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Cancer is an illness affecting patients' physical and psychosocial wellbeing: high numbers report problematic levels of distress at many points through diagnosis, treatment and survivorship. Conclusive evidence for the long-term benefits of psychological interventions is lacking and this may be because (a) they employ a too

OBJECTIVE -To evaluate the effectiveness of behavioral interventions for adolescents with type 1 diabetes based on a systematic review of the literature.RESEARCH DESIGN AND METHODS -The literature was identified by searching 11 electronic databases, hand-searching 3 journals from their start dates, and contacting individual researchers. Only articles that reported evaluations of behavioral (including educational and psychosocial) interventions for adolescents (age range 9-21 years) with type 1 diabetes that included a control group were included in the present review. Data summarizing the key features of the interventions and their effects were extracted from each article. Where possible, effect sizes for the randomized control trials (RCTs) were calculated.RESULTS -The search process identified 64 reports of empirical studies. Of these, 35 studies included a control group, and 24 were RCTs. Effect sizes could be calculated for 18 interventions. The overall mean effect size calculated across all outcomes was 0.33 (median 0.21), indicating that these interventions have a small-to medium-sized beneficial effect on diabetes management. Interventions that were theoretically based were significantly more effective than those that were not (P Ͻ 0.05, 1-tailed).CONCLUSIONS -Research to date indicates that these interventions are moderately effective. Several methodological weaknesses to be avoided in future studies are noted. It is also recommended that investigators use the reach, efficacy, adoption, implementation, and maintenance (RE-AIM) framework to guide the design of future studies, which should result in more disseminable interventions. RE-AIM assesses the intervention' s reach, or percent or representativeness of patients willing to participate; efficacy across a range of outcomes; adoption, or the percent and representativeness of settings willing to implement the intervention; implementation, or the consistency of the delivery of the intervention as intended; and maintenance, or the extent to which delivery of the intervention becomes a routine part of health care in the medical setting. Diabetes R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t sDIABETES CARE, VOLUME 23, NUMBER 9, SEPTEMBER 2000 1417Hampson and Associates (e.g., psychosocial, metabolic, self-management, and knowledge) was examined. Behavioral interventions aim primarily to change psychosocial and self-management outcomes, which are seen as intervening variables that contribute to metabolic outcomes (23,24). Therefore, we examined whether effects were larger for intervening (psychosocial, self-management, and knowledge) variables than for metabolic outcomes. We also used meta-analysis to test whether interventions based on theoretical principles were more effective than those that were not theoretically based (25).Finally, those interventions that yielded the largest effect sizes were evaluated in terms of the reach, efficacy, adoption, implementation, and maintenance (RE-AIM) framework (26). RE-AIM assesses the in...

Findings may reflect publication bias, but suggest interventions can affect patients' lives for the better in a variety of ways. It is difficult to interpret the clinical importance of statistically significant improvements reported in most studies. There is a need for methodologically more robust research with meaningful follow-up periods, designed in a manner that separates specific and nonspecific effects. Cost-effectiveness evidence is required to provide clear guidance on service extensions.

Further well-designed large trials with longer follow-up periods are needed to be able to draw firm conclusions about the efficacy and effectiveness of massage for cancer patients.