Enhancing the effectiveness of diabetes self-management education: the diabetes literacy project. A Web-Based Dietary Intervention for People with Type 2 Diabetes: Development, Implementation, and Evaluation Culturally Competent Diabetes Education for Mexican Americans: The Starr County Study Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review protocol An Empowerment-Based Diabetes Self-management Education Program for Hispanic/Latinos Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus A Church-based Diabetes Self-management Education Program for African Americans With Type 2 Diabetes A model of translational research for diabetes prevention in low and middle-income countries: The Diabetes Community Lifestyle Improvement Program (D-CLIP) trial. Development, Validation, and Evaluation of Web-Based Iranian Diabetic Personal Health Record: Rationale for and Protocol of a Randomized Controlled Trial Effectiveness of a Culturally Tailored Diabetes Self-Management Program for Chinese Americans Self-care strategies for nurses: A psycho-educational intervention for stress reduction and the prevention of burnout. Implementation and Evaluation of a Low Health Literacy and Culturally Sensitive Diabetes Education Program A Community Health Worker Intervention for Diabetes Self-Management Among the Tz’utujil Maya of Guatemala Heart failure self-management education: a systematic review of the evidence. The Effect of a Community-Based Self-Help Intervention: Korean Americans With Type 2 Diabetes. A Community-Based Diabetes Prevention Program Effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes: a systematic review Picture Good Health: A Church-Based Self-Management Intervention Among Latino Adults with Diabetes QUARITE (quality of care, risk management and technology in obstetrics): a cluster-randomized trial of a multifaceted intervention to improve emergency obstetric care in Senegal and Mali Behavioural interventions for type 2 diabetes: an evidence-based analysis. The OnTrack Diabetes Web-Based Program for Type 2 Diabetes and Dysphoria Self-Management: A Randomized Controlled Trial Protocol Implementation of clinical guidelines on diabetes and hypertension in urban Mongolia: a qualitative study of primary care providers’ perspectives and experiences Community-based care for the management of type 2 diabetes: an evidence-based analysis.
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 Background Diabetes is becoming a very important health issue in rapidly developing nations and there is an urgent need to improve overall diabetes self-management education in these countries . Although e-health is an emerging theme , only a few successful web-based studies on diabetes self-management have been reported . Purpose We describe the development , implementation , and process evaluation of an Internet-delivered dietary intervention program ( myDIDeA ) for diabetic patients in a developing country . MethodS pecific dietary components to be included in the intervention module were first identified through a comprehensive review of literature and guidelines . The lesson plans and the study website were then developed based on the evidence , Transtheoretical Model ’s Stages of Change and user-centered design approach . Finally , the effectiveness of the website was tested through a r and omized-controlled trial to promote dietary change in patients with type 2 diabetes . The participants in the intervention group ( n = 66 ) were given access to myDIDeA for 6 months . Process evaluation in form of intervention adherence and program reception were conducted at post intervention . Results The response rate for the process evaluation was 89 % . On average , each participant logged in at least once for each lesson plan and spent almost 12 min on the site . The participants ’ content satisfaction , acceptability , and usability scores were satisfactory . The primary outcome of the trial , Dietary Knowledge , Attitude , and Behavior score was strongly correlated with content satisfaction ( r = 0.826 , p < 0.001 ) , acceptability ( r = 0.793 , p < 0.001 ) and usability of the website ( r = 0.724 , p < 0.001 ) , and moderately correlated with frequency of log-in ( r = 0.501 , p < 0.05 ) and duration spent in the website ( r = 0.399 , p < 0.05 ) . Conclusion The process evaluation of myDIDeA demonstrates its feasibility , and future studies should identify the possibility of extending the use of Internet-based intervention programs to other health behaviors and issues related to self-management of chronic conditions . In addition , interactivity , peer support via social media , and other means to stimulate the interest of participants can be explored PURPOSE Few culturally competent health programs have been design ed for Mexican Americans , a group that bears a disproportionate burden of Type 2 diabetes . In Starr County , a Texas-Mexico border community , investigators design ed and tested a culturally competent intervention aim ed at improving the health of this target population . The purpose of this article is to describe the development process of this diabetes education and support group intervention . METHODS The development stages were ( 1 ) community assessment , ( 2 ) intervention design , ( 3 ) selection or development of outcomes , ( 4 ) pilot testing , and ( 5 ) a r and omized clinical investigation . RESULTS Focus group participants identified knowledge deficits regarding diabetes and self-management strategies , and suggested characteristics of an effective intervention for Mexican Americans . Outcome measures included metabolic control indicators , a newly developed knowledge instrument , and an existing health belief instrument . Preliminary analyses indicated that the intervention was successful in significantly improving metabolic control in the target population . CONCLUSIONS Developing successful diabetes interventions for minority groups requires a number of stages , careful planning , assessment of cultural characteristics of the target population , and a systematic approach to implementation Background Cluster r and omised trials ( CRTs ) are a key instrument to evaluate public health interventions , particularly in low- and middle-income countries ( LMICs ) . Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned . Evaluation of implementation fidelity ( IF ) is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions . Current CRT reporting guidelines offer no guidance on IF assessment . We will systematic ally review the scientific literature to study current practice s concerning the assessment of IF in CRTs of public health interventions in LMICs . Methods We will include  CRTs of public health interventions in LMICs that planned or assessed IF in either the trial protocol or the main trial report ( or an associated document ) . Search strategies use Medical Subject Headings ( MESH ) and text words related to CRTs , developing countries , and public health interventions . The electronic data base search was developed first for MEDLINE and adapted for the following data bases : EMBASE , CINAHL , PubMed , and EMB Review s , to identify CRT reports in English , Spanish , or French published on or after January 1 , 2012 . To ensure availability of a study protocol , we will include CRTs reporting a registration number in the abstract . For each included study , we will compare planned versus reported assessment of IF , and consider the dimensions of IF studied , and data collection methods used to evaluate each dimension . Data will be synthesis ed using quantitative and narrative techniques . Risk of bias for individual studies will be assessed using the Cochrane Collaboration Risk of Bias Tool criteria and additional criteria related to CRT methods . We will investigate possible sources of heterogeneity by performing subgroup analysis . This review was not eligible for inclusion in the PROSPERO registry . Discussion Fidelity assessment may be a key tool for making studies more reliable , internally valid , and externally generalizable . This review will provide a portrait of current practice s related to the assessment of intervention fidelity in CRTs and offer suggestions for improvement . Results will be relevant to research ers , those who finance health interventions , and for decision-makers who seek the best evidence on public health interventions 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 Diabetes is the leading cause of major complications , such as end-stage renal disease and lower extremity amputations , and is a significant contributor to ischemic heart disease , stroke , peripheral vascular disease , and vision loss ( 1 ) . There has been increasing acceptance of the importance of individualizing glycemic management and assessment of risk for adverse events , especially hypoglycemia ( 26 ) . This is of great importance for all patients , especially older adults ( aged 65 years ) with comorbid conditions . In 2013 , 12.0 million older adults in the United States had diabetes , comprising 40 % of the 30.2 million persons with the disease ( 7 ) . Older adults account for an estimated 60 % to 70 % of the U.S. Department of Veterans Affairs ( VA ) and U.S. Department of Defense ( DoD ) diabetic population ( largely retirees ) ( VA/DoD. Unpublished data ) . These considerations make safe and effective diabetes management a policy priority for health care providers ( physicians , nurses , dietitians , and pharmacists ) and policymakers in both the VA and the DoD. The 2017 VA/DoD Clinical Practice Guideline ( CPG ) for the Management of Type 2 Diabetes Mellitus in Primary Care offers health care providers an evidence -based framework to evaluate , treat , and manage persons with type 2 diabetes  mellitus in the context of their individual needs and preferences ( 8) . The current article is a summary of key CPG recommendations , which was developed with multiple stakeholders to ensure representation by a broad spectrum of clinicians . It provides practice recommendations for the care of patients with diabetes , with an emphasis on shared decision making . Guideline Development and Review Process These recommendations were developed using methods established by the VA/DoD Evidence -Based Practice Work Group ( EBPWG ) ( 9 ) , which are aligned with st and ards for trustworthy guidelines ( 10 ) . The EBPWG and the U.S. Army Medical Comm and selected guideline panel cochairs ( 1 each from the VA and the DoD ) . The cochairs then selected a multidisciplinary panel of practicing clinician stakeholders , including primary care physicians ( family and internal medicine ) , endocrinologists , medical nutritionists , pharmacists , diabetes educators , and nurse practitioners . At the start of the CPG development process and at other key points throughout , all members were required to su bmi t disclosure statements for potential conflicts of interest in the previous 24 months . Verbal affirmations of no conflicts were used during meetings throughout the development process . The project team was also subject to r and om Web-based surveillance ( for example , ProPublica ) . The VA/DoD contracted with The Lewin Group , a third party with expertise in clinical practice guideline development , to facilitate meetings . The guideline panel , in collaboration with the ECRI Institute , developed 9 key questions using the PICOTS ( population , intervention , comparator , outcomes , timing of outcomes measurement , and setting ) format . A systematic search of the peer- review ed literature from January 2009 through March 2016 was conducted to find evidence relevant to the key questions that focused on r and omized trials , systematic review s , and meta-analyses of fair or better quality . One key question was up date d through 14 June 2016 . The search methods and results are detailed in the full guideline ( 8) . The guideline panel rated recommendations by using the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) method ( 11 ) . The guideline panel focused on developing new and up date d recommendations using the evidence review for the key questions . The panel also considered , without a complete review of the relevant evidence , the current applicability of recommendations that were included in the 2010 CPG . As part of the development process , a patient focus group was also convened to better underst and the perspectives of patients receiving diabetes treatment in the VA and the DoD. Five patients were included , consistent with the requirements of the federal Paperwork Reduction Act . All patients had type 2 diabetes and were veterans receiving care in the VA . The focus group explored knowledge of treatment options , views on the delivery of care , patients ' needs and preferences , and the effect of diabetes on their lives . Important concepts that emerged from the focus group were shared with the panel and informed guideline development . It was acknowledged that this convenience sample may not be representative of all VA and DoD patients receiving treatment for type 2 diabetes . The draft guideline was sent to more than 15 expert review ers inside and outside the federal sector . Comments were review ed and , where appropriate , were incorporated into the final guideline based on panel consensus . The VA/DoD EBPWG approved the final document on 3 April 2017 and released it on 17 April 2017 . Recommendations are presented in the Table , and an algorithm for establishing a personalized glycemic goal and treatment plan is presented in the Figure . Key recommendations are review ed in this article . Table . Summary of Recommendations From the 2017 VA/DoD CPG on the Management of Type 2 Diabetes Mellitus Figure . Algorithmic approach to evaluating glycemic control risk factors , setting a personalized glycemic control target range , providing self-management ( including lifestyle and nutrition ) education , and initiating or reevaluating medication therapy . Recommendations Provide Patient-Centered Care and Incorporate Shared Decision Making The CPG strongly encourages clinicians to incorporate shared decision making and partner with their patients . Shared decision making is the process by which the patient and family , in conjunction with the care provider , reach an agreement about a plan of care and treatment . Key principles include readiness of the patient and family , tools with underst and able information about the benefits and harms of all options , and strategies to identify and incorporate patient preferences . Patients can not effectively participate in care and shared decision making unless they underst and diabetes and how they can be involved in planning and carrying out the jointly developed care plan . Shared decision making reinforces a trusted therapeutic relationship and increases patient satisfaction and treatment buy-in with regard to the methods used to reach a particular goal or treatment plan ( 1214 ) . It should be used not only for patients with stable glycemic control but also to assist those who are not able or willing to make lifestyle changes and decisions that affect their diabetes at any time during the course of treatment . At a minimum , shared decision making should be included at the time of diagnosis , during difficulties with management , and at times of transition or development of complications ( 14 ) . Benefits include greater knowledge of medications ( 13 ) and underst and ing of risks ( 14 ) . In addition , patient-centered care and shared decision making together may decrease patient anxiety , increase trust in clinicians ( 15 ) , and improve treatment adherence ( 16 ) . Family involvement should be considered if appropriate , especially in older adults ( 17 ) . Patient information should be culturally appropriate ; underst and able and actionable by people with limited literacy skills ; and accessible to those with physical , sensory , or learning needs ( 18 ) . As part of the patient-centered care approach to diabetes management , clinicians should explore with the patient the outcomes of previous opportunities for shared decision making , their ability to self-manage , prior efforts to change health behaviors , past treatment experiences ( including reasons for discontinuing treatment ) , and relevant clinical outcomes . In actively sharing decisions , they should involve the patient in prioritizing problems to be addressed and setting specific goals regardless of the setting or level of care . Assess Patient Characteristics and Nonglycemic Factors When Interpreting Results of Hemoglobin A1c , Fructosamine , and Other Glycemic Biomarker Testing Many factors affect measurement of hemoglobin A1c ( HbA1c ) besides the level of glycemia ( 19 ) . Because HbA1c level depends on the duration of erythrocyte exposure to glucose , conditions that alter erythrocyte life span affect the measured level of HbA1c ( 20 , 21 ) . Iron deficiency anemia , which prolongs erythrocyte life span and exposes the cell to glucose for a longer period , is associated with falsely elevated HbA1c levels ( 22 ) . In contrast , conditions that shorten erythrocyte life span ( such as hemolytic anemia ) may result in falsely low HbA1c levels . Various other conditions , such as chronic kidney disease , may alter HbA1c measurement . Hemoglobin variants can result in falsely elevated or falsely lowered HbA1c levels , depending on the assay used ( 2325 ) . In addition , oral hypoglycemic agents ( metformin or sulfonylureas ) may alter the relationship between blood glucose and HbA1c levels , although the clinical significance is unclear ( 26 ) . There are also racial/ethnic differences in HbA1c levels for a given level of glycemia . A previous study found that African Americans with prediabetes ( 27 ) had HbA1c values that were 0.4 % higher than among white persons ; those who were within 3 years of diagnosis ( 28 ) also had higher HbA1c values than white persons for any measure of glycemia . This difference can not be explained by measured differences in glycemia , clinical factors known to affect HbA1c measurement , or sociodemographic factors ( 27 , 28 ) . Therefore , it is recommended that a new diagnosis of diabetes be based on a confirmatory fasting blood glucose level of at least 7.0 mmol/L ( 126 mg/dL ) if the initial HbA1c value is 6.5 % to 6.9 % . How and where the HbA1c level is measured can also affect results because of intralaboratory variation ( variation in test accuracy and precision ) and interlaboratory variation ( variation related to use of different test methods ) . A single HbA1c measurement , even from a Introduction Diabetes self-management education interventions in community gathering places have been moderately effective , but very few studies of intervention effectiveness have been conducted among African Americans with type 2 diabetes . This paper describes a church-based diabetes self-management education intervention for African Americans , a r and omized controlled trial to evaluate the intervention , and baseline characteristics of study participants . Methods A New DAWN : Diabetes Awareness & Wellness Network was conducted among 24 churches of varying size in North Carolina . Each church recruited congregants with type 2 diabetes and design ated a diabetes advisor , or peer counselor , to be part of the intervention team . Participants were enrolled at each church and r and omized as a unit to either the special intervention or the minimal intervention . The special intervention included one individual counseling visit , twelve group sessions , three postcard messages from the participant 's diabetes care provider , and twelve monthly telephone calls from a diabetes advisor . Baseline data included measures of weight , hemoglobin A1c , blood pressure , physical activity , dietary and diabetes self-care practice s , and psychosocial factors . The study to evaluate the intervention ( from enrollment visit to last follow-up ) began in February 2001 and ended in August 2003 . Results Twenty-four churches ( with 201 total participants ) were r and omized . Sixty-four percent of the participants were women . On average , the participants were aged 59 years and sedentary . They had an average of 12 years of education , had been diagnosed with diabetes for 9 years , had a body mass index of 35 , had a  hemoglobin  A1c level of 7.8 % , and had a reported dietary intake of 39 % of calories from fat . Conclusion A New DAWN is a culturally sensitive , church-based diabetes self-management education program for African Americans with type 2 diabetes that is being evaluated for effectiveness in a r and omized controlled trial . The outcomes of A New DAWN will contribute to the literature on community-based interventions for minority population s and help to inform the selection of approaches to improve diabetes care in this population AIMS The Diabetes Community Lifestyle Improvement Program ( D-CLIP ) aims to implement and evaluate in a controlled , r and omized trial the effectiveness , cost-effectiveness , and sustainability of a culturally appropriate , low-cost , and sustainable lifestyle intervention for the prevention of type 2 diabetes mellitus in India . METHODS D-CLIP , a translational research project adapted from the methods and curriculum developed and tested for efficacy in the Diabetes Prevention Program , utilizes innovated methods ( a step-wise model of diabetes prevention with lifestyle and metformin added when needed ; inclusion of individuals with isolated glucose tolerance , impaired fasting glucose , and both ; classes team-taught by professionals and trained community educators ) with the goals of increasing diabetes prevention , community acceptability , and long-term dissemination and sustainability of the program . The study outcomes are : diabetes incidence ( primary measure of effectiveness ) , cost-effectiveness , changes in anthropometric measures , plasma lipids , blood pressure , blood glucose , and HbA(1c , ) Program acceptability and sustainability will be assessed using a mixed methods approach . CONCLUSION D-CLIP , a low-cost , community-based , research program , addresses the key components of translational research and can be used as a model for prevention of chronic diseases in other low and middle-income country setting Background Diabetes is one of the four main types of noncommunicable or chronic diseases . Iran is among the countries with the highest incidence of diabetic patients . A study demonstrated that the collection of diabetic data is neither organized nor st and ardized . There is currently no instance of electronic personal health records particularly used for diabetic patients in Iran , hence the need for one , which will be useful for self-care of diabetic patients . Objective The objective of the study is to examine the impact of a Web-based diabetic personal health record ( DPHR ) on the self-care status of diabetic patients as compared with the control group . Methods This study is a r and omized control trial , which involves a systematic review of literature of the preferred data elements regarding a DPHR , and reevaluating the results with the opinions of local endocrinologists . Inclusion criteria were as follows : type 2 diabetic patients between 20 - 70 of age who live in the Mashhad City and having the disease for at least one year . The sample size is 72 people that were r and omly assigned to the control and intervention groups . The participants in the intervention group were allowed access to the Web-based DPHR system , while those in the control group will continue to receive the usual care for 4 months . The study primary outcome measures include self-care status of participants and planned visit adherence . Results At the moment , there is an ongoing recruitment of participants , and preliminary results will be published in early 2016 . Conclusions We expect the final DPHR model , developed and tested during this study , to help diabetic patients to actively participate in their care management process , and also to empower the physician in providing more quality informed decisions regarding their patients . Trial Registration i rct .ir I RCT 2013082914522N1 ; http://www.i rct .ir/ search result .php?id=14522&number=1 ( Archived by WebCite at http://www.webcitation.org/6cC4PCcau ) 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 The purpose of this project is to develop and evaluate a psycho-educational program that assists nurses to develop stress management plans . Discussion of nursing-specific risk factors , practice with relaxation techniques , and exploration via art are used as interventions . Quantitative and qualitative measures of stress and burnout are conducted pre- and postcourse using the  Maslach Burnout Inventory , Draw-a-Person-in-the-Rain Art Assessment , and wellness plans .  Descriptive statistics are used , and preliminary analysis indicates that the course is useful in impacting levels of emotional exhaustion . There are opportunities for evolving the program so that more enduring change in self-care is generated & NA ; Low health literacy is more prevalent in persons with limited education , members of ethnic minorities , and those who speak English as a second language , and is associated with multiple adverse diabetes‐related health outcomes . This study examined the effectiveness of a low health literacy and culturally sensitive diabetes education program for economically and socially disadvantaged adult patients with type 2 diabetes . A pre – post prospect i ve study design was used to examine outcomes over 12 months . Outcome measures included diabetes knowledge , self‐efficacy , and self‐care , measured using reliable and valid survey tools , and A1C . Over this period of time 277 patients were enrolled in the program , with 106 participants completing survey data . At the completion of the program patients had significant improvements in diabetes knowledge ( p < .001 ) , self‐efficacy ( p < .001 ) , and three domains of self‐care including diet ( p < .001 ) , foot care ( p < .001 ) , and exercise ( p < .001 ) . There were no significant improvements in the frequency of blood glucose testing ( p = .345 ) . Additionally , A1C values significantly improved 3 months after completing the program ( p = .007 ) . In conclusion , a diabetes education program design ed to be culturally sensitive and meet the needs of individuals with low health literacy improves short‐term outcomes Despite the high prevalence of diabetes in rural Guatemala , there is little education in diabetes self-management , particularly among the indigenous population . To address this need , a culturally relevant education intervention for diabetic patients was developed and implemented in two rural communities in Guatemala . An evaluative research project was design ed to investigate if the structured , community-led diabetes self-management intervention improved selected health outcomes for participants . A one-group , pretest – posttest design was used to evaluate the effectiveness of the educational intervention by comparing measures of health , knowledge , and behavior in patients pre- and postintervention . A survey instrument assessed health beliefs and practice s and hemoglobin A1c ( HgA1c ) measured blood glucose levels at baseline and 4 months post initiation of intervention ( n = 52 ) . There was a significant decrease ( 1.2 % ) in the main outcome measure , mean HgA1c from baseline ( 10.1 % ) and follow-up ( 8.9 % ; p = .001 ) . Other survey findings were not statistically significant . This study illustrates that a culturally specific , diabetes self-management program led by community health workers may reduce HgA1c levels  in rural population s of Guatemala . However , as a r and om sample was not feasible for this study , this finding should be interpreted with caution . Limitations unique to the setting and patient population are discussed in this article OBJECTIVE The objective of this systematic review is to identify educational content and techniques that lead to successful patient self-management and improved outcomes in congestive heart failure education programs . METHODS MEDLINE , CINAHL and the Cochrane Central Register of Controlled Trials , as well as reference lists of included studies and relevant review s , were search ed . Eligible studies were r and omised controlled trials evaluating congestive heart failure self-management education programs with outcome measures . Two of the investigators independently abstract ed descriptive information , education content topics and outcomes data . RESULTS A total of 7413 patients participated in the 35 eligible congestive heart failure self-management education studies . The congestive heart failure self-management programs incorporated 20 education topics in four categories : ( i ) knowledge and self-management ( diagnosis and prognosis , pathophysiology of how congestive heart failure affects the body , aims of treatment , management and symptoms , medication review and discussion of side-effects , knowing when to access/call the general practitioner , communication with the physician , follow up for assessment or reinforcement ) ; ( ii )  social interaction and support ( social interaction and support , stress , depression ) ; ( iii )  fluids management  ( sodium restriction , fluid balance , daily measurement of weight , ankle circumference , self-monitoring and compliance relative to fluids ) ; and ( iv )  diet and activity  (  dietary assessment and instructions  , physical activity and  exercise  , alcohol intake , smoking cessation ) . A total of 113 unique outcomes in nine categories ( satisfaction , learning , behaviour , medications , clinical status , social functioning , mortality , medical re source utilisation and cost ) were measured in the studies . Sixty ( 53 % ) of the outcomes showed significant improvement in at least one study . CONCLUSION Educational interventions should be based on scientifically sound research evidence . The education topic list developed in this review can be used by patients and clinicians to prioritise and personalise education INTRODUCTION Korean Americans are one of the most underserved ethnic/linguistic minority groups owing to cultural and institutional barriers ; there is an urgent need for culturally competent diabetes management programs in the Korean American community for those with type 2 diabetes . The purpose of this study was to test the effectiveness of a community-based , culturally tailored , multimodal behavioral intervention program in an ethnic/linguistic minority group with type 2 diabetes . DESIGN An RCT with waitlist comparison based on the Predisposing , Reinforcing , and Enabling Constructs in Education/environmental Diagnosis and Evaluation (PRECEDE)-Policy , Regulatory , and Organizational Constructs in Educational and Environmental Development ( PROCEED ) and self-help models . Data were collected between September 2010 and June 2013 and were analyzed in August-December 2014 . Statistical significance was set at p<0.05 . SETTING / PARTICIPANTS In a naturally occurring community setting , a total of 250 Korean Americans with type 2 diabetes were r and omized into an intervention group ( n=120 ) or a control group ( n=130 ) . INTERVENTION The intervention consisted of key self-management skill-building activities through 12 hours of group education sessions , followed by integrated counseling and behavioral coaching by a team of RNs and community health workers . MAIN OUTCOME MEASURES Primary ( clinical ) outcomes were hemoglobin A1c , glucose , total cholesterol , and low-density lipoprotein at baseline and at 3 , 6 , 9 , and 12 months . Secondary ( psychosocial and behavioral ) outcomes included diabetes-related quality of life , self-efficacy , adherence to diabetes management regimen , and health literacy . RESULTS During the 12-month project , the intervention group demonstrated 1.0%-1.3 % ( 10.9 - 14.2 mmol/mol ) reductions in hemoglobin A1c , whereas the control group achieved reductions of 0.5%-0.7 % ( 5.5 - 7.7 mmol/mol ) . The differences between the two groups were statistically significant . The intervention group showed statistically significant improvement in diabetes-related self-efficacy and quality of life when compared with the control group . CONCLUSIONS RN/community health worker teams equipped with culturally tailored training can be effective in helping an ethnic/linguistic minority group manage diabetes in the community Purpose With growing numbers of people at risk for diabetes and cardiovascular disease , diabetes educators report increasing referrals for intervention in prevention of these conditions . Diabetes educators have expertise in diabetes self-management education ; however , they are generally not prepared for delivery of chronic disease primary prevention . The purpose of this project was to determine if individuals at risk for diabetes who participate in an intervention delivered by trained diabetes educators in existing diabetes self-management education community-based programs can reduce risk factors for diabetes and cardiovascular disease . Methods Diabetes educators in 3 outpatient-hospital programs ( urban , suburban , and rural ) received training and support for implementation of the Group Lifestyle Balance program , an adaptation of the Diabetes Prevention Program lifestyle intervention , from the Diabetes Prevention Support Center of the University of Pittsburgh . Adults with prediabetes and /or the metabolic syndrome were eligible to enroll in the program with physician referral . With use of existing diabetes educator networks , recruitment was completed via on-site physician in-services , informative letters , and e-mail contact as well as participant-directed newspaper advertisement . Results Eighty-one participants enrolled in the study ( 71 women , 10 men ) .  Mean overall weight loss was 11.3 lb ( 5.1 % , P < .001 ) ; in addition , significant decreases were noted in fasting plasma glucose , low-density lipoprotein cholesterol , triglycerides , and blood pressure . Conclusions These results suggest that the Group Lifestyle Balance program delivered by diabetes educators was successful in reducing risk for diabetes and cardiovascular disease in high-risk individuals . Furthermore , diabetes educators , already integrated within the existing health care system , provide yet another re source for delivery of primary prevention programs in the community Executive summary Background As a chronic condition , the prevalence of Type 2 diabetes is increasing worldwide and adherence to oral medications , an essential component of self‐management , has been shown to improve glycaemic control . However compliance with oral medication adherence remains poor . Educating people with Type 2 diabetes is an important strategy to enhance self‐management ability , including medication‐taking behaviour . Objectives The overall objective of the review was to determine the effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes . Inclusion criteria Types of participants Studies involving adults over 18 years old with Type 2 diabetes , with or without co‐morbidities , currently taking oral hypoglycaemic medication without insulin treatment , and with aglycated haemoglobin ( HbA1c ) > 7.0 % prior to the intervention were considered . Aglycated haemoglobin ( HbA1c ) concentration of less than 7.0 % , is important in order to delay or prevent diabetes‐related complications . Participants could be from the primary , tertiary or acute care setting . Types of intervention The review focused on various forms of educational interventions delivered by healthcare professionals aim ed at improving participants ’ knowledge . Types of outcomes The review evaluated outcomes measuring oral hypoglycaemic adherence including HbA1c , fasting blood glucose levels and other relevant indicators . Types of studies Studies that were r and omized controlled trials ( RCTs ) or case‐control studies were considered . Search strategy A three‐stage search strategy was employed . Papers in English and between the years 1990‐2009 were search ed in the following data bases : CINAHL , Medline , Mosby 's Nursing Consult , PsycINFO , PubMed , ScienceDirect , Scopus , TRIP and Web of Science . Full text was retrieved when the titles and abstract s of studies fulfilled the inclusion criteria . Method ological quality Full papers were assessed for method ological quality independently by two review ers using critical appraisal checklists from the Joanna Briggs Institute ( JBI ) . A third review er was consulted whenever there were disagreements between the two review ers . Data collection / extraction Details of each study included in the review were extracted using st and ardized data extraction forms developed by JBI . Extraction was conducted independently by two review ers . Data synthesis Meta‐ analysis was not possible due to method ological and statistical heterogeneity of the included studies . Hence study findings are presented in narrative form . Results Seven studies included in the final review consisted of seven RCTs . Five studies concluded that the educational intervention was effective in promoting oral hypoglycaemic adherence compared to usual care . These included pharmacist‐led interventions , individual diabetes education provided by nurses and diabetes group education based on a self‐management approach . Similarities among these interventions were provision of information on oral hypoglycaemic medication and the need for regular education sessions . However , small sample s in some studies limited generalization of results . Conclusions Implication s for practice Increased knowledge of oral hypoglycaemic issues and reinforcement of the importance of medication adherence were useful in promoting adherence . Regular education sessions allow individuals to reinforce information and educators to identify barriers to medication adherence . Educational interventions focusing on self‐management strategies appear more likely to achieve positive outcomes . Implication s for research Further trials involving larger sample s and population s with poor glycaemic control are needed . The effects of educational interventions , influence of additional take‐home written material , the optimal interval length of follow‐up and duration of education sessions , and specific processes of individual or group education which have been identified as effective need further exploration ABSTRACT BACKGROUND Churches may provide a familiar and accessible setting for chronic disease self-management education and social support for Latinos with diabetes . OBJECTIVE We assessed the impact of a multi-faceted church-based diabetes self-management intervention on diabetes outcomes among Latino adults . DESIGN This was a community-based , r and omized controlled , pilot study .SUBJECTSOne-hundred adults with self-reported diabetes from a Midwestern , urban , low-income Mexican-American neighborhood were included in the study . INTERVENTIONS Intervention participants were enrolled in a church-based diabetes self-management program that included eight weekly group classes led by trained lay leaders . Enhanced usual care participants attended one 90-minute lecture on diabetes self-management at a local church . OUTCOME MEASURES The primary outcome was change in glycosylated hemoglobin ( A1C ) . Secondary outcomes included changes in low-density lipoproteins ( LDL ) , blood pressure , weight , and diabetes self-care practice s . KEY RESULTS Participants ’ mean age was 54 ± 12 years , 81 % were female , 98 % were Latino , and 51 % were uninsured . At 3 months , study participants in both arms decreased their A1C from baseline ( −0.32 % , 95 % confidence interval [ CI ] : -0.62 , -0.02 % ) . The difference in change in A1C , LDL , blood pressure and weight from baseline to 3-month and 6-month follow-up was not statistically significant between the intervention and enhanced usual care groups . Intervention participants reported fewer days of consuming high fat foods in the previous week ( −1.34 , 95 % CI : -2.22 , -0.46 ) and more days of participating in exercise ( 1.58 , 95 % CI : 0.24 , 2.92 ) compared to enhanced usual care from baseline to 6 months . CONCLUSIONS A pilot church-based diabetes self-management intervention did not reduce A1C , but result ed in decreased high fat food consumption and increased participation in exercise among low-income Latino adults with diabetes .  Future church-based interventions may need to strengthen linkages to the healthcare system and provide continued support to participants to impact clinical outcomes Background Maternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate , even though childbirth services are available , even in the poorest countries . Reducing them is the aim of two of the main Millennium Development Goals . Many initiatives have been undertaken to remedy this situation , such as the Advances in Labour and Risk Management ( ALARM ) International Program , whose purpose is to improve the quality of obstetric services in low-income countries . However , few interventions have been evaluated , in this context , using rigorous methods for analyzing effectiveness in terms of health outcomes . The objective of this trial is to evaluate the effectiveness of the ALARM International Program ( AIP ) in reducing maternal mortality in referral hospitals in Senegal and Mali . Secondary goals include evaluation of the relationships between effectiveness and re source availability , service organization , medical practice s , and satisfaction among health personnel . Methods / Design This is an international , multi-centre , controlled cluster-r and omized trial of a complex intervention . The intervention is based on the concept of evidence -based practice and on a combination of two approaches aim ed at improving the performance of health personnel : 1 ) Educational outreach visits ; and 2 ) the implementation of facility-based maternal death review s . The unit of intervention is the public health facility equipped with a functional operating room . On the basis of consent provided by hospital authorities , 46 centres out of 49 eligible were selected in Mali and Senegal . Using r and omization stratified by country and by level of care , 23 centres will be allocated to the intervention group and 23 to the  control  group . The intervention will last two years . It will be preceded by a pre-intervention one-year period for baseline data collection . A continuous clinical data collection system has been set up in all participating centres . This , along with the inventory of re sources and the satisfaction surveys administered to the health personnel , will allow us to measure results before , during , and after the intervention . The overall rate of maternal mortality measured in hospitals during the post-intervention period ( Year 4 ) is the primary outcome . The evaluation will also include cost-effectiveness . Trial Registration The QUARITE trial is registered on the Current Controlled Trials website under the number IS RCT N46950658 UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis  BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine whether behavioural interventions are effective in improving glycemic control in adults with type 2 diabetes . BACKGROUND Diabetes is a serious chronic condition affecting millions of people worldwide and is the sixth leading cause of death in Canada . In 2005 , an estimated 8.8 % of Ontario 's population had diabetes , representing more than 816,000 Ontarians . The direct health care cost of diabetes was $ 1.76 billion in the year 2000 and is projected to rise to a total cost of $ 3.14 billion by 2016 . Much of this cost arises from the serious long-term complications associated with the disease including : coronary heart disease , stroke , adult blindness , limb amputations and kidney disease . Type 2 diabetes accounts for 90 - 95 % of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older , prevalence in younger population s is increasing due to a rise in obesity and physical inactivity in children . Data from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) has shown that tight glycemic control can significantly reduce the risk of developing serious complications in type 2 diabetics . Despite physicians ' and patients ' knowledge of the importance of glycemic control , Canadian data has shown that only 38 % of patients with diabetes have HbA1C levels in the optimal range of 7 % or less . This statistic highlights the complexities involved in the management of diabetes , which is characterized by extensive patient involvement in addition to the support provided by physicians . An enormous dem and is , therefore , placed on patients to self-manage the physical , emotional and psychological aspects of living with a chronic illness . Despite differences in individual needs to cope with diabetes , there is general agreement for the necessity of supportive programs for patient self-management . While traditional programs were didactic models with the goal of improving patients ' knowledge of their disease , current models focus on behavioural approaches aim ed at providing patients with the skills and strategies required to promote and change their behaviour . Several meta-analyses and systematic review s have demonstrated improved health outcomes with  self-management support programs in type 2 diabetics . They have all , however , either looked at a specific component of self-management support programs ( i.e. self-management education ) or have been conducted in specific population s. Most review s are also qualitative and do not clearly define the interventions of interest , making findings difficult to interpret . Moreover , heterogeneity in the interventions has led to conflicting evidence on the components of effective programs . There is thus much uncertainty regarding the optimal design and delivery of these programs by policymakers . EVIDENCE -BASED ANALYSIS OF EFFECTIVENESS : RESEARCH QUESTIONS Are behavioural interventions  effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics ( e.g. delivery of intervention , length of intervention , mode of instruction , interventionist etc . ) ? INCLUSION CRITERIA English Language Published between January 1996 to August 2008 Type 2 diabetic adult population ( > 18 years)R and omized controlled trials ( RCTs ) Systematic review s , or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control ( HbA1c ) with extractable data Studies with a minimum of 6-month follow up EXCLUSION CRITERIA Studies with a control group other than usual care Studies with a sample size < 30 Studies without a clearly defined intervention OUTCOMES OF INTEREST PRIMARY OUTCOME glycemic control ( HbA1c ) SECONDARY OUTCOMES systolic blood pressure ( SBP ) control , lipid control , change in smoking status , weight change , quality of life , knowledge , self-efficacy , managing psychosocial aspects of diabetes , assessing dissatisfaction and readiness to change , and setting and achieving diabetes goals . SEARCH STRATEGY A search was performed in OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , The Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1996 and August 2008 . Abstract s were review ed by a single author and studies meeting the inclusion criteria outlined above were obtained . Data on population characteristics , glycemic control outcomes , and study design were extracted . Reference lists were also checked for relevant studies . The quality of the evidence was assessed as being either high , moderate , low , or very low according to the GRADE methodology . SUMMARY OF FINDINGS The search identified 638 citations published between 1996 and August 2008 , of which 12 met the inclusion criteria and one was a meta- analysis ( Gary et al. 2003 ) . The remaining 11 studies were RCTs ( 9 were used in the meta- analysis ) and only one was defined as small ( total sample size N=47 ) . SUMMARY OF PARTICIPANT DEMOGRAPHICS ACROSS STUDIES : A total of 2,549 participants were included in the 11 identified studies . The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years . Most studies reported gender with a mean percentage of females of approximately 67 % . Of the eleven studies , two focused only on women and four included only Hispanic individuals . All studies evaluated type 2 diabetes patients exclusively . STUDY CHARACTERISTICS : The studies were conducted between 2002 and 2008 . Approximately six of 11 studies were carried out within the USA , with the remaining studies conducted in the UK , Sweden , and Israel ( sample size ranged from 47 to 824 participants ) . The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality ( based on the Consort Checklist ) . Differences in quality were mainly due to method ological issues such as inadequate description of r and omization , sample size calculation allocation concealment , blinding and uncertainty of the use of intention-to-treat ( ITT ) analysis . Patients were recruited from several setting s : six studies from primary or general medical practice s , three studies from the community ( e.g. via advertisements ) , and two from outpatient diabetes clinics . A usual care control group was reported in nine of 11 of the studies and two studies reported some type of minimal diabetes care in addition to usual care for the control group . INTERVENTION CHARACTERISTICS : All of the interventions examined in the studies were mapped to the 2007 Self-management Mapping Guide . The interventions most often focused on problem solving , goal setting and encouraging participants to engage in activities that protect and promote health ( e.g. modifying behaviour , change in diet , and increase physical activity ) . All of the studies examined comprehensive interventions targeted at least two self-care topics ( e.g. diet , physical activity , blood glucose monitoring , foot care , etc . ) . Despite the homogeneity in the aims of the interventions , there was substantial clinical heterogeneity in other intervention characteristics such as duration , intensity , setting , mode of delivery ( group vs. individual ) , interventionist , and outcomes of interest ( discussed below ) . DURATION , INTENSITY AND MODE OF DELIVERY : Intervention duration s ranged from 2 days to 1 year , with many falling into the range of 6 to 10 weeks . The rest of the interventions fell into categories of ≤ 2 weeks ( 2 studies ) , 6 months ( 2 studies ) , or 1 year ( 3 studies ) . Intensity of the interventions varied widely from 6 hours over 2 days , to 52 hours over 1 year ; however , the majority consisted of interventions of 6 to 15 hours . Both individual and group sessions were used to deliver interventions . Group counselling was used in five studies as a mode of instruction , three studies used both individual and group sessions , and one study used individual sessions as its sole mode of instruction . ( ABSTRACT Background The prevalence of type 2 diabetes is rising with the majority of patients practicing inadequate disease self-management . Depression , anxiety , and diabetes-specific distress present motivational challenges to adequate self-care . Health systems globally struggle to deliver routine services that are accessible to the entire population , in particular in rural areas .  Web-based diabetes self-management interventions can provide frequent , accessible support regardless of time and location Objective This paper describes the protocol of an Australian national r and omized controlled trial ( RCT ) of the OnTrack Diabetes program , an automated , interactive , self-guided Web program aim ed to improve glycemic control , diabetes self-care , and dysphoria symptoms in type 2 diabetes patients . Methods A small pilot trial is conducted that primarily tests program functionality , efficacy , and user acceptability and satisfaction . This is followed by the main RCT , which compares 3 treatments : ( 1 ) delayed program access : usual diabetes care for 3 months postbaseline followed by access to the full OnTrack Diabetes program ; ( 2 ) immediate program : full access to the self-guided program from baseline onward ; and ( 3 ) immediate program plus therapist support via Functional Imagery Training ( FIT ) . Measures are administered at baseline and at 3 , 6 , and 12 months postbaseline . Primary outcomes are diabetes self-care behaviors ( physical activity participation , diet , medication adherence , and blood glucose monitoring ) , glycated hemoglobin A1c ( HbA1c ) level , and diabetes-specific distress . Secondary outcomes are depression , anxiety , self-efficacy and adherence , and quality of life . Exposure data in terms of program uptake , use , time on each page , and program completion , as well as implementation feasibility will be conducted . Results This trial is currently underway with funding support from the Wesley Research Institute in Brisbane , Australia . Conclusions This is the first known trial of an automated , self-guided , Web-based support program that uses a holistic approach in targeting both type 2 diabetes self-management and dysphoria . Findings will inform the feasibility of implementing such a program on an ongoing basis , including in rural and regional locations . Trial Registration Australian and New Zeal and Clinical Trials Registration number : ACTRN12612000620820 ; https://anzctr.org.au/Trial/ Registration /Trial Review .aspx?ACTRN=12612000620820 ( Archived by WebCite at http://www.webcitation.org/6a3BeXC5 m ) Background Hypertension and diabetes , key risk factors for cardiovascular disease , are significant health problems globally . As cardiovascular disease is one of the leading causes of mortality in Mongolia since 2000 , clinical guidelines on arterial hypertension and diabetes were developed and implemented in 2011 . This paper explores the barriers and enablers influencing the implementation of these guidelines in the primary care setting . Methods A phenomenological qualitative study with semi-structured interviews was conducted to explore the implementation of the diabetes and hypertension guidelines at the primary care level , as well as to gain insight into how practitioners view the usability and practicality of the guidelines . Ten family health centres were r and omly chosen from a list of all the family health centres ( n = 136 ) located in Ulaanbaatar City . In each centre , a focus group discussion with nurses ( n = 20 ) and individual interviews with practice doctors ( n = 10 ) and practice managers ( n = 10 ) were conducted . Data was analysed using a thematic approach utilising the Theoretical Domains Framework . Results The majority of the study participants reported being aware of the guidelines and that they had incorporated them into their daily practice . They also reported having attended guideline training sessions which were focused on practice skill development . The majority of participants expressed satisfaction with the wide range of re sources that had been supplied to them by the Mongolian Government to assist with the implementation of the guidelines . The re sources , supplied from 2011 onwards , included screening devices , equipment for blood tests , medications and educational material s. Other enablers were the participants ’ commitment and passion for guideline implementation and their belief in the simplicity and practicality of the guidelines . Primary care providers reported a number of challenges in implementing the guidelines , including frustration caused by increased workload and long waiting times , time constraints , difficulties with conflicting tasks and low patient health literacy . Conclusions This study provides evidence that comprehensive and rigorous dissemination and implementation strategies increase the likelihood of successful implementation of new guidelines in low re source primary care setting s. It also offers some key lessons that might be carefully considered when other evidence -based clinical guidelines are to be put into effect in low re source setting s and elsewhere UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes  : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care . CLINICAL NEED TARGET POPULATION AND CONDITION Diabetes ( i.e. diabetes mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the body 's ability to produce or effectively use insulin . The majority ( 90 % ) of diabetes patients have type 2 diabetes . ( 1 ) Based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics . While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines , factors associated with glycemic control are less well studied , one of which is the provider(s ) of care . Multidisciplinary approaches to care may be particularly important for diabetes management . According guidelines from the Canadian Diabetes Association ( CDA ) , the diabetes health care team should be multi- and interdisciplinary . Presently in Ontario , the core diabetes health care team consists of at least a family physician and /or diabetes specialist , and diabetes educators ( registered nurse and registered dietician ) . Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management . Several systematic review s and meta-analyses have examined multidisciplinary care programs , but these have either been limited to a specific component of multidisciplinary care ( e.g. intensified education programs ) , or were conducted as part of a broader disease management program , of which not all were multidisciplinary in nature . Most review s also do not clearly define the intervention(s ) of interest , making the evaluation of such multidisciplinary community programs challenging . EVIDENCE -BASED ANALYSIS METHODS RESEARCH QUESTIONS What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse , registered dietician and physician ( primary care and /or specialist ) for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 2 ] INCLUSION CRITERIA English language full-reportsPublished between January 1 , 2000 and September 28 , 2008R and omized controlled trials ( RCTs ) , systematic review s and meta-analysesType 2 diabetic adult population ( ≥18 years of age)Total sample size ≥30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines ( of which at least one must be a specialist in diabetes ) with integrated communication between the care providers . Compared to usual care ( defined as health care provision by non-specialist(s ) in diabetes , such as primary care providers ; may include referral to other health care professionals/services as necessary)≥6 months follow-up EXCLUSION CRITERIA Studies where discrete results on diabetes can not be abstract edPredominantly home-based interventions Inpatient-based interventions OUTCOMES OF INTEREST The primary outcomes for this review were glycosylated hemoglobin ( rHbA1c ) levels and systolic blood pressure ( SBP ) . SEARCH STRATEGY A literature search was performed on September 28 , 2008 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1 , 2000 and September 28 , 2008 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with unknown eligibility were review ed with a second clinical epidemiologist , then a group of epidemiologists until consensus was established . The quality of evidence was assessed as high , moderate , low or very low according to GRADE methodology . Given the high clinical heterogeneity of the articles that met the inclusion criteria , specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario , models of care that were commonly reported in the literature , as well as suggestions from an Expert Advisory Panel Meeting held on January 21 , 2009 . SUMMARY OF FINDINGS The initial search yielded 2,116 unique citations , from which 22 RCTs trials and nine systematic review s published were identified as meeting the eligibility criteria . Of these , five studies focused on care provided by at least a nurse , dietician , and physician ( primary care and /or specialist ) model of care ( Model 1 ; see Table ES 1 ) , while three studies focused on care provided by at least a pharmacist and primary care physician ( Model 2 ; see Table ES 2 ) . Based on moderate quality evidence , specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in HbA1c of 1.0 % compared with usual care . The effects of this model on SBP , however , are uncertain compared with usual care , based on very-low quality evidence . Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in both HbA1c of 1.05 % ( based on high quality evidence ) and SBP of 7.13 mm Hg ( based on moderate quality evidence ) compared to usual care . For both models , the evidence does not suggest a preferred setting of care delivery ( i.e. , primary care vs. hospital outpatient clinic vs. community clinic ) . Table ES1 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.00 [ -1.27 , -0.73]4 % (p=0.37)Moderate- quality Subgroup : Moderate-to-High Quality -0.91 [ -1.19 , -0.62]0 % (p=0.74)Systolic Blood Pressure ( mm Hg)-2.04 [ -13.80 , 9.72]89 % (p=0.002)Very-low quality * Mean change from baseline to follow-up between intervention and control groupsTable ES2 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.05 [ -1.57 , -0.52]0 % (p=0.75)High- quality Systolic Blood Pressure ( mm Hg)-7.13 [ -11.78 , -2.48]46 % (p=0.17)Moderate quality * Mean change from baseline to follow-up between intervention and control groups
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 .