Investing in Oregon's expanded food and nutrition education program (EFNEP): documenting costs and benefits

An Economic Evaluation of Food Safety Education Interventions: Estimates and Critical Data Gaps

The economic evaluation of food safety interventions is an important tool that practitioners and policy makers use to assess the efficacy of their efforts. These evaluations are built on models that are dependent on accurate estimation of numerous input variables. In many cases, however, there is no data available to determine input values and expert opinion is used to generate estimates. This study uses a benefit-cost analysis of the food safety component of the adult Expanded Food and Nutrition Education Program (EFNEP) in Ohio as a vehicle for demonstrating how results based on variable values that are not objectively determined may be sensitive to alternative assumptions. In particular, the focus here is on how reported behavioral change is translated into economic benefits. Current gaps in the literature make it impossible to know with certainty how many people are protected by the education (what are the spillover effects?), the length of time education remains effective, and the level of risk reduction from change in behavior. Based on EFNEP survey data, food safety education led 37.4% of participants to improve their food safety behaviors. Under reasonable default assumptions, benefits from this improvement significantly outweigh costs, yielding a benefit-cost ratio of between 6.2 and 10.0. Incorporation of a sensitivity analysis using alternative estimates yields a greater range of estimates (0.2 to 56.3), which highlights the importance of future research aimed at filling these research gaps. Nevertheless, most reasonable assumptions lead to estimates of benefits that justify their costs.

Obesity-Related Policy/Environmental Interventions: A Systematic Review of Economic Analyses

CONTEXT

Policy and environmental changes to support and encourage individual-level nutrition and physical activity behavior are underway in many parts of the U.S. and around the world at national, state, and local levels. Yet, to the authors' knowledge, no summary of the cost-benefit or cost-effectiveness studies of obesity-related policy/environmental interventions exists.

EVIDENCE ACQUISITION

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement guidelines were followed to identify, screen, and describe the protocols used in this systematic review. In 2014, a unique search was conducted of titles and abstracts in MEDLINE, EconLit, SCOPUS, and Web of Science databases that were published from January 2002 through January 2014 in English-language, peer-reviewed journals. The search terms described obesity, physical activity, and diet in combination with economic evaluation.

EVIDENCE SYNTHESIS

In 2014 and 2015, the results were analyzed. A total of 27 studies met the inclusion criteria, of which 26 described separate interventions. Of the 27 included studies, eight focused on the community and built environment, seven assessed nutrition-related changes, nine reported on the school environment, and three evaluated social marketing and media interventions. The vast majority of included studies reported beneficial economic outcomes of the interventions.

CONCLUSIONS

Given the large and growing literature on the health and behavioral outcomes of policy and environmental interventions, the relatively low number of located cost-benefit and cost-effectiveness economic assessments appears to indicate a prime opportunity for the research community to address.

Improved Overall Quality of Diets Reported by Expanded Food and Nutrition Education Program Participants in the Mountain Region

OBJECTIVE

To evaluate the Expanded Food and Nutrition Education Program, a large US Department of Agriculture nutrition education program for low-income people, by comparing the overall quality and cost of diets when entering and exiting the program.

METHODS

Secondary analysis of data collected in 2011 from female participants in the Mountain region. Dietary recalls were collected by paraprofessionals. Outcome measures were the differences between Healthy Eating Index-2005 scores and costs of diets at entry and exit. Significance was determined using the Wilcoxon signed-rank test.

RESULTS

At entry the mean total Healthy Eating Index-2005 score was 49.1 (out of a possible 100) and at exit, 55.2 (P < .001) (n = 3,338). Eight of 12 component scores also improved significantly whereas the sodium score worsened. The estimated median cost of diets was 13% higher at exit compared with entry.

CONCLUSIONS

Participants' overall diet quality improved and was accompanied by an increase in food cost.

Critical review of economic evaluation studies of interventions promoting low-fat diets

Various national and local policies encouraging healthy eating have recently been proposed. The present review aims to summarize and critically assess nutrition-economic evaluation studies of direct (e.g., diet counseling) and indirect (e.g., food labeling) interventions aimed at improving dietary habits. A systematic literature review was performed by searching 5 databases (PubMed, Ovid Medline, EconLit, Agricola, and Embase) using a combination of diet-related (fat, diet, intake, nutrition) and economics-related (cost-effectiveness, cost-benefit, cost-utility, health economics, economic evaluation) key words. The search yielded 36 studies that varied in target population, study design, economic evaluation method, and health/economic outcome. In general, all provide limited experimental evidence and adopt the framework of economic evaluations in healthcare. Certain important aspects were not well considered: 1) the non-health-related effects of nutrition interventions on well-being; 2) the private nature of food expenditures; 3) the distributional effects on food expenditures across socioeconomic groups; and 4) the general economic implications (e.g., agrofoods, import/export) of such interventions. Overall, the methodology for the economic evaluation of nutrition interventions requires substantial improvement.

EFNEP's impact on the quality of life of its participants and educators

OBJECTIVE

Determine whether the Expanded Food and Nutrition Education Program (EFNEP) affects the quality of life (QOL) of its participants and educators.

DESIGN

Longitudinal, where QOL was measured 3 times for participants (pre, post, 3-month delayed post) and educators (before and 6 and 12 months after training).

SETTING

Participants' and educators' QOL was measured in Colorado, Kansas, Missouri, and Nebraska. Georgia and Texas measured educators; Minnesota and Virginia measured participants.

PARTICIPANTS

English speaking EFNEP participants and educators.

MAIN OUTCOME MEASURES

The investigators used the QOL Profile to measure QOL in 3 domains: Being (who one is), Belonging (connection with social and physical environment), and Becoming (achieving personal goals).

ANALYSIS

Chi-square and t tests compared group demographics; repeated-measures ANOVA detected changes over time; ANCOVA examined the influence of demographic variables.

RESULTS

Both groups had QOL Profile scores above 1.5, which is considered acceptable. Participants improved from pre to post in the Being domains including Overall Being (least square means [standard error of the mean], 3.1 [0.2] to 4.1 [0.3]), and in Social Belonging (3.5 [0.3] to 3.8 [0.3]); most improvements were sustained at 3 months. Educators improved in the Belonging domains, and a number of scores continued to improve at 1 year after training, for example, Social Belonging (4.2 [0.5], 5.0 [0.5], and 5.8 [0.6]); and Community Belonging (3.5 [0.5], 3.8 [0.5], and 4.7 [0.5]) at the 3 time points, respectively.

CONCLUSIONS AND IMPLICATIONS

EFNEP improved the QOL of participants, primarily in the Being domain, and of educators, primarily in the Belonging domain. The QOL profile has the potential to broaden the assessment of EFNEP impacts.

Cost-effectiveness model for youth EFNEP programs: what do we measure and how do we do it?

The Youth Expanded Food and Nutrition Education Program (EFNEP) is one of the United States Department of Agriculture's hallmark nutrition education programs for limited-resource youth. The objective of this study was to gather opinions from experts in EFNEP and related content areas to identify costs, effects (impacts), and related instruments to develop a cost-effectiveness model (instrument) for youth EFNEP, which does not exist. A cost-effectiveness model determines the economic or financial cost of producing an impact. The findings highlight several challenges in identifying inputs through consensus and provide a roadmap for the creation of a model that can be adopted by state EFNEP coordinators.

Evaluation of an educational intervention using the enhanced food safety cost-of-illness model

In recent years, a number of federally sponsored state-based food safety education programs have conducted economic evaluations aimed at demonstrating the efficacy of their approaches. These evaluations have typically been based on the "Virginia method," a comprehensive, but overly simplistic means of estimating benefit-cost ratios for food safety and nutrition education programs. In this article, we use the enhanced food safety cost-of-illness model, coupled with a more complete food safety education intervention model to evaluate the efficacy of the Ohio Family Nutrition Program. We find that, under most reasonable assumptions, the derived benefit-cost ratios imply that this program is socially beneficial. The model presented here is of particular use because it can be replicated to evaluate other broad-based food safety programs.

Economic cost of foodborne illness in Ohio

Past efforts to evaluate the economic burden of risks from foodborne illness in the United States have generally taken the form of studies focused on a single or a small number of "important" pathogens. As a result, the economic impact of many less prominent pathogens has not been sufficiently explored. Consequently, currently available studies only provide cost estimates for fewer than 4 million of the 76 million cases of foodborne illness, are incomplete, and, as a result, underestimate the efficacy of broad-based intervention programs. We present a cost-of-illness model that enhances the oft-cited U.S. Department of Agriculture Economic Research Service model. Our model uses a more comprehensive set of pathogens, includes pathogen-specific hospitalization costs, and includes measures to account for lost quality of life. We also use Monte Carlo simulations to evaluate the effects of uncertainty in our analysis. We find the estimated annual expected economic cost of foodborne illness for Ohio to be between $1.0 and $7.1 billion, which translates into a per-Ohio resident cost of $91 to $624. Our results can be used to evaluate the effectiveness of broad-based food safety programs.

Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: a systematic literature review

OBJECTIVE

This systematic review assesses the impact of peer education/counseling on nutrition and health outcomes among Latinos and identifies future research needs.

DESIGN

A systematic literature search was conducted by: (1) searching Internet databases; (2) conducting backward searches from reference lists of articles of interest; (3) manually reviewing the archives of the Center for Eliminating Health Disparities among Latinos; (4) searching the Journal of Nutrition Education and Behavior; and (5) directly contacting researchers in the field. The authors reviewed 22 articles derived from experimental or quasi-experimental studies.

OUTCOME MEASURES

Type 2 diabetes behavioral and metabolic outcomes, breastfeeding, nutrition knowledge, attitudes and behaviors.

RESULTS

Peer nutrition education has a positive influence on diabetes self-management and breastfeeding outcomes, as well as on general nutrition knowledge and dietary intake behaviors among Latinos.

CONCLUSIONS AND IMPLICATIONS

There is a need for longitudinal randomized trials testing the impact of peer nutrition education interventions grounded on goal setting and culturally appropriate behavioral change theories. Inclusion of reliable scales and the construct of acculturation are needed to further advance knowledge in this promising field. Operational research is also needed to identify the optimal peer educator characteristics, the type of training that they should receive, the client loads and dosage (ie, frequency and amount of contact needed between peer educator and client), and the best educational approaches and delivery settings.