The objective of this research was to apply and extend
economic evaluation methods—cost effectiveness
analysis (CEA) and cost benefit analysis (CBA)—to
the Expanded Food and Nutrition Education Program
(EFNEP) in New York State. EFNEP is a national
nutrition education program, delivered through the
Cooperative State Research, Education, and Extension
Service in all 50 States and 6 territories with funding
from the U.S. Department of Agriculture. It is
designed to improve the diet and nutritional well-being
of low-income families and to contribute to their
personal development. The authors adopted a broad
societal perspective, consistent with the goal that the
economic evaluation provide more general guidance
on the allocation of resources among EFNEP, other
food and nutrition programs, and other uses. The evaluation
also has important implications for allocations
of resources and program management within a State.
Previous research reported CBAs for the Virginia, Iowa,
and Tennessee EFNEPs. The Tennessee CBA measured
actual savings in food expenditures realized by participants
and reported an average savings over 5 years of
$2.48 in direct food costs for every dollar spent on
EFNEP. The Virginia and Iowa studies assessed projected
health benefits of between $10 and $11 for every
dollar spent. Neither study included estimates of CEAs
or of society’s willingness to pay for improved health.
In fiscal year 2000, when data were collected for the
present study, 5,730 adult participants graduated from
the New York EFNEP. For the cost-benefit analysis,
the study included all costs of the adult program
(Federal, State, and local dollars). The authors
collected information from graduates of EFNEP nutrition
education classes on nutrition and food safety
practices before and after attending the classes. Health
benefits, estimated from the outcome data, were monetized
using secondary data sources. The method used
in Virginia was replicated, and revisions were made for
comparison. Incidence rates for the diseases assessed
were updated from those used in the previous studies.
Lifetime risk (cumulative incidence) was used for
chronic conditions. Criteria for success in dietary
change, as well as rates for diet-attributable
risk—particularly for osteoporosis, stroke, and
commonly occurring infant diseases—were changed to
be more consistent with current understanding of the
effect of diet on health outcomes. The effectiveness of
EFNEP in reducing future health care costs and
society’s willingness to pay for the projected improvements
in morbidity and mortality were estimated. The
CEA used quality-adjusted life-years (QALYs) to
measure people’s utility levels and preferences over
different health states, expressing these in a common
metric.
The estimated benefit-to-cost ratio for New York’s
adult EFNEP was $3.17 to $1.00. Cost per graduate
was higher in New York ($849) than in Virginia ($553)
or Iowa ($710). In addition, a smaller percentage of
participants had changed to optimal nutrition behaviors
in New York. Therefore, the benefit-to-cost ratio in
New York was only about one third of those reported
for Virginia and Iowa.
The authors expanded the analyses to include the CEA
that resulted in a total of 245 QALYs. Comparing the
direct costs of EFNEP with the alternative of having
no program, the New York EFNEP was estimated to
have an incremental cost-effectiveness ratio of $19,842
per QALY saved. The program was estimated to lower
medical and productivity costs. Previous research estimated
that society is willing to pay in excess of
$200,000 per QALY. Hence, the willingness-to-pay
analysis resulted in a benefit-to-cost ratio of
$10.08 to $1.00.
The study also included cost-benefit analyses on two
subgroupings of data in an attempt to understand variation
across the State from a programmatic perspective.
First, the effect of population size and density
was investigated by comparing benefit-to-cost ratios
across rural counties (<50,000 residents), urban counties
(>50,000 residents), and New York City (NYC).
Programs in rural areas had the highest benefit-to-cost
ratios ($1.05 to $1.00 compared with $0.94 to $1.00 in
NYC and $0.56 to $1.00 in other urban areas). The
urban result is probably due to several urban programs
in the State with overall poor outcomes. Second, the
study investigated the effect of different program
delivery methods by comparing benefit-to-cost ratios
among local programs delivering more than 60 percent
of their classes in groups, those delivering more than
60 percent individually, those balanced with 40 to 60
percent delivered in groups and 40 to 60 percent delivered
individually, and those using a mixed method in
which classes were delivered in groups along with
individual contacts with participants. Individual education
produced higher benefit-to-cost ratios than group
education. The best results were seen among counties
that provided a combination of group and individual
instruction. This method appeared to improve efficiency
and retain the individualized education that had
the greatest effect.
Based on state-of-the-art economic analyses, the New
York EFNEP lowered cost in terms of projected future
health care costs. The authors note that caution should
be used when interpreting the study results. Many
potential benefits of the program, such as nutrition and
food safety benefits to other family members, could
not be captured in the study, which leads to an underestimate
of the program’s benefits. On the other hand,
the people who graduate from EFNEP are probably
those who are most likely to benefit from it. Therefore,
the program benefits may not be as great for the
general population as those estimated for the people
who completed the program. However, these results
can be used by Federal policymakers to help guide
funding decisions, and could also be useful at the State
level to guide decisions about funding and program
changes to improve health outcomes.