Enhancing the effectiveness of diabetes self-management education: the diabetes literacy project. An Empowerment-Based Diabetes Self-management Education Program for Hispanic/Latinos Who Participates in Diabetes Self-management Interventions? Association of health literacy with self-management behavior in patients with diabetes. Barriers to self-management of diabetes: a qualitative study among low-income minority diabetics. Efficacy of a self-management education program for people with type 2 diabetes: results of a 12 month trial. Designing and evaluating a web-based self-management site for patients with type 2 diabetes - systematic website development and study protocol Effectiveness of self-management promotion educational program among diabetic patients based on health belief model Patients' education, and its impact on care outcomes, resource consumption and working conditions: data from the International Diabetes Management Practices Study (IDMPS). Effectiveness of a Culturally Tailored Diabetes Self-Management Program for Chinese Americans Enhancing Diabetes Self-care Among Rural African Americans With Diabetes Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems. Effect of Problem-Solving-Based Diabetes Self-Management Training on Diabetes Control in a Low Income Patient Sample New Models of Self-Management Education for Minority Ethnic Groups: Pilot Randomized Trial of a Story-Sharing Intervention A Randomized Study of the Effects of a Home Diabetes Education Program Diabetes Learning in Virtual Environments: Testing the Efficacy of Self-Management Training and Support in Virtual Environments (Randomized Controlled Trial Protocol). Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial.
Patient empowerment through self-management education is central to improving the quality of diabetes care and preventing Type 2 Diabetes .  Although national programs exist , there is no EU-wide strategy for diabetes self-management education , and patients with limited literacy face barriers to effective self-management . The Diabetes Literacy project , initiated with the support of the European Commission , aims to fill this gap . The project investigates the effectiveness of diabetes self-management education , targeting people with or at risk of Type 2 Diabetes in the 28 EU Member States , as part of a comprehensive EU-wide diabetes strategy . National diabetes strategies in the EU , US , Taiwan , and Israel are compared , and diabetes self-management programs inventorized . The costs of the diabetes care pathway are assessed on a per person basis at national level . A comparison is made of the (cost)-effectiveness of different methods for diabetes self-management support , and the moderating role of health literacy , organization of the health services , and implementation fidelity of education programs are considered . Web-based material s are developed and evaluated by r and omized trials to evaluate if interactive internet delivery can enhance self-management support for people with lower levels of health literacy . The 3-year project started in December 2012 . Several literature review s have been produced and protocol development and research design are in the final stages . Primary and secondary data collection and analysis take place in 2014 . The results will inform policy decisions on improving the prevention , treatment , and care for persons with diabetes across literacy levels Purpose The purpose of this pilot study was to evaluate the effects of a culturally sensitive , empowerment-based diabetes self-management education program for Spanish-speaking Hispanic/Latinos . Methods A prospect i ve quasi-experimental repeated measures design tested the effectiveness of the ¡ Si , Yo Puedo Controlar Mi Diabetes ! diabetes self-management education program . In sum , 144 persons residing in 2 Texas counties at the Texas-Mexico border ( Starr and Hidalgo ) served as participants . Two groups were formed , an intervention and a control ( wait list ) . Clinical ( A1C ) , cognitive , attitudinal , behavioral , and cultural assessment s were collected at baseline and 3 months . Results Demographic characteristics for the intervention and control groups were similar . Both groups were predominately female , low income , older than 40 years , and minimally acculturated . Baseline and posttest findings showed that the intervention group had a significant reduction in A1C values ; median difference was 0.3 ( n = 45 ) , especially for those with higher baseline values . Participants in the intervention group also improved in their self-efficacy and self-care scores . Conclusions Findings from the study suggest that additional dissemination of a diabetes self-management education program for Spanish-speaking Hispanic/Latinos is warranted to improve clinical outcomes and associated diabetes self-efficacy and self-care behaviors PURPOSE The purpose of this study was to examine reasons for nonparticipation and drop out in a diabetes self-management intervention . METHODS A total of 468 recently screen-detected patients , receiving usual care or intensive pharmacological treatment  , were invited and r and omized into either a control or intervention condition , consisting of a brief self-management course . A nonresponse survey was conducted , and participants , non participants , and dropouts were compared on sociodemographic variables , diabetes attitudes , and self-care . RESULTS A total of 227 patients consented and were allocated to the control ( n=108 ) or intervention group ( n=119 ) . Two hundred forty-one patients declined participation , 41 dropped out , and 78 completed the intervention . Major reasons for refusal and drop out were hesitancy toward research and practical barriers . Non participants were less educated and reported higher self-management , while participation also varied by treatment and disease duration : intensively treated patients were more likely to participate in their first year , and usual-care patients participated more often 2 to 3 years after diagnosis . Dropouts had a lower education level but did not differ on any other measure . CONCLUSION Participants , non participants , and dropouts did not differ in their attitudes toward diabetes , but the intervention did attract patients with lower self-care . Variations in participation by treatment and disease duration suggest that patients prefer self-management interventions at different times depending on their medical treatment . Finally , education appears to be the most important factor determining participation . Alternative strategies are needed to attract and retain patients with low education Limited health literacy , common in patients with diabetes , has been associated with worse diabetes outcomes ( 1–4 ) . While patients with limited health literacy have worse diabetes knowledge ( 2–5 ) , knowledge does not necessarily predict outcomes ( 6–8 ) . Because diabetes requires extensive self-care , differences in self-management behaviors may be a key contributor to the disparity in outcomes . In fact , low health literacy has been associated with poor self-care in other chronic illnesses ( 9,10 ) . However , no study has examined the relationship between health literacy and self-management behaviors in patients with diabetes . In addition , studies have not assessed whether diabetes education , which is widely recommended , is effective in improving self-management behaviors in patients with limited health literacy . The objectives of our study were to examine the association of health literacy with self-management behaviors in patients with diabetes and to determine whether diabetes education  improves self-management behaviors in patients with limited compared with adequate health literacy . Underst and ing the relationship between health literacy and self-management behaviors should enhance efforts to improve diabetes outcomes . We conducted a prospect i ve observational study of patients enrolled in diabetes education classes at the Hospital of the University of Pennsylvania . The classes consist of an individual meeting with a diabetes educator and three weekly 3-h group classes and are recognized by the American Diabetes Association ( 11 ) . All patients ≥18 years of age present for a regularly scheduled diabetes class were recruited . OBJECTIVES Diabetes self-management is a key element in the overall management of diabetes . Identifying barriers to disease self-management is a critical step in achieving optimal health outcomes . Our goal was to explore patients ' perceptions about barriers to self-management of diabetes that could possibly help explain poor health outcomes among minority patients . STUDY DESIGN Four focus groups were conducted among 31 predominately African American patients with diabetes who were enrolled in the Baltimore Cardiovascular Partnership Study , a NIH-funded multiyear prospect i ve partnership study . The topic guide consisted of a series of open-ended questions about knowledge of current health status , medication use , continuity of care , blood glucose level and nutrition . RESULTS The focus groups confirmed that previously reported barriers to self-management persisted and identified new concerns that could be associated with poor health outcomes among minority patients with diabetes .  Attitudes , perceptions and behaviors surrounding diabetes and self-management of the condition did vary across individuals , however , the variation appeared to reflect the individual 's knowledge and opinions rather than patient 's age , sex , or culture . The primary barrier to diabetes self-management result ed from lack of knowledge of target blood glucose and blood pressure . Several participants found some of the health information to be quite confusing . CONCLUSIONS Diabetes is a major public health concern and the lack of awareness of target blood glucose and blood pressure further complicates the problem . The limited health literacy seen in this study could help explain several of the barriers to self-management . The barriers to self-management identified in this qualitative study are amenable to intervention that could improve health outcomes AIM Patient education that enhances one 's self-management ability is of utmost importance for improving patient outcomes in chronic diseases . We developed a 12 month self-management education program for type 2 diabetes , based on a previous 6 month program , and examined its efficacy . METHODS A r and omized controlled trial was carried out on out patients with type 2 diabetes from two hospitals who met the criteria and gave consent to participate . They were r and omly divided into an intervention group that followed the program and a control group that followed usual clinical practise . The intervention group received < 30 min of monthly interviews based on the program 's textbook and biweekly telephone calls from a nurse educator throughout the 12 months . RESULTS Of the 50 participants in the intervention group and the 25 participants in the control group , 42 and 23 , respectively , completed the program ( a completion rate of 84.0 % ) . The body weight , HbA1c , self-efficacy , dietary and exercise stages , quality of life , diastolic blood pressure , and total cholesterol level were significant by two-way repeated- measures anova . As for changes over time within the groups , only the intervention group showed significant differences by Friedman 's test . The complication prevention behaviors showed a high implementation rate in the intervention group . The overall evaluation of this program by the participants was very high and , therefore , they highly recognized the need for this type of program . CONCLUSIONS Self-management education works successfully in relation to patients ' behavior modification skills , degree of goal attainment , and self-efficacy , consequently improving their health outcomes Background Given that patients provide the majority of their own diabetes care , patient self-management training has increasingly become recognized as an important strategy with which to improve quality of care . However , participation in self management programs is low . In addition , the efficacy of current behavioural interventions wanes over time , reducing the impact of self-management interventions on patient health . Web-based interventions have the potential to bridge the gaps in diabetes care and self-management . Methods Our objective is to improve self-efficacy , quality of life , self-care , blood pressure , cholesterol and glycemic control and promote exercise in people with type 2 diabetes through the rigorous development and use of a web-based patient self-management intervention . This study consists of five phases : ( 1 ) intervention development ; ( 2 ) feasibility testing ; ( 3 ) usability testing ; ( 4 ) intervention refinement ; and ( 5 ) intervention evaluation using mixed methods . We will employ evidence -based strategies and tools , using a theoretical framework of self-efficacy , then elicit user feedback through focus groups and individual user testing sessions . Using iterative re design the intervention will be refined . Once finalized , the impact of the website on patient self-efficacy , quality of life , self-care , HbA1c , LDL-cholesterol , blood pressure and weight will be assessed through a non-r and omized observational cohort study using repeated measures modeling and individual interviews . Discussion Increasing use of the World Wide Web by consumers for health information and ongoing revolutions in social media are strong indicators that users are primed to welcome a new era of technology in health care . However , their full potential is hindered by limited knowledge regarding their effectiveness , poor usability , and high attrition rates . Our development and research agenda aims to address these limitations by improving usability , identifying characteristics associated with website use and attrition , and developing strategies to sustain patient use in order to maximize clinical outcomes Introduction : Diabetes is a chronic disease ; it can cause serious complications . Diabetes self-management is essential for prevention of disease complications . This study was conducted to evaluate self-management promotion educational program intervention efficiency among diabetic patients in Iran and health belief model ( HBM ) was applied as a theoretical framework . Material s and Methods : Overall , 120 Type 2 diabetic patients referred to rural health centers in Gachsaran , Iran participated in this study as r and omly divided into intervention and control group . This was a longitudinal r and omized pre- and post-test series control group design panel study to implement a behavior modification based intervention to promotion self-management among diabetic patients . Cross-tabulation and t-test by using SPSS statistical package , version 16 was used for the statistical analysis . Results : Mean age was 55.07 years ( SD = 9.94 , range : 30 - 70 ) . Our result shows significant improvements in average response for susceptibility , severity , benefit and self-management among intervention group . Additionally , after intervention , average response of the barrier to self-management was decreased among intervention group . Conclusion : Our result showed education program based on HBM was improve of self-management and seems implementing these programs can be effective in the and prevention of diabetes complications AIM To evaluate the impact of diabetes education provided to patients with type 2 diabetes mellitus ( T2DM ) in non-controlled studies ( " real-world conditions " ) on quality of care , re source consumption and conditions of employment . METHODS This cross-sectional study and longitudinal follow-up describe the data ( demographic and socioeconomic profiles , clinical characteristics , treatment of hyperglycaemia and associated cardiovascular risk factors , re source consumption ) collected during the second phase ( 2006 ) of the International Diabetes Management Practice s Study ( IDMPS ) . Patients received diabetes education directly from the practice nurse , dietitian or educator , or were referred to ad hoc group-education programmes ; all programmes emphasized healthy lifestyle changes , self-care and active participation in disease control and treatment . Educated vs non-educated T2DM patients ( n=5692 in each group ) , paired by age , gender and diabetes duration , were r and omly recruited for the IDMPS by participating primary -care physicians from 27 countries in Eastern Europe , Asia , Latin America and Africa . Outcome measures included clinical ( body weight , height , waist circumference , blood pressure , foot evaluation ) , metabolic ( HbA(1c ) levels , blood lipid profile ) and biochemical control measures . Treatment goals were defined according to American Diabetes Association guidelines . RESULTS T2DM patients ' education significantly improved the percentage of patients achieving target values set by international guidelines . Educated patients increased their insulin use and self-care performance , had a lower rate of chronic complications and a modest increase in cost of care , and probably higher salaries and slightly better productivity . CONCLUSION Diabetes education is an efficient tool for improving care outcomes without having a major impact on healthcare costs Purpose The purpose of the study was to test the feasibility and efficacy of a diabetes self-management and education program for Chinese Americans in a support group format . The rationale for the study was to create culturally appropriate diabetes education and management programs in response to the growing diabetes prevalence among Chinese Americans . The investigators hypothesized that participants will have improved diabetes knowledge and practice s , hemoglobin A1C , and social support . The study objectives were at least : 50 % will have significant improvements in diabetes knowledge and practice activities , 30 % of participants will have significant improvements in A1C , and 50 % will report a gain in emotional support . Methods The program consisted of 12 90-minute diabetes education and support group sessions offered in a medical office setting . The sample included 23 Chinese Americans with either type 1 or type 2 diabetes . Using a single-group , pre-post test design , A1C and diabetes knowledge were assessed at baseline and 6 months . Data were collected through clinical assessment s and written question naires . Results The results indicated high attendance and statistically significant increases in glycemic control and diabetes knowledge . Statistically insignificant differences were shown in diabetes management practice s. Secondary outcomes assessed participants ’ perceived diabetes management and emotional and social support . Conclusions Diabetes Self-Management : A Cultural Approach ( DSMCA ) support group model demonstrates that a culturally tailored support group utilizing a community-based participatory research approach is an effective format to improve diabetes self-management skills among Chinese Americans . The program can be adapted for other ethnic population s. The efficacy of the intervention can be further tested in larger r and omized trials Purpose The purpose of this study is to test the feasibility of conducting a community-based r and omized controlled trial evaluating a culturally tailored community-based group diabetes self-management education ( DSME ) program among rural African Americans . Methods Thirty-two African American rural adults with type 2 diabetes were recruited and 25 adults were retained and participated in an interventional study design ed to test the effectiveness of the “ Taking Care of Sugar ” DSME program for the 2-year follow-up . Participants were selected from rural central Virginia . Primary outcomes variables included average blood sugar levels , cardiovascular risk factors , and general physical and mental health . These outcomes were assessed at baseline , 3 months , 6 months , and 12 months post baseline . Results From baseline to 3-month follow-up assessment , participants exhibited significant improvement on several physiological and behavioral measures . Given the small sample size , hypothesis testing was limited . Results show change from baseline over time , illustrating that the primary outcome of A1C decreased , although not significant . Additionally , participants reported more knowledge about diabetes self-management and personal care skills ( ie , exercise and foot care ) that persisted over time . The feasibility of the culturally tailored DSME was established , and participation with the program was high . Conclusions A community-based group DSME program using storytelling is feasible . This research will help to inform clinicians and health policymakers as to the types of interventions that are feasible in a larger rural population . If such a program is carried out , we can improve knowledge , reduce complications , and improve quality of life among rural African Americans OBJECTIVE We sought to identify interest in different modes of self-management support among diabetes patients cared for in public hospitals , and to assess whether demographic or disease-specific factors were associated with patient preferences . We explored the possible role of a perceived communication need in influencing interest in self-management support . METHODS Telephone survey of a r and om sample of 796 English and Spanish-speaking diabetes patients ( response rate 47 % ) recruited from four urban US public hospital systems . In multivariate models , we measured the association of race/ethnicity , primary language , self-reported health literacy , self-efficacy , and diabetes-related factors on patients ' interest in three self-management support  strategies ( telephone support , group medical visits , and Internet-based support ) . We explored the extent to which patients believed that better communication with providers would improve their diabetes control , and whether this perception altered the relationship between patient factors and self-management support acceptance . RESULTS Sixty-nine percent of respondents reported interest in telephone support , 55 % in group medical visits , and 42 % in Internet . Compared to Non-Hispanic Whites , Spanish-speaking Hispanics were more interested in telephone support ( OR 3.45 , 95 % CI 1.97 - 6.05 ) and group medical visits ( OR 2.45 , 95 % CI 1.49 - 4.02 ) , but less interested in Internet self-management support ( OR 0.56 , 95 % CI 0.33 - 0.93 ) . African-Americans were more interested than Whites in all three self-management support strategies . Patients with limited self-reported health literacy were more likely to be interested in telephone support than those not reporting literacy deficits . Forty percent reported that their diabetes would be better controlled if they communicated better with their health care provider . This perceived communication benefit was independently associated with interest in self-management support ( p<0.001 ) , but its inclusion in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences . CONCLUSION Many diabetes patients in safety-net setting s report an interest in receiving self-management support , but preferences for modes of delivery of self-management support vary by race/ethnicity , language proficiency , and self-reported health literacy . PRACTICE IMPLICATION S Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient population s. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these setting Background Lower socioeconomic status is associated with excess disease burden from diabetes .  Diabetes self-management support interventions are needed that are effective in engaging lower income patients , addressing competing life priorities and barriers to self-care , and facilitating behavior change . Objective To pilot test feasibility , acceptability , and effect on disease control of a problem-based diabetes self-management training adapted for low literacy and accessibility . Design Two-arm r and omized controlled trial powered to detect a 0.50 % change in A1C at follow-up with a 2-sided alpha of 0.05 in a pooled analysis . Participants Fifty-six urban African-American patients with type 2 diabetes and suboptimal blood sugar , blood pressure , or cholesterol control recruited from a diabetes registry within a university-affiliated managed care organization . Interventions A group , problem-based diabetes self-management training design ed for delivery in an intensive and a condensed program format . Three intensive and three condensed program groups were conducted during the trial . Main Measures Clinical ( A1C , systolic blood pressure [ SBP ] , diastolic blood pressure [ DBP ] , LDL and HDL cholesterol ) and behavioral ( knowledge , problem solving , self-management behavior ) data were measured at baseline , post-intervention , and 3 months post-intervention ( corresponding with 6–9 months following baseline ) . Results Adoption of both programs was high ( > 85 % attendance rates , 95 % retention ) . At 3 months post-intervention , the between-group difference in A1C change was −0.72 % ( p = 0.02 ) , in favor of the intensive program . A1C reduction was partially mediated by problem-solving skill at follow-up ( ß = −0.13 , p = 0.04 ) . Intensive program patients demonstrated within-group improvements in knowledge ( p < 0.001 ) , problem-solving ( p = 0.01 ) , and self-management behaviors ( p = 0.04 ) . Among the subsets of patients with suboptimal blood pressure or lipids at baseline , the intensive program yielded clinical ly significant individual improvements in SBP , DBP , and LDL cholesterol . Patient satisfaction and usability ratings were high for both programs . Conclusions A literacy-adapted , intensive , problem-solving-based diabetes self-management training was effective for key clinical and behavioral outcomes in a lower income patient sample Objective No model of self-management education or peer support has yet achieved widespread reach and acceptability with minority ethnic groups . We sought to refine and test a new complex intervention in diabetes education : informal story-sharing groups facilitated by bilingual health advocates . Methods Pilot r and omized trial with in-depth process evaluation in a socioeconomically deprived area . 157 people referred for diabetes education were r and omized by concealed allocation to an intervention ( storysharing group in their own language ) or control ( ‘ usual care ’ self-management education , through an interpreter if necessary ) arm . Story-sharing groups were held in five ethnic language s and English ( for African Caribbeans ) , and ran fortnightly for six months . Primary outcome was UKPDS ( UK Prospect i ve Diabetes Study ) risk score . Secondary outcomes included attendance , HbA1c , well-being and enablement . Process measures included ethnographic observation , and qualitative interviews with staff and patients . Results Some follow-up data were obtained on 87 % of participants . There was no significant difference between intervention and control arms in biomedical outcomes . Attendance was 79 % in the story-sharing arm and 35 % in the control arm ( p < 0.0001 ) , and patient enablement scores were significantly higher ( 8.3 compared to 5.9 , p < 0.005 ) . The model was very popular with clinicians , managers and patients , which helped overcome numerous challenges to its successful embedding in a busy public sector diabetes service . Conclusion People from minority ethnic groups in a socioeconomically deprived area were keen to attend informal story-sharing groups and felt empowered by them , but clinical outcomes were no better than with conventional education . Further research is needed to maximize the potential and evaluate the place of this appealing service model before it is introduced as a part of mainstream diabetes services Home health nurses provided individualized instruction in diabetes self-care within the home environment of 393 diabetic individuals . Each subject was r and omly assigned to either the intervention ( those receiving home teaching ) or control ( those not receiving home teaching ) group . At 6 mo postenrollment , intervention subjects showed significantly greater self-care knowledge and skills than control subjects , although the actual differences between the two groups in terms of self-care skills were probably too small to have any practical meaning . The primary objective of the study , which was the reduction of the number of preventable diabetes-related hospitalizations ( ketoacidosis , ketotic coma , nonketotic coma , insulin reaction , and diabetes out of control ) , was not achieved ; no differences between the groups were noted after 12 mo of follow-up . Similarly , length of hospital stay , foot problems , emergency room and physician visits , and sick days were roughly equivalent in both groups during the follow-up year . These results suggest that , in the absence of concurrent changes in the health-care delivery system and strategies for influencing attitudes toward self-care , education alone is ineffective BACKGROUND Ongoing self-management improves outcomes for those with Type 2 diabetes ( T2D ) ; however , there are many barriers to patients receiving assistance in this from the healthcare system and peers . Findings from our pilot study showed that a virtual diabetes community on the Internet with real-time interaction among peers with T2D- and with healthcare professionals-is feasible and has the potential to influence clinical and psychosocial outcomes . OBJECTIVE The purpose of this article is to present the protocol for the Diabetes Learning in Virtual Environments ( LIVE ) trial . PROTOCOL Diabetes LIVE is a two-group , r and omized controlled trial to compare effects of a virtual environment and traditional Web site on diet and physical activity . Our secondary aims will determine the effects on metabolic outcomes ; effects of level of engagement and social network formation in LIVE on behavioral outcomes ; potential mediating effects of changes in self-efficacy ; and diabetes knowledge , diabetes-related distress , and social support on behavior change and metabolic outcomes . We will enroll 300 subjects at two sites ( Duke University/Raleigh-Durham , NC and New York University/New York , NY ) who have T2D and do not have serious complications or comorbidities . Those r and omly assigned to the intervention group have access to the LIVE site where they can find information , synchronous classes with diabetes educators , and peer support to enhance self-management . Those in the control group have access to the same informational and educational content in a traditional asynchronous Web format . Measures of self-management , clinical outcomes , and psychosocial outcomes are assessed at baseline and 3 , 6 , 12 , and 18 months . DISCUSSION Should LIVE prove effective in improved self-management of diabetes , similar interventions could be applied to other prevalent chronic diseases . Innovative programs such as LIVE have potential for improving healthcare access in an easily disseminated alternative model of care that potentially improves the reach of self-management training and support Patients in a low-income community health center with Type 2 diabetes ( N = 81 ) taking a one-day education workshop  as part of their diabetes medical management were r and omly assigned either to education alone or to a combination of education and acceptance and commitment therapy ( ACT ) . Both groups were taught how to manage their diabetes , but those in the ACT condition also learned to apply acceptance and mindfulness skills to difficult diabetes-related thoughts and feelings . Compared with patients who received education alone , after 3 months those in the ACT condition were more likely to use these coping strategies , to report better diabetes self-care , and to have glycated hemoglobin ( HbA-sub(1C ) ) values in the target range . Mediational analyses indicated that changes in acceptance coping and self-management behavior mediated the impact of treatment on changes in HbA-sub(1C )
Interventions were generally effective on behavior change and patients ’ glycemic control in the short term ( ≤9 months ) .
Conclusions The limited studies available suggest that diabetes self-management education programs in developing countries are effective in the short term but must be tailored to conform to the cultural aspects of the target population
Purpose Although self-management education is a key factor in the care for diabetes patients , its implementation in developing countries is not well documented .
This systematic review considers the published literature on diabetes self-management education in high and low mortality developing countries .
The aim is to provide a state of the art of current practice s and assess program outcomes , cultural sensitivity , and accessibility to low literate patients .