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Marriage Education and Marriage Education and Health Care Reform: Health Care Reform:

What’s the Connection?What’s the Connection?Workshop #320Workshop #320

Smart Marriages Conference, 2009Smart Marriages Conference, 2009

Jana Staton, Ph.D., LCPCJana Staton, Ph.D., LCPCMarriage Works Learning CenterMarriage Works Learning Center

Patty Howell, Ed.M., A.G.C.Patty Howell, Ed.M., A.G.C.California Healthy Marriages CoalitionCalifornia Healthy Marriages Coalition

Lara Rezzarday, MPALara Rezzarday, MPANational Multiple Sclerosis SocietyNational Multiple Sclerosis Society

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Overview of PresentationOverview of Presentation

To articulate the alignment between To articulate the alignment between Healthy Marriages and HealthHealthy Marriages and Health

Why emphasize Prevention? Why emphasize Prevention?

Relevance: Marriage Relevance: Marriage Education/Relationship Education is Education/Relationship Education is essentialessential to health care reform to health care reform

Relationship Education in practiceRelationship Education in practice Making the case to national and local Making the case to national and local

leadersleaders

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““Healthy Marriage” Definition Healthy Marriage” Definition Often Misunderstood Often Misunderstood

from http://www.childtrends.org from http://www.childtrends.org

Healthy Marriage/ Relationships

•Safety•Satisfaction•Communication•Interaction/time together•Commitment to the couple•Intimacy/emotional support•Healthy conflict resolution• Fidelity•Commitment to the children•Duration over time

Child Well-being

•Positive socio- emotional outcomes•Cognitive attainment and educational achievement•Good health and safety• Positive attitudes/ values towards marriage & children•Confident dating behavior, sexual activity, relationship skills•Marital stability in adulthood

Definition: Consequences for Adults, Children

Adult Well Being

•Physical longevity•Better mental health•Wealth•Social Support• Satisfaction & happiness•Less risk-taking (substance abuse, illegal activities

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Marital/Family Breakdown is a Health Marital/Family Breakdown is a Health Care Issue with Hidden CostCare Issue with Hidden Cost

US divorce rate continues at close to 40%US divorce rate continues at close to 40%– 1 million+ US divorces each year1 million+ US divorces each year– Impacts approx. 1,500,000 more kids each Impacts approx. 1,500,000 more kids each

yearyear Fewer couples are marrying—instead Fewer couples are marrying—instead

cohabiting & having childrencohabiting & having children– Estimated 2.4 million children in cohabiting familiesEstimated 2.4 million children in cohabiting families– Estimated that half of cohabiting families will break up Estimated that half of cohabiting families will break up

over time over time

America’s Families & Living Arrangements, US Census Estimates, 2008. America’s Families & Living Arrangements, US Census Estimates, 2008.

http://www.census.gov/population/www/socdemo/hh-fam/cps2008.html.http://www.census.gov/population/www/socdemo/hh-fam/cps2008.html.

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Direct Economic Costs of Direct Economic Costs of Divorce & Family FragmentationDivorce & Family Fragmentation

David Schramm—David Schramm—Journal of Family & Journal of Family & Economic IssuesEconomic Issues– Social Services burden on State Social Services burden on State

and Federal coffers = and Federal coffers = $$30,000 30,000 per divorceper divorce

Ben Scafidi—Ben Scafidi—The Taxpayer CostsThe Taxpayer Costs of Divorce and Unwed Childbearingof Divorce and Unwed Childbearing

– $112 Billion/year$112 Billion/year for US for US taxpayerstaxpayers

– State-level estimates are State-level estimates are included in report at Institute for included in report at Institute for American Values: American Values: http://www.americanvalues.org/hhttp://www.americanvalues.org/html/coff_mediaadvisory.htmtml/coff_mediaadvisory.htm

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Working UPSTREAM to Reduce Working UPSTREAM to Reduce (Hidden) DOWNSTREAM Costs (Hidden) DOWNSTREAM Costs

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Argument for Linking ME/REArgument for Linking ME/REto Health & Well-beingto Health & Well-being

Framework:Framework: ME/RE = A preventive ME/RE = A preventive intervention to reduce chronic illness intervention to reduce chronic illness and promote well-being in families & and promote well-being in families & couples. couples.

ME/RE has a well-documented ME/RE has a well-documented connection to healthier children connection to healthier children ANDAND healthier adults.healthier adults.

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Argument for Linking ME/REArgument for Linking ME/REto Health & Well-being, cont.to Health & Well-being, cont.

ME/RE enables health care institutions to invest in ME/RE enables health care institutions to invest in prevention = prevention =

• Enormous benefits for their patientsEnormous benefits for their patients• Enormous PR value as caring institutionEnormous PR value as caring institution• Enormous PR value as socially responsible institutionEnormous PR value as socially responsible institution• Enormous PR value as cutting edge institution—part of the Enormous PR value as cutting edge institution—part of the

“solution” to U.S. health care problems “solution” to U.S. health care problems • Great cost-effectivenessGreat cost-effectiveness

– ppoossiittiivvee

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Benefits of Healthy Marriages Benefits of Healthy Marriages for Health Promotionfor Health Promotion

Key points for Health Care ReformKey points for Health Care Reform::

– ChildrenChildren:: health & well-being depends health & well-being depends on safe, stable, nurturing parents, and on safe, stable, nurturing parents, and especially on two biological parent especially on two biological parent familiesfamilies

– AdultsAdults: : health depends on healthy health depends on healthy immune system functioning, low chronic immune system functioning, low chronic stress, adherence to health care stress, adherence to health care regimens, which in turn depend on social regimens, which in turn depend on social relationships & support.relationships & support.

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Research Summaries to Support Research Summaries to Support ME/RE in Health Care Reform ME/RE in Health Care Reform

www.CaMarriage.com www.healthymarriageinfo.org

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Research on the Connection between

Marital Outcomes & Health Outcomes —

Healthy and Unhealthy

Top 8 Findings

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#1 #1 Healthy Lifetime RelationshipsHealthy Lifetime RelationshipsBenefit Benefit BothBoth Partners’ Health Partners’ Health• Marriage has positive lifetime health

benefits for men –reduces risky behaviors, increases social support. (Wood, 2007)

• Marriage has positive lifetime health benefits for women – increasing with duration and quality (Lillard & Waite, 1995)

• Even low-income married couples have better health than unmarried peers (Schoenborn, 2004 US Census).

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Waite, L. (2005).“Marital biography and health.” Plenary address, Smart Marriages and Happy Families Conference, Dallas, TX: Coalition for Marriage, Family and Couples Education. Charts used by permission of the author., based on Lillard, L.A. & Waite, L.J(1995). ‘Till death do us part: Marital disruption and mortality. American Journal of Sociology, 100, 1131-1156.

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#2 #2 Kids are Healthier Kids are Healthier • Children are healthiest growing up with 2

biological parents, compared to other family arrangements (Bramlett & Blumberg, 2003). o Children of divorce have more acute & chronic

illness as adults (Maier & Lachman, 2000).o Young children in high-conflict families have high

levels of stress hormones, a marker of chronic stress (Gottman & Katz, 1989).

o Conflictual marriages AND divorce are both associated with poorer health outcomes for children & teens (Furstenberg & Kiernan, 2001; Kaye et al., 2009).

o More ER asthma visits for children of unstable unmarried co-parents (Harknett, 2005).

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#3 #3 Marital Quality is KeyMarital Quality is Key

• Marital quality, not marital status, explains health benefits - and risks - of marriage for both children & adults:o Negative interactions – criticism, demands, emotional

withdrawal – are the biggest risks for poor health.o Frequency of reported positive or supportive behaviors shows

little association with better health! (Bookwala, 2005; Umberson 2006; De Vogli, 2007)

o Poor marital quality wipes out impact of other health benefits of marriage. (Umberson et al., 2005; Bookwala, 2005)

o Couples in very unhappy, distressed marriages have worse health outcomes over 12 years than do equally unhappy couples who divorce in that period (Hawkins & Booth, 2005).

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How Does Research How Does Research Measure “Marital Quality”?Measure “Marital Quality”?

Health & Retirement Survey (HRS) (Waite & Hughes, 2009)

• Do you and your spouse/partner like to do things together, or do things apart?

• How enjoyable is it for you to spend time together with your partner?

Midlife in the US (MIDUS); funded by Nat’l Institute on Aging

Positive spousal/partner behaviors -- How much:• Does your spouse care for you?• Does your spouse understand the way you feel?• Does your spouse appreciate what you do?

Negative spousal behaviors – How often does:• Your spouse make too many demands on you?• Your spouse make you feel tense?• Your spouse criticize you?

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#4 Marital Quality and Teen #4 Marital Quality and Teen Risk BehaviorsRisk Behaviors

• Marital conflict, family disruptions directly affect teen health risk behaviors. (Brown, 2006; Feinberg, et al., 2007)

• Teen & later adult health is directly linked to risky health behaviors: smoking, drugs, early sexual activity, delinquency. (Healthy Marriages, Healthy Lives, 2008)

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Epigenetics: Why Healthy Families and Epigenetics: Why Healthy Families and Healthy Marriages MatterHealthy Marriages Matter

Epigenetics: Epigenetics: The study of gene-environmentThe study of gene-environmentinteractionsinteractions

• Healthy family processes suppress the Healthy family processes suppress the expression of genetic tendencies such as expression of genetic tendencies such as aggression, early sexual activity, substance aggression, early sexual activity, substance abuseabuse (Halpern, et al., 2007;(Halpern, et al., 2007; Guo, Roettger, Cai, 2008).Guo, Roettger, Cai, 2008).

• Families that eat together suppress the Families that eat together suppress the expression of gene variants (MAOA & DRD2) expression of gene variants (MAOA & DRD2) associated with delinquent/violent adolescent associated with delinquent/violent adolescent behavior (BOTH male & female) behavior (BOTH male & female) Guo, Roettiger, Cai, Guo, Roettiger, Cai, 2008).2008).

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# 5 # 5 Heart Disease Links toHeart Disease Links toMarriage & Marital Quality Marriage & Marital Quality

Married men & women are less likely to die from heart Married men & women are less likely to die from heart attacks, more likely to return to health attacks, more likely to return to health (Zhang & Hayward, (Zhang & Hayward, 2006; Johnson, et al., 2000).2006; Johnson, et al., 2000).

Men and women in ‘Men and women in ‘high-quality’ high-quality’ marriages live longer marriages live longer with CVD, independent of severity of illness, than do with CVD, independent of severity of illness, than do those in ‘low quality’ marriages (those in ‘low quality’ marriages (Coyne, et al., 2001; Coyne, et al., 2001; Rohrbaugh, et al., 2006).Rohrbaugh, et al., 2006).

Women are more likely to develop early signs of heart Women are more likely to develop early signs of heart disease (metabolic syndrome) if they are in less disease (metabolic syndrome) if they are in less satisfying relationships satisfying relationships (Gallo, et al., 2003).(Gallo, et al., 2003).

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#6 #6 Marital Quality & Aging Marital Quality & Aging Marital quality has MUCH more impact on adult health Marital quality has MUCH more impact on adult health

as we ageas we age:: (Umberson, et al., 2006)(Umberson, et al., 2006)

– Poor health in older adults is directly correlated with Poor health in older adults is directly correlated with negativenegative spousal interactions. spousal interactions. (Bookwala, 2005)(Bookwala, 2005)

– Remarriage brings health benefits, making up for Remarriage brings health benefits, making up for negative impacts of divorce.negative impacts of divorce. ((Sbarra, 2008, Waite, 2005)Sbarra, 2008, Waite, 2005)

– Having a spouse in old age reduces nursing home & Having a spouse in old age reduces nursing home & hospital admissions & protects against loss of ADL.hospital admissions & protects against loss of ADL. (Schoenborn, 2004)(Schoenborn, 2004)

–

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#7 #7 PPartner Support Blocks Stressartner Support Blocks Stress

Support from husband (holding a hand) Support from husband (holding a hand) blocks pain and lowers stress response in blocks pain and lowers stress response in happily married wives undergoing happily married wives undergoing experimental electric shocks.experimental electric shocks. (Coan, et al., 2006)(Coan, et al., 2006)

““Warm Partner Support” in stressful Warm Partner Support” in stressful experimental conditions lowers blood experimental conditions lowers blood pressure and heart rate, and increases pressure and heart rate, and increases oxytocin, protecting the cardiovascular and oxytocin, protecting the cardiovascular and immune system. immune system. (Grewen, et al., 2003-2005), Light, et al., 2005)(Grewen, et al., 2003-2005), Light, et al., 2005)

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#8 Potential Pathway from Marital Quality #8 Potential Pathway from Marital Quality to Adult Chronic Illnessto Adult Chronic Illness

The big finding!The big finding!

Marital Marital Adults Adults Chronic Major Chronic Major

Conflict Conflict Chronic inflammatory chronic Chronic inflammatory chronic

& Distress Stress & Distress Stress response response illnesses illnesses (immune system)(immune system)

Many OtherMany Other

Sources of StressSources of Stress

Based on Dr. Janice Kiecolt-Glaser presentation “Families & Health: Inflammation Based on Dr. Janice Kiecolt-Glaser presentation “Families & Health: Inflammation

as a Central Pathway.” Families & Health Conference, NCMR/NIH, June 2, as a Central Pathway.” Families & Health Conference, NCMR/NIH, June 2, 20092009

Accessed online at http://ncmr.bgsu.edu/events/families_and_health.htmlAccessed online at http://ncmr.bgsu.edu/events/families_and_health.html

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Chronic Illness and Relationship Education in Practice National Multiple Sclerosis Society: Relationship Matters

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Risk Factors for a Marriage Living Risk Factors for a Marriage Living with Chronic Illness with Chronic Illness

Ongoing unpredictabilityOngoing unpredictability Expectations about the relationship Expectations about the relationship

are challengedare challenged Strained resources (financially and Strained resources (financially and

emotionally)emotionally) Symptoms interfere with sexuality, Symptoms interfere with sexuality,

communication and intimacycommunication and intimacy

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How NMSS How NMSS Relationship MattersRelationship Matters Program Addresses the Problems Program Addresses the Problems

Allows couples to “normalize” the Allows couples to “normalize” the problem and offer examples, problem and offer examples, solutions (“we aren’t alone”).solutions (“we aren’t alone”).

Teaches tools for consistent Teaches tools for consistent communication, despite communication, despite unpredictability.unpredictability.

Encourages couples to embrace Encourages couples to embrace adaptations and being open to adaptations and being open to change (sexuality, having fun, etc.). change (sexuality, having fun, etc.).

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Marriage Education Curriculum Marriage Education Curriculum Designed for Couples Living With MSDesigned for Couples Living With MS

Program offers three ways to learn: Program offers three ways to learn: in-person, teleclasses and online.in-person, teleclasses and online.

Focuses on Focuses on couple relationshipcouple relationship, not , not caregiving or the person with MScaregiving or the person with MS

Offers additional resources through Offers additional resources through National MS Society (counseling, National MS Society (counseling, support groups, financial assistance)support groups, financial assistance)

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(Data as of 7/2009)

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Data as of 7/2009

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(As of 7/2009)

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Connecting Marriage & Relationship Connecting Marriage & Relationship Education to Health Care ReformEducation to Health Care Reform

ME/RE Education More safe, stable ME/RE Education More safe, stable healthy marriages healthy marriages

Fewer health risk behaviorsFewer health risk behaviors Less chronic stressLess chronic stress Chronic illness preventionChronic illness prevention Lower costs for treating physical Lower costs for treating physical

& mental illnesses (social support, & mental illnesses (social support, adherence)adherence)

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Effectiveness of Marriage Education/Relationship Education

Several meta-analyses: 100+ studies: “Clear evidence that Marriage

Education programs work—to reduce strife, improve communication, increase parenting skills, increase stability, and enhance marital happiness.”

Researchers concluded that “…Marriages can do more than merely survive: They can

also thrive when couples learn the skills to make their relationships work.”

– Fagan, Patterson & Rector. “Marriage and Welfare Reform: The Overwhelming Evidence that Marriage Education Works.” The Heritage Foundation: Backgrounder #1606.

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Effectiveness of ME/RE, cont.

Other meta-analyses:• Giblin, Sprenkle, Sheenan, 1985.• Butler & Wampler, 1999.• Markman, et al., 1993.• Carroll & Doherty, 2003. • Hawkins, Blanchard, Baldwin & Fawcett,

2008.• Blanchard, Hawkins, Baldwin & Fawcett,

2009.

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Effectiveness of ME/RE, cont.

“Preliminary research shows that marriage education workshops can make a real difference in helping married couples stay together and in encouraging unmarried couples who are living together to form a more lasting bond. Expanding access to such services.. Should be something everybody can agree on…”

– Barack Obama, 2006. The Audacity of Hope. New York: Three Rivers Press, p. 334.

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2008 Wingspread Conference 2008 Wingspread Conference RecommendationsRecommendations

– Where Marriage Educators Can Start – Where Marriage Educators Can Start Look for Health Care AlliesLook for Health Care Allies::

– In ‘patient-centered care’ & Medical Home Model.In ‘patient-centered care’ & Medical Home Model.– Life course transitions in primary health care - Life course transitions in primary health care -

dating, new baby, empty nesters.dating, new baby, empty nesters.– Lifestyle programs for chronic illness--heart, Lifestyle programs for chronic illness--heart,

diabetes, multiple sclerosis.diabetes, multiple sclerosis.– Early childhood intervention – Head Start, Olds Early childhood intervention – Head Start, Olds

Nurse-Family Partnership.Nurse-Family Partnership.– Education & Continuing Education for medicalEducation & Continuing Education for medical

residents, physicians, nurses.residents, physicians, nurses.

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Words that Words that OpenOpen Health Care Health Care and Community Agency Doors and Community Agency Doors

““Innovative approach to addressing Innovative approach to addressing health care problems in the U.S.”health care problems in the U.S.”

““SAFE, stable, healthy families”SAFE, stable, healthy families” ““Healthy Marriages”Healthy Marriages” ““Evidence-based practice” Evidence-based practice” (PREP is listed in SAMHSA NREPP for mental health)(PREP is listed in SAMHSA NREPP for mental health)

““Marital quality”—directly affects adult Marital quality”—directly affects adult health health

““Prevention” of family breakdownPrevention” of family breakdown

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WHY talk about “Marital & WHY talk about “Marital & Relationship Quality”?Relationship Quality”?

Health now recognized as being created Health now recognized as being created through an ongoing interrelationship through an ongoing interrelationship between between bio-psycho-social factorsbio-psycho-social factors

Therefore, Therefore, the family is a primary place the family is a primary place where health is created, or health is where health is created, or health is damageddamaged

The The quality of the marital relationship is quality of the marital relationship is key to the quality of health created within key to the quality of health created within the family contextthe family context

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Unique Factors about Bio-Health Unique Factors about Bio-Health Care & Public PolicymakersCare & Public Policymakers

Inclusiveness for all couples is REQUIRED Inclusiveness for all couples is REQUIRED in health care.in health care.

Skeptical about marriage: many have Skeptical about marriage: many have been through distressed, low-quality been through distressed, low-quality marriage and divorce.marriage and divorce.

Many don’t know the research connecting Many don’t know the research connecting marital/relationship marital/relationship qualityquality to health to health outcomes, esp. adult physical health.outcomes, esp. adult physical health.

They cannot afford to be wrong.They cannot afford to be wrong.

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YES WE CAN!YES WE CAN!BE VERY SPECIFIC: BE VERY SPECIFIC:

ME/RE TEACHESME/RE TEACHES:: Healthy Mate ChoiceHealthy Mate Choice SafetySafety Effective Communication & Conflict Resolution Effective Communication & Conflict Resolution

SkillsSkills CommitmentCommitment Ways to Protecting Friendship & IntimacyWays to Protecting Friendship & Intimacy

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YES WE CAN!, cont.YES WE CAN!, cont.

ME/RE targets negative interactions linked to ME/RE targets negative interactions linked to poorer physical & mental health;poorer physical & mental health;

These targets are difficult and expensive to These targets are difficult and expensive to address downstream and much easier and address downstream and much easier and less costly to address upstream;less costly to address upstream;

ME/RE Works;ME/RE Works; ME/RE is a timely and innovative approach for ME/RE is a timely and innovative approach for

addressing numerous health care problems; addressing numerous health care problems; ME/RE helps couples provide long-term and ME/RE helps couples provide long-term and

effective social support associated with effective social support associated with numerous health outcomes.numerous health outcomes.

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SUMMARY SUMMARY ME/RE can support and increase # of ME/RE can support and increase # of

healthy, lifelonghealthy, lifelong marriages; marriages; ME/RE can help reduce ME/RE can help reduce enormousenormous social social

service burden associated with family service burden associated with family breakdown;breakdown;

ME/RE can reduce health care costs ME/RE can reduce health care costs resulting from marital distress & family resulting from marital distress & family breakdown;breakdown;

Opportunity and importance for us to Opportunity and importance for us to communicate this message of alignment.communicate this message of alignment.

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Full Citations in Notes & on HandoutFull Citations in Notes & on Handout

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Thank you for being involved in this with us!

Jana Staton– jstaton@montana.org

Patty Howell– Patty@CaMarriage.com

Lara Rezzarday– Lara.rezzarday@nmss.org

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We Have a Great Opportunity to Contribute