Valorization of Field-Spent Granular Activated Carbon as Heterogeneous Ozonation Catalyst for Water Treatment.

Developing sustainable cost-effective strategies for valorization of field-spent granular activated carbon (s-GAC) from industrial water treatment has gained much interest. Here, we report a cost-effective strategy for the regeneration of s-GAC as an adsorbent in a large-scale drinking water treatment plant and used as an efficient and durable ozonation catalyst in water. To achieve this, a series of samples is prepared by subjecting s-GAC to thermally controlled combustion treatments with and without pyrolysis. The catalytic performance of the optimized sample is evaluated for oxalic acid degradation as the model pollutant under batch (>15 h) and continuous flow operations (>200 h). The partially deactivated catalyst upon reuse is restored by thermal treatment. Electron paramagnetic resonance and selective quenching experiments show the formation of singlet oxygen (1O2) during catalytic ozonation. The GAC-ozonation catalyst is efficient to minimize the formation of chlorinated disinfection by-products like trihalomethanes and haloacetic acids in an urban wastewater effluent.

Sustainable and Nutritional Recommendations for the Development of Menus by School Food Services in Spain.

BACKGROUND: Recommendations for the development of school menus can promote healthier, more sustainable food systems. In Spain, these recommendations depend on regional governments (Autonomous Communities-CCAAs) that develop their own guides. The objective of this study was to explore the nutritional and sustainability recommendations for the development of menus by school food services in Spain. METHODS: Guides were reviewed that were available on the official web pages of the councils of health and education. Twenty-four variables were studied and organized into three categories: characteristics, nutritional recommendations and sustainability. The number of recommendations included in each guide was counted. The weekly frequency of the suggested food provision for each food group was calculated, as was the average, median, standard deviation, confidence interval and interquartile index. RESULTS: Overall, 13 guides were reviewed from different CCAAs. All of them included at least three of the nutritional recommendations, two suggested restrictions in the provision of foods with high quantities of salt and six suggested restrictions in foods with high levels of trans and saturated fats and sugars. All except one guide recommended the weekly provision of foods by food group: protein-rich foods (n = 8), cereals and root vegetables (n = 6), vegetables (n = 5.2) and fruit (n = 4.3). Of the eight criteria for sustainability studied, nine guides included one or none. CONCLUSIONS: Guides for the provision of meals at school in Spain promote the incorporation of healthy foods; however, they rarely restrict foods with high levels of fat, salt and sugar, and the promotion of food sustainability is only just beginning. These guides should be reviewed and updated to include recommendations that promote healthy and sustainable food systems.

School Fruit and Vegetables Scheme: Characteristics of Its Implementation in the European Union from 2009/10 to 2016/17.

The "School Fruit and Vegetables Scheme" (SFVS) was proposed in 2009/10 as a strategy to support the consumption of Fruit and Vegetables (FV), decrease rates of obesity, improve agricultural income, stabilize markets, and ensure the current and future supply of these foods. However, there is little information about how it was carried out in the EU. Given the potential of the SFVS to support healthier, more sustainable food systems, the objective of this study was to identify the characteristics of SFVS implementation from 2009/10 to 2016/17 in the EU. A longitudinal, observational, and retrospective study was carried out based on secondary data. A total of 186 annual reports of the Member States (MS) participating in the SFVS from 2009/10 to 2016/17 were consulted: European and national budget, funds used from the EU, participating schools and students, duration of the SFVS, FV offered, and application of sustainability criteria, expenditure per student, days of the week, the quantity of FV offered per student and other indicators were calculated. The majority of MS participated in the SFVS during the study period with a heterogeneous implementation pattern in terms of funds used, coverage, duration, quantity (totals and by portion), and cost of FV distributed per student. The sustainability criteria for the FV distribution were also not applied uniformly in all the MS. Establishing minimum recommendations for SFVS implementation are recommended to maximize the benefits of the SFVS. The results may be useful for planning new strategies to help address and improve current health and environmental problems.

Facilitating Factors and Opportunities for Local Food Purchases in School Meals in Spain.

The objective of this study is to explore the facilitating factors and opportunities that can promote the implementation of local food purchase (LFP) in Spanish school meals in the opinions of key informants (IK). A qualitative study was carried out based on in-depth interviews with 14 KI capable of influencing Spanish food policy (Representatives of consumers and/or producers, representatives of organizations that promote LFP, and representatives of the government and/or academics). They were asked about opportunities and facilitating factors for implementation of LFP. Interviews were recorded and transcribed. A qualitative content analysis was carried out with Atlas ti. The analysis of the interviews produced two categories that include factors that- in the interviewees' opinions- can promote LFP (social fabric and policy) and three categories that bring together the factors that represent opportunities for implementation in school meal programs in Spain (the policy agenda, regional characteristics and regional context). The overlap between social and political demands were considered to be facilitating factors for LFP. Furthermore, in the opinions of KI, the presence of health and sustainability issues on the public agenda, the existence of a structured productive system and political changes represent an opportunity to implement LFP.

Dating Violence Victimization among Adolescents in Europe: Baseline Results from the Lights4Violence Project.

Dating violence (DV) among adolescents is a public health issue because of its negative health consequences. In this study, we aimed to analyse the prevalence and the psychosocial and socioeconomic risk and protective factors associated DV among male and female adolescents in Europe. It was performed a cross-sectional study based on a non-probabilistic sample of 1555 students aged 13-16 years (2018-2019). The global prevalence of DV victimization was significantly greater among girls than boys (girls: 34.1%, boys: 26.7%; p = 0.012). The prevalence of DV in both girls and boys was greater for those over age 15 (girls: 48.5% p < 0.001; boys: 35.9%; p = 0.019). There was an increased likelihood of DV victimization among girls whose fathers did not have paid employment (p = 0.024), who suffered abuse in childhood, and reported higher Benevolent Sexism [PR (CI 95%): 1.01 (1.00-1.03)] and machismo [1.02 (1.00-1.05)]. In the case of boys, the likelihood of DV increased with abuse in childhood (p = 0.018), lower parental support [0.97 (0.96-0.99)], high hostile sexism scores (p = 0.019), lower acceptance of violence (p = 0.009) and high machismo (p < 0.001). Abuse in childhood was shown to be the main factor associated with being a victim of DV in both population groups, as well as sexism and machismo attitudes. These results may contribute to future DV prevention school programs for both, teenagers and children of elementary school ages.

The Role of School Social Support and School Social Climate in Dating Violence Victimization Prevention among Adolescents in Europe.

The aim of the article is to show the role of school social support and school social climate in dating violence victimization prevention among adolescents in Europe. Study participants were students from secondary schools (age 13-16) in Spain, Italy, Romania, Portugal, Poland and UK. The analysis in this text concern student with dating experience (n = 993) (57.2% of girls and 66.5% of boys). School social support was measured by School Social Climate, Factor 1 Scale (CECSCE) and by Student Social Support Scale (CASSS), subscales teachers and classmates. The association between school social support and different types of dating victimization (physical and/or sexual dating violence, control dating violence and fear) was measured by calculating the prevalence ratios and their 95% confidence intervals, estimated by Poisson regression models with robust variance. All the models were adjusted by country and by sociodemographic variables. The results show that the average values of all types of social support are significantly lower in young people who have suffered any type of dating violence or were scared of their partner. The likelihood of suffering physical and/or sexual dating violence decreased when school social support increased [PR (CI 95%): 0.96 (0.92; 0.99)]. In the same way, the likelihood of fear decreased when school social climate increased [PR (CI 95%): 0.98 (0.96; 0.99)].There is an association between school social support and school social climate and experiences of being victim of dating violence among adolescents in Europe. Our results suggest that in the prevention of dating violence building a supportive climate at schools and building/using the support of peers and teachers is important.

Competencias y contenidos de salud pública en los programas del Grado en Veterinaria en las universidades españolas / Public health competencies and contents in Spanish university degree programmes of Veterinary Medicine

Objetivo: Consensuar las competencias profesionales de salud pública que deben adquirir los/las estudiantes en el Grado en Veterinaria y los contenidos fundamentales que deben incluir los programas de salud pública según el criterio de docentes de salud pública del Grado en Veterinaria representantes de distintas universidades españolas. Métodos: Se organizó la 3ª Reunión del Foro de Profesorado Universitario de Salud Pública en la Facultad de Veterinaria de la Universidad de Córdoba (12-13 de enero de 2016). Participaron 42 docentes de nueve universidades españolas con Grado en Veterinaria y se distribuyeron en cinco grupos durante tres sesiones de trabajo para identificar y clasificar las competencias propias del grado, proponer contenidos de salud pública para las competencias identificadas, y organizar los contenidos en bloques temáticos. Los resultados se discutieron en distintas sesiones plenarias hasta alcanzar acuerdos. Resultados: El mayor número de competencias identificadas corresponde a actividades de las funciones «Valorar las necesidades de salud de la población» y «Desarrollar políticas de salud». El programa resultante incluye contenidos básicos organizados en cinco bloques: 1) Fundamentos de salud pública; 2) Estudio e investigación en salud pública; 3) Producción, sanidad animal y medio ambiente; 4) Seguridad alimentaria; y 5) Educación sanitaria y comunicación. Conclusiones: Los acuerdos alcanzados pueden ser un buen punto de partida para orientar una propuesta formativa en salud pública del grado para los futuros profesionales de veterinaria

Objective: To reach a consensus among public health faculty from various Spanish universities about the core public health competencies that should be integrated into the Veterinary Medicine degree training. Methods: The 3rd Forum of University Professors of Public Health was held at the School of Veterinary Medicine of the University of Cordoba (12-13 January 2016). Forty-two university professors and lecturers from nine Spanish universities with veterinary degrees participated in the forum. They were divided into five working groups during three working sessions to identify and classify core public health competencies for the Veterinary Medicine degree, propose public health contents for the identified competencies and organize such contents in thematic blocks. The results were discussed in different plenary sessions. Results: The highest number of core competencies was identified in the activities related to the following public health functions: «Assessment of the population's health needs» and «Developing health policies». The final programme included basic contents organized into five units: 1) Fundamentals of public health; 2) Study and research in public health; 3) Production, animal health and environment; 4) Food security; and 5) Health education. Conclusions: The public health core competencies and contents identified in this Forum may be considered as a starting point to update public health training programmes for future veterinary professionals

[Public health competencies and contents of Nursing degree programs in Spanish universities]. / Competencias y contenidos de Salud Pública del Grado de Enfermería en las universidades españolas.

OBJECTIVE: The Forum of Public Health University Teachers aims to update the Public Health training in the degree studies. The aim was to determine the competences and basic contents of Public Health of Nursing Degree in Spain according to the criterion of the university academic staff. METHODS: Qualitative study, based on the nominal group technique. The snowball sampling was used to recruit Public Health professors of the Nursing degree, with full time dedication and preferably of the area of Preventive Medicine and Public Health. Finally, 17 professors from 11 public universities participated, who formed the Forum of University Professors of Public Health of the Nursing Degree, which was held at the University of Barcelona. RESULTS: Nursing professors selected 43 of the 80 competences which are recognized for Public Health professionals. The majority corresponded to the functions 'Assessing population health needs' and 'Developing health policies'. Professors also got to agree about 47 issues organized in 7 blocks, with contents on introduction of Public Health, demography, health determinants, epidemiology of communicable and non-communicable diseases, health systems and health management, and health promotion and education for health. CONCLUSIONS: The university teachers agreed on Public Health competencies and contents suitable for the Nursing Degree. This consensus constitutes a reference to elaborate educational guides of Public Health for Nursing Degree.

OBJECTIVO: El Foro de Profesorado Universitario de Salud Pública pretende actualizar la formación de Salud Pública en los estudios de grado.El objetivo fue determinar las competencias y contenidos básicos de Salud Pública del Grado de Enfermería en España según el criterio del profesorado universitario. METODOS: Estudio cualitativo, basado en la técnica de grupo nominal. Se consultaron las guías docentes de las asignaturas de Salud Pública y se empleó la técnica bola de nieve para reclutar a profesorado de Salud Pública del Grado de Enfermería, con dedicación a tiempo completo y preferentemente del área de Medicina Preventiva y Salud Pública. Participaron 17 docentes de 11 universidades públicas, que constituyeron el Foro de Profesorado Universitario de Salud Pública del Grado de Enfermería, celebrado en la Universitat de Barcelona en enero de 2017. RESULTADOS: Se seleccionaron 43 de las 80 competencias profesionales reconocidas para el ámbito de la Salud Pública. La mayoría, se correspondieron con las funciones de 'Valorar las necesidades de salud de la población' y 'Desarrollar las políticas de salud'. También se consensuaron 47 unidades temáticas organizadas en 7 bloques, con contenidos sobre introducción a la salud pública, demografía, determinantes de salud, epidemiología de enfermedades trasmisibles y no trasmisibles, sistemas sanitarios y gestión, y promoción y educación para la salud. CONCLUSIONES: El profesorado universitario consensuó competencias y contenidos de Salud Pública adecuados para el Grado de Enfermería. Dicho consenso constituye una referencia para elaborar guías docentes de Salud Pública en el Grado de Enfermería.

Electrospun poly(hydroxybutyrate) scaffolds promote engraftment of human skin equivalents via macrophage M2 polarization and angiogenesis.

Human dermo-epidermal skin equivalents (DE) comprising in vitro expanded autologous keratinocytes and fibroblasts are a good option for massive burn treatment. However, the lengthy expansion time required to obtain sufficient surface to cover an extensive burn together with the challenging surgical procedure limits their clinical use. The integration of DE and biodegradable scaffolds has been proposed in an effort to enhance their mechanical properties. Here, it is shown that poly(hydroxybutyrate) electrospun scaffolds (PHB) present good biocompatibility both in vitro and in vivo and are superior to poly-ε-caprolactone electrospun scaffolds as a substrate for skin reconstruction. Implantation of PHB scaffolds in healthy rats polarized macrophages to an M2-type that promoted constructive in vivo remodelling. Moreover, implantation of DE-PHB composites in a NOD/SCID mouse xenograft model resulted in engraftment accompanied by an increase in angiogenesis that favoured the survival of the human graft. Thus, PHB scaffolds are an attractive substrate for further exploration in skin reconstruction procedures, probably due in part to their greater angiogenic and M2 macrophage polarization properties. Copyright © 2017 John Wiley & Sons, Ltd.

[Public health competencies and contents in Spanish university degree programmes of Veterinary Medicine]. / Competencias y contenidos de salud pública en los programas del Grado en Veterinaria en las universidades españolas.

OBJECTIVE: To reach a consensus among public health faculty from various Spanish universities about the core public health competencies that should be integrated into the Veterinary Medicine degree training. METHODS: The 3rd Forum of University Professors of Public Health was held at the School of Veterinary Medicine of the University of Cordoba (12-13 January 2016). Forty-two university professors and lecturers from nine Spanish universities with veterinary degrees participated in the forum. They were divided into five working groups during three working sessions to identify and classify core public health competencies for the Veterinary Medicine degree, propose public health contents for the identified competencies and organize such contents in thematic blocks. The results were discussed in different plenary sessions. RESULTS: The highest number of core competencies was identified in the activities related to the following public health functions: «Assessment of the population's health needs¼ and «Developing health policies¼. The final programme included basic contents organized into five units: 1) Fundamentals of public health; 2) Study and research in public health; 3) Production, animal health and environment; 4) Food security; and 5) Health education. CONCLUSIONS: The public health core competencies and contents identified in this Forum may be considered as a starting point to update public health training programmes for future veterinary professionals.

Competencias y contenidos de Salud Pública del Grado de Enfermería en las universidades españolas / Public health competencies and contents of Nursing degree programs in Spanish universities

Fundamentos: El Foro de Profesorado Universitario de Salud Pública pretende actualizar la formación de Salud Pública en los estudios de grado. El objetivo fue determinar las competencias y contenidos básicos de Salud Pública del Grado de Enfermería en España según el criterio del profesorado universitario. Métodos: Estudio cualitativo, basado en la técnica de grupo nominal. Se consultaron las guías docentes de las asignaturas de Salud Pública y se empleó la técnica bola de nieve para reclutar a profesorado de Salud Pública del Grado de Enfermería, con dedicación a tiempo completo y preferentemente del área de Medicina Preventiva y Salud Pública. Participaron 17 docentes de 11 universidades públicas, que constituyeron el Foro de Profesorado Universitario de Salud Pública del Grado de Enfermería, celebrado en la Universitat de Barcelona en enero de 2017. Resultados: Se seleccionaron 43 de las 80 competencias profesionales reconocidas para el ámbito de la Salud Pública. La mayoría, se correspondieron con las funciones de 'Valorar las necesidades de salud de la población' y 'Desarrollar las políticas de salud'. También se consensuaron 47 unidades temáticas organizadas en 7 bloques, con contenidos sobre introducción a la salud pública, demografía, determinantes de salud, epidemiología de enfermedades trasmisibles y no trasmisibles, sistemas sanitarios y gestión, y promoción y educación para la salud. Conclusiones: El profesorado universitario consensuó competencias y contenidos de Salud Pública adecuados para el Grado de Enfermería. Dicho consenso constituye una referencia para elaborar guías docentes de Salud Pública en el Grado de Enfermería

Background: The Forum of Public Health University Teachers aims to update the Public Health training in the degree studies. The aim was to determine the competences and basic contents of Public Health of Nursing Degree in Spain according to the criterion of the university academic staff. Methods: Qualitative study, based on the nominal group technique. The snowball sampling was used to recruit Public Health professors of the Nursing degree, with full time dedication and preferably of the area of Preventive Medicine and Public Health. Finally, 17 professors from 11 public universities participated, who formed the Forum of University Professors of Public Health of the Nursing Degree, which was held at the University of Barcelona. Results: Nursing professors selected 43 of the 80 competences which are recognized for Public Health professionals. The majority corresponded to the functions 'Assessing population health needs' and 'Developing health policies'. Professors also got to agree about 47 issues organized in 7 blocks, with contents on introduction of Public Health, demography, health determinants, epidemiology of communicable and non-communicable diseases, health systems and health management, and health promotion and education for health. Conclusions: The university teachers agreed on Public Health competencies and contents suitable for the Nursing Degree. This consensus constitutes a reference to elaborate educational guides of Public Health for Nursing Degree

Scalable and Environmentally Benign Process for Smart Textile Nanofinishing.

A major challenge in nanotechnology is that of determining how to introduce green and sustainable principles when assembling individual nanoscale elements to create working devices. For instance, textile nanofinishing is restricted by the many constraints of traditional pad-dry-cure processes, such as the use of costly chemical precursors to produce nanoparticles (NPs), the high liquid and energy consumption, the production of harmful liquid wastes, and multistep batch operations. By integrating low-cost, scalable, and environmentally benign aerosol processes of the type proposed here into textile nanofinishing, these constraints can be circumvented while leading to a new class of fabrics. The proposed one-step textile nanofinishing process relies on the diffusional deposition of aerosol NPs onto textile fibers. As proof of this concept, we deposit Ag NPs onto a range of textiles and assess their antimicrobial properties for two strains of bacteria (i.e., Staphylococcus aureus and Klebsiella pneumoniae). The measurements show that the logarithmic reduction in bacterial count can get as high as ca. 5.5 (corresponding to a reduction efficiency of 99.96%) when the Ag loading is 1 order of magnitude less (10 ppm; i.e., 10 mg Ag NPs per kg of textile) than that of textiles treated by traditional wet-routes. The antimicrobial activity does not increase in proportion to the Ag content above 10 ppm as a consequence of a "saturation" effect. Such low NP loadings on antimicrobial textiles minimizes the risk to human health (during textile use) and to the ecosystem (after textile disposal), as well as it reduces potential changes in color and texture of the resulting textile products. After three washes, the release of Ag is in the order of 1 wt %, which is comparable to textiles nanofinished with wet routes using binders. Interestingly, the washed textiles exhibit almost no reduction in antimicrobial activity, much as those of as-deposited samples. Considering that a realm of functional textiles can be nanofinished by aerosol NP deposition, our results demonstrate that the proposed approach, which is universal and sustainable, can potentially lead to a wide number of applications.

[Public health competencies and contents in pharmacy degree programs in Spanish universities]. / Competencias y contenidos comunes de salud pública del grado en farmacia de las universidades españolas.

OBJECTIVE: To identify public health core competencies and contents in pharmacy degrees at a meeting of public health lecturers in pharmacy degrees from various public and private universities. METHODS: The first Meeting of the Forum of University Teaching Staff in Pharmacy Degrees was held at the Faculty of Medicine in the Complutense University, Madrid, Spain on the 19(th) and 20(th) of November 2013. The meeting was attended by 17 lecturers. Participants brought their own teaching programs and were given two previous studies on public health competencies for analysis of public health contents and competencies in pharmacy degrees. Working groups were formed and the results were shared. RESULTS: The highest number of core competencies was identified in the following functions: "Assessment of the population's health needs" and "Developing health policies". The final program included basic contents organized into 8 units: Concept of Public Health, Demography, Epidemiological Method, Environment and Health, Food Safety, Epidemiology of Major Health Problems, Health Promotion and Education, and Health Planning and Management. CONCLUSIONS: Representation of almost all the Spanish Pharmacy Faculties and the consensus reached in the description of competences and program contents will greatly improve the quality of teaching in this area.

A comparison of electrospun polymers reveals poly(3-hydroxybutyrate) fiber as a superior scaffold for cardiac repair.

The development of biomaterials for myocardial tissue engineering requires a careful assessment of their performance with regards to functionality and biocompatibility, including the immune response. Poly(3-hydroxybutyrate) (PHB), poly(e-caprolactone) (PCL), silk, poly-lactic acid (PLA), and polyamide (PA) scaffolds were generated by electrospinning, and cell compatibility in vitro, and immune response and cardiac function in vitro and in vivo were compared with a noncrosslinked collagen membrane (Col) control material. Results showed that cell adhesion and growth of mesenchymal stem cells, cardiomyocytes, and cardiac fibroblasts in vitro was dependent on the polymer substrate, with PHB and PCL polymers permitting the greatest adhesion/growth of cells. Additionally, polymer substrates triggered unique expression profiles of anti- and pro-inflammatory cytokines in human peripheral blood mononuclear cells. Implantation of PCL, silk, PLA, and PA patches on the epicardial surface of healthy rats induced a classical foreign body reaction pattern, with encapsulation of polymer fibers and induction of the nonspecific immune response, whereas Col and PHB patches were progressively degraded. When implanted on infarcted rat heart, Col, PCL, and PHB reduced negative remodeling, but only PHB induced significant angiogenesis. Importantly, Col and PHB modified the inflammatory response to an M2 macrophage phenotype in cardiac tissue, indicating a more beneficial reparative process and remodeling. Collectively, these results identify PHB as a superior substrate for cardiac repair.

Chitosan and chitosan-ZnO-based complex nanoparticles: formation, characterization, and antibacterial activity.

Nanostructured chitosan (CS) and a chitosan-Zn based (Zn-CS) complex have been synthesized and simultaneously deposited on cotton fabrics using ultrasound. SEM measurements revealed that the coating consists of nanoparticles (NPs) of ca. 40 nm in diameter, homogeneously dispersed along the yarns. XANES studies pointed out that the complex consisted of a less than 2.1 nm ZnO core to which the chitosan was bonded. Additionally, FTIR measurements indicated the in situ formation of a Zn-CS complex which is the only deposited material on the cotton surface. The antibacterial properties of the CS and Zn-CS coated textiles were tested against Gram positive and Gram negative bacteria species. More than two-fold increase of the antibacterial activity of Zn-CS NP coated textiles was detected as compared to the fabrics treated with the sonochemically synthesized CS NPs alone. The sonochemical technique appears to be a suitable method for producing organic NPs of soluble compounds, without loss of their intrinsic properties, i.e. the antimicrobial activity of chitosan. Moreover, hybrid nanoorganometallic particles were simultaneously synthesized and deposited on cotton sonochemically.

Children as agents of their own health: exploratory analysis of child discourse in Spain.

The promotion of children's decision-making is one of the principles of health-promoting schools, and the empowerment of children means that they are enabled to influence their lifestyles and living conditions. The aim of this study was to find out the suggestions of Spanish school pupils in Year 3 and Year 6 of primary education to promote their own health and the health of the people closer to them, through their ideas about health. We analyse the discourse on health in the school environment from focus groups of primary school pupils aged around 8 and 12 of five schools in the town of Alicante (Spain). The groups were organized according to the type of school (public, private), the socioeconomic status of the neighbourhood (residential, working-class) and gender (single-sex, mixed groups) to ensure both the highest intergroup diversity and intra-group homogeneity. The findings show that primary school pupils have a wide and diverse notion of health. The application of the focus group technique has proved useful in eliciting information from groups of primary school pupils, and involving students in health-promoting programmes because it allows them to identify the social and interpersonal determinants of health. There is a firm basis to consider school pupils as health agents, particularly regarding interventions within the school environment itself. With the support of teachers, it is possible to train school pupils as community health agents, and increase their control over their own health.