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    How are health promotion programs evaluated economically?

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    Identifying the economic benefit of program implementation and delivery can provide insight into the value of public health investments to the overall health system. It also can help program managers identify, measure, and compare activities with the necessary impact, scalability, and sustainability to optimize population health. By identifying the benefit of a health promotion program, program staff are able to determine the size and characteristics of the population to be reached, the projected impact of the intervention, and the estimated cost (Rabarison et al., 2015; Mckenzie, 1986). Program staff would also have a better understanding of program operations, and be able to tell what levels of intervention are most cost-effective. This information can influence decisions about how many people they need to hire, or how many people they can serve effectively. By identifying the economic benefit of a program, it can also influence legislators, policymakers, and other funders' decision on whether to invest in the program (Sewell and Marczak, n.d).

    Cost-benefit analysis (CBA) weighs the cost of the program against the dollar value of the program's benefits. This can be applied either before, during, or after program implementation, to assess the program's efficiency. This type of analysis is calculated by subtracting costs from benefits to obtain the net benefits. Cost-effectiveness analysis (CEA), on the other hand, identifies and places dollars on the cost of a program. The costs are related to specific measures of program effectiveness. CEA helps determine which interventions to prioritize, by ranking them according to the cost of each unit of health benefit they produce. To calculate CEA, costs is divided by units of effectiveness. Units of effectiveness are the outcomes central to the objectives of the program. The first step in calculating CBA and CEA is to clearly specify the problem and for whom the analysis is going to be calculated. The next step is to specify the objectives. There should be one or more objectives that are closely related to the problem. Once the objectives are specified, the next step is to identify alternatives. Other approaches should be identified that will achieve the objectives. The alternatives should be cost-effective, offer a variety of approaches, and ones that would be appropriate for comparison. Describing production relationships is the next step in the CEA and CBA process. The resources necessary to carry out the alternative are identified. An explanation of how the resources are combined are provided, and the outcomes are predicted as well. After the resources have been identified, the costs are analyzed. Cost analysis provide insight into the operation of the program. This includes the overall cost of implementing and sustaining a program and costs for specific program activities. The costs includes the resources that would benefit the community. Direct controllable and uncontrollable costs should be considered (Cellini and Kee, 2010; Child Welfare Research and Evaluation, 2011; McKenzie, 1986). Once the costs are analyzed, the benefits and effectiveness of the program is identified. In this step, the different outcomes should be categorized. For the CEA, the analyst quantifies only the most important benefit to get the units of effectiveness. If more than one benefit is important, separate cost-effectiveness ratios for an additional outcome or two are calculated. The benefits must be related to the objectives of the program. For the CBA, the analyst quantifies all benefits and ascribes dollar values to them. Discounting is the next step necessary in calculating CEA and CBA. Future costs and monetary values of future benefits are discounted to their present value. Discounting can tell program managers how much future benefits and costs are worth today. It also provides a more accurate assessment of a program's economic impact (McKenzie, 1986; McCrory, n.d). A sensitivity analysis should be used when analyzing uncertainties, which is the next step in processing CEA and CBA. One way this can be done is by presenting uncertain areas in front of a group of experts. A consensus can then be reached on what should be used in place of uncertain data. Finally, the last step involves interpreting the results. Based on results from CEA and CBA, program staff are able to make decisions about the program. Any ethical, legal, and/or societal issues are identified before final decisions are made ( McKenzie, 1986).

    One example of an organization who utilized CEA and CBA is the smoking cessation programs. The costs of heavy cigarette smoking were calculated and were approximately $20.3 billion. This included the cost of hospital care, medical care, absenteeism, and premature deaths. This was useful in showing that smoking cessation programs can provide financial benefits. Another example is colorectal cancer screening programs. Their analysis were based on the number of cases of colorectal cancer that would have occurred in the absence of screening, and the direct and indirect costs associated with each case. The program also assumed that all cases prevented were due to on-site screening. These estimates of savings were useful in showing the value companies themselves have placed in the savings ( McKenzie, 1986). The nutrition education program was another example provided in which CEA and CBA was calculated. Effects, such as the reduction of calorie intake or of serum fat levels, were identified along with health benefits (McKenzie, 1986).

    1. Cellini, Stephanie; Kee, James (2010). Cost-Effectiveness and Cost-Benefit Analysis. Handbook of Practical Program Evaluation. Retrieved from: http://home.gwu.edu/~scellini/CelliniKee21.pdf.

    2. Child Welfare Research and Evaluation (2011). Cost Analysis in Program Evaluation. Children's Bureau. Retrieved from: https://www.acf.hhs.gov/sites/default/files/cb/cost_analysis_guide.pdf.

    3. McKenzie, J.F (1986).Cost-Benefit and Cost-Effectiveness as a Part of the Evaluation of Health Promotion Programs. The Eta Sigma Gamman, 18(2). 10-16. Retrieved from: http://media.pearsoncmg.com/bc/bc_mckenzie_health_6/AppendixB_McKenzie6e.pdf.

    4. McCrory, John (n.d). Discounting. CBKB. Retrieved from: http://cbkb.org/toolkit/discounting/.

    5. Rabarison, Kimberly; Bish, Connie; Massoudi, Mehran; Giles, Wayne (2015). Economic Evaluation Enhances Public Health Decision Making. Frontiers in Public Health. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4478374/.

    6. Sewell, Meg; Marczak, Mary (n.d). Using Cost Analysis in Evaluation. The University of Arizona. Retrieved from: http://ag.arizona.edu/sfcs/cyfernet/cyfar/Costben2.htm.

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