Examples of Diabetes Research Projects - PowerPoint PPT Presentation

View by Category
About This Presentation

Examples of Diabetes Research Projects


Diabetes Australia Facts 2008. Type 2 Diabetes (T2DM) in CALD populations: ... I ate McDonalds once and fell ill for a couple of days; so home cooking. ... – PowerPoint PPT presentation

Number of Views:317
Avg rating:3.0/5.0
Slides: 95
Provided by: communit74
Learn more at: http://www.bibalex.org


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Examples of Diabetes Research Projects

  • Examples of Diabetes Research Projects

Diabetes Supercourse, Alexandria 11 Jan 2009
  • How Turkish and Arabic Speaking Communities
    (TASC) View Diabetes and Pre diabetes?
  • A qualitative Study
  • Nabil Sulaiman, Doris Young, John Furler, Elaine
    Hadj, Helen Corbett

Medical Research Grants Restricted Purposes funds
Diabetes Australia Facts 2008
  • Type 2 Diabetes (T2DM) in CALD populations
  • Prevalence of diabetes
  • Prevalence of risk factors
  • Complications
  • Hospitalisations due to non-treatable diabetes
  • Death rates due to diabetes

DM in M.E born Vs. Australian born
  • highest SRR for self-reported DM
  • twice the rate (79.8 vs 46.2/1000) of DM
  • highest hospitalisations rate, and
  • 2nd highest MRR from DM
  • AIHW Cat. No. AUS 38. Canberra, 2003.

Diabetes CVD in Hume
  • DALYs for diabetes in Hume is the highest in
    Victoria (6.8 vs. 4.1 per 1,000 female) (6.6 vs.
    4.5 per 100,000 males)
  • DALYs for cardiovascular disease is the second
    highest in Victoria (31.9 vs. 27.6 per 1,000
    females) (35.4 vs. 32.2 per 1,000 males)

Diabetes in Arabs Turks
  • M.E. born highest age-standardised
  • Prevalence ratio in M (3.60) and F (2.43)
  • Incidence rate ratios M(1.73) F(2.30)
  • Hospitalisations ratios M(2.07) F(1.52)
  • Death rates higher in Arabic speaking residents
    in NSW (25.4 vs 13.4 per 100,000)

Diabetes in Arabs Turks
  • gt40 Arab American have dysglycemia
  • 18 diagnosed or undiagnosed diabetes
  • 23 impaired fasting glucose or impaired glucose
  • 12.3 in Turks living in Holland vs 3 in ethnic
  • 35 in Bahrain, 13 in Turkey

Risk Factors Hume Household Survey (PHP 1999)
  • 76 were physically inactive compared with 43
    average for Victoria
  • 62 had weight problems
  • 39 had high cholesterol
  • 49 smoked

What could be done?
  • 57 reduction of T2D by modifying physical
    activity and dietary change (Lindstrom et al,
    2003 and Knowles et al, 2003)
  • Uptake of such lifestyle changes in lower SES
    CALD groups has been poor
  • gt50 of people born in M.E. countries did not
    undertake physical exercise compared with 34 of

Meta-analysis of 11 trials in CALD
  • Improved HbA1c after intervention at 3M
  • Weight Mean Difference -0.3 at 3M and 0.6 at 6M
  • Knowledge scores improved at 3M
  • Healthy life style improvement at 3M
  • No difference in secondary outcomes lipid
    levels, qoL, self-efficacy, BP
  • Hawthorne K, Robles Y, Cannings-John
    R, Edwards S. Culturally appropriate health
    education for type 2 diabetes in ethnic minority
    groups. Cochrane Database of Systematic Revies
    2008 (3)

  • Explore insight, perception, attitudes and
    practices of TASC, in relation to physical
    activity (PA), diet and obesity
  • The feasibility of peer led model of engaging the
    community in diabetes prevention

  • Focus Groups
  • In depth interviews with key informants
    (bilingual GPs, diabetes educators, practice
    nurses, dieticians, physios etc.
  • Develop culturally sensitive resources for TASC
    in Turkish and Arabic languages.

Focus Groups - recruitment
  • Who?
  • Over the age of 45 years
  • Speaks Arabic or Turkish language
  • Family history of diabetes
  • Overweight
  • Dont do exercise regularly
  • How?
  • BHS bilingual staff
  • Adult Day Activity Centre
  • Community Centre- Blair Street
  • Families and Friends

  • Three FG with Turkish speaking
  • Two FG with Arabic speaking
  • Mean age 58.8 (range 41y 73 y)
  • FM 41 11
  • All living in and around Hume
  • Interpreters from TIS
  • Facilitators Elaine Hadj and NS
  • Transcribed by Sue Foley
  • Analysis and cross analysis (NS Helen)

Focus Group Themes
  • What does the word diabetes mean to you?
  • ? causes diabetes
  • ? factors associated with diabetes
  • ? factors increase risk of diabetes
  • ? diabetes and diet?
  • ? diabetes and overweight/ obesity
  • ? role of exercise in diabetes

Focus Group Themes
  • Is adult diabetes preventable? How can you
    prevent diabetes?
  • ? type of exercise is appropriate for your
    community/ yourself? How often do you/your
    community exercise
  • ? motivate you/ your community to do exercise
  • ? types of diet do you/your family/ community
  • ? diabetes and body weight

Findings what diabetes meant to you?
  • Acknowledgement of the severity its a bad
    disease which is second to cancer,
  • Physical and psychological well beingAll of my
    ancestors, they have Diabetes, this why I said it
    is horrible disease, and some of them they had
    amputations of their limbs. Three of them their
    hands or their legs they were amputated, but one
    of them refused to do such a thing ..

What diabetes meant to you?
  • Specific
  • It means stress or It means a lot of food
    that you cant eat.
  • When the pancreas is not working so well it is
    not producing Insulin for the body to maintain
    the sugar levels and the amount of sugar in the
    blood goes quite high .

What do you associate with Diabetes?
  • It affects the eyes
  • swelling and ulceration of the legs (The legs
    get swollen and sometimes blood will come out and
    it doesnt heal).
  • Cuts dont heal
  • Increased thirst and urination
  • Poor dietary habits or eating the wrong food,
    limitations on food choices
  • Stress (Stress is one of the main things that
    causes illnesses)
  • Lack of exercise, Cholesterol, High blood

Causes of diabetes
  • Lifestyle Poor diet and eating habits
  • We eat so much, I dont know, maybe because we
    eat so many times a day like 10 oclock, 11 we
    eat. We eat . and then we watch TV, we eat
    chips, so a sign of we eat all of the time.
  • I think its because we eat too much food, not
    the way we prepare, but we eat too much.
  • Stress and tension
  • Diet and stress. I am worried that it will come
  • Anxiety is another reason behind many diseases,
    the anxiety, tension and stress
  • its destiny
  • its hereditary

Causes Anxiety, tension stress
  • That also stress causes Diabetes as well if
    someone is overly stressed for long lengthy
  • The Diabetes well the sugar level in my body if
    I was sad or happy it either picks up and goes
    quite high or drops down to very low levels with
    sadness or happiness.
  • And I was adding to that stress that illnesses
    including Diabetes is caused by stress. Stress
    is one of the main things that causes illnesses.

Causes Food
  • fast food as the culprit.
  • You get very sick when you have bad food. Fast
    food anyway. Its terrible for your body and you
    getting sick.
  • I think I shouldnt eat any Takeaway food. None
    whatsoever. I ate McDonalds once and fell ill for
    a couple of days so home cooking. What I mean
    is, they are too fatty.
  • Í think meat and rice in my opinion is not
    right, but again meat and bread also another

Environmental factors
  • climate change I dont know that my sugar levels
    going to Turkey for instance is quite maintained
    when I am over there and when I come back here it
    creeps up again.
  •  I should say that it is not only going overseas
    but going to high places up in the hills or the
    forest or something, living there for a while I
    often maintain my sugar levels.
  •  I dont know again but it is because of the
    clarity of the air maybe and the oxygen level is
    quite high.

Environmental factors - cont
  • All the .. the skin, the meat, they all contain
    additives and we eat every cold chicken for
    example I believe that my condition had
    developed because of that.
  • For example you go to Turkey and you get an egg,
    a village egg, it will be natural and the eggs
    here they dont have any vitamins.
  • (In Australia) it is the way they grow their
    food, everything has a chemical additive, if they
    want to grow bigger eggs, bigger fruit, there is
    chemicals .

Physical activity
  • Walking is good
  • Its the cheapest exercise, it is healthy and it
    is outdoors
  • Exercise brings your blood sugars down
  • Helps with weight control
  • Improves blood circulation
  • Maintains sugar levels
  • Helps in weight reduction
  • Improved state of mind

Physical activity
  • it is incidental walking yes that you dont have
    the benefit of a car, you are only there for a
    short period but you have to walk a lot and at
    some places you have got no choice but to walk,
    you know 10 kilometres a day or 15.
  • When I went to Syria I lost 8 Kilos I walked a
    lot and didnt do any exercise bike, and I ate a
    lot. . Here you get into the car and you just
    drive in the car.
  • the session I have had with a Diabetes Nurse and
    she told me that My sugar levels were quite
    high up to 16 and 20 and when I have started
    walking which was recently I now walk every day
    and 1 ½ hours each day so my sugar levels have
    come down dramatically to about 7.

Barriers to regular exercise
  • Not feeling safe from dogs and other people
    (Walking in the street is not safe.)
  • Housework to complete
  • Family commitments like babysitting, housework
  • Women dont make time for themselves
  • Laziness
  • Historically, exercise is not a part of Turkish
  • Not culturally appropriate for older women to
    walk in the streets or go swimming (..60, 70
    year old woman going under and going swimming or
    walking, it is not looked upon as nice.)
  • Too old or too ill
  • Not enough time

Regular exercise facilitators
  • When directed to do so by their doctor
  • Group walks and group exercises
  • Ethnic dancing
  • Teacher or leader for walking and exercise groups
  • Exercise equipment or machine at home
  • Attending the gym and cycling
  • Illness and illness prevention
  • Weight control
  • A desire to get out of the house, a means of
  • for relaxation (gardening)
  • As a community, unless you are ill and you have
    to exercise so you wont die, then that is the

Diabetes prevention
  • .there are many factors for me, the diet,
    exercises and tensions, stress.
  • Well, you can prevent by watching what you eat,
    doing exercise, walking, less stress, no stress,
    keep away from stress.
  • You cant prevent it from happening, but you can
    or the amount of Diabetes you get can be
    controlled. The severity of it.

Work and Diabetes
  • As a person I only found that I had Diabetes
    when I left work after about six months of
    leaving work.
  • I used to be working in the past and as I have
    given up work I have sustained Diabetes, I think
    it may have been because of inactivity that I
    have sustained Diabetes and not enough exercise

Other Causes
  • Obesity The amount of fat in your body that is
    as you get fatter you would have less chance of
    being active and inactivity causes and your
    pancreas would slow down.
  • Old age
  • Ethnicity

Diabetes and diet.
  • Foods that were detrimental to their health and
    to the health of people with diabetes
  • Fast foods
  • Fatty/oily food
  • Sweets
  • Breads
  • Rice
  • Pasta
  • Many fruits
  • Fatty meats

Diet and Diabetes
  • Eating anything and everything
  • Sweets, bread. All sugary things are bad Certain
    fruits for instance grapes, oranges.
  • Eating has something to do with it of course,
    you can eat anything but you have to eat it in
    moderation. It is the amount of food that is
    quite important.
  • I just gave up bananas and I found out that if
    you eat quite mature bananas that could have
    effects on your level of Diabetes but if you have
    not so mature like almost green bananas that is
    probably okay and having not 2 oranges but maybe
    ½ an orange or ½ an apple would be okay.

Diet and Diabetes
  • we used to eat anything that was culturally
    appropriate we eat a lot of nuts and things so
    handfuls of it usually and she (diabetes
    educator) told us that you can eat these nuts
    still but only that fits in the palm of your
  • Because it is sour I tend to eat green apples
    and grape fruit tend to bring down the levels of
    sugar. Just like grape fruit and lemon I
    think it has the affect of dropping down the
    sugar level because of the sourness. The green
    apple has the same effect and the red apple lifts
    up the levels of Diabetes.

Foods that counter sweetness
  • Because it is sour, I tend to (eat) green apples
    and grape fruit tend to bring down the levels of
  • I have read in the paper that eating Grape
    Fruit can cause death.. I dont know how but I
    read it in a health section of the paper, I used
    to like grape fruit but as Diabetics dont take
    it anymore. I used to eat two grape fruits a day
    thinking it was a fruit of life, you know a fruit
    that would maintain your life, lengthen your life
    and I had a tree in the backyard when I learnt
    about the affects of it I chopped it down.

Diabetes and obesity
  • Lots of weight, being overweight and it is
    heredity as well, you cant help it sometimes.
  • the main cause of Diabetes is being overweight
    and if someone is overweight they almost surely
    will have Diabetes.
  • What is happening is if you eat and eat and keep
    the nutrition in your body without burning, its
    not like a petrol tank. If you went and filled up
    with petrol you cant put more when it is full,
    but the body is able to take more and more and it
    stores more, it increases your risk.

Health Education
  • The doctor and the hospital
  • In some instances nurses, dieticians and other
  • Negative experiences with Doctors and Hospitals
    I have been seeing the doctors and the Diabetes
    specialists for many years and they could not
    help me and I have just seen an educator here and
    she has helped me.
  • Need for InterpretersI went for an appointment
    (to have my eyes checked) and an interpreter
    wasnt booked and with that I couldnt understand
    what the doctor was saying and they have given me
    another appointment in a years time and now I
    dont know what the hell is going on.

Community Empowerment
  • Limited response
  • Volunteering for peer support is limited
  • Wiling to participate in peer-led diabetes
  • Partnerships with
  • Local Council
  • Community Health Centres
  • Exercise centres

Health Education Resources
  • Written information to be shown to other family
    members or friends
  • Information is best provided when translated to
    languages other than English
  • Suggestions
  • Doctors
  • The hospital, Health Centres
  • Ethno-specific newspapers, Brochures and flyers
  • Community radio
  • Meetings similar to the focus group to share
    information and provide support to one another

  • Good understanding of the severity of diabetes
  • The need to alter life stye
  • More information
  • More education
  • Cultural and social barriers
  • Interventions
  • Doctors
  • Groups

Sulaiman ND, Furler JS, Hadj EJ, Corbett HM,
Young D. Health Promot J Austr. 2007
  • The
  • Peer-led Diabetes Prevention Program for TASC
    in Melbourne

  • Develop an evidence based, culturally appropriate
    peer-led diabetes prevention resources and
    program for TASC
  • Trial the program
  • Evaluate the program using

Methodology- how?
  • Design Pre and post intervention trial (action
    research methods)
  • Peer- leaders
  • Diabetes prevention program
  • Participants
  • Evaluation

Methodology- how?
  • 12 peer leaders recruited from TASC
  • Program was developed (food, exercise, group
    dynamics ..etc)
  • 2- full days training of leaders
  • Each leader engage 10 people

Training Program
  • Principles of peer-led program
  • Role of diet, physical activity and stress
  • Group facilitation, engaging
  • Motivational techniques and chronic disease
  • Leaders were paid for their training time,
    recruitment of participants and implementing the

Outcome Indicators
  • Changes in knowledge and attitudes
  • Changes in behaviours
  • Changes in body weight and waist circumference

Data collection
  • Questionnaire and interviews knowledge,
    attitudes and behaviour
  • "Three-day Food Diary" and physical activity)
  • Weight, waist circumference were measured
  • Pedometer to act as incentive for walking

  • Gender females (73)
  • Age 47 (40-45 y) and 25 (gt55 y )
  • COB
  • Turkey (45)
  • Iraq (39)
  • Lebanon (12)

They get health information from
  • Doctors (92)
  • Television (70)
  • Friends (54)
  • Nurses (35)
  • Brochures (35)
  • Family (36)
  • Internet (29)
  • Ethnic media (29).

What did you like?
  • 77 appreciated the information
  • 69 the skills learned
  • 63 the support provided
  • 95 learned healthy eating skills
  • 70 maintaining healthy weight
  • 75 how to loose weight
  • 73 value regular exercise
  • 48 information access and
  • 42 attitudinal change

Effectiveness of the program using 10-points
  • 68 gave 9 or 10 points
  • 18 gave 7 or 8 points
  • 2 gave 5 points (undecided)
  • 2 gave 3 or 4 points

Self-reported lifestyle changes
  • Changes after program
  • 89 in food preparation
  • 79 dietary intake
  • 82 shopping
  • 81 feeling of well being
  • 79 physical activity
  • 69 body weight

Weight and Waist
  • Weight significant reduction in weight mean
    weight pre78.1kg, post77.3 Z score-3.415
  • Waist circumference (Z-2.569, P010)

What are the main reasons for not taking any
actions to lower your risks?
Practices n n p-value
No time to cook own meal 35 37.2 18 20 0.004
Like to eat fast food 23 24.5 10 11.1 0.029
Too busy to follow a routine 23 24.5 34 37.8 0.053

Time in minutes you spent walking for
recreation/exercise in the last week (mean)
n n p-value
Exercise 180 180 258 258 0.007
What are risk factors for diabetes
Have you done anything to lower risk during last
3 months Plt0.001)
What motivated you to join the program
  1. The program was effective in improving knowledge
    and enhancing exercise in Melbourne, Australia
  2. Peer-led diabetes prevention program should be
    piloted/ replicated in Sharjah to explore

  • Limited intervention
  • Administered by trained peers equipped with
    culturally appropriate education
  • Native language
  • Significant improvement in
  • knowledge and attitudes
  • limited changes in lifestyle behaviour
  • The changes were maintained three months after
    the intervention.

Thank you

Uptake of lifestyle
  • However, uptake of such lifestyle changes has
    been poor
  • Programs developed to enhance the uptake, such
  • Diabetes Nurse Educator
  • Coach program
  • Chronic Disease Self- management
  • Others

Adapted from World Health Organization. The World
Health Report life in the 21st century, a vision
for all. Geneva WHO, 1998.
The increasing global prevalence of diabetes
Patients (millions)
Type 1
Type 2
Estimates from
McCarty and Zimmet, 1994
Projected growth of Type 2 diabetes by region
Type 2 diabetes prevalence (millions)
Amos et al. 1997
Lifestyle modification
  • If a 1 reduction in HbA1c is achieved, you could
    expect a reduction in risk of
  • 21 for any diabetes-related endpoint
  • 37 for microvascular complications
  • 14 for myocardial infarction
  • Diet
  • Exercise
  • Weight loss
  • Smoking cessation

However, compliance is poor and most patients
will require oral pharmacotherapy within a few
years of diagnosis
Stratton IM et al. BMJ 2000 321 405412.
Type 2 diabetes in different populations
Lowest rates
Highest rates
(Rural India)
Asian Indian
(Fijian Indian)
(Rural Kiribati)
(Urban Kiribati)
(Rural Tunisia)
(Oman UAE)
(Central Mexico)
(US Mexican)
(Rural China)
(Mauritian Chinese)
(Rural W. Samoa)
(Urban W. Samoa)
(Rural Tanzania)
(US Afr. Amer.)
(Laurino, Italy)
(Rural Fiji)
(Urban Fiji)
Prevalence of Type 2 diabetes ()
Amos et al. 1997
Diabetes Australia Facts 2008
  • T2DM in CALD populations
  • Prevalence of diabetes
  • Prevalence of risk factors
  • Complications
  • Hospitalisations due to non-treatable diabetes
  • Death rates due to diabetes

Diabetes Australia Facts 2008
  1. Prevalence of diabetes is increasing over time
  2. Reduces quality of life
  3. Preventable via lifestyle modifications
  4. Some population groups are at higher risk
    including CALD

Meta-analysis of 11 trials in CALD
  • Improved HbA1c after culturally at 3M
  • Weight Mean Difference -0.3 at 3M and 0.6 at
  • Knowledge scores improved at 3M
  • Healthy life style improvement at
  • No difference in secondary outcomes lipid
    levels, qoL, self-efficacy, BP,
  • Hawthorne K, Robles Y, Cannings-John
    R, Edwards S. Culturally appropriate health
    education for type 2 diabetes in ethnic minority
    groups. Cochrane Database of Systematic Revies
    2008 (3)

What are the main reasons for not taking any
actions to lower your risks?
Practices n n p-value
No time to cook own meal 35 37.2 18 20 0.004
Like to eat fast food 23 24.5 10 11.1 0.029
Too busy to follow a routine 23 24.5 34 37.8 0.053

Time in minutes you spent walking for
recreation/exercise in the last week (mean)
n n p-value
Exercise 180 180 258 258 0.007
2. Qualitative Study
  • Qualitative focus groups to investigate
    feasibility and cultural appropriateness,
    barriers and facilitators of known interventions
    in Sharjah

  • The target setting is primary health care
    centers. People visiting all primary health care
    centers/ Hospitals in Sharjah will be targeted.
    Risk factors are
  • Diabetes
  • Physical activity
  • High cholesterol
  • Unhealthy eating (poor diet)
  • Smoking

  • Case-finding/ screening for prediabetes and
    diabetes in PHC
  • Consultation with doctors, nurses and patients to
    identify appropriate diabetes intervention
  • Engaging people with diabetes/ pre-diabetes in
    CDSM programs and the COACH
  • Family study to look at the genetic profile
  • CME for doctors and nurses in EB diabetes
  • Training nurses to be diabetes nurse educators
    (DNE) to provide the interventions in PHC

(No Transcript)
Models of Diabetes Care in PHC Dr Nabil
SulaimanThe University of Sharjah The
University Melbourne
This Presentation
  • Trends in diabetes
  • Lifestyle interventions- evidence
  • Models of interventions in PHC
  • Diabetes Nurse Educator (DNE)
  • COACH model
  • Chronic Disease Self management

Diabetes in UAE
  • High prevalence in the Gulf Countries. In the UAE
    the prevalence is
  • 24 of adults
  • 40 with diabetes and IGT
  • Diabetes is occurring in younger age

Environmental and behavioral changes
  • New dietary habits (what and how we eat),
  • Lack of physical activity,
  • Overweight/ obesity, and
  • Stresses of urbanization and working condition
  • will lead to further rise of CVD and diabetes,
    and their risk factors.

  • RCT in Finland and the USA have demonstrated that
    the incidence of diabetes can be reduced by about
    57 by modifying
  • Physical activity and
  • Diet
  • (Tuomilehto et al 2001, Knowler et
    al 2002)

Lifestyle Changes
  • However, uptake of such lifestyle changes has
    been poor
  • Programs developed to enhance the uptake, such
  • Diabetes Nurse Educator
  • Coach program
  • Chronic Disease Self- management
  • Others

In Primary Health Care
  • In Australia, people with T2D have 80 of their
    care in General Practice
  • Diabetes requires the GP to practise biomedical,
    anticipatory and psychosocial care using
    evidence-based and patient-centred medicine and
  • Patient to engage actively in managing their

Diabetes Nurse Educator
  • Trained nurse
  • Engage, educate and empower patient to manage
    diabetes and impact of disease on patient and
  • Based on trust and partnership between PHC
    centre- Diabetes nurse educator and patient
  • Patient determines agreed targets
  • Continuity and access

Diabetes Coach Program
  • Tested in Melbourne using RCTs for CVD
  • Trained nurse or dietitian to do COACH
  • Following diagnosis or after discharge from
  • Education and empowerment
  • Patient determines agreed targets
  • Follow up consultation or phone calls
  • Showed benefit in several outcomes

Chronic disease self management
  • Is an effective way in which patients are
    empowered to become more active and effective in
    managing their disease.
  • Patient engages in activities that protect and
    promote health, monitoring and managing of
    symptoms and signs of illness, managing the
    impacts of illness on functioning, emotions and
    interpersonal relationships and adhering to
    treatment regimes

(No Transcript)
Chronic Disease Self Management(CDSM) Stanford
Kate LorigDirector of the Stanford Patient
Education Research Center
Stanford CDSM Program
  • Is a workshop where people with different chronic
    diseases attend
  • Teaches the skills needed in the day-to-day
    management of treatment and to maintain and/or
    increase lifes activities.
  • The Program has been adopted by NHS, the Diabetes
    Society of British Columbia in Canada, Kaiser
    Permanente, etc
  • It has been translated into Chinese, Vietnamese,
    Norwegian, and Italian. The patient book is
    available in Japanese

Stanford Program
  • Small-group workshops,
  • Generally 6 weeks long,
  • Meeting once a week for about 2 hours,
  • Led by a pair of lay leaders with health
    problems of their own,
  • The meetings are highly interactive, focusing on
    building skills, sharing experiences and support.

One Step Ahead
  • Seminars for people with pre diabetes
  • Evidence of reduction of 0.5 HbA1C

Patient empowerment through CDSM
  • Patient empowerment has a crucial role in the
    treatment of chronic disease
  • knowledge and skill development to understand and
    manage ones condition and the confidence to use
    that training for better self care and greater
  • Feeling of control and skill development to
    achieve a more interactive relationship with
    health care professionals, with the capacity to
    demand good quality care
  • The patient becomes a better self advocate/agent,
    more able to get from the health system what they
    need in particular.
About PowerShow.com