title: Cost-effectiveness of health-related lifestyle advice delivered by peer or lay advisors: synthesis of evidence from a systematic review.
abstract: 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 synthesises evidence on the cost-effectiveness of HRLA interventions aimed 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.
  
  
  METHODS
  The best available evidence on the cost-effectiveness of HRLA interventions was obtained using systematic searches of 20 electronic databases and key journals, as well as searches of the grey literature and the internet. Interventions were classified according to the primary health behaviour targeted and intervention costs were estimated where necessary. Lifetime health gains were estimated (in quality-adjusted life years, where possible), based on evidence of effectiveness of HRLAs in combination with published estimates of the lifetime health gains resulting from lifestyle changes, and assumptions over relapse. Incremental cost-effectiveness ratios are reported.
  
  
  RESULTS
  Evidence of the cost-effectiveness of HRLAs was identified from 24 trials included in the systematic review. The interventions were grouped into eight areas. We found little evidence of effectiveness of HRLAs for promotion of exercise/improved diets. Where HRLAs were effective cost-effectiveness varied considerably: Incremental Cost effectiveness Ratios were estimated at £6,000 for smoking cessation; £14,000 for a telephone based type 2 diabetes management; and £250,000 or greater for promotion of mammography attendance and for HIV prevention amongst drug users. We lacked sufficient evidence to estimate ICERs for breastfeeding promotion and mental health promotion, or to assess the impact of HRLAs on health inequalities.
  
  
  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. Further development of HRLA interventions needs to target specific population health needs where potential exists for significant improvement, and include rigorous evaluation to ensure that HRLAs provide sufficient value for money.
authors.affiliation: Faculty of Health & Life Sciences/Fuse UKCRC Centre for Translational Research in Public Health, Room H012, Coach Lane Campus East, Northumbria University, Newcastle-upon-Tyne NE7 7XA, UK. sue.carr@northumbria.ac.uk.
authors.forename: Mark
authors.initials: M
authors.lastname: Pennington
authors.forename: Shelina
authors.initials: S
authors.lastname: Visram
authors.forename: Cam
authors.initials: C
authors.lastname: Donaldson
authors.forename: Martin
authors.initials: M
authors.lastname: White
authors.forename: Monique
authors.initials: M
authors.lastname: Lhussier
authors.forename: Katherine
authors.initials: K
authors.lastname: Deane
authors.forename: Natalie
authors.initials: N
authors.lastname: Forster
authors.forename: Susan M
authors.initials: SM
authors.lastname: Carr