Early investments in state capacity promote persistently higher levels of social capital.

Social capital has been shown to positively influence a multitude of economic, political, and social outcomes. Yet the factors that affect long-run social capital formation remain poorly understood. Recent evidence suggests that early state formation, especially investments in state capacity, are positively associated with higher levels of contemporary social capital and other prosocial attitudes. The channels by which early state capacity leads to greater social capital over time are even less understood. We contribute to both questions using the spatial and temporal expansion of the US postal network during the 19th century. We first show that county-level variation in post office density is highly correlated with a bevy of historical and contemporary indicators of social capital (e.g., associational memberships, civic participation, health, and crime). This finding holds even when controlling for historical measures of development and contemporary measures of income, inequality, poverty, education, and race. Second, we provide evidence of an informational mechanism by which this early investment in infrastructural capacity affected long-run social capital formation. Namely, we demonstrate that the expansion of the postal network in the 19th century strongly predicts the historical and contemporary location of local newspapers, which were the primary mode of impersonal information transmission during this period. Our evidence sheds light on the role of the state in both the origins of social capital and the channels by which it persists. Our findings also suggest that the consequences of the ongoing decline in local newspapers will negatively affect social capital.

Implementation of a billable transitional care model for stroke patients: the COMPASS study.

BACKGROUND: The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework. METHODS: We evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models. RESULTS: Adoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC. Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals. IMPLEMENTATION: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days. Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42-6.27, p = 0.002). Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC. CONCLUSIONS: COMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status. TRIAL REGISTRATION: ClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.

Receipt of Tobacco Direct Mail Coupons and Changes in Smoking Status in a Nationally Representative Sample of US Adults.

Introduction: Direct-to-consumer tobacco marketing, including direct mail and email coupons, is a potentially influential marketing strategy. We examined the associations between receipt of tobacco direct mail/email coupons and trajectories of smoking behavior among US adults. Methods: Data were from the US Population Assessment on Tobacco and Health (PATH) Study adult sample (n = 32160) collected during 2013-2014. Participants self-reported their smoking status (every day, some days, not at all) 12 months prior to the survey (T0) and at the time of the survey (T1). Three smoking trajectories were identified: nonsmokers progressing to current smokers, current smokers continuing to smoke, and among current smokers at T0, progressing to or continuing with daily smoking. Participants also reported receipt of direct mail/email tobacco coupons in the 6 months preceding T1 (yes/no). Weighted multiple logistic regression models were used to test the associations between receiving direct mail/email tobacco coupons and different smoking trajectories adjusted for demographic characteristics. Results: One in eight (12.4%) US adult nonsmokers and 36.2% adult smokers at T0 reported receiving tobacco coupons. Receipt of tobacco coupons was negatively associated with poverty status. Receipt of tobacco coupons was associated with increased odds of progression to current smoking (AOR = 1.76, 95% CI = 1.45 to 2.12), continuation of smoking (AOR = 1.34, 95% CI = 1.09 to 1.65), and current smokers' progression to or continuation with daily smoking (AOR = 1.70, 95% CI = 1.50 to 1.91). Conclusions: Direct-to-consumer tobacco coupons may promote progression of smoking among nonsmokers, and continuation of smoking and progression to daily smoking among smokers in US adults. Implications: Distributing direct mail coupons is a strategy employed by tobacco companies to promote their products. We found, in a US national study, that many adults received tobacco coupons, and receiving these coupons was associated with subsequent progression of smoking among nonsmokers, and continuation of smoking and daily smoking among smokers. Scrutiny over the use of direct mail coupons and its effects on population health is warranted. Future research is needed to evaluate the effect of different interventions to reduce the impact of these coupons on smoking behaviors.

Patterns of use and expenses associated with mail-service pharmacy in adults with diabetes.

OBJECTIVES: To identify socioeconomic factors associated with mail-service pharmacy use and compare the differences in disease-specific prescription medication and medical utilization expenses in a nationally representative sample of adults with diabetes. DESIGN: A retrospective, longitudinal, cross-sectional study. SETTING: United States in 2006-11. PARTICIPANTS: Medical Expenditure Panel Survey household component (MEPS-HC) participants aged 18 years or older diagnosed with diabetes and prescribed antidiabetic medications. MAIN OUTCOME MEASURES: Likelihood of mail-service pharmacy use, diabetes-related medical utilization, and medication expenses. RESULTS: Among 4,430 eligible participants identified in the 2006-11 surveys, representing more than 83 million U.S. individuals, nearly 13% of the participants obtained two-thirds or more of their antidiabetic medications via mail service predominantly. Mail-service pharmacy users were older, had high school or college degrees, had higher incomes, and were more likely to be covered by private insurance. There were no significant differences in diabetes-related medical utilization and drug expenses between the two groups. CONCLUSION: Besides pharmacy benefit design, sociodemographic and economic factors influenced drug dispensing channel use (mail service versus community pharmacy). No significant differences in diabetes-related drug and medical expenses between mail-service and community pharmacy users were observed.

Feasibility and acceptability of alternate methods of postnatal data collection.

This study was done in preparation for the launch of the National Children's Study (NCS) main study. The goal of this study was to examine the feasibility (completion rates and completeness of data), acceptability, staff time and cost-effectiveness of three methods of data collection for the postnatal 3- and 9-month questionnaires completed as part of NCS protocol. Eligible NCS participants who were scheduled to complete a postnatal questionnaire at three and nine months were randomly assigned to receive either: (a) telephone data collection (b) web-based data collection, or (c) self-administered (mailed) questionnaires. Event completion rates and satisfaction across the three data collection methods were compared and the influence of socio-demographic factors on completion rates and satisfaction rates was examined. Cost data were compared to data for completion and satisfaction for each of the delivery methods. Completion rates and satisfaction did not differ significantly by method, but completeness of data did, with odds of data completeness higher among web than phone (p < 0.001) or mail (p < 0.001). Costs were highest for the phone, followed by mail and web methods (p < 0.001). No significant differences in participant time (i.e. burden) across the three data collection methods were seen. Mail and phone data collection were the least complete of the three methods and were the most expensive. Mailed data collection was neither complete nor exceptionally economical. Web-based data collection was the least costly and provided the most complete data. Participants without web access could complete the questionnaire over the phone.

Survey methods and response rates among rural community dwelling older adults.

BACKGROUND: Rural older adults are not often targeted for surveys, and little is known about survey response rates in this population. Because overall numbers of rural older adults are small, it is important to consider techniques to improve their survey response rates. OBJECTIVES: The purpose of this study was to work with community partners to determine whether rural older adults participating in a rural county home-delivered meals program were more likely to respond to an injury risk survey hand-delivered via the postal service or hand-delivered by the home-delivered meals drivers. METHODS: All home-delivered meals clients older than 65 years old were randomized to one of two groups. One group (n = 70) received the following via the postal service: a prenotice letter, a survey packet containing a description of the survey, the survey, a stamped and addressed return envelope, and a reminder/thank-you card. Older adults in the other group (n = 69) were personally handed the survey packet by the home-delivered meals driver. RESULTS: The overall survey response rate was 43.9%. Older adults who were handed the survey packets by the home-delivered meals drivers were older and significantly more likely to return the survey (57%) compared with those who received survey materials in the mail (31%). Only 27% of respondents agreed to be contacted regarding participation in future face-to-face interviews. When taking into account response rates, postage costs alone were over five times higher for the postal-delivered surveys compared with the hand-delivered surveys. DISCUSSION: By working with community partners, we were able to determine that older adults in a rural community were more likely to respond to surveys personally handed to them by someone they knew.

An analysis of response rate and economic costs between mail and web-based surveys among practicing dentists: a randomized trial.

This study explored the economic costs and response rate of mail and web-based surveys with practicing dentists. A random sample of 6,000 practicing dentists was randomly assigned into three groups of 2,000: choice (mail or web-based), postal mail, or web-based. The Florida Tobacco Control Survey 2009, which is composed of 28 questions (including subject demographic questions), served as the survey instrument. A total of 1,232 surveys were returned by the three different groups (21% overall response rate). Response rates were best for the mail (26%) with the worst response rate coming from the Web group (11%). However, a cost-effectiveness analysis revealed that web surveys were 2.68 times more cost effective.

Web-based questionnaires: the future in epidemiology?

The traditional epidemiologic modes of data collection, including paper-and-pencil questionnaires and interviews, have several limitations, such as decreasing response rates over the last decades and high costs in large study populations. The use of Web-based questionnaires may be an attractive alternative but is still scarce in epidemiologic research because of major concerns about selective nonresponse and reliability of the data obtained. The authors discuss advantages and disadvantages of Web-based questionnaires and current developments in this area. In addition, they focus on some practical issues and safety concerns involved in the application of Web-based questionnaires in epidemiologic research. They conclude that many problems related to the use of Web-based questionnaires have been solved or will most likely be solved in the near future and that this mode of data collection offers serious benefits. However, questionnaire design issues may have a major impact on response and completion rates and on reliability of the data. Theoretically, Web-based questionnaires could be considered an alternative or complementary mode in the range of epidemiologic methods of data collection. Practice and comparisons with the traditional survey techniques should reveal whether they can fulfill their expectations.

Use of a web-based questionnaire in the Black Women's Health Study.

The authors assessed the utility and cost-effectiveness of using a World Wide Web-based questionnaire in a large prospective cohort study, the Black Women's Health Study (BWHS). In 1995, 59,000 African-American women were recruited into the BWHS through a paper questionnaire. Follow-up paper questionnaires have been mailed every 2 years since then. During the 2003, 2005, and 2007 questionnaire cycles, participants were given the option of completing a Web-based questionnaire. The cost of developing and processing a returned paper questionnaire was 4 times that of a returned Web questionnaire, primarily because of return postage costs and greater processing time for paper questionnaires. The proportion of respondents who completed a Web questionnaire doubled from 2003 to 2007, from 10.1% to 19.9%, but the characteristics of those completing the Web questionnaire remained the same. Web response was greatest at younger ages (20.9% of those aged <30 years) and declined with age to 3.6% among women aged 60 years or more. Web questionnaires were filled out more completely than paper questionnaires, regardless of the sensitivity of a question. The use of a Web questionnaire in the BWHS resulted in cost savings and more complete responses. Although there are advantages to using a Web questionnaire, the use of multiple means of soliciting questionnaire responses is still needed.

Sample Transport Optimization: Mali Pilot Study.

In Mali, qualified laboratories for testing of dangerous pathogens are centralized in Bamako. Creating a specimen transport system respecting timeline, specimen quality, biosafety, and biosecurity standards is a challenge. The current ad hoc system that relies on untrained public transport companies carries risks of spoilage, accidental release of pathogens, and delays, which compromise specimen quality. This pilot study aimed to evaluate the effectiveness (ie, timeline, quality of specimen, and cost) of using the trained postal service for sample transportation from district to central level, compared with the current system. The postal service intervention ran from mid-2016 to mid-2017 and covered 3 districts. Data were collected in the same districts during the same period of the preceding year for comparison. In all, 41 specimens were shipped using public transportation and 51 were shipped using the postal service. These included suspected meningitis, measles, yellow fever, and polio samples. Only 46% of samples sent by public transportation were received in Bamako within 72 hours of collection, compared to 71% of samples shipped via the postal service (p < .05). Further, 93% of samples shipped by public transportation arrived in good condition at the receiving laboratory, compared to 98% by postal service. Although cost comparisons were difficult (flat fee vs per-specimen fare), the average cost per specimen was 8 times higher with the postal service. Shipment of specimens from districts to central level using the postal service was feasible and appeared to be faster than public transportation, thus allowing specimen quality to be preserved. Further analysis regarding the most efficient costing mechanism is needed.

Combining web-based and mail surveys improves response rates: a PBRN study from PRIME Net.

PURPOSE: The advent of Web-based survey tools has provided the investigator with an alternative to paper-based survey methods that in many instances may be less expensive to implement than traditional paper-based surveys. Newer technology, however, does not diminish the importance of obtaining an adequate response rate. METHODS: We analyzed response rate data obtained from a survey implemented across 3 practice-based research networks (PBRNs) in which the survey was first implemented electronically with 5 rounds of electronic solicitation for an Internet-based questionnaire and then by 2 rounds of a paper-based version mailed only to nonresponders. RESULTS: Overall, 24% of the total survey responses received were in the paper mode despite intense promotion of the survey in the electronic phase. CONCLUSIONS: Our results suggest there is still an important role for the use of paper-based methods in PBRN survey research. Both hard copy and electronic survey collection methods may be required to enhance clinician response rates in PBRNs.

A comparison of web-based and paper-based survey methods: testing assumptions of survey mode and response cost.

Web-based surveys have become more prevalent in areas such as evaluation, research, and marketing research to name a few. The proliferation of these online surveys raises the question, how do response rates compare with traditional surveys and at what cost? This research explored response rates and costs for Web-based surveys, paper surveys, and mixed-mode surveys. The participants included evaluators from the American Evaluation Association (AEA). Results included that mixed-mode, while more expensive, had higher response rates.

A comparison of mail-service and retail community pharmacy claims in 5 prescription benefit plans.

BACKGROUND: Little evidence has been presented to date that would either support or refute a widely held belief that mail-service pharmacy utilization routinely produces savings in drug benefit costs for prescription benefit plan sponsors. OBJECTIVE: To present a comparative analysis of mail-service and community pharmacy service drug benefit costs for 5 employer-sponsored prescription drug benefit plans. METHODS: A cross-sectional comparison of 17,725 matched transaction pairs of community and mail-service prescriptions from a data set comprised 484,987 prescription claims from a convenience sample of 5 employer-sponsored prescription benefit plans. Differences between community pharmacy and mail-service prescription transactions were examined at the per-unit level of analysis for drug ingredient costs, dispensing fees, co-payments, dollar amounts paid by plan sponsor, and total dollar amounts. RESULTS: Overall, the total cost of prescriptions was lower through mail-service pharmacies for all 5 plans studied. Two of 5 plans had co-payment incentives to use mail-service, yet plan sponsors paid more for mail-service drugs; respectively, 4.5% and 8.3% more overall, 25.0% and 21.4% more for generic medications; and 3.0% and 7.0% more for brand name medications. Mail-service co-payments were 48.9% and 51.7% lower. Mail-service utilization rates were 15.2% and 31.5% of the total number of prescriptions dispensed in the period studied. Three of 5 plans had no co-payment incentive to use mail-service and paid less for mail-service drugs; respectively, 18.7%, 6.6%, and 15.7% less overall; 17.4%, 15.6%, and 7.9% less for generic medications; and 18.8%, 5.2%, and 16.6% less for brand name medications. Mail-service co-payments were 10.5% more, 5.2% less, and 1.8% more than community pharmacy co-payments, respectively. Mail-service utilization rates were 0.8%, 1.2%, and 4.4%. CONCLUSION: Co-payment incentives to use mail-service pharmacies instead of community pharmacies were associated with higher mail-service utilization rates and with higher costs to plan sponsors. Absence of a co-payment incentive to use mail-service pharmacies was associated with lower mail-service utilization rates and with lower costs to plan sponsors.

Do postage stamps versus pre-paid envelopes increase responses to patient mail surveys? A randomised controlled trial.

BACKGROUND: Studies largely from the market research field suggest that the inclusion of a stamped addressed envelope, rather than a pre-paid business reply, increases the response rate to mail surveys. The evidence that this is also the case regarding patient mail surveys is limited. METHODS: The aim of this study is to investigate whether stamped addressed envelopes increase response rates to patient mail surveys compared to pre-paid business reply envelopes and compare the relative costs. A sample of 477 initial non-responders to a mail survey of patients attending breast clinics in Greater Manchester between 1/10/2002 - 31/7/2003 were entered into the trial: 239 were randomly allocated to receive a stamped envelope and 238 to receive a pre-paid envelope in with their reminder surveys. Overall cost and per item returned were calculated. RESULTS: The response to the stamped envelope group was 31.8% (95% CI: 25.9% - 37.7%) compared to 26.9% (21.3% - 32.5%) for the pre-paid group. The difference (4.9% 95% CI: -3.3% - 13.1%) is not significant at alpha = 0.05 (chi2 = 1.39; 2 tailed test, d.f. = 1; P = 0.239). The stamped envelopes were cheaper in terms of cost per returned item (1.20 pounds) than the pre-paid envelopes (1.67 pounds). However if the set up cost for the licence to use the pre-paid service is excluded, the cost of the stamped envelopes is more expensive than pre-paid returns (1.20 pounds versus 0.73 pounds). CONCLUSION: Compared with pre-paid business replies, stamped envelopes did not produce a statistically significant increase in response rate to this patient survey. However, the response gain of the stamped strategy (4.9%) is similar to that demonstrated in a Cochrane review (5.3%) of strategies to increase response to general mail surveys. Further studies and meta analyses of patient responses to mail surveys via stamped versus pre-paid envelopes are needed with sufficient power to detect response gains of this magnitude in a patient population.

Remote biochemical verification of tobacco use: Reducing costs and improving methodological rigor with mailed oral cotinine swabs.

INTRODUCTION: Multi-site tobacco cessation trials could benefit from remote biochemical verification for tobacco use without invasive, time-consuming, or expensive collection processes. To the authors' knowledge, there have been no previous studies examining the predictive validity of oral fluid swabs for the detection of cotinine levels with samples collected off-site and mailed for on-site interpretation. METHODS: Tobacco users were recruited through an online survey and participants who met the initial eligibility criteria were invited to take part. Those who elected to enroll provided two positive iScreen Oral Fluid Device (OFD) cotinine test samples during an in-office visit. One sample was used as a control and stored in a temperature-regulated location, while the other was mailed from one of ten surrounding counties. Mailing method and time from collection to mailing were varied, and results were assessed against control samples. RESULTS: Twenty tobacco users enrolled in the study. Participants ranged in age from 18 to 31 (M = 16.45, SD = 1.54). Several types of tobacco use were reported, with electronic cigarettes the most commonly reported product. None of the mailed sample interpretations changed from pre- to post-mailing, with up to twenty-one days from sample collection to results confirmation. CONCLUSIONS: Results indicate that the use of mailed oral swabs may be an easy to use, reliable, and low-cost option for the detection of cotinine in tobacco users when in-person collection is not feasible. Test result interpretations were found to be unchanged after mailing, and after extended post-collection time gaps.

Economic Impact of Financial Incentives and Mailing Nicotine Patches to Help Medicaid Smokers Quit Smoking: A Cost-Benefit Analysis.

An RCT designed to increase Medicaid smokers' quitting success was conducted in California during 2012-2013. In the trial, alternative cessation treatment strategies were embedded in the state's ongoing quitline services. It found that modest financial incentives of up to $60 per participant and sending nicotine patches induced significantly higher cessation rates compared with usual care alone and usual care plus nicotine patches. Building upon that study, this study assessed potential population-level costs and benefits of integrating financial incentives and nicotine patches in a quitline setting for Medicaid smokers. A cost-benefit analysis was undertaken from the Medicaid program's perspective. The Cardiovascular Disease Policy Model was used to simulate future healthcare expenditures over a 10-year horizon for each treatment strategy for a study cohort of California Medicaid enrollees who were aged 35-64 years in 2014 (n=2,452,000). To simulate potential population-level benefits under each treatment strategy, each treatment was applied to all active smokers in the study cohort (n=478,300). Sensitivity analyses were conducted by varying key parameters, such as cessation costs, discount rate, relapse rates, and time horizon. Adding both financial incentives and nicotine patches to usual quitline care would result in $15 million net savings over 10 years, with a benefit-cost ratio of 1.30 compared with the usual care plus nicotine patches strategy. It would yield $44 million net savings, with a benefit-cost ratio of 1.90 compared with usual care alone. The strategy of providing financial incentives and mailing nicotine patches directly to Medicaid smokers who call the quitline is cost saving. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

A pedometer-based walking intervention in 45- to 75-year-olds, with and without practice nurse support: the PACE-UP three-arm cluster RCT.

BACKGROUND: Guidelines recommend walking to increase moderate to vigorous physical activity (MVPA) for health benefits. OBJECTIVES: To assess the effectiveness, cost-effectiveness and acceptability of a pedometer-based walking intervention in inactive adults, delivered postally or through dedicated practice nurse physical activity (PA) consultations. DESIGN: Parallel three-arm trial, cluster randomised by household. SETTING: Seven London-based general practices. PARTICIPANTS: A total of 11,015 people without PA contraindications, aged 45-75 years, randomly selected from practices, were invited. A total of 6399 people were non-responders, and 548 people self-reporting achieving PA guidelines were excluded. A total of 1023 people from 922 households were randomised to usual care (n = 338), postal intervention (n = 339) or nurse support (n = 346). The recruitment rate was 10% (1023/10,467). A total of 956 participants (93%) provided outcome data. INTERVENTIONS: Intervention groups received pedometers, 12-week walking programmes advising participants to gradually add '3000 steps in 30 minutes' most days weekly and PA diaries. The nurse group was offered three dedicated PA consultations. MAIN OUTCOME MEASURES: The primary and main secondary outcomes were changes from baseline to 12 months in average daily step counts and time in MVPA (in ≥ 10-minute bouts), respectively, from 7-day accelerometry. Individual resource-use data informed the within-trial economic evaluation and the Markov model for simulating long-term cost-effectiveness. Qualitative evaluations assessed nurse and participant views. A 3-year follow-up was conducted. RESULTS: Baseline average daily step count was 7479 [standard deviation (SD) 2671], average minutes per week in MVPA bouts was 94 minutes (SD 102 minutes) for those randomised. PA increased significantly at 12 months in both intervention groups compared with the control group, with no difference between interventions; additional steps per day were 642 steps [95% confidence interval (CI) 329 to 955 steps] for the postal group and 677 steps (95% CI 365 to 989 steps) for nurse support, and additional MVPA in bouts (minutes per week) was 33 minutes per week (95% CI 17 to 49 minutes per week) for the postal group and 35 minutes per week (95% CI 19 to 51 minutes per week) for nurse support. Intervention groups showed no increase in adverse events. Incremental cost per step was 19p and £3.61 per minute in a ≥ 10-minute MVPA bout for nurse support, whereas the postal group took more steps and cost less than the control group. The postal group had a 50% chance of being cost-effective at a £20,000 per quality-adjusted life-year (QALY) threshold within 1 year and had both lower costs [-£11M (95% CI -£12M to -£10M) per 100,000 population] and more QALYs [759 QALYs gained (95% CI 400 to 1247 QALYs)] than the nurse support and control groups in the long term. Participants and nurses found the interventions acceptable and enjoyable. Three-year follow-up data showed persistent intervention effects (nurse support plus postal vs. control) on steps per day [648 steps (95% CI 272 to 1024 steps)] and MVPA bouts [26 minutes per week (95% CI 8 to 44 minutes per week)]. LIMITATIONS: The 10% recruitment level, with lower levels in Asian and socioeconomically deprived participants, limits the generalisability of the findings. Assessors were unmasked to the group. CONCLUSIONS: A primary care pedometer-based walking intervention in 45- to 75-year-olds increased 12-month step counts by around one-tenth, and time in MVPA bouts by around one-third, with similar effects for the nurse support and postal groups, and persistent 3-year effects. The postal intervention provides cost-effective, long-term quality-of-life benefits. A primary care pedometer intervention delivered by post could help address the public health physical inactivity challenge. FUTURE WORK: Exploring different recruitment strategies to increase uptake. Integrating the Pedometer And Consultation Evaluation-UP (PACE-UP) trial with evolving PA monitoring technologies. TRIAL REGISTRATION: Current Controlled Trials ISRCTN98538934. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 37. See the NIHR Journals Library website for further project information.

Direct mailing was a successful recruitment strategy for a lung-cancer screening trial.

OBJECTIVE: To analyze advertising, recruitment methods, and study participant demographics for the National Lung Screening Trial (NLST) site at Wake Forest University School of Medicine to define efficient ways to recruit participants for general clinical trials. STUDY DESIGN AND SETTING: Recruitment method data, demographics, geographic location, and date of enrollment were collected from all 1,112 NLST participants. Marketing data and financial records were analyzed to determine the effectiveness of each recruitment method. RESULTS: The total amount spent on advertising was $144,668, with the cost of enrollment per participant averaging $130. For black participants, the recruitment cost per person was $406, whereas for white and other race participants, the cost was $122 (P<0.0001). To encourage minority enrollment, $13,192 was spent on television advertising geared toward black viewers, resulting in eight black participants at an average cost per person of $1,649. Direct mailing cost $143 per participant recruited, whereas TV ads cost $382 per participant. CONCLUSION: Direct mailing to a targeted group was the most efficient way to recruit participants. Printed advertising methods, that is, newspaper ads and brochures, were quite effective, whereas television ads were expensive. Appropriate minority recruitment needs sufficient attention and resources to ensure census groups are adequately represented.