Integrating diabetes self-management with the health goals of older adults: A qualitative exploration

Objective. This study investigates the life and health goals of older adults with diabetes, and explores the factors that influence their diabetes self-management. Methods: Qualitative in-depth interviews were conducted with 24 older adults with diabetes and other morbid conditions and/or their caregivers, when appropriate. ^ Results. Participants’ provided a consistent set of responses when describing life and health goals. Participants described goals for longevity, better physical functioning, spending time with family, or maintaining independence. Diabetes discordant conditions, but not diabetes, were seen as barriers to life goals for participants with functional impairments. Functionally independent participants described additional health goals that related to diabetes self-management as diabetes was seen often a barrier to life goals. Caregivers, co-morbid conditions, denial and retirement were among the factors that influenced initiation of diabetes self-management. ^ Conclusion. Participants endorsed health goals and diabetes self-management practices that they believed would help them accomplish their life goals. Functional capabilities and social support were key factors in the relationship between diabetes self-management and their broader goals. ^ Practice implications. When planning diabetes treatments, clinicians, patients and caregivers should discuss the relationship between diabetes self-management and health and life goals as well as the affects of functional limitations and caregiver support.^

Border intervention by Promotores for type 2 diabetes

Purpose of the study. This study had two components. The first component of the study was the development and implementation of an infrastructure that integrated Promotores who teach diabetes self-management into a community clinic. The second component was a six-month randomized clinical trial (RCT) designed to test the effectiveness of the Promotores in changing knowledge, beliefs, and HbA1c levels among Mexican American patients with type 2 diabetes. ^ Methods. Starfield's adaptation of the Donbedian structure, process, and outcome methodology was used to develop a clinic infrastructure that allowed the integration of Promotores as diabetes educators. The RCT of the culturally sensitive Promotores-led 10-week diabetes self-management program compared the outcomes of 63 patients in the intervention group with 68 patients in a wait-list, usual care control group. Participants were Mexican Americans, at least 18 years of age, with type 2 diabetes, who were patients at a Federally Qualified Health Center on the Texas-Mexico border. At baseline, three months, and six months, data were collected using the Diabetes Knowledge Questionnaire (DKQ, the Health Beliefs Questionnaire (HBQ, and HbA1c levels were drawn by the clinic laboratory. A mixed model methodology was used to analyze the data. ^ Results. The infrastructure to support a Promotores-led diabetes self-management course designed in concert with administration, the physicians, and the CDE, resulted in (1) employment of Promotores to teach diabetes self-management courses; (2) integration of provider and nurse oversight of course design and implementation; (3) management of Promotora training, and the development of teaching competencies and skills; (4) coordination of care through communication and documentation policies and procedures; (5) utilization of quality control mechanisms to maintain patient safety; and (6) promotion of a culturally competent approach to the educational process. The RCT resulted in a significant improvement in the intervention group's DKQ scores over time (F [1, 129] = 4.77, p = 0.0308), and in treatment by time (F [2, 168] = 5.85, p = 0.0035). Neither the HBQ scores nor the HbA1c changed over time. However, the baseline HbA1c was 7.49, almost at the therapeutic level. The DKQ, HBQ, and HbA1c results were significantly affected by age; the DKQ and HbA1c by years with diabetes. ^ Conclusions. The clinic model provides a systematic approach to safely address the educational needs of large numbers of patients with type 2 diabetes who live in communities that suffer from a lack of health care professionals. The Promotores-led diabetes self-management course improved the knowledge of patients with diabetes and may be a culturally sensitive strategy for meeting patient educational needs. The low baseline HbA1c levels in this border community suggested that patients in this Federally Qualified Health Center on the Texas-Mexico border were experiencing good medical management of their diabetes. ^

Health outcomes, quality improvement and cost-effectiveness of the Community Diabetes Education (CoDE) program: Results of a randomized controlled trial

The objectives of this dissertation were to evaluate health outcomes, quality improvement measures, and the long-term cost-effectiveness and impact on diabetes-related microvascular and macrovascular complications of a community health worker-led culturally tailored diabetes education and management intervention provided to uninsured Mexican Americans in an urban faith-based clinic. A prospective, randomized controlled repeated measures design was employed to compare the intervention effects between: (1) an intervention group (n=90) that participated in the Community Diabetes Education (CoDE) program along with usual medical care; and (2) a wait-listed comparison group (n=90) that received only usual medical care. Changes in hemoglobin A1c (HbA1c) and secondary outcomes (lipid status, blood pressure and body mass index) were assessed using linear mixed-models and an intention-to-treat approach. The CoDE group experienced greater reduction in HbA1c (-1.6%, p<.001) than the control group (-.9%, p<.001) over the 12 month study period. After adjusting for group-by-time interaction, antidiabetic medication use at baseline, changes made to the antidiabetic regime over the study period, duration of diabetes and baseline HbA1c, a statistically significant intervention effect on HbA1c (-.7%, p=.02) was observed for CoDE participants. Process and outcome quality measures were evaluated using multiple mixed-effects logistic regression models. Assessment of quality indicators revealed that the CoDE intervention group was significantly more likely to have received a dilated retinal examination than the control group, and 53% achieved a HbA1c below 7% compared with 38% of control group subjects. Long-term cost-effectiveness and impact on diabetes-related health outcomes were estimated through simulation modeling using the rigorously validated Archimedes Model. Over a 20 year time horizon, CoDE participants were forecasted to have less proliferative diabetic retinopathy, fewer foot ulcers, and reduced numbers of foot amputations than control group subjects who received usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life-year gained was estimated for CoDE intervention participants over the same time period. The results from the three areas of program evaluation: impact on short-term health outcomes, quantification of improvement in quality of diabetes care, and projection of long-term cost-effectiveness and impact on diabetes-related health outcomes provide evidence that a community health worker can be a valuable resource to reduce diabetes disparities for uninsured Mexican Americans. This evidence supports formal integration of community health workers as members of the diabetes care team.^

A systematic review and meta-analysis of diabetes disease management programs

Context. Despite the rapid growth of disease management programs, there are still questions about their efficacy and effectiveness for improving patient outcomes and their ability to reduce costs associated with chronic disease. ^ Objective. To determine the effectiveness of disease management programs on improving the results of HbA1c tests, lipid profiles and systolic blood pressure (SBP) readings among diabetics. These three quantitative measures are widely accepted methods of determining the quality of a patient's diabetes management and the potential for future complications. ^ Data Sources. MEDLINE and CINAHL were searched from 1950 to June 2008 using MeSH terms designed to capture all relevant studies. Scopus pearling and hand searching were also done. Only English language articles were selected. ^ Study Selection. Titles and abstracts for the 2347 articles were screened against predetermined inclusion and exclusion criteria, yielding 217 articles for full screening. After full article screening, 29 studies were selected for inclusion in the review. ^ Data Extraction. From the selected studies, data extraction included sample size, mean change over baseline, and standard deviation for each control and experimental arm. ^ Results. The pooled results show a mean HbA1c reduction of 0.64%, 95% CI (-0.83 to -0.44), mean SBP reduction of 7.39 mmHg (95% CI to -11.58 to -3.2), mean total cholesterol reduction of 5.74 mg/dL (95% CI, -10.01 to -1.43), and mean LDL cholesterol reduction of 3.74 mg/dL (95% CI, -8.34 to 0.87). Results for HbA1c, SBP and total cholesterol were statistically significant, while the results for LDL cholesterol were not. ^ Conclusions. The findings suggest that disease management programs utilizing five hallmarks of care can be effective at improving intermediate outcomes among diabetics. However, given the significant heterogeneity present, there may be fundamental differences with respect to study-specific interventions and populations that render them inappropriate for meta-analysis. ^

A comparison of healthcare access, healthcare utilization and asthma self-management for Hispanic children in border and non-border regions of Texas

The purpose of this culminating experience was to investigate the relationships between healthcare utilization, insurance coverage, and socioeconomic characteristics of children with asthma along the Texas-Mexico Border. A secondary data analysis was conducted on cross-sectional data from the Texas Child Asthma Call-back Survey, a follow-up survey to the random digit dialed Behavior Risk Factor Surveillance Study (BRFSS) conducted between 2006-2009 ( n = 556 adults living in households with a child with asthma).^ The proportion of Hispanic children with asthma in Border areas of Texas was more than twice that of non-Border areas (84.8% vs. 28.8%). Parents in Border areas were less likely to have their own health insurance (OR = 0.251, 95% C.I. = 0.117-0.540) and less likely to complete the survey in English than Spanish (OR = 0.251 95% C.I. = 0.117-0.540) than parents in non-Border areas. No significant socio-economic or health care utilization differences were noted between Hispanic children living in Border areas compared to Hispanic children living in non-Border areas. Children with asthma along the Texas-Mexico Border, regardless of ethnicity and language, have insurance coverage rates, reported cost barriers to care, symptom management, and medication usage patterns similar to those in non-Border areas. When compared to English-speakers, Spanish-speaking parents in Texas as a whole are far less likely to be taught what to do during an asthma attack (50.2% vs. 78.6%).^ Language preference, rather than ethnicity or geographical residence, played a larger role on childhood asthma-related health disparities for children in Texas. Spanish-speaking parents in are less likely to receive adequate asthma self-management education. Investigating the effects of Hispanic acculturation rates and incongruent parent-child health insurance coverage may provide better insight into the health disparities of children along the Texas-Mexico Border.^

Descriptive analysis of Ben Taub Pediatric Weight Management Program

The purpose of this study is to descriptively analyze the current program at Ben Taub Pediatric Weight Management Program in Houston, Texas, a program designed to help overweight children ages three to eighteen to lose weight. In Texas, approximately one in every three children is overweight or obese. Obesity is seen at an even greater level within Ben Taub due to the hospital's high rate of service for underserved minority populations (Dehghan et al, 2005; Tyler and Horner, 2008; Hunt, 2009). The weight management program consists of nutritional, behavioral, physical activity, and medical counseling. Analysis will focus on changes in weight, BMI, cholesterol levels, and blood pressure from 2007–2010 for all participants who attended at least two weight management sessions. Recommendations will be given in response to the results of the data analysis.^

Relationships among epilepsy self-management, health outcomes, and socioeconomic status

The purpose of this study was to investigate the association between epilepsy self-management and disease control and socio-economic status. Study participants were adult patients at two epilepsy specialty clinics in Houston, Texas that serve demographically and socioeconomically diverse populations. Self-management behaviors- medication, information, safety, seizure, and lifestyle management were tested against emergency room visits, hospitalizations, and seizure occurrence. Overall self-management score was associated with a greater likelihood of hospitalizations over a prior twelve month time frame, but not for three months, and was not associated with seizure occurrence or emergency room visits, at all. Scores on specific self-management behaviors varied in their relationships to the different disease control indicators, over time. Contrary to expectations based on the findings of previous research, higher information management scores were associated with greater likelihood of emergency room visits and hospitalizations, over the study's twelve months. Higher lifestyle management scores were associated with lower likelihood of any emergency room visits, over the preceding twelve months and emergency room visits for the last three months. The positive associations between overall self-management scores and information management behaviors and disease control are contrary to published research. These findings may indicate that those with worse disease control in a prior period employ stronger self-management efforts to better control their epilepsy. Further research is needed to investigate this hypothesis.^

Self -management behavior in patients with cystic fibrosis

Self-management is being promoted in cystic fibrosis (CF). However, it has not been well studied. Principal aims of this research were (1) to evaluate psychometric properties of a CF disease status measure, the NIH Clinical Score; (2) to develop and validate a measure of self-management behavior, the SMQ-CF scale, and (3) to examine the relation between self-management and disease status in CF patients over two years.^ In study 1, NIH Clinical Scores for 200 patients were used. The scale was examined for internal consistency, interrater reliability, and content validity using factor analysis. The Cronbach's alpha (.81) and interrater reliability (.90) for the total scale were high. General scale items were less reliable. Factor analysis indicated that most of the variance in disease status is accounted for by Factor 1 which consists of pulmonary disease items.^ The SMQ-CF measures the performance of CF self-management. Pilot testing was done with 98 CF primary caregivers. Internal consistency reliability, social desirability bias, and content validity using factor analysis were examined. Internal consistency was good (alpha =.95). Social desirability correlation was low (r =.095). Twelve factors identified were consistent with conceptual groupings of behaviors. Around two hundred caregivers from two CF centers were surveyed and multivariate analysis of variance was used to assess construct validity. Results confirmed expected relations between self-management, patient age, and disease status. Patient age accounted for 50% and disease status 18% of the variance in the SMQ-CF scale.^ It was hypothesized that self-management would positively affect future disease status. Data from 199 CF patients (control and education intervention groups) were examined. Models of hypothesized relations were tested using LISREL structural equation modeling. Results indicated that the relations between baseline self-management and Time 1 disease status were not significant. Significant relations were observed in self-management behaviors from time 1 to time 2 and patterns of significant relations differed between the two groups.^ This research has contributed to refinements in the ability to measure self-management behavior and disease status outcomes in cystic fibrosis. In addition, it provides the first steps in exploratory behavioral analysis with regard to self-management in this disease. ^

The impact of a brief foot care intervention for persons with diabetes

Purpose of the study. The purpose of this randomized controlled clinical trial was to determine if a brief intervention would improve foot self-care behaviors in adult patients with Type 2 diabetes who presented to the emergency department for non-emergent care in a predominantly Hispanic southwestern border community. ^ Methods. A pre-post-test, three-group design was used to compare the foot self-care behaviors of patients who received usual care to those who received lower extremity amputation (LEA) risk assessment and to those who received LEA risk assessment plus a brief foot self-care intervention. After being randomized into 3 groups (N = 167), baseline assessments of demographics, diabetes history, acculturation, and the Summary of Diabetes Self Care Activities (SDSCA) questionnaire and Modified Insulin Management Diabetes Self Efficacy Scale (MIMDSES) were completed in English or Spanish. At one-month, 144 (84%) participants were available for follow-up by the research assistant masked to group assignment. ^ Results. At baseline, significant differences in foot self-care behaviors and self monitoring blood glucose were noted based on ethnicity and gender. Men had significantly lower confidence in their ability to manage their diabetes overall. There was a significant difference between baseline and follow up self reported foot self-care behaviors within the intervention group (t (47) = −4.32, p < .01) and the control group (t (46) = −2.06, p < .05). There were no significant differences between groups for self-reported foot self-care behaviors. There was a significant difference in observed foot self-care behaviors between groups (F(2,135) = 2.99, p < .05). Self-efficacy scores were positively correlated with self-reported self-care behaviors. ^ Conclusions. This predominantly Hispanic population with type 2 diabetes reported performing diabetes self-care behaviors less than five days a week. There were within group changes, but no significant between group changes in reported self-care behaviors. However, at the one month follow up, there were significant differences between groups in observed foot self-care behaviors with the intervention group demonstrating the most accurate behaviors. Differences based on gender and ethnicity emphasize the need to individualize diabetes education. Priorities for culturally competent diabetes education, approaches to increasing self-efficacy and future research directions are suggested. ^

The effectiveness of a promotora-led intervention for Mexican Americans with type 2 diabetes

Purpose. The purpose of this randomized control repeated measures trial was to determine the effectiveness of a self-management intervention led by community lay workers called promotoras on the health outcomes of Mexican Americans with type 2 diabetes living in a major city on the Texas - Mexico border. The specific aims of this study, in relation to the intervention group participants, were to: (1) decrease the glycosylated hemoglobin (A1c) blood levels at the six-month assessment, (2) increase diabetes knowledge at the three and six-month assessments, and (3) strengthen the participants' beliefs in their ability to manage diabetes at the three and six-month assessments.^ Methods. One hundred and fifty Mexican American participants were recruited at a Catholic faith-based clinic and randomized into an intervention group and a usual-care control group. Personal characteristics, acculturation and baseline A1c, diabetes knowledge and diabetes health beliefs were measured. The six-month, two-phase intervention was culturally specific and it was delivered entirely by promotoras. Phase One of the intervention consisted of sixteen hours of participative group education and bi-weekly telephone contact follow-up. Phase Two consisted of bi-weekly follow-up using inspirational faith-based health behavior change postcards. The A1c levels, diabetes knowledge and diabetes health beliefs were measured at baseline, and three and six months post-baseline. The mean changes between the groups were analyzed using analysis of covariance. ^ Results. The 80% female sample, with a mean age of 58 years, demonstrated very low: acculturation, income, education, health insurance coverage, and strong Catholicism. No significant changes were noted at the three-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 six months, adjusting for health insurance coverage. The diabetes health belief scores decreased in both groups.^ Conclusions. This study demonstrated that an intervention led by promotoras could result in decreased A1c levels and increased diabetes knowledge in spite of the very low acculturation, educational level and insurance coverage of the intervention group participants. Clinical implications and recommendations for future research are suggested. ^

Physician's adherence to the standard protocol for diabetes treatment in Brooke Army Medical Center (BAMC)

The level of compliance with clinical practice guidelines for patients with Type II Diabetes Mellitus was evaluated in 157 patients treated at BAMC from 1 January 2006 to 1 January 2007. This retrospective analysis was conducted reviewing data from medical records and following the VA/DOD protocols that health care providers are expected to follow at this facility. Data collected included patient’s age and gender, presence or absence of complications of diabetes, physical examination findings, glycemic and lipid control, eye care, foot care, kidney function, and self-management and education. Subjects were selected performing systematic random sampling, and included both male and female patients, from a variety of ages and ethnic groups. The Diabetes complications screened for included glycemic and lipid complications, retinopathy, cardiovascular complications, peripheral circulation complications, and nephropathy. The results revealed that 19.10% had no complications and that the most common complications were: cardiovascular (49.68%), glycemic and lipid control (10.82%), retinopathy and peripheral circulation (8.28% each), and nephropathy (2.54%). Only 2.54% of the records reviewed did not include information on complications. Strictly following the Department of Defense guidelines, six treatment modules were evaluated independently and together to get a final percentage of adherence to the clinical practice guidelines. It was established that the level of adherence was going to be graded as follows: Extremely deficient: 0-15%; very poor: 16-30%; Poor and in need of improvement: 31-45%. Acceptable: 46-60%; Good: 61-80%, and Excellent: 81-100%. The results indicated that the percentage of physicians' adherence to each protocol was as follows: 88.31%, 89.93%, 90.63%, 89.42%, 89.42% and 89.64%. When the results were pooled, the level of adherence to the clinical practice guidelines was 89.55%, proving my hypothesis that Brooke Army Medical Center physicians have excellent adherence to the standard protocols for Diabetes Type II to treat their patients. ^

Roadmap for implementing the Chronic Care Model for weight management: Healthcare Institution's Response to Obesity (HIRO)

Background. Excess weight and obesity are at epidemic proportions in the United States and place individuals at increased risk for a variety of chronic conditions. Rates of diabetes, high blood pressure, coronary artery disease, stroke, cancer, and arthritis are all influenced by the presence of obesity. Small reductions in excess weight can produce significant positive clinical outcomes. Healthcare organizations have a vital role to play in the identification and management of obesity. Currently, healthcare providers do not adequately diagnose and manage excess weight in patients. Lack of skill, time, and knowledge are commonly cited as reasons for non-adherence to recommended standards of care. The Chronic Care Model offers an approach to healthcare organizations for chronic disease management. The model consists of six elements that work together to empower both providers and patients to have more productive interactions: the community, the health system itself, self-management support, delivery system design, decision support, and clinical information systems. The model and its elements may offer a framework through which healthcare organizations can adapt to support, educate, and empower providers and patients in the management of excess weight and obesity. Successful management of excess weight will reduce morbidity and mortality of many chronic conditions. Purpose. The purpose of this review is to synthesize existing research on the effectiveness of the Chronic Care Model and its elements as they relate to weight management and behaviors associated with maintaining a healthy weight. Methods: A narrative review of the literature between November 1998 and November 2008 was conducted. The review focused on clinical trials, systematic reviews, and reports related to the chronic care model or its elements and weight management, physical activity, nutrition, or diabetes. Fifty-nine articles are included in the review. Results. This review highlights the use of the Chronic Care Model and its elements that can result in improved quality of care and clinical outcomes related to weight management, physical activity, nutrition, and diabetes. Conclusions. Healthcare organizations can use the Chronic Care Model framework to implement changes within their systems to successfully address overweight and obesity in their patient populations. Specific recommendations for operationalizing the Chronic Care Model elements for weight management are presented.^

Effective interventions for lowering HbA1C in African Americans with type 2 diabetes: A review

This synthesis of the literature provides descriptive analysis and outlines current self-management interventions for African Americans with type 2 diabetes. Specifically, this study describes and explores the design of those studies whose interventions have been shown to lower HbA1C levels in this population by at least 0.5% points, an improvement that provides approximately 10% reduction in long term complications from this disease.^ Results. In total, 37 articles were reviewed and 17 articles met inclusion criteria for analysis. Analysis of each study's methodology and results was performed and selected studies with interventions that resulted in improvements in HbA1C outcomes equal to 0.5% or greater for both group 1 and 2 were summarized by intervention type in table format. Descriptive analysis, outlining the number and characteristics of proximal and distal mediating components addressed in Group 1 studies, was performed in order to determine whether mediating components may have had some relation to effectiveness of intervention on outcome HbA1C. Descriptive analysis revealed that no particular design is substantially more effective than another among Behavioral studies although, there may be an advantage in using culturally sensitive, group interventions that address greater numbers of distal mediating components. Among Process studies, structured approaches (i.e. algorithm care and scheduled follow up), as well as utilization of specialty and group care are represented as effective for African American populations. ^ Conclusions. It may be summarized that by targeting behavior and addressing provider delivery (i.e. algorithm use, group care, home care, and provider follow up) in this population, a greater yield in outcome improvements may be accomplished. However, many gaps exist in a review process that stratifies results and focuses on identifying group specific intervention successes and failures. Further research in different populations will aid researchers and practitioners in discovering the best evidence, and identifying models that could be utilized in practice to achieve the best diabetes management for at risk groups.^

Food intake in nonpurging obese women who binge eat before and after a behavioral weight loss program

Little is known about the impact of behavioral programs to decrease binge eating in obese persons who do not purge. This study was conducted to compare the amount of change in the reduction of binge days and selected nutrients in women who had joined a behavioral weight loss program. Forty-six women in the behavioral self management (BSM) group and thirty-six women in the Wait List Control (WLC) groups completed seven day food records at baseline and six months. These records were analyzed for calories, percentage of calories from protein, carbohydrate, fat and dietary fiber/ 1000 calories and were marked as "binge" or "nonbinge" days. Foods were also divided into 12 food groups but only six contributing to fat intake were chosen for analysis: dairy; fat; grains and starchy vegetables; meat, fish, and poultry; meat, fish, and poultry combinations; snacks and desserts. At six months, there was no difference in the amount of change in any of the selected nutrients between the BSM and WLC groups or in the amount of change within each food group except in the meat, fish, and poultry combination and in the snacks and desserts groups because both groups experienced similar changes at six months. Binge and nonbinge day nutrient analysis by BSM and WLC showed that at baseline and six months within the BSM group, calories increased significantly on binge days. Within the WLC group at six months, percentage of calories from protein was significantly decreased on binge days.^ The significant finding of this study was the reduction in the amount of change in the number of binge days at six months between the BSM and WLC groups ($-$2.2 versus $-$1.1 respectively). These data suggest that behavioral programs can successful reduce binge days, but that significant change in food intake may require more intensive treatment. ^

A process evaluation of the childhood lead poisoning prevention program in Houston, Texas, 1992--1995

A process evaluation of the Houston Childhood Lead Poisoning Prevention Program, 1992-1995, was conducted. The Program's goal is to reduce lead poisoning prevalence. The study proposed to determine to what extent the Program was implemented as planned by measuring how well Program services were actually: (1) received by the intended target population; (2) delivered to children with elevated blood lead levels; (3) delivered in compliance with the Centers for Disease Control and Prevention and Program guidelines and timetables; and (4) able to reduce lead poisoning prevalence among those rescreened. Utilizing a program monitoring design, the Program's pre-collected computer records were reviewed. The study sample consisted of 820 children whose blood lead levels were above 15 micrograms per deciLiter, representing approximately 2.9% of the 28,406 screened over this period. Three blood lead levels from each participant were examined: the initial elevated result; the confirmatory result; and the next rescreen result, after the elevated confirmatory level. Results showed that the Program screened approximately 18% (28,406 of 161,569) of Houston's children under age 6 years for lead poisoning. Based on Chi-square tests of significance, results also showed that lead-poisoned participants were more likely to be younger than 3 years, male and Hispanic, compared to those not lead poisoned. The age, gender and ethnic differences observed were statistically significant (p =.01, p =.00, p =.00). Four of the six Program services: medical evaluations, rescreening, environmental inspections and confirmation, had satisfactory delivery completion rates of 71%-98%. Delivery timetable compliance rates for three of the six services examined: outreach contacts, home visits and environmental inspections were below 32%. However, dangerously elevated blood lead levels fell and lead poisoning prevalence dropped from 3.3% at initial screening to 1.2% among those rescreened, after intervention. From a public health perspective, reductions in lead poisoning prevalence are very meaningful. Based on these findings, the following are recommendations for future research: (1) integrate Program database files by utilizing a computer database management program; (2) target services at Hispanic male children under age 3 years living in the highest risk neighborhoods; (3) increase resources to: improve tracking and documentation of service delivery and provide more non-medical case management and environmental services; and (4) share the evaluation methodology/findings with the Centers for Disease Control and Prevention administrators; the implications may be relevant to other program managers conducting such assessments. ^