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0O39 NOTICE: THIS MATERIAL ),lAY BE PROTECTED gY. COPYRIGHT LAW (TITLE 17 U. S. CODJ~ Is Health Promotion Cost Effective? " l)cp,ownc~l ,!1" P,'ct'cotlrc .tf¢'dlci~tc and (~mtmu,~tfv I tc~ttrh, trod + ~lo,~([y .Ih.dir'al A lil@R~IIII'~ review ~lwvCycd applicalhm~ nl'co~l analyses in cvaluathm ol" programs the promotion of a healthy life-style. Some confusionwas uncovered regarding the de~ni- tions of such concepts as healt~ education, disease del¢cl~on, and health prolcczion. All may facilitate positive long-term behavior paltern~, but are less e~ective when used in isolatiom In ~he review, sev¢~l approaches were £ound using co~t analysis [n ~he sho~- and long-term eva'lUatied 0£ prog~ms. Fe~ :ev~duation~ included appr~pda(¢ ¢~sI-an¢lys[s techniques or l~ra~g¢follow=up of the cFf~¢~.of ~he pr~;tm, TheoDOre. the m~ra~~.t :~F~erviccs ~O ~romet¢ health cannot y~ he detcrm~ned. The ~ropo;~e~mo~[ is in,traded as a ~ocial and po hical judgments. INTRODUCTION The need to reorder our personal, professional, and governmental pr~oHtie~ regarding health expenditures is ~o [onger at issue. The debate now revolves around how an~ by whom this reordering will be carried out and what criteria will .be used to justify the result. The Surgeon General's ReporK_"Heahhy 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 7~ during this period, with I! 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 ben¢fits and to support nonduplicatcd ~ervices and innovative methods of funding health care. Federat and state governmen{s have carried out programs ¢o control the development and distribution of h~alth manpower and new technology, and insurance companies and other businesses have joined in encouraging new, less costly methods of delivering services. With this proliferation o~ cos[-comainment programs, how- ever, the ne~t question has been. logically, which combination o£ methods will provide opdmum health £or the population at ~he [eas~ cost? Warner and Hucton (36) have analyzed the growth and composition of the Ihcrnture regarding cos{ beheld[ and cos~ effectiveness in heahh care. The first publicalions appeared in the mid-.1960~. During the 1970s. the health-care commu- ' Tt~ ~hom ~'prinl rcqu¢~ ~htmld be mldr¢~,ed a[: O[~c¢ ¢~f Re,earth in Medical £d~¢a¢mn. Room 114. Kedl¢r Bldg.. The Univ¢~i~" ¢~[ T¢~a~ ~t~al Branch at G;d~esIo~. Galveston. Tex. 77Y50. 3"105280122

nity was offered many explanations of these concepts and their potential uses and ap~l~e~:i.o,n~. ~ott~ eost~b~St anal~rsis (CBA), an~d cost-effectivetless, analysis ~'.we-ve.~~~, ~nd 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 prepondera_,nce of'health-care expenditure~s h~ve been devoted to treating illness a~ad ~e~t~abil~ating tl~ dis~abled rather than ~reventing morbidity_and pro- -moiTifi~:~a,l-~l~? O,~:¢ 4~i.¥t¢-~the cur~i-Federa~l; healt,~ dollar is al,loeated tbr p~e'-vehtlo~_~or~a~nt,~_di ~iw~i~s ~,t:~). A s~.~essful di:~easelpre:vention poli~cy would ~1~ i~fft~ ~e~e~ d~t~ng ,t, lae ,l~d~uctivre y~ars o~'1~ and, due to' increased Iongev- .ity,, would ~eq,uire ,~ 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 ~n life-style and personal habits that affect health. Unhealthy behavior o.r life-style was estimated to" be responsible for approximately half or" the mortality in the United States in 1976, ._ with inadequate, health care accounting for only 10r~.~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 prdportion 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 literalure review was carried out to determine the cost effectiveness of lhe measures devel- oped 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 from 1969 through 1979' in English-language journals. Articles dealing with cost analyses of health-care services, technology, and delivery, with disease detection, and with environ.mental~ hazard and aceid'ent protection, were excluded. For practical rea- sons, unpublished papers, workshop proceedings, and government publications were also excluded. Although the search was primarily for empirical studies, several conceptual models and projected applications of certain cost-analysis TI05280123

326 ROGERS, EATON. AND BRUHN ,methods were included as exam,pies. A few representative articles dealing with ~.d'i~-re:,~l"ete~ctior~ ~n:~ delivery of servicez Computer-based indices were the primary source of citations, alon~ with refer- ences from those citations, numerous unpublished documents, and ~rsonal con- ta~ with, rezear~,hers in, the field,. A foi-1"9~8:- 1979 un:der the subject heading oF'" ~con0-mies of'Heal'tia 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 Promotion/Sociomedical Aspects"; and Journal of Economic Literature was searched for 1974-1979. Since the focuz of the review was to assess efforts to motivate or change b.ehawior-., each article was evaluated with, .respect to the health-related beha,eior invo,lved~. the motlvalional technique used!. and the approach of the investigator. The a, rfi~l.es W~e,re a.,Iso classified by ~ype of s..~,d¥, s~m,ple de-scription,, 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 simp!e to complex. .. : Green defined three levels of evaluation." process, impact. and outc0m6. Th6 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 fo_rth. Impact evaluation emphasizes the immediate impact of health promotion, the ~mpact 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-lnventory approach: collecting data at two or more points through special surveys. C. The compa~tive, how-we-~tack-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. Ti05280124

D, The controlled comparison, or quasiexperimental approach: the Stanford U~versity three-eo.mmunity study in Califi,~rnia is ~,n exa~mpte. - .~-'.~aq~, ~id:v e~r:~ ~,~:pi~je~- t, 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 effective- hess, however, must be based on the more rigorous approaches of controlled comparison and experimentatipn. fINDINGS • ~¢ major el~,_~C~s o¢~¢ 11 ~s~u~dies~.foun~ in the current review are shown in ~r~ie h Ga~en'a:~ 15) definitions ot,eva, luation, and study design were used. All but on~ ~,~e a~l~s. ~o~ g;~gc~eSS ~CEA)', Foot¢~ ~md ~rfurt's~(1:2) CBA study t~s included ~or f~, u~¢F~I~ ma~$1, ,f~r sercemng evaluation. ~fe research hypotheses or program objectives ~re unique to each paper, but ninon8 them cover th~ defined health risks such as nutrition, hypertension, smoking, obesity, and screening ~or multiple risks. The objective of program evaluation is flexible, and can include diverse groups, from workers ~n a particular work site to self-selected members of local health clinics or, in one case, Motherc~at~ centers in Haiti. :This flexibility is an advantage-and an.illustration of the adaptability of ~fie CEA technique. Seven of the eleven studies were focused on impact evaluation, which-is the ty~ 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 maJnu- trition, normal blood pressure levels, adult normal weight, and national incidence and survival for cancer, and pre- and post-test measurements were used to stu~ 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 simihtr objectives. In the studies of malnutri- tion 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 tbr malnutrition in another (22). The latter study also measured the nutritional condition of the siblings, whereas the tbrmer 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 Ibr 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 aeom, bination 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, Ti05280125

Ber~l (1979l e! uL ~ 1978~ Erfurl ( 1977l ()1- FI.~I)INGS: |~.VAI UAIION MI!THODS ANI) DESI(IN IN St UDIE50~ I'{~E~LTI~ PROMOTION Cost AH~t,Y~. C)bj~¢~w~ and health I'l~k I)uradon Sellin~ Ag~ ~roup Educal~on ~o chm~e I ye;ir , India. home. , Presehot~l nuzruh,md kno~vl=dge rural heallh and of malllttlrllion = ; : ~ yea='~ D~nmark, Wm~en. Comparisor~ of IWu uhevilv Ilyperh't~.~i¢.l :;creeoing I0 dCleCl cases early r¢li:r fi~r Irea|ment 14 weeks Calirornia. hospit!ll , , clinic 2 ye;tr.q I Deil~.)it. ' Aduhs industrial and comm,uni|y ~i~es Melhndology I Dtclary and belief survey: treatment ;lad cducalion. ~r home ~o sui| cultural pall¢ ¢1~ ~ screening wilh smear me[hod Knowledge test of nulrilion: persunali|y invcnlory; and post-w=ighl: beh.',viof nzodificalion VS drug Estlma~¢ cosl of screening vs l~inge bcnefilS paid employee Victims of ca~diqvascular disea~¢

( 19791 IIDFP C++opm~1,ivc groo,p ~ 1979~ Illg el .I. 19781 Maccoby and Fnrquh:~++ (197.S) Mo,,,kow~tz /and Fox 119751 l,~,odnlc k and I 19781 ,St ycos ~,lld M.ndigo ( 1974} Indianapolis, worksite Bahlsnoi'c.. ¢omniUnily houschohls 3- 4 months Hail;. treatment: mothercraft I - 2 year cenler fifllow-up l year (in progress) 4 year'.. 4 monlh~ semirural comm|,nilie+ Cincinnati. hospital clinic Californi~ health clinic Dommlc:m Republic community' clini~ Adulls, G~gup behavior modification; young .pre- and pos|-weight, blood ~ ~prcs~sur¢, and smoking: ' - program cosls Aduh.s, ~ ~yglc+malic fifth>w-up vs .30-6~' +-~ ,rgf¢rral to M,D. Pot h~perlcnsfim lieatmcnl Prcsch~.~ ,/~ainntri~,ion. trc;.mcnt: an.d. ..+ ffu~ition nnd child care inolher~$ c~dficaliOn fi=r mothers ~h~sical exam Of suhnumpl¢: J~lonsiv¢ il~Ml'~lclion; Ihrc¢ ~ltiludc, and behavior Women + M'ahln~ography, physical exam 40-70~ a~nd biopsy; program cost~ AdollS. + , Pre~. and posl.,,crecning 30-74. heallh clinic

Aut,hot (.~! ( 19781 Erl'url (19771 { 1979| HDFP Coop~ralive ~)up (1'979) TABLE ltdeUStlrenlenl crileria Promotional technique Evaluation M.;.tjo r lindlngs level Weight gain to normal; cost and time in hospital v~ home; inlbrmution retention Reduction in incidence of cervical cuucur Absolute weight Ios~; adherence (o program Reduced nlurhidity and ¢o'.t of benctils paid to employees Reduced weight. smokiqg, and blood pre',sare Reduced morlality and morbidity; percentage controlled hypertensives Home-based education and treatment screening; early diagnosis Behavior modilication in group; education Scree,~ing Screening 'and edocaffon: group behavior modilicatlon Screening, treatment, and eduealion; : syslemalie follow-up Home lrcatment 'costs 113.- I.g6 ' Impact , of hos~itaR better in[ol~ll~l_aljo~ j retemion at home Repeated Screening can ,l~l/d, ' to reduction in inc,dene~of cervical cancer Behavlu¢ modification six ~ nine times as co~l . as M.D. drug !remmenl,.[Or obesity Reducing cost or' cardiov~tseular disease 3~ pays cost ot~ program; industry Setl.~lg more cost efficienl Iha~2. community:, routine s~en follow-up re,~ults in blood ~ pressure Conlro[ SCreening c0~ts $7- 101~,~-I • employee; health proca~nio-n program = $2,Uyear/cnt~h . for 'reduction of muhiple~ri~ks Systcm..~ti.c ~ontrOl ~I1 and a~aintain high percentage hypertensives: reductit~ it) 5-yem" mortality {17%,) is sigpi~cantly differen~ ~m referred control Outcome [mpi,ct ,Outcome Impact On~Gome ~...- (A} Accumula¢~ un weight and k)~ ~." (C) Screened randomized '~l groups l~mifl~d (B) Pre- and, follow-t~p pre. and pu~O~e~ ~,"

King Nutritional coudition 0f Malnutrition Cost of $10/chiid for effective ~.~ al. child compared wi~h trca~nenl and ~herapy and prewmlon (1978) 'Boston Standard and Io maternal cdu~allon mahmlriliun condition nf Ulll[~alcd ' ~ibliogs: Haiti's costs Maccoby and Reduced risk on Education via Mass media can be a~ ¢Eeclive Fa~Uhar anmml survey mass media; as I lu 1 effo~s for (197,S~ behavior informalion, aoitud¢, and modification behavior change !hal suslaincd Mo~kowil= I(I-y¢ar survival by Scr¢¢ning Maximum benc~l is in delcclion (1975~ per ~rso~year gaiucd requires bolh mammogram and physical by M.D.~ bcncfiK = 22 dcaih~ avcrlcd Rodnick an~ Reduction in risk, Mulliphasic "'Combined use of hcahh- ~nbb morbidily, and mortality screening: haznrd ~lpp~aisal ~uh~phasic (1978~ ~ducafion: screening and pa~em behavior education can lead modification reduclion in cardiac and othc~ risk Ibclors in well-mmivaled groups Slyco~ and Number o1' patients Personalized Messenger ddivery ofwrillen Mundigo who made appoimmenl education and malcr[al i~ five times as cost (1974i at planning clinic invitation effective as'personal ~isil Impact (B) Corn whh pr¢- and on sclf-scl¢ctcd ,Imp~Icl OutcOme (D) Multiple-risk among three com~ rando .mized high-risk subsum tre;flmcnl and,co,Ill (A) Historical dcsc, with self-selected sample ' l,mpa:ct (B) Conducted pre- posl-leSls Wilh of self-selected Impact (D) Systematic sample; controlled comparts0! by motivator and inmore consistent | Kc.y to .wudy de,',igu.,,. IA) I'|isloric;.d recnrd keeping--accumulated dala only: (B);lnventory approach--periodically collect dala; (C) Co~on-- with ~imi'lar group or nutiomd ~tandard~: (D) Controlled comparison or quasiex~rimenhd apprOach--wilh alternalive or no program gruup[~ Irolled experimental approach~nscg random assignment to groups similar to clinical Irial: (FI Full evaluative ~search project~muhiple groU~ari- ~ons of mnhiple 4rentnlenls. .

333 ~ooF,~s. E,vro~. AN, D B~U~ s~ ~. ch~.n.ge~ ~ health s~a~us or m~rbidit~ or ~a~li,t~. Th'~ee ~m~act s~:d~es inventory approach, with behavior modification and education techniques or screeni~, Des~ C. the how-we-stack-u~-against-others approach. ~as used. by merit ~pproach. !~. was--used' in 0n~cr~teome evaluation of ( 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 f~orn the review, Most studies were not designed to evaluate the cost effectiveness o,f h¢:-a-lth~promotion programs. Thus.- the-.~riteria f~or co,st etTect.i.veness and-for s~¢~ss ~f h'~:a.l:t~h~ .promotion were sol,Iota defined Clearly Or .measured precisely., o~seif-selected'participants rather than randbm selection. Approximately .half of the studies flailed to use control or comparison groups, so for purposes of CE~A, 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 !.q genera!, t~llow-up_strategles to.assess _change in behavior of subje_c_ts 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 ~veakness in the. existing literature_ In_ one 5-year study., however, system- atic 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 lhe 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 Ibr controlled evaluation,~ and long-term monitoring. Two programs that de'41t with malnutrition among preschoolers in developing countries (2. 22) fimnd that relntively long.term beh~wior change resulted from providing nutrition education to mothers, based on personal belie~rs and local customs in a home or field setting rather than the hospital. This method was found to cost le~s as ~,ell as prevent the possible morbidity that could be intredue.ed by a

HEALTH PRO~'tOI"ION: COST EFFECTIVE:~ 333 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 -~,eithe~wa~-eo'n~'lled~st~dybu,rra'rhe~,rd~'riFt'i'o~'~'fi'e~d: demonstration; in which personal beliel~, local customs, and cultural norms were used in a plan to educate, and to change behavior, at a low cost, ~blication of the results of such explorato~ 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 componen~ and a long-term plan for follow-up, with publication of results ' 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 _ . -~ family-planning clinic services. In another study in which methods of achieving modificati0n.~pproach was foun~_[o_~e less expen~[~__and ~quaiiy as effe~t.[~e as individual ~reatment ~whieh included medication) from a physician (5VBoth of .... these investigations ineluded.~ca~efuily controlle~_e~alUations of the ~h0~-tetm _ impact of._a_Py0motional techni_q~e compared wi~h .~0nventlo~al methods., but neither included long-term follow:u-p. Empirical:investigations have concluded that both- mass media and indi~idual approaches to health promotion can be successful under different conditions. Some have provided evidence, of sustained impact on behavior. O~en 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 com- pared 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 rhea proceeds to determine which program, technique, or interventio,~ is most effective in reaching that ~oal {6~. Since programs with equal criteria for eft~ctive- hess are necessa~ in order to determine which costs less. the go~ls 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 mea- sures are aot reducible to the unit of dollars, which is the measure in common among cost-benefit analyses. Methods for measuring costs must also be explic- itl~ defined and must be comparable, especiully when qualitative variables are expressed in quantitative terms. In general. CEA requires less complex measure- ment and stud~ designs, and are performed over a shorter term, than CBA. for which all costs and outcomes, immediate and over a projected lifetime, must be asfigned a monetary value. Confusion among health professionals over the defini- tion of cost anulysis, the health-promotion ct~,~cept, 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- Tt05280131