ABSTRACTS

Volume 11, Supplement 2
2006

Vol. 11, Supplement 2: Contents | Editorial | Introduction | Abstracts

The Cost-Effectiveness of Health Communication Programs: What Do We Know?
    Paul Hutchinson A1 and Jennifer Wheeler A1

A1 Department of International Health and Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA

While a considerable body of evidence has emerged supporting the effectiveness of communication programs in augmenting health, only a very small subset of studies has examined also whether these programs are costeffective, that is, whether they achieve greater health gains for available financial resources than alternative interventions. In this article, we examine the available literature on the cost-effectiveness of health behavior change communication programs, focusing on communication interventions involving mass media, and, to a lesser extent, community mobilization and interpersonal communication or counseling. Our objective is to identify the state of past and current research efforts of the cost-effectiveness of behavior change communication programs. This review makes three principal conclusions. First, the analysis of the cost-effectiveness of health communication programs commonly has not been performed. Second, the studies reviewed here have utilized a considerable diversity of methods and have reflected varying levels of quality and adherence to standard cost-effectiveness methodologies. This leads to problems of transparency, comparability, and generalizability. Third, while the available studies generally are indicative of the cost-effectiveness of communication interventions relative to alternatives, the evidence base clearly needs to be expanded by additional rigorous cost-effectiveness analyses.

Cost-Effectiveness Analysis for Health Communication Programs
   David K. Guilkey A1, Paul Hutchinson A2, Peter Lance A3

A1 University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
A2 Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
A3 Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

This article describes methods for analyzing the cost-effectiveness of health communication programs, focusing in particular on estimating program effectiveness with econometric methods that address experimental and quasiexperimental designs (and their absence), national or subnational program coverage, and endogenously targeting of programs. Experimental designs provide a gold standard for assessing effectiveness but are seldom feasible for large-scale health communication programs. Even in the absence of such designs, however, fairly simple methods can be used to examine intermediate objectives, such as program reach, which in turn can be linked to program costs to estimate cost efffectiveness. When moving beyond program reach to behavioral or other outcome measures, such as contraceptive use or fertility, or when faced with full-coverage national programs, more elaborate data and methods are required. We discuss data requirements and assumptions necessary in each case, focusing on single-equation multiple regression models, structural equations models, and fixed effects estimators for use with longitudinal data, and then describing how cost information can be incorporated into econometric models so as to get measures of the cost-effectiveness of communication interventions.

Multivariate Causal Attribution and Cost-Effectiveness of a National Mass Media Campaign in the Philippines
     D. Lawrence Kincaid A1 and Mai Phuong Do A1

A1 Center for Communication Programs, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland, USA

Cost-effectiveness analysis is based on a simple formula. A dollar estimate of the total cost to conduct a program is divided by the number of people estimated to have been affected by it in terms of some intended outcome. The direct, total costs of most communication campaigns are usually available. Estimating the amount of effect that can be attributed to the communication alone, however is problematical in full-coverage, mass media campaigns where the randomized control group design is not feasible. Single-equation, multiple regression analysis controls for confounding variables but does not adequately address the issue of causal attribution. In this article, multivariate causal attribution (MCA) methods are applied to data from a sample survey of 1,516 married women in the Philippines to obtain a valid measure of the number of new adopters of modern contraceptives that can be causally attributed to a national mass media campaign and to calculate its cost-effectiveness. The MCA analysis uses structural equation modeling to test the causal pathways and to test for endogeneity, biprobit analysis to test for direct effects of the campaign and endogeneity, and propensity score matching to create a statistically equivalent, matched control group that approximates the results that would have been obtained from a randomized control group design. The MCA results support the conclusion that the observed, 6.4 percentage point increase in modern contraceptive use can be attributed to the national mass media campaign and to its indirect effects on attitudes toward contraceptives. This net increase represented 348,695 new adopters in the population of married women at a cost of U.S. $1.57 per new adopter.

Measuring the Cost-Effectiveness of a National Health Communication Program in Rural Bangladesh
    Paul Hutchinson A1, Peter Lance A2, David K. Guilkey A2, Mohammad Shahjahan A3, Shahida Haque A3

A1 Department of International Health and Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
A2 Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
A3 Bangladesh Center for Communication Programs, Dhaka, Bangladesh

In this article we examine the cost-effectiveness of the Smiling Sun multichannel media campaign, which was undertaken in Bangladesh from 2001 to 2003 and involved a nationally broadcast television serial drama supported by radio, television, newspaper, and billboard advertisements and local promotion activities. The goal was to encourage the use of a package of family health services at NGO (nongovernmental organization) Service Delivery Program (NSDP) providers. This analysis relates the costs of the Smiling Sun campaign at the national and local level to measures of change in the use of health services, namely, antenatal care and childhood immunizations. Effectiveness is measured using data from cross-sectional surveys conducted in 2001 and 2003 in NSDP catchment areas in rural Bangladesh. The statistical approach, bivariate probit estimation, controls for nonrandom exposure to the program's media messages, advertisements, and signs. Using national-level data, we find that the Smiling Sun campaign was both effective and cost-effective, inducing higher levels of service utilization for only $0.05 per additional antenatal care (ANC) user and only $0.30 and $0.36 for each additional child vaccinated for measles and DPT3, respectively. With respect to local promotion activities, the cost per attributable behavior change was considerably higher—nearly $8 per new ANC user, $37 per new DPT3 vaccination, and $32 per new measles vaccination.

Cost-Effectiveness of Environmental–Structural Communication Interventions for HIV Prevention in the Female Sex Industry in the Dominican Republic
   Michael Sweat A1, Deanna Kerrigan A1, Luis Moreno A2, Santo Rosario A2, Bayardo Gomez A3, Hector Jerez A3, Ellen Weiss A4, Clare Barrington A1

A1 The Johns Hopkins University, Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, USA
A2 Centro de Orientación y Investigación Integral, Santo Domingo, Dominican Republic
A3 Centro de Promoción y Solidaridad Humana, Puerto Plata, Dominican Republic
A4 The Population Council, Horizons Project, Washington, DC, USA

Behavior change communication often focuses on individual-level variables such as knowledge, perceived risk, self-efficacy, and behavior. A growing body of evidence suggests, however, that structural interventions to change the policy environment and environmental interventions designed to modify the physical and social environment further bolster impact. Little is known about the cost-effectiveness of such comprehensive intervention programs. In this study we use standard cost analysis methods to examine the incremental cost-effectiveness of two such interventions conducted in the Dominican Republic in sex establishments. In Santo Domingo the intervention was environmental; in Puerto Plata it was both environmental and structural (levying financial sanctions on sex establishment owners who failed to follow the intervention). The interventions in both sites included elements found in more conventional behavior change communication (BCC) programs (e.g., community mobilization, peer education, educational materials, promotional stickers). One key aim was to examine whether the addition of policy regulation was cost-effective.

Data for the analysis were gleaned from structured behavioral questionnaires administered to female sex workers and their male regular paying partners in 41 sex establishments conducted pre- and postintervention (1 year follow-up); data from HIV sentinel surveillance, STI screening results conducted for the intervention; and detailed cost data we collected. We estimated the number of HIV infections averted from each of the two intervention models and converted these estimates to the number of disability life years saved as compared with no intervention. One-way, two-way, three-way, and multivariate sensitivity analysis were conducted on model parameters. We examine a discount rate of 0%, 3% (base case), and 6% for future costs and benefits.

The intervention conducted in Santo Domingo (community mobilization, promotional media, and interpersonal communication) was estimated to avert 64 HIV infections per 10,000 clients reached, and resulted in a cost per disability-adjusted life year (DALY) saved of $1,186. In Puerto Plata a policy/regulatory intervention was added, which resulted in 162 HIV infections averted per 10,000 clients reached, and yielded a cost per DALY saved of $457. Cost-effectiveness estimates were most correlated to the discount rate used and base rates of sexually transmitted infection (which affects the HIV transmission rate).

Both intervention models resulted in cost-effective outcomes; however, the intervention that included policy regulation resulted in a substantially more cost-effective outcome.

Comparative Cost-Effectiveness of the Components of a Behavior Change Communication Campaign on HIV/AIDS in North India
    Suruchi Sood A1 and Devaki Nambiar A1

A1 Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs (JHU/CCP), Baltimore, Maryland, USA

Numerous studies show that exposure to entertainment–education-based mass media campaigns is associated with reduction in risk behaviors. Concurrently, there is a growing interest in comparing the cost-effectiveness of HIV prevention interventions taking into account infrastructural and programmatic costs. In such analyses, though few in number, mass media campaigns have fared well. Using data from a mass media communication campaign in the low HIV prevalence states of Uttar Pradesh, Rajasthan, and Delhi in Northern India, in this article we examine the following: (1) factors that mediate behavior change in different components of the campaign, comprising a TV drama, reality show for youth audiences, and TV spots; (2) the relative impact of campaign components on the behavioral outcome: condom use; and (3) the cost-effectiveness calculations arising from this analysis. Results suggest that recall of the TV spots and the TV drama influences behavior change and is strongly associated with interpersonal communication and positive gender attitudes. The TV drama, in spite of being the costliest, emerges as the most cost-effective component when considering the behavioral outcome of interest. The analysis of the comparative cost-effectiveness of individual campaign components provides insights into the planning of resources for communication interventions globally.

Cost-effectiveness Studies of Behavior Change Communication Campaigns: Assessing the State of the Science and How to Move the Field Forward
   Kevin D. Frick A1

A1 Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, Health Services Research and Development Center, Baltimore, Maryland, USA

This article does not have an abstract.