Beyond the Individual: Evaluating Community-Based Health Promotion and Prevention Strategies and Palliative Care Domains of Effect Simon Eckermann and Nicola McCaffrey


Chapter 4 considers challenges faced undertaking health economic analysis to evaluate health promotion and palliative care programs and strategies in complex community settings and more importantly highlight principles and some promising methods and approaches to address these challenges.

When evaluating community-based health promotion programs, the principles and evaluation approach to health system decision making need to take a community perspective. In other words, assessing community acceptance of strategies and expected community net benefit given behavioural, lifestyle and health effects (intended and unintended) across community populations reached are central to determining the success and long-term effectiveness and cost effectiveness of these interventions.

Conventional within-study and individual focussed cost-effectiveness methods, with typical short-term evaluation time frames, and extrapolation modelling methods (such as those considered in Chaps. 2 and 3) have struggled to appropriately assess health promotion and primary prevention strategies. These methods fail to tractably gauge community acceptance or capture the diffusion of long-term outcomes across populations in complex community settings such as schools, aged communities, community gardens and walking groups, etc. Alternative evaluation methods are needed to navigate the coverage (population scope and duration) and comparability of the longterm and diffuse community and population impacts of health promotion strategies.

The research of Shiell and Hawe, pointing to the value of assessing community impacts with network and multiplier methods, is shown in this chapter as a more robust and appropriate approach to satisfying coverage and comparability principles in such community-based health promotion programs. In modelling terms, such multipliers and their trajectory over time are key to assessing long-term community acceptance, network impacts and success of community-based health promotion and prevention programs, in triangulation with qualitative assessment of community acceptance and program impacts on individuals’ attitudes, behaviours, etc.

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S. Eckermann, Health Economics from Theory to Practice,

DOI 10.1007/978-3-319-50613-5_4

Use of multiplier methods to enable robust evaluation in such settings is illustrated in evaluating the Stephanie Alexander Kitchen Garden National Program (SAKGNP), a health promotion and primary prevention program undertaken in primary schools (Eckermann et al. 2014; Yeatman et al. 2014).

The need for new methods to address difficulties with the use of conventional individual patient-based effectiveness (e.g. QALY) and cost-effectiveness approaches is also shown to arise at the other end of the health-care spectrum - palliative care. Limitations of conventional cost-effectiveness methods in the palliative setting are shown to arise with lack of robust consideration of the multiple key domains reflecting palliative patients’ preferences, including finalising personal and financial affairs, process of death, place of care and distress of family, friends and carers (McCaffrey et al. 2016b). Such domains are not amenable to integration with survival time and hence cannot be incorporated into single-effect comparisons in conventional cost effectiveness analysis - even where patient QALYs are estimated. In addressing these problems, the research of McCaffrey (McCaffrey 2013; McCaffrey et al. 2015a) is highlighted as enabling robust comparison of multiple outcome domains under uncertainty, methods which are considered in detail in Chap. 10, and naturally extends multiple strategy methods from Chap. 8. Such multiple outcome domain comparisons are shown to be necessary to consider diverse outcomes beyond those able to be integrated with survival into individual patient QALYs, informing wider community utility functions and aspects of utility within health. Further, even within a QALY framework, significant value to decision makers in many circumstances is suggested from being able to robustly present multiple events or effects, given the potential for these rates, as well as utility weights, to differ between individuals, communities and across jurisdictions and over time.

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