Download - Is health promotion cost effective?

PREVENTIVE MEDICINE 10, 324-339 (1981)

Is Health Promotion Cost Effective?

PEGGY JEAN ROGERS,**’ ELIZABETH K. EATON,‘? AND

JOHN G. BRUHN*

*Department of Preventive Medicine and Community Health, and tMoody Medical Library, The University of Texas Medical Branch at Galveston, Galveston, Texas 77550

A literature review surveyed applications of cost analyses in evaluation of programs for the promotion of a healthy life-style. Some confusion was uncovered regarding the definitions of such concepts as health education, disease detection, and health protection. All may facilitate positive long-term behavior patterns, but are less effective when used in isolation. In the review, severa approaches were found using cost analysis in the short- and long-term evaluation of programs. Few evaluations included appropriate cost-analysis techniques or long-range follow-up of the effects of the program. Therefore, the overall cost effectiveness of services to promote health cannot yet be determined. The proposed model is intended as a guide for future evaluations. Such studies are essential to insure that the decision-making process regarding health service funding priorities is based on objective criteria, as well as social and political judgments.

INTRODUCTION

The need to reorder our personal, professional, and governmental priorities regarding health expenditures is no longer at issue. The debate now revolves around how and by whom this reordering will be carried out and what criteria will be used to justify the result. The Surgeon General’s Report, “Healthy People” (18), points out that 9% of the gross national product in 1979 was spent on health care, compared with only 6% in 1960. The annual expenditure on health increased more than 70% during this period, with 11 cents of every federal dollar now allocated for health care.

Both public and private sectors have responded with activities aimed at cost containment. The principal means have been to regulate benefits and to support nonduplicated services and innovative methods of funding health care. Federal and state governments have carried out programs to control the development and distribution of health manpower and new technology, and insurance companies and other businesses have joined in encouraging new, less costly methods of delivering services. With this proliferation of cost-containment programs, however, the next question has been, logically, which combination of methods will provide optimum health for the population at the least cost?

Background

Warner and Hutton (36) have analyzed the growth and composition of the literature regarding cost benefit and cost effectiveness in health cam. The first publications appeared in the mid- 1960s. During the 1970s the health-care commu-

’ To whom reprint requests should be addressed at: Office of Research in Medical Education, Room 114, Keiller Bldg., The University of Texas Medical Branch at Galveston, Galveston, Tex. 77550.

324

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HEALTH PROMOTION: COST EFFECTIVE? 325

nity was offered many explanations of these concepts and their potential uses and applications. Both cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA) require that the significant costs and the desired results of methods of addressing a health problem be identified, measured, and compared. They differ, however; CBA measures both cost and success in monetary terms, and CEA may measure days of illness prevented or years of life, without monetary value attached. In CBA, a ratio between cost and monetary benefit is constructed, which can be compared among programs, regardless of the desired results of a specific program. Programs to be compared by CEA must use the same criteria for success (other than money) in order to determine whether one is more effective than another for the same monetary outlay.

The preponderance of health-care expenditures have been devoted to treating illness and rehabilitating the disabled rather than preventing morbidity and pro- moting health. Only 4% of the current Federal health dollar is allocated for prevention-oriented activities (18). A successful disease prevention policy would be most effective during the productive years of life and, due to increased longev- ity, would require a major restructuring of retirement and social security systems (14). During the past two decades, a better understanding of the risk factors and complex causes of chronic diseases has been achieved, with the result that increased attention has been given to changes needed in life-style and personal habits that affect health. Unhealthy behavior or life-style was estimated to be responsible for approximately half of the mortality in the United States in 1976, with inadequate health care accounting for only 10%. Yet, health dollars are allocated in reverse proportion to their potential effectiveness in maintaining health, which is the presumed objective. Increasing the 4% share of health expenditures for prevention of diseases due to life-style may be expected to eliminate a larger proportion of related mortality than the more expensive treatment and rehabilitation measures which now account for the bulk of health costs.

Objective

The purpose of this paper is to review the empirical efforts made to determine the cost effectiveness of health promotion, as distinct from disease prevention, environmental protection, and health information. More specifically, a literature review was carried out to determine the cost effectiveness of the measures developed to aid and motivate people to avoid harmful actions and to form habits that will benefit them.

PROCEDURE

The scope of the current review covers the literature published fi-om 1969 through 1979 in English-language journals. Articles dealing with cost analyses of health-care services, technology, and delivery, with disease detection, and with environmental hazard and accident protection, were excluded. For practical rea- sons, unpubhshed papers, workshop proceedings, and government pubiications were also excluded. Although the search was primarily for empirical studies, several conceptual models and projected applications of certain cost-analysis

326 ROGERS, EATON, AND BRUHN

methods were included as examples. A few representative articles dealing with disease detection and delivery of services were also reviewed.

Computer-based indices were the primary source of citations, along with references from those citations, numerous unpublished documents, and personal con- tacts with researchers in the field. A few new relevant journals which do not yet appear in the computer indices were searched individually. Five major computer-based searches were undertaken: MEDLINE, to search Index Medicus for 1978- 1979 under the subject heading of “Economics of Health Education,” etc.; BACKFILES, to search Index Medicus for 1969- 1977 under “Cost Analysis of Health Promotion,” etc. ; Excerpta Medica, which covers a set of journals that partially overlaps the set in Index Medicus, was searched under “Health Eco- nomics and Management”; Clearinghouse on Health Indexes was searched under “Health PromotionlSociomedical Aspects”; and Journal of Economic Literature was searched for 1974- 1979.

Since the focus of the review was to assess efforts to motivate or change behavior, each article was evaluated with respect to the health-related behavior involved, the motivational technique used, and the approach of the investigator. The articles were also classified by type of study, sample description, setting, time span, criteria of effectiveness, and measurement techniques. In addition, the level and complexity of the evaluation design were assessed, according to the framework presented by Green (15). Claims of cost effectiveness for any program are only as strong as the evidence assembled to support them, and valid evidence can come only from systematic attempts to evaluate the programs and to make comparisons among them. Such attempts may focus on various phases of a program, and their study design may range from simple to complex.

Green defined three levels of evaluation: process, impact, and outcome. The emphasis inprocess is on professional practice, such as peer review and audit; the criteria used in measurement are often the numbers of educational booklets dis- tributed and so forth. Impact evaluation emphasizes the immediate impact of health promotion, the impact of methods of practice on knowledge, attitudes, beliefs, and behavior, and the impact on environmental change. Impact studies are the type of health promotion studies that are needed most. Evaluation of outcome is focused on long-term mortality and morbidity after detection and treatment. Outcome studies are useful in conducting both cost-benefit and cost-effectiveness analyses, but it is premature to expect evaluation of outcome for health-promotion programs because of the time needed for complete results. Therefore, measures of impact that are currently available may be used to assess the cost effectiveness of promotion programs, as suggested by Green (15). Green provides a classification of study designs as follows:

A. The historical, record-keeping approach: a simplistic approach yielding graphs and records that demonstrate what is occurring in the community.

B. The stop-everything-inventory approach: collecting data at two or more points through special surveys.

C. The comparative, how-we-stack-up-against-others approach: by borrowing or copying record forms from other similar studies, we can compare studies or can compare data with various national data available.


D. The controlled comparison, or quasiexperimental approach: the Stanford University three-community study in California is an example.

E. The controlled experimental approach: comparable to the clinical trial in medical studies.

F. The full-blown, evaluative research project. These definitions are used to classify the research methods summarized in

Table 1. The first three approaches are relatively simple techniques, which may be useful for initial exploratory studies. Truly reliable evaluations of cost effectiveness, however, must be based on the more rigorous approaches of controlled comparison and experimentation.

FINDINGS

The major elements of the 11 studies found in the current review are shown in Table 1. Green’s (15) definitions of evaluation and study design were used. All but one were analyses of cost effectiveness (CEA). Foote and Erfurt’s (12) CBA study is included for its useful model for screening evaluation. The research hypotheses or program objectives are unique to each paper, but among them cover the defined health risks such as nutrition, hypertension, smoking, obesity, and screening for multiple risks. The objective of program evaluation is flexible and can include diverse groups, from workers in a particular work site to self-selected members of local health clinics or, in one case, Mothercraft centers in Haiti. This flexibility is an advantage and an illustration of the adaptability of the CEA technique. Seven of the eleven studies were focused on impact evaluation, which is the type of evaluation needed most at present in health promotion, according to Green.

The criteria of success varied among several categories: the pre- and post-test results were measured against such standards as the Boston Standard for malnutrition, normal blood pressure levels, adult normal weight, and national incidence and survival for cancer, and pre- and post-test measurements were used to study absolute changes in weight, blood pressure, and cigarette consumption during a program. In the studies that evaluated outcome, the criteria used to measure success were morbidity and mortality rates and reduction in fringe benefits that were paid to employees. In the studies of impact, no consistent criteria were used for measurement, even in those with similar objectives. In the studies of malnutrition in preschool children, for example, weight gain to normal was used as the criterion in one study (2), and comparison of children’s weight with the Boston Standard for malnutrition in another (22). The latter study also measured the nutritional condition of the siblings, whereas the former compared patients’ time and costs in the hospital vs those at home. No standard criteria were formulated for these nutrition studies, so the relative costs for their levels of effectiveness cannot be assessed. The use of techniques of health promotion, however, were more consistent among these 11 studies. Seven used both education and behavior modification techniques. Others used screening for early identification of disease or a combination of treatment and screening with education.

The study designs were the element emphasized least in the papers reviewed. One impact study (2) and one outcome evaluation (28) used Green’s Design A, a simple design to demonstrate what is occurring in the program or community,

TABL

E 1

SUM

MAR

Y OF

FI

NDIN

GS:

EVAL

UATI

ON

MET

HODS

AN

D DE

SIGN

IN

ST

UDIE

S OF

HE

ALTH

PR

OMOT

ION

COST

AN

ALYS

ES

Auth

or(s

) O

bjec

tive

and

heal

th

risk

Dur

atio

n Se

tting

Ag

e gr

oup

Met

hodo

logy

Bai (1

972)

Ed

ucat

ion

to c

hang

e nu

rritio

nal

know

ledg

e an

d be

havi

or;

man

agem

ent

of m

alnu

tritio

n

1 ye

ar

Indi

a,

hom

e,

Pres

choo

l D

ieta

ry

and

belie

f su

rvey

: ru

ral

heal

th

and

treat

men

t an

d ed

ucat

ion

in

cent

er

mot

hers

ho

me

to s

uit

cultu

ral

patte

rn

Berg

et

(197

9)

Cer

vica

l sc

reen

ing

to

redu

ce

mor

bidi

ty/m

orta

lity

of in

vasi

ve c

ance

r of

th

e ut

erin

e ce

rvix

vi

a ea

rly

diag

nosis

8 ye

ars

Den

mar

k,

citie

s W

omen

, C

ytol

ogic

m

ass

30-4

9 sc

reen

ing

with

:

smea

r m

etho

d

Dah

ms

et a

l. (1

978)

Foot

e &

Erfu

rt (1

977)

Com

paris

on

of tw

o m

etho

ds

of tr

eatin

g ob

esity

14 w

eeks

C

alifo

rnia

, ho

spita

l cl

inic

Hyp

erte

nsio

n sc

reen

ing

to d

etec

t ca

ses

early

and

re

fer

for

treat

men

t

2 ye

ars

Det

roit,

in

dust

rial

and

com

mun

ity

site

s

Adul

ts,

youn

g Kn

owled

ge

test

of

nutri

tion;

pe

rson

ality

in

vent

ory;

pr

e-

and

post

-wei

ght;

beha

vior

mod

ifica

tion

vs d

rug

Adul

ts

Estim

ate

cost

of

scre

enin

g vs

frin

ge

bene

fits

paid

to

em

ploy

ee

vict

ims

of

card

iova

scul

ar

dise

ase

Grov

e et

al.

(197

9)

Dem

onst

rate

he

alth

pr

omot

ion

in a

cor

pora

te

setti

ng

with

m

ultip

le

heal

th

beha

viors

HD

FP

Coo

pera

tive

grou

p (1

979)

Hype

rtens

ion

scre

enin

g an

d fo

llow

-up

to d

etec

t hi

gh

perc

enta

ge

of c

ases

and

m

aint

ain

long

-term

co

ntro

l

King

et

al.

(197

8)

Man

age

mal

nutri

tion

and

eval

uate

ed

ucat

ion

cent

er

for

child

ca

re a

nd

nutri

tion

as to

the

rape

utic

impa

ct

and

long

-rang

e re

sults

Mac

coby

an

d Fa

rquh

ar

(197

5)

Educ

atio

n an

d re

info

rcem

ent

of b

ehav

iora

l ch

ange

to

(in

pro

gres

s)

redu

ce

mul

tiple

ca

rdio

vasc

ular

ris

ks,

incr

ease

sk

ill le

arni

ng

and

redu

ce

mor

talit

y

Mos

kowi

tz

Brea

st ca

ncer

sc

reen

ing

and

Fox

to i

ncre

ase

surv

ival

ra

tes

(197

5)

via

early

dia

gnos

is

Rod

nick

an

d Bu

bb

(197

8)

Mul

tipha

sic

scre

enin

g to

red

uce

1 ye

ar

redu

ce

mul

tiple

ris

ks

via

educ

atio

n an

d be

havio

ral

chan

ge

Styc

os a

nd

Mun

digo

(197

4)

Com

paris

on

of m

esse

nger

vs

2

mon

ths

pers

onal

vi

sit

of m

otiv

ator

to

ef

fect

fam

ily

plan

ning

ac

tion

6 m

onth

s

S-ye

ar

follo

w-u

p

3-4

mon

ths

treat

men

t; l-2

ye

ar

follo

w-u

p

1 ye

ar

4 ye

ars,

4

mon

ths

Indi

anap

olis,

w

orks

ite

Baltim

ore,

co

mm

unity

ho

useh

olds

Hai

ti,

mot

herc

raft

cent

er

Cal

iforn

ia

sem

irura

l co

mm

unitie

s

Cin

cinn

ati,

hosp

ital

clin

ic

Cal

iforn

ia

heal

th

clin

ic

Dom

inica

n R

epub

lic

com

mun

ity

clin

ic

Adul

ts,

youn

g

Adul

ts,

30-6

9

Pres

choo

l an

d m

othe

rs

Adul

ts,

35-3

9

Wom

en

40-7

0

Adul

ts,

30-7

4

Wom

en,

child

-

Gro

up

beha

vior

mod

ifica

tion;

pr

e- a

nd p

ost-w

eigh

t, bl

ood

pres

sure

, an

d sm

okin

g;

prog

ram

co

sts

Syst

emat

ic

follo

w-u

p vs

re

ferra

l to

M.D

. fo

r hy

perte

nsio

n tre

atm

ent

Mal

nutri

tion

treat

men

t; nu

tritio

n an

d ch

ild

care

ed

ucat

ion

for

mot

hers

Phys

ical

ex

am

of s

ubsa

mpl

e;

mas

s m

edia

te

chni

que

vs.

med

ia

and

inte

nsiv

e in

stru

ctio

n;

thre

e an

nual

co

mm

unity

su

rvey

s of

inf

orm

atio

n,

attit

ude,

an

d be

havio

r

Mam

mog

raph

y,

phys

ical

ex

am

and

biop

sy;

prog

ram

co

sts

Pre-

and

pos

tscr

eeni

ng

at

heal

th

clin

ic

Pers

onal

de

liver

y vs

impe

rson

al

of c

oupo

n to

be

rede

emed

fo

r ap

poin

tmen

t be

arin

g

TABL

E I-C

ontin

ued

Auth

or(s

) M

easu

rem

ent

crite

ria

Prom

otio

nal

tech

niqu

e M

ajor

findi

ngs

Eval

uatio

n le

vel

Stud

y de

sign

Bai (1

972)

Berg

et

(197

9)

et al.

(197

8)

Foot

e &

Erfu

rt (1

977)

Gro

ve

et al.

(197

9)

HD

FP

Coo

pera

tive

.sro

w (1

979)

Wei

ght

gain

to

nor

mal

; co

st a

nd t

ime

in h

ospi

tal

vs h

ome;

in

form

atio

n re

tent

ion

Red

uctio

n in

in

ciden

ce

of

cerv

ical

ca

ncer

Abso

lute

we

ight

lo

ss;

adhe

renc

e to

pro

gram

Redu

ced

mor

bidi

ty

and

cost

of

bene

fits

paid

to

em

ploy

ees

Redu

ced

weig

ht,

smok

ing,

an

d bl

ood

pres

sure

Redu

ced

mor

talit

y

Hom

e-ba

sed

educ

atio

n an

d tre

atm

ent

Mas

s scre

enin

g;

early

dia

gnos

is

Beha

vior

mod

ifica

tion

in g

roup

; ed

ucat

ion

Scre

enin

g

Scre

enin

g an

d ed

ucat

ion;

gr

oup

beha

vior

mod

ifica

tion

Scre

enin

g,

treat

men

t, an

d m

orbi

dity

; pe

rcen

tage

an

d ed

ucat

ion;

co

ntro

lled

hype

rtens

ives

sy

stem

atic

fo

llow

-up

Hom

e tre

atm

ent

cost

s l/3

- l/6

of

hos

pita

l; be

tter

info

rmat

ion

rete

ntio

n at

hom

e

Impa

ct

(A)

Accu

mul

ated

da

ta o

n m

agni

tude

of

cha

nge

in

weig

ht

and

know

ledg

e

Repe

ated

sc

reen

ing

can

lead

O

utco

me

(C)

Scre

ened

ta

rget

gr

oup;

to

red

uctio

n in

inc

iden

ce

of

com

pare

d da

ta w

ith

Dan

ish

cerv

ical

ca

ncer

N

atio

nal

Hea

lth

Serv

ice

Beha

vior

mod

ifica

tion

six

to

nine

tim

es a

s co

st e

ffect

ive

as M

.D.

drug

tre

atm

ent

for

obes

ity

Impa

ct

(E)

Con

trolle

d ex

perim

ent;

rand

omize

d tre

atm

ent

grou

ps

from

se

lf-se

lect

ed

sam

ple

Redu

cing

cost

of

card

iova

scul

ar

dise

ase

3% p

ays

cost

of

prog

ram

; in

dust

ry

setti

ng

is

mor

e co

st e

ffici

ent

than

co

mm

unity

; ro

utin

e sc

reen

fo

llow

-up

resu

lts

in b

lood

pr

essu

re

cont

rol

Out

com

e (B

) C

ondu

cted

pr

e-

and

post

scre

enin

g;

follo

w-u

p of

pat

ient

s in

sam

ple

Scre

enin

g co

sts

$7-

IQ/y

ear/

empl

oyee

; he

alth

pr

omot

ion

prog

ram

=

$24/

year

/eac

h fo

r re

duct

ion

of m

ultip

le

risks

Impa

ct

(B)

Pre-

an

d po

st-m

easu

res

cond

ucte

d wi

thin

vo

lunt

eer

stud

y gr

oup

Syst

emat

ic

cont

rol

can

iden

tify

and

mai

ntai

n hi

gh p

erce

ntag

e hy

perte

nsiv

es;

redu

ctio

n in

S-

year

mor

talit

y (1

7%)

is

sign

ifica

ntly

di

ffere

nt

from

re

ferre

d co

ntro

l gr

oup

Out

com

e (E

) Ho

useh

old

sam

ples

wi

th

rand

omize

d tre

atm

ent

grou

ps;

follo

w-u

p of

pat

ient

s;

pre-

and

po

st-m

easu

res

King

et

al.

(197

8)

Mac

coby

an

d Fa

rquh

ar

(197

5)

Mos

kowi

tz

and

Fox

(197

5)

Rod

nick

an

d Bu

bb

(197

8)

Styc

os a

nd

Mun

digo

( 197

4)

Nut

ritio

nal

cond

ition

of

child

co

mpa

red

with

Bo

ston

St

anda

rd

and

to

cond

ition

of u

ntre

ated

si

blin

gs;

Hai

ti’s

cost

s

Redu

ced

risk

on

annu

al

surv

ey

IO-y

ear

surv

ival

by

de

tect

ion

stag

e; c

ost

per

pers

on/y

ear

gain

ed

Red

uctio

n in

ris

k,

mor

bidi

ty,

and

mor

talit

y

Num

ber

of p

atie

nts

who

mad

e ap

poin

tmen

t at

pla

nnin

g cl

inic

Mal

nutri

tion

Cos

t of

$lO

/chi

ld

for

effe

ctiv

e tre

atm

ent

and

ther

apy

and

prev

entio

n of

m

ater

nal

educ

atio

n m

alnu

tritio

n

Educ

atio

n vi

a m

ass

med

ia;

beha

vior

mod

ifica

tion

Scre

enin

g

Mul

tipha

sic

scre

enin

g;

educ

atio

n;

beha

vior

mod

ifica

tion

Pers

onal

ized

educ

atio

n an

d in

vita

tion

Mas

s m

edia

ca

n be

as

effe

ctiv

e as

1 to

1

effo

rts f

or

info

rmat

ion,

at

titud

e,

and

beha

vior

chan

ge

that

is

su

stai

ned

Max

imum

be

nefit

is

in d

etec

tion

of c

ance

r <5

m

m.

which

re

quire

s bo

th

mam

mog

ram

an

d ph

ysic

al

by M

.D.;

net

bene

fit

= 22

dea

ths

aver

ted

“Com

bine

d us

e of

hea

lth-

haza

rd

appr

aisa

l m

ultip

hasic

sc

reen

ing

and

patie

nt

educ

atio

n ca

n le

ad

to

redu

ctio

n in

car

diac

an

d ot

her

risk

fact

ors

in

wel

l-mot

ivate

d gr

oups

”

Mes

seng

er

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such as changes in health status or morbidity or mortality. Three impact studies (16, 22, 30) and one outcome evaluation (12) used Design B, the stop-everything- inventory approach, with behavior modification and education techniques or screening. Design C, the how-we-stack-up-against-others approach, was used by Berget (4) in an outcome study which compared results with national norms and averages. A quasiexperimental design, D, was used in two impact studies (27, 33) for comparison of personal vs mass education techniques. The controlled experiment approach, E, was used in one outcome evaluation of hypertension control (19, 20) and one impact study of weight reduction methods (5). Thus, only three of the impact studies used a sufficiently rigorous research design to evaluate the cost effectiveness of the technique of health promotion.

DISCUSSION

Some major methodologic limitations of empirical investigations were apparent from the review. Most studies were not designed to evaluate the cost effectiveness of health-promotion programs. Thus, the criteria for cost effectiveness and for success of health promotion were seldom defined clearly or measured precisely. Results could not be generalized because of frequent use of convenience samples of self-selected participants rather than random selection. Approximately half of the studies failed to use control or comparison groups, so for purposes of CEA, promotional techniques cannot be compared with one another or with other inter- ventions on the basis of cost or effectiveness. Such isolated efforts are useful in the exploratory stages of program development but must be followed by carefully controlled evaluations to establish cost effectiveness.

In general, follow-up strategies to assess change in behavior of subjects in the studies was poor, and little effort was made to ascertain whether changes were sustained over time. Since long-term attitude and behavior change is the primary rationale for health-promotion programs, failure to evaluate it on this basis is a major weakness in the existing literature. In one 5-year study, however, systematic follow-up in a focused program was found to be more effective in achieving high levels of adherence to hypertension control than referral to personal physi- cians for long-term maintenance (19, 20). This method was concluded to be less expensive in the long run. One of the more comprehensive health promotion studies (27) concluded that, given enough time and appropriate mass media mate- rials, the less costly technique of mass media for information, attitude change, and behavior change is just as effective as more expensive face-to-face techniques. A 2-year follow-up indicated sustained behavior change. The authors recommended that ways be found to use media to stimulate and coordinate programs of inter- personal instruction in natural communities and work sites for delivery of skill training and counseling on health habits. These groups would provide excellent opportunities for controlled evaluations and long-term monitoring.

Two programs that dealt with malnutrition among preschoolers in developing countries (2, 22) found that relatively long-term behavior change resulted from providing nutrition education to mothers, based on personal beliefs and local customs in a home or field setting rather than the hospital. This method was found to cost less as well as prevent the possible morbidity that could be introduced by a


hospital stay (2). These were two of the smallest studies with respect to money and staff, but were excellent examples of health-promotion programs. Both were aimed at infhtencing long-range behavior as well as immediate health status. Neither was a controlled study but rather a description of a field demonstration, in which personal beliefs, local customs, and cultural norms were used in a plan to educate, and to change behavior, at a low cost. Publication of the results of such exploratory programs is essential in planning similar future projects, yet personal communication with researchers in this area reveals that other informal studies are being conducted but are unpublished. Future studies undertaken on a small scale will be more helpful if they incorporate a carefully designed evaluation component and a long-term plan for follow-up, with publication of results in stages. This process would allow rapid replication of programs, with immediate impact in a variety of settings, as well as long-term monitoring of results.

In a third-world study of family planning acceptance that assessed behavioral change over a short term (33), the individual case worker was found to be no more effective, and more costly, than a simple messenger in recruiting initial users of family-planning clinic services. In another study in which methods of achieving weight reduction in obese clinic patients were assessed, the group behavior- modification approach was found to be less expensive and equally as effective as individual treatment (which included medication) from a physician (5). Both of these investigations included carefully controlled evaluations of the short-term impact of a promotional technique compared with conventional methods, but neither included long-term follow-up.

Empirical investigations have concluded that both mass media and individual approaches to health promotion can be successful under different conditions. Some have provided evidence of sustained impact on behavior. Often a novel approach is successful, and neither size nor cost of the study bears any relation- ship to the success of the program. As yet, however, carefully designed cost analyses have not been conducted so that the various approaches can be compared as to expense, as well as to short-term impact and long-term outcome. Analysis of cost effectiveness assumes that a particular health goal is desirable and then proceeds to determine which program, technique, or intervention is most effective in reaching that goal (6). Since programs with equal criteria for effectiveness are necessary in order to determine which costs less, the goals and criteria to be used for success must be defined clearly. Programs to be compared must agree on the goals and dimensions of the criteria to assess outcome, since these measures are not reducible to the unit of dollars, which is the measure in common among cost-benefit analyses. Methods for measuring costs must also be explic- itly defined and must be comparable, especially when qualitative variables are expressed in quantitative terms. In general, CEA requires less complex measurement and study designs, and are performed over a shorter term, than CBA, for which all costs and outcomes, immediate and over a projected lifetime, must be assigned a monetary value. Confusion among health professionals over the defini- tion of cost analysis, the health-promotion concept, and the ethical issue of denied health benefits on the basis of cost, has resulted in a reluctance to conduct such evaluations. Effectiveness and cost of proposed health-promotion efforts, how-


ever, must be studied empirically, first in small-scale pilot programs (7) and then in larger clinical trials (8, 25), with repeated monitoring of behavioral change and outcome, in order to convince policy makers that such efforts are the most efft- cient means to improve health status (10, 35). The current lack of sound empirical evaluation precludes any determination of the cost effectiveness of health- promotion programs.

The literature review also uncovered several articles that presented a variety of conceptual frameworks and applications of models for cost analysis of either health promotion or health services. The most common use of cost analysis seems to be in screening programs, particularly those for hypertension and cancer. Other articles also claimed high levels of cost effectiveness for multiphasic screening, but the large number of false positives involved in such programs make this conclusion doubtful (3). This problem may be overcome by combining testing with physical exams by a nurse practitioner (13). One investigation used national survey reports and economic indicators of patterns of consumption to evaluate the effects of mass media antismoking campaigns from 1964 to 1975 (34). The inves- tigators concluded that the campaign contributed to significant reductions in consumption and that the current absence of such a campaign may permit a renewed rise in consumption by new generations. Industrial health-promotion programs seem to be increasing in number, and cost savings for the companies involved are claimed (24), but few controlled studies have been published (11).

Two articles (32, 37), considered to be the first systematic attempts at cost analysis, focus on the detection and management of hypertension in medical practice. The authors applied a cost-analysis model to morbidity and mortality data gathered in the Framingham study of cardiovascular disease, and concluded that resources might be allocated better if they were directed toward improving adherence to the antihypertensive regimen, rather than to screening large numbers of new cases, which are unlikely to be controlled after detection. Support for this conclusion was reported in one of the controlled empirical investigations dis- cussed earlier (19, 20). Although this model is impressive, it is also statistically complex and employs long-term measures of outcome rather than immediate impact for the cost-effectiveness analysis. Another model (12), which was also directed toward the cost of hypertension screening, compared aspects of impact that are more appropriate to a cost-effectiveness analysis. These estimates were gen- erated within the context of an industrial program and compared the cost of a screening and follow-up program with the cost of hinge benefits and of replacing employees who developed cardiovascular disease.

One reason for ambivalence about including screening programs among health-promotion programs is their lack of effort to motivate behavioral change beyond the experimental intervention of the program (21). Screening programs are usually limited to detection of disease and seldom include education or health promotion. The terms “disease prevention,” “health protection,” and “health education” are used interchangeably in the literature to refer to the concept of health promotion. Health promotion is oriented more properly toward the establishment or reinforcement of societal norms that further health objectives over a person’s lifetime, whereas the first three terms apply to specific actions that may


be elements of such a process (7). Such distinctions are important because “health,” or a general high level of well-being as an end state, is not considered by most individuals to be of a high priority and, therefore, needs to be promoted (7, 2%

For example, protection from disease agents and negative aspects of the environ- ment, which obviously interfere with one’s functioning and preferred life-style, is readily acceptable as important and deserving of change. The promotion of health, however, must be clearly distinguished as the establishment of positive attitudes toward healthy behavior and as a method of ensuring and enhancing those aspects of life-style that have the highest priority for both individuals and groups. Until health-promotion activities are contrasted with other health-related programs, no comparisons can be made as to their relative costs or effectiveness, regardless of the rigor of the evaluation design.

RECOMMENDATIONS

Health Promotion Program Evaluation

Future efforts to assess the costs and effectiveness of health promotion programs must be designed specifically for that purpose, with careful adherence to a defined protocol. A proposed model for such a health promotion study is outlined in Fig. 1.

First, a health-related target must be identified. Target areas can range from health promotion designed to prevent disease, to health promotion designed to change health behavior in a particular setting. An example of a health-related target might be nutrition in children under the age of 5 living in an economically depressed area.

Step 2 of the model is to define the specific behavior objectives. In the above example, the specific behavior would be to have the mother feed the child in such a way that the child would be brought to a weight level above that of malnutrition.

Steps 1 and 2 are closely related. Each specific health-related target must have a similar behavioral objective, especially in cost-effectiveness studies, in order to have a firm basis for future comparisons. For example, in order to compare nutrition in children, the objectives of the study must embody the same criteria and definitions.

Step 3 is a further refinement in specifying behavioral objectives. By defining the criteria of success for specific behavioral objectives, standards of comparison can be chosen as guides to achieving a certain level of success. In nutrition studies of children, the Boston Standard for malnutrition could be used.

In step 4 the study design may be as simple as Green’s designs A, B, or C or the more rigorous D, E, or F (15). For a strong cost-effectiveness evaluation, the more rigorous approaches are preferred. A time line will indicate when the measurements will be taken, that is, before and after the program intervention and at what intervals over a longer follow-up period.

In step 5, sample size, age, and other characteristics need to be specific for the


STEPS ELEMENTS

2.

1.

I DEFINE HEALTH RELATED TARGET

I

I DEFINE SPECIFIC BEHAVIOR OBJECTIVE*

’ for CEA must be similar for health related target

3. DEFINE OUTCOME CRITERIA I

1 4. I SPECIFY STUDY DESIGN

I

1

6. ,+, +,

7.

8.

i

I

v

J

9. COMPARE PAE AND POST

l Actual behavior fo be changed or ellmanated . Amount and type of change l Length of time for change to occur . Direction of change

l Decreased cost/benefit or unit of effectweness l lmplxation of behawor change . Standards to be achieved wng national or

defmed standards as comparison l Morbidity or mortality

. Time lane - Pert chart

. Type of design A E (Green) l Whid, fools, when to apply

l Sample size . Age group . Target group . Random sample of indlvidualr

Method of mearurmg behavior to be rruded . Tool

- resrld - int.?rview - questionnaire

- record

. Record meawrement

Measure behavior to be studied . Tool . Record

FIG. 1. General model for health promotion program evaluation.

sample groups and control or comparison groups chosen. In a rigorous approach, a random sample should be used for both target and comparison groups. When the amount of change is expected to be small, larger samples are needed to demonstrate program effects.

Step 6, the method of measuring the behavior to be studied, is also important. As Green (15) points out, standardized formats for collecting data are recommended in order to compare behavioral change across studies. Standardized questionnaires from the National Health Survey are available as well as a mul-

2

3

4

5

6

COSTZFFECTIVENESS ANALYSIS COST-BENEFIT ANALYSIS

Target Program

Comparison or Delaved Prwram

+ *

Awgn Monetary Value to Program Costs

I Implement Program(r) I

I Measure Outcome Levels- 1 I - Post-Nonmonetary

I

I

C&date Ratio:

CortIAmt. Change I

Target Program

2 Long-Range (Benefit1 Program Outcome Criteria in Monetary Terms

3

4

5a Measure Immediate Outcome Levels- Port-Calculate Monetarv value I

E&q Calculate Intermediate Ratio: 6a

I f

I

5b

6b

fvfeasure Long.Range Outcome Levelr- Post-Calculate Monetary Value

4 Calculate Final Ratio.

CostlAmt. Change -In Monetary Terms

I Compare Ratios Among Prqlranr Lower Ratio = Hi$wr Cost-Eff.

I

I 1

7 j Lower Ratio = Hagher Cost-Benefit

1 Compare RatloT Programs

Evaluate Sire of Ratio According to Available Rnourcer and Priorities

8 Evaluate Size of Ratio Accordmg to Available Resources and Priormer

r Repeat Steps 5 and 6 Periodically -1 9 Repeat Steps 5a and 6a Periodically

HEALTH PROMOTION: COST EFFECTIVE?

FIG. 2. Comparison of cost-effectiveness and cost-benefit analyses.

337

titude of other tests and measures. These tests and measurements in step 6 must be made before and soon after the program or treatment has been applied, as well as at appropriate intervals afterward (step seven).

For the post-test, step 8, the same measurement tools and the same test conditions must exist as for the pretest, step 6, so that the results of the two may be compared. In cost-effectiveness studies, outcome will be expressed in cost per unit of effectiveness.


Cost-Effective vs Cost-Benefit Analysis

Health professionals need to be offered more information about flexible models of cost analysis to motivate them to conduct empirical investigations on the cost effectiveness of health promotion. Cost-effectiveness analysis (CEA) is preferable to cost-benefit analysis (CBA) as the technique for evaluation of health-promotion programs. Early programs are essentially exploratory efforts and must necessarily use quantitative approximations of qualitative measures, such as short-term behavior change, for which monetary values are not available. For the time being, it is more useful to monitor these actual changes in behavior over a long period of time than to apply the rather complex and abstract statistical models to assess the monetary value of program effects and long-term benefits that are required in a cost-benefit analysis.

Cost-effectiveness analysis permits a more flexible research design and obviates the need to deny potential health benefits to a comparison group. CEA allows the promotional technique to be compared with any alternative or conventional technique for achieving the same objective, assessed by similar criteria. Another method allows a comparison with a group that receives no program initially, but which is scheduled to receive the same program in a second cycle. CBA may also compare a variety of program objectives, but only in monetary terms applied to health status criteria over the long term. This requires denial of benefits to other groups used for comparison.

Smaller ratios indicate greater efftciency in either CEA or CBA. A cost- effectiveness analysis assumes the objective is worth achieving, then seeks the most effective and least costly way of doing it. A cost-benefit analysis assumes the effectiveness of a certain method but seeks to evaluate the cost efftciency of the method compared to the benefits achieved, both present and future. The general process of each type of analysis is outlined in Fig. 2. Health-promotion programs have yet to demonstrate their effectiveness or efftciency conclusively and require the dual evaluation of cost-effectiveness analysis.

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3. Bates, B., and Yellin, J. A. The yield of multiphasic screening. JAMA 222, 74 (1972). 4. Berget, A. Influence of population screening on morbidity and mortality of cancer of the uterine

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6. Dittman, D. A., and Smith, K. R. Consideration of benefits and costs: A conceptual framework for the health planner. Health Care Manag. 4, 45-63 (1979).

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8. Farquhar, J. W. The community-based model of life style intervention trials. Amer. J. Epidemiol. 108, 103- 111 (1978).

9. Farquhar, J. W., Maccoby, N., Wood, P. D., et al. Community education for cardiovascular health. Lancer 1, 1192- 1195 (1977).

HEALTH PROMOTION: COST .EFEECTIVE? 339

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