MY NAME IS DR. ROBERT MAYS JUNIOR. CERTAINLY MY PLEASURE TO HELP COMPLETE THIS WONDERFUL MEETING THAT OR CONFERENCE THAT'S TAKING PLACE. EVERYONE HAS GIVEN THEIR LINEAGE IN RELATION TO BEING PART OF RURAL SO I HAVE TO GIVE YOU MY QUICK ACKNOWLEDGEMENT THAT I GREW UP IN A MIGRATORY MILITARY FAMILY, NAVY, SERVED MY OWN SELF FOR A LONG TIME, 30 YEARS, AND IN THAT TIME I SERVED IN SOME AUSTERE AND REMOTE RURAL ISOLATED POPULATIONS AND LOCATIONS CONSIDERING VIETNAM, THAILAND, PANAMA, GERMANY, AND FT. RILEY, KANSAS. WHICH IS I THINK VERY RURAL. I LISTEN TO THE MORNING FARM REPORT AT 4 A.M. AND I LEARNED ABOUT WHEAT AND MILO AND HOG FUTURES AND SO ON. ANYWAY, AS I SAID, GREAT TO BE HERE. WHAT WE'RE GOING TO DO THIS AFTERNOON IS PRESENT TWO PRESENTATIONS, THEY'LL BE 30 MINUTES EACH SEPARATED BY A 15 MINUTE Q&A SESSION AND OUR TITLE, I NEED TO TAKE A QUICK LOOK, SUMMARY OF RESEARCH GAPS AND SUGGESTIONS. WE CHANGED THE WORD THAT INITIALLY SAID RECOMMENDATIONS. WHEN WE DO THAT WORD IT OBLIGATES THE FEDERAL GOVERNMENT SWOA OAR HERE TO GIVE SUGGESTIONS OR IDEAS FOR FUTURE RESEARCH. OUR FIRST PANEL WHICH WE HAVE TO ADJUST TIME TO MAKE SURE IT'S A 30 MINUTE PRESENTATION PLUS 15, WILL BE REPORTED ON BY DR. MONICA BASKEN. THE SPEAKERS AT THE TABLE WITH DR. MARK DOZEIR. DR. BARKER, DR. PAULA GARDENER AND DR. MARK GREENBERG. WE ALSO HAVE HAS ONE OF THE DISCUSSANTS,S IN LAURA CHURCH WHO IS MEMBER OF THE NAVAJO NATION BITTER WATER CLAN BORN FOR THE BLACK STREET WOOD CLAN, HER MATERNAL GRAND FA THEERS CLAN IS THE HONEY COMB CLAN AND PATERNAL GRAND FA THEERs -- FATHER'S CLAN IS THE GREEN MEADOW PEOPLE. THIS PANEL WAS SUPPORTED BY FACILITATORS DR. ELIZABETH ROBINSON, DR. MARGOLES AND THE PLANNING COMMITTEE WAS CHARLOTTE PRATT AND CARMEN MOTEN WHO PROVIDED SUPPORT. SO WITHOUT FURTHER ADIEU IF WE COULD HAVE DR. BASKIN COME FORWARD. >> GOOD AFTERNOON. SO I AM GOING TO COME TOGETHER AND VERY BRIEFLY REVIEW THE SINT SINCE FROM OUR TEAM LAST EVENING ABOUT WHAT WE HAVE HEARD OVER THE LAST COUPLE OF DAYS. AGAIN, TALK ABOUT WHERE WE THINK RESEARCH GAPS ARE AND MAKE SOME SUGGESTIONS ABOUT THINGS THAT WE CONSIDERED IN THE FUTURE. SO AGAIN, WE FOCUS MORE ON THE PREVENTION AN INTERVENTION STRATEGIES, AGAIN, THESE ARE THE INDIVIDUALS THAT WERE GROUPED TOGETHER LAST NIGHT OVER A PLANNING SESSION AND WE STARTED OFF WITH THINKING ABOUT WHAT ARE SOME OF THOSE CONDITIONS THAT ARE CURRENTLY RECEIVING WHAT WE CALL SOME ATTENTION? OUR ORIGINAL GUIDELINES WERE THINGS RECEIVING A LOT OF ATTENTION AN WE WERE HARD-PRESSED TO COME UP WITH GOOD TOPICS THAT RECEIVED CURRENTLY A LOT OF ATTENTION IN THIS AREA. SO WE TALKED ABOUT THINGS THAT HAVE GOTTEN SOME ATTENTION BUT WE THOUGHT AS A TEAM MORE NEEDS TO BE DONE. AMONG THOSE TOPICS ARE THINGS LIKE DIABETES, CHILDHOOD ASTHMA, OCCUPATIONAL HEALTH AND INJURY, ENVIRONMENTAL ANDING AGRICULTURAL EXPOSURE. TOBACCO USE, ALCOHOL AND OTHER DRUGSCH IMMUNIZATION AND TO SOME EXTENT OBESITY. ON THE OTHER HAND WE THOUGHT THERE WERE OTHER THINGS THAT ARE VERY IMPORTANT, THINGS CLEARLY TALKED ABOUT OVER THE LAST TWO DAYS THAT HAVE NOT RECEIVED A GREAT DEAL OF ATTENTION AND WE THINK CERTAINLY SHOULD BE THE FOCUS OF FUTURE RESEARCH. THIS INCLUDES EVEN IN THE AREA OF SUBSTANCE USE SPECIFICALLY TOBACCO USE AND PREGNANCY, WE HEARD FROM SPEAKERS YESTERDAY ABOUT ELEVATED USE AMONG RURAL RESIDENTS, PREGNANT WOMEN AND TOBACCO. WE ALSO KNOW FROM LITERATURE THERE IS A SIGNIFICANT PRESCRIPTION DRUG MISUSE THAT HAS IMPACT ON BOTH IN TERMS OF PREGNANT WOMEN AN YOUNGER ADULTS. THE TRIAD OF CHRONIC PAIN OPIATE USE AN DEPRESSION IS AN AREA THAT AGAIN HAS NOT RECEIVED ENOUGH ATTENTION BUT CERTAINLY IS AN AREA THAT SEVERAL CLINICIANS IN THE GROUP HAVE EXPERIENCED AND WE THINK IS WORTH ADDITIONAL INFORMATION. OUR TEAM TALKED ALSO ABOUT PRE-CONCEPTION AND PRE-NATAL HEALTH. THE IDEA THAT WE NEED EFFECTIVE ASSESSMENTS OF RISK AND THAT REALLY LOOKING AT THE EFFICACY OF THE CURRENT EFFICACY OF PRE-NATAL CARE AND CHILDHOOD OUTCOMES IN PARTICULAR. WHAT'S CURRENTLY HAPPENING, HOW WELL CAN WE LOOK AT THOSE THINGS THAT ARE HAPPENING IN PRACTICE AND HOW WELL THEY'RE PREDICTIVE OF CHILD OUTCOMES AND EARLY CHILDHOOD OUTCOMES AN PRE-NATAL CARE SO WE WANT TO PLACE EMPHASIS ON THAT. THEN IN GENTLEMEN TALL HEALTH, MATERNAL DEPRESSION AS WELL AS CHILDHOOD MENTAL HEALTH AND OTHER FAMILY MENTAL HEALTH ISSUES AS WELL. WE ALSO BELIEVE IN THE AREA OF OBESITY. PEOPLE TALKED ABOUT IT, RAISED A LOT OF QUESTIONS OVER THE LAST SEVERAL DAYS, THERE IS QUITE A BIT OF ATTENTION TO THE FIELD OF OBESITY IN TERMS OF CLINICIANS, RESEARCHERS, AND EVEN THE LAY PUBLIC. BUT THERE'S SOME SPECIFIC GAPS THAT HAVE BEEN IDENTIFIED OVER THE COURSE OF THE LITERATURE AND EVEN IN THIS CONFERENCE. THINGS LIKE THIS ISSUE OF HIRE RATES OF OBESITY AND DISABLED POPULATIONS, CLEARLY HIGHLIGHTED ON YESTERDAY'S PANEL AS AN AREA WE DON'T KNOW A LOT ABOUT. WE ALSO TALK ABOUT A COUPLE OF THINGS THAT WE LABEL BEING PARADOXES SO THE PARADOX OF HAVING ELEVATED OBESITY, PREVALENCE EVEN WHEN THERE'S INCREASED LEVELS OF PHYSICAL ACTIVITY IN RURAL POPULATIONS. HOW DO THOSE THINGS FIT TOGETHER, WHAT IS NOT WORKING WITH THAT ENERGY BALANCE EQUATION, WE NEED TO STUDY THAT MORE TO BETTER INFORM INTERVENTION. WE ALSO TALKED A LITTLE BIT ABOUT THE PARADOX OF ELEVATED OBESITY AMONG POPULATIONS WITH HIGH POVERTY. IF YOU'RE THINKING OBESITY MAYBE PRIMARILY AN ISSUE OF OVERCONSUMPTION BUT YOU HAVE PEOPLE THAT ARE -- HAVE -- DEALING WITH -- EXCUSE ME, DEALING WITH ISSUES OF POVERTY AND NOT ABLE TO PURCHASE CERTAIN THINGS HOW IS THAT HAPPENING? SO WE NEED TO LOOK AT BIOLOGICAL MECHANISM, BEHAVIORAL MECHANISMS AND EXPLORE THAT MORE. WE ALSO TALKED ABOUT A COUPLE OF OTHER UNIQUE THINGS THAT MANY OF US EXPERIENCED IN WORKING WITH THESE POPULATIONS TE ( MENTIONED IN GREAT LENGTH TODAY, HOW THAT MAY IMPACT BUT SEVERAL OF US, PARTICULARLY THOSE OF US IN THE DEEP SOUTH AND THE BIBLE BELT, TALKED ABOUT THE ROLE OF REALLY JOHN AND RELIGIOUSTY IN TERMS OF POSITIVE HEALTH OUTCOMES AND LEADING INTO ISSUES OF RESILIENCE AS WE WERE THE NEXT ITEM THERE. WHY IS IT THAT THERE ARE SOME INDIVIDUALS IN RURAL COMMUNITIES THAT TEND TO HAVE POSITIVE OUTCOMES. WE TEND TO FOCUS ON WHAT'S WRONG, WHAT THE PROBLEMS ARE THERE BUT IN SPITE OF THE POVERTY, LOWER EDUCATION, LOWER INCOME AND ACCESS, THERE ARE POCKETS OF INDIVIDUALS THAT DO VERY WELL. YESTERDAY AND BRIEFLY TODAY PEOPLE TALKED ABOUT THE AMISH COMMUNITY PERHAPS ONE OF THOSE IMMUNITIES THAT STILL IS MANAGES TO DO VERY WELL IN SPITE OF WHAT MOST OF US WOULD BE PROBABLY A LIMITED MEANS. WE TALKED ABOUT KNOWN FACTORS THAT CONTRIBUTED TO AT BIRTH HEALTH OUTCOMES SO WE KNOW THAT LIMITED HEALTHCARE ACCESS IS ATTRIBUTABLE OR LINKED WITH POOR OUTCOME. WE KNOW THAT POOR HEALTH LITERACY IS LINKED, POVERTY, LOW EDUCATIONAL ATTAINMENT, AND THERE ALSO HAVE BEEN THE IOM REPORT ABOUT ISSUES OF DISCRIMINATION AND UNEQUAL TREATMENT THAT ALSO INFLUENCE OUTCOMES. FEW THINGS THAT WE HIGHLIGHTED THAT HAVE NOT BEEN EXPLORED BUT THERE'S GOOD REASON TO HYPOTHESIZE THEY MAYBE LINKED, ISSUES OF STRESS AND STRESS AT THE INDIVIDUAL LEVEL, WE DONE KNOW A LOT ABOUT THE BIOLOGICAL MECHANISMS THAT MIGHT BE THERE IN TERMS OF CORTISOL LEVELS AND THAT STRESS RESPONSE SYSTEM AND HOW IT MIGHT IMPACT THE IMMUNE SYSTEM. WHAT ARE SOME BIOMARKERS THAT WE MIGHT NEED TO LOOK AT AND ADDRESS, AND WHAT MAY POTENTIALLY MAYBE DISEASE PATHWAYS ALONG THE STRESS MODEL. WE ALSO MENTION IT'S NOT JUST AT THE INDIVIDUAL LEVEL BUT THERE ARE COMMUNITY LEVEL STRESSORS AS WELL. THINGS LIKE NATURAL DISASTERS THAT OCCUR AND AS A COMMUNITY THERE'S A LEVEL OF STRESS THAT OCCURS. AND WE NEED TO BE ABLE(eÖ TO EXPLORE AND EXAMINE THOSE AND LOOK AT BOTH SHORT TERM AND POTENTIAL LONG TERM EFFECTS ON CHILD HEALTH. THERE ARE MEMBERS OF THE GROUP THAT MENTION THINGS LIKE BIRTH ORDER AND SPACING THAT MAY HAVE IMPLICATIONS ON HEALTH OUTCOMES OF CHILDREN, ONE EXAMPLE P MENTIONED LAST NIGHT WAS A MOTHER WHO HAS MULTIPLE CHILDREN REALLY LEARNED FROM THAT FIRST PREGNANCY, THAT FIRST BIRTH AND SAYS OKAY I KNOW NOW FOR THAT SECOND, THAT THIRD CHILD WHAT I'M SUPPOSED TO DO. SO THAT CHILD MAY HAVE DIFFERENT OUTCOMES, DIFFERENT PARENTING STYLES AND BEHAVIORS THAT OCCUR LATER ON. THE OTHER THING THAT'S TRUE OF HAVING MULTIPLE KIDS UNDER AGE 2, 3, HAS DIFFERENT LEVELS OF STRESSORS, THERE'S DIFFERENCE THINGS TO EXAMINE. AND THERE WAS CONVERSATIONS ON THE PANEL YESTERDAY ABOUT THE BUILT ENVIRONMENT. THINGS LIKE IS THIS COMMUNITY SITUATED IN A PLACE NEAR A HIGH BAY? SMALLER RURAL COMMUNITIES THAT ARE NEAR THOROUGH FAIRS, YOU HAVE TRANSIENT PEOPLE COMING IN AND OUT, THINGS LIKE THAT THAT MAY INFLUENCE, YOU HAVE DIFFERENCES IN YOUR BUILT ENVIRONMENT AND THEN THE PHYSICAL ENVIRONMENT, THE NUTRITION ENVIRONMENT AND ALL THINGS LIKE THAT MAYBE CONTRIBUTING TO THE HEALTH OUTCOMES. WE ALSO TALKED ABOUT WHAT MIGHT BE SOME CO-MORBID CONDITIONS THAT HAVEN'T BEEN EXPLORED THAT MUCH. SO AGAIN, ON YESTERDAY'S PANEL THE LINK BETWEEN CHILDHOOD OBESITY AND POOR ORAL HEALTH. STRESS AND OBESITY, DISABILITIES AND OBESITY AND JUST IN GENERAL, INTERSECTION OF MINORITY HEALTH AND MORALITY, AGAIN, YESTERDAY PEOPLE TALKED ABOUT BEING IN A RURAL COMMUNITY MAY PRE-DISPOSE TO POOR HEALTH OUTCOMES BUT BEING A MINORITY IN A RURAL COMMUNITY MAY EVEN FURTHER PRE-DISPOSE OF YOU TO POOR HEALTH OUTCOMES. THEN WE TALKED ABOUT AREAS THAT ARE REALLY PRIME FOR A LOT OF COLLABORATION, ACROSS AGENCIES, PUBLIC AND PRIVATE FUNDING SOURCES, CLINICIANS. THESE WERE THE THREE THAT READILY CAME TO THE TOP OF OUR MINDS IN TERMS OF WHERE WE MIGHT BE TO READILY LEVERAGE AND TAKE ADVANTAGE. CHILDHOOD OBESITY. ALREADY THEIR INTERAGENCY COLLABORATIONS BETWEEN DIFFERENT UNITS OF THE HEALTH AND HUMAN SERVICES, CDC, NIH, PRIVATE FOUNDATIONS, ROBERT WOOD JOHNSON FOUNDATION IS AN EXAMPLE SO THERE'S A LOT OF THINGS GOING ON THAT CAN BE LEVERAGED TO CONTINUE THIS COLLABORATIVE RESEARCH. PRE-NATAL HEALTH WAS ANOTHER ONE THAT WAS IDENTIFIED, AGAIN, THERE ARE LOTS OF PEOPLE THAT ARE REALLY ENERGIZED IN TALKING ABOUT WHAT CAN YOU DO AHEAD, DURING THIS TIME OF PREVENTION TO REALLY IMPROVE HEALTH&N– OUTCOMES. THEN THE TOPIC OF THIS MULTI-GENERATIONAL ISSUE. AS WE HAVE A POPULATION NOW WITH ALL THE CENSUS DATA COMING OUT, THIS YEAR, WE HAVE A POPULATION THAT'S AGING, AND SURVIVING LONGER AS WELL AS WE HAVE A LOT OF FERTILE IN MINORITY AREAS IN RURAL COMMUNITIES SO WE WANT TO LOOK ACROSS THE LIFE SPAN TO LINK WITH AGENCIES THAT HAVE BEEN FOCUSED MORE ON CHILD AND PRE-NATAL CARE AND MATERNAL HEALTH BUT ALSO THOSE AGENCIES THAT MAYBE LOOKING AT OLDER POPULATIONS AND BEING ABLE TO COLLABORATE ON HEALTH ISSUES. WHAT DO WE KNOW CURRENTLY WORKS? SO THESE ARE JUST A FEW THAT AGAIN, READILY CAME TO OUR MIND LAST NIGHT. WE KNOW THAT EDUCATIONAL PROGRAMS HAVE SUCCESS IN IMPROVING OUTCOMES IN CHILDREN. PARENTING STYLES, PARENTING BEHAVIOR, HEALTH PROMOTION AND EDUCATION PROGRAMS HAVE BEEN HELPFUL IN INCREASING AWARENESS AND SCREENING. ISSUES THAT HAVE -- PROGRAMS THAT FOCUS ON HEALTH LITERACY AND IMPROVING HEALTH LITERACY AND EARLY CHILDHOOD EDUCATION. EXAMPLES OR DISCUSSION YESTERDAY ABOUT HEAD START OR EARLY PRE-K PROGRAMS ALWAYS HELPFUL IMPROVING THINGS AROUND EARLY CHILDHOOD EDUCATION, EARLY CHILD HEALTH OUTCOMES. CHILDHOOD IMMUNIZATION PROGRAMS ARE HELPFUL AS WELL AS NUTRITION IN PREGNANT WOMEN. THERE STILL IS A NEED FOR NEW PREVENTION AN INTERVENTION STRATEGIES TO MOVE US FORWARD IN TERMS OF HEALTH OUTCOMES FOR CHILDREN. PRE-CONCEPTION AND PRENATAL CARE CAN BE ENHANCED AND IMPROVED. BETTER INTERVENTION STRATEGIES, THE EXISTENCE OF ASSESSMENT TOOLS IN GENERAL TO PREDICT ADVERSE BIRTH AND EARLY CHILDHOOD OUTCOMES, TAKING ADVANTAGE OF THE PREVENTION THAT SHOULD BE OUT THERE BUT WE NEED THE RIGHT TOOLS TO BE ABLE TO LINK UP AND SAY EXACTLY WHICH ARE THOSE FACTORS MOST RELEVANT TO LAYER OUTCOMES. WE ALSO TALK ABOUT THE NEED FOR BETTER INTERVENTIONS AN PREVENTION STRATEGIES AN WELL CHILD CARE, JUST ASKING THE CHECK BOXES HAVE YOU DONE THIS, HAVE YOU DONE THAT, IT'S NOT REALLY THAT EFFICACIOUS AT THIS POINT SO WE NEED MORE EMPHASIS ON EVIDENCE BASE AND THOSE TYPES OF INTERVENTIONS LIKELY TO LEAD TO ACTUAL BEHAVIOR CHANGE. WE ALSO NEED TO FIGURE OUT HOW TO BETTER IMPROVE ADHERENCE, WE HAVE LOTS OF PRESCRIXES OUT THERE, WE TELL PEOPLE TO DO THINGS BUT ARE THEY SHOWING UP WHEN THEY'RE SUPPOSED TO, FOLLOWING THE PRESCRIPTIONS WE'RE PROVIDING TO THEM. WE NEED TO FIND WAYS TO CONTINUE TO IMPROVE ADHERENCE. COMPUTER BASED, TECHNOLOGY BASE TYPES OF WAYS TO INTERACT WITH INDIVIDUALS TO REACH INDIVIDUALS WHO MAY TYPICALLY NOT BE COMING IN ON A REGULAR BASE FOR CARE. THERE ARE SOME DELIVERY MODELS DISCUSSED OVER THE LAST COUPLE OF DAYS AND OTHER OTHERS WE KNOW THAT TEND TO WORK WELL IN RURAL COMMUNITIES. SO TELEHEALTH IS ONE, MOBILE APPLICATIONS, INTERNET AND PHONE-BASED INTERVENTIONS, TEND TO WORK WELL IN RURAL SETTINGS, COMMUNITY HEALTH WORKERS, OR TRAINED LAY HEALTH PROFESSIONALS ALSO ARE HELPFUL IN TERMS OF EXTENDING THE SERVICE THAT MAYBE PROVIDED AT A ORGANIZATION OR HEALTH CLINIC OR HEALTH PROVIDER, INTO THE COMMUNITY TO PEOPLE WHO ALREADY ARE TAPPED FOR ADVICE. SO MAKING SURE THEY ARE APPROPRIATERY TRAINED AND -- APPROPRIATELY TRAINED AND PROVIDING THE RIGHT OR CORRECT INFORMATION AND LINKING THAT INDIVIDUAL IN THE COMMUNITY WITH THE HEALTHCARE IS ALSO A HELPFUL STRATEGY. WE TALKED ABOUT THE PATIENT CENTERED MEDICAL HOME AS ONE -- ANOTHER WAY IN PARTICULAR USING TECHNOLOGY, THAT PATIENT SENT HOME MAY NOT BE PHYSICALLY LOCATED WITHIN THE COMMUNITY, COULD BE A HOME THAT COULD BE ACCESSED VIA TECHNOLOGY. WE TALK ABOUT GROUP BASED OR SOME PEOPLE FAMILIAR WITH CENTERING MODELS RELATED TO PREGNANCY BUT OTHER MODELS AROUND PARENTING BEHAVIORS AND OTHER THING CAN BE UTILIZED. DELIVERING HEALTH INFORMATION THROUGH ESL COURSES AND OTHER THINGS HAPPENING, PARTICULARLY MIGRANT AND OTHER MINORITY COMMUNITIES. OBVIOUSLY WE WANT TO MAKE SURE THAT WE HAVE APPROPRIATE MEASURES FOR SOME OF THE PROGRAMS THAT WE'RE TALKING ABOUT, IN TERMS OF PROCESS AND OUTCOME. SOME OF THE TYPICAL THINGS WE WANT TO LOOK AT IN TERMS OF METRICS, INCLUDE PATIENT SATISFACTION, IMPLEMENTATION QUALITY AND FIDELITY, FOCUSING ON THE FEEDBACK LOOP. WE GET INFORMATION GIVEN BACK TO PROVIDERS PREVENTION AN INTERVENTION STAFF AND THAT'S USED FOR MAKING ADJUSTMENTS INTO THE PROGRAM SO ON AND SO FORTH. IN TERMS OF OUTCOMES, A LOT IS GOING TO BE SPECIFIC TO EXACTLY WHAT THE PROGRAM IS GOING TO BE BUT IN GENERAL WE TALK ABOUT A THE RURAL HEALTHY PEOPLE 2020 AS PERHAPS ONE OF THE OUTCOME MEASURES STILL IN DEVELOPMENT. WE ALSO MENTION WE WANT TO KNOW ABOUT COST EFFECTIVENESS WE WANT TO MIC SURE THE PROGRAMS OUT THERE ARE REALLY GIVING US THE MOST BANG FOR THE BUCK. WE WANT TO HAVE GOOD MEASURES, FOR ASSESSING PHYSICAL ACTIVITY IN RURAL CHILDREN, THESE BEHAVIORS ARE LINKED TO A NUMBER OF CHRONIC CONDITIONS. WHAT WE KNOW FOR SURE IS THERE ARE LIMITED IN TERMS OF ABILITY TO REACH THIS PARTICULAR POPULATION. ALSO MEASURES OF DISPARITIES AN HEALTH OUTCOMES AMONG YOUTH WITH DISABILITIES I THINK ONE THING I WAS STRUCK BY THE PRESENTATION YESTERDAY IS HOW MUCH WE JUST DONE KNOW AND THAT IS WE THINK ABOUT THAT AS ANOTHER MINORITY GROUP THAT IS A SUBSTANTIAL POPULATION THAT WE NEED TO BE MORE COGNIZANT COLLECTING INFORMATION ON. IN TERMS OF THEORETICAL PRAIM WORK. THERE'S A COUPLE OF MULTI-LEVEL ONES, THE SOCIAL ECOLOGICAL THAT WE TALKED ABOUT, THERE'S A NEED FOR MORE STRUCTURAL MODELS. WE NEED THE METHODOLOGY OUT THERE, WE NEED TO FIGURE OUT WHAT ARE THOSE THINGS THAT ARE CRITICALLY IMPORTANT TO COMMUNITY LEVEL OR MULTI-LEVEL INTERVENTIONS. AT THE INDIVIDUAL LEVEL WE TALK ABOUT THINGS RELEVANT TO INDIVIDUALS SUCH AS STRESS AND COPING OR RISK AND RESILIENCE AN THINKING ABOUT SUSTAINABILITY, LOOKING AT 'RE AIM OR PRECEDE PROCEED MODEL TO LOOK AT HOW DO YOU START WITH THESE PROGRAMS AND CONTINUE THEM OVER TIME. OUR GROUP HAS BEEN -- HAS A LOT OF EXPERIENCE WORKING WITH A DIVERSE AMOUNT OF PARTNERS AND SO WE THROUGH IN EVERYBODY WE CAN OF THINK OF. LOCAL GOVERNMENT, PUBLIC HEALTH AGENCY, SCHOOLS, HIGHER ACADEMIC EDUCATIONAL FACILITIES, EMPLOYER, FAITH LEADERS, COMMUNITY-BASED ORGANIZATIONS. WE REALLY FEEL LIKE PARTICULARLY IN THESE RURAL AREAS EVERY RESOURCE THAT YOU CAN POSSIBLY TAP INTO IS GOING TO BE HELPFUL IN DESIGNING, IMPLEMENTING AND SUSTAINING THE PROGRAM. THEIR ROLE, OTHER PEOPLE CAN HELP WITH FOCUS GROUPS TO PRODUCE A STRATEGIES AN METRICS, IDENTIFYING WHAT COMMUNITY PERCEIVES THE PROBLEM AS WELL AS SOLUTIONSCH THEY CAN INFORM US ABOUT WHAT OUTCOMES AND WHAT ARE BEST METHODS FOR MEASUREMENT, HELPING WITH RECRUITMENT AND RETENTION. THE PANEL YESTERDAY BEAUTIFULLY TALKED ABOUT HOW KEY CERTAIN MEMBERS OF THE COMMUNITY ARE TO THAT RECRUITMENT AND RETENTION. THEY CAN ALSO HELP WITH THE DATA COLLECTION AS WELL AS THE INTERPRETATION. OF WHAT THAT DATA IS, MAKING SURE WE'RE NOT CONTINUING TO VICTIMIZE THEM BY WHAT WE SAY ABOUT THE COMMUNITY. THEY'RE CRITICAL FOR THE PLAN OF SUSTAINABILITY, CAPACITY BUILDING IS RELEVANT AS WELL AS HELPING ENGAGE CONVERSATIONS AB WHAT THIS LEVEL -- ONCE THIS LEVEL OF FUNDING IS GONE, HOW IS THIS PARTICULAR PROGRAM OR EFFORT GOING TO CONTINUOUSLY BE FUNDED. AND SERVING IN ADVISORY CAPACITY. THE BEST LAID PLAN ALWAYS DON'T HAPPEN THAT WELL SO HELPING TO TROUBLESHOOT WHEN THINGS DON'T GO AS PLANNED. SO THERE ARE A NUMBER OF SETTINGS THAT WE HAVE HAD EXPERIENCE WITH, IN TERMS OF ENGAGING COMMUNITY CENTER, SCHOOLS, FAITH BASED SETTINGS, HOME AND ANYWHERE PEOPLE ARE. SO PEOPLE TALKED ABOUT THE BARS YESTERDAY OR GROCERY STORE, I THINK FOR MOST OF US ON THE PANEL WE'LL TAKE YOU WHEREVER. SO THE FLEXIBILITY TO BE ABLE TO REACH PEOPLE IS NOT JUST ONE PLACE THAT YOU FIND THEM, YOU HAVE TO MEET PEOPLE WHERE THEY ARE. WE ALSO RECOGNIZE THERE ARE SOME BARRIERS TO NCI THIS RESEARCH. AGAIN IN THE TWO DAY CONFERENCE PEOPLE TALKED ISSUES OF TRUST, AND EVEN TALKED ABOUT THE BIOETHICAL ISSUES. ARE YOU REALLY TRYING TO HELP ME OR AM I JUST A GUINEA PIG, WHAT ARE YOU GOING TO DO AFTER YOU COLLECT IT, WHOSE DATA IS IT AND CONCERNS ABOUT PRIVACY AND CONFIDENTIALITY. WE HAVE TO TACKLE THESE ISSUES AND TALK INTO A GROUP OF INDIVIDUALS WHO SOME MAYBE PERCEIVED AS BEING VULNERABLE. THERE'S O ALSO BARRIERS TO RESEARCH FUNDING. SO REVIEWERS APPRECIATION OR LACK THEREOF OF COMMUNITY ENGAGED RESEARCH, CHALLENGES REALLY IMPLEMENTING THE, QUOTE, GOLD STANDARD OF A RANDOMIZED CLINICAL TRIAL IN THESE KINDS OF SETTINGS. THE ELEVATED COST OF CONDUCTING RESEARCH IN RURAL COMMUNITIES. MOST OF THE MAJOR ACADEMIC INSTITUTIONS AREN'T LOCATED IN THESE AREAS. SO THERE'S THE TRAVEL COST, THE COST OF HIRING INDIVIDUALS AND INFRASTRUCTURE COSTS SO IT MAY NOT NICELY FIT IN THAT CAP THAT WE'RE USUALLY FORCED TO FIT INTO. THEN ALSO THE FUNDING STREAMS THAT ARE DEDICATED TO SPECIFIC ORGANS OR DISEASES AREN'T NECESSARILY SUITED TO SOME OF THE REAL WORLD INTERVENTIONS THAT ARE OUT THERE. IN TERMS OF RESEARCH APPROACH, THE STUDIES THAT WE HAVE BEEN TALKING ABOUT THE THEORETICAL MODELS ARE QUITE COMPLEX. SO WE HAVE BEEN TALKING ABOUT DOING THINGS THAT INDIVIDUAL GROUP AN COMMUNITY LEVELS, IT MAYBE DIFFICULT TO ISOLATE INTERVENTION AFFECTS AND THERE'S LOGISTICAL ISSUES, TRANSPORTATION, EQUIPMENT, SO FORTH. THEN THE BARRIERS RELATED TO TRANSLATION OF RESEARCH TO PRACTICE AND/OR POLICY. THE ISSUES OF BILLIBILITY, SCALABILITY, SUSTAINN 'T. ALL THOSE THINGS WE HAVE TO KEEP THINKING ABOUT AND BE CREATIVE IN TERMS OF BEING ABLE TO ADDRESS. THEN MEMBERS TALKED THE LACK OF COMMUNITY OWNERSHIP OF PREVENTION. PEOPLE ARE GENERALLY THINKING THIS IS STILL SOMEBODY COMING IN WITH THEIR OWN PLANS AN IDEAS AND MAKING SURE COMMUNITIES CAN OWN THIS AND TAKE I ON FOR THEMSELVES. WE CAME ONE A FEW THINGS THAT MIGHT BE HELPFUL TO TACKLING SOME OF THESE CHALLENGES, MANY PEOPLE HAVE TALKED OVER THE LAST TWO DAYS ABOUT COMMUNITY ENGAGED RESEARCH. WE HAVE ALSO TALK A LOT ABOUT DIVERSE PARTNERSHIP INCLUDING PUBLIC AN PRIVATE INSURERS, ONE IN PARTICULAR WOULD BE VERY HELPFUL TO OUR WORK, PUBLIC HEALTH PROVIDERS, EDUCATION GOVERNMENT, WOULD BE RELEVANT AND IMPORTANT PARTNERS. ALSO IN TERMS OF THE FUNDING MECHANISM AND STUDY SECTION REVIEWERS, WE NEED TO MAKE SURE WE HAVE MORE REVIEWERS WITH TRAINING, EXPERIENCE IN RURAL HEALTH AND COMMUNITY ENGAGED RESEARCH SO THEY'RE IN THE ROOMS, TO HEAR THESE PROPOSALS BEING DISCUSSED AND CAN REALLY HIGHLIGHT CRITICAL ASPECTS THAT MAYBE SOMEONE WHO DOES NOT HAVE THIS FAMILIARITY MAY NOT PICK UP ON. OTHER GUIDANCE, WHITE PAPERS, OTHER GUIDANCE, REALLY HELP REVIEWERS TO REALLY GET IT. I NOW THERE WAS A PAPER THAT WAS PRESENTED PUBLISHED THIS YEAR, TALKED AB MIXED METHODS, QUALITATIVE METHODS, THAT WAS HELPFUL TO A NUMBER OF INDIVIDUALS TO UNDERSTAND A LITTLE BIT MORE ABOUT THAT. FLEXIBLE FUNDING MECHANISM, FLEXIBILITY IN TERMS OF FILE LINES AN BUDGET. I KNOW THAT THE NIMHD IN PARTICULAR HAVE ANNOUNCEMENTS WITH MULTIPLE PHASES OF RESEARCH FUNDING FOR PLANNING, THAT'S A FEW YEARS AND THERE'S COMING BACK IN FOR A LONGER FIVE YEAR EFFICACY INTERVENTION. THEN ALSO A COUPLE OF YEARS AS ANOTHER APPLICATION FOR DISSEMINATION AN TRANSLATION. THOSE MIGHT BE MECHANISMS AN IDEAS SIMILAR TO THAT, THAT MAYBE VERY HELPFUL. AND CAPACITY BUILDING. SO ALSO OF PEOPLE TALKED ABOUT LEAVING SOMETHING BEHIND, MAKING SURE WE HAVE A WORK FORCE THAT CAN CAN CONTINUE THIS, REALLY BUILDING THINGS COMMUNITY LEVEL BUT ALSO CAPACITY BUILDING AT THE RESEARCHER LEVEL AS WELL. THERE ARE MANY RESEARCHERS THAT HAVE THE CAPABILITY TO DO THIS WORK, THEY NEED MORE TRAINING AND TOOLS TO MAKE IT WORK. STRATEGIES FOR FACILITATING SUSTAINABILITY OF THESE EFFORTS. COMMUNITY ENGAGED RESEARCH CAN BE HELPFUL, THE IMMUNITY CAPACITY BUILDING IS GOING TO BE CRITICAL, THEN AGAIN, PARTICIPATION OF PUBLIC AND PRIVATE FUNDERS AND RELEVANT PARTNERS. THOSE ARE REALLY THE THREE KEY THINGS THAT I THINK OUR GROUP CAME UP WITH THAT IS GOING TO MAKE SURE THAT EFFECTIVE PROGRAMS CAN BE SUSTAINED OVER TIME. IN TERMS OF METRICS OF SUSTAINABILITY, HOW THE LONGEVITY ISSUE, HOW LONG THESE PROGRAMS STAY AROUND, PARTNERSHIP, HOW MANY WERE FORMED, WHAT KIND OF PARTNERSHIPS AND WHAT ROLES THESE PARTNERS HAD WILL BE HELPFUL AS WELL. ANY LESSONS LEARNED AND THE PROGRAM REVISIONS THAT RESULTED AS A RESULT OF THAT FEEDBACK LOOP WILL BE IMPORTANT METRICS TO KEEP IN MIND. THEN WE'RE LOOKING AT HEALTH OUTCOMES. WHAT IMPROVEMENTS HAPPEN AND HOW THEY CHANGE OVER TIME, WITHIN CHILDREN AND WITHIN THE COMMUNITY AT LARGE. WE ALSO WANT TO LOOK IN TERMS OF SUSTAINABILITY. IF YOU HAVE A WONDERFUL WHEEL THAT'S NOT BROKEN, WE WANT TO REPLICATE, WE DON'T HAVE TO REINVENT ALL THE TIME. HOW DO WE REPLICATE TO OTHER COMMUNITIES WITH SOME ADAPTATIONS AS NECESSARY. WE HAVE A GREAT MODEL TO SHARE THAT. COST EFFECTIVENESS. BOTTOM LINE, ARE WE FOR THE INVESTMENT, THE FINANCIAL EMOTIONAL, WORK FORCE INVESTMENT, ARE WE REALLY BEING ABLE TO SHOW DEMONSTRATING CHANGE AND IMPROVE OUTCOME. SO THAT WAS THE MAIN THINGS THAT OUR GROUP CAME UP WITH IN TERMS OF SUGGEST SYNTHESIS OF WHAT WE HEARD OVER THE LAST COUPLE OF DAYS IN OUR EXPERIENCES, AND SUGGESTIONS AS WE MOVE FORWARD. AT THIS POINT WE'LL TAKE ANY QUESTIONS. >> THANK YOU VERY MUCH, DR. BAS SKIN. WE HAVE THE FLOOR OPEN, THIS IS YOUR OPPORTUNITY TO COMMENT ON WHAT THIS PANEL HAS PUT TOGETHER, THAT'S GOING -- BEING PREPARED NOW BY THE SCIENCE WRITER AS SUGGESTIONS. IF THERE'S SOMETHING YOU THINK SHOULD SUPPLEMENT THE COMMENTS, FLOOR IS OPEN, YOU MAY ADDRESS THE PANELISTS THEMSELVES OR MAKE YOUR OWN COMMENT OR SUGGESTION. THIS ONE IS RELATED TO PREVENTION INTERVENTION STRATEGIES. >> (INDISCERNIBLE) AMERICAN ACADEMY OF PEDIATRICS, TEXAS TECH UNIVERSITY, EL PASO. COUPLE OF ISSUES THAT ARE IMPORTANT. THREE ISSUES. FIRST ONE IS THE DISCONNECT PRACTITIONERS FEEL BETWEEN DIFFERENT AGENCIES AND PAYORS, THE FINANCIAL SYSTEM. I TRULY BELIEF ANY PROJECT TO SURVIVE NEEDS TO CONSIDER FINANCING. NO QUESTION IF YOU DONE CONSIDER WHO IS GOING TO PAY WHAT TO WHOM, NOTHING WILL HAPPEN. REALLY WHEN I GO TO MEETINGS OF THIS SORT, SOMEBODY THAT'S ABSENT ALL THE TIME, CMS, AND JAT JI TO PAY FOR THE CARE PROVIDED AND LOOKING AT RURAL REIMBURSEMENT AND FINANCING SYSTEMS, IT'S HANDICAP, BECAUSE THERE'S NO SYSTEM THAT ALLOW REALISTICALLY THE FINANCING ACCORDING TO CONDITIONS PREB AT THAT TIME AND THAT PLACE. SO THAT WOULD BE THE FIRST SUGGESTION TO YOU GUYS, YOU HAVE TO LOOK AND IN FORUMS LIKE THIS WE NEED THE PRESENCE OF THE FINANCIAL ARM OTHERWISE NOTHING WILL WORK. SECOND THING THAT'S MISSING THAT IS VERY IMPORTANT, RECRUITMENT AND RETENTION OF PROVIDERS. I HAVE COMMENTING WITH JAMES AND DR. BELLA, THERE'S NOT ENOUGH EFFORT TO RECRUIT AN ENTICE PEOPLE FROM THE COMMUNITIES THEMSELVES. EVEN HIGH SCHOOL LEVEL, YOUNGER THAN THAT, TO GET INTO THE HEALTH PROFESSIONS, TO FINANCE SOMEHOW THE EDUCATION, SCHOLARSHIPS AT THE TIME OF PRE-MED, EVEN BEFORE, GET INTO MEDICAL SCHOOL, GET THEM TRAINED WITH DIFFERENTIAL CURRICULUM IF YOU WANT, EPIDEMIOLOGY, PUBLIC HEALTH, WHAT HAVE YOU. I WAS TRAINED IN CHILE, I HAVE 7 YEARS PUBLIC HEALTH AS PART OF MEDICAL SCHOOL TRAINING. ACTUALLY WE ARE TRAINING OUR PHYSICIANS IN A BASKETBALL COURT AND WE PUT THEM TO PLAY BASEBALL. WE'RE IN THE DOING THE RIGHT THING. PARTICULARLY WHEN YOU'RE TRYING TO EDUCATE PEOPLE, HEALTHCARE PROVIDERS, NUSSING STAFF -- NURSING STAFF, PHYSICIAN, WHAT HAVE YOU, NO ONE CONTRIBUTES MORE THAN PEOPLE THAT ARE RAISED IN THE PLACE WHERE THEY WERE COMING FROM. THAT'S PROVEN OVER AN OVER. PARTICULARLY IN BLACK COMMUNITIES. NEW YORK THEY HAVE A WONDERFUL PLACE BLACK PHYSICIAN RETURNING TO COMMUNITY MADE IMPACT IN NOT ONLY THE CARE THEY PROVIDE, THE TRUST AND THE CONFIDENCE AND THE GOING BACK, BUT ALSO IN INTERVENTION OF THE COMMUNITY LEVEL. NO QUESTION YOU PROVIDE THAT CURRICULUM DIFFERENTIAL, A REAL DIFFERENTIAL NOT LIKE THE FOUR YEAR SCHOOL, FIRST YEAR AND SECOND YEAR INTERVENTIONS AND FOURTH YEAR WITH ELECTIVES AND DURING THE REST OF THE TRAINING PRIMARY CARE, THAT INCLUDES THE ENTICEMENT OF THE PRIMARY CARE PRACTITIONERS TOWARDS REIMBURSEMENT THAT'S APPROPRIATE. NOT TO LOOK AT THEM LOWER THAN ANY OF THE OTHER PRACTITIONERS BECAUSE THAT IS THE CRISIS WE'RE HAVING TODAY. SO REALLY HERE, THE RIGHT HAND IS NOT TALKING TO THE LEF. WE'RE DOING THE RESEARCH, TRYING TO IMPLEMENT SOME CHANGES AND YET THEY ARE NOT COMMUNICATION OR REALLY CREATING SYSTEM THAT WILL REIMBURSE APPROPRIATELY THE PERSON TRAINED. THAT'S THE SECOND ITEM THAT'S MISSING. THE THIRD ITEM MISSING IS FOR THE INSIDER, THE PEOPLE THAT LIVE IN WASHINGTON, THE RESEARCHERS ARE GOING TO ALL THIS 20 AGENCIES SPONSORING THIS MEETING, IT'S EASY TO GET FAMILIAR WITH THE AGENCY THOUGH THERE ARE SOME, NOT SURE HOW YOU CAN FORGET ALL THEM BUT IT COULD HELP IN THE DISES DIZ FOR SOMEBODY THAT'S AN OUTSIDER LIKE ME COMING FROM THE I CAD MY TO UNDERSTAND A LITTLE BIT BETTER THE RELATIONSHIP WITH DIFFERENT AGENCIES SO THIS INTERAGENCY COMMUNICATION CAN BE ALLOWED TO HELP OUTSIDERS, QUOTE UNQUOTE, THAT WANT TO BE INSIDERS THAT WANT TO CONTRIBUTE WHAT TRAIK CONTRIBUTE AT THE INTERPROFESSIONAL LEVEL TO PROVIDE THE INPUT THAT WE CAN PROVIDE. THANK YOU. I APOLOGIZE. I HAVE TO LEAVE BECAUSE MY PLANE -- I HAVE TO CATCH A PLANE. >> THANK YOU FOR YOUR COMMENTS. ARE THERE ANY OTHER COMMENTS? PLEASE. >> ROBERT CAN I MAKE A COMMENT OR TWO. >> GO AHEAD, PLEASE. >> HELLO, LAURA CHURCH. TWO THINGSCH ONE, IF YOU COULD ADD IN TERMS OF PARTNERSHIP THE TRIBAL LEADERSHIP IT'S IMPORTANT AS RESEARCH IS BEING CONSIDERED IN NATIVE COMMUNITIES THAT YOU LOOK AT LEADERSHIP OF THE TRIBES, TRIBAL SOVEREIGNTY AND WORKING WITH THAT. THE SECOND THING THAT I HAVE UNDER YOUR INVOLVEMENT WITH COMMUNITY MEMBERS IS TO CONSIDER COMMUNITY MEMBERS OR YOUR MEMBER OF THE ADVISORY TEAM TO SERVE AS COMMUNITY CO-PRINCIPLE INVESTIGATOR. I THINK MANY TIMES, I HAD WONDERFUL CONVERSATION BEFORE THE LUNCH SESSION ABOUT SOMETIMES RESEARCHERS FROM OTHER ENTITIES MAY COME TO A COMMUNITY AND YES, MEETINGS MAY START LATE, FOR SOME REASON THERE IS A DISCONNECT BUT IF YOU THINK ABOUT HAVING A COMMUNITY LIAISON IN THE ROLE OF A COMMUNITY PI OR CO-PI THEY'RE THERE LOCALLY, CAN HELP TRANSLATE THE TRUST. THEY CAN HELP LOOKING AT SHARING THE IMPORTANCE OF VALUE OF THAT PARTICULAR INITIATIVE OR THAT PROJECT. AND I THINK COMMUNITY MEMBERS WOULD BE ABLE TO GET QUESTIONS ANSWERED NOT PERIODICALLY BUT SOMETIMES ON A WEEKLY BASIS BECAUSE THAT COMMUNITY CO-PI IS THERE LIVING IN THAT COMMUNITY. THANK YOU. >> THANK YOU. >> FIRST OF ALL I WANT TO THANK MONICA FOR DOING AN INCREDIBLE JOB OF PRESENTING A VERY COMPLICATED SET OF RECOMMENDATIONS. [APPLAUSE] >> WE ARE ALL A LITTLE WOOZY LAST NIGHT AFTER DINNER TRYING TO PUT THIS TOGETHER SO SHE DID AN UNBELIEVABLE JOB. A COUPLE OF THINGS THE ADD TO IT. ONE IS WE CALL IT THE TYPE 2 ISSUE. THERE ARE A LOT OF EVIDENCE-BASED PROGRAMS THAT WE KNOW WORK BUT WE DONE HAVE INFRASTRUCTURE IN COMMUNITIES TO IMPLEMENT THEM SO I THINK IT'S THREADED THROUGH SOME OF THE RECOMMENDATIONS BUT NOT EXPLICITLY. WE NEED COMMUNITY BASED PREVENTION SYSTEMS. WE NEED TO WORK WITH KEY LEADERS, STAKEHOLDERS IN COMMUNITIES TO BUILD CAPACITY, TO IMPLEMENT THESE EVIDENCE-BASED PROGRAMS IN A WAY CONTEXTUALLY SENSITIVE TO NEEDS OF THEIR COMMUNITIES. I GUESS THE SECOND THING, WE SORT OF DISCUSSED LAST NIGHT BUT NOT FOR LONG. SCHOOL DROP-OUT IS A PUBLIC HEALTH ISSUE. AND IT HAS ALL KINDS OF CYCLICAL ASPECTS. SCHOOL DROP-OUT IS HIGH IN RURAL COMMUNITIES. SCHOOL DROP-OUT IS LETTED TO TOBACCO USE. WE SEE PEOPLE THAT GRADUATED FROM COLLEGE, PEOPLE THAT DON'T GRADUATE FROM HIGH SCHOOL USE TOBACCO NINE TIMES THE RATE OF COLLEGE GRADUATES. TOBACCO USE HAS BECOME VERY RELATED TO EDUCATIONAL OUTCOMES. AND IT RELATES TO THE ISSUE THAT WAS DISCUSSED WHICH IS PRE-NATAL HEALTH BUT ALSO PRE-CONCEPTUAL HEALTH. THERE'S A CYCLE HERE OF MANY PEOPLE NOT GRADUATING FROM HIGH SCHOOL, DOING RISK TAKING IN EARLY ADULTHOOD AND THAT PRE-CONCEPTUAL PERIOD NOT LIVING HEALTHY LIFESTYLES BEFORE THEY BECOME PREGNANT SO THERE'S A PROCESS HERE OF THE HIGHEST RISK POPULATIONS OFTEN YOUNG ADULTS WHO ARE NOT FINISHING HIGH SCHOOL LIVE IN RISKY LIFESTYLE CONDITIONS AND BEGIN THE PROCESS OF NEXT GENERATION SO THINKING ABOUT THIS LIFESTYLE PROCESS IN ESPECIALLY CHILDREN NOT SUCCEEDING IN SCHOOL. >> THANK YOU FOR THE WONDERFUL SUMMARY. TWO POINTS TO MAKE, TWO SUGGESTIONS THAT I'LL LEAVE FOR YOU TO DECIDE IF IT SHOULD BE ADDED. ENCOURAGE AS WE'RE THINKING TO INTERVENTION AB PREVENTION THAT WE'RE DOING ALREADY, ESPECIALLY RURAL COMMUNITIES THAT WE ALSO BE COGNIZANT OF TRYING NOT TO DO IT AT THE EXPENSE OF PROMOTION OF HEALTH. SO WHEN WE TALK ABOUT INTERVENTION AN PREVENTION, THE PROGRAMS THAT ARE OUT THERE, I AGREE WE* SUCCESSFUL PROGRAMS INITIATIVES ALREADY THAT WE CAN TAP INTO. WE ALSO WHEN WE'RE USING THE LANGUAGE OF INTERVENTION AND PREVENTION ALSO TALK ABOUT THE NEED TO PROMOTE FROM ZERO ON. MY SECOND POINT SPEAKING TO SOMEBODY -- BALSANA WITH USDA. SPEAKING AS SOMEBODY WHO WORKS FOR A FUNDING AGENCY, FEDERAL FUNDING AGENCY, I ENCOURAGE THOSE OF YOU WHO ARE RESEARCHERS AN WHO COME TO US FOR FUNDING TO ALSO THINK ABOUT HOW THE FUNDS THAT WE HAVE ARE BEING ALLOCATED AND BEING DISPERSED. WHAT I MEAN BY THAT IS I HAVE A COMPETITIVE GRANT OPPORTUNITY THAT I'M OVERSEEING WITH ANOTHER COLLEAGUE AND THIS YEAR WE HAD A LITTLE BIT LESS FUNDING FURTHER THAN WE HAD THE YEAR BEFORE, THE YEAR BEFORE WAS LESS THAN THE YEAR BEFORE. SO WE'RE TRYING TO FIGURE OUT HOW TO ENABLE MORE RESEARCHERS TO DO RESEARCH WITH THESE FUNDS THAT ARE SOMEWHAT UNSTABLE. WHAT HAS WORKED FOR US AND WE DECIDED TO DO IS WE DO VIRTUAL PANELS. IN THIS KIND OF GOES BACK TO US TALKING ABOUT TELEHEALTH. IT'S A DIRVE THING BUT WE HAVE TECHNOLOGIES THAT ALSO CAN'T ALLOW US TO DO REVIEWS OF SCIENTIFIC REVIEW IN A DIFFERENCE WAY. IT MIGHT GO AGAINST LOCAL ECONOMY, OTHER THINGS TO SUPPORT BUT WE CHOSE SAVING $50,000 TO GIVE FOR A PLANNING GRANT OR ANOTHER GRANT GIVES US ANOTHER GRANTEE AND SOLUTION POSSIBLY DOWN THE ROAD. SO JUST SOMETHING I WANT TO SHARE. THANK YOU. >> I WAS AT THE RURAL INFORMATION CENTER BUT THAT'S PART OF THE AGRICULTURE RESEARCH SERVICE SO WE'RE ANOTHER ARM WITHIN USDA AND PART OF WHAT I WOULD LIKE TO SEE MORE OF IS MORE VARIETY OF FOLKS SITTING IN THIS AUDIENCE. JUST MENTION EDUCATION AS BEING PART OF THAT HEALTH EQUATION SO WE SHOULD HAVE THE DEPARTMENT OF EDUCATION SITTING HERE. THEY HAVE A RURAL DIVISION. THOSE FOLKS SHOULD BE AT THIS TABLE. ALSO THE DEPARTMENT OF LABOR WHICH HAS A LOT OF WORK FORCE DEVELOPMENT ISSUES, THEY HAVE TRAINING CENTERS AND FACILITIES THROUGHOUT THE UNITED STATES AND ARE REALLY PUSHED TO MAKE THAT EMPLOYMENT AND OPPORTUNITIES AVAILABLE. SO ANOTHER WAY THAT WE MIGHT BE ABLE TO GET INTO SCHOOLS WITH CAREER DEVELOPMENT. ALSO WITHIN THE AGRICULTURAL RESEARCH SERVICE WE HAVE A HUMAN NUTRITION LABORATORY. THROUGHOUT THE UNITED STATES, THERE'S ONE IN MARYLAND BUT ALSO SOME THROUGHOUT THE UNITED STATES THAT DEAL WITH CHILDHOOD OBESITY OR OVERALL OBESITY IN RURAL AREAS AS WELL AS YOU URBAN AREA. WE LOOK AT AGRICULTURE SAFETY PROGRAMS AND THINGS LIKE THAT. SO BRINGING THOSE RESEARCHERS ALSO TO THE TABLE BECAUSE THEY ARE DEALING WITH RURAL POPULATIONS. AND NUTRITION WHICH IS HUGE, AS FAR AS HEALTH BENEFITS AN HEALTH OUTCOMES, THE USDA BUDGET BEING LARGE BUT THE LARGEST PORTION OF THAT BUDGET GOES TO THE THE FOOD PROGRAM. WHICH ARE ESSENTIAL PART OF RURAL COMMUNITIES AND POVERTY ISSUES WITHIN CHILDREN. SO THE HEAD START PROGRAM, SOME OF THEM CAN USE THE FOOD DISTRIBUTION PROGRAMS, THEY HAVE AFTER-SCHOOL FOOD PROGRAMS THAT CAN BE DONE THROUGH FAITH-BASED ORGANIZATIONS AS WELL AS BREAKFAST AND LUNCH PROGRAMS THAT ARE MORE KNOWN THROUGHOUT AND THE SUMMER PROGRAMS THAT TRY TO PROVIDE FOOD FOR THOSE KIDS THAT AREN'T IN SCHOOL ANY MORE THAT HAVE SUDDENLY DON'T HAVE THAT NUTRITION OPTION. SO HAVING THAT AS WELL AS THE NEW PROGRAMS THAT ARE LOOKING AT THE NEW INITIATIVES NEW PUSHES WITHIN USDA WITH FARMED INSTITUTIONS, WHERE YOU'RE BRINGING FARMED SCHOOL PROGRAMS, FARM NURSING PROGRAMS, FARM TO HOSPITAL PROGRAMS WHERE YOU'RE PROVIDING A LARGER PORTION OF HEALTHIER NUTRITIOUS FOODS LOCALLY GROWN. THERE'S A WIDE VARIETY OF FOLKS THAT ARE SORT OF MISSING FROM THIS GREAT CONFERENCE AND THE INFORMATION HERE HAS BEEN VERY GOOD. JUST KIND OF MAYBE BRINGING MORE PEOPLE INVOLVED, NOT BEING SMALL BECAUSE WE'RE NOT LOOKING AT THE COMPLEXITY OF THE ISSUE. >> THANK YOU. BEFORE WE CLOSE, I HAVE A COMMENT I WANTED TO MAKE BECAUSE I THOUGHT ABOUT THERE IS A POPULATION THAT I WORK WITH AND THAT'S CONSIDERED OR CALLED REENTRY TO COMMUNITY POPULATION. REENTRY FROM INCARCERATION AN RETURN FROM MILITARY OPERATIONS. AS JUST TO SAY FOR THE RECORD, THERE ARE ABOUT 2.4 MILLION PEOPLE IN PRISON HERE IN THE UNITED STATES, AN ABOUT 10 MILLION PEOPLE PER YEAR CYCLE THROUGH JAILS. THOSE ARE NOT DISCRETE NUMBERS, MIGHT BE A PERSON GOING THROUGH 3 OR 4 TIMES ON ONE OR TWO DAY CYCLE THROUGH THE JAIL SYSTEM BUT 640,000 PER YEAR RETURN TO COMMUNITIES AND MANY ARE RETURNING TO RURAL COMMUNITIES AND FAMILIES WHERE THERE ARE CHILDREN. THERE ARE THINGS TO KNOW ABOUT HOW TO PREVENT THE RETURN TO PRISONS AND JAILS BEING FROM THE NATIONAL INSTITUTE OF MENTAL HEALTH, WE'RE CONCERNED ABOUT THE 24% WHO DESCRIBE SEVERE MENTAL HEALTH PROBLEMS IF NOT MENTAL ILLNESS AND CERTAINLY MENTAL HEALTH PROBLEMS BY THE TIME THEY'RE OUT OF LONG TERM LOCK-UP. MANY TIMES AUSTERE AND -- I WON'T USE THAT WORD BUT BEING LOCKED UP 23 HOURS A DAY CAN CAUSE MENTAL HEALTH PROBLEMS OR MENTAL ILLNESS. SO I WOULD LIKE TO HAVE US RECALL THAT AS A PERHAPS GAP THAT NEEDS SOME ATTENTION AS WE MOVE FORWARD, DEPARTMENT OF HEALTH AND HUMAN SERVICES DOES HAVE A REENTRY TEAM THAT MEETS, DEPARTMENT OF JUSTICE IS WORKING ON THINGS, SECOND CHANCE AMENDMENT, MYTH BUSTING THAT TELLS PEOPLE THAT ARE LOCKED UP, THINGS THEY HAVE ACCESS TO ONCE THEY RETURN TO THE IMMUNITY SO MORE WE CAN DO IN THAT AREA. WE'RE MOVING THROUGH OUR TIME PERIOD HERE BUT I WANT TO MAKE SURE THAT I SAY FROARD OUR PRESENTER FOR THIS -- FOR THE RECORD THAT OUR PRESENTER IS DR. BASKIN IN THE ASSOCIATE PROFESSOR IN THE DIVISION OF MEDICINE UNIVERSITY OF ALABAMA IN BIRMINGHAM SCHOOL OF MEDICINE AND A SCIENTIST IN THE UAB MINORITY HEALTH AND RESEARCH CENTER AT -- AND UAB NUTRITION OBESITY RESEARCH CENTER. WE HAVE ONE MORE PERSON. >> YES, I WAS THINKING AS YOU WERE SPEAKING, I THOUGHT EARLIER, ANGELINE BUSH, CENTRAL FLORIDA COLLEGE OF NURSING. THE WHOLE NOTION OF ABUSE, DOMESTIC AND SEXUAL ABUSE AND YOU HAD THE TRIAD OF DRUG USE AND HIGH RISK BEHAVIOR, OFTEN NOT JUST FEMALES, I'M TALKING, I DON'T KNOW WHERE THAT FITS AND I THINK THE INTERVENTIONS ARE DIFFERENT, THE WAY THEY'RE PRESENTED IS DIFFERENT BECAUSE OF THE INFORMAL NETWORKS AND CONFIDENTIALITY SO I DON'T KNOW WHERE THAT FITS THERE BUT IT'S A THOUGHT. >> THANK YOU. PLEASE JOIN ME IN GIVING THIS DEAR PANEL A GREAT ROUND OF APPLAUSE. THANK YOU. [APPLAUSE] >> WE'RE GOING TO ASK FOR OUR NEXT SET OF PANELISTS TO COME FORWARD SINCE WE DID HAVE A LATE START DUE TO DIFFICULTIES WITH THE PODCAST. THOSE SPEAKERS WHO PARTICIPATED ARE DR. JANICE PROBST, ALEXANDER ANDERS. DR. MCMURRAY, DR. TERRY BATLINER, DR. ANGELINE BUSBY. FACILITATORS. YOU CAN EXCHANGE YOUR SIGNS. FACILITATORS ARE CAPTAIN TINA TOPE AND DR. NOJACK RINER. THE PLANNING PARTICIPANTS WERE MYSELF, DR. ROBERT MAYS JR. AND DR. IDA BALSANO. SO THIS PORTION AND OUR FINAL PRESENTATION ON THE SUMMARY OF RESEARCH GAPS AN SUGGESTIONS FOR FUTURE RESEARCH WILL ADDRESS RECRUITMENT AND RETENTION APPROACHES. AND THE PRESENTER FOR THIS PANEL IS DR. TERRY BATLINER, ASSOCIATE DIRECTOR WITH THE CENTER FOR NATIVE ORAL HEALTH RESEARCH AT THE COLORADO SCHOOL OF PUBLIC HEALTH. THANK YOU. >> NEXT SET OF SLIDES. IF THIS WAS A GRADE SCHOOL IN THE '60s I THINK THE PREVIOUS GROUP ONE THE BLUE BIRDS AND WE WOULD BE THE AARDVARKS BECAUSE MONICA WAS AMAZING AT HER PRESENTATION. SO BEAR WITH US AS WE GO THROUGH THE -- THIS IS OUR SUMMARY OF RECRUITMENT AND RETENTION IDEAS. WE HAVE A FEW POINTS, AND A FEW TOPICS AND WE'LL END WITH SOME GRAND SUGGESTIONS. FIRST WE MUST FOCUS ON ALL RELATED ENTITIES, PARENTS, FAMILY, ORGANIZATIONS AN COMMUNITIES. WE MUST ENCOURAGE A DEVELOPMENTAL PERSPECTIVE AND ENCOURAGE RESEARCH OVER THE ENTIRE COURSE OF LIFE BECAUSE IF ALL OF THESE THINGS ARE IMPROVED THE LIFE AND HEALTH OF KIDS WILL BE IMPROVED. SOME BASIC QUESTIONS THAT CAME UP, THERE WAS A QUESTION TO DISCUSS THE CURRENT RECRUITMENT APPROACHES FOR ENGAGING HARD TO REACH HIGH RISK POPULATIONS AND WE COVERED THAT IN OUR PRESENTATIONS THIS WEEK. TRUST BUILDING IS THE CORNERSTONE OF RECRUITMENT. WANT TO WORK WITH ORGANIZES THAT SERVE PEOPLE TRYING TO RECRUIT, INVOLVE PEOPLE FROM COMMUNITIES TO BE PART OF OUR STUDIES. WE WANT TO ALLOW FUTURE APPROACHES SHOULD ALLOW TIME FOR PLANNING AN RELATION SHIL BUILDING BECAUSE THAT'S KEY TO RECRUITMENT OF RURAL PEOPLE AND STUDIES. OBVIOUSLY LOCAL EMPLOYEES TO BE PART OF YOUR STUDY AND YOU NEED THE PAY THEM REASONABLY, AND YOU WANT TO PROVIDE PARTICIPANT COMPENSATION THAT ATTRACTS PEOPLE LOW SOCIOECONOMIC STATUS INTO THE STUDIES. SO CURRENT RETENTION APPROACHES, COUPLE OF POINTS ON THAT. WE NEED TO KNOW THE PARTICIPANTS, WE NEED TO -- IF WE DONE KNOW THEM WE NEED TO HIRE PEOPLE THAT KNOW THE COMMUNITY AND WILL KNOW OUR PARTICIPANTS. WE NEED TO WORK WITH GROUPS AN AGENCIES THAT KNOW THEIR CLIENTS AND THEY CAN HELP US TO KEEP TRACK OF PARTICIPANTS. WE NEED TO KNOW HOW TO EFFECTIVELY COMMUNICATE WITH PARTICIPANTS, HOW AND WHEN TO CONTACT PARTICIPANTS. AS I DISCUSSED IN NATIVE COMMUNITIES WHERE A LOT OF PEOPLE HAVE PRE-PAID CELL PHONE, TOUGH TO GET FOLKS AT THE END OF THE MONTH. NEW RECRUITMENT APPROACHES, SOME POINTS TO CONSIDER. RECIPROCITY, AGAIN, THIS IS A BIT OF A PLEA FOR MORE TIME UP FRONT. COMMUNITY NEEDS TIME TO LEARN ABOUT THE RESEARCHERS AND NEW RESEARCHERS NEW TO A COMMUNITY NEED TIME TO LEARN ABOUT THE COMMUNITY. SO WE HOPE FUNDLING FACILITATE THAT IN THE FUTURE. HEALTH SERVICES RESEARCH REQUIRES RECRUITMENT OF PROVIDERS, ALLIED HEALTH WORKERS AND ADMINISTRATORS. WE TALKED ABOUT A LOT OF PROJECTS THAT RECRUIT PEOPLE, INDIVIDUALS FROM THE COMMUNITY THAT AREN'T NECESSARILY INVOLVED WITH THE HEALTHCARE SYSTEM. THERE'S SOME THOUGHTS OF DIFFERENT WAYS OF ATTRACTING THESE HEALTH WORKERSCH THESE PEOPLE CAN ALSO HELP RECRUIT OTHER TYPES OF PARTICIPANTS. SO YES NEED TO BE INCLUSIVE IN APPROACHES TO RESEARCH IN THE FUTURE. LESBIAN GAY BISEXUAL SEXUAL POPULATIONS IN RURAL POPULATIONS SHOULDN'T BE FORGOTTEN, AND ONE WITH RESPECT TO SUICIDE PREVENTION. I'M HERE TO TELL YOU THERE ARE UNDOCUMENTED PEOPLE THAT LIVE IN RURAL AREAS, WE SEEM TO NOT WANT TO EVER TALK ABOUT THAT BECAUSE OF THE POLITICAL SITUATION IN THIS COUNTRY. BUT THERE ARE A LOT OF PEOPLE L THAT HAVE HEALTH PROBLEMS AND ISSUES, THOSE HEALTH PROBLEMS AFFECT OUR HEALTHCARE SYSTEM AND CAN ALSO AFFECT THE HEALTH OF OTHERS. WE MUST COME TO GRIPS WITH RESEARCH AND TREATMENT AND SERVICES TO UNDOCUMENTED PEOPLE. TRIBES, CLEARLY Y'ALL KNOW THAT I THINK MORE WORK NEEDS TO BE DONE WITH TRIBES, PEOPLE WITH DISABILITIES MUST ROUTINELY BE INCLUDED, NOT EXCLUDED. THERE ARE NEW EXAMPLES OF ISOLATED GROUPS LIVING -- DIVERSE GROUPS LIVING IN ISOLATED AREAS SUCH AS AFRICAN IMMIGRANTS IN A SMALL TOWN OF FT. MORGAN, COLORADO. THAT'S JUST AN EXAMPLE OF MANY EXAMPLES AROUND THE COUNTRY THAT WE SHOULDN'T IGNORE. SO STRATEGIES FOR ENGAGING POPULATIONS NEEDING PRIORITY ENGAGEMENT. FIRST IDENTIFY THOSE OFTEN OVERLOOKED AND COMMUNICATE WITH THEM AB THEIR NEEDS. THE STRATEGIES INCLUDE TRUST BUILDING AS ALWAYS, RELATIONSHIPS WITH PEOPLE BUILDING THOSE, RELATIONSHIPS WITH ORGANIZATIONS, HIRE FROM THE GROUP AND MENTORS OF THE GROUP AS WE MOVE THROUGH OUR RESEARCH PROJECTS. TRY TO DEVELOP PEOPLE FROM THE COMMUNITY THAT CAN IN THE FUTURE DO RESEARCH THEMSELVES. ENGAGEMENT WILL TAKE PLACE IN A LOT OF WAYS IN THE FUTURE, TOUCHED ON BY THE OTHER GROUP, I HAD MART PHONES, NEW DEVICES THAT WERE DISCUSSED THIS MORNING WILL ALLOW MORE FACE TO FACE COMMUNICATION ON THE FLY. WE MUST ENSURE RURAL AREAS HAVE THE ABILITY TO DEAL WITH ADVANCED TECHNOLOGY, WE MUST MAKE SURE THAT RURAL AREAS AND PEOPLE CAN GET THESE DEVICES. BARRIERS THROUGH RECRUITMENT ANDnb RETENTION, THERE'S A LACK OF UNDERSTANDING AB RESEARCH IN RURAL AREAS I TALKED IN MY PRESENTATION ABOUT PROBLEMS WITH RANDOMIZED TRIALS AND THAT THE ADVANCEMENT OF SCIENCE IS NOT ENOUGH TO FOR MANY PEOPLE TO THINK THAT'S A REASON TO DO RESEARCH IN THE COMMUNITY. THE COMMUNITY SHOULD BE INVOLVED IN IDENTIFYING WHICH RESEARCH TOPICS ARE GOING TO BE DISCUSSED. WHAT'S IMPORTANT TO THEM. COMMUNITY CAPACITY MUST BE DEVELOPED THROUGH PROVISION OF TECHNICAL ASSISTANCE TO SUCCESSFULLY CONDUCT RESEARCH AND TO MOVE THAT RESEARCH ALONG INTO THE FUTURE. I NEED SOME HELP FROM THE PANEL. WE MUST NOT ONLY THINK OF DOCTORS AN DENTISTS AN NURSES AS A HEALTHCARE PROVIDERSES THAT WE SHOULD WORK WITH, WE NEED DIFFERENT TYPES OF PROVIDERS TO THINK OF DIFFERENT TYPES OF PROVIDERS IN THEIR ROLE IN RURAL COMMUNITIES SUCH AS HEALTHCARE WORKERS AND THEY SHOULD BE ENGAGED IN RESEARCH. SOMEBODY BROUGHT UP THIS PATH. >> THAT WOULD BE ME. I MENTIONED LAST NIGHT THAT I'M IN THE OFFICE FOR RESEARCH ON DISPARITIES AN GLOBAL MENTAL HEALTH AS WELL AS THE OFFICE OF RESEARCH ON RURAL MENTAL HEALTH AND IN ORD GLOBAL MENTAL HEALTH WE HAD A U-19. THAT U-19 MECHANISM FUNDS RE?ERNLG AFRICA LOOKING AT WAYS IN WHICH THEY CAN TASK SHIFT OR TAKE CERTAIN SKILL SETS AND HAVE PEOPLE WITH LESS EXPERTISE -- NOT EXPERTISE, LESS ACADEMIC TRAINING TO HANDLE THOSE TASKS. THIS IS SOMETHING MOVING AWAY FROM THE HIV AIDS ARENA AND MENTAL HEALTH ARENA. SO I MENTIONED LAST NIGHT PERHAPS TASK SHIFTING MIGHT BE CONSIDERED IN THE VARIOUS COMMUNITIES, IT MIGHT BE A RETURN TO WHAT FOLKS ARE DOING ANYWAY UNDER VARIOUS TITLES OF COMMUNITY HEALTH WORKER OR OTHER KINDS OF ROLES BUT IT SHOULD BE RESEARCHED TO MAKE SURE THAT WHEES BEING ADAPTED IS TRULY BEING EFFECTIVE IN TERMS OF MOVING FROM PRACTICE BASED EVIDENCE TO RESEARCH-BASED EVIDENCE. THAT'S WHAT THE TASK SHIFTING IS ABOUT. >> ANYBODY ELSE WANT TO TALK ABOUT THE USDA? WE'LL LEAVE THAT ONE. OKAY. GREAT. WE JUST WANT TO RE-EMPHASIZE THE FRAMEWORK WE THINK SHOULD BE DEVELOPED AND THE APPROACH THAT SHOULD BE TAKEN IN THE FUTURE, SHOULD BE A DEVELOPMENTAL FRAMEWORK WITH RESEARCH LOOKING AT ALL ASPECTS OF LIFE, ALL THE PEOPLE SURROUNDING A CHILD IN A RURAL AREA. WE ALSO OFFER PHASES OF COMMUNITY-BASED PARTICIPATORY OR COLLABORATIVE RESEARCH. SOFT OFFER THESE FOR EVERYBODY CONSIDERATION AND JUST THOUGHT -- >> OKAY. THAT'S FOR THE RECORD. NOW, OUR GRAND SUGGESTIONS. WE DON'T WANT TO LOSE THE ENERGY OF THIS CONFERENCE. SO THE WORK GROUP WE BELIEVE THERE SHOULD BE A WORK GROUP TO PLAN A TTT CENTER. THE TTT CENTER IS A TRANSAGENCY SENOR, TRANSDISCIPLINARY AN TRANSLATIONAL. WHY DON'T YOU TALK A BIT ABOUT THIS. (OFF MIC) >> FROM THIS -- FOR A MINUTE AND A WAY OF THINKING THE TASK AT HAND, THE TASK FOR THIS PANEL, APPLICABLE TO THE PANEL BEFORE US. ONE TASK IS TO CAPTURE, THE OTHER IS TO CAPITALIZE. THE CAPTURING TASK IS WHAT WE'RE DOING RIGHT NOW AND THAT IS -- THAT'S ALL ABOUT -- I WANT TO SORT OF CAPTURE WHAT MARK SAID ABOUT THE FORMER PRESENTER. IF YOU HEARD OUR CONVERSATION AT TABLE AND YOU WOULD BE VERY IMPRESSED WITH WHAT TRRY JUST DID TO CAPTURE THOSE IDEAS BUT IT RELATES TO A BIGGER POINT, THERE'S AN IMMENSE AMOUNT OF INFORMATION, BEEN VERY RICH, THE IDEAS HAVEX8 DAUGHTER WOULD SAY. THERE'S A GOZILLION OF THEM. SO WHAT WE'RE TRYING TO DO HERE NOW IS TO DISTILL THEM, TO CAPTURE THEM AS BEST WE CAN BECAUSE THAT CAN HELP US GAIN CLARITY ON THESE IDEAS, HOW THEY INTERRELATE, HELP COMMUNICATE THEM AN HELP WITH WHAT WE ALL WANT. THIS IS WHAT'S COMING BACK TO THIS BIGGER POINT, TRANSLATING THEM INTO ACTION. SOME OF WHAT YOU SEE, WE DIDN'T EXACTLY FOLLOW THE OUTLINE ON THE FIRST TASK OF CAPTURING BUT A CONCEPTUAL FRAMEWORK TO HELP US GET CLEAR ON IDEAS HOW THEY FIT. HOW WE COMMUNICATE THE IDEAS FROM THESE TWO PANELS TO OTHERS. THAT RELATES SPECIFICALLY TO THIS DEVELOPMENTAL FRAMEWORK YOU SAW. WE WHEN THROUGH THAT QUICKLY AND WE CAN TALK MORE ABOUT THAT. BUT THAT WAS THAT'S PART OF WHAT WE THINK SHOULD BE A CONCEPTUAL FRAMEWORK FOR DOING THIS WORK WITH RURAL COMMUNITIES. I THINK CONCEPTUALIZING THIS WARRANTS MORE ATTENTION SO AGAIN, WE CAN MAKE IT CLEAR, WE CAN COMMUNICATE, FIGURE HOW TO BEST TRANSLATE THESE WONDERFUL IDEAS INTO ACTION. THIS IS A -- SO THAT'S ABOUT THE TASK OF CAPTURING THIS, THAT'S WHAT TERRY HAS BEEN DOING, WHAT WAS AT THE HEART OF THINKING ABOUT THIS DEVELOPMENTAL FRAMEWORK. THAT SETS THE STAGE FOR THE SECOND, TO SEIZE THE OPPORTUNITY, CAPITALIZE ON THIS AND WE CAME UP WITH SEVERAL BIG IDEAS NOT ALL WHICH WE HAVE GOTTEN TO. BUT WE TALKED ABOUT WHAT IF WE COULD CARRY THE IMPETUS FORWARD, DEVELOP A WORK GROUP, A WORK GROUP TO THINK ABOUT THE POSSIBILITY -- >> SEEING IF I HAD -- OKAY. A WORK GROUP. >> THIS IS GRAND. BUT THE IDEA TO START WITH A WORK GROUP, CONVENING APPROPRIATE REPRESENTATIVE PEOPLE FROM THIS CONFERENCE TO THINK THROUGH WHATEVER WAY APPROPRIATE TO THINK THROUGH WHETHER OR NOT THERE MIGHT BE A POSSIBILITY FOR SOMETHING LIKE THIS TRANSAGENCY INITIATIVE THAT FOSTERS TRANS-DISCIPLINARY APPROACHES, SORT OF KIND OF THINKING THROUGH HOW DIFFERENT DISCIPLINES CONTRIBUTE TO DECIDE LOWIZING THE TOTAL EFFORT WITH FOCUS ON TRANSLATIONAL RESEARCH WHICH IS AT THE HEART ABOUT GETTING THE RESEARCH INTO PRACTICE. AND THE LAST PANEL TALKED ABOUT TYPE 2 -- THAT'S ONE OF THE THEMES BUILDING CAPACITY ABOUT TRANSLATING THIS KIND OF WORK, ABOUT RECRUITMENT AND RETENTION AND BEYOND, INTO (INAUDIBLE) I DON'T KNOW IF YOU WANT TO SAY WE HAD SOME OTHER BIG IDEAS. >> WELL, LET'S TALK ABOUT THE BRAIDED FUND AGO PROACH FOR A PUN -- FUNDING APPROACH FOR A MINUTE, THAT WAS ONE OF THE SUGGESTIONS TO BREAK DOWN BARRIERS MORE AND BREAK IT DOWN WITH RESPECT TO THE FUNDING AND THAT YOU HAVE RESEARCH ORGANIZATIONS COUPLED WITH SERVICE PROVIDING ORGANIZATIONS IN THE GOVERNMENT FUNDING APPROACHES THAT CAN HELP IMPROVE SITUATIONS IN RURAL AREAS, HOPEFULLY. WHAT OTHER THINGS DID I MISHERE? >> I THINK THAT CAPTURES ANYBODY SUITED WITH BIGGER IDEAS, BIGGEST IS THIS IDEA OF A WORK GROUP. THE OTHER ONE WE DIDN'T TALK ABOUT BUT MAYBE SHOULD A LITTLE IS IOM STUDY. TO START WITH, LOOK AT WHAT'S ALREADY BEEN DONE TO SYNTHESIZE, TO ADDRESS THESE ISSUES THAT THIS CONFERENCE IS ALL AB AND CONSIDER WHETHER OR NOT THERE SHOULD BE SOMETHING DONE TO SUPPLEMENT THEM, WHETHER OR NOT SOMETHING ON THE ORDER OF NATIONAL RESEARCH COUNCIL, INSTITUTE OF MEDICINE KIND OF REPORT. ABOUT HEALTH AND -- ENHANCING HEALTH OUTCOMES IN RURAL COMMUNITIES. WE DON'T WANT TO TO REINVENT THE WHEEL. START WITH LOOKING AT WHAT'S OUT THERE FOR THAT MATTER, YESTERDAY I TALKED ABOUT THESE PANELS, A SERIES OF PANELS IN THE '90s, THEY DID GREAT WORK, THERE WERE SPECIAL ISSUES AND A LOT OF WHAT THEY RECOMMENDED STILL HASN'T BEEN ACHIEVED, I HEARD SEVERAL THINGS BEING RECOMMENDEDDED COME UP HERE AGAIN. BUT THAT WOULD BE PART. LOOK WHAT'S OUT THERE, REVIEW IT AND CONSIDER WHETHER SOMETHING BEYOND THAT HELPFUL REALLY CRYSTALLIZED, MOBILEIZED AND HELPED US MOVE FORWARD. >> AN ADDITIONAL ISSUE THAT I HAVE BEEN THINKING ABOUT PARTICULARLY AS I LISTEN TO TERRY'S PRESENTATION AND MONICA AND OTHERS THAT HAVE TALKED ABOUT RECRUITMENT AND RETENTION, IT WOULD BE INTERESTING TO HAVE A SINTIZATION OF APPROACHES OF PEOPLE THAT HAVE UTILIZE AID CROSS THE VARIOUS FOCUSED OR EMPHASIS GROUP. I REALLY LOVE WHAT LORNA SAID EARLIER. SYNTHESIZE ACROSS WAYS PEOPLE RETAINED, RECRUITED AND RETAINED POPULATIONS AND THEN WHAT'S DISSIMILAR? SO IT MAYBE WHEN WE LOOK AT THE APPROACHES UNDERTAKEN TO RECRUIT PIPE FRL THE TRIBAL AGENCIES OR AFRICAN AMERICANS IN RURAL COMMUNITY, LATINO POPULATIONS, WE MAYBE USING SIMILAR APPROACHES IN LOTS OF WAYS TO REACH THESE POPULATIONS. IF THAT'S THE CASE IT WOULD BE GREAT TO KNOW THAT. WHAT IS DIFFERENT SO THERE'S A MODEL THAT GUIDES EFFORTS THAT WE HAVE, A CENTRAL MODEL THAT WE CAN HAVE OR NOT. OR DEVELOP A USEFUL MODEL. I FEEL I CONSTANTLY TRY TO CREATE WAYS OF DOING THIS BY ADDING OR TAKING AWAY FROM WHAT I HAVE DONE BEFORE BUT ONCE WE HAVE THIS SYNTHESIZED WAY OF UNDERSTANDING THIS RECRUITMENT AND RETENTION, IT CAN HELP MOVE US FORWARD. >> WE'RE KIDDING STARTING WITH THE IDEA OF HAS ANYBODY BEEN TO A RURAL MEETING WHERE YOU DON'T HAVE FOOD? YOU DON'T HAVE THAT WITHOUT FOOD PAID FOR OUT OF GRANTS. I WANT TO TURN TO THE POINT YESTERDAY ABOUT THE PROGRAMS THAT NIH HAS BEEN INVOLVED WITH FOR YEARS ABOUT RECRUITING RESEARCHERS, SCIENTISTS, FROM DISADVANTAGED GROUPS AND PEOPLE WITH DISABILITIES. ONE OF THE THINGS THAT HAPPENS WITH THOSE PROGRAMS IS THEY WILL PROVIDE SUPPLEMENTAL -- NIH WILL PROVIDE SUPPLEMENTAL FUNDING ABOVE THE GRANTS DOLLARS FOR THE ACCOMMODATIONS, FOR RESEARCHERS WITH DISABILITIES. SO IF THEY NEED ACCOMMODATIONS FOR DISABILITY IN THEIR LABS OR FACILITIES, THOSE CAN BE SUPPLEMENTED. IS THERE A SIMILAR MODEL THAT COULD -- THAT'S BEEN THERE FOR A LONG TIME. IS THERE A SIMILAR MODEL THAT COULD BE USED TO OFFER THE NECESSARY SUPPORT IN THESE KIND OF DISADVANTAGED ENVIRONMENTS THAT COULD COVER THINGS LIKE FOOD AND INTERPRETERS, LANGUAGE INTERPRETERS AND SIGN LANGUAGE INTERPRETERS, TO PROVIDE THE ACCOMMODATIONS NECESSARY AROUND PHYSICAL SENSORY OR COGNITIVE DISABILITIES BUT OTHER ACCOMMODATIONS CULTURALLY NECESSARY, NIH HZ A MODEL FOR THAT, IN THE RECRUITING FOR SCIENTISTS IS COULD SOME OF THAT BE BROUGHT BACK IN, IS THERE A METHOD FOR DOING SOMETHING LIKE THAT? SINCE THE MODEL IS ALREADY THERE FOR RECRUITING SCIENTISTS FROM DISADVANTAGED, COULD BE BROUGHT DOWN. ALSO I WOULD LIKE TO MAKE -- I DON'T THINK ACCESSIBILITY SHOULD BE -- HAVE TO BE INCLUDED IN SUPPLEMENT. ACCESSIBILITY SHOULD BE BUILT INTO EVERYTHING, LIKE THIS PODIUM ISN'T ACCESS TO SOMEBODY IN A MOBILITY DEVICE BUT WITH THE TELECOM, TELEHEALTH, TELEMEDICINE, WHATEVER E AND M ARE, TO KEEP IN MIND THE ACCESSIBILITY OF THE DEVICES TO PEOPLE WHO MAY HAVE LEARNING DISABILITIES, PHYSICAL DISABILITIES, SENSORY DISABILITIES EITHER WITH HEARING OR VISION AND TO BE PURCHASING SYSTEMS THAT ALREADY ARE ACCESSIBLE TO BE BUILDING ON THOSE SYSTEMS, THAT SHOULDN'T BE SUPPLEMENTAL, THAT'S INTEGRAL. BECAUSE UNLESS YOU HAVE A WELCOMING AND INCLUSIVE ENVIRONMENT A HOSPITABLE ENVIRONMENT WE COULD LEARN THAT FROM SOME OF THE WORK DONE ON THAT VELMA TALKED ABOUT AND TRIBE STUFF. PEOPLE DON'T COME TO IT. THEY'RE IMPLICITLY, ACTUALLY THEY'RE EXPLICIT -- THEY'RE IMPLICITLY EXCLUDE BECAUSE THINGS THEY NEED TO GET THERE AREN'T THERE. >> I WOULD MAKE A COMMENT WE DID DISCUSS LAST NIGHT FEASIBILITY OF TAKING PRODUCTS IN THIS CONFERENCE AN INCORPORATING THEM INTO CURRENT AND PENDING RELEVANT NATIONAL STRATEGIC PLANS. I THINK YOU HEARD DR. ROLL LYNNS EARLY THIS MORNING OR THIS AFTERNOON TALK ABOUT THE NATIONAL -- THE NATIONAL PARTNERSHIP FOR ACTION TO END HEALTH DISPARITIES PLAN. AND THERE'S SOME OTHER THINGS THAT THERE'S NATIONAL ACTION ALLIANCE SUICIDE PREVENTION, A NUMBER OF NATIONAL PLANS THAT ARE IN PLACE NOW AND MORE ROLLED OUT. WE SHOULD BE ABLE TO TAKE AN OPPORTUNITY FROM OUR SCIENCE NOTES HERE, TO WHATEVER WE PRODUCE HERE RELEVANT TO BE ADDED TO THOSE STRATEGIC PLANS. DO WE HAVE ANY QUESTIONS? WE'RE GOING TO MOVE TO QUESTIONS RIGHT NOW. I KNOW THAT IT'S GETTING LATE. WE HAVE FLIGHTS TO TAKE. AND AND REALLY LIKE TOO HEAR FROM YOU, WE'RE NOT GOING TO RUSH OURSELVES. THANK YOU. SIR. >> HELLO. (INDISCERNIBLE) FROM THE UNIVERSITY OF MISSOURI COLUMBIA. AND I WANT TO THANK EVERYONE, THIS HAS BEEN REALLY INCREDIBLY EDUCATIONAL EXPERIENCE FOR ME. I JUST WANTED TO ADD ONE OTHER SUGGESTION I GUESS. IT HAS TO DO WITH SORT OF APPRECIATING THE POPULATION THAT WE'RE WORKING WITH. I HAVE HEARD SO MANY TIMES WE HAVE BEEN TALKING ABOUT THIS -- THESE ISSUES BUT I THINK THAT WE NEED PROMINENT BECAUSE OF THIS SITUATIONS THAT WE PUT OURSELVES INTO AND THE PEOPLE THAT WE WORK WITH. WE NEED TO MAKE PROMINENT ISSUES SURROUNDING ETHICS IN TERMS OF ETHICS TRAINING AND THIS CUTS ACROSS RECRUITMENT RETENTION, THE ACTUAL RESEARCH ITSELF, THE ISSUES THAT WE -- THAT MANY PEOPLE TALKED ABOUT IN TERMS OF MAKING SURE WE'RE PROVIDING THE SERVICES THAT AND THE SORT OF MEETING THE NEEDS OF OUR COMMUNITIES AND DOING SO IN WAYS THAT NOT ONLY FULFILL THE SENSITIVITY AND RESPECT OUR POPULATIONS PRESERVE BUT BALANCE IT IS SCIENTIFIC INTEGRITY AND OBJECTIVES OF RESEARCH THAT WE CONDUCT. SOMETHING JUST WHEN DEAD. >> THANK YOU. MA'AM. >> I WOULD LIKE TO MAKE A COUPLE OF COMMENTS FIRST TO ECHO THE SPEAKER BEFORE ME AND -- >> IDENTIFY YOURSELF AS A SCIENCE WRITER PLEASE? GO AHEAD. >> YOUR NAME. >> I WOULD JUST LIKE TO ECHO THE APPRECIATION TO THE COMPS, IT'S BEEN VERY GOOD. I WOULD ALSO LIKE TO MAKE A PLUG HERE FOR LOOKING AT ORAL HEALTH AS A COMPLEX OF DISEASES AND DISORDERS IN THEIR OWN RIGHT. AS WELL AS IN ADDITION TO OTHER COMORBIDITIES THEY COME ALONG WITH. I THINK THAT WE HAVE SEEN OVER THE LAST FEW DAYS THAT'S A MAJOR DISORDER. I HAVE ALSO BEEN STRUCK AS AN ANTHROPOLL GIST BY HOW MUCH WE HAVE FOCUSED ON ISSUES OF CULTURE. BUT IT ALSO STRUCK ME THAT WE WERE TALKING ABOUT OTHER PEOPLE'S CULTURE. WE HAVE NEVER TALKED AT ANY LENGTH AT ALL ABOUT THE CULTURE OF BIOMEDICINE OR BIOSCIENCE HOW THAT UNDERPINS OUR RESEARCH ACTIVITIES AND HOW WHICH REALLY UNDERSTAND OUR OWN VALUES AND ASSUMPTIONS AND WHAT WE TAKE IN TO TRY AND WORK WITH OTHER COMMUNITIES I THINK THAT WE WON'T FULLY UNDERSTAND HOW TO INTERSECT WITH THEM, HOW TO RECRUIT, HOW TO RETAIN THEM IN OUR STUDIES OR HOW TO ENGAGE THEM IN THE FIRST PLACE. SO I THINK THAT WE NEED TO UNDERSTAND A LOT MORE ABOUT WHAT HAPPENS IN THE ACTUAL CLINICAL ENCOUNTER. WE DON'T KNOW VERY MUCH ABOUT IT. WE KNOW A LITTLE BIT MORE PHYSICIANS ANNIE KIND OF HEALTH PRACTITIONER BUT UNTIL WE UNDERSTAND WHETHER THERE'S DIFFERENCES IN INTERACTIONAL PATTERNS IN RURAL COMMUNITIES VERSUS URBAN COMMUNITIES I THINK WE'RE MISSING A RATHER LARGE PART HOW TO INTERVENE EFFECTIVELY IN COMMUNITIES BE THEY RURAL OR URBAN. >> THANK YOU. DO WE HAVE ANY OTHER COMMENTS? ANYONE LIKE TO RESPOND TO COMMENT ABOUT WHAT I HAVE WRITTEN DOWN HERE AS ENGAGEMENT, SOMETHING WE'RE LOOKING AT POTENTIAL FOA, NIMH, THE NEED TO BETTER UNDERSTAND THE ENGAGEMENT PROCESS? >> I JUST WANTED TO UNDERSCORE POINT YOU MADE BEFORE THAT, ABOUT CRITICALLY EVALUATING ONGOING INITIATIVES WHICH THIS INITIATIVE MIGHT CONNECT IN THE SPIRIT I MENTIONED BEFORE, CARRYING FORWARD CAPTURING THE IMPETUS. I WOULD BE REMISIF I DIDN'T MENTION THAT ONE OF THE SPECIFIC ONES TO ATTEND TO IS NATIONAL PREVENGS STRATEGIES, ONE THAT HAS AS ONE OF FOUR MAJOR STRATEGIC DIRECTIONS ADDRESSING HEALTH DISPARITIES AN SPECIFICALLY REFERENCES RURAL POPULATIONS AND A LOT OF WHAT WE TALKED ABOUT IS SOMETHING THAT COULD FURTHER WHAT SUGGESTED BY STRATEGIC DIRECTION, ARTICULATED IN THE NATIONAL PREVENTION STRATEGY. AND THERE'S A FUND FOR TO SUPPORT THAT THAT MIGHT HELP MOVING FORWARD. >> THANK YOU. >> JUST ONE MORE COMMENT. >> YOUR NAME PLEASE. >> LOUISE RENELL FROM USDA. ONE THING THAT I THINK SHOULD ALSO A PLAYER THAT WEL MENTIONED THAT ARE IN RURAL COMMUNITIES THAT ARE A VITAL PART OF MANY RURAL COMMUNITIES IS THE PUBLIC LIBRARY. THE PUBLIC LIBRARY IN MANY CASES PROVIDES THE ONLY BROADBAND AVAILABILITY AND FOR DISABLED MANY TIMES HAS OPTIONS FOR A MEETING PLACE THAT DISABLED FOLKS ARE ABLE TO PARTICIPATE IN MEETING SETTINGS. THE OTHER THING IS TECHNOLOGY NOT ONLY IN THE SENSE OF BROADBAND BUT RURAL LIBRARIANS ON THE FOREFRONT OF TEACHING AND TRAINING FOR USING MOBILE DEVICES, WHETHER IT BE SMART PHONES, CONNECTING INTO INFORMATION THROUGH YOUR SMART PHONE, THROUGH YOUR iPAD, HOW TO DOWNLOAD AND ALSO LENDING OPPORTUNITIES FOR BOOKS AND EREADERS. A WIDE VARIETY OF TECHNICAL SOURCES, THEY DON'T ONLY HELP WITH HAVING THOSE AVAILABLE BUT ALSO ON TEACHING PEOPLE HOW TO USE THEM MORE EFFECTIVELY. SO I CAN SEE AS PARTNER WITH A MAYBE COMMUNITY HEALTH WORKER THE ABILITY TO USE MAYBE SOME MOBILE DEVICES WHICH IN SOME CASES AS WAS MENTIONED EARLIER, RURAL COMMUNITIES ARE ALMOST JUMPING AS WE ALSO SEE IN INTERNATIONALLY, JUMPING THE BROADBAND ISSUE AND GOING STRAIGHT INTO A SMART PHONE OR A MOBILE HEALTH OR MORE MOBILE INFORMATION. >> I'M CHERYL JONES FROM UNIVERSITY OF IOWA CHILD HEALTH SPECIALTY CLINICS. TWO OTHER PARTNERS THAT ARE STRONG AT LEAST IN MY COMMUNITY ARE RURAL TELEPHONE COMPANY, THEY HAVE DONE IN OUR COUNTY HAVE TAKEN BROADBAND BASICALLY THEIR GOAL IS TO GET TO EVERY RESIDENT OF THE COUNTY. SO MANY RURAL COOPERATIVE PHONE COMPANIES ARE REALLY WORKING VERY HARD AND VERY CRUCIAL IF YOU'RE LOOKING AT SOME OF THE TECHNOLOGY WE'RE TALKING ABOUT FOR THE HOSPITAL. THE OTHER ONE IS THE RURAL ELECTRIC COOPERATIVE. THEY HAVE WORKED VERY STRONGLY WITH US ON A NUMBER OF HEALTH INITIATIVES TO GET INFORMATION OUT TO THEIR MEMBERS, THEY SERVE BASICALLY EVERYBODY IN THE COUNTY AS VIRTUALLY THE PHONE COMPANY. SO THOSE ARE PARTNERS AND THE OTHER ONE IS OUR SALE BARNS FOR OUR LIVESTOCK SALES. IF YOU WANT TO REACH RURAL FAMILIES TO GET INFORMATION OR WHATEVER, THOSE ARE SOME OF THE SOCIAL NETWORKS THAT ARE OUT THERE AND THEY HAVE THEIR COOPERATIVE LUNCHEONS AND AT THE SALE BARN YOU REACH A LOT OF GUYS BUT WWEN GO TOO. THESE ARE SOME -- IF YOU'RE LOOKING ABOUT ENGAGING COMMUNITIES OTHER THAN INDIVIDUALS PER SE BUT ALSO INDIVIDUALS, MANY OFTEN TIMES LEADERS IN THEIR COMMUNITIES, THOSE ARE SOME OTHER RESOURCES TO THINK ABOUT IN RURAL COMMUNITIES. >> THANK YOU. I GUESS NOW THAT YOU MENTIONED OUTREACH I'M A COMMANDER OF AN AMERICAN REGION POST. IN MANY RURAL COMMUNITIES AMERICAN LEGION, VFW, FLEET RESERVE, SOME ORGANIZATIONS ARE WELL ORGANIZED HAVE A GREAT NETWORK OF COMMUNICATING AND OUTREACH SO WE CAN THINK ABOUT THAT PARTICULAR GROUP. >> SPEAKING OF NETWORKS, TERRY HASN'T TAKEN TO TASK COMING BACK TO THAT POINT ABOUT COOPERATIVE EXTENSION. SORRY. SO I THE POINT THAT WAS ON THE SLIDE THAT WE SAID TO COME BACK TO TALKING ABOUT THE LARGER CONTEXT, THAT WASN'T MY PARTICULAR POINT SO I COULD MAKE A RELATED ONE SORT OF TO START WITH TO UNDERSCORE WHAT HAS COME UP SEVERAL TIMES IN THE COURSE CENTRAL TO MY PRESENTATION ABOUT THE TREMENDOUS RESOURCE THAT EXISTS, PRETTY MUCH STILL EVERY TEAM IN THIS COUNTRY THROUGH THE EXTENSION SYSTEM THAT USED TO BE DESCRIBED THE LARGEST INFORMAL EDUCATION SYSTEM IN THE WORLD, THE MODEL THAT I PRESENTED WAS ABOUT ONE WAY, A VALIDATEDRY SYSTEM FOR EVIDENCE BASED INTERVENTION BUS THERE ARE OTHER THINGS THAT COULD BE CONSIDERED THAT COULD BE SERVED THE POINT ON THE SLIDE WAS ABOUT HOW THE EXTENSION SYSTEM COULD FACILITATE THE TRAINING OF HEALTHCARE WORKERS, ONE OF THE THINGS WE'RE TALKING ABOUT THAT KIND OF GETS TO THAT POINT IS CREATIVE WAYS OF EXTENSION PEOPLE TEAMING UP, ESPECIALLY PEOPLE -- EXTENSION PEOPLE DOING NUTRITION EDUCATION WITH PUBLIC HEALTH PEOPLE SCHOOL PEOPLE, TO HELP FACILITATE TRAIN FOR DELIVERING EVIDENCE-BASED PROGRAMS, THEY'RE ALL LIFESTYLE CHANGE AN OBESITY PREVENTION. >> THANK YOU. THAT COMPLETES OUR PRESENTATION FOR THIS AFTERNOON. WOULD YOU JOIN ME IN THANKING THE PANELISTS. [APPLAUSE] AND I WOULD ASK YOU TO REMEMBER TO FILL OUT YOUR EVALUATION SHEETS AND THEN I'M GOING TO HAVE DR. WHITE TO PLEASE COME UP AND MAKE SOME COMMENTS FOR US. THERE SHE IS. >> THIS CERTAINLY HAS BEEN AN EXCITING TWO DAYS. I WANT TO THANK Y'ALL FOR JOINING US IN THIS ENDEAVOR ON BEHALF OF THE PLANNING COMMITTEE. ALSO THANK THE PLANNING COMMITTEE MEMBERS FOR GIVING US TIME AND SUPPORT THAT WE NEEDED TO BE ABLE TO PLAN AND EXECUTE THIS ENDEAVOR. THE SPEAKERS DID AN OUTSTANDING JOB OUTLINING AND DESCRIBING ISSUES BASED IN RURAL RESIDENCES IN TERMS OF HEALTH AND ALSO GAVE US SOME GREAT SUGGESTIONS HOW WE CAN MOVE FORWARD THINGS WE SHOULD BE DOING MORE OF OR LESS OF IN SOME CASES. AND WE DON'T SEE THIS AS AN END TO THE CONFERENCE BUT A BEGINNING OR FIRST NEXT STEPS SINCE WE HAVE BEEN ON THIS JOURNEY FOR A WHILE IN TRYING TO IMPROVE RURAL HEALTH OUTCOMES. WHEN THE PLANNING COMMITTEE FIRST GOT TOGETHER ONE OF THE LARGER OUTCOMES THAT WE WERE ANTICIPATING WAS TO BE ABLE TO DO A WHITE PAPER BUT OVER THE COURSE OF THESE TWO DAYS I HAVE HEARD CONVERSATIONS AROUND A BOOK CHAPTER, CONVERSATIONS AROUND A JOURNAL SUPPLEMENT OR SOME SPECIAL ISSUES TO A JOURNAL, I HAVE HEARD THE GROUPS PRESENTED TODAY TALK ABOUT USING THE PEOPLE THAT WE ASSEMBLE TOGETHER TODAY AND YESTERDAY TO FORM A WORK GROUP, THE TRANSAGENCY TRANSDISCIPLINARY TRANSLATION GROUP OF FOLKS, ALSO TO DO A SYNTHESIS OF WHAT'S ALREADY BEEN DONE, SYNTHESIS OF RECRUITMENT AND RETENTION APPROACHES DONE IN DIFFERENCE GROUPS AND SEE WHERE THEY CONNECT AND WHERE THEY DISCONNECT. SO MY WARNING TO THE PLANNING COMMITTEE AND TO OUR SPEAKERS IS STAY TUNED, YOU'LL BE CONTINUING TO CONTACT YOU AFTER THE MEETING HAS ENDED. I WANT TO THANK YOU ALL FOR COMING. AND THE ACTUAL MEETING WAS VIDEOCAST LIVE SO IT'S GOING TO BE AVAILABLE IN ARCHIVE AND WE ALSO ARE GOING TO BE WORKING WITH SPEAKERS TO GET THEIR SLIDES WITH PERMISSION POSTED TO THE WEBSITE SO PEOPLE WHO WESTERN ABLE TO ATTEND THE MEETING CAN ACCESS THOSE MATERIALS AT A LATER POINT. SO WITH THIS I WILL CLOSE, THANK YOU AND SAFE TRAVELS TO THOSE WHO TRAVEL FROM AFAR. THANK YOU.