COMMUNITY PROFILE FOR THE NATIONAL CAPITAL AREA

M+R STRATEGIC SERVICESSUSAN G. KOMEN FOR THE CURE

05.16.07

Overview ....................................................................................................................... 1

Findings ........................................................................................................................ 3

Methods and Scope .......................................................................................... 4

Community Resources Don't Reach Many in Need ........................................... 5

Accessibility of Resources and Programs ............................................................ 6

Are Resources Appropriate and of Acceptable Quality? ..................................... 6

Solutions Recommended by Community Members .......................................... 7

Gaps for Certain Populations ............................................................................ 8

Beliefs and Attitudes That Influence Breast Health Statistics ............................... 8

Common Themes and Important Messages ...................................................... 9

Conclusions ................................................................................................................. 11

TABLE OF CONTENTS

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EXECUTIVE SUMMARYEXECUTIVE SUMMARY

T he Washington DC metro area community needs assessment encompasses a broad anddiverse area that includes the entire Washington DC metropolitan area, Northern Virginiacommunities and suburban Maryland counties north of Washington. This is a large commu-

nity that has a diverse population, where people from all over the world live, sometimes only tem-porarily. It Is also home to a large African American and Hispanic population.

The health care system in the community is one of the finest in the country and arguably In theworld, and includes the renown research facilities at the National Institutes of Health and theNational Cancer Institute. But despite these resources being right here In the community, there Isa large and growing population that faces barriers to care and cannot access these facilities for avariety of reasons, Including lack of health care coverage, lack of Information about available serv-ices, language barriers and difficulty navigating a complex and disjointed system of health careand financing.

Within the breast cancer community of providers, survivors and advocates, there is great concernabout breast cancer statistics In this population. Washington DC, for example, has the highestbreast cancer mortality rate in the U.S. Community members are recognize the assets of the com-munity and realize the potential to affect breast cancer statistics is there If the community comestogether, pools Its collective knowledge and develops a more organized mechanism to shareInformation and resources.

The community also concludes that special attention must be paid to reaching underserved pop-ulations that may face unique barriers for a variety of reasons: language, legal status, income oreconomic status, lack of health care coverage, and cultural myths about breast cancer. Communityleaders conclude that using the faith community effectively could positively affect breast cancerstatistics over time if the effort were properly supported with funding and other resources.

The assessment, which Included an analysis of a variety of current statistical Information, a surveyof community leaders and activists and in-depth Interviews with breast cancer survivors, providersand medical professionals concluded that these are the areas of greatest need with the greatestpotential to achieve positive outcomes:

TOP PRIORITY AREAS OR GAPS: WHAT ARE THE NEEDS AND

WHERE CAN KOMEN HAVE THE MOST SIGNIFICANT IMPACT?

1. Assist the working poor in medically underserved areas like Anacostia.While the region includes some of the finest health care and medical research institutions inthe world, there are still areas where access to breast health and breast cancer services isextremely limited. The most notable area is in the Southeast quadrant of Washington, DC eastof the Anacostia River. The Anacostia area has some of the poorest neighborhoods in the areaand has an almost exclusively African-American population. This area is grossly underserved bythe health care system. The lack of access to breast health services is contributing to very highbreast cancer mortality rates.

Women in Anacostia, particularly the working poor who do not qualify for Medicaid or the DCHealthcare Alliance, would benefit tremendously from having a full and comprehensive arrayof breast health services along the continuum of care. This should include screening, diagno-sis, treatment and follow up services available to women in their own neighborhoods deliv-ered through institutions they trust.

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Interviewees note that an investment in a mobile mammography unit could have a positiveimpact in Anacostia and other underserved areas. Select other communities have used thesesuccessfully,but they are notably expensive to maintain and operate. However, key informantsbelieve that, given the density of the population, the region could support another mobilemammography unit with an investment of public and private funds.

A shift in policy that “closes the gap” for the working poor is essential and should be consid-ered a high priority in this community. Even working women, able to pay privately for healthinsurance, may still not be able to afford costs associated with time off of work, co-payments,deductibles, and ongoing childcare expenses if they are too ill to work and care for their chil-dren. These problems are especially evident in Anacostia. Expanding breast cancer screeningand Treatment Act eligibility guidelines through Medicaid and the Alliance would allow morewomen to actively seek breast health services, necessary treatment and follow-up care – pre-venting more costly, and often fatal, late diagnoses.

2. Use the faith community in a more comprehensive way.The breast health service delivery system needs an infusion of additional resources so it canfully utilize the potential of the faith community. This community must be mobilized to morefully join promising efforts to fight breast cancer in the region. Using the faith community andhealth ministry programs will have an enormous impact on breast cancer statistics if these ini-tiatives were properly developed and adequately funded. The recruitment of navigators work-ing through local faith-based organizations should be a top priority.

3. Invest in the community to build a sustainable breast health services infrastructure.Having provided seed money for the development and implementation of many promisingbreast cancer programs in this community, Komen could have an even greater impact with asignificant investment in the overall infrastructure of the breast health and breast cancer serv-ice delivery system. Such an investment would promote a more comprehensive and sustain-able delivery system and ensure that programs that have presented evidence of success inreducing breast cancer mortality can thrive beyond the period of initial grant funding. Breasthealth service program directors are eager to learn from one another, to implement programsthat are effective and to stop spending resources on programs that have not demonstratedsuccess.

4. Invest in community-based breast health services that effectively remove cultural andlanguage barriers for women seeking information or breast health services. Given theenormous diversity of the DC area population, many women in the community are not wellserved by providers who do not offer services in a culturally competent manner or services inlanguages other than English. Providers would have wider opportunities to serve a broaderpopulation if they had the resources to develop culturally competent programs and couldcommunicate with people in their native languages. Komen should invest in programs andservices that are already being developed or in new or innovative programs that address lan-guage and cultural barriers. Breast health services would be more widely utilized by womenin the community if they were provided education about the importance of breast health andassistance in navigating the delivery system in languages they understand.

F I N D I N G SF I N D I N G S

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METHODS AND SCOPE

This community profile draws on the expertise and experience of key informants from theNational Capital Area including physicians, nurses, breast care navigators, breast cancer sur-vivors, breast cancer program directors, researchers, faith community leaders, parish nurses

and community organization executives.

Of particular note were the contributions of one key informant, a breast cancer survivor of over 10years, who led an informal discussion with her church breast cancer support group to help guideour recommendations. Our informant asked the group, comprised of African-American women inWashington, DC, to offer their thoughts about the breast care delivery system, their own experi-ences and what community improvements they would like to see for breast cancer patients, sur-vivors and their families. The insights and responses gleaned from that discussion are melded intothe community profile and are woven into the overall recommendations.

The community profile is also informed by survey responses from 277 Komen online advocateswho live in the area studied. These advocates had previously taken action on Komen’s public pol-icy website, www.ActNowEndBreastCancer.org. Respondents were asked to identify their involve-ment in the breast cancer issue so that the perspectives of groups such as survivors, co-survivors,doctors, nurses and social workers could be analyzed and compared.

The community profile includes a comprehensive data set on the demographics of the communi-ty as well as a comprehensive listing of all the services available. The data contained in the appen-dix includes a detailed map of the service area and a variety of other sources that paint a clear pic-ture of the entire community.

In addition, the community profile was informed by a more comprehensive study completed in2006 by the DC Cancer Coalition. DC has the highest breast cancer mortality rate in the nation.In addition, implementation of the DC Cancer Control Plan has implications for residents of theDC suburbs, many of whom travel to the District to receive services.

The majority of key informants interviewed for the community profile noted that the DC CancerCoalition study was perceived as credible and very comprehensive, having been developed in acollaborative process that included input from key stakeholders from across the region. It took fouryears to complete and was initiated with funding from the federal Centers for Disease Control andPrevention. Many of the interview subjects participated in the development of the DC CancerControl Plan. Interviewees strongly suggested that the DC Cancer Control Plan be taken into con-sideration in this community profile so as not to duplicate the time, talent, and collaboration thatwere essential to its development. The DC Cancer Control Plan was drafted as a blueprint forreducing DC’s worst in the nation breast cancer mortality rate by 2010. The community profileincorporates the Plan’s findings, recommendations and statistics where appropriate.

This community profile includes Washington, DC, Montgomery and Prince George’s counties insuburban Maryland, and Loudon, Fairfax, Prince William, and Arlington counties in northernVirginia as well as the city of Alexandria.

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COMMUNITY RESOURCES DON’T REACH MANY IN NEED

Most of the institutions that provide a full range of breast health and breast cancer servicesare located in metropolitan areas including the District of Columbia, the city ofAlexandria, Fairfax, and the suburbs of Montgomery and Prince George’s counties that

are closest to the District. Despite the availability of a comprehensive state of the art health caredelivery system and the world renown research institutions at the National Institutes of Health andthe National Cancer Institute, many area residents, particularly the poor or working poor, do nothave reasonable, affordable access to complete breast care. Their unmet needs include screening,treatment, follow up services for survivors, palliative care at the end of life and support for familymembers after a loved one had died from breast cancer.

For DC residents who are uninsured, options for coverage of breast health services are Medicaid(for very low income residents) and the DC Health Care Alliance. The Alliance is technically for theworking poor – people who are employed but who do not have employer-sponsored health insur-ance or other health care coverage. While it is a tremendous resource for some, it has its limita-tions. The income thresholds set by Alliance rules are relatively low, so many workers with low pay-ing jobs still do not qualify. Many working poor have little access to services because they do notqualify for either Medicaid or the Alliance.

In addition, only two health care institutions in DC, Providence Hospital and Howard UniversityHospital, accept Alliance patients. Providers complain that Alliance payments are “low and slow.”As a result, access for working poor women, even if they are fortunate enough to qualify for theAlliance, is limited. Once they need specialty care, such as surgery, radiation or oncology, Alliancepatients often do not receive the necessary services. Dedicated primary care physicians at the city’scommunity clinics, such as those run by Unity Health, often go to great lengths to ensure theirpatients receive services if they do suspect breast cancer. However, they must rely on a limited net-work of friends and colleagues to assist the patients by providing free care.

Many primary care physicians are unaware of the resources that are available, such as the CapitalBreast Care Center (CBCC), LaClinica Del Pueblo and Nueva-Vida. These organizations provide freeservices along the continuum of care for people with breast health needs. They could serve asmodels for other communities looking to develop a comprehensive array of free or low-cost serv-ices for low-income women. Locally, medical professionals, faith and community leadersneedmore information about such existing programs, including information about how to referpatients and how to support such programs so they can expand their reach.

In the Virginia areas studied, people who are uninsured rely on a network of free or low cost clin-ics to provide care when they are diagnosed with breast cancer. These clinics include the ArlandiaClinic which serves Arlington and Alexandria residents. Maryland residents in the area studied useLaCasa or the Holy Cross Hospital Health Center. Women may also rely on hospitals or health caresystems to provide charity care, but that source of care is unreliable because funds are limited andservices cannot be guaranteed.

In the National Capital Area, patients who have no formal insurance coverage do best when theyreceive some support to work their way through the health care system. Whether the support isformal, though a breast care navigator program, for example, or informal through friends, peoplein their faith community or family, having someone to help tend to the patient and assist them asneeded facilitates the diagnosis and treatment for breast cancer patients. It Is difficult for unin-sured women to find the resources they need on their own If they are diagnosed with breast can-cer. They need a comprehensive array of services and finding them without help is difficult forpatients who cannot pay. Women in the area studied rely frequently on an informal network , suchas church health ministers. These health ministers are often medical professionals, including nurs-

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es, who are skilled at helping fellow members of their place of worship find the resources theyneed, including screening, diagnostic, treatment and follow up services. There is a tremendousneed to remove barriers to accessing appropriate breast health services In this region.

ACCESSIBILITY OF RESOURCES AND PROGRAMS

T he Washington DC area has a comprehensive and reasonably inexpensive public transporta-tion system comprised of buses and the Metro subway / rail system. This system is ideal forpeople who have no limitations with mobility, are not frail and have no language barriers that

would prevent them from navigating the public transportation system. For these women, trans-portation to breast health service centers is fairly accessible. However, older women, women whoare frail or who have limited mobility, and women who do not speak or read English have signifi-cant trouble getting to and from breast health service centers.

Furthermore, women in Southeast Washington, DC tend to travel the farthest to receive servicesbecause most DC breast health facilities are located in the upper Northwest area of the city. Thereare very limited services available in Southeast neighborhoods, including Anacostia. Many womenwho live farthest away from the service providers, and those who have trouble navigating the pub-lic transportation system, rely on friends and family for rides to and from medical facilities.

Women throughout the area have many other barriers besides transportation. Working womenmay find it difficult to take time off work to keep appointments. They also face the prospect of lostwages if they are paid hourly and do not have a medical leave benefit. In addition, women withyoung children may face other financial barriers because they may not be able to arrange for orpay for childcare while they receive medical care. Area women facing a breast cancer diagnosisconfront a myriad of ongoing problems with childcare and lost wages if they hope to receive ade-quate treatment, which may require physically and emotionally draining surgery and substantialtime off of work.

The most successful breast care navigator programs work with women to remove all these barri-ers to receiving adequate care. They arrange for childcare and transportation services for womenwho need those services. Some even arrange for respite care for women who are undergoing long-term treatment and could benefit from time away from their young children.

The most substantial barrier to delivering breast health services to those who need them is a lackof information about what is available and how to access it. This is particularly true among the low-est income women in the area. Breast care navigators have made great strides in removing thesebarriers for the women with cancer that they serve, but there simply are not enough navigators inthe service area to meet the demonstrated need.

ARE RESOURCES APPROPRIATE AND OF ACCEPTABLE QUALITY?

W omen who have insurance and women who are fortunate enough to receive servicesfrom a breast care navigator generally receive high quality services that are appropriateand accessible. However, research on health disparities suggests that low income women

and minority women may not receive the same level of service.

The region boasts a very comprehensive and sophisticated state-of-the-art health care delivery sys-tem and research facilities, yet these services are out of reach for many low-income and minoritywomen, particularly those geographically isolated in the region’s poorer neighborhoods. Theproblem is also very severe for immigrant women.

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Furthermore, language and cultural barriers are often not adequately addressed within the healthcare delivery system, creating barriers for some minority and non-English speaking women.Navigator programs can address language and cultural barriers by helping women with setting upappointments, explaining what will happen during the medical procedure, providing emotionalsupport in a culturally sensitive manner and even providing interpretive services for women whodo not speak or understand English. Since there are too few navigators available, these supportservices are not provided to all women who need them.

SOLUTIONS RECOMMENDED BY COMMUNITY MEMBERS:

PARTNER AND INVEST WITH THE FAITH COMMUNITY AND BUILD ASUSTAINABLE BREAST CARE INFRASTRUCTURE.

C ommunity members interviewed and surveyed think the region is poised to make progressin reducing breast cancer mortality statistics. Many were especially pleased that the DC gov-ernment in particular is taking cancer very seriously and is taking positive steps to address

the problems through its Cancer Control Plan. Interviewees felt that Virginia and Maryland couldbenefit from addressing cancer in a similar, comprehensive way. Interviewees throughout theregion said the area could benefit substantially from using an approach that educates and trainswomen about the importance of early detection, including clinical breast exams, breast self examsand mammography.

Many believe that the faith community is an untapped resource, and that working through healthministers and other leaders in community based religious organizations has the greatest potentialto impact breast cancer statistics. But faith-based organizations need financial support and otherresources if they are to take on this challenge in a sustainable way. Breast cancer is clearly not theonly health care issue in the community, and faith-based organizations balance their resources withthe needs they see firsthand and those the community identifies as important. Faith-based organi-zations’ priorities can change before their work is complete, and these shifts may diminish their ini-tial efforts. The region needs a fully funded faith based initiative that is sustainable over time anddesigned by members of the faith community in a manner that takes into consideration the lan-guage, culture and religious beliefs of the community.

Many breast care navigators have had particular success with moving breast cancer patientsthrough the system and taking a holistic approach to their care, providing emotional and psycho-social support. But there are too few trained and qualified navigators to assist all those who needthis type of support. It is here that the faith community can have an impact as well. Many healthministers serve as de-facto navigators for breast cancer and other cancer patients as well. It will becritical to invest resources in training health ministers and other trusted faith community leaderswho understand the community in which they live, lead and work. Such an undertaking has enor-mous potential to fill a void in the breast care services delivery system.

The community is yearning for systemic changes that will enable the regional breast cancer network(providers at all levels, patients, survivors, advocates, outreach and education organizations andcommunity based religious groups) to be more coordinated and collaborative in their efforts toreduce breast cancer mortality rates. The top criticisms of the current system from the provider per-spective are the lack of communication and coordination about existing breast health programs anda lack of evaluation procedures for these programs. Key informants, particularly past and currentKomen grantees, said they would benefit tremendously from the opportunity to connect with oth-ers in the region that may have ideas and resources that could support their programs.

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Those in the area’s breast health field want to learn from one another, pursue evidence-based com-munity programs targeted to specific populations, and conduct rigorous evaluations of existingefforts. Extending grant periods may help facilitate more thorough evaluations which would includeongoing follow up with patients who were served in the program. Key informants suggested eitherincluding an evaluation component in all new grant programs or hiring an outside scientific orresearch consulting firm to evaluate programs for effectiveness. Interviewees also suggested focus-ing on demonstrable program impacts on breast health statistics.

GAPS FOR CERTAIN POPULATIONS

T he region is extremely diverse with respect to ethnicity, culture, religion, level of educationand socioeconomic status. Interview subjects identified two populations as having significantbarriers and needs: Latina women who are recent immigrants and African or African

American women, particularly those younger than 45.

Latina women were singled out as having special needs for several reasons. They may have lan-guage barriers that prevent them from utilizing educational or outreach materials. They may alsostruggle to communicate effectively with providers and may not understand instructions aboutmedical procedures or expectations if they are not delivered in their native language. They mayalso fail to seek treatment or follow through with referrals because they may be undocumentedand fear their immigration status may be called into question.

African women and African American women under 40 were identified for several reasons. First,they are often not properly referred to the medical system if physicians or other practitionersbelieve they are too young to have developed breast cancer, so this can delay proper diagnosisand treatment. African American women in general are more likely than white women to be diag-nosed with large tumors, and these large tumors tend to be more aggressive, difficult to treat andpresent at a later stage. African American women have a slightly higher incidence rate of breastcancer before age 42. Proper outreach and education in a culturally competent manner is essen-tial. Providing information and education about early detection and treatment to African Americanwomen before as early as 40 or younger in a meaningful way that addresses the myths, fears andnegative attitudes about breast cancer screening and treatment could affect breast cancer statis-tics in this community. In addition, medical professionals who serve young African Americanwomen need to be properly educated about the potential risks that are unique to these womenand be diligent about delivering appropriate screening and diagnostic services.

BELIEFS AND ATTITUDES THAT INFLUENCE

BREAST HEALTH STATISTICS

Despite all the publicity about breast cancer risks and proven detection and treatment strate-gies, many area women still have a fatalistic view about cancer and fail to seek a diagnosisbecause they would rather not know definitively that they have cancer. In some subcul-

tures, a cancer diagnosis carries an enormous stigma and contributes to failure to seek treatmentor a diagnosis.

On the positive side, widely available information about advances in treatment and early detectionhas given some women hope that breast cancer is not an automatic death sentence. Many of thoseinterviewed credited Komen with an enormous contribution in raising awareness.

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Others report that it is very difficult to educate women about breast cancer after they havereceived a diagnosis. They are less able to process helpful information because they are distractedwith complicated emotions and often feel overwhelmed. Interviewees note how difficult it is fornewly diagnosed women to understand the nuances of cancer, including metastases, treatmentoptions, and the need for follow up and self care.

Most agree that making an impact on attitudes and beliefs in the area is difficult work and progressunder the best of circumstances is slow. They point to the faith community as a reliable source forassistance in this regard because it is an ongoing point of contact for target populations and candeliver a repeated and consistent message. Most experts are convinced that a one-time contactwith a medical professional is not sufficient to inform women fully about breast cancer issues, andthat it may take years for some women to fully integrate early detection into their overall healthcareroutine.

COMMON THEMES AND IMPORTANT MESSAGES

T he importance of making inroads in working with the faith community was stressed by nearlyevery person interviewed for this assessment. Most agree that this is an area of potential part-nership and collaboration that can have a real impact on breast cancer challenges in the region.

Many are also eager to see advances in the health care delivery system that would integrate breasthealth into an overall holistic approach so that the system “treats people and not body parts.” Thecurrently disjointed system is most difficult to navigate for people that rely on public programs formedical care. A holistic approach to breast health services would also allow providers to coordi-nate with other agencies that provide services to patients, such as housing agencies, child careproviders, transportation programs, and treat the patient in the context of family and community.This would help address many of the barriers identified by key informants.

An investment in the development of a sustainable infrastructure was another common theme orrequest from the people who contributed to this community profile. A regional “clearinghouse”of information that could be accessible to all those involved in the breast care delivery systemwould go a long way towards reducing breast cancer mortality statistics. Such a clearinghousecould be the foundation for an ongoing collaboration amongst all the key stakeholders in theregion. The clearinghouse could provide opportunities to share resources, educate stakeholdersabout available programs and services, and facilitate an exchange of ideas about promising prac-tices. The clearinghouse could provide access to potential peer reviewers who could evaluate pro-gram ideas or proposals. In addition, It would serve as a source for local and regional events relat-ed to breast cancer and could Include news clips about local or regional programs and events.Such a clearinghouse could be modeled after a very successful collaborative developed by theClearinghouse for the Community Living Exchange Collaborative (www.hcbs.org).

C O N C L U S I O N SC O N C L U S I O N S

TOP PRIORITY AREAS OR GAPS: WHAT ARE THE NEEDS AND

WHERE CAN KOMEN HAVE THE MOST SIGNIFICANT IMPACT?

1. Assist the working poor in medically underserved areas like Anacostia.While the region includes some of the finest health care and medical research institutions inthe world, there are still areas where access to breast health and breast cancer services isextremely limited. The most notable area is in the Southeast quadrant of Washington, DC eastof the Anacostia River. The Anacostia area has some of the poorest neighborhoods in the areaand has an almost exclusively African-American population. This area is grossly underserved bythe health care system. The lack of access to breast health services is contributing to very highbreast cancer mortality rates.

Women in Anacostia, particularly the working poor who do not qualify for Medicaid or the DCHealthcare Alliance, would benefit tremendously from having a full and comprehensive arrayof breast health services along the continuum of care. This should include screening, diagno-sis, treatment and follow up services available to women in their own neighborhoods deliv-ered through institutions they trust.

Interviewees note that an investment in a mobile mammography unit could have a positiveimpact in Anacostia and other underserved areas. Select other communities have used thesesuccessfully,but they are notably expensive to maintain and operate. However, key informantsbelieve that, given the density of the population, the region could support another mobilemammography unit with an investment of public and private funds.

A shift in policy that “closes the gap” for the working poor is essential and should be consid-ered a high priority in this community. Even working women, able to pay privately for healthinsurance, may still not be able to afford costs associated with time off of work, co-payments,deductibles, and ongoing childcare expenses if they are too ill to work and care for their chil-dren. These problems are especially evident in Anacostia. Expanding breast cancer screeningand Treatment Act eligibility guidelines through Medicaid and the Alliance would allow morewomen to actively seek breast health services, necessary treatment and follow-up care – pre-venting more costly, and often fatal, late diagnoses.

2. Use the faith community in a more comprehensive way.The breast health service delivery system needs an infusion of additional resources so it canfully utilize the potential of the faith community. This community must be mobilized to morefully join promising efforts to fight breast cancer in the region. Using the faith community andhealth ministry programs will have an enormous impact on breast cancer statistics if these ini-tiatives were properly developed and adequately funded. The recruitment of navigators work-ing through local faith-based organizations should be a top priority.

3. Invest in the community to build a sustainable breast health services infrastructure.Having provided seed money for the development and implementation of many promisingbreast cancer programs in this community, Komen could have an even greater impact with asignificant investment in the overall infrastructure of the breast health and breast cancer serv-ice delivery system. Such an investment would promote a more comprehensive and sustain-able delivery system and ensure that programs that have presented evidence of success inreducing breast cancer mortality can thrive beyond the period of initial grant funding. Breasthealth service program directors are eager to learn from one another, to implement programsthat are effective and to stop spending resources on programs that have not demonstratedsuccess.

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4. Invest in community-based breast health services that effectively remove cultural andlanguage barriers for women seeking information or breast health services. Given theenormous diversity of the DC area population, many women in the community are not wellserved by providers who do not offer services in a culturally competent manner or services inlanguages other than English. Providers would have wider opportunities to serve a broaderpopulation if they had the resources to develop culturally competent programs and couldcommunicate with people in their native languages. Komen should invest in programs andservices that are already being developed or in new or innovative programs that address lan-guage and cultural barriers. Breast health services would be more widely utilized by womenin the community if they were provided education about the importance of breast health andassistance in navigating the delivery system in languages they understand.

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