ORIGINAL

Cinar and
ARTICLE
Schou

Impact of Empowerment on Toothbrushing

and Diabetes Management
Ayse Basak Cinara/Lone Schoub
Purpose: To assess the impact of empowerment (health coaching, HC) on toothbrushing self-efficacy (TBSE) and toothbrushing frequency (TB) and their effects on diabetes management (HbA1c, physical activity) and quality of life in
comparison to health education (HE) among patients with diabetes type 2 (DM2).
Materials and Methods: The data (HbA1c [glycated haemoglobin], TB, physical activity, TBSE, quality of life) were collected at baseline and at post-intervention at outpatient clinics of two hospitals in Istanbul, Turkey. Participants were
allocated randomly to HC (n = 77) and HE (n = 109) groups.
Results: At baseline, there were no statistical differences between HC and HE groups in terms of all measures (P >
0.05). At post-intervention, there was improvement in oral health- and diabetes-related variables in the HC group,
whereas only TBSE and TB slightly improved in the HE group (P < 0.05). At post-intervention among patients brushing
their teeth at least once a day, HC group patients were more likely to be physically active and to have high self-efficacy
than those in HE group (P < 0.01). TBSE was correlated with favourable HbA1c levels (< 6.5%) in the HC group and
quality of life (P < 0.05) in both groups.
Conclusion: The findings show that HC-based empowerment towards improving self-efficacy is more effective at improving toothbrushing behaviour than is HE and that interaction contributes significantly to diabetes management in
terms of reduced HbA1c, increased physical activity and quality of life. TBSE can be a practical starting point for empowerment and toothbrushing can be used as an effective and practical behaviour to observe personal success in
diabetes management.
Key words: diabetes type II, health coaching, quality of life, toothbrushing, toothbrushing self-efficacy
Oral Health Prev Dent 2014;12:337-344
doi: 10.3290/j.ohpd.a32130

aintaining positive lifestyles through good selfcare practices and adherence to daily regimes
is a challenge for type 2 diabetes mellitus (DM2)
patients (WHO, 2003; Minet et al, 2009). People
differ in their appraisal of and ability to effectively
cope with the demands of diabetes self-care management (Minet et al, 2009), in particular due to
different personal behavioural coping mechanisms.
Patients with type 2 diabetes (DM2) find themselves unable to follow recommended lifestyles (a
healthy diet, regular physical exercise, twice daily
tooth-brushing, no smoking), which makes them

Assistant Professor, Oral Public Health Department, Institute of

Odontology, University of Copenhagen, Denmark.

Head of Section, Global Oral Public Health Department, the Department of Odontology, University of Copenhagen, Denmark.

Correspondence: Dr. Ayse Basak Cinar, Department of Odontology,

University of Copenhagen, Norre Alle 20, DK-2200 Copenhagen,
Denmark. Tel: +45-2757-6552. Email: aci@sund.ku.dk

Vol 12, No 4, 2014

Submitted for publication: 13.05.12; accepted for publication: 18.04.13

more prone to DM2-related complications and poor

oral health, leading to a poor overall quality of life
(WHO, 2003; Cinar, 2008; Minet et al, 2009).
Patients with periodontitis are more likely to
have diabetes type 2 (Le, 1993; Sandberg et al,
2000; Guneri, 2004), which bears a high risk for
further complications such as cardiovascular problems (Genco et al, 2000; Marjanovic and Buhlin,
2013) and mortality at an early age (Avlund et al,
2009). One method which is of major importance
for preventing the initiation or progression of periodontal diseases is daily toothbrushing (Le,
2000). However, studies assessing the association of toothbrushing frequency with glycemic control and quality of life among DM2 patients are
scarce. Bakhshandeh et al (2008) and Merchant et
al (2012) found that glycemic control was associated with twice-daily toothbrushing. Cinar et al
(2013a) found that DM2 patients who reported
less than daily toothbrushing were more likely to

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Cinar and Schou

have unfavourable HDL and a low quality of life (Cinar et al, 2013a).
Health 2020 (WHO, 2013) targets empowered
individuals, and thus empowered communities,
motivating them to respond proactively to new or
adverse situations; it is supported by people-centred health systems and health-care system interventions (WHO, 2012). Health Coaching (HC) is a
self-empowerment-oriented behavioural approach
and intervention for transformation and maintenance of positive health behaviours. HC facilitates
individuals in transforming their cognitive and emotional functioning to adopt positive health behaviours by setting up personal goals and specific action plans. The study by Cinar and Schou (2013)
has shown that HC is statistically more effective
than HE at reducing HbA1c and at improving oral
health and self-efficacy.
The present study aimed to assess the impact
of empowerment, namely HC, on toothbrushing
self-efficacy and toothbrushing frequency, and their
effects on diabetes management (glycemic control,
physical activity) and quality of life in comparison to
health education among DM2 patients.

MATERIALS AND METHODS

The present study is part of a prospective intervention study among DM2 patients (n = 186), randomly selected from the outpatient clinics of two hospitals in Istanbul, Turkey. The power and sample size
is explained elsewhere (see Cinar and Schou,
2013; Cinar et al, 2013b). Eligibility criteria were:
1) confirmed DM2; 2) age 3065 years with at
least 4 functional teeth; 3) no psychological treatment or hospitalisation.
Ethical approval of and written permission for
the study were granted by the Ministry of Health.
The methodology of the study has been described
previously (Cinar and Schou, 2013; Cinar et al,
2013b). Information regarding HbA1c was taken
from the latest medical records at the hospital. Of
the patients participating, 96% (baseline visit, n =
179; final visit, n = 178) filled out the self-assessed
questionnaires. Of 186 participants, the dropout
rate was 7% (n = 8) and the corresponding figure
for the participants who did not regularly participate in all sessions was 13% (n = 24).
The health behaviour questionnaires were translated into and back-translated from Turkish by two
native speakers to ensure comparability with the
original forms in English. The data in the present

338

study originate from the self-assessed questionnaires and HbA1c (glycated haemoglobin expressed
as the percentage of haemoglobin that is exposed
to glucose) that were collected at baseline and at
the end of study.

Procedure and randomisation

At the baseline visit, participants provided informed
consent and filled out questionnaires (including demographic background, psychosocial and behavioural variables). The last current medical reports
(HbA1c, fasting blood glucose, HDL, LDL, triglyceride) were obtained from the hospital. Subsequently, all participants were invited for baseline oral examination, which was performed by two calibrated
examiners. Following the oral examination, participants were randomly allocated to either the HC (n
= 77) or formal oral health education (HE) (n = 102)
group by a researcher who was blind to outcome
measures. HC and HE were described earlier in detail (Cinar, 2012; Cinar and Schou, 2013).
The study included two phases (10-month initiation and maintenance, 6-month follow-up). During
the 10-month initiation and maintenance, participants were invited for free periodontal cleaning and
three seminars about oral health and diabetes
management. At the end of the 6-month follow-up
phase, the same outcome measures were obtained.

Outcome variables
Self-reported toothbrushing frequency as explained
earlier (Cinar and Schou, 2013) was taken from a
previous study (Cinar, 2008). Self-reported toothbrushing frequency, How often do you brush your
teeth?, was recorded on a 5-point Likert Scale
(never = 0, once a week or less = 1, 25 times/
week = 2, once daily = 3, twice or more daily = 4).
This was dichotomised for further analysis as unfavourable: brushing less than once a day and favourable: brushing at least once a day.

Diabetes management
Glycemic control was measured in terms of HbA1c.
Taking the target level HbA1c < 6.5% (International
Diabetes Federation, IDF) as the cut-off point, the
respective variable was obtained from the latest

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Cinar and Schou

health records provided by either hospital or the

participants. Values were dichotomised into favourable = 0 and unfavourable = 1.
Self-reported physical activity, taken from an earlier study (Christensen et al, 2010), was asked by a
multiple choice question Please tick the activity
that fits you best. There were four choices: 1.
read, watch TV or other things in a sitting position;
2. walking, active house work at least four hours
per week; 3. jogging, running and other kind of running exercises or hard work in a garden 2-3 hours
per week; 4. tough training, competive sports more
than once a week. Responses were re-classified
into three categories by pooling the last two choices into one, i.e. physically highly active, since relatively few participants chose them. For further analysis, answers were dichotomised into unfavourable:
physically inactive and favourable: physically active categories. The toothbrushing self-efficacy
(TBSE) scale (Cinar et al, 2005; Cinar, 2008; Cinar
et al, 2012) was used to assess the individuals
belief in his/her competency to brush his/her teeth
daily across different challenging situations by answering the question How sure are you that you
can brush your teeth. TBSE consisted of 8 items
on a five-point Likert scale (0 = not sure at all to
5 = absolutely sure). The design and validity-reliability measures of the scale have been described
previously (Cinar et al, 2005; Cinar, 2008; Cinar et
al, 2012). Sum scores for the TBSE scale were dichotomised by taking the means (HC: 18.5 and HE:
16.7) as the cut-offs and placing them into favourable: mean and above, and unfavourable: below
mean categories.
The modified version of WHOQOL-Bref (WHO,
2004), referring to the physical and psychological
domains, was used to assess the quality of life in
the present study. It included 6 items in total, 3
physical and 3 psychological, and responses
ranged on a 5-point Likert scale (items 1 and 2: 0
= not at all to 4= very extreme amount; items
35: 0 = very extreme amount to 4 = not at all;
item 6: 0 = always to 4 = never). The validity and
the reliability of the scale were tested earlier (Cinar
et al, 2013a). By using the means as the cut-offs
(HC: 13.5 and HE: 13.9), the sum scores for the
modified quality of life scale were dichotomised
into favourable: mean and above, and unfavourable: below mean.

Vol 12, No 4, 2014

Data analysis
Statistical analyses were performed using SPSS v.
17 (Chicago, IL, USA). For assessment of correlation and baseline similarities/differences between
HC and HE groups, the Spearman rank correlation
and independent samples t-test, respectively, were
used. Paired-samples t-tests were used for normally distributed data to assess change over time for
each group alone. Statistical significance was set
at 0.05 for each test.
Principal component analysis (PCA) can be used
to hypothesise an underlying construct. The PCA
approach is thus used to find a few combinations of
variables, called components or clusters, that adequately explain the overall observed variation,
thereby reducing the complexity of the data (Cinar
et al, 2013b). In the present study, factor analysis
was applied to the variables by using PCA and Varimax rotation to analyse not the associations but
the interrelationships (connected by shared background factors) and common underlying dimensions among toothbrushing frequency, physical activity, HbA1c levels and psychological variables
(self-efficacy and quality of life). These variables
were classified into discriminative clusters (latent
variables) based on factorial loadings, ranging from
highest to lowest values. Loadings below 0.25 were
extracted for ease of communication. The clusters
were named based on the variable with the highest
loading. Factors were extracted if the Kaiser criterion of an eigenvalue greater than 1 was met.

RESULTS
At baseline, there were no statistical differences
between HC and HE groups in terms of the behavioural, clinical and psychological measures (P <
0.05) (Table 1). In the HC group, 66% of the patients reported brushing their teeth at least once a
day, whereas only 52% of the HE-group patients did
so (P < 0.05). Almost half of the patients in both
groups were likely to be physically active (HC: 55%
vs HE: 48%; P < 0.05).
At post-intervention, there was 0.6% improvement in HbA1c levels in the HC group (P < 0.05),
whereas there was no improvement in the HE group
(P < 0.05). HC patients were more likely to be physically active at the end of the intervention; moreover, the percentage of patients in this group who
brushed their teeth twice a day dramatically increased (P = 0.001) (Table 1).

339

Cinar and Schou

Table 1 Between- and within-group differences from baseline to post-intervention over 16 months*
Health coaching (HC) group
n

Baseline

Post-intervention

HbA1c (%)

70

7.5%

6.9%

Toothbrushing (%)
Never or rare
25 times/week
Once a day
Twice a day

77
14
20
34
32

1
11
18
70

42
55
4

15
69
16

Physical activity (%)

77
Physically inactive
Physically active
Physically highly active
TBSE
(mean SD)

71

Quality of life
(mean SD)

68

Health education (HE) group

n

0.001 92

Baseline

Post-intervention

7.8%

7.8%

ns

ns

0.001

0.001

ns

0.001

25
23
30
22

9
22
44
25
ns

ns

0.001

46
48
6

48
42
10
0.002

ns

0.001

ns

ns

ns

0.001 76

0.001 65

0.001 70
18.5 11.9 29.3 8.6

16.7 11.8 20.9 11.4

0.003 65

13.5 4.2

P-values
P-values post-interbaseline
vention
(HCHE) (HCHE)

14.9 4.5

13.9 4.9

13.8 4.6

*The total number for each variable differs because the same participants did not answer all the questions; n for each variable represents
paired matches. ns: non-significant.

At post-intervention, those in the HC group who

brushed their teeth at least once a day were more
likely to be physically active than those who brushed
less often than daily (89% vs 56%, OR = 6.3; CI
95% 1.329.0; P < 0.05). At least once a day
toothbrushers were more likely to have higher selfefficacy than less than once a day toothbrushers
in both HC (71% vs 11%, OR = 1.4; CI 95% 1.11.8;
P = 0.001) and HE groups (48% vs 0%, OR = 1.8;
CI 95% 1.32.3; P = 0.001).
At post-intervention, among patients brushing
their teeth at least once a day, those in the HC
group were more likely to be physically active and
to have high self-efficacy than those in the HE
group (physically active: 89% vs 60%, OR = 2.1 CI
95% 1.53.2, P = 0.001; self-efficacy mean: 71%
vs 43%, OR = 1.7 CI 95% 1.12.5, P = 0.006).
Among those who brushed less than once a day,
members of the HC group were less likely to have
unfavourable HbA1c levels (>6.5%) than members
of the HE group (50% vs 87%, OR = 3.6 CI 95%
1.210.8, P < 0.05).
There were two clusters in the HC group based
on principal component analysis: oral health and
diabetes management (Table 2). The oral health
cluster was composed of the variables toothbrushing, physical activity and self-efficacy, revealing
that at least once a day toothbrushing was interrelated with being physically active and having high

340

self-efficacy. The oral health cluster was correlated

with the diabetes management cluster as follows:
improved self-efficacy was correlated with favourable HbA1c levels (rs = 0.25, P < 0.05) and quality
of life (rs = 0.28, P < 0.01). Favourable toothbrushing was correlated with improved quality of life (rs =
0.27, P < 0.05).
Among the HE group, the oral health cluster was
composed of HbA1c, toothbrushing and self-efficacy, revealing that at least once a day toothbrushers were more likely to have improved favourable
HbA1c and self-efficacy levels (Table 3). The oral
health cluster was correlated with the diabetes
management cluster as follows: toothbrushing frequency was correlated with being physically active
(rs = 0.27) and improved quality of life (rs = 0.28,
P < 0.05). Improved self-efficacy was correlated
with quality of life (rs = 0.31, P < 0.01).

DISCUSSION
To our knowledge, this is one of the first behavioural interventions to analyse the effectiveness of
an individualised HC intervention vs health education in terms of toothbrushing frequency and selfefficacy and their effects on diabetes management
(physical activity, HbA1c) and quality of life. It targets internal motivation by linking behavioural goals

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Table 2 Factor analysis for assessing clusters of favourable toothbrushing and diabetes management
among patients with diabetes type 2 in the health
coaching (HC) group

Table 3 Factor analysis for assessing clusters of favourable toothbrushing and glycemic control (HbA1c)
among patients with diabetes type 2 in the health education (HE) group

HC group

Oral health

Diabetes management

HE group

Oral health

Diabetes management

Favorable HbA1c

0.870

Favourable HbA1c

0.715

Toothbrushing at
least once a day

0.890

Toothbrushing at
least once a day

0.667

0.301

Being physically
active

0.595

0.376

Being physically
active

0.857

Favourable TBSE

0.635

0.313

Favourable TBSE

0.836

Favourable
quality of life

0.576

Favourable
quality of life

0.764

The clusters in the study group, in total, accounted for 59.1% of the
total variance [composed of component 1 (oral health): 32.0% and
component 2 (diabetes management): 27.1%]. All variables were
coded as favourable vs unfavourable. Favourable: toothbrushing at
least once a day and regular physical exercise, TBSE and quality of
life ( mean) and clinical measure (favourable HbA1c < 6.5%).
*Loading below 0.25 extracted for ease of communication. The
clusters are named based on the variable with highest loading.

The clusters in the study group, in total, accounted for 57.5% of the
total variance [composed of component 1 (oral health): 33.9% and
component 2 (diabetes management): 23.8%]). All variables were
coded as favourable vs unfavourable. Favourable: toothbrushing at
least once a day and regular physical exercise, TBSE and quality of
life ( mean) and clinical measure (favourable HbA1c < 6.5%).
*Loading below 0.25 extracted for ease of communication. The
clusters are named based on the variable with highest loading.

to patients values and personal vision of health by

the use of health coaching (HC) approach. To our
knowledge, there has not been any coaching intervention in dentistry to date. HC in the present study
stems from Motivational Interviewing (MI) (Miller
and Rollnick, 2012) and self-efficacy (Bandura
1977, 1997) focusing on personal empowerment
to adopt healthy behaviours. Recent studies to improve oral health behaviour by MI and social cognitive theory are scarce. Freudenthal and Bowen
(2010) found that mothers in the MI group more
frequently brushed the teeth of their children. It
was also observed that children of parents who received MI sessions about brushing twice a day
more frequently brushed their teeth over a two-year
period (Ismail et al, 2011). Clarkson et al (2009)
reported that patients receiving Social Cognitive
Theory-based intervention were more likely to improve their toothbrushing habits in terms of frequency, duration and method.
Regular monitoring of HbA1c values is now the
principal way to measure and track long-term glycemic control in diabetes (Skeie et al, 2001). The results of this study indicate that the HC resulted in
improvements in glycemic control (HbA1c) over the
16 months of the study. HbA1c levels of patients in
the HC group dropped by 7%, whereas HbA1C levels in the HE group remained the same, which
agrees with an earlier study (Wolever et al, 2010).

Self-efficacy beliefs may play a key role in awareness of ones own Hb1Ac levels as they are related
to engagement in positive health behaviours. Syrjl et al (1999) and Kneckt et al (1999) found that
high levels of dental self-efficacy beliefs were associated with better HbA1c levels among patients
with diabetes type 1 and insulin dependency. In the
present study, the HC group had a significantly
higher improvement in TBSE beliefs compared to
the HE group at post-intervention, which may explain why the HC group had significantly reduced
HbA1c levels.
Recent studies about the interrelation between
toothbrushing frequency and Hba1c are few. Merchant et al (2012) reported that glycemic control
was positively associated with regular toothbrushing among children with diabetes type 1. A study by
Syrjl et al (2002) showed that firmer intention to
brush the teeth was related to a lower HbA1c level
among patients with diabetes type 1. Among patients with diabetes type 1, those having better
TBSE and a higher frequency of toothbrushing had
better HbA1c levels (Kneckt et al, 1999; Syrjl et
al, 1999). In earlier studies, TBSE was found to be
strongly correlated with toothbrushing (Cinar et al,
2009, 2012) and awareness about ones own
Hba1c levels (Cinar et al, 2012). In the present
study, toothbrushing frequency and self-efficacy,
interrelated with each other in both the HC and the

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Cinar and Schou

HE groups, interacted with Hba1c in different patterns in these two groups. In the HC group, improved TBSE was correlated with favourable HbA1c
levels, whereas in the HE group, it shared the same
cluster with HbA1c, indicating that they have common risk factors. Physical activity and toothbrushing frequency shared the same cluster oral health
in the HC group; this may indicate that health
behaviours which concern lifestyle share the same
cluster. An explanation for this may be that health
behaviours, including oral health, co-occur as separate clusters, either as health-enhancing or healthdetrimental behaviours in the same individual (Donovan and et al, 1993; Astrm and Rise, 2001;
Cinar and Murtomaa, 2011). The contribution of
increased levels of TBSE to the maintenance of
regular toothbrushing may facilitate other lifestylerelated behaviours, such as physical activity, which
corroborates with earlier studies which observed
that higher self-efficacy was associated with performing diabetes self-care behaviours (Al-Khawaldeh et al, 2012; Gao et al, 2013). Gao et al (2013)
found that having higher self-efficacy was associated with performing diabetes self-care behaviours
and these behaviours were directly linked to glycemic control. Allen et al (2008) showed that improving self-efficacy beliefs led to a significant increase
in physical activity and a decrease in HbA1c levels.
In light of these studies, the correlation between
TBSE and HbA1c in the present study can be explained by a mediating/intermediary role of TBSE
between lifestyle behaviours and HbA1c.
In the HE group, the clustering between HbA1c,
self-efficacy and toothbrushing may underline common chronic-disease management skills based on
empowerment. Many patients find or feel themselves unable to follow recommended lifestyle
practices, which makes them more prone to diabetes-related complications, poor oral health and
obesity, which in turn leads to poor quality of life
(WHO, 2003; Cinar, 2008; Minet et al, 2009).
Toothbrushing is a simple but effective and easily
adjustable health behaviour, the impact of which on
the oral environment can be observed easily and in
a shorter period of time, compared to the time period required for visible outcomes of other health
behaviours. Observation of success in performance
of a health behaviour may increase self-confidence,
which may lead to better control of HbA1c by regulation of self-care practices, such as healthly diet
and adherence to medical regimes; the correlation
found between physical activity and toothbrushing
may support that. The fact that there was no im-

342

provement in HbA1c levels along with slight improvement at TBSE levels may underline the need
to increase TBSE beliefs to improve glycemic control. However, further studies are necessary to assess the interrelation between glycemic control
and oral health behaviour-related measures.
Quality of life was correlated with TBSE and
toothbrushing among both HC- and HE-group patients. Cinar and Schou (2013) reported that quality of life was correlated with toothbrushing, which
agrees with other authors (Chen et al 1996; Astrm et al, 2006). The interaction between oral
health behaviour-related measures and diabetes
management (HbA1c, physical activity) in the HC
and HE groups may contribute to the quality of life.
Further studies are required to elucidate the complex interaction and contribution patterns found in
this study. For now, however, it is noteworthy that
oral health-related measures are interrelated with
diabetes management and quality of life. Improvement in these measures can lead to better diabetes management. In HE group, a significantly higher
increase in TBSE levels may be necessary before
significant improvements in physical activity, twice
daily toothbrushing, quality of life and HbA1c levels
are attained. This emphasises that self-empowerment is one of the key factors in improving diabetes management and the quality of life. Future
studies should explore these issues.
A limitation of the present study is the small
sample size. Due to a number of organisational
challenges (personnel, training, funding, time etc.)
it was not possible to increase the number of participants. However, the original sample size is within the range of sample sizes of other studies in the
field, as discussed previously. Even though the
sample is small and not representative of the general population of DM2 patients in Turkey, it may
serve as a model for further studies. To our knowledge, this study is the first of its kind which analyses the interrelation of toothbrushing and self-efficacy for diabetes management and quality of life by
comparing health coaching and health education.
As discussed earlier (Cinar and Schou, 2013), the
strengths of the study are that: 1. it has a comparison group (HC vs HE), 2. it has a relatively long
period of intervention (16 months including a follow-up), 3. it is structured and uses internationally
accredited content of HC, and 4. it uses a validityreliability-tested self-efficacy measurement instrument. Furthermore, all HbA1c measures were taken from the records of the hospitals, eliminating
the possibility of bias from self-reports.

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CONCLUSION
Whether TBSE and toothbrushing are a cause or an
effect in relation to better diabetes management
and quality of life of patients with DM2 is a topic for
further studies. However, the present findings show
that the HC approach based on empowerment by
improving self-efficacy is more effective than HE at
improving toothbrushing behaviour. This interaction
contributes significantly to diabetes management
in terms of reduced HbA1c, increased physical activity and quality of life. Maintaining health despite
diabetes requires successful daily health practices. The data from this study suggest that HC unlocks positive self-intrinsic motivation, anchoring
self-efficacy beliefs for maintaining healthy lifestyles, e.g. through toothbrushing. TBSE may be a
practical starting point for empowerment, and
toothbrushing can be used as an effective and
practical behaviour to observe personal success in
diabetes management. Further studies thus may
provide new insights into and more effective outcomes of health promotion for diabetes patients.

ACKNOWLEDGEMENTS
We would like to express our deepest thanks to Prof. Nazif Bagriacik
(Head, Turkish Diabetes Association), Associate Prof. Mehmet Sargin and Head Diabetes Nurse Sengul Isik (Diabetes Unit, S.B. Kartal
Research and Education Hospital) for all their support and help during the research. We thank Prof. Aytekin Oguz for his help with the
preparation of the documents for the ethical approval. We also
thank Prof. I Oktay and periodontologist Duygu Ilhan for training for
clinical oral examinations, ZENDIUM for oral health care kits,
SPLENDA (TR) for the promotional tools, ChiBall World Pty Ltd for
exercise chi-balls, and to IVOCLAR Vivadent, Plandent, Denmark for
provision of CRT kits. Many thanks are due to our patients for their
participation and cooperation. The research is part of an international project that has two phases: the Turkish phase presented
here is supported by the FDI and the International Research Fund of
University of Copenhagen. The second phase is in Denmark. It is
supported by BRIDGES, which is an IDF program supported by an
educational grant from Lilly Diabetes. We would also like to thank
Christian Dinesen (Danish Coaching Institute) for the coaching training and his continuous support in both phases of the project.

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