Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411019EnglishN2018October10HealthcareHealth and Policy Environment of Internal Labour Migrants in India –  A Literature Review and Future Direction   English0107Manas Ranjan BeheraEnglishDesigning and implementing equitable health policies requires greater participation from the all groups of stakeholders. However, disadvantaged groups are under-represented in Indian policy making fora. Internal labour migrants in India, for example, are consistently left-out from the various social and development policies and lack a voice in the programmes that are intended to benefit them. This can jeopardize the responsiveness of health and social needs for migrants and undermine their overall development. It is necessary therefore to design innovative strategies that can bolster migrants participation. This paper looks at the current situation of internal migrants in India including their health and policy environment and offers several insights that could transform policy making it more inclusive. It suggests more funding opportunities for future research activities and implementation of sound migrant-friendly health initiatives.  EnglishMigration, Internal labour migrants, Policies for migrants, Health risks, IndiaIntroduction Since the beginning of human existence and civilization migration has been an integral part of life.1 All over the world, millions of people leave their native places to get better opportunities such as employment, education, secure their essential needs and lead a better life. This behavioural landscape of migration among people has added to a change in traditional boundaries between linguistics, dialects, societies and ethnic gatherings of both national and global regions. Thus, migration stands as an evolving process that not only influences migrants but also the lives of people both in origin and destination nations.2,3,4 India stands low and middle income countries is currently experiencing a significant growth in economy; yet, there are low priority geographical areas where pockets of disadvantaged groups stay whose development indicators are disturbing.5 One of such groups belong to the internal labour migrants and this segment of populations face exclusion from various developmental programmes, such as education and health. According to the United Nations Educational, Scientific and Cultural Organization (UNESCO), internal migration is defined by as a movement of people from one area (city, district or region) to another within the same country.6 In India, free movement is a fundamental right and there is no restriction for internal movements. The Indian constitution 1950, states “All citizens shall have the right to move freely throughout the territory of India; to reside and settle in any part of the territory of India”7 Internal migration in India 2011 Indian census estimated the population of India to be 1.21 billion.8 Approximately 309 million of people constitute as internal migrants in India9 which is 30% of the India’s total population.9  The National Sample Survey Office of India estimates around 326 million to be internal migrants (28.5 per cent).10 The internal labour migrants are projected to be more than 10 million (nearly 6 million of intra-state migrants and 4.5 million of inter-state migrants) in the country.11 The labour migrants are mainly employed in plantation and cultivation, construction sites, quarries, brick-kilns, fish processing, transportation and manufacturing units.11,12  Further, the leading source state of migration in India includes Tamil Nadu, Uttar Pradesh, Uttarakhand, Andhra Pradesh, Bihar, Odisha, Madhya Pradesh, Rajasthan, Jharkhand and Chhattisgarh and the destination places are mainly Delhi, Punjab, Haryana, Karnataka, Gujrat and Maharashtra. There are also main corridor of migration within the country mainly Odisha to Gujarat, Odisha to Andhra Pradesh and Rajasthan to Gujarat, Uttar Pradesh to Maharashtra, Bihar to National Capital Region Delhi and Bihar to Haryana and Punjab.13 The current projection estimates that the internal migrants may increase to 400 million14 which far exceeds the estimation made by the Indian governments i.e. 11.4 million.15 However, some scholars argue that the actual number of internal migration in India is grossly underestimated as the Indian census and National Sample Surveys do not adequately capture the data on rural-rural migration, short-term migration, and women’s migration which occurs due to non-marital reason and trafficking- all of which tremendously contribute to migration.16  In India, among every ten individuals, three are internal migrants7 and the government has given low priority to internal migration. There are mainly two types of migration in India: (a) long-term migration and (b) short-term migration/circular migration. Long-term migration is defined as the relocation of an individual or family members, whereas short term or seasonal/circular migration is defined as both coming and going movements between origin and destination place. Estimation suggest that the number of short term migration in India ranges from 15 million10 to 100 million.17 In addition, seasonal migration has been rising in recent years where women are usually employed as house maids and head-load transporter and men choose manual labours.12  Women are also constituting an overwhelming number of internal migrants: 70 percent based on Indian Census of 2001 and 80% according to NSSO (2007-08). Further, marriage is mentioned by women participants as the most frequent reason for migration, quoted by 91.3 percent of women respondents in rural areas and 60.8 percent from urban areas.10 Around 30 per cent of youth in the age group of 15-29 years9,14 and 15 million of children are internal migrants.18,19 Further, studies argue that circular migration are frequently representative of the vulnerable sections of the society such as the Scheduled Casts (SCs), Scheduled Tribes (STs) and Other Backward Castes (OBCs) who are poor and face economic and livelihood deficit to live and prosper.17 Health status of internal labour migrants in India Though migration is considered as an alternative livelihood strategy and brought benefits to many individual and family income, voluminous negative consequences still remain.20,21 Internal labour migrants are highly susceptible to unhygienic environment, staying in deprived and filthy environment, afflicted with occupational hazards and facing long-time separation from spouse and family members. In addition, they are often excluded from various government developmental schemes such as health and education that prevents access to affordable health services. This has resulted in multipronged health complications such as communicable diseases like malaria22, HIV/AIDS and Tuberculosis23. Occupational health issues such as eye problem and stomach pain are common among male migrants, whereas women migrants suffer from reproductive tract infections, anaemia and violence at large. Also, a large number of migrant labourers working on construction sites are commonly injured by falls and injuries caused by machines resulting in amputations.24 Poor health care utilization among migrant populations in government health facilities have also contributed in the increase of maternal and child health indicator. Further, migrant children suffer from poor immunization and malnutrition. The National Family Health Survey (NFHS) – III, 2005-06 mention that for the age under-five mortality rate among the urban migrants is 72.7 which is significantly higher than the urban national average of 51.9.25 Policies, laws and programmes pertaining to migrants’ health The existing policies and laws do not specifically mention legal and social protection of the migrant workers in India. In spite of the fact that, India is signatory to the International Labour Organization (ILO) conventions it has not yet ratified to the Convention of Migrant Workers (CMW) that allows a common platform for protecting the migrants. The United Nations Convention on Migrant Workers clearly stated various laws on migrant’s rights and puts migrants subject as a global issue. However, India neither adopted these conventions nor set clear agenda on migrant issue. Therefore, the rights of migrants are not protected, including the most important aspect of migrant health. The important health policies in India such as National Health Policy (2001) aim to achieve acceptable standard of health among general population with emphasis on equitable access to public health services across the country. However, it does not address migrant health in specific26. At present, within the national framework of health programmes and policies, there is little address of health of migrant workers. For example, the National Population Policy (2002) of India articulates the government’s commitment towards informed and voluntary choices for citizenswhile availing the reproductive and other health care services.27 Also, the “Vison 2020” policy of India aim to achieve universal health coverage by 2020 and envision that India would be healthier, prosperous and more educated than at any time in the history of its development.28 However, all these policies aim at improving population health in general, neglecting the migrant’s health in specific. Deshinkar and Sandi (2012) argues that, if migrants positive impact harness properly, then migrants can stand as a core of human development.29 There are few labour laws in India that mention about the conditions of migrant workers. The Inter-state Migrant Workmen Regulation Act (ISMWRA), 1979 talks about contractor-led movements of inter-state migrant labour and mainly focuses on how to prevent exploitation caused by out-of-state contractors. However, it is not enforced properly. One major flaw in ISMWRA is that the family members of the migrant workers who find job independently do not fall under ISMWRA.30 Another law of migrant workers under the Building and Other Construction Workers Act, 1996 aims to improve the quality of life among migrants and sets a 20-kg load for women as a handling limit. Under this act, considerable amount of funds has been collected by welfare boards of construction department for migrants in several states, but programme implementation was found negligible due to paucity of registration of migrant workers. The main disadvantage of this act is that it does remain silent about locational benefit or inter-sectorial mobility and perceive construction worker as an immobile.31 Further, The Minimum Wages Act (1948) and The National Employment Guarantee Act 2005 bring some hope by providing little financial security to migrants.  To address and monitor the migrant workers HIV/AIDS, India established a National HIV and AIDS Policy and the World of Work in 2009, with the ratification of International Labour Organization Convention No 111 on Discrimination in respect of Employment and Occupation. This policy statement brings a compressive framework where non-discrimination against labour workers was made on the basis of their real or perceived HIV status. This helped Indian government to expand its HIV policy and programmes in the work-place as a key component of mainstreaming strategy under third phase National AIDS Control Program (NACP III 2007-2012). Under this policy, all public and private enterprises, formal and informal sectors are encouraged to establish workplace policies and programmes based on the principles of non-discrimination, gender, equity, health work environment, non-screening for the purpose of employment, confidentiality, prevention and care and support.32 At present, the most of the migrant health service are provided by Non-Governmental Organization (NGOs) and there are few evidences where government policy support migrant population. The Integrated Child Development Scheme (ICDS) – A Government of India runs a programme allowing all migrant children to obtain nutritional supplements at destination sites from the anganwadis centre (the place where nutrition supplements are given and connected with existing health care services). Pregnant mothers are availing antenatal and postnatal services from these anganwadi centres which are further linked to nearest health care centres. Adolescent girls are also given nutritional requirements for anaemia and are provided with life skills and sex education under ICDS programmes. One Indian Non-Government Organization (NGO) named Disha foundation working with migrant communities in Maharashtra since 2002, have identified the sites for establishment of such anganwadis that are convenient for migrant workers and encouraged them to avail the existing government health services at affordable cost. There are also some programmes for migrant workers in the informal sector where migrants require registration cards, in some cases identity cards. To facilitate this process, another organization named Aajeevika Bureua in Rajasthan state of Udaipur provides a number of services to migrants helping in the registration process and issuing of identity cardsd for the migrant workers.7 The National Rural Health Mission (NRHM) is India’s flagship health programme undertaken by the government of India and launched in April 2005 with an objective to address the health needs of undeserved population in rural areas.33 Since, NRHM targets the rural population, urban migrants remain neglected. However, the National Urban Health Mission (NUHM) has been approved by the Government of India in 2013 and implemented in all state capitals, district headquarters and cities/towns to meet the health care needs of the urban poor.34 It specifically focuses on slum dwellers, other marginalized groups like construction workers, urban migrants, street vendors and homeless people and targets the provision of essential primary health care through community involvement and greater partnership. Thus, it is a good news for health planers, experts and implementers to see to what extent policies would be formulated and implemented under NUHM for targeting better migrant’s health. Future direction India runs several central government sponsored vertical health programmes in the areas of both communicable and non-communicable diseases. These programmes are often set for long period and need constant supervision to improve its quality. At the same time, it poses challenges in maintaining quality services and monitoring health outcomes among migrant populations.34  At present, a very few government run programmes have data on migrants; almost no other health programmes have data too. Even if data remains, it is only confined to labour market. There is an urgent need to channel and store all information pertaining to migrant health and develop proper tracking mechanisms for better health outcomes. Currently, National AIDS Control Programme IV (NACP IV 2012-17) aims at providing outreach services among migrant populations. It provides preventive and curative services to a few migrant population categories such as sex workers, truckers and construction workers. Some of the preventive approach under this programme includes condom promotion strategy, peer outreach approach, spreading educational message and community mobilization activities. In addition, capacity building activities for grass root health workers has been in place to identify risk and vulnerability among migrant populations. Counselling facility for the migrant spouses has also been carried out for psychosocial support, risk and vulnerability reduction. Further, the Link Worker Scheme (LWS) introduced under NACP III (2007-2012), aims “to reach out the high-risk population in rural areas which are basically scattered and also for the invisible rural migrants with a comprehensive package of preventive services”.35 Another project is Indian Population Project which was initiated by Ministry of Health &Family Welfare, Government of India with the support from the World Bank and aims at providing outreach service to migrants. It has been implemented in few selected cities of India such as Mumbai, Delhi, Bengaluru, Hyderabad, Kolkata and Chennai with an objective to improve health service delivery in urban areas. This project also takes help of link-workers in addressing child health and reproductive health in urban slum areas. It is important to study carefully these projects and gain lessons how to scale up and replicate such outreach interventions in other parts of the country for better migrants health. Migrant populations are sometimes alienated from the government health services due to their migration status as they are considered to be temporary workers. In addition, private health care is too expensive for them resulting a poor utilization of health care. In India, urban local bodies (ULB) have taken power and authority to improve city infrastructure and services. However, it is increasingly seen that, these ULBs are still controlled by the state governments and less focused on health outreach activities. According to the 74th Amendment to the constitution of India, ULBs are responsible for planning and development of urban areas, but in reality there are not involved in doing that. Due to this, migrants’ issues and concerns are not reflected in many urban plans and services36 and thus, urban planning seems to be failure in India.37 Therefore, it is paramount that ULBs initiate public health outreach activities and devise more ‘city migrant-friendly’ initiative, so that supportive assistance to migrants can be given. Further, there is strong requirement for implementing mobile health services, so that migrants can access onsite health service delivery instantly. There are two important urban development programmes initiated by central government.  One is Jawaharlal Nehru Urban renewal Mission (JNNURM) and another is Rajiv Awas Jojana (RAY). JNNURM aims to improve urban infrastructure and provides basic services to urban poor, whereas RAY aims at providing housing facilities for urban slum dwellers. Both programmes are significant step towards addressing the needs of urban poor and slum dwellers. However, these programmes are silent in addressing the specific issues of migrants, though shelters are most basic requirements for many migrants and slum dwellers as a large number of homeless people are still located in many large cities of India.30 Therefore, providing night shelters and building hostels for working men and women could be the answer while developing the development plans in the urban areas. Existing literature suggests that preventing migration could be counterproductive7,38,39 because migration helps in human development and fulfils human aspiration. The recent UNESCO publication (2013) mentions weak integration of migration at the destination places and recommends ten key areas for integration and inclusion of migrant services in developmental plans of India (See Box 1).7 Box 1: Key Strategies for Integration and Inclusion of Migrants in Urban Areas Registration and Identity – It is important that internal migrants are given with a proof of identity cards that are universally recognized and enable them to access various government welfare schemes anywhere in India. Political and Civic Inclusion – Assurance of voting rights of internal migrants can be made through special provisions and their inclusion in planning and decision making process can be strengthened. Labour Market Inclusion – Dialogue with labour market employer for various opportunities that migrants intend to benefit and need for training, skill up-gradation programme and placement for internal migrants with the support from NGOs are needed. Where ever migrants are illiterate and poor, awareness generation is required to know their rights. Legal Aid and Dispute Resolution – Special mechanisms are needed where internal migrants should be able to access legal aid and counselling support, so that they can safeguard themselves against wage and work associated malpractices. Further, provision of enabling environment helps migrants to be able to negotiate with contractors or employers in managing grievance and dispute-handling. Inclusion of Women Migrant – Identify research gaps and add knowledge to the gender dimension of migration. Mechanisms are needed to address exploitation, discrimination and women trafficking. Inclusion through Access to Food – Essential basic services such as access to food for internal migrants can be made convenient through the public distribution system (PDS) where migrant populations reside at any place can benefit. Inclusion through Housing – Provide rental house, dormitory accommodation and private house to the uneducated and labour migrants. In addition, slum areas need to be upgraded with provision of basic services. Educational Inclusion– Construction of hostels are required at the source place where left behind children can be retained in school hostels and worksite schools at destination place can be established where children can go with their parents. Public Health Inclusion – Avoid stigmatization as migrants are prone to various diseases and recognize that children and women migrants are vulnerable to health risks and infections. Thus, inclusion of public health intervention and out-reach health services needs to be strengthened that can be accessible at affordable cost. Financial Inclusion - Strengthen banking facilities for saving purpose and ensure that remittances transfer should be made safe and secure in the source and destination areas.       Conclusion India faces tremendous challenges on internal migration and need to formulate proper policies and programmes to improve migrants’ health. The existing programmes need to be expanded and upgraded and effective implementation of these programmes as well as their integration of source-exit-destination levels would be crucial in improving the status of migrants health. Further, migration policy should not be viewed as a labour policy but need to be incorporated with city development plans and programmes as it is increasingly clear that rural to urban migration is predominate in India. In addition, social security benefits must be embedded in labour policy as 90 per cent of the workforce employ in informal sector. Access to health services and decent living conditions must be included in the migration policy ensuring that migrant rights prevail and that they should not deny access to basic services such as housing and health. The 12th Five Year Plan (2012-17) prepared by Planning Commission of India sees rural to urban migration as a ‘distress migration’ which mainly arise due to poverty and thus, implementation rural development programmes are crucial in curtailing rural to urban migration.37,40 Further, sensitization and capacity building workshop for policy makers, experts and stakeholders concerned with migrants health such as ministry of health & family welfare, Non-Governmental Organizations, Urban development, Labour and Employment, Employees association of migrants, financial institutions and insurance companies needs to be carried out in a large scale to deal with the complexities and problems among migrant population. It is therefore a high time to mainstream migrant programmes and policies for better inclusion of migrant development. Notes a.Migration data of Indian Census 2001 is used in this study, since the data on migration from the Indian Census 2011 is not yet formally available. See http://www.censusindia.gov.in/2011-common/census_data_2001.html                                                                                                              b. There are two types of international tool on migrant rights: first is the International Covenant on Civil and Political Rights that mainly protects human rights and its facility apply universally; and second is the CMW and the ILO conventions that primarily focus on migrants. Despite of such several efforts, migrants are still continued to be protected under the umbrella of general internal law, international law and labour law, human rights law. However, with the adoption of CMW, the provisions of protecting migrants obtained formal sanction. The CMW was adopted in the 45th session of the General Assembly on 18 December 1990. See http://www2.ohchr.org/english/bodies/cmw/cmw.htm c. The United Nations International Convention on the protection of the Rights of all Migrant Workers and their family members came to force on 1 July 2003. It establishes a compressive international treaty that aims at protecting migrant workers’ rights and emphasize on building a link between migration and human rights, which later on increasingly seen as a crucial policy issue globally. The main objective of this convention is to protect migrant workers and their family members and promotion of migrant rights in each country. See http://unesdoc.unesco.org/images/0014/001435/143557e.pdf d. The Government of India has launched a programme called ‘ADHAR’ – a biometric based Unique Identity (UID) for the inhabitants of India. Under this programme, migrants have the opportunity to get an ADHAR card which can be used as a residential proof and identification and helps in accessing welfare schemes of government. In this process, many migrants have found to be lacking supportive documents for their identification. For facilitating the inclusion of migrant workers in the UID programme, a memorandum of understanding has been signed with National Coalition of Organization for Security of Migrant Workers, Unique Identification Authority of India (UIDAI) and a group Non-government Organization (NGOs). See http://uidai.gov.in. However, the current governor of Reserve Bank of India, Mr Raghuram Rajan has allowed migrant workers to open bank accounts without producing residential address documents. See http://timesofindia.indiatimes.com/business/india-business/Raghuram-Rajan-throws-weight-behind-government-move-to-have-bank-accounts-for-all/articleshow/40067746.cms Conflict of interest: The author has declared that no conflict of interests exist. Source of Funding: This work has not been supported by any funding agency. Acknowledgement: Author acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author are also grateful to editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Englishhttp://ijcrr.com/abstract.php?article_id=2530http://ijcrr.com/article_html.php?did=2530 Adler LL, and Gielen UP. Migration: Immigration and emigration in international perspective. Connecticut, USA: Greenwood Publishing Group, Incorporated. 2003.  Castles S. International migration at the beginning of the twenty-first century: Global trends and issues. Massachusetts, USA: Blackwell Publishers.2000. Wiess TL. Approaches to and diversity of international migration. World migration 2003 (pp. 4-24). Geneva, Switzerland: International Organization for Migration.2003. Wagenknecht M. International migration during the 19th century. Norderstedt, Germany: GRIN Verlag.2007. Government of India. Planning Commission. National Human Development Report 2001. Oxford University Press, New Delhi.2001. United Nations Economic, Social and Cultural Organization (UNESCO).2015. Migrant/migration. [Cited 2017,Feb 2018] Retrieved from http:/www.unesco.org/new/en/social-and-human-sciences/themes/international-migration/glossary/migrant/ United Nations Educational, Scientific and Cultural Organization (UNESCO) 2013. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411019EnglishN2018October10HealthcareAdherence to Medications in Chronic Kidney Disease: Prevalence, Predictors and Outcomes   English1419Bhupendra VermaEnglish Amrita SinghEnglish J. S. BishnoiEnglish Anil Kumar MishraEnglishBackground: In India there is scarcity of studies regarding medication non-adherence in CKD (chronic kidney disease) patients and there is lack of any prospective data. Objective: To study the prevalence and predictors of medication non-adherence in patients of CKD and outcomes of nonadherence prospectively over 2 years. Material and Methods: In this multi-centric, prospective observational study a total of 510 patients were included after obtaining consent. A validated scale of medication adherence, Morisky 8-item Medication Adherence Scale (MMAS-8) was used to calculate adherence. The primary outcome of the study was all-cause mortality and secondary outcome was composite of all-cause mortality and progression of CKD or occurrence of ESRD (end-stage renal disease). Results: Longitudinal evaluation showed increase in non-adherence over time, from 58% at baseline to 82% at two years. Overall, 18% patients were taking alternative medicines. The rate of all-cause death in low adherence population was numerically double as compared to patients with high adherence (1.4vs 0.7 per 100 patient-years), though the difference was statistically non-significant. The secondary outcome in low adherence population was 5.5 per 100 patient-years compared to 9.9 per 100 patient-years in high adherence population (hazard ratio [HR] = 1.53, 95% confidence interval [CI] = 1.21-1.74).  Conclusion: Non adherence to medication is very prevalent among CKD patients in India, which further increases with duration of treatment. High use of alternative medicine was seen without physician’s knowledge, especially in patients on haemodialysis. Moreover, we found that low medication adherence was significantly associated with composite of mortality and disease progression.  EnglishHaemodialysis, Morisky 8-item Medication Adherence Scale (MMAS-8), CKD progression, Death, Alternative medicineIntroduction Chronic kidney disease (CKD) is a major public health problem leading to increased morbidity and mortality worldwide. CKD is defined as kidney damage (structural or functional abnormalities of the kidney) or estimated glomerular filtration rate (eGFR) Englishhttp://ijcrr.com/abstract.php?article_id=2532http://ijcrr.com/article_html.php?did=2532 KDIGO, CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation, prevention and management of chronic kidney disease-mineral and bone disorder. Kidney Int. 2013; 3:1–150. Agarwal SK, Dash SC, Irshad M,  et al. 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Cedillo-Couvert EA, Ricardo AC, Chen J. Self-reported Medication Adherence and CKD Progression. Kidney Int Rep. 2018; 3(3):645-651. Lindberg M, Lindberg P. Overcoming obstacles for adherence to phosphate binding medication in dialysis patients: A qualitative study. Pharm World Sci. 2008; 30:571–6.  Lars Osterberg, M.D., and Terrence Blaschke, M.D. Drug therapy adherence to Medication. N Engl J Med 2005; 353; 5:487-497. Chiu YW, Teitelbaum I, Misra M, et al. Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance dialysis patients. Clin J Am Soc Nephrol. 2006; 4: 1089-1096.  Neri L, Martini A, Andreucci VE, et al. Regimen complexity and prescription adherence in dialysis patients. Am J Nephrol.2011; 34: 71-76. Magacho EJ, Ribeiro LC, Chaoubah A, et al. Adherence to drug therapy in kidney disease. Braz J Med Biol Res.2011; 44: 258-262. Schmitt KE, Edie CF, Laflam P, et al. Adherence to antihypertensive agents and blood pressure control in chronic kidney disease. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411019EnglishN2018October10HealthcareSulforaphane and Its Relationship with the Intestinal Flora   English2023Pooja DosieahEnglish Tan LuxuanEnglish Zhang ZhenyuEnglishSulforaphane is a compound that is correlated to the iso-thiocyanate family.It is well studied to be anti-carcinogenic preventing stomach cancers, antimicrobial, anti-inflammatory and neuroprotective in addition to its sufficient ability to protect against aging and diabetes. Sulforaphane reveals a direct positive effect on the intestinal tissues as it shows a sufficient ability in presenting a high antimicrobial respond that leads to the prevention of uprising various bacteria including both the gram-positive and the gram-negative ones such as Escheria coli and Helicobacter pylori in addition to other types of bacteria. The main objective of this study is to report a profound review of the recent papers done on this topic in order to clarify the relationship between the sulforaphane and intestine. For this review, however, there are no many articles that indicate the intimate relation, ten articles and reports from PubMed and Google Scholar databases have been included in this review of literature in order to demonstrate sulforaphane and its functions and effects towards the intestinal flora. This updated literature synthesis compromised that sulforaphane has a direct positive influence on the intestinal flora. Thus more attention should be put into consideration regarding the increase of its intake.  EnglishSulforaphane, Broccoli sprouts, Myrosinase enzyme, Glucoraphanin, Intestinal floraIntroduction Sulforaphane is simply obtained when the enzyme myrosinase is capable of transforming the glucosinolate glucoraphanin into sulforaphane [1]. It is well known that the enzymes glucoraphanin and myrosinase are located in different sites of the plant anatomy, this mechanism change takes place when the plant is prone to damage may be through different ways as an example chewing, blending and chopping allowing the bi-product of the compounds to be mixed and reacted [2]. The numerous small aged broccoli sprouts, as well as cauliflower, are considered to be a rich reservoir of the enzyme good glucoraphanin. Amongst, sulforaphane is also a section from an entire chain of disease preventions phytochemicals through plants, which are known as called isothiocyanates [3]. In the body, sulforaphane works as a stimulator of basic enzymes secretion, which is capable of neutralizing the free radicals [4]. Although inflammation in addition to free radicals is considered to be causes of different types of malignancy. Thus, Isothiocyanates can also function as cancer activating enzymes blocker in the human body system, leading to the second way of prevention [5]. Sulforaphane has been reported as basic offensive tool towards the infections through Helicobacter pylori bacteria, which are highly correlated within the global pandemic of gastrointestinal malignancy and it is a strong catalysing way of protective enzymes production that is capable of preventing inflammation and oxidation through the transcription factor Nrf2 (NF-E2 p45-related factor-2; that also can attack H. pylori in vitro and it also inhibits the formation of stomach tumours that are chemically induced in a rodent model [6]. Sulforaphane Composition and its function The Cellular composition of Broccoli and other several leaves has been reported for many years. Several studies have been done on this part and it was concluded that most of the broccoli sprouts contain massive amounts of vitamins and minerals due to the presence of glucosinolates, which are healthy for the human body intake [7,8]. According to the recent statistics done, it has been demonstrated that the components of broccoli seed mainly the glucoraphanin which is existent in high amounts in addition to the sulforaphane and isothiocyanate which a baseline of cancer attack. Sulforaphane as one of the components of the broccoli sprouts is presented in several cruciferous vegetables. It has been revealed for its ability to induce phase II detoxification enzymes and considered to be an anti-carcinogenic. Further studies have been suggested as another challenging function of sulforaphane in correlation with the chemoprotectivemaneuver dealing with the direct termination of the activity of HDAC (Histone deacetylase)[9]. The latent has been accomplished through the recent studies on the human colon malignant cells as well as human prostate cells, resulting in an excessive histone acetylation has been reported on the exposure sulforaphane [10]. The available results of HDAC inhibition via sulforaphane are correlated with malignant cells of the breast. Sulforaphane has the ability to reduce the xenografts of the prostate cancer in addition to its ability to suppress the intestinal polyps according to the experiment done on mice with an association with altered histone acetylation and the inhibition process of HDAC. Another study has presented that HDAC could be inhibited by the sulforaphane N-acetyl cysteine after metabolism, other studies have been illustrated the influences of the HDAC inhibition on the isothiocyanates. Synthetic isothiocyanate phenylhexyl is capable of accomplishing the inhibition of HDAC and the chromatin and their role in leukemia that stops the rate of growth [11]. According to a study performed on the inhibition of the HDAC and it was concluded that there is a correlation within the histone marks. Although there is a slight increase in the amount of the intake in the histone that underwent acetylation as H3 and H4 as well as H3K4   and H3K9 after methylation in coordination with the histone loss. [12]. It has been concluded that the intake of sixty-eight grams of broccoli sprouts could be able to inhibit the HDAC via the peripheral blood mononuclear cells with the time ranges from three to six hours in addition to the histone induction of acetylated H3 and H4 [13]. The mentioned results could be a reference to provide the transitional approach of the HDAC inhibition through natural diets intake as broccoli sprouts  [14]. Sulforaphane and its anti-carcinogenic effect Nowadays, Cancer is considered to be a critical disease that leads to approximately 13% of the rate of the mortality globally which is increasing rapidly within the recent years [15]. Many causes could lead to cancer, one of them is related with the Life routine especially for the inappropriate nutrition and the bad habits associated with it which can be aetiologies for cancer, thus individuals should put into their consideration how important is the proper diet intake and avoid those health threatening lifestyles [16]. Healthy suggestions on the daily diets intake should be systemized with correlation with therapies in order to make a basic defence block against different kinds of diseases, it could also be achieved by adding some Hippocratic as well as traditional Chinese medicine [17]. The positive outcome of the diets intake based on plants was associated with the ability to be anti-cancerous and antioxidant in addition to the stoppage of some enzymes that could cause malignancy [18,19]. Several types of research have been done on this approach and it has been reported the proper daily diets that depend on the plant can protect against lung cancer, and some other body systems mainly the digestive system as an example stomach cancer and oesophageal cancer in addition to oral cancers [20]. Normally, for any human diet, its components mainly contain substances responsible for pleiotropic action mechanisms that in term impact the multiple targets in both intracellular and extracellular complex. The mentioned reaction is a big beneficial mechanism to provide protection against cancer. It is highly recommended to use sulforaphane as a main ingredient in the human daily diets because of its ability to be anti-inflammatory, antioxidant and anti-carcinogenic [21]. As reported by the research team of the experimental laboratory regarding the gastrointestinal tract, Sulforaphane phase two detoxification enzymatic activity, undergoing mediation process through ARE-NRF2 pathway as an example the enzyme glutathione transferase, UDP-glucuronyltransferase, NAD (P) H:quinoneoxidoreductase I and hemi-oxygenase-1 (HO-1), that leads to an opposite influence on the electrophilic and oxidative toxic products  that needed to be diminished and inactivated prior to the macromolecular. Sulforaphane was also reported as a catalyst of interaction with KEAP1 by binding covalently to thiol groups of the inhibited proteins. Furthermore, the process of the expression of genes by the oligonucleotide implied a function of sulforaphane for the up-regulation expression of the NQO1, GST and GCL that found in the small intestine of experimental mice of the wild type  [22]. However, the other type of mice Nrf2-null mice showed a decreased of enzymes secretion. Cornell at et al revealed the Nrf2 breakdown with siRNA association with sulforaphane induction hemi-oxygenase-1 (HO-1) up-regulation [23, 24,25]. Similar related impacts have been approached in other various studies correlated with vivo and it has been concluded that sulforaphane shows a high tendency to be a direct cause of phase two enzyme in experimental under the sulforaphane intake for several days with high amounts that may reach 1000 mml/kg [26,27, 28]. A critical issue that should be put into consideration indicates the ROS depletion through the usage NRF2 as an agent containing sulforaphane to be able to stop the initiation of being cancerous to the healthy tissues, Even though the activation of the NRF2 pathway in the final step could be affected by the sufficient mechanism of the specific treatments including the chemotherapies and the radiotherapies that mainly depend on ROS production [29,30,31]. Conclusion Sulforaphane is a constituent of cruciferous vegetables; its existence in a human diet leads to a healthy environment for the body system as Sulforaphane is highly antioxidant to the adverse effects of the toxic substances in addition to its ability of being anti-carcinogenic, it was also found that sulforaphane is capable of preventing cellular inflammations and pain because of the high rate of the enzyme glutathione induction and it is also able to prevent cancer cells from entering the breast ability not only for the cardiothoracic system but also for other systems indicating prostate cancers liver and others, recent researches have been revealed a direct correlation between the sulforaphane within the intestinal flora in the digestion process, that enhances the entire process of metabolism as the mechanism of its interaction is initiated the reaction within the human body mainly the area of interest which is located at the gastrointestinal tract, that leads to the production of some enzymes that are defensive to damage via any kind of chemicals which in coordination protects the gastric cells to be, and an optimum prevention of gastric atrophy, in addition, it was also reported that Sulforaphane reveals a critical issue in the preventing H-pylori and capable to  help for protection against various types of cancer  including stomach cancer. Thus, studies on sulforaphane are not sufficient to know the long-term effects, some show, no adverse effects are reported within the high dose intake but other studies have been revealed a negative impact regarding the large amounts of sulforaphane in the daily intake, so further studies are highly recommended to figure out the effect of the large doses in the human body systems. ACKNOWLEDGEMENT I would like to extend my gratitude to my professor, Dr Zhang Zhen Yu and my colleague Dr Tan Lu Xuan for encouraging me and helping me in writing this article. I am also grateful to all the authors, editors and publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of Funding:  No funding Conflict of Interest:No conflict of interest. Englishhttp://ijcrr.com/abstract.php?article_id=2533http://ijcrr.com/article_html.php?did=25331.Nakamura K, Koyama M, Ishida R, Kitahara T, Nakajima T, Aoyama T. Characterization of bioactive agents in five types of marketed sprouts and comparison of their antihypertensive, antihyperlipidemic, and antidiabetic effects in fructose-loaded SHRs. J Food Sci Technol. 2016;53(1):581-90. 2.Senanayake GV, Banigesh A, Wu L, Lee P, Juurlink BH. The dietary phase 2 protein inducer sulforaphane can normalize the kidney epigenome and improve blood pressure in hypertensive rats. Am J Hypertens. 2012;25(2):229-35. 3.Talalay P, Fahey JW, Healy ZR, et al. Sulforaphane mobilizes cellular defenses that protect skin against damage by UV radiation. Proceedings of the National Academy of Sciences of the United States of America. 2007;104(44):17500-17505. doi:10.1073/pnas.0708710104. 4.Tortorella SM, Royce SG, Licciardi PV, Karagiannis TC. Dietary Sulforaphane in Cancer Chemoprevention: The Role of Epigenetic Regulation and HDAC Inhibition. Antioxidants & Redox  Signaling. 2015;22(16):1382-1424. doi:10.1089/ars.2014.6097. 5.Abbaoui B, Riedl KM, Ralston RA, et al. Inhibition of Bladder Cancer by Broccoli Isothiocyanates Sulforaphane and Erucin: Characterization, Metabolism and Interconversion. Molecular nutrition & food research. 2012;56(11):10.1002/mnfr.201200276. doi:10.1002/mnfr.201200276. 6.Royston KJ, Tollefsbol TO. The Epigenetic Impact of Cruciferous Vegetables on Cancer Prevention.Current pharmacology reports. 2015;1(1):46-51. doi:10.1007/s40495-014-0003-9. 7.Cheung KL, Khor TO, Kong AN. Synergistic effect of combination of phenethyl isothiocyanate and sulforaphane or curcumin and sulforaphane in the inhibition of inflammation. Pharm Res. 2009;26(1):224-31. 8.Clarke JD, Hsu A, Riedl K, et al. Bioavailability and inter-conversion of sulforaphane and erucin in human subjects consuming broccoli sprouts or broccoli supplement in a cross-over study design. Pharmacol Res. 2011;64(5):456-63. 9.Shapiro T, Fahey J, Wade K, Stephenson K and Talalay P. Chemoprotective Glucosinolates and Isothiocyanates of Broccoli Sprouts. 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The chemical diversity and distribution of glucosinolates and isothiocyanates among plants. Phytochemistry 2001, 56, 5–51. 20.Shapiro, T.A.; Fahey, J.W.; Wade, K.L.; Stephenson, K.K.; Talalay, P. Human metabolism and excretion of cancer chemoprotective glucosinolates and isothiocyanates of cruciferous vegetables. Cancer Epidemiol. Biomark. Prev. 1998, 7, 1091–1100. 21. Zhang, Y.; Tang, L. Discovery and development of sulforaphane as a cancer chemopreventive phytochemical. Acta Pharmacol. Sin. 2007, 28, 1343–1354. Medicines 2015, 2 152 22. Myzak, M.C.; Karplus, P.A.; Chung, F.L.; Dashwood, R.H. A novel mechanism of chemoprotection by sulphoraphane:inhibition of histone deacetylase. Cancer Res. 2004, 64, 5767–5774. 23.Cornblatt, B.S.; Ye, L.; Dinkova-Kostova, A.T.; Erb, M.; Fahey, J.W.; Singh, N.K.; Chen, M.S.; Stierer, T.; Garrett-Mayer, E.; Argani, P.; et al. Preclinical and clinical evaluation of sulphoraphane for chemoprevention in the breast. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411019EnglishN2018October6HealthcareDiabetic Patients ‘Perception of Their Relationship with Family Caregiver and Health-Care Providers: A Qualitative Study in the Diabetes Centre of the National Public Health Institute of Côte d’Ivoire English0813Marie Laurette Agbre YaceEnglish Kadidiatou Raissa KouroumaEnglish Yvonne Tano-KamelanEnglish Daouda DoukoureEnglishObjective: This study aimed to investigate diabetic patients’ perceptions of their relationship with healthcare providers and family caregivers. Methods: This qualitative study using semi-structured questionnaires was performed from February to April 2018, in the Diabetes Centre of the National Public Health Institute. Data were subject to thematic analysis. Data saturation was reached after 49 interviews. Results: the majority of the patients reported having good relationship with family caregivers and the healthcare team; actors they consider important in the management of their diabetes. The main factors that can improve the involvement of the couple patients/family caregivers were: good reception, more information and diabetes education, short waiting time. Conclusion: family caregiver, diabetic patient and healthcare provider relationship is a necessary social dynamic for the diabetic patient: the keystone of the quality of care. It is important to make further for better decision-making in order to implement of a true winning partnership between patient, family caregiver and healthcare provider. EnglishDiabetes, Patient, Family caregivers, Healthcare services, Cote d’IvoireINTRODUCTION Diabetes is a growing public health concern. Indeed, according to the World Health Organization (WHO), in 2015, an estimated 1.6 million of death were directly attributable to diabetes1. Besides this chronical disease has an impact on the society, health system and individual affected by the disease. Diabetes treatment is also part of a triangular relationship between family caregiver/patient/healthcare providers. However, the relationship between these three actors has an impact on the quality and the continuity of care at home. In the specialist literature different factors which influence compliance with the treatment have been identified such as socio-demographic characteristics and relationships with the disease, the therapy itself, family caregivers and healthcare providers 2, 3, 4. The healthcare provider-patient relationship is the factor with a stronger predictive power3. Indeed, this relationship is an important concept in health care, especially in primary care. Numerous studies have found out that the relationship between healthcare provider and patient is often superficial and centered more on purely systematic and physiological aspects, without taking into account the patients’ expectations, and making unilateral decisions, depending on their experience5,6. However, it is established that actions need to be centered on the patient instead of being centered on the disease and the interests of the health institutions, thus providing integrated care 7,8,9. The theoretical framework of the evaluation of the experience lived during the trajectory of care and services takes into account eight dimensions of the experience of care, based on the model of care centered on the patient and his family10. These eight dimensions are: respect for patients' values, preferences and needs (including involvement in decisions, listening, courtesy); access to care; coordination of care across different services; information, education and communication with professionals; physical comfort (including tranquility, cleanliness and safety, and pain relief); emotional support; the involvement of family and friends; transition and continuity of care10. In Côte d’Ivoire where the prevalence of diabetes is around 4.94% according to the International Diabetes Federation (IFD), very little is known about the diabetic patient perception of family caregiver and healthcare providers. Thus, as part of the National Public Health Institute of Côte d’Ivoire (INSP) policy of continuous improvement in the quality of care for diabetic patients followed up at the Diabetes Center (CADA) who ongoing needs and are cared for at home by family caregivers; we performed this study with the objectives to understand in depth diabetic patients’ views and experiences of their relationship with healthcare providers and family caregivers in the care-giving process. MATERIAL AND METHODS The study utilized a qualitative approach centered on semi-structured interviews to assess diabetic patients’ views and experiences regarding their relationship with health-care providers and family caregivers. This qualitative research was part of a larger study on the family caregiver/diabetic patient/ health-care provider relationship, performed at CADA. CADA’s mission is the outpatient management of diabetic patient, with an active line of more than 58,000 patients up to date. The centre receives in average 50 patients per day. The nursing staff includes twelve doctors, four nurses and one nurse aid. The study was conducted from February to April 2018. The questions of the interview guide asked during the interviews were based on a review of the literature11 and objectives were focused on the patient’ views and experiences with their family caregivers and health-care providers. The interview guide was pre-tested on a sample of 10 patients and this helped us to improve its content. The patients were chosen at random and the interviews were conducted face to face by 3 researchers. Each interview lasted 30-45 min and was tape-recorded. Informed consent was sought before each interview. Participants were informed about the aim of the research project and what participation in semi-structured interviews meant. They were all informed that the participation was voluntary and that confidentiality would be secured throughout the research process. The semi-structured interviews data were analyzed following recommended guidelines for qualitative research. Data collection and data analysis were carried out simultaneously. The researchers transcribed all of the interviews immediately after completing them. The data collected from interviews were transcribed in their entirety, coded and analyzed using a content and thematic analysis of the transcripts12. Data saturation was reached after 49 interviews. RESULTS Of the 49 patients who consented to be interviewed, around two third were women and only 19 had the help of a family caregiver. The age range was 35–75 years: patients aged between 40 and 49 years were the most numerous. Regarding the socio-professional category, the majority of the participants exercised a liberal profession followed by the unemployed and civil servants. (Table1). The data analysis resulted in the identification of three main themes with corresponding sub?themes related to the diabetic patients' perception of their relationship with healthcare providers and family caregivers: (1) Family caregivers as key actor for the diabetic patients; (2) Relationship with health-care providers between paternalism and effective communication, (3) Facilitators for a better involvement of the couple diabetic patient/ family caregiver in the care-giving process. Table 2 presents an overview of the main themes together with their corresponding sub?themes. Data used to illustrate the findings are verbatim quotes which have been altered as little as possible to retain authenticity, while maintaining anonymity. Family caregiver as key factor In general diabetic patients declared having good relationship with their family caregivers and this theme emerged from the diabetic patients' descriptions of how they perceived their relationship with their family caregivers, and is illustrated by the following subthemes: help in following treatment (medicines, diet, physical activity), help in translating the instructions given by the health-care providers, financial support. Help in following treatment All participants receiving help from a relative stated that they are very helpful in treatment adherence. One diabetic patient expressed it as follows: “My wife helps me a lot, she is strict with me concerning my diet, she always reminds me for my medicines and she encourages me do to some physical exercise, she even comes with me when I am walking” (diabetic patient 43). Help in translating instructions Moreover, family caregivers are useful for patient who does not speak French. Family caregivers can translate into dialect the instructions and information given by the healthcare staff. Many diabetic patients emphasized this essential aspect, as illustrated by one of them: “I did not go to school, so French is not easy. It is my son there who accompanies me. When the doctor talks, he explains it to me in our dialect and then I understand” (diabetic patient 31). Financial support Nineteen diabetic patients also mentioned the financial support of their family caregivers. Of them, one reported a situation where his daughter had an unpleasant behavior towards him because of the financial support she provides: "It is my daughter who accompanies me to my appointments, when we are sick we see everything. Some day we came for my appointment and the doctor said that I had to amputate my toe, when we finished my daughter got upset saying she was tired of spending money for my treatment. That day, I really hurt" (diabetic patient13). Relationship with health-care provider: between paternalism and effective communication This theme emerged from the diabetic patients' descriptions of how they perceived their relationship with the heath-care providers. The corresponding subthemes were: effective communication, health provider as a figure of authority. All the participants highlighted the importance of the health-care providers and the key role they play in the evolution of their health. It was a statement that we found frequently during the analysis of the interviews. However the quality of relationship depends on the health-care providers approach. Effective communication Forty one participants stated that their health-care provider has established a good relationship with them. One of them reported it as follows: "My doctor is very kind with me, he knows how to talk to me, so that I do not stress too much about my illness. When I come to consultations, he takes his time to listen to me, I feel very important and cared. He even has my daughter’s phone number and he often calls her to check on me." (diabetic patient 02). Health-care providers as figure of authority Nine diabetic patients described the relationship the health-care provider has established with them as paternalist and still perceived health-care providers as a figure of authority as stated by one of them:" when I come to the consultation, our discussions are limited to instructions for treatment. Doctors know the right medicines to treat us. We do not know anything about diabetes we should follow their instructions. They know their job and we do not have to quarrel or argue with them "(diabetic patient 07). Facilitators for a better involvement of the couple diabetic patient/ family caregiver This theme reflects on the facilitating factors that can reinforce their implication in care-giving process and their collaboration with the healthcare staff. This is described by the following three subthemes: healthcare provider’s related factors; CADA organization related factors; healthcare financing related factors. Healthcare provider’s related factors All the participants emphasized the importance of a good reception by healthcare provider as illustrated by a patient: “when we come to the hospital and we are warmly welcomed, respected and doctors listen to us, there is no reason not to get involved” (diabetic patient 01) The vast majority of the patient also deplored the lack of information on diabetes, as stated by one patient: “As far I am concerned, it will be easier for my family caregivers and me to get involved if we know everything about the disease. We must be at the same level of information. Doctors should give us more information on diabetes” (diabetic patient 44). CADA organization related factors For many diabetic patients the organizational practices of CADA should be improved regarding appointments management. One diabetic patient described a situation where he argued with the healthcare provider:"Some day, I came for my appointment but the doctor came late, I got upset because it's not normal. We are sick and we are the ones to come early. Doctors must come early to take us quickly (diabetic patient 20). " Another factor was the waiting time which is too longue according to the diabetic patient interviewed as stated by this patient:" When we come here, we can wait one hour or more before being received by the healthcare provider, it is very difficult for us. Sometimes we need to eat, but we cannot go outside to look for food by for fear of missing the appointment (diabetic patient 15). " Healthcare financing related factors Ten of the diabetic patients declared that the reduction of the treatment cost can improve their implication in the care process. One of them expressed it as follows:" We have so many medicines and medical examination that sometimes it is not possible for me to respect my appointment. The treatment is too expensive, if the government finds a solution to reduce the cost, my wife and me will get more involved in the care process (diabetic patient 22). Moreover, three diabetic patients also cited the availability of medicine such insulin as a facilitating factor as mentioned by one of them:" How do you want my family caregiver and me to be involved when diabetic medicine are not available (diabetic patient 19). " DISCUSSION Strengths and limitations of the study The limitation of our study is linked to the interviews’ setting. Indeed, the interviews took place in CADA which may have induced a refusal to answer or generated social desirability response bias that is difficult to interpret. The strength of our study consists in its originality and the context. CADA medical team is desirous to establish a strong family caregiver/diabetic patient/ health-care provider partnership. To succeed in this partnership, it is important to know in depth the patients view and expectations about the relationship they establish with healthcare providers and family caregivers. To this end, it is essential to develop study in proximology within CADA. The originality of this new area of research is to consider the role of healthcare provider and family caregiver as determining factors in the patient’s environment, and therefore the effectiveness of the disease management and care13. Comparison with existing literature Our findings showed that diabetic patients interviewed have in general a good relationship with their family caregivers and the health-care providers working at CADA. Family caregivers are the backbone of healthcare system, and they are more and more involved in the care-giving process. In our study, the patients declared that family caregivers play an important role notably in helping them to follow the treatment, to translate instructions given by the health-care providers from French to dialect. They also give a financial support which is essential for the adherence to treatment. The importance of family caregivers, especially during consultations, was also highlighted by Fanzang in French oncology patients14. However the presence of the family caregivers can be constraining of stressful15. In our study only one diabetic patient related a situation where his daughter who accompanied him misbehaved towards him. The nature of the relationship patient/family caregiver can have an impact on the quality and the continuity of care at home, it is important for the healthcare providers to be attentive, listen in both patient and family caregiver. As regard diabetic patient/health-care provider relationship, the majority of diabetic patient declared to have a good relationship with them and effective communication. Health-care providers should have effective communication with their patients in order to improve patient health outcomes16. However we noticed some health-care providers still establish paternalist relationship with patients. In our study we did not explore the perception of the patient concerning the impact of poor relationship patient-physicians on the care-giving process. However in the study we conducted among health professionals in CADA, these declared that a poor relationship with diabetic patient could lead to the abandonment of the health structure and care17. Moreover, a study carried out in China which investigated how aspects of the patient-physician relationship are associated with diabetes-related distress, insulin adherence, and glycemic control, showed that: patient dissatisfied with aspects of their interactions with physicians, exhibited poor insulin adherence18. On the other hand, the qualitative study performed by Beverly and colleagues highlights the fact that both physicians and patients often assumed responsibilities for poor clinical outcomes in the treatment of type 2 diabetes. Patients felt defeated, depressed and expressed lack of self-efficacy, while physicians pointed to health system constraints and high expectations19. Numerous studies have shown that patients prioritize the relational qualities of their caregivers19,20. In our study, relational qualities (listening, respect, kindness, hospitality) were cited by patients as one of the factors that facilitate their implication as well as that of their family caregiver in the care-giving process. In addition to this facilitator, the information and education of patients and family caregiver, the reduction of waiting time were also cited. For best patient outcomes, it is essential that patients have a more active role in their care20. When patients work in partnership with healthcare providers: complications decrease and care is better. Additionally, physicians’ perceived responsibility and patients’ self-blame for difficulty achieving treatment goals may serve as barriers to an effective relationship. Physicians and patients may benefit from a greater understanding of each other’s frustrations and challenges in diabetes management19. Implications for future research and healthcare providers practices The establishment of a positive and trusting therapeutic relationship with patients and family caregivers is recognized as an essential component of healthcare providers practice and is important for effective care.  It is crucial for healthcare providers of CADA to use a framework to develop therapeutic relationships with the couple patient/family caregiver. It also important in clinical practice, to explore and understand the challenges in developing effective therapeutic relationships with patient at the healthcare system level, and considers how these challenges can be addressed through the implementation of proximology study13. CONCLUSION In healthcare system, the key to any successful patient health outcomes is the recognition of the inseparable partnership between the couple patient/family and health professional. There is a need for decision makers to recognize the importance and the impact of this partnership on the quality of care. It is also crucial for health professionals to ensure that they work together with the couple patient/family caregiver, to establish effective communication and to pay attention to their needs in order to improve the quality of care. AUTHOR CONTRIBUTIONS M.L.A.Y and K.R.K had the initial idea for this study and wrote the research proposal. K.R.K, D.D and Y.T.K conducted interviews: read, coded, and thematically analyzed the transcripts; and wrote the manuscript. M.L.A.Y and K.R.K reviewed and edited the manuscript. All contributors had access to the data and can take responsibility for the integrity of the data and the accuracy of the data analysis. CONFLITS OF INTERESTS: Authors declare no conflict of interest ACKNOWLEDGEMENTS The authors would like to thank CRESAR-CI (Cellule de Recherche en Santé de la Reproduction de Côte d’Ivoire) for its technical and financial support during the study implementation. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Englishhttp://ijcrr.com/abstract.php?article_id=2541http://ijcrr.com/article_html.php?did=25411. Organisation Mondiale de la Santé, http://www.who.int/mediacentre/factsheets/fs312/fr/ consulté le 23 mars 2018. 2. Heredia Galán MV. ¿Qué influye en la adherencia al tratamiento de la diabetes? Rol de Enfermería 2004, 27:57-60. 3. Carratalá Munuera C, Orozco Beltrán D, Gil Guillén V, Merino Sánchez J. 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