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Population Health Intervention
Research Centre
University of Calgary
3rd Floor, TRW Building
3280 Hospital Drive NW
Calgary, AB T2N 4Z6
CANADA
tel: (403) 210-9316
fax: (403) 210-3818
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Project Snapshots
A Census of Economic Evaluations in Health Promotion
The issue: What do we know about the economic value of health promotion? In what areas has the work been done? Where are the gaps in the evidence?
The research: Our research team carried out a systematic search of economic evaluations of health promotion published between 1990 and 2001. We read the abstracts of 4,200 publications to ensure that the studies were relevant. We confined our study to programs with well people (directed at keeping them well). From this reading, we found 414 publications that fit our criteria. Studies were classified according to the strategic intent of the intervention, the risk factor being tackled, the setting (e.g., school, community, or worksite) and the population.
The results: Our main findings were that the economic evidence is heavily concentrated in just a few areas of health promotion practice. In terms of type of health promotion, most of the economic evaluations (42%) were about clinical interventions to prevent disease (e.g., cost effectiveness of vaccination). The next largest category involved interventions, like counseling, that encouraged people to adopt healthy lifestyles (34%). But there was little work being done in some vital areas, such as comprehensive risk factor interventions, school health promotion, community-based cancer prevention, and interventions to promote physical activity.
Consequences and significance: Not enough is known about promising areas in health promotion to which a lot of effort and energy has been devoted in the last 10 years. This means that many practitioners and programs are vulnerable to being cut back, because policy makers will usually call for evidence of cost effectiveness to justify where they put health dollars. This needs to be redressed as a matter of urgency.
The results of this census have been used already to inform planning and priority setting in British Columbia and Ontario, as well as in Wales, Finland, and Australia.
This was just the first step. We would like to take this work to the next stage and examine the quality of the evidence in particular areas (as it appears highly variable) and build a research program here to meet the gaps.
Also available as an annotated bibliography of economic evaluations in public health (1990-2001). Centre for Health and Policy Studies, University of Calgary. Available from: Annotated Bibliography
Tobacco, the biggest killer: How the Alberta media continues to promote it
The issue: Every year the number of people who die from tobacco-related disease in Canada is equivalent to two jumbo jets crashing every week, killing all passengers.
In 2002, the Calgary Health Region got serious about tobacco control and became the first health region in Canada to say that people can’t smoke anywhere on CHR property. Not inside. Not outside in designated areas. Not anywhere.
The study: Our research team worked with the CHR’s tobacco control team to evaluate the new tobacco control policies. We asked a few questions:
(1) How well was the policy implemented by the hospital security staff?
(2) Have other health regions learned from the CHR and followed suit?
(3) How did the media pick up the story, and how were tobacco control issues represented?
We collected all news items, editorial, letters and columns from the Calgary Herald and the Edmonton Journal (2001-2003) that had the words ‘smoking’, ‘cigarette’ or ‘tobacco’ in them. We sampled 2,046 articles, which contained 3,962 separate references to smoking. That’s what we looked at closely.
Results: Half of the stories were about the harm of tobacco and about tobacco control policies (price increases, by-laws, bans). We were pleased about this. But what worried us was that one quarter of the references to smoking were counter productive to public health goals. These were editorials or columns attacking smoking policies and also references to smoking that appeared in the entertainment, leisure, or sport sections “accidentally” or that were incidental to the real point of the story. For instance, a story might mention that Brad Pitt or Wayne Gretzky were smoking when they were in town. Ninety eight per cent of all these incidental references were pro-smoking (i.e., just 2% were in favour of non smoking, for example, mentioning that a new restaurant was smoke free). In fact, a person reading the newspaper was three times more likely to encounter an implicit, in-favour-of-smoking celebrity than they were likely to encounter high-profile, anti-tobacco celebrities like Jackie Chan or Heather Crowe (the non-smoking waitress who has since died of lung cancer caused by exposure to second-hand smoke).
Coincidence? We don’t know. It may look a little paranoid to say that the Alberta media was part of a conspiracy to promote tobacco. But there is research showing that tobacco placement in movies is as high now as it was in the 1950s (when smoking was the norm). There was a recent article in the prestigious medical journal, The Lancet, showing that this form of incidental product placement could be recruiting as many as 1000 new young smokers a day. There is also evidence that the tobacco industry recruited journalists to undermine the scientific evidence about the risk of second-hand smoke. In our study, 8% of all articles were attacking the need for tobacco control. Maybe that’s just free speech. Ours was the first study of its type in Canada. We’ve recommended more investigation in other provinces.
Could people who are against childhood vaccination change the minds of those who are in favour of it?
The problem: Childhood vaccination is one of the great success stories of the last century. With full vaccination, childhood diseases like whooping cough, measles and polio could be eliminated. But they haven’t been. Why? In many western countries, childhood vaccination rates are falling. One reason may be the increasing prominence in the media of the arguments of the anti-vaccination lobby, i.e., people who think vaccination is harmful and that vaccination is part of a government and scientific conspiracy.
We respect the right of parents to make choices for themselves and families. But the reason that vaccination is a public health issue, and not just a personal choice, is that diseases are infectious. In other words, when a parent decides not to vaccinate their child, it’s not just their own child for whom they are making choices, but the health of all children with whom their child comes into contact.
The study: Groups of mothers of young children, who were in favour of vaccination, were shown videos of news items that featured anti-vaccination stories and viewpoints. Many mothers claimed to be deeply shocked by seeing pictures of vaccine-damaged children and hearing accounts given by the children’s parents. In discussion, however, mothers regained and reinforced their positive views about vaccination by talking about the trust they had in their own doctors, the opinions of their family members, and their concerns about parents who would run the (more likely) risk of their child being damaged by the disease rather than the vaccination. Mothers were then shown pro-vaccination news stories, and they talked about how the messages in these stories could be strengthened.
The outcomes: This project led to training workshops with GPs on how to talk to parents about vaccination and media training for researchers and doctors. In particular, we learned to teach doctors that the “scientific facts are not enough” and that, in the media, scientists risk appearing hard-hearted if they merely list a bunch of scientific facts about vaccination, especially if they are followed by emotive pictorial scenes from parents and children. We learned that more appropriate counter arguments have to meet the “sub text” of the issue. In other words, images of vaccine-damaged children are best countered with images of children damaged by polio and measles, not by a person in a white coat talking about probability. Part of the media training was also to convey that although there may be two sides to an issue, it is not necessarily “fair” for each to get equal exposure in the media, especially when the actual proportion of conscientious objectors to vaccination is less than 5%.
What are people willing to pay for health promotion?
The problem: Some types of health promotion can be purchased “over the counter,” like when people enroll in yoga class, pay a bit more for organic food, or get a personal trainer. People know what they are paying. By parting with the cash, they are saying: “It’s worth it to me.”
But most health promotion is not paid for this way. The most effective interventions we have to promote health are actions carried out within the public sector, such as nurses providing up-to-date advice to new mothers on how to prevent childhood illness, or recreational programs for seniors, or school programs intended to reduce smoking, drinking, or bullying among teenagers.
The problem is that people “don’t see” these programs. They get paid for by taxes, and they get taken for granted. They may get cut back, and years might pass before anyone notices. In the meantime, health might worsen.
We designed a study to investigate how much people care about health promotion, using the same methods that have been used to assess how much people care about health care.
The research: The method is called willingness to pay. People are given descriptions of services and asked what they would be willing to pay from their own pocket for them. This method is used with new medications and technologies in hospitals. We surveyed a random sample of 594 people and asked them three questions: what would you be willing to pay extra, from your own municipal taxes yearly, for each of these?
- improved roads in your local area;
- a community-based program to prevent post-natal depression and improve the health of new mothers in your local area;
- a school-based program to reduce smoking, drinking, and drug use among adolescents by making them feel more engaged and connected to school.
The results: People were altruistic. Even though almost everyone benefits from roads, people were willing to pay 50% more for programs that bought benefits for specific others, not necessarily themselves. The average amount they were willing to pay was $32 for the school program, $31 for the mothers program, and $20 for the roads. Because we did this study in the context of the cost-effectiveness evaluation of the new mothers program, we knew how much that program would actually cost for a municipality to run every year. It was less than $15 per household. In other words, people are willing to pay more than the program actually cost. The results show that people are saying: “It’s worth it to me, even though it’s not for me.”
Conclusions: This is good ammunition for health promotion to use with politicians and policy makers. It adds to the evidence needed to justify resources going into prevention.
How do health managers think about risk and return-on-investment?
The problem: We were the first to publish the idea that investment portfolios (from finance) could be applied to health promotion. We argued that we would not get enough improvement in health over time if we only spent money on “blue chip” areas – like patient education and exercise programs after heart attack. We want to encourage investment in high-risk, but potentially high-gain areas, like health promotion with communities. But would health managers take to the idea? Do decision makers in health services think about risk in the same ways that economists or managers in other fields do?
The research: To find out, we interviewed managers in health regions in Alberta. We wanted to see whether they thought of risk and return when they were deciding how to allocate resources. We compared their answers to those of managers in the oil and gas industry by asking them to tell us about how they think about risk and return.
The results: The oil and gas people thought of risk the way the economists do. Risk was seen positively. Risk is opportunity or the likelihood that an investment would pay off. The more risky the venture, the greater the expected return would have to be to warrant moving ahead. In contrast, the health managers saw risk negatively. Risk was a hazard or a source of harm. Risk in the health system is much harder to quantify, more varied in its sources, and more severe in its consequences. Health managers were therefore more cautious – that is, more risk averse – when it comes to allocating resources.
But a big difference we noticed between the two sectors was in the way they each deal with risk. The oil and gas industry has developed sophisticated systems to ensure that risk is properly evaluated and managed. Extensive field-based data on everything to do with operations is constantly in use to check progress and alert managers of the need to intervene. We call it “maximum information” conditions. By contrast, the health managers work under “minimum information” conditions. They have less information with which to check whether past spending was meeting its objectives. Their information systems don’t tell them how well they are doing every day. They don’t know what prevention programs are in place. Instead, their information systems are geared to tell them when things go wrong (“adverse event”) or nearly do (“near miss”).
Conclusions: In terms of the way the health sector uses words, we may not be able to change the way risk is seen as harm. But we may be able to help people to see opportunity. Health managers make decisions that affect lives. But right now they are drawn into ways of managing that are destined to be reactive. We can’t expect health managers to act more proactively until they reorient their information systems. To benefit from portfolio thinking, they will need information at their finger tips about the full breadth of operations (in treatment and prevention), not just about the things that might be going wrong.
Feeling alienated at school: how risky health behaviours start
The problem: Evidence from other countries suggests that when children and adolescents feel cared for by people at their school they are less likely to start smoking, drinking alcohol or using drugs. We want to improve the health of children and youth, but not just to deal with health problems now. Patterns laid down in childhood start chronic disease processes that affect adulthood as well. This study set out to find out if health risk behaviours among adolescents in Alberta were predicted by feeling alienated at school. If so, could we interest schools in doing something about it?
The research: We surveyed a total of 620 students a high school and in a junior high school. Just over 70% of parents gave permission for their child to take part. We used questions known to be valid and reliable for assessing student mental health, health risks and the way students feel about their school.
The results: This is just a summary of what we found. In the high school, students who liked only half their teachers or less (44% of the student total) were 70% more likely to use marijuana, 20% more likely to smoke, 43% more sexually active and two and a half times more likely to reportdepression. In the junior high school the proportion of students experiencing depressive symptoms was 15%.
The outcomes: The high school readily agreed to tackle student health issues with us. They are in the 4th year of an experimental intervention called CORE, Creating Opportunities for Resilience and Engagement, that was funded through AADAC and the Alberta Heritage Foundation for Medical Research. With the help of a part time facilitator and the formation of a school action team, teachers, parents and students were led through a structured process to address ways to make the school more cohesive and welcoming. This tackled things like school policies (e.g., bullying), the curriculum(training teachers in teaching for emotional well being); and classroom strategies to create opportunities for student involvement. A follow-up survey in the school two years later showed reductions in risk behaviors, although the size of the school was too small for these reductions to be statistically significant. This was the encouraging first step we needed for a trial which would take CORE to another 40 schools. This is the number we would need to prove statistically that the change in health risks we observed were really caused by CORE. The trial will also include an economic evaluation – that is, we will calculate the cost per case of smoking prevented and the cost per case of depression prevented. The junior high school is still considering what they want to do about their results and a facilitator hired through the Calgary Health Region is leading that work with that school, in consultation with us.
Using Photography to Bring Out Student Voices about their School
The problem: Researchers are keen to understand more about the quality of the “social environment” of school because it seems to have a big impact on student learning
outcomes and their health outcomes. The trouble is that the usual way to measure a social environment is with surveys, and kids usually have little say about the questions they are asked. The method may particularly disadvantage youth who don’t like academic tasks (reading, writing, checking boxes), so the method can defeat the purpose of the enquiry.
The project: As an experiment, we put disposable cameras in the hands of a group of high school students and asked them to use the cameras to capture the “social environment” of their school in whatever way they saw fit. The context was a health promotion project to see if the social environment of the school could be more welcoming to youth. But we had to be sure we could communicate with students in the first place.
The results: Over a period of several weeks, students took photos and then brought them back to the group. They engaged in discussion about what their photos meant, why they took them, and what their thoughts were while they were taking them. This method, called “photovoice,” is particularly effective in getting shy people to speak. We tape recorded the conversations and analysed the results.
The story, told independently by most students, was how the school was segmented into clear territories that welcome some students and alienate others. Being “in” or “out” was associated with cliques known to gather in particular spots. Being one of the popular kids put you around a place called “the pole.” Being a smoker put you down near “the pit.” Being a recent migrant from Africa put you far away from the heart of the school. Being younger meant being intimidated by older kids in particular places. Having a car maintained what the students called “a divide.”
The consequences and significance: The students’ photos were displayed prominently in the school. They kicked off discussions with teachers and the wider school body about what could be done to address the alienation some students felt. Particular strategies were devised to cut down congestion, intimidation, and give more recognition to people and groups feeling disconnected. The photovoice project has turned into a regular annual event in the school as a way of keeping in touch with student views. As researchers, we learned that we might have completely misread this school if we had relied on traditional (psychological) assessment methods. It taught us to be more conscious about capturing the experience of cliques and sub groups if we want to truly understand a school.
It is now two years later, and the health promotion project in this school is entrenched – one of the encouraging signs is decreased smoking rates.
Does neighbourhood affect health status in Alberta? How?
The problem: The biggest predictors of health status are a person’s income, employment and education as well as family history and his/her lifestyle (like whether someone eats right, exercises, does not smoke and so on). But in the last two decades it has been shown that there are other factors on top of this that make a crucial difference – like where a person fits in the status hierarchy at work. Even the neighbourhood were a person lives has an independent effect on a person’s health status. Twenty years ago it was shown that a person living in a poverty area who does not smoke, drink, who exercises, is not overweight and has a job is still twice as likely to die prematurely than a person with the same health habits, who does not live in a poverty area. We set out to see if there are so called “neighbourhood” effects on health in Alberta, and to see if we could begin to understand them. Neighbourhood effects are important because if we can make changes to neighbourhoods, we can potentially improve the health of thousands of people at one time.
The study: We examined a data base kept by heart surgeons on 4372 people who have undergone cardiac catheterization in Alberta. We looked at what we could understand about death rates from a person’s postcode, and from how they had answered personal and lifestyle questions recorded in their file within one year of admission.
The results: A person’s self reported income level was associated with death rates two and a half years after having the procedure. Higher incomes were associated with better survival. But we also were able to examine the effect of having a low income and living in a low income neighbourhood, by using census data that gives every post code in Alberta a score on the average income of that postcode. An analysis that looked at both of these together revealed that low-income people have poorer survival and lower quality of life scores if they live in low income neighborhoods, but not if they live in high income neighborhoods.
The consequences and significance: It was important to collect local data on this issue. Up until this point the “neighbourhood hypothesis” about health was being driven by researchers from places like Chicago, San Francisco and Glasgow. These places are very different from Calgary. What could be causing death rates there, might not be causing death rates here. But with our local findings, we are confident that it is worthwhile pursuing a research agenda here that tries to unpack what is going on with neighborhood effects.
In parallel to this we are setting up collaborations to intervene in communities and improve health and quality of life in low income neighbourhoods. This is our reason for working in Bowness and why we have conducted population-level surveys of health and quality of life there. Bowness is a community known for its community spirit and strength. Maybe sense of community is a protective factor for health? We are also working directly with agencies like the United Way and City of Calgary on policies to help eliminate poverty, and ways to make all neighborhoods more liveable and encouraging of physically active lifestyles. A new post doctoral fellowship on this has been created.