Consumer Participation

This article summarizes the findings of a study of community-wide strategies for preventing homelessness among families and single adults with serious mental illness, conducted for the US Department of Housing and Urban Development. The study involved six communities, of which this article focuses on five. A major finding of this study was that it was difficult to identify sites with communitywide strategies, and even harder to find any that maintained data capable of documenting prevention success. However, the five communities selected for this study presented key elements of successful strategies including mechanisms for accurate targeting, a high level of jurisdictional commitment, significant mainstream agency involvement, and mechanisms for continuous system improvement.

Objective Patient and public involvement (PPI) in research has expanded nationally and internationally over the last decade, and recently there has been significant attention given to understanding its impact on research. Less attention has been given to the impact of PPI on the people involved, yet it has been shown that the success of PPI in research can be reliant on the processes of engagement between these individuals and communities. This paper therefore critically explores the impact of PPI on service users, researchers and communities involved in health and social care research. Data Sources Searches were undertaken from 1995 to April 2012 in the electronic databases MEDLINE, EM-BASE, PsycINFO, Cochrane library, CINAHL, HMIC and HELMIS. Searches were undertaken for grey literature using the databases InvoNet and NHS Evidence. Study Selection Studies were included if they included the impact of PPI on individual service users, researchers or communities under research. Studies were excluded if they were in a foreign language (unless they were deemed critical to the systematic review) or were in children and adolescent services. Study Appraisal Data were extracted using a narrative synthesis, and quality was assessed using the Critical Appraisal Skills Programme. Main Results Service users reported feeling empowered and valued, gaining confidence and life skills. Researchers developed a greater understanding and insight into their research area, gaining respect and a good rapport with the community. The community involved in research became more aware and knowledgeable about their condition. However, lack of preparation and training led some service users to feel unable to contribute to the research, while other service users and communities reported feeling overburdened with the work involved. Researchers reported difficulties in incorporating PPI in meaningful ways due to lack of money and time. Conclusion This is the first international systematic review to focus on the impact of PPI on the people involved in the process. The beneficial and challenging impacts reported highlight the importance of optimising the context and processes of involvement, so creating the potential for PPI to impact positively on the research itself.

Objective: To identify differences in earnings after spinal cord injury (SCI) attributable to demographic factors, injury severity, and education using a regression model that accounts for employment status, conditional earnings (earnings of those employed only), and unconditional earnings (earnings from employment for all participants with $0 recorded for those unemployed). Design: Secondary analysis of cross-sectional survey data. Setting: A midwestern university hospital and a private hospital in the southeastern United States. Participants: Adults with traumatic SCI of at least 2 years duration and under the traditional retirement age of 65 completed mailed surveys (nϭ615). Interventions: Not applicable. Main Outcome Measures: Conditional and unconditional earnings. Earnings were measured by a single item that grouped earnings into the following 8 categories:

There is no SDM in clinical practice in Brazil. The first steps have been taken towards research and tool development recently. Likewise, our society is starting to get involved with decision making in health care. This paper aims to offer an overview of the Brazilian health system history, its values, and its influence on SDM. The participative social control concept is introduced as a result of the movement against the dictatorship era. In addition, the influence of social changes on the Medical Ethical Code is delineated. SDM state of the art in Brazil is also discussed and the challenges to implement it on clinical practice are described. Regardless the challenges, it is possible to make a positive assessment of SDM in Brazil.

Community public health interventions based on citizen and community participation are increasingly discussed as promising avenues for the reduction of health inequalities and the promotion of social justice. However, very few authors have provided explicit principles and guidelines for planning and implementing such interventions, especially when they are linked with research. Traditional approaches to public health programming emphasise expert knowledge, advanced detailed planning, and the separation of research from intervention. Despite the usefulness of these approaches for evaluating targeted narrow-focused interventions, they may not be appropriate in community health promotion, especially in Aboriginal communities. Using the experience of the Kahnawake Schools Diabetes Prevention Project, in Canada, this paper elaborates four principles as basic components for an implementation model of community programmes. The principles are: (1) the integration of community people and researchers as equal partners in every phase of the project, (2) the structural and functional integration of the intervention and evaluation research components, (3) having a flexible agenda responsive to demands from the broader environment, and (4) the creation of a project that represents learning opportunities for all those involved. The emerging implementation model for community interventions, as exemplified by this project, is one that conceives a programme as a dynamic social space, the contours and vision of which are defined through an ongoing negotiation process. r (L. Potvin). 0277-9536/03/$ -see front matter r 2002 Published by Elsevier Science Ltd. PII: S 0 2 7 7 -9 5 3 6 ( 0 2 ) 0 0 1 2 9 -6

Introduction and Aims. Consumer participation in decision-making about service planning is common in certain health services in Australia but is thought to be largely underdeveloped in drug treatment services. This paper (1) describes the current practices within Australian drug treatment services that aim to include consumers in service planning and provision; and (2) determines how much consumers know about the existing opportunities for involvement. Design and Method. Sixty-four randomly selected service providers (representing 64 separate services) completed interviews about the current arrangements for consumer participation within their services (response rate ¼ 82%). A total of 179 consumers completed interviews assessing their knowledge of the consumer participation activities available at the service they attended. Results. Consumer participation activities were not uncommon in drug treatment services, although the existing activities were concerned largely with providing information to or receiving information from consumers. Activities that included consumers in higher forms of involvement, such as those in which consumers took part in decision-making, were largely uncommon. Consumers had a considerable lack of knowledge about the participation activities available to them, revealing a lack of communication between providers and consumers. Conclusions. While service providers were making efforts to engage consumers in service planning and provision (despite the general lack of State or Commonwealth policy directives and extra funding to do so), these appear ineffectual because of poor communication between providers and consumers. As a starting point, a critical part of any meaningful consumer participation initiative must include systems to ensure that consumers know about available opportunities.

The Independence through Community Access and Navigation (I-CAN) intervention was developed to increase community participation in adults with schizophrenia spectrum disorders (SSD) through identification of interest-based recreation activities and supported participation. Ten individuals consented to participate in a 10-week pilot intervention. Eight individuals participated in the intervention, during which time they worked with a recreational therapist to identify interest-based recreation activities, develop participation goals and coparticipate with the recreational therapist. At the end of the intervention, seven participants were involved in a semistructured interview to understand their perceptions of the intervention, including its outcomes and effectiveness. Therapists' notes and transcripts from the semistructured interviews were used to understand clients' perception of the intervention. Thematic analyses of seven exit interviews suggested the primary perceived outcomes of the intervention included: increased community involvement; development of planning skills; and the development of coping skills. These were facilitated by the therapeutic relationship between the client and therapist. This project provides preliminary support for the I-CAN as a participant-centered method for individuals with SSD to develop skills in the community. Implications for practice and future research are presented.

Clubhouses and consumer-run drop-in centers (CRDIs) are two of the most widely implemented models of consumer-centered services for persons with serious mental illness. Differences in structure and goals suggest that they may be useful to different types of consumers. Information on what types of consumers use which programs would be useful in service planning. This study analyzes data from the authors' NIMH-funded research on 31 geographically matched pairs of clubhouses and CRDIs involving more than 1,800 consumers to address the following question: are there significant differences in the characteristics and outcomes of members of clubhouses versus CRDIs? Results from multilevel analyses indicated that clubhouse members were more likely to be female, to receive SSI/SSDI, to report having a diagnosis of schizophrenia, and to live in dependent care; and they reported both a greater number of lifetime hospitalizations and current receipt of higher intensity traditional MH services. Controlling for differences in demographic characteristics, psychiatric history, and mental health service receipt, clubhouse members also reported higher quality of life and were more likely to report being in recovery. CRDI consumers were more likely to have substance abuse histories. Possible reasons for the differences are discussed. The results suggest that CRDIs are a viable alternative to more traditional mental health services for individuals who might not otherwise receive mental health services.

The present investigation is a case study of Lucknow, the main metropolis in Northern India, which succumbs to a major problem of municipal solid waste and its management. A qualitative investigation using strengths, weaknesses, opportunities and threats analysis (SWOT) has been successfully implemented through this community participation study. This qualitative investigation emphasizes the limited capabilities of the municipal corporationÕs resources to provide proper facilitation of the municipal solid waste management (MSWM) services without community participation in Lucknow city. The SWOT analysis was performed to formulate strategic action plans for MSWM in order to mobilize and utilize the community resources on the one hand and municipal corporationÕs resources on the other. It has allowed the introduction of a participatory approach for better collaboration between the community and municipal corporation in Lucknow (India). With this stakeholder-based SWOT analysis, efforts were made to explore the ways and means of converting the possible ÔthreatsÕ into ÔopportunitiesÕ and changing the ÔweaknessesÕ into ÔstrengthsÕ regarding a community-based MSWM programme. By this investigation, concrete strategic action plans were developed for both the community and municipal corporation to improve MSWM in Lucknow.

There are many challenges to transporting evidence-based treatments from laboratories into real-world settings. However, if we hope to make our evidence-based treatments accessible and available to children and usable by community professionals, effectiveness research is imperative. We argue that schools represent an ideal real world setting in which to conduct such research. The goals of this paper are to present

The purpose of this study was to investigate the experiences that teenagers with physical disabilities have of their participation at school. Fourteen students from several locations in Norway aged between 13 and 18 years took part. Data were collected through focus-group interviews and individual interviews. The analysis revealed three main themes: Just like the others*but not quite; Participation in terms of being where things actually happen and; Participation as studentÁteacher cooperation. A major finding was the importance the students put on being where things actually happen, this being regarded as being even more important than doing the same activities as the other students. Opportunities to increase cooperation by holding short meetings with teachers on how to solve both practical and learning problems promoted participation. The need to include the individual's experience in the concept of participation is discussed.

The continuum ofvalues and principles eVIe'ent in (urrent health promotion practice. Article Focus of value or principle Worldview17 Epistemology19 Holistic, ecological, salutogenic health promotion value or principle Organic Constructionist, Subjectivist Description of each end of the values and principles continuum Seeing the world as a living, breathing, dynamic, whole as opposed to seeing the world as an unchanging, static machine. Acknowledging that all peopleareconnected and that collectively they construct knowledge and understanding abouttheir worlds, as distinct from believing that there is only one truth that isascertained by an objective observer. Conventional health promotion value or principle Mechanistic Objectivist Reductionist, Positivist Science 2 ,5,l l Ecological Using the science of ecology, which recognises that people existin multipleecosystems, from the individual level, to the family, group, community and population level. All parts within the whole system affecteach other, and the whole isgreater than the sum of the parts. Ecological science incorporates the tenets of connectedness, complementarity, uncertainty and non-locality. Thisprincipleisdistinctfrom reductionism or positivism, in which understanding aboutthe whole comes from simply understanding each part. Health paradigm 11 ,17

WHAT ABOUT POLICY REGARDING SDM? Since 1999, there has been a small but growing interest by academics, the government, and society as a whole in strengthening patients' and professionals' involvement in shared decision making (SDM). Two governmental policy documents that indicate support for SDM are (1) Health Reform in 2003 and (2) Sanitary Objectives 2011-2020, which includes a brief section on client participation and SDM. WHAT ABOUT TOOLS - DECISION SUPPORT FOR PATIENTS? Research by Chilean academics has highlighted the patients' desire to participate in health decisions and effective approaches for enhancing health professionals' skills in interprofessional SDM; however, little has been done to support this need and the work is centralised in only one academic institution. Decision support tools and coaching interventions are limited to patients considering decisions about managing type 2 diabetes. WHAT ABOUT PROFESSIONAL INTEREST AND IMPLEMENTATION? Althoug...

Over the past two decades, the United States has attracted large South Asian populations, who have imported tobacco products previously unique to the native subcontinent. South Asian cigarette use prevalence is consistently lower than other U.S. Asian subgroups; however, most surveys fail to capture smokeless products accurately. In part because of the pervasive use of popular smokeless cultural products resulting in greater population attributable risk of oral malignancies, many countries outside the United States have developed surveillance systems to capture these products and implemented effective population-level or community-based intervention strategies. This minority population in the United States continues to be "at risk" of suffering from a disproportionate burden of diseases, which are plausibly linked to the use of these products. The primary focus of this article is to provide an exhaustive literature review of tobacco use patterns and existing tobacco control strategies among South Asians in the United States. Framed within the social ecological model, the article suggests that there needs to be more detailed assessment of cultural tobacco products, a concurrent increase in cultural competencies of health care providers and provision of cessation resources outside the clinical setting. At the policy level, future efforts should adequately regulate these products and oversight must include such products in efforts to reduce rates of use. Concurrently, communitybased efforts are needed to change social norms related to perceived health benefit and lack of stigma. This will help ensure that appropriately framed messages around use rates and burden of disease are addressed through culturally valued institutions and leaders.

The rise of the active health care consumer in the United Kingdom requires a reformulation not only of the traditional relationship between patients and doctors, but also of the macro-politics of health which reflect and service that relationship. Market and democratic themes have supplied an ideological impetus to the pressures for change. The well-publicised problems of medical self-regulation have given them practical political expression. However, the response from the policy community still reflects the dominant partners within it, medicine and the state. What neither partner has recognised is that the functionality of the policy community has been undermined by the different and issuebased challenges to the traditional patient-doctor relationship. As a result, the state is likely to remain the lead player in an increasingly unstable politics of health where consumerist issues are on the policy agenda, but patient groups are still excluded from the policy community. r

There is a prevailing argument that what small towns lack in formal services they make up for in close ties among rural people and a shared understanding of the notion of community. Drawing on research undertaken in 9 small towns across Canada, the authors examine how the concept of community operates with respect to the provision ofin-home and community care for seniors. The analysis is based on interviews with 55 key informants from local governments, health and social care agencies, voluntary sector organizations, and community groups. The findings reveal the paradox of the conventional belief that rural communities can compensate for lack of services for seniors while failing to take into account the uncertain coping ability of the local informal sectors. The authors challenge rural health policy decision-makers, researchers, and providers to debunk assumptions about services for seniors in rural Canada.

Vegetation degradation, especially the disappearance of woody vegetation and a diminished grass cover, has aroused the concern of the Maasai community (semi-nomadic pastoralists) of Kajiado District, Kenya. The district is one of Kenya's arid and semi-arid districts. Over recent years, they have observed their land resources deteriorate due to the desertification process caused by the land use practices of man. They have identified indicators of desertification such as increase of bare lands, which have been invaded by previously unknown grasses and weeds that are of no economic value, and also the disappearance of some useful plant species. It is due to the above concerns that a group of 30 farmers have been very keen to participate in on-farm research to strategize on ways to halt and even reverse the desertification process. The participatory research has identified useful trees that the farmers have been planting around homesteads, as woodlots on their farms to provide woodfuel, shade, and to act as windbreaks. They have also identified species for planting as live fences instead of using thorny tree branches as fencing material, which contributes further to the desertification process. Due to the termite menace on young tree seedlings, the farmers use indigenous knowledge to prepare concoctions using locally available materials, which they apply to planting holes and on seedlings. During awareness campaigns, the farmer research group highlights the need to conserve vegetation resources and also expounds on the concept of planting two trees after one is felled.

The aim of this collaborative public health study was to engage families, agencies, and programs in reducing secondhand smoke exposure in Central Harlem, New York City. Baseline interviews (n5657) and focus groups (n54) were conducted with adult members of households with children who had asthma and asthma-like symptoms in the Harlem Children's Zone Asthma Initiative. The interviews concerned the prevalence and determinants of exposure of enrolled children to secondhand smoke. Key findings were that participants: (1) were generally aware of the hazards of secondhand smoke; (2) used strategies to reduce exposure to secondhand smoke in their homes; (3) believed that outdoor pollutants are sometimes just as bad for the health of their children as secondhand smoke; and (4) used smoking to provide stress relief and help diffuse otherwise volatile situations in their homes. The Harlem Smoke-Free Home Campaign was launched in October 2007 based in part on these findings.

Community participation was identified as one of the key components of Primary Health Care as articulated in the Alma Ata declaration of 1978 and is enjoying a renewal of interest in both low and high income countries. There remains, however, an on-going challenge in how to assess its role in achieving health improvements. This is largely due to the multiplicity of definitions of community participation, which has made it difficult to evaluate its impact on desired programme outcomes, such as uptake and sustainability, as well as broader health improvements. This paper addresses this challenge by first defining a continuum of community participation that captures its many forms, and then incorporates this into an evaluation framework that enables an analysis of the process of participation and links this with health and programme outcomes. The continuum of participation and framework is based upon the spidergram of Rifkin, Muller, and Bichmann (1988), but modified in the light of the growing literature on community participation and also in relation to our original requirements to evaluate the role of community participation in nutrition-related child survival programmes. A case-study is presented to provide a worked example of the evaluation framework and its utility in the evaluation of community participation. While this is a literature-based and retrospective analysis, it demonstrates how the evaluation tool enables a nuanced analysis of the different ways in which communities can participate in the delivery of health-related interventions. It could be used prospectively by those involved in programme design and implementation to further our understanding of community participation and its relationship with health outcomes, as well as key programme outcomes, such as sustainability.

Lay persons who are trained to conduct research in their own communities form an essential part of many research projects. However, the effects of conducting research in their own communities have not been adequately explored. This paper examines the experiences, perceptions, and challenges faced by a group of community researchers during their involvement in a research project that examined if, and how, the relationships between mothers and their adolescent daughters could be harnessed to develop a daughter-initiated cervical cancer intervention. Seven community researchers interviewed 157 mother-daughter pairs in Cape Town, South Africa. We examine the use of journaling as a tool to document the experiences of community researchers, and we consider how journaling may help the community-based researcher grapple with the research process, and, more broadly, what such journal content illustrates with respect to the nature and challenges of community-engaged health research. An analysis of the content of the journals provides a strong indication of how personal and intimate the research process can be for community researchers by virtue of the background that they bring into the process as well as the additional weight of the research process itself. The complexities of navigating dual and somewhat oppositional roles -the role of impartial scientist or researcher and the role of invested community person -has been both underestimated and insufficiently researched.

Academic service partnerships are critical for schools of nursing to maintain credibility regarding their missions of education, research, service, and practice. In this paper, we describe a case study of a ten year program, the Living Independently For Elders (LIFE) Program at the University of Pennsylvania School of Nursing that has provided community-based long-term care to high-risk older adults. Quality of care and financial outcomes were met with nurse faculty engagement, administrative commitment, and integration of business practices. As a result, high risk older adults receive care in their communities rather than nursing homes, and the school- owned and -operated program is a nationally recognized innovative nursing model of care. Strategies are described that can be used globally as more schools of nursing embrace and strengthen service partnerships.

Background: Few studies have investigated transition programs and outcomes for young adults with disability as viewed from the parent perspective. The current Australian study provided a voice for parents to report on the experiences and outcomes for young adults following their recent transition from school into post-school life. Method: A mailed survey gathered statewide data from parents (N = 218) whose family member had completed schooling at secondary or special school. The majority of those participating were parents of young adults with intellectual disability and high support needs. Results: Findings detail school preparation for employment, community activities, and daily living; parent and student involvement in transition goal-setting; and post-school outcomes for young adults and their families. Conclusions: Parental reflections on family adjustment and life satisfaction for the young adult since leaving school highlight the lack of post-school options, and the impact of these circumstances on the whole family.

The literature on fisheries co-management is almost silent on the issue of the movement of fisherfolk within fisheries, although such movement must have implications for the effectiveness of co-management. The introduction of co-management often involves the formation of new structures that should enable the participation of key stakeholder groups in decision-making and management, but such participation is challenging for migrating fishers. The article reports on a study on Lake Victoria, East Africa, which investigated the extent of movement around the lake and the implications of movement for how fishers participate and are represented in co-management, and the implications of the extent and nature of movement for co-management structures and processes. The analysis draws on the concept of space from the literature on participation in development and on a framework of representation in fisheries co-management in addressing these questions. The created space is on an 'invited&...

Objective: The purpose of this study was to explore which of 17 categories of child maltreatment South Africans evaluated as most serious and to determine if those working with abuse and neglect evaluated abuse and neglect differently from those who did not.

Until around 1995 it was challenging to make the scientific results of research projects publicly available except through presentations at meetings or conferences, or as papers in academic journals. Then it began to be clear that the Internet could become the main medium to publish and share new information with a much wider audience. The DESIRE Project (desertification mitigation and remediation of land-a global approach for local solutions) has built on expertise gained in previous projects to develop an innovative online 'Harmonized Information System' (HIS). This documents the context, delivery and evaluation of all tasks in the DESIRE Project using non-scientific terminology, with much of it also available in the local languages of the study sites. The DESIRE-HIS makes use of new possibilities for communication, including video clips, interactive tools, and links to social media networks such as Twitter. Dissemination of research results using this approach has required careful planning and design. This paper sets out the steps that have culminated in a complete online Information System about local solutions to global land management problems in desertification-affected areas, including many practical guidelines for responsible land management. As many of those who are affected by desertification do not have Internet access, printable dissemination materials are also available on the DESIRE-HIS.

Community participation is becoming increasingly popular within the field of disaster management. International disaster policies, frameworks and charters embrace the notion that communities should play an active role in initiatives to identify vulnerabilities and risks and to mitigate those dangers, and, in the event of a disaster, that they should play a proactive part in response and recovery (see, for example, UNISDR, 1994; The Sphere Project, 2004; United Nations, 2005). A number of studies have investigated the participation of communities in disaster preparedness and mitigation efforts (see, for instance, Scott-Villiers, 2000;, There is, however, limited reflection on the challenges to ensuring participation in the operational context of disaster response. This paper draws on a study of the policy and practice of participatory damage assessment in Fiji to identify and discuss the barriers to formal implementation of community participation in a post-disaster context.

This literature review was carried out to examine the effects of user involvement in shared decision-making processes and the methods/tools available to psychiatric nurses to measure and encourage user involvement. A systematic literature review was then used in this study. Many studies indicate that an increased involvement of service users leads to better care, better treatment compliance, improved health outcomes and higher levels of patient satisfaction. The tools and methods described are designed to measure the ability to participate, the process of implementation and the evaluation of healthcare services. An adequate instrument to measure user involvement will be necessary to underpin the positive effects. Although care providers have a statutory duty to help shape user involvement, and the tools required are available, care providers are still insufficiently inclined to take up this duty.

Social capital is a relatively new concept which has attracted significant attention in recent years. No consensus has yet been reached on how to measure social capital, resulting in a large number of different tools available. While psychometric validation methods such as factor analysis have been used by a few studies to assess the internal validity of some tools, these techniques rely on data already collected by the tool and are therefore not capable of eliciting what the questions are actually measuring.

Background: Despite indoor home environments being where people spend most time, involving residents in testing those environments has been very limited, especially in marginalized communities. We piloted participatory testing and reporting that combined relatively simple tests with actionable reporting to empower residents in Main South/Piedmont neighborhoods of Worcester, Massachusetts. We answered: 1) How do we design and implement the approach for neighborhood and household environments using participatory methods? 2) What do pilot tests reveal? 3) How does our experience inform testing practice? Methods: The approach was designed and implemented with community partners using community-based participatory research. Residents and researchers tested fourteen homes for: lead in dust indoors, soil outdoors, paint indoors and drinking water; radon in basement air; PM2.5 in indoor air; mold spores in indoor/outdoor air; and drinking water quality. Monitoring of neighborhood particulates by residents and researchers used real-time data to stimulate dialogue. Results: Given the newness of our partnership and unforeseen conflicts, we achieved moderate-high success overall based on process and outcome criteria: methods, test results, reporting, lessons learned. The conflict burden we experienced may be attributable less to generic university-community differences in interests/culture, and more to territoriality and interpersonal issues. Lead-in-paint touch-swab results were poor proxies for lead-in-dust. Of eight units tested in summer, three had very high lead-in-dust (>1000 μg/ft 2 ), six exceeded at least one USEPA standard for lead-in-dust and/or soil. Tap water tests showed no significant exposures. Monitoring of neighborhood particulates raised awareness of environmental health risks, especially asthma. Conclusions: Timely reporting back home-toxics' results to residents is ethical but it must be empowering. Future work should fund the active participation of a few motivated residents as representatives of the target population. Although difficult and demanding in time and effort, the approach can educate residents and inform exposure assessment. It should be considered as a core ingredient of comprehensive household toxics' testing, and has potential to improve participant retention and the overall positive impact of long-term environmental health research efforts.

This study focuses on the assessment and treatment of the conversations of a couple where one partner has aphasia. The assessment and treatment, informed by conversation analysis, are described, and some implications for the relation between language and psychosocial issues discussed.

Diabetes is prevalent among African-American and Latino Detroit residents, with profound consequences to individuals, families, and communities. The REACH Detroit Partnership engaged eastside and southwest Detroit families in focus groups organized by community, age, gender, and language, to plan community-based participatory interventions to reduce the prevalence and impact of diabetes and its risk factors. Community residents participated in planning, implementing, and analyzing data from the focus groups and subsequent planning meetings. Major themes included: 1) diabetes is widespread and risk begins in childhood, with severe consequences for African Americans and Latinos; 2) denial and inadequate health care contribute to lack of public awareness about pre-symptomatic diabetes; 3) diabetes risks include heredity, high sugar, fat and alcohol intake, overweight, lack of exercise, and stress; and 4) cultural traditions, lack of motivation, and lack of affordable, accessible stores...