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American Journal of Health Education
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Improving Diabetes Care in the Latino Population:
The Emory Latino Diabetes Education Program
Britt Rotberg, Rachel Greene, Anyul M. Ferez-Pinzon, Robert Mejia &
Guillermo Umpierrez
To cite this article: Britt Rotberg, Rachel Greene, Anyul M. Ferez-Pinzon, Robert Mejia &
Guillermo Umpierrez (2016) Improving Diabetes Care in the Latino Population: The Emory
Latino Diabetes Education Program, American Journal of Health Education, 47:1, 1-7, DOI:
10.1080/19325037.2015.1111177
To link to this article: http://dx.doi.org/10.1080/19325037.2015.1111177
Published online: 08 Jan 2016.
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2. Improving Diabetes Care in the Latino Population: The Emory Latino Diabetes
Education Program
Britt Rotberg, Rachel Greene, Anyul M. Ferez-Pinzon, Robert Mejia, and Guillermo Umpierrez
Emory University School of Medicine
ABSTRACT
Background: The incidence of diabetes in Latinos is 12.8% compared to 9.3% of the general
population. Latinos suffer from a higher prevalence of diabetic complications and mortality than
whites yet receive less monitoring tests and education. Purpose: (1) Identify changes in clinical
indicators among subjects with type 2 diabetes participating in the Emory Latino Diabetes Education
Program (ELDEP), (2) identify changes in risk reduction examinations, and (3) describe the
independent contribution of sociodemographic characteristics and biomedical indicators as
predictors of class return. Methods: A quasi-experimental study was conducted over 5 years in
Latinos with type 2 diabetes mellitus. One hundred forty-two patients receiving culturally
appropriate diabetes self-management education and support (DSME/S) were included from 7
primary care clinics in Georgia. Questionnaires and biomedical markers were collected at baseline
and 3-month follow-up. Results: Results from this study show that A1C was lowered from 9.1% at
baseline to 7.8% at follow-up (P , .001), blood pressure decreased from 135/85 to 128/79 mmHg (P ,
.001), and home blood glucose monitoring increased from 63% to 85% (P , .001). Risk-reduction
examinations increased significantly from baseline to follow-up. Predictors of attendance for DSME/S classes
were income, physical activity, and previous class attendance (P , .05). Discussion: ELDEP was effective in
providing DSME/S, decreasing biomedical markers, and increasing risk reduction examinations.
Translation to Health Education Practice: Exploring culturally appropriate, community-based
interventions to foster engagement in follow-up care may be useful in improving diabetes self-
management in Latinos.
ARTICLE HISTORY
Submitted 10 June 2015
Accepted 10 August 2015
Background
Latinos are the largest minority group, currently
comprising 17.1% of the general population, and are
expected to reach 31% by the year 2060.1
The incidence
of diabetes in Latinos is 12.8% compared to 9.3% of
the general population.2
They suffer from a higher
prevalence of diabetic complications and mortality than
whites with diabetes.3
In addition, Latinos have higher
rates of renal disease and retinopathy, have poorer
glycemic control, and receive fewer diabetes monitoring
tests compared to whites. As a result, diabetes self-
management education (DSME) and behavioral support
have emerged as effective strategies to improve the
outcomes of control and management of type 2 diabetes,
including in Latino populations.4
Nonetheless, research
has shown that participation among Latinos for diabetes
education programs is lower than for non-Latino whites
even though they are 2 to 5 times more likely to develop
diabetes.5
Latinos face multiple barriers that impact their diabetes
care and attendance to follow-up visits, including
socioeconomic status, minimal education, illegal status,
low literacy and health literacy, work-related conditions,
transportation issues, and lack of access to health
insurance.6-8
Health-related behaviors and biomedical
markers have not been extensively studied in regards to
program attendance among Latinos.8
Purpose
The purpose of this study was to test the impact of a
culturally tailored, literacy-sensitive diabetes self-man-
agement intervention on improving clinical indicators of
care (HgA1c, blood pressure, body mass index [BMI]),
increasing risk-reduction examinations (eye exams, foot
exam, flu vaccine), and improving diabetes-related
behaviors (home glucose monitoring, physical activity).
Secondary outcomes include identifying independent
q 2016 SHAPE America
CONTACT Rachel Green rachel.greene@emory.edu Department of Endocrinology, Emory University School of Medicine, 49 Jesse Hill Jr Dr. SE, Atlanta, GA
30303.
AMERICAN JOURNAL OF HEALTH EDUCATION
2016, VOL. 47, NO. 1, 1–7
http://dx.doi.org/10.1080/19325037.2015.1111177
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3. contributors of sociodemographic predictors and meta-
bolic indicators of class return at follow-up.
Methods
Design and study sample
The study was conducted in 7 local clinics throughout the
state of Georgia. Participants were referred to the DSME
classes by a physician, nurse, community health care
worker, or friend or were informed about the program via
local Latino media (radio stations, television). Sample
eligibility criteria were as follows: Spanish-speakers who
identified themselves as Latino or Hispanic, age 18
or over, with type 2 diabetes. Participants’ biomedical
markers (HbA1c, blood pressure, waist circumference,
height, weight, and BMI) were measured and each
participant completed a questionnaire at baseline and
3-month follow-up. The questionnaires assessed partici-
pants’ sociodemographic information, frequency of
medical care, knowledge of diabetes, nutrition habits,
risk reduction examinations, blood glucose monitoring,
medication regimen, eating habits, and physical activity
levels. The questionnaires were developed specifically for
the Emory Latino Diabetes Education Program (ELDEP)
and are currently being tested for validity and reliability.
All participants provided informed consent and the study
was approved by the Emory Institutional Review Board.
Study conditions
Patients attended an initial 3.5-hour diabetes self-
management education class conducted by a Registered
Nurse, Certified Diabetes Educator, and/or a Registered
Dietitian. The first 30 minutes were dedicated to patients
completing the questionnaires and collecting biomedical
measures (A1C, height, weight, BMI, waist circumfer-
ence, blood pressure). Once participants completed the
initial class, they were invited to attended monthly
follow-up sessions termed “Diabetes Club” or “Club de
Diabetes.” Due to the volume of patients, phone call
support was provided 2 times a year by a peer diabetes
instructor and advocate. Because the nature of the
ELDEP program was unique and the educators provide
DSME in various settings, the patients were invited to
return to class; it was their choice to return or not.
Patients could choose to attend class every month or
every year. Either way, ELDEP was a continuous support
system to patients for years.
Grady Memorial Hospital in Atlanta was the home base
of the program and educators traveled on a monthly basis
to the 7 different clinics throughout Georgia (Grady
Healthy System North DeKalb Clinic, Grady Health
System International Medical Center, Grady Healthy
System Diabetes Clinic, Lake Park & Farmworkers Clinic,
North Fulton Regional Hospital, Latin American Associ-
ation, and Northwest Medical Center). The ELDEP
curriculum used the social cognitive theory (SCT) as a
framework, addressing the 3 main constructs of behavioral
factors, personal factors, and environmental factors.
To address behavioral factors, this program promotes
self-efficacious behaviors for chronic diseases, including
increasing self-management behaviors such as nutrition
management, medication adherence, and glucose moni-
toring. Personal behaviors are addressed through increas-
ing participants’ knowledge of the disease and attitude
toward living with diabetes. Finally, environmental factors
are addressed via discussing barriers to treatment and
providing participants with methods for increasing health
care access within their community.9-11
The ELDEP curriculum developed for the study was
entitled “Viva Mas y Mejor . . . Con su Diabetes Bajo
Control (Live Longer and Better . . . With Your Diabetes
Under Control)” and was the first nationally accredited
all-Spanish diabetes education program. In addition to
the SCT, the ELDEP curriculum was based on the
AADE-7 Self-Care Behaviors (healthy eating, being
active, monitoring, taking medication, risk reduction,
healthy coping, and problem solving).12
The objectives of
the program were to support informed decision making,
self-care behaviors, and problem solving and develop
collaborations with the health care team in order to
improve overall patient care.
ELDEP curriculum
The ELDEP curriculum was made to be culturally
appropriate by addressing common foods eaten by the
Latino community, the culture around food, faith, folk
remedies, family structure, and how to overcome language
barriers with health care providers. The intervention
consisted of the 3.5-hour initial DSME class, which
covered 8 lessons, as well as the monthly “Club de
Diabetes” classes. The initial DSME curriculum discussed
8 topics that address all 3 of the constructs of the SCT—
personal, behavioral, and environmental factors.
Personal factors—increasing knowledge of and
attitudes toward diabetes:
. “My Diagnosis of Diabetes”: Sharing stories
related to the diagnosis of diabetes and criteria for
diagnosis.
. “Living with Diabetes”: Identifying depression
symptoms, fears, and anguish caused by diabetes,
family dynamics, and social support networks.
Assessing the confidence and conviction of the
disease and self-care behaviors.
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4. Behavioral factors—increasing self-efficacy and skills
related to diabetes self-management:
. “Monitoring my Diabetes and Taking Medi-
cations”: Covering biometric targets that are
important for diabetes control: fasting and
postprandial blood glucose, A1C, weight, BMI,
cholesterol and the importance of maintaining
these values within the acceptable limits to avoid
complications. In addition, this lesson included
explaining the different medications taken by
patients and possible interactions and side effects
and establishing a daily medication regimen.
Increasing self-efficacy through self-management
behaviors addresses behavioral factors within the
SCT.
. “Checking my Blood Sugar”: Demonstrating the
correct use of glucose meters and the connection
between glucose results and decisions related to
diabetes control. In addition, patients created a
schedule for checking blood glucose appropriate
to his or her diabetes control, the type of
medications he or she uses, and identifying
solutions for sick days.
. “Reducing the Risk of Complications”: Explain-
ing common complications due to diabetes and
identifying the importance of getting eye, foot,
and kidney tests. This lesson also incorporated
how to ask the doctors for results and teaching
patients how to do daily self-foot exams.
Environmental factors—addressing barriers to access and
increasing influence on others:
. “Staying Active”: Describing the recommended
amount and frequency of physical activity,
identifying when to monitor blood glucose,
working to increase physical activity by doing
exercises he or she enjoys, and finding ways to
exercise in the home if the community is unsafe
or not conducive to exercising.
. “Healthy Eating”: This lesson included defining
carbohydrates and those foods that increase
blood sugar. Topics include different meal
planning approaches, how to shop on a budget,
identifying a set schedule for meals, and
reviewing the plate method using food models.
. “Problem Solving”: The last lesson focused on
setting goals that are specific, measureable,
achievable, realistic, and time-bound (SMART),
which were monitored at follow-up visits. This
closing module focused on the patients’ current
support systems and how they were being helped
with their diabetes by family and/or friends. Each
patient set a goal related to increasing the quality
of their support network. For example: identify-
ing a person within class to exercise with or
asking a family member or peer to help them with
a certain self-care behavior.
The design of the classes was more conversational versus
didactic where participants were encouraged to share
their experiences throughout the sessions. Once partici-
pants attended the initial class, they were invited to the
follow-up “Club” sessions where a variety of topics were
covered: reducing the risk of diabetes-related compli-
cation (foot, eye, kidney, and dental care), community
resources available for support, healthy coping and
problem solving (increasing environmental support and
dealing with emotions related to diabetes), healthy eating
(reading nutrition labels and carbohydrate counting),
and medications (names, when to take, establishing
routines). Additionally, patients participated in activities
such as dance (Zumba) lessons, group exercise routines,
cooking demonstrations, or diabetes jeopardy.
Educational materials
The educational materials developed by ELDEP and
provided to the participants included the “Viva más y
major . . . con su diabetes bajo control” guide, which
addressed the 3 SCT constructs and covered the 7 AADE
self-care behavior framework. Participants also received
the “Viva más y major . . . con su diabetes bajo control”
DVD, which included 6 topics on diabetes self-manage-
ment: the importance of controlling your diabetes,
healthy eating, physical activity, knowing your values,
glucose monitoring, and insulin preparation and
administration. Written supplemental information for
the DVD included the mini guides—sections of the
complete guide for follow-up classes where one topic is
covered. Additionally, participants received “My Health
Status” binders where patient’s medications and anthro-
pometric and biochemical data are written in order for
them to see the effectiveness of the diabetes treatment
and self-care plan.
Data management and analyses
The study was a pre–post quasi-experimental design.
Data were analyzed using SPSS software (SPSS 20.0).
Descriptive analyses compared baseline and 3-month
follow-up assessments of demographic, behavioral, and
biometrical characteristics among participants.
An intention-to-treat analysis approach was used to
avoid the effects of participant dropout during the study.
Additionally, we conducted a multivariate logistic
regression model to identify predictors for class return
DIABETES CARE AMONG LATINOS 3
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5. at 3 months. The following variables were controlled for
when looking at predictors for return visits: demo-
graphics (age, gender, education level, employment
status, literacy, access to insurance, country of origin,
and previous DSME class attendance), diabetes-related
behaviors (physical activity, healthy eating, eye exam, flu
vaccination, dental exam, and foot exam), and biometrics
(A1C, blood pressure, and BMI). Healthy eating was
measured using a modified plate method assessment
developed by ELDEP and physical activity was measured
using the 2013 Centers for Disease Control and
Prevention Behavioral Risk Factor Surveillance System
Questionnaire on exercise and physical activity.13
Results
There were a total of 142 participants in the study. The
characteristics of the sample are summarized in Table 1.
There was a high attrition rate in this study, with 810
participants coming to the initial class but only 142
coming to both the initial and follow-up classes. This
attrition is largely due to the low socioeconomic status of
the participants and lack of access to transportation to
attend the classes. All of the participants were of Hispanic
origin with a mean age of 47.2 ^ 12.4. Approximately
61% of participants were female and 49% were employed.
A total of 76% had an annual income of less than $15 000
and 24% had access to health insurance. Most of the
participants had very low literacy levels, with 56% unable
to read Spanish and 59% unable to write Spanish. A total
of 93% were unable to read English and 95% were unable
to write English.
When looking at biomedical markers, participants
who returned for follow-up at 3 months (n ¼ 142)
decreased their A1C from 9.1% to 7.0% (P , .001),
decreased their systolic blood pressure from 135 to 128
mmHg (P , .001), and decreased their diastolic blood
pressure from 85 to 79 mmHg (P , .001). Additionally,
participant weight lowered an average of 2 pounds
(P ¼ .11) and waist circumference decreased an average
of one inch (P ¼ .96; Table 2).
Diabetes self-management behaviors also improved
from baseline to follow-up, as demonstrated in Table 3.
Yearly eye exams increased from 43% to 56% (P , .001),
daily self-foot exams increased from 49% to 71%
(P , .001), and yearly flu vaccination increased from
37% to 56% (P , .001). Physical activity increased from
50% at baseline to 87% at follow-up (P , .001).
Additionally, home blood glucose monitoring increased
from 60% at baseline to 90% at follow-up (P , .001) and
keeping a blood glucose log increased from 42% at
baseline to 69% at follow up (P , .001). Diabetes-related
knowledge (knowing which type of diabetes they had and
foods that increase blood glucose) increased from 57% at
baseline to 83% at follow-up (P , .001).
Table 4 displays crude odds ratios and adjusted odds
ratio for class return. Participants who had never attended
a diabetes class in the past, who did not regularly engage
in physical activity, and had an income of ,$15 000 per
year at baseline were at a higher risk for not returning to
class for follow-up than their counterparts.
Discussion
For the past 5 years, ELDEP served as a support system
for Latino providers and patients throughout Atlanta.
The program aimed to assist Spanish-speaking patients
with their diabetes care in order to improve biomedical
markers and improve overall quality of life by
continuously guiding the participants to acquire knowl-
edge and assist them in expanding their support network
and in achieving their behavioral goals. ELDEP proved to
be an effective intervention in providing diabetes self-
management education and support by lowering clinical
indicators of care in Latinos. Patients who attended both
the initial class and 3-month follow-up “Club” sessions
lowered their A1C by an average of 1.2%. Patients were
more likely to have yearly eye exams, yearly dental exams,
and yearly flu vaccinations at follow-up. Previous studies
of Latinos with diabetes have failed to produce significant
Table 2. Mean difference in clinical outcomes at baseline and
3-month follow-up.a
Characteristics Baseline Follow-Up P Value
Total number of participants (n) 142 142
A1C (%) 9.1 7.8 ,.001
Systolic blood pressure (mmHg) 134.9 127.5 ,.001
Diastolic blood pressure (mmHg) 85.0 78.7 ,.001
Weight (lb) 170.5 168.3 .11
Waist Circumference (in.) 39.9 38.9 .96
a
Paired t tests were conducted among those with complete data at follow-
up (n ¼ 142).
Table 1. ELDEP participants’ sociodemographic characteristics.
Characteristics Results
Total participantsa
142
Age (years) 47.2 ^ 12.4
Gender
Female, % (n) 61.3 (87)
Male, % (n) 38.7 (55)
Employed, % (n) 49.3 (70)
Income , $15 000/year, % (n) 76.1 (108)
Access to health insurance, % (n) 23.9 (34)
Literacy
Unable to read Spanish, % (n) 55.6 (79)
Unable to write Spanish, % (n) 59.9 (85)
Unable to read English, % (n) 93.0 (132)
Unable to write English, % (n) 95.1 (135)
a
Total participants corresponds to participants who attended both the
initial and follow-up classes.
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6. improvements in physical activity; however, ELDEP
participants who returned to class were more likely to
engage in physical activity such as dance classes.14
Participants were also more likely to use their blood
glucose monitor and record results as a result of the
program. ELDEP successfully lowered patients’ biome-
dical markers at higher values compared to similar
education programs.15
The diabetes instructor and
advocates (peer leaders), who participated in the
ELDEP program and assisted with calling the partici-
pants to remind them of the Club meetings, had strong
ties with the participants; however, many participants did
not return to class. Research has shown that telephone
reinforcements do not improve the effectiveness of
Spanish diabetes self-management programs and more
personalized or interactive reinforcement may be more
effective in increasing these return rates.16
The results of this study indicate that having attended
a DSME class at another location, engaging in routine
physical activity, and having an income of $15 000 or
more are significant indicators of patients returning to
follow-up visits. Interestingly, language, insurance, age,
employment, and education levels were not significant
factors in the participants returning to class. In addition,
baseline A1C and BMI did not have an influence in
returning to class, which reinforces the concept that
when a patient’s confidence (how confident are you to
engage in a certain behavior) and conviction (how
important is a certain behavior to you) are low, one can
predict that the patient has a high risk of not returning to
class.17
If this is the case, the educator can reassess the
educational session to focus on increasing confidence and
conviction.
There are multiple characteristics of the Latino culture
that have a negative effect on diabetes self-management,
such as faith, fatalism, attraction to folk remedies, culture
around food, prioritizing the needs of family members
over their own, and experiencing language differences
with their health care providers.18
However, cultural and
linguistic barriers can be ameliorated via culturally
appropriate diabetes self-management education and
support (DSME/S) programs incorporating personal and
environmental factors from Social Cognitive Theory.15
These programs should provide culturally and linguis-
tically appropriate education to their patients, as well as
emphasize patient input in setting goals.15
When health
care providers are knowledgeable of the cultural and
linguistic differences in their patients, the providers can
better understand their patients’ individual experiences
and establish an appropriate course of treatment to
improve patient self-management.19,20
DSME/S programs utilizing community-based
approaches are effective in improving self-management
skills because the programs are based on patient needs and
emphasize the teaching of problem-solving and decision-
making skills. Education taking place in a community
setting, such as by nonprofit, community-based organiz-
ations and churches, may also increase participation.
In addition to the familiarity associated with the
community setting, trusting social relationships is also
of high significance, which may be culturally important
for some Latino subgroups.21
In addition, DSME
programs should focus on the emotional well-being
Table 3. Diabetes self-management behaviors: comparison
between baseline and 3-month follow-up data (n ¼ 142).a
Baseline Follow-Up
Characteristics % (n) % (n) P Value
Receive yearly eye exam 42.9 (61) 55.7 (79) ,.001
Receive yearly dental exam 28.9 (41) 34.5 (49) ,.001
Perform daily foot exam 45.8 (65) 71.1 (101) ,.001
Receive yearly flu vaccine 37.3 (53) 56.7 (80) ,.001
Engage in physical activity 50.0 (71) 86.6 (123) ,.01
Home blood glucose monitoring 59.9 (85) 90.8 (129) ,.001
Keep a blood glucose log 41.5 (59) 69.0 (98) ,.001
Know type of diabetes they have 52.1 (74) 83.8 (119) ,.001
a
Paired t tests were used for follow-up comparisons; n ¼ 142 at baseline
and follow-up.
Table 4. Multivariate analysis for predicting not returning to class.a
Variable Crude OR (95% CI) AOR (95% CI) n (%)
Have never attended a DSME class 2.21 (1.57–3.10) 2.39 (0.95–6.01)* 40 (28.2)
Age (.47 years) 1.21 (0.92–1.61) — 79 (55.6)
Years of school (,5 years) 1.08 (0.79–1.49) — 108 (76.1)
No physical activity 3.30 (1.78–6.09)*** 2.89 (1.10–7.60)* 6 (4.2)
No complication reduction examinations 1.01 (0.73–1.41) — 31 (21.8)
Unhealthy eating patterns 1.59 (1.12–2.25)*** — 117 (82.4)
No insurance 2.63 (1.98–3.49)*** — 92 (64.8)
Limited English proficiency 1.41 (0.89–2.22) — 129 (90.8)
No current employment 0.80 (0.67–1.16) — 76 (53.5)
Income (,$15 000 a year) 1.09 (0.78–1.53) 3.23 (1.41–7.39)** 113 (79.6)
Country of origin (Mexico) 0.98 (0.73–1.33) — 100 (70.4)
A1C at baseline (.8.0 %) 1.49 (1.12–1.98)*** — 78 (54.9)
BMI at baseline 0.93 (0.70–1.24) — 70 (49.3)
a
OR indicates odds ratio; AOR, adjusted odds ratio; CI, confidence interval; DSME, diabetes self-management education; BMI, body mass index.
*P , .05. **P , .01. ***P , .001. Multivariate results using logistic regression modeling (backward elimination).
DIABETES CARE AMONG LATINOS 5
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7. of their participants. The compromises associated with
diabetes management can lead to emotional distress,
especially anxiety and depression.21
The emotional
distress related to diabetes management is more common
in the Latino population and leads to negative self-
management behaviors, such as a high-fat/caloric food
intake, poor cognitive strategies, and elevated blood
glucose levels.21
ELDEP’s Club sessions focused largely on
assisting the patient with their social support network.
Qualitative data analysis has shown that many patients
returned to the Club classes in order to see the educators
and their fellow participants. Therefore, DSME programs
should focus not only on a culturally and linguistically
competent curriculum but should incorporate emotional
well-being as part of coping.
A limitation of the study is the one-group pretest–
posttest research design, resulting in the lack of a control
group. Though having a control group allows for the best
measurement of the effect of ELDEP, the use of a single-
group pretest–posttest design was practical for our
participants and still allowed us to measure theeffect of the
program. Another limitation of this program includes the
self-reported nature of the questionnaire. Though this is a
common issue in studies on human behavior, it is widely
accepted.22
Additionally, the behavioral data collected in
the questionnaires were not always fully completed by the
participants and were therefore not included in the study.
The questionnaires were created specifically for ELDEP
and have not yet been used or validated outside of ELDEP.
In addition, intervention attendance decreased during
follow-up. One factor for this could be that the follow-up
class is offered once a month on a weeknight when many
participants are at work. High attrition rates reflect the
reality of community-based interventions and health
centers serving low-income Spanish-speaking patients.
In contrast to clinical trials or studies that recruit
motivated patients, we recruited patients from the
community who largely were not seeking care and did
not have primary care physicians. These patients are often
“difficult to reach” due to phone number changes,
transportation limitations, low income, and other
barriers.13
Translation to Health Education Practice
ELDEP continues to develop relationships in the
community to raise awareness of the importance of
diabetes education and increase capacity training for
healthcare professionals to improve the overall patient
care of Latinos with diabetes. Results show that culturally
sensitive DSME/S has a profound effect on the biomedical
values of Latino participants in Georgia. Much of the
current diabetes education is being offered by specially
trained diabetes educators who are part of health care
organizations (i.e., hospitals, universities, clinics).
Although the information provided by these educators is
of quality, a minimal number of people are reached.23,24
Building interventions based on Social Cognitive Theory
that understand both an individual and broader social
context for diabetes self-management and that can be
appropriately tailored to different cultures can be helpful
in assisting minorities with diabetes.25
Additionally,
assessing level of acculturation would be an important
factor to consider when delivering the curriculum because
a lower level of acculturation has been associated with
greater risk of diabetes.26,27
Furthermore, it is important to
focus on emotional coping in order to prepare the
participants for the depression and anxiety associated with
diabetes because both emotions are associated with
negative self-management behaviors.21
Lastly, culturally
appropriate interventionsfor Latinopatientswith diabetes
should be explored in order to increase patient follow-up
and participation. This could be accomplished by
expanding outside of the medical facility and exploring
avenues within the community that focus on identifying
decreasing cultural barriers.
Funding
Funding for ELDEP was provided by Sanofi-Aventis.
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