is health promotion cost effective?
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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 defini- tions 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.
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 Generals 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, how- ever, the next question has been, logically, which combination of methods will provide optimum health for the population at the least cost?
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-
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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 in- creased 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 expen- ditures 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.
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 devel- oped to aid and motivate people to avoid harmful actions and to form habits that will benefit them.
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 refer- ences 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 pro- gram, 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.
HEALTH PROMOTION: COST EFFECTIVE? 327