title: Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. An economic model of the long-term health care burden of Type II diabetes Mortality in relation to smoking: 50 years' observations on male British doctors Promotora Diabetes Intervention for Mexican Americans Increasing use of mammography among older, rural African American women: results from a community trial. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. A model to estimate the lifetime health outcomes of patients with Type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS no. 68) A randomized trial of an intervention to improve self-care behaviors of African-American women with type 2 diabetes: impact on physical activity. Body and soul. A dietary intervention conducted through African-American churches. Cost-Effectiveness of Extending Screening Mammography Guidelines To Include Women 40 to 49 Years of Age Peer-delivered smoking counseling for childhood cancer survivors increases rate of cessation: the partnership for health study. Randomized trial of an intervention to improve mammography utilization among a triracial rural population of women. A randomized controlled study of the Arthritis Self-Management Programme in the UK. Randomized controlled trial of a social support ('buddy') intervention for smoking cessation. The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial A randomized controlled trial of a "buddy" systems to improve success at giving up smoking in general practice. Long-term effects of a communication intervention for Spanish-dominant Latinas. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study Efficacy of home-based peer counselling to promote exclusive breastfeeding: a randomised controlled trial The effect of peer support on breast-feeding duration among primiparous women: a randomized controlled trial. Duration of smoking abstinence and success in quitting. Evaluation of a culturally appropriate smoking cessation intervention for Latinos Maternal outcomes of a randomized controlled trial of a community-based support program for families of children with chronic illnesses. A Family-based Intervention to Promote Healthy Lifestyles in an Aboriginal Community in Canada Opening pathways to cancer screening for Vietnamese-American women: lay health workers hold a key. Prescription of transdermal nicotine patches for smoking cessation in general practice: evaluation of cost-effectiveness Randomised controlled trial of a lay-led self-management programme for Bangladeshi patients with chronic disease. Provider counseling, health education, and community health workers: the Arizona WISEWOMAN project. HIV prevention among drug users: outcome of a network-oriented peer outreach intervention. Analysis of the Cost-Effectiveness of Mammography Promotion by Volunteers in Rural Communities Cost effectiveness of the Expert Patients Programme (EPP) for patients with chronic conditions
abstract: BACKGROUND African Americans suffer disproportionately from diabetes complications , but little research has focused on how to improve diabetic control in this population . There are also few or no data on a combined primary care and community-based intervention approach . METHODS We r and omly assigned 186 urban African Americans with type 2 diabetes ( 76 % female , mean A SD age 59 A 9 years ) to 1 of 4 parallel arms : ( 1 ) usual care only ; ( 2 ) usual care + nurse case manager ( NCM ) ; ( 3 ) usual care + community health worker ( CHW ) ; ( 4 ) usual care + nurse case manager/community health worker team . Using the framework of the Precede-Proceed behavioral model , interventions included patient counseling regarding self-care practice s and physician reminders . RESULTS The 2-year follow-up visit was completed by 149 individuals ( 84 % ) . Compared to the Usual care group , the NCM group and the CHW group had modest declines in HbA(1c ) over 2 years ( 0.3 and 0.3 % , respectively ) , and the combined NCM/CHW group had a greater decline in HbA(1c ) ( 0.8 % . P = 0.137 ) . After adjustment for baseline differences and /or follow-up time , the combined NCM/CHW group showed improvements in triglycerides ( -35.5 mg/dl ; P = 0.041 ) and diastolic blood pressure , compared to the usual care group ( -5.6 mmHg ; P = 0.042 ) . CONCLUSIONS Combined NCM/CHW interventions may improve diabetic control in urban African Americans with type 2 diabetes . Although results were clinical ly important , they did not reach statistical significance . This approach deserves further attention as a means to reduce the excess risk of diabetic complications in African Americans Abstract . Aims /hypothesis : To develop a long-term economic model of health care for Type II diabetes initially for the United Kingdom ; characterize experiences of diabetes-related morbidities and the use of health care re sources among a typical Type II diabetes cohort ; to estimate lifetime differences in expected health outcomes and costs attributable to Type II diabetes ; and to facilitate evaluation of policies or interventions in treating Type II diabetes from the funder 's perspective . Methods : A compact spreadsheet structure of interconnected Markov chain modules was developed to facilitate rapid estimation of costs and outcomes for whole population s. Recent clinical findings from the United Kingdom Prospect i ve Diabetes Study and other sources were incorporated and a detailed costing module developed from United Kingdom observational data . Results : The model allows the assessment of costs and long-term complications experienced by people suffering from Type II diabetes , including direct health care costs associated with the main diabetic complications and second-order effects on other health services required by such patients . Initial results suggest that the lifetime cost of health care for patients from the diagnosis of diabetes is more than double that for an equivalent non-diabetic population . Conclusion /interpretation : The model is intended for use by health care policy makers and payers to assess the long-term budgetary impact of trends in a variety of demographic and epidemiological factors on future services , and is also useful to physicians when considering the impact of new treatment strategies or programmes to modify risk factors for diabetic complications . [ Diabetologia ( 2001 ) 44 : 2140–2155 Abstract Objective To compare the hazards of cigarette smoking in men who formed their habits at different periods , and the extent of the reduction in risk when cigarette smoking is stopped at different ages . Design Prospect i ve study that has continued from 1951 to 2001 . Setting United Kingdom . Participants 34 439 male British doctors . Information about their smoking habits was obtained in 1951 , and periodically thereafter ; cause specific mortality was monitored for 50 years . Main outcome measures Overall mortality by smoking habit , considering separately men born in different periods . Results The excess mortality associated with smoking chiefly involved vascular , neoplastic , and respiratory diseases that can be caused by smoking . Men born in 1900 - 1930 who smoked only cigarettes and continued smoking died on average about 10 years younger than lifelong non-smokers . Cessation at age 60 , 50 , 40 , or 30 years gained , respectively , about 3 , 6 , 9 , or 10 years of life expectancy . The excess mortality associated with cigarette smoking was less for men born in the 19th century and was greatest for men born in the 1920s . The cigarette smoker versus non-smoker probabilities of dying in middle age ( 35 - 69 ) were 42 % ν24 % ( a twofold death rate ratio ) for those born in 1900 - 1909 , but were 43 % ν 15 % ( a threefold death rate ratio ) for those born in the 1920s . At older ages , the cigarette smoker versus non-smoker probabilities of surviving from age 70 to 90 were 10 % ν 12 % at the death rates of the 1950s ( that is , among men born around the 1870s ) but were 7 % ν 33 % ( again a threefold death rate ratio ) at the death rates of the 1990s ( that is , among men born around the 1910s ) . Conclusion A substantial progressive decrease in the mortality rates among non-smokers over the past half century ( due to prevention and improved treatment of disease ) has been wholly outweighed , among cigarette smokers , by a progressive increase in the smoker ν non-smoker death rate ratio due to earlier and more intensive use of cigarettes . Among the men born around 1920 , prolonged cigarette smoking from early adult life tripled age specific mortality rates , but cessation at age 50 halved the hazard , and cessation at age 30 avoided almost all of it PURPOSE The purpose of this r and omized controlled trial is to determine the effectiveness of an intervention led by promotoras ( community lay workers ) on the glycemic control , diabetes knowledge , and diabetes health beliefs of Mexican Americans with type 2 diabetes living in a major city on the Texas-Mexico border . METHODS One hundred fifty Mexican American participants were recruited at a Catholic faith-based clinic and r and omized into 2 groups . Personal characteristics , acculturation , baseline A1C level , diabetes knowledge , and diabetes health beliefs were measured . The intervention was culturally specific and consisted of participative group education , telephone contact , and follow-up using inspirational faith-based health behavior change postcards . The A1C levels , diabetes knowledge , and diabetes health beliefs were measured 3 and 6 months postbaseline , and the mean change between the groups was analyzed . RESULTS The 80 % female sample , with a mean age of 58 years , demonstrated low acculturation , income , education , health insurance coverage , and strong Catholicism . No significant changes were noted at the 3-month assessment , but the mean change of the A1C levels , F(1 , 148 ) = 10.28 , P < .001 , and the diabetes knowledge scores , F(1 , 148 ) = 9.0 , P < .002 , of the intervention group improved significantly at 6 months , adjusting for health insurance coverage . The health belief scores decreased in both groups . CONCLUSIONS The intervention result ed in decreased A1C levels and increased diabetes knowledge , suggesting that using promotoras as part of an interdisciplinary team can result in positive outcomes for Mexican Americans who have type 2 diabetes . Clinical implication s and recommendations for future research are suggested OBJECTIVES A community trial was undertaken to evaluate the effectiveness of the North Carolina Breast Cancer Screening Program , a lay health advisor network intervention intended to increase screening among rural African American women 50 years and older . METHODS A stratified r and om sample of 801 African American women completed baseline ( 1993 - 1994 ) and follow-up ( 1996 - 1997 ) surveys . The primary outcome was self-reported mammography use in the previous 2 years . RESULTS The intervention was associated with an overall 6 percentage point increase ( 95 % confidence interval [ CI ] = -1 , 14 ) in community-wide mammography use .  Low-income women in intervention counties showed an 11 percentage point increase ( 95 % CI = 2 , 21 ) in use above that exhibited by low-income women in comparison counties . Adjustment for potentially confounding characteristics did not change the results . CONCLUSIONS A lay health advisor intervention appears to be an effective public health approach to increasing use of screening mammography among low-income , rural population OBJECTIVES This study evaluated the effectiveness ( changes in health behaviors , health status , and health service utilization ) of a self-management program for chronic disease design ed for use with a heterogeneous group of chronic disease patients . It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities . METHODS The study was a six-month r and omized , controlled trial at community-based sites comparing treatment subjects with wait-list control subjects .  Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease , lung disease , stroke , or arthritis .  Health behaviors , health status , and health service utilization , as determined by mailed , self-administered question naires , were measured . RESULTS Treatment subjects , when compared with control subjects , demonstrated improvements at 6 months in weekly minutes of exercise , frequency of cognitive symptom management , communication with physicians , self-reported health , health distress , fatigue , disability , and social/role activities limitations . They also had fewer hospitalizations and days in the hospital . No differences were found in pain/physical discomfort , shortness of breath , or psychological well-being . CONCLUSIONS An intervention design ed specifically to meet the needs of a heterogeneous group of chronic disease patients , including those with comorbid conditions , was feasible and beneficial beyond usual care in terms of improved health behaviors and health status . It also result ed in fewer hospitalizations and days of hospitalization Aims /hypothesisThe aim of this study was to develop a simulation model for Type 2 diabetes that can be used to estimate the likely occurrence of major diabetes-related complications over a lifetime , in order to calculate health economic outcomes such as quality -adjusted life expectancy . Methods Equations for forecasting the occurrence of seven diabetes-related complications and death were estimated using data on 3642 patients from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) . After examining the internal validity , the UKPDS Outcomes Model was used to simulate the mean difference in expected quality -adjusted life years between the UKPDS regimens of intensive and conventional blood glucose control . Results The model ’s forecasts fell within the 95 % confidence interval for the occurrence of observed events during the UKPDS follow-up period . When the model was used to simulate event history over patients ’ lifetimes , those treated with a regimen of conventional glucose control could expect 16.35 undiscounted quality -adjusted life years , and those receiving treatment with intensive glucose control could expect 16.62 quality -adjusted life years , a difference of 0.27 ( 95 % CI : −0.48 to 1.03 ) . Conclusions /interpretationsThe UKPDS Outcomes Model is able to simulate event histories that closely match observed outcomes in the UKPDS and that can be extrapolated over patients ’ lifetimes . Its validity in estimating outcomes in other groups of patients , however , remains to be evaluated . The model allows simulation of a range of long-term outcomes , which should assist in informing future economic evaluations of interventions in Type 2 diabetes OBJECTIVE To determine whether a culturally appropriate clinic- and community-based intervention for African-American women with type 2 diabetes will increase  moderate-intensity physical activity ( PA ) . RESEARCH DESIGN AND METHODS In this r and omized controlled trial conducted at seven practice s in central North Carolina , 200 African-American women , > or = 40 years of age with type 2 diabetes , were r and omized to one of three treatment conditions : clinic and community ( group A ) , clinic only ( group B ) , or minimal intervention ( group C ) . The clinic-based intervention ( groups A and B ) consisted of four monthly visits with a nutritionist who provided counseling to enhance PA and dietary intake that was tailored to baseline practice s and attitudes ; the community-based intervention ( group A ) consisted of three group sessions and 12 monthly phone calls from a peer counselor and was design ed to provide social support and reinforce behavior change goals ; and the minimal intervention ( group C ) consisted of educational pamphlets mailed to participants . The primary study outcome was the comparison of PA levels between groups assessed at 6 and 12 months by accelerometer , which was worn while awake for 7 days . RESULTS Totals of 175 ( 88 % ) and 167 ( 84 % ) participants completed PA assessment at 6 and 12 months , respectively . For comparison of PA , the P value for overall group effect was 0.014 . Comparing group A with C , the difference in the average adjusted mean for PA was 44.1 kcal/day ( 95 % CI 13.1 - 75.1 , P = 0.0055 ) . Comparing group B with C , the difference in the average adjusted mean was 33.1 kcal/day ( 95 % CI 3.3 - 62.8 , P = 0.029 ) . The intervention was acceptable to participants : 88 % were very satisfied with clinic-based counseling to enhance PA , and 86 % indicated that the peer counselor 's role in the program was important . CONCLUSIONS The intervention was associated with a modest enhancement of PA and was acceptable to participants OBJECTIVES Body and Soul was a collaborative effort among two research universities , a national voluntary agency ( American Cancer Society ) , and the National Institutes of Health to disseminate and evaluate under real-world conditions the impact of previously developed dietary interventions for African Americans . METHODS Body and Soul was constructed from two successful research -based interventions conducted in African-American churches . Components deemed essential from the prior interventions were combined , and then tested in a cluster r and omized-effectiveness trial . The primary outcome was fruit and vegetable intake measured with two types of food frequency question naires  at baseline and 6-month follow-up . RESULTS At the 6-month follow-up , intervention participants showed significantly greater fruit and vegetable ( F&V ) intake relative to controls . Post-test differences were 0.7 and 1.4 servings for the 2-item and 17-item F&V frequency measures , respectively . Statistically significant positive changes in fat intake , motivation to eat F&V , social support , and efficacy to eat F&V were also observed . CONCLUSIONS The results suggest that research -based interventions , delivered collaboratively by community volunteers and a health-related voluntary agency , can be effectively implemented under real-world conditions There is universal agreement [ 1 - 4 ] that women 50 to 69 years of age should undergo  screening mammography  because r and omized , controlled trials have shown that such screening reduces breast cancer mortality in this age group [ 5 , 6 ] . This consensus is bolstered by the results of cost-effectiveness analyses that consistently show that this benefit can be achieved at a reasonable cost [ 7 - 9 ] . In contrast , whether women 40 to 49 years of age should undergo screening mammography is controversial [ 10 - 15 ] . Pooled results of large r and omized , controlled trials have shown no mortality reduction in 40- to 49-year-old women after 7 to 9 years of screening [ 5 , 16 - 18 ] . However , a statistically significant reduction in breast cancer mortality becomes apparent 10 to 14 years after the initiation of screening [ 19 ] . Some authors have argued that this delayed benefit should not be ignored [ 11 ] . However , the reality of constrained health care re sources requires that any benefit from preventive services be achieved at a reasonable cost . Two recently published analyses [ 20 , 21 ] suggest that mammographic screening in younger women may be as cost-effective as screening in older women . The first analysis [ 20 ] calculated average cost-effectiveness by comparing a strategy of screening  40- to 69-year-old women with no screening . Most of the benefit achieved by using this strategy occurs when women are 50 to 69 years of age . Therefore , this analysis did not address whether it is cost-effective to screen women from 40 to 49 years of age in addition to screening them from 50 to 69 years of age . To determine whether the additional benefit obtained by extending screening mammography to women 40 to 49 years of age comes at a reasonable cost would require an incremental cost-effectiveness analysis [ 22 - 26 ] . The second analysis [ 21 ] used a simplified life-expectancy accounting method , did not discount costs or benefits , and associated screening mammography with unsubstantiated mortality reductions ( 30 % for the base case ) . Neither analysis [ 20 , 21 ] included an important aspect of the results of screening mammography trials in 40- to 49-year-old women : that is , no benefit occurs until 10 years after the initiation of screening . An earlier analysis [ 10 ] found screening mammography to be more expensive in women 40 to 49 years of age than in women 50 years of age and older . This previous analysis calculated incremental cost-effectiveness , discounted costs and benefits , and included an estimated delay between the onset of screening and the onset of a mortality benefit . Our analysis extends this work by including up date d pooled results of the r and omized , controlled trials [ 19 ] ; actual delay times before the onset of benefits ; and up date d costs of mammography and treatment of breast cancer . Methods Model We developed a Markov model [ 27 , 28 ] that compared the life expectancy of women undergoing different breast cancer screening strategies . Except for women in whom breast cancer was diagnosed at the initiation of screening , women were healthy at entry into the model . At the end of each 1-year cycle , women were in one of four health states : They remained healthy , developed breast cancer and remained alive , died of breast cancer , or died of another cause . The transition probabilities [ that is , the probabilities of developing breast cancer , dying of breast cancer , and dying of another cause ] were both age- and strategy -dependent . The base-case analysis compared three strategies : 1 ) no screening ; 2 ) screening biennially from 50 to 69 years of age ; and 3 ) screening every 18 months from 40 to 49 years of age , followed by screening biennially from 50 to 69 years of age . The rationale for these screening intervals is discussed below . We calculated the cost-effectiveness of screening in women 50 years of age and older by comparing the first strategy with the second strategy . To determine the incremental cost-effectiveness of screening in 40- to 49-year-old women , we compared the second and third strategies . Costs and benefits were discounted at a rate of 3 % per year for the base-case analysis [ 23 ] . Benefits Trials of screening mammography have shown no reduction in breast cancer mortality among screened women until several years after the initiation of screening [ 5 , 18 , 29 , 30 ] . Meta-analyses and one pooled analysis have shown that among 40- to 49-year-old women , the summary relative risk reduction in breast cancer mortality 7 to 9 years after the initiation of screening is about 1 , indicating no reduction in mortality [ 5 , 16 - 18 ] . Ten to 12 years after the initiation of screening , a nonsignificant trend toward reduced mortality is evident in the screened group ( Figure 1 , left ) [ 5 , 18 , 29 , 30 ] . Recently up date d results show a statistically significant 16 % reduction that occurs 10 to 14 years after the initiation of screening [ 19 ] . For women 50 to 69 years of age , there is an initial period of about 5 years that shows no benefit from screening ( Figure 1 , right ) [ 18 , 29 , 30 ] . Figure 1 . Cumulative breast cancer mortality in  screened  ( black circles ) compared with  nonscreened ( white circles ) women . Left . Right . In our model , for women who start screening at 50 years of age , a 27 % reduction in breast cancer mortality ( Table 1 ) [ 5 ] begins 5 years after the initiation of screening and continues until age 74 years . Although screening ends at 69 years of age , we assumed that women would continue to benefit for another 5 years because of early detection of breast cancer in the last years of screening . For women who begin screening at 40 years of age , a 16 % reduction in breast cancer mortality starts at age 50 years ; this reduction increases to 27 % at age 55 years . Table 1 . Information Used To Calculate Life Expectancy Screening Interval The screening interval in r and omized , controlled trials of screening mammography has varied from 12 to 33 months for women 50 years of age and older . Pooled results of the efficacy of mammography  stratified by length of screening interval do not differ for women in this age group [ 5 ] . From published results [ 5 ] , we determined a 28 % ( 95 % CI , 15 % to 31 % ) reduction in breast cancer mortality in women 50 years of age and older who were screened every 18 to 33 months and a 25 % ( CI , 1 % to 43 % ) reduction in those screened every 12 months . For the base-case analysis , we therefore chose to perform biennial screening in women 50 years of age and older because screening more often only increases cost without increasing the benefits of screening . For the base-case analysis , we used the pooled reduction in breast cancer mortality ( 27 % ) [ 5 ] from all r and omized , controlled trials to determine the cost-effectiveness of biennial screening in 50- to 69-year-old women ; in a sensitivity analysis , we determined the cost-effectiveness of annual screening . The screening interval in r and omized , controlled trials has varied from 12 to 24 months for women 40 to 49 years of age . Pooled results of the efficacy of screening mammography  stratified by length of screening interval did not show a statistically significant reduction in breast cancer mortality for 12-month or 18- to 24-month screening intervals [ 5 ] . As noted above , recently reported pooled results of all r and omized , controlled trials , which on average used a screening interval of 18 months , showed a statistically significant 16 % reduction in breast cancer mortality 10 to 14 years after the initiation of screening [ 19 ] . We therefore assumed that a 16 % reduction in breast cancer mortality would be achieved with screening done every 18 months . This screening interval is consistent with the guidelines of organizations [ 2 , 3 ] that recommend screening every 1 to 2 years for 40- to 49-year-old women . In sensitivity analyses , we calculated the cost-effectiveness of annual and biennial screening , assuming the same 16 % reduction in breast cancer mortality among screened women . Utilities Because there are few data on the utility that women place on life after treatment of breast cancer or the utility placed on living with metastatic breast cancer , we did not include utilities in the base-case analysis . Data from a small Australian study [ 33 ] ( which observed a utility of about 0.8 for life after treatment of breast cancer and a utility of about 0.3 for life with metastatic cancer ) are included in a sensitivity analysis to determine the extent to which cost per year of life saved might differ from cost per quality -adjusted life-year saved . Costs We included three costs : the cost of screening mammographic examinations , the cost of evaluating abnormal mammograms , and the cost of treating breast cancer ( Table 2 ) . Additional details on derivations of costs are given in the Appendix . The cost of screening mammography  was based on the average cost ( $ 91 ) reported by the National Cancer Institute 's National Survey of Mammography Facilities [ 34 ] . This cost was inflated to 1995 dollars ( $ 106 ) by using the consumer price index for medical services . We assumed that women in whom breast cancer was diagnosed continued to undergo screening mammography of the opposite breast , at the same cost , after the initial diagnosis of breast cancer . Table 2 . Information Used to Calculate Costs The cost of evaluating abnormal mammographic results was calculated as a weighted average of procedures that may follow abnormal mammograms . This cost was also inflated to 1995 dollars . The distribution and types of follow-up procedures were based on those reported by the National Cancer Institute 's National Survey of Mammography Facilities [ 35 ] . A range of costs for each procedure was based on data from Medicare , Pennsylvania Blue Cross , Group Health Cooperative , and Kaiser Permanente ( Brown M. Personal communication ) . The percentage of abnormal mammograms was based on the percentage seen with high- quality modern screening mammography ( Table 2 ) [ 36 ] . Population -based data on the cancer stage at diagnosis in screened compared with nonscreened women are sparse . PURPOSE Cancer survivors smoke at rates that are only slightly lower than the general population . This article reports on the final outcomes of Partnership for Health , a smoking cessation intervention for smokers in the Childhood Cancer Survivors Study ( CCSS ) . METHODS This study is a r and omized control trial with follow-up at 8 and 12 months that involved smokers ( n = 796 ) enrolled onto the CCSS cohort . Participants were r and omly assigned to either a self-help or a peer-counseling program that included up to six telephone calls from a trained childhood cancer survivor , tailored and targeted material s , and free nicotine replacement therapy . The intervention was delivered by telephone and postal service mail . RESULTS The quit rate was significantly higher in the counseling group compared with the self-help group at both the 8-month ( 16.8 % v 8.5 % ; P < .01 ) and 12-month follow-ups ( 15 % v 9 % ; P < or = .01 ) . Controlling for baseline self-efficacy and readiness to change , the intervention group was twice as likely to quit smoking , compared with the self-help group . Smoking cessation rate increased with an increase in the number of counseling calls . The cost of delivering the intervention was approximately 300 dollars per participant . The incremental cost-effectiveness of the intervention compared with controls was 5,371 dollars per additional quit . CONCLUSION Interventions to prevent future illnesses are of critical importance to childhood cancer survivors . The Partnership for Health intervention result ed in a doubling of smoking cessation quit rates . Because of the seriousness of smoking among childhood cancer survivors , this intervention model may be appropriate as a multicomponent treatment program for survivors who smoke INTRODUCTION Mammography is underused by certain groups of women , in particular poor and minority women . We developed a lay health advisor ( LHA ) intervention based on behavioral theories and tested whether it improved mammography attendance in Robeson County , NC , a rural , low-income , triracial ( white , Native American , African American ) population . METHODS A total of 851 women who had not had a mammogram within the past year were r and omly assigned to the LHA intervention ( n = 433 ) or to a comparison arm ( n = 418 ) during 1998 - 2002 .  Rates of  mammography  use after 12 - 14 months ( as verified by medical record review ) were compared using a chi-square test . Baseline and follow-up ( at 12 - 14 months ) surveys were used to obtain information on demographics , risk factors , and barriers , beliefs , and knowledge about mammography . Linear regression , Mantel-Haenszel statistics , and logistic regression were used to compare barriers , beliefs , and knowledge from baseline to follow-up and to identify baseline factors associated with mammography . RESULTS At follow-up , 42.5 % of the women in the LHA group and 27.3 % of those in the comparison group had had a mammogram in the previous 12 months ( relative risk = 1.56 , 95 % confidence interval [ CI ] = 1.29 to 1.87 ) . Compared with those in the comparison group , women in the LHA group displayed statistically significantly better belief scores ( difference = 0.46 points on a 0 - 10 scale , 95 % CI = 0.15 to 0.77 ) and reduced barriers at follow-up ( difference = -0.77 points , 95 % CI = -1.02 to -0.53 ) , after adjusting for baseline scores . CONCLUSIONS LHA interventions can improve mammography utilization . Future studies are needed to assess strategies to disseminate effective LHA interventions to underserved population The objective of this study was to determine whether the Arthritis Self-Management Programme ( ASMP ) improves perceptions of control , health behaviours and health status , and changes use of health care re sources . The design was a pragmatic r and omized controlled study ; participants were allocated to ASMP ( Intervention Group ) or a 4-month waiting-list Control Group . The Intervention Group completed a 12-month follow-up . In total , 544 people with arthritis were recruited from the community--311 in the Intervention Group and 233 in the Control Group . Main outcome measures included : arthritis self-efficacy , health behaviours ( exercise , cognitive symptom management , diet and relaxation ) and health status ( pain , fatigue , anxiety , depression and positive affect ) . At 4 months follow-up , the ASMP had a significant effect on arthritis self-efficacy for other symptoms and pain subscales . Performance of a range of health behaviours ( cognitive symptom management , communication with physicians , dietary habit , exercise and relaxation ) was significantly greater among the Intervention Group . The Intervention Group were significantly less depressed and had greater positive mood . In addition , trends towards decreases on fatigue and anxiety were noted . Physical functioning , pain and GP visits remained stable at 4 months . A similar pattern of findings was found at 12 months follow-up for the Intervention Group . Furthermore , a significant improvement was found on pain and visits to GPs had decreased . Apart from a small improvement on physical functioning among the Intervention Group participants with osteoarthritis 12 months , all effects were independent of the type of arthritis . The findings suggest that the ASMP is effective in promoting improvements in perception of control , health behaviours and health status , when delivered in UK setting OBJECTIVE To assess the effectiveness of including a social support intervention ( ' buddy system ' ) in a group treatment programme to aid  smoking cessation . METHODS Five hundred and sixty-three smokers attended groups at a smokers ' clinic . These groups were r and omized either to be ( a ) groups in which smokers were paired with another person to provide mutual support ( buddy condition : n=237 in 14 groups ) or ( b ) to receive the same treatment without the buddy component ( control : n=326 in 20 groups ) . Participants were seen weekly for the first 4 weeks after stopping then followed up again after 26 weeks . RESULTS Smokers in the buddy condition were no more likely than smokers in the control condition to stay abstinent at 1 , 4 or 26 weeks . The effect was in the right direction at week one post-quit but after controlling for potential confounders the difference was not significant ( odds ratio=1.45 ( 95 % CI ; 0.92 - 2.29 ) , p=0.06 ) . CONCLUSIONS We were unable to show that a buddy system improved abstinence rates of group treatment programmes . This might be due to the high level of social support already achieved through the groups . PRACTICE IMPLICATION S The buddy system is a simple and very low cost addition to a group treatment programme ; but the results from this study suggest that the kind of buddy system tested may not add substantially to the success rates . However there may be merits in a more intensive or protracted form of buddying Objective : Supporting patients ’ self care could have a major effect on the management of long-term conditions , which has led to worldwide interest in effective self care interventions . In Engl and , self care support is being developed through the “ Expert Patients Programme ” , which provides lay-led generic courses to improve patients ’ self care skills . However , the clinical and cost effectiveness of such courses remains unclear . Methods : Two-arm pragmatic r and omised controlled trial design with waiting list control in community setting s in Engl and . 629 patients with a wide range of self-defined long-term conditions were studied . The lay-led self care support group involved 6-weekly sessions to teach self care skills . Primary outcomes were self-efficacy , reported energy and routine health services utilisation at 6 months . A cost-effectiveness analysis was also conducted . Results : Patients receiving immediate course access reported considerably greater self-efficacy and energy at 6-month follow-up , but reported no statistically significant reductions in routine health services utilisation over the same time period . The cost-effectiveness analysis showed that patients receiving immediate course access reported considerably greater health related quality of life , and a small reduction in costs . If a quality adjusted life year was valued at £ 20 000 ( $ 39 191 ; € 30 282 ) , there was a 70 % probability that the intervention was cost effective . Conclusions : Lay-led self care support groups are effective in improving self-efficacy and energy levels among patients with long-term conditions , and are likely to be cost effective over 6 months at conventional values of a decision-maker ’s willingness to pay . They may be a useful addition to current services in the management of long-term conditions AIMS To assess the effect on abstinence rates of pairing up smokers attending a general practice smokers , clinic to provide mutual support between clinic sessions . DESIGN R and omized controlled trial comparing a " buddy " condition with a " solo condition " in which smokers received the e same treatment but were not paired up . SETTING A general practice smokers ' clinic in London . PARTICIPANTS One hundred and seventy-two smokers recruited by mailshot . INTERVENTION . Smokers attended a nurse-led smokers clinic 1 week prior to their quit date , on the quite date , 1 week later and 3 weeks after that . Smokers in the buddy condition were paired with another smoker trying to give up at the same time to provide mutual support between clinic sessions . MEASUREMENT The main outcome measure was the percentage of smokers still abstinent from cigarettes at end of treatment ( weeks from quite date ) , verified by expired air carbon monoxide concentration . FINDINGS The percentage of smokers still abstinent at the end of treatment was significantly higher in the buddy condition than the solo condition ( 27 % vs. 12 % ) . CONCLUSIONS A buddy system can provide an effective element of a smoking cessation intervention at minimal cost . Further research is needed to establish the long-term efficacy of this approach and examine the effectiveness of incorporating social support into other types of smoking cessation programmes BACKGROUND Few studies compare the influence of different types of dietary interventions on the dietary practice s of Latinas in the short and long term . The present study examined the 1-year impact of two innovative behavior-change approaches to reduce dietary fat and increase fiber . DESIGN Three-group r and omized controlled trial : ( 1 ) personalized dietary counseling via lay heath advisors ( promotoras ) plus tailored print material s delivered via the mail , ( 2 ) tailored mailed print material s only , and ( 3 ) targeted mailed " off-the-shelf " material s. SETTING / PARTICIPANTS A total of 357 Latinas were r and omly assigned to the three aforementioned conditions . INTERVENTION Promotora and tailored print material s. MAIN OUTCOME MEASURES Fat intake ( total grams of fat and percent calories from dietary fat ) and number of grams of dietary fiber . RESULTS Earlier work reported that at immediate post-intervention the promotora group achieved significantly lower levels of total fat grams , and lower levels of energy intake , total saturated fat , total carbohydrates , glucose , and fructose than the targeted group . However , the present longitudinal analyses suggest that the effects achieved by the promotoras dissipated over the 12-month follow-up period while the effects of the tailored group concurrently improved . CONCLUSIONS The high interactivity ( i.e. , calls , visits ) of the promotora condition may have been the most salient reinforcer and may have led to further tailoring , making this type of intervention more effective than the comparison groups in the short term . Further research should explore whether booster sessions involving promotoras help to maintain the impact over time Abstract Objective : To determine the relation between exposure to glycaemia over time and the risk of macrovascular or microvascular complications in patients with type 2 diabetes . Design : Prospect i ve observational study . Setting : 23 hospital based clinics in Engl and , Scotl and , and Northern Irel and . Participants : 4585 white , Asian Indian , and Afro-Caribbean UKPDS patients , whether r and omised or not to treatment , were included in analyses of incidence ; of these , 3642 were included in analyses of relative risk . Outcome measures : Primary predefined aggregate clinical outcomes : any end point or deaths related to diabetes and all cause mortality . Secondary aggregate outcomes : myocardial infa rct ion , stroke , amputation ( including death from peripheral vascular disease ) , and microvascular disease ( predominantly retinal photo-coagulation ) . Single end points : non-fatal heart failure and cataract extraction . Risk reduction associated with a 1 % reduction in up date d mean HbA1c adjusted for possible confounders at diagnosis of diabetes . Results : The incidence of clinical complications was significantly associated with glycaemia . Each 1 % reduction in up date d mean HbA1c was associated with reductions in risk of 21 % for any end point related to diabetes ( 95 % confidence interval 17 % to 24 % , P<0.0001 ) , 21 % for deaths related to diabetes ( 15 % to 27 % , P<0.0001 ) , 14 % for myocardial infa rct ion ( 8 % to 21 % , P<0.0001 ) , and 37 % for microvascular complications ( 33 % to 41 % , P<0.0001 ) . No threshold of risk was observed for any end point . Conclusions : In patients with type 2 diabetes the risk of diabetic complications was strongly associated with previous hyperglycaemia . Any reduction in HbA1c is likely to reduce the risk of complications , with the lowest risk being in those with HbA1c values in the normal range ( < 6.0 % ) BACKGROUND Exclusive breastfeeding is recommended worldwide but not commonly practised . We undertook a r and omised controlled study of the efficacy of home-based peer counselling to increase the proportion of exclusive breastfeeding among mothers and infants residing in periurban Mexico City . METHODS Two intervention groups with different counselling frequencies , six visits ( 44 ) and three visits ( 52 ) , were compared with a control group ( 34 ) that had no intervention .  From March , 1995 , to September , 1996 , 170 pregnant women were identified by census and invited to participate in the study . Home visits were made during pregnancy and early post partum by peer counsellors recruited from the same community and trained by La Leche League . Data were collected by independent interview . Exclusive breastfeeding was defined by WHO criteria . FINDINGS 130 women participated in the study . Only 12 women refused participation . Study groups did not differ in baseline factors . At 3 months post partum , exclusive breastfeeding was practised by 67 % of six-visit , 50 % of three-visit , and 12 % of control mothers ( intervention groups vs controls , p<0.001 ; six-visit vs three-visit , p=0.02 ) . Duration of breastfeeding was significantly ( p=0.02 ) longer in intervention groups than in controls , and fewer intervention than control infants had an episode of diarrhoea ( 12 % vs 26 % , p=0.03 ) . INTERPRETATION This is the first reported community-based r and omised trial of breastfeeding promotion . Early and repeated contact with peer counsellors was associated with a significant increase in breastfeeding exclusivity and duration . The two-fold decrease in diarrhoea demonstrates the importance of breastfeeding promotion to infant health BACKGROUND Most mothers stop breast-feeding before the recommended 6 months post partum . A systematic review showed that breast-feeding support programs by health care professionals did not substantially improve breast-feeding outcomes beyond 2 months post partum . We conducted a r and omized controlled trial to evaluate the effect of peer ( mother-to-mother ) support on breast-feeding duration among first-time breast-feeding mothers . METHODS We recruited 256 breast-feeding mothers from 2 semi-urban community hospitals near Toronto and r and omly assigned them to a control group ( conventional care ) or a peer support group ( conventional care plus telephone-based support , initiated within 48 hours after hospital discharge , from a woman experienced with breast-feeding who attended a 2.5-hour orientation session ) . Follow-up of breast-feeding duration , maternal satisfaction with infant feeding method and perceptions of peer support received was conducted at 4 , 8 and 12 weeks post partum . RESULTS Significantly more mothers in the peer support group than in the control group continued to breast-feed at 3 months post partum ( 81.1 % v. 66.9 % , p = 0.01 ) and did so exclusively ( 56.8 % v. 40.3 % , p = 0.01 ) . Breast-feeding rates at 4 , 8 and 12 weeks post partum were 92.4 % , 84.8 % and 81.1 % respectively among the mothers in the peer support group , as compared with 83.9 % , 75.0 % and 66.9 % among those in the control group ( p < or = 0.05 for all time periods ) . The corresponding relative risks were 1.10 ( 95 % confidence interval [ CI ] 1.01 - 2.72 ) at 4 weeks , 1.13 ( 95 % CI 1.00 - 1.28 ) at 8 weeks and 1.21 ( 95 % CI 1.04 - 1.41 ) at 12 weeks post partum . In addition , when asked for an overall rating of their feeding experience , significantly fewer mothers in the peer support group than in the control group were dissatisfied ( 1.5 % v. 10.5 % ) ( p = 0.02 ) . Of the 130 mothers who evaluated the peer support intervention , 81.6 % were satisfied with their peer volunteer experience and 100 % felt that all new breast-feeding mothers should be offered this peer support intervention . INTERPRETATION The telephone-based peer support intervention was effective in maintaining breast-feeding to 3 months post partum and improving satisfaction with the infant feeding experience . The high satisfaction with and acceptance of the intervention indicates that breast-feeding peer support programs , in conjunction with professional health services , are effective BACKGROUND For most smokers , quitting is a difficult process . Many smokers try to quit repeatedly before they succeed , with some relapsing even after a lengthy period of abstinence . Few population -based cohort studies have examined relapse among former smokers . Quantification of the relationship between the duration of abstinence and the likelihood of continued abstinence is important for the evaluation of ongoing public health interventions and the design of smoking-cessation programs . PURPOSE We analyzed longitudinal data from a large , representative population cohort of former smokers and estimated the probability of future relapse for different duration s of abstinence at baseline ( e.g. , 1 to <3 months and 3 to < 6 months ) . METHODS From the 1990 California Tobacco Survey that used a r and om-digit-dialed computer-assisted telephone survey to interview 24296 California adults ( baseline interview ) from June 1990 through February 1991 , a stratified r and om sample of 4642 adults was reinterviewed from March 1992 through July 1992 . Both surveys assessed smoking status using st and ard questions about the lifetime use of 100 cigarettes and the self-classification of current smoking : 1 ) " Have you smoked at least 100 cigarettes in your lifetime ? " and 2 ) " Do you smoke cigarettes now ? " We included all 1449 former smokers at baseline interview who answered " yes " to the first question and " no " to the second and who also provided a valid date at both of the surveys when asked , " When did you last smoke regularly ? " All data were weighted to account for the study design and to ensure that the estimates were representative of the California population by age , sex , race/ethnicity , education , and geographic region . RESULTS Only about 12 % of the former smokers who had quit for less than 1 month at baseline remained continuously abstinent at the follow-up interview . This percentage increased to 25 % for those who had quit from 1 to less than 3 months ; it increased again to 52 % if the duration of quitting was from 3 to less than 6 months , but it increased only slightly to 59.2 % for those who had quit from 6 to less than 12 months . Overall , the likelihood of remaining continuously abstinent until the follow-up interview was about 90 % for former smokers who had quit for 3 months or longer and 95 % for those who had quit for 1 year or longer . CONCLUSIONS AND IMPLICATION S We suggest that self-reported cessation for more than 3 months be considered as an intermediate criterion for success both in longitudinal studies and the cross-sectional evaluation of community interventions . If a more stringent criterion is needed , we recommend self-reported cessation for at least 1 year Background : Many believe that smoking cessation programmes for Latinos should be tailored to the values and beliefs of the culture . However , r and omised studies of culturally appropriate smoking cessation interventions with Latinos are rare . Methods : Latino smokers ( n = 313 ) were r and omised to an intervention condition or a comparison group . The intervention was a three month programme based on social cognitive constructs and delivered in the smoker ’s home by trained lay health advisors , or promotores . Comparison group participants were referred to the California Smoker ’s Helpline in Spanish . Predictors of abstinence among all participants also were examined . Results : About one week post-intervention , vali date d ( carbon monoxide ) past week abstinence rates were more than twice as high in the intervention group ( 20.5 % ) than in the comparison ( 8.7 % ) ( p ≤ 0.005 ) . The pattern of results held for self reported abstinence , and after recoding dropouts to non-abstinence . The primary predictor of abstinence was number of cigarettes smoked per day at baseline , a common measure of addiction . Conclusions : The culturally appropriate intervention facilitated abstinence in Latino smokers , at least in the short term . Strengths and weaknesses of the study are discussed BACKGROUND Parents of children with chronic illnesses are at high risk for secondary mental health problems , such as anxiety and depression . OBJECTIVE To evaluate maternal outcomes of a support intervention for families of children with selected chronic illnesses . DESIGN A r and omized controlled clinical trial design with repeated measures 1 year apart . SETTING A community-based family support intervention linked to subspecialty and general pediatric clinics and practice s in a metropolitan area . PARTICIPANTS A population -based sample of 193 mothers of children aged 7 to 11 years ; the children were diagnosed as having diabetes , sickle cell anemia , cystic fibrosis , or moderate to severe asthma . About 15 % of the persons contacted refused to participate in the research , and 14 % of the families were lost to follow-up . INTERVENTION The 15-month intervention , the Family-to-Family Network , was design ed to enhance mothers ' mental health by linking mothers of school-aged children with selected chronic illnesses with mothers of older children with the same condition . The program included telephone contacts , face-to-face visits , and special family events . MAIN OUTCOME MEASURES Beck Depression Inventory score and the Psychiatric Symptom Index . RESULTS Maternal anxiety scores for participants in the experimental group decreased during the intervention period for all diagnostic groups and for the total group ; scores for the control group increased ( F = 5.07 , P = .03 ) . In multiple regression analyses , the intervention group was a significant predictor of posttest anxiety scores ( P = .03 ) . Effects were greater for mothers with high baseline anxiety ( P<.001 ) and for those who were themselves in poor health ( P<.01 ) . CONCLUSIONS A family support intervention can have beneficial effects on the mental health status of mothers of children with chronic illnesses . This type of intervention can be implemented in diverse pediatric setting Context Obesity is a major public health problem in North America , particularly in Aboriginal people . Objective To determine if a household-based lifestyle intervention is effective at reducing energy intake and increasing physical activity among Aboriginal families after 6 months . Design , Participants , and InterventionR and omized , open trial of 57 Aboriginal households recruited between May 2004 and April 2005 from the Six Nations Reserve in Ohsweken , Canada . Aboriginal Health Counsellors made regular home visits to assist families in setting dietary and physical activity goals . Additional interventions included provision of filtered water , a physical activity program for children , and educational events about healthy lifestyles . Results 57 households involving 174 individuals were r and omized to intervention or usual care . Intervention households decreased consumption of fats , oils and sweets compared to usual care households ( -4.9 servings per day vs. -3 servings/day , p=0.006 ) , and this was associated with a reduction in trans fatty acids ( -0.2 vs. + 0.6 grams/day , p=0.02 ) . Water consumption increased ( + 0.3 vs. -0.1 servings/day , p<0.04 ) and soda pop consumption decreased ( -0.3 vs. -0.1 servings/day , p=0.02 ) in intervention households compared to usual care . A trend toward increased knowledge about healthy dietary practice s in children , increased leisure-time activity and decreased sedentary behaviours was observed , although these differences were not statistically significant . Conclusion A household-based intervention is associated with some positive changes in dietary practice s and activity patterns . A larger and longer-term intervention which addresses both individual change and structural barriers in the community is needed . Résumé Context eL’obésité est un problème de santé publique majeur en Amérique du Nord , particulièrement chez les Autochtones . ObjectifDéterminer si une intervention de modification du mode de vie centrée sur les ménages parvient à réduire l’apport énergétique et à accroître l’activité physique dans des familles autochtones au bout de six mois . Méthode , participants et interventionEssai ouvert aléatoire auprès de 57 ménages autochtones recrutés entre mai 2004 et avril 2005 dans la réserve des Six-Nations à Ohsweken ( Ontario ) , au Canada . Des conseillers en santé autochtone ont fait des visites à domicile périodiques pour aider les familles à se fixer des objectifs de saine alimentation et d’activité physique . D’autres mesures ont aussi été instaurées : on a fourni de l’eau filtrée aux ménages , offert un programme d’activité physique aux enfants et organisé des activités de sensibilisation aux modes de vie sains . RésultatsLes 57 ménages ( 174 personnes ) ont été répartis aléatoirement en deux groupes , l’un recevant les mesures d’intervention et l’autre , les soins habituels . Les ménages recevant les mesures d’intervention ont diminué leur consommation de matières grasses , d’huile et de sucreries par rapport aux ménages recevant les soins habituels ( -4,9 portions/jour contre -3 portions/jour , p=0,006 ) , et cette diminution était associée à une baisse de la consommation d’acides gras trans ( -0,2 contre + 0,6 g/jour , p=0,02 ) . Par ailleurs , leur consommation d’eau a augmenté ( + 0,3 contre -0,1 portion/jour , p<0,04 ) , et leur consommation de boissons gazeuses a diminué ( -0,3 contre -0,1 portion/jour , p=0,02 ) . Nous avons aussi observé une amélioration des connaissances des enfants sur la saine alimentation , une augmentation de l’activité pendant les temps libres et une diminution des comportements sédentaires , mais ces changements n’étaient pas significatifs . Conclusion Une intervention centrée sur les ménages est associée à certains changements positifs dans l’alimentation et l’activité physique . Il faudrait élargir et prolonger l’initiative , en tenant compte à la fois des changements individuels et des obstacles structurels dans la communauté PURPOSE We describe a controlled trial of a community outreach intervention to promote recognition , receipt , and screening-interval maintenance of clinical breast examinations ( CBE ) , mammograms , and Pap smears among Vietnamese-American women . METHODS Over a 3-year period ,  indigenous lay health workers conducted small-group sessions of Vietnamese women in a low-income district of San Francisco , California . Women in Sacramento , California , served as controls . Lay workers conducted 56 sessions on general prevention , 86 on cervical cancer , and 90 on breast cancer . Surveys of 306 to 373 women were conducted in the study communities in 1992 and 1996 . RESULTS In the intervention community , recognition of screening tests increased significantly between pre- and postintervention surveys : CBE , 50 to 85 % ; mammography , 59 to 79 % ; and Pap smear , 22 to 78 % ( P = 0.001 for all ) . Receipt of screening tests also increased significantly : CBE , 44 to 70 % ( P = 0.001 ) ; mammography , 54 to 69 % ( P = 0.006 ) ; and Pap smear , 46 to 66 % ( P = 0.001 ) . Best-fitting logistic regression models , adjusting for preintervention rates and significant covariates , also showed statistically significant odds ratios for the intervention effect ( P < 0.0001 ) . CONCLUSIONS Trained Vietnamese lay health workers significantly increased Vietnamese women 's recognition , receipt , and maintenance of breast and cervical cancer screening tests BACKGROUND The 1998 UK government White Paper Smoking Kills emphasises that normal practice should be for general practitioners ( GPs ) , practice nurses , and others to offer advice and support to smokers in their efforts to stop . However , GPs are not allowed to write NHS prescriptions for nicotine-replacement therapy , even though this is the only effective pharmaceutical treatment available in the UK . We estimated the cost-effectiveness , for the NHS , of allowing GPs to prescribe transdermal nicotine patches for up to 12 weeks . METHODS We used data from a r and omised , placebo-controlled efficacy trial of nicotine patches and a survey of associated re source use in 30 GP surgeries in 15 English counties . We calculated the health benefit of nicotine-patch treatment in number of life years that would be saved by stopping smoking at various ages , and used an abstinence-contingent treatment model to calculate the incremental cost per life year saved by GP counselling with nicotine-patch treatment over GP counselling alone .  Cost effectiveness was assessed on the basis that GPs would provide repeat NHS prescriptions for up to 12 weeks if the treatment was proving successful . FINDINGS If GPs were allowed to prescribe transdermal nicotine patches on the NHS , for up to 12 weeks , the incremental cost per life year saved would be : Pound Sterling 398 per person younger than 35 years ; Pound Sterling 345 for those aged 35 - 44 years ; Pound Sterling 432 for those aged 45 - 54 years ; and Pound Sterling 785 for those aged 55 - 65 years . INTERPRETATION The low cost per life year saved would make GP intervention against smoking a cost-effective life-saving treatment . The priniciples of the government White Paper could be cost-effectively extended into general practice to reduce smoking and smoking-related illnesses BACKGROUND Reducing the impact of chronic disease in minority ethnic groups is an important public health challenge . Lay-led education may overcome cultural and language barriers that limit the effectiveness of professionally-led programmes . We report the first r and omised trial of a lay-led self-management programme - the Chronic Disease Self-Management Programme ( CDSMP ) ( Expert Patient Programme ) - in a south Asian group . AIM To determine the effectiveness of a culturally-adapted lay-led self-management programme for Bangladeshi adults with chronic disease . DESIGN OF STUDY R and omised controlled trial . SETTING Tower Hamlets , east London . METHOD We recruited Bangladeshi adults with diabetes , cardiovascular disease , respiratory disease or arthritis from general practice s and r and omised them to the CDSMP or waiting-list control .  Self-efficacy ( primary outcome ) , self-management behaviour , communication with clinician , depression scores , and healthcare use were assessed by blinded interviewer-administered question naires in Sylheti before r and omisation and 4 months later . RESULTS Of the 1363 people invited , 476 ( 34 % ) agreed to take part and 92 % ( 439/476 ) of participants were followed up . The programme improved self-efficacy ( difference : 0.67 , 95 % confidence interval [ CI ] = 0.08 to 1.25 ) and self-management behaviour ( 0.53 ; 95 % CI = 0.01 to 1.06 ) . In the 51 % ( 121/238 ) of intervention participants attending three or more of the 6-weekly education sessions the programme led to greater improvements in self-efficacy ( 1.47 ; 95 % CI = 0.50 to 1.82 ) and self-management behaviour ( 1.16 ; 95 % CI = 0.50 to 1.82 ) , and reduced HADS depression scores ( 0.64 ; 95 % CI = 0.07 to 1.22 ) . Communication and healthcare use were not significantly different between groups . The programme cost pound123 ( 181 ) per participant . CONCLUSION A culturally-adapted CDSMP improves self-efficacy and self-care behaviour in Bangladeshi patients with chronic disease . Effects on health status were marginal . Benefits were limited by moderate uptake and attendance BACKGROUND The Arizona Well-Integrated Screening and Evaluation for Women Across the Nation ( WISEWOMAN ) project used provider counseling , health education , and community health workers ( CHWs ) to target chronic disease risk factors in uninsured , primarily Hispanic women over age 50 . METHODS Participants were recruited from two Tucson clinics participating in the National Breast and Cervical Cancer Early Detection Program ( NBCCEDP ) . Women were r and omly assigned into one of three intervention groups : ( 1 ) provider counseling , ( 2 ) provider counseling and health education , or ( 3 ) provider counseling , health education , and CHW support . At baseline and 12 months ( 1998 - 2000 ) , participants were measured for height , weight , waist and hip circumference , and blood pressure . Blood tests were conducted to check blood glucose , cholesterol , and triglyceride levels . At each time point , participants also completed 24-hour dietary recalls and question naires focusing on their physical activity levels . RESULTS A total of 217 women participated in baseline and 12-month follow-up . Three fourths were Hispanic . All three intervention groups showed an increase in self-reported weekly minutes of moderate-to-vigorous physical activity , with no significant differences between the groups . Significantly more women who received the comprehensive intervention of provider counseling , health education , and CHW support progressed to eating five fruits and vegetables per day , compared with participants who received only provider counseling or provider counseling plus health education . CONCLUSIONS All three interventions increased moderate-to-vigorous physical activity but not fruit and vegetable consumption . The intervention group with provider counseling , health education , and CHW support significantly increased the number of women meeting national recommendations for fruit and vegetable consumption A network-oriented HIV prevention intervention based on social identity theory and peer outreach was implemented for HIV positive and negative drug users . A community sample of 250 were r and omly assigned to an  equal-attention control condition or  a  multisession , small-group experimental condition , which encouraged peer outreach ; 94 % of participants were African American , and 66 % used cocaine or opiates . At follow-up , 92 % of participants returned , and experimental compared with control group participants were 3 times more likely to report reduction of injection risk behaviors and 4 times more likely to report increased condom use with casual sex partners . Results suggest that psychosocial intervention emphasizing prosocial roles and social identity , and incorporating peer outreach strategies , can reduce HIV risk in low-income , drug-using communities The Community Trial of Breast Cancer Screening Promotion assessed the effectiveness and cost-effectiveness of mammography promotion  by community volunteer groups in rural areas using three different intervention approaches : individual counseling , community activities , and a combined intervention including both .  Societal costs of the interventions were calculated and used in conjunction with measures of effectiveness to calculate cost-effectiveness in terms of cost per additional mammogram and cost per year of life saved . Methods of collecting and using cost information to assess the cost-effectiveness of community interventions are described . The Community Activities intervention was found to be the most cost-effective , at approximately $ 2,000 for each additional regular mammography user in the community . The cost per year of life saved associated with mammography promotion was approximately $ 56,000 per year of life saved . Exploratory analyses suggest that the most cost-effective method of promoting mammography use may vary with the target population Objective : To assess the cost effectiveness of the Expert Patients Programme ( EPP ) intervention compared to a treatment as usual alternative . Design : Two-arm pragmatic r and omised controlled trial design with waiting list control . Setting : Community setting s in Engl and . Patients : Patients with a wide range of self-defined long-term conditions . Intervention : The EPP based on the US chronic disease self management program ( CDSMP ) , a lay-led self-care group involving six weekly sessions to teach self-care support skills . Main outcome measures : Costs estimated over a 6-month period from a societal perspective . Health outcomes estimated in terms of quality adjusted life years ( QALYs ) generated by patients ’ response to the EQ5D at baseline and 6-month follow-up . Results : The intervention group is associated with better patient outcomes , at slightly lower cost . Specifically , the intervention group has a 0.020 QALY gain compared with the control group , and a reduced cost of around £ 27 per patient . The intervention would therefore be considered dominant . While the QALYs gained are small in absolute terms , an additional 0.02 QALY is equivalent to an extra one week of perfect health per year . When the value of a QALY is £ 20 000 the EPP has a probability of 94 % of being cost effective . Indeed , for all plausible values of willingness-to-pay for a QALY the EPP group is more likely to be cost effective than the control group . Conclusions : The EPP intervention evaluated in this trial is very likely to provide a cost effective alternative to usual care in people with long-term conditions
target: We found little evidence of effectiveness of HRLAs for promotion of exercise/improved diets .
  Conclusions Overall , there is limited evidence suggesting that HRLAs are cost-effective in terms of changing health-related knowledge , behaviours or health outcomes .
  The evidence that does exist indicates that HRLAs are only cost-effective when they target behaviours likely to have a large impact on overall health-related quality of life .
background: Background Development of new peer or lay health-related lifestyle advisor ( HRLA ) roles is one response to the need to enhance public engagement in , and improve cost-effectiveness of , health improvement interventions .
  This article synthesis es evidence on the cost-effectiveness of HRLA interventions aim ed at adults in developed countries , derived from the first systematic review of the effectiveness , cost-effectiveness , equity and acceptability of different types of HRLA role .