should be led the way you would  like to lead it and challenge  yourself in identifying your own  beliefs as your own and not the  norm. 

 We all like to think we're  right.  I certainly think I'm right and  the way I do things is the right  way to do things.  Every one of us thinks that.  So just again challenge yourself  that what we think is the norm  and the way we think things  should be done, it may not be  the norm.  Quick example of a norm that I  learned when I married my  Madison-born husband.  When he's sick he likes to eat  Jell-O, and he thinks that  normal.  (laughter)  I think a lot of  people think that that's a good  thing if you have a stomach  ache, you're not feeling well,  you grew up with it, Jell-O  sounds really good.  I find Jell-O just the most  disgusting thing that could be  put in front of me.  It's unnatural in its colors, in  its look, there is no way.  And I would, if I'm not feeling  well and somebody brings that I  would be really much sicker. 

 We had this discussion he's like  everybody eats Jell-O.  No, I don't eat Jell-O.  So the next question is what  would you eat if you're not  feeling well and you have a  little stomach ache?  Plain white rice.  And he said that's weird.  I think plain white rice is not  as weird as Jell-O.  This is a natural food group.  So again simple things that we  consider sometimes the norm  because that's just the way we  grew up.  That was the way we do things  may not be the norm for other  people.  So the first way of knowing that  it's not the norm is to realize  what are those things for us.  We all have, for example, the  personal biases and assumptions   that I talked about. 

 And they're based on our  experiences.  A quick one that I'll tell you  that many of us in healthcare  certainly share is drunk  driving.  It drives us crazy because I  certainly work in a trauma  center and I see what can happen  when people are driving under  the influence.  So I have to know that that's  one of the places where I have  very strong opinions and very  strong biases so if I'm working  with a family and a patient  where the accident may have been  caused by a father who was  driving under the influence, I  need to know that I have to have  a very clear red flag in my head  so that I don't let that  influence in way or shape the  way I deal with the family.  I'll give you another one that  certainly is one that people  have very strong opinions about,  undocumented immigrants.  We all may have our personal  opinions, it's a free country.  We all can have our opinions.  But when you're in a  professional environment, in a  work environment when our job is  to provide the same level of  education and health to every  single one of our children,  where are we about our own  feelings about that issue may be  influencing the way that we're  providing those services to a  child or a family and how the  institution's way of dealing  with that issue is influencing  the way that we're dealing with  a family and a child.  I'll switch quickly, I'm going  to run out of time, switch  quickly to immigrant and refugee  experiences because I told you I  wanted to kind of give you a  little bit of focus because I  could talk about cultural  competency in general for hours  and hours.  So I wanted to give you at least  some specifics about a specific  group that does have many, many  challenges that I know many of  you in the school and in the  healthcare system see those  challenges and how we've really  have put in place some  interventions I think in Dane  County that have been very  successful and I think can be  replicated in many ways. 

 Healthcare access.  We know that immigrant and  refugee populations have much  less healthcare access than the  general population.  And we also know that it's  already not great in the general  population to start with.  The US healthcare system is a  very, very complex system.  Imagine if you didn't know  anything about the system and  you're just brought and put in  the middle of the healthcare  system in the US.  For those of us who work in it  on a daily basis have a hard  time figuring it out.  There is also limitations by law  of access to most government  programs for immigrant and  refugee populations.  Most notably, BadgerCare Plus.  Everybody likes to say that all  children in Wisconsin have  access to healthcare now.  Well, that sounds really good as  a one liner, that's not the  reality of the many children  that we work with on a daily  basis. 

 And I'm not even going to go  into the underinsured children.  But language, language is  another of the challenges that  poses a barrier to access for  immigrant and refugee  populations.  Obviously when there is a  language barrier it's much more  difficult to understand the  system and to be able to enter  into big institutional systems  and understand what you have  access to through the schools,  what activities are available,  after school activities are  available.  Again, we are very lucky in our  community in Dane County that we  do have a really great services  available for language access,  but often they still pose a  barrier for the families if they  don't know how to access those  services, if they don't know how  to, for example contact the  bilingual resource specialist in  the school or an interpreter in  the healthcare system.  Often there is very poorly  translated materials that lead  to more confusion than clarify  things for families.  And one of the things I often  see is that if there is a  language barrier more often than  not the family is handed badly  translated material and there is  no conversation because it's  just easier to hand them a  written piece of material and  tell them the list of after  school programs than spend 20  minutes with an interpreter  explaining it.  Well, there maybe literacy  issues, there maybe just  understanding issues.  That piece of paper may not be  the best way to communicate  information to that family.  There is also certain  expectations about provider  behavior that come, again, from  a culture that is not used to a  partnership but is used to the  school being a place where the  kids just go, learn, they come  back.  There is not much a dialogue  going on. 

 The teacher just deals with the  kids in the schools.  So there is sometimes a  challenge to engage the parents  and really being a partner with  the schools.  Because often they come from  countries where that wasn't the  way you deal with schools.  So specific things that you can  think of doing when dealing with  specifically immigrant families.  Obviously dealing with the  language barrier on a regular  basis.  Not just once in a while we're  just going to have a meeting and  then we're going to have an  interpreter.  But how do they access the  entire system on an ongoing  basis whenever they need to as  any other parents and have the  language barrier be removed for  them.  Socioeconomic status is  obviously a huge driver of some  of the decisions that parents  can make about healthy  lifestyles and cannot make.  Where are they at their poverty  level?  What can they have access to and  what they don't have access to.  The parents level of education,  and again this is what you need  to ask the questions because  often I see assumptions made. 

 This family comes from Mexico,  the parents probably don't know  how to read Spanish.  Not assumptions but evaluating,  what is your level of education.  I can tell you we have a lot of  immigrants that are highly  educated from their country of  origin, and again are here  working in positions and jobs  that have nothing to do with  what they were doing in their  country of origin.  So no assumptions about that but  really trying to assess what the  level of education is.  Immigration status and again  assessing what the immigration  status is because as I told you  before the immigration status is  going to make a difference in  the level of access of programs  for that family.  So knowing whether they're in a  path of citizenship or their  undocumented or not, again just  for the simple reason of knowing  whether they're going to have  access to certain type of  services or not.  We have a lot of split families  in the immigrant community, and  by split families I mean the  parents maybe here with one  child and they've left two  children behind in the country  of origin.  Asking those questions and  knowing what the stressors are  in that family that create some  of the health issues that are  going on in the family is  really, really important.  We often see that the child  that's here gets overwhelming  amount of attention because  parents feel so bad that they've  left two children behind, which  all of us would if that was the  situation that we were in, but  again some of the issues that we  see with discipline and  nutrition and activity have to  do with the fact that the family  is feeling so stressed about  having left other children  behind that they don't want to  do anything that is remotely  disciplinary in nutrition and  other things with the child that  they have here.  There is also a lot of trauma  that can be associated with  immigration and the immigration  experience, certainly the  refugee experience and where  people came from. 

 We have immigrants that come  from all over the world, from  Kosovo to other places.  So those children may have  really suffered trauma or the  parents may have suffered true  trauma.  So again how they approach some  of the things that we think are  very important and they may not  be a big priority because they  are suffering from some other  very, very serious trauma and  post-traumatic stress issues.  Acculturation, again another  question that's really important  to ask and evaluate about each  family, how long have they been  in the US and how much have they  identified themselves with the  culture of origin.  And that can change dramatically  from one family to the other  depending on how long they have  been here.  Here are some quick  recommendations.  I won't read through all of them  but making sure that you learn  about what the social stressors  and barriers are for immigrant  communities and immigrant  families is really, really  important.  And that can only happen with an  individual evaluation with that  family.  And then partnering with  community specific resources.  Knowing what resources are out  there in the community that  really are culturally competent  resources for those specific  families. 

 I put some examples there for  you of organizations in Dane  County.  Here is, quickly, an example of  the Latino Health Council and  what we do.  We have a health fair every year  that is very well attended.  We have a chronic disease  conference where we talk to  families about, all in Spanish,  about nutrition, about diabetes,  again we know that Latinos are a  much high risk of diabetes.  We continue seeing obesity as a  huge issue in Latino children,  even more than in the general  population.  And given the propensity of  diabetes it becomes even a  larger issue.  So, again, we do a chronic  disease conference.  We've also started to do a  mental health conference every  year where we talk to families  about stress and how to handle  stress because it's a huge issue  in the immigrant community.  We have a radio program every  month from 9:00 to 11:00 that is  widely listened to in the  community.  People listen to the program  from wherever they are working  and any place in the community  and it's amazing the number of  questions that we get. 

 So we partner a lot with  actually school people to try to  get information out about  healthy lifestyles for children  in our radio program.  And then finally I put there  some resources  and newroutes.org  is the main website.  This is a Robert Wood Johnson  funded a program that is dealing  with how to use media, and  mostly social media, to do  health education in immigrant  communities.  And so they've developed great  tools such as booklets, YouTube  videos that are in language for  the immigrant community that you  can use, they are free, you can  download, you can share with  families, you can tell them how  to access them.  Many of our families use the  public libraries and have access  to the internet through the  public libraries.  They're a great educational tool  that has been developed across  the country.  And then here is another Robert  Wood Johnson program is Center  for Health and Healthcare in  Schools, caring across  communities.  And again their work has been  around immigrant communities and  health education.  I'll stop here so that I can  have you ask questions for 10  minutes.  >>(inaudible)  >> The Latino Health Council and  we have an African-American  health network. 

 And United Asian Services is a  community based organization  that provides services to the  Asian community, mostly Hmong  community, but also the Laotian,  Cambodian community here in our  area.  And have a lot of expertise in  that area.  Again these are just examples.  Bay View Community Center is a  great resource for working with  the Hmong community.  They have great programming  there that is very culturally  competent and meets where the  community feels very  comfortable.  One of the biggest aspects of  making sure that you use  community specific resources is  because the community really  trusts those resources, they  know the community leaders who  are usually involved in those  organizations.  And they feel much more  comfortable using services if  they have that connection with  somebody in their own community.  Questions?  >> (inaudible)  >> Whether the schools could  serve as a medical home for  children, is the question.  And in many ways, the schools  are a medical home.  I wouldn't say a home but they  are certainly the gateway that  evaluates what the needs of  those children are and then  usually, the school nurses are  the biggest partners, I can say,  for somebody like me who works  at UW Health and I'm looking at  Stephanie who works at St. 

 Mary's.  They are the biggest gateway to  make sure that those kids get to  us.  Because they see the issues that  are going on with the health of  those kids in the school every  day.  They are the ones that can open  the doors, the school nurses are  the ones that allow the doors to  open in the healthcare  organization to get the other  kind of care that they may need.  I don't know if you want to add.  >> (inaudible)  >> I'm sorry, I'm summarizing  because they told me that they  can't hear the comments from the  public for the recording, so,  the comment was that in other  states, such as in Maryland,  there are a lot of school-based  clinics, about 120, in Milwaukee  there are some too.  And it would seem that it would  make sense to have school-based  clinics in all schools since  they tend to be the center of  the universe for the children  and the families.  Did you want to make a comment  about that?  No, I'm talking about the person  that raised her hand.  >> (inaudible)  How can children  access healthcare on a daily  basis?  In fact, sometimes we are the  ones that take them to  healthcare appointments.  Dental appointments, cardiology  appointments. 

 Because unfortunately, members  of their family can't or don't.  >> Let's flip that, with you  leading the charge...  >> The comment was that in  Madison, we do have pediatric  nurse practitioners or advanced  practice nurses in our schools  and they are often the ones that  make sure that they children get  to their healthcare  appointments, dental  appointments, often because  their families can't, so they do  really help children access  healthcare.  And the other comment was that  maybe we should just have it all  happen within the school.  >> We that are pediatric nurse  practitioners, we actually can  prescribe under protocols, and  we do actually prescribe for  things like ear infections or  other minor things, we can  actually give them prescriptions  for treatment, so we do tend to  do that because they can't  access care.  >> Nurse practitioners can  prescribe for minor things,  under certain protocols within  the school.  Question?  >> (inaudible)  >> Stress and stress prevention  are actually huge issues  especially in the immigrant and  refuge population because the  experience of immigration itself  creates a huge amount of stress  and we know that, for example,  in our Latino community,  depression, especially  depression among women, the  mothers, is very high.  And it's the highest level it's  ever been actually right now  because both the unknowns of  immigration status and the  economy.  So the programs that we have at  the Latino health council, we  started to have actually in the  fall every year, a conference.  We call it a conference, but  really it is a set of workshops  for the community. 

 The workshops talk about stress,  how to handle stress, and  relaxation techniques.  They are the most popular events  that we have.  The relaxation, yoga, how to use  exercise among our immigrant  women, are really, really very  popular.  So we have those.  There is also some really great  non-profits in the city of  Madison who have made a huge  effort in making sure that they  are providing good counseling,  stress prevention and stress  intervention for the community.  One of them is the Rainbow  Project, which I'm sure, which  is at the higher end of a --  needs, but they do a great job  of providing services for really  a very wide range of our  multicultural community.  So those are a couple of the  organizations that do a lot of  work around stress and how to  handle stress issues.  >> (inaudible)  >> So how can we start changing  the trend of obesity because  we've been talking about this  for a long time and it seems  like the kinds of interventions  that have been recommended up  till now don't seem to be making  a difference.  I would say that's exactly where  cultural competence is important  because it's very easy for us to  go in and say, well, here's the  rules.  You live by my norm and my  rules. 

 You need to exercise three times  a week, you may not have room in  your apartment to even move  around because there's three  families living in your  apartment, no less think about  exercising.  You may be working two jobs, but  okay, the whole family needs to  exercise three times a week.  And here's what you should eat  and it costs ten times more than  you can afford.  So those are, a norm that we're  trying to tell people how to do  it.  Which may work for some people,  but obviously it's not working  for a lot of people.  Instead of that, really trying  to consciously evaluate what  those, what are the barriers for  that family for healthier  eating?  And what do they eat?  What's their favorite foods?  And then trying to figure out,  not the perfect solution, but  how can you start making some  changes and some differences.  When we talk on the radio  program, we don't tell people,  stop completely, for example,  eating the kinds of food that  you're used to, first the foods  that Latinos eat, they don't  create obesity back in the  country of origin.  Apparently, obesity happens  here.  Why?  Because there is much more  exercising happening there  because people walk.  And they don't walk here. 

 So the differences in the kind  of environment people are in  here and for them to understand  that they may not think that  they've changed their eating  habits, but their environment  has changed.  And also the processing of the  food has changed.  It's not maybe the food that  they were growing themselves  back there, there may be other  stuff in the food that they  don't realize.  That canned food has other stuff  that they didn't know.  So really starting that  education but not from a point  of let's change your eating, but  let's see what you're eating and  see if we can make some  adjustments to what you're  eating.  And talk about it from that  perspective.  Food pyramids, which fortunately  people are getting away from,  but they're really funny.  Because if you don't eat bread,  I've been in places where people  say, "Well, just don't eat as  much bread."  If you don't eat bread at all,  and nobody's telling you that  bread is really this category of  food that may include these  other things that you eat, maybe  it's tortillas, how many  tortillas do you eat, whatever  it is, then it doesn't make any  sense.  So it's trying to see what the  barriers are to exercising.  Telling people to exercise, we  all know we should exercise, but  what are the barriers?  And telling for example to, an  immigrant family that came from  much warmer climates to go out  and walk in the middle of the  winter if they can't afford a  health club?  We're not going to go out in  that. 

 I'm sorry, but I'm not going out  and taking a walk in this  temperature even after 15 years  of living here.  So I need to come up with other  solutions to deal with my needs  for exercise if I'm not going to  be able to afford, or if I'm not  comfortable in a health club.  >> (inaudible)  >> You're right, to have that  connection.  One of the most successful  programs I forgot to mention  about exercise is the -- Health  Hour in south Madison.  It's within the Villager Mall in  the South Madison Family Center  on Saturday mornings and the  reason that it's very successful  is because it's peers.  It's people that really are  under the same circumstances in  life.  It's a social hour where  exercise happens.  But it really becomes a social  hour.  So what they do is they do an  hour of nutrition education and  then some exercise, and children  are part of it, too.  So the parents bring the  children. 

 The children are actually  separately having exercise under  the supervision of some great  nursing students, while the  parents have some time off from  their children who are  exercising and playing  separately, for social  interaction and their own  exercise and nutrition  education.  So those are the kinds of  interventions that work because  they provide more than you go  alone and do this exercise.  It provides what people are  lacking and addresses the issue  that was brought up here which  is stress and depression and all  that because it provides social  outlet.  Which is what you really want in  an environment that people are  comfortable with and they can  walk to, because it's a  community center.  >> (inaudible)  >> I guess I don't see it as  either negative or positive, I  see it as whatever people are  comfortable doing naturally and  some kids naturally like to be  around different groups, and  whatever that "different group"  is.  It doesn't have to be race and  ethnicity.  The interest thing is that the  race and ethnicity is obvious to  people as they look to the room,  but they don't think about all  the other levels of differences  among kids and who hangs out  with what kids based on other  thing.  The kids that are more  socio-economically well-to-do  are together, and the ones that  don't...  And that's maybe not as  apparent, but it just happens  and, as I said, I don't  particularly think it's a good  thing or bad thing, but I think  we just need to be realistic  that we all tend to want to be  around people that we're  comfortable with.  If the institution provides an  environment where everybody's  comfortable with everybody, then  it's not to happen as much, is  what I would say. 

 >> Okay, we'll need to stop  there, so thank you everybody  for coming.  The next break-out session will  start at 7:45.  (applause)