Measuring the benefits of health promotion programmes: Application of the contingent valuation method

Abstract

Economic evaluation of health promotion programmes presents well documented challenges. These programmes often generate significant non-health benefits which are typically ignored within economic evaluation. This study explored the use of the contingent valuation (CV) method to value the broader benefits of a women's group programme to improve maternal and newborn health in Nepal.

Interviews were conducted with 93 women's group members, 70 women non-members and 33 men. Respondents were asked to give reasons for their willingness-to-pay (WTP) in terms of health and/or non-health benefits. WTP was regressed against socio-economic and demographic variables using ordinary least squares.

Seventy eight percent of respondents were willing-to-pay for the women's groups. There was no significant difference between the WTP of women's group members compared to female non-members. Men were willing-to-pay significantly more than women. WTP reflected non-health benefits in over 80% of cases. At least 11% of women attending meetings and 38% of those not attending were WTP for altruistic motives.

Future research should address the relative value of non-health compared to health benefits; and motivations behind non-user values and their consistency across settings.

Introduction

Numerous challenges face health economists seeking to evaluate the economic efficiency of health promotion programmes [1], [2], [3], [4], [5], [6]. Such programmes generally rely upon community participation to achieve outcomes and encourage information sharing amongst peers and group action. As behaviour change takes time, health effects may not always be observed within the time frame of evaluation, although non-health benefits may occur and improve social welfare. Non-health benefits, such as the provision and sharing of information, are characteristic of many health promotion programmes [3]. The demand for some health care interventions may be a derived demand for information [7], [8]. Knowledge can be of ‘decisional’¹ value in terms of changing behaviour and improving health. Numerous studies also point to the ‘non-decisional’ value of knowledge, including a decrease in anxiety/concern [9], [10], [11], [12] and an entertainment value, the joy of learning [13]. The subsequent process of knowledge integration can also affect the way people feel about themselves, their self-image and ability to make informed choices. In this way health promotion programmes can lead to greater self-esteem [14]; self-efficacy [15]; confidence [11]; decreased embarrassment [16]; and reduced anxiety or concern [10], [11], [12]. By aiming to change the community environment, health promotion programmes may also generate benefits or disbenefits to the broader community, not directly participating in the programme. Possible values held by non-participants include the option of participating in the programme at a later date (option value); altruistic feelings towards those benefiting from the programme (altruism); and indirect learning from others or reassurance from knowing others have learned (passive use value).

Health economists generally assume that the objective of interventions is to maximise health and broader benefits are generally not valued within economic evaluation. Cost-effectiveness analysis has been the most common form of economic evaluation used to evaluate health promotion programmes [17]. Intermediate outcomes such as behaviour change, changes in knowledge, attitudes, and practice [18]; health service utilisation or preference for treatment options [19], [20]; or the level of participation in treatment decision-making [21], are often used. This limits the comparability of cost-effectiveness results from health promotion programmes with that of other interventions. Health outcomes are reported where evidence exists or where they can be derived through modelling [22], [23]. Life years gained or quality adjusted life years (QALYs) are also sometimes estimated [24], [25], [26], [27], [28], [29], [30], [31]. However, even these generic measures of outcome can fail to capture the full range of intervention benefits. For example, Wutzke et al. (2001) admit that the use of life years saved from alcohol prevented deaths ignored other benefits from reduced alcohol consumption to individuals and society, such as increased quality of life, reduced health care cost, crime and violence [27]. Although in principle they could be, non-health outcomes and non-use values have not, as yet, been incorporated into a QALY framework [32], [33] and tend to be ignored. The focus on health outcomes is consistent with the traditional theory of demand for health care as a derived demand for health, with health as the only utility-deriving attribute in the demand function for healthcare. However, it does not allow for a more ‘holistic’ measurement of the benefits of health promotion programmes.

The valuation of non-health benefits of broader health care interventions has been the focus of a number of contingent valuation (CV) studies (e.g. [12], [34], [35]). Whilst a number of studies have used willingness-to-pay (WTP) to estimate the benefits of health promotion or preventative programmes (e.g. [36], [37], [38], [39], [40]), the role and influence of non-health benefits on willingness-to-pay for health promotion programmes has not yet been explored. Furthermore, there have only been limited attempts by health economists to capture non-use values through the CV method [33], [41], [42], [43], despite an extensive literature on altruism in economics and it's role within willingness-to-pay and cost-benefit analysis (e.g. [44], [45], [46]).

The overall aim of this study was to use the CV method to value the benefits of a community-based participatory intervention with women's groups aimed at improving maternal and newborn health, and to assess to what extent non-health benefits and non-use values were important.