Costs of implementing and maintaining Comprehensive school health: the case of the Annapolis Valley Health Promoting Schools program.

Ohinmaa, Arto ; Langille, Jessie-Lee ; Jamieson, Stuart 等

Childhood overweight has become a major public health concern. In Canada, the prevalence of overweight in childhood has increased dramatically from 15% in 1977/78 to 26% in 2004. (1,2) School-aged children embodied the bulk of this increase as rates for children aged 2-5 remained relatively unchanged. (1) There is mounting evidence that childhood overweight persists into adulthood and is associated with a number of co-morbidities including type 2 diabetes mellitus, cardiovascular disease and some cancers, leading to a reduced life expectancy and quality of life. (3,4) The health care costs of overweight constitute a tremendous burden to society and are subject to sharp increases. (5) Direct health care costs associated with excess body weight in Canada were estimated to be $1.8 billion in 1997, (6) and the overall annual national costs (direct and indirect costs) to be $4.3 billion in 2001. (5) The health care cost of diabetes in Canada has been projected to nearly double between 2000 and 2016 from CAD $4.66 billion to about CAD $8.14 billion. (7)

School-based programs have a great potential to prevent childhood overweight because they reach almost all children and at an early age. (8) Comprehensive school health (CSH) has been shown to be very effective in preventing overweight and obesity. (9) CSH is an internationally recognized framework for supporting both education and health in a planned, integrated and holistic way. (10,11) CSH is the preferred term by the Joint Consortium for School Health but is synonymous with Health Promoting Schools, the term most commonly used in Europe and Australia, and with Coordinated School Health, commonly used in the United States. (11) Few primary prevention programs have included economic evaluations, and to date, no studies have reported on the costs associated with implementing and maintaining CSH. (12-14)

The Annapolis Valley Health Promoting Schools (AVHPS) program is a CSH program with documented benefits regarding the prevention of overweight and obesity. (9) For other schools, school boards and governments, it is important to know the costs of this program as part of their considerations to invest in CSH. The aim of the present study is to estimate the societal costs of school-boardwide implementation and maintenance of CSH.

METHODS

The AVHPS program

The AVHPS project began in 1997 as a grassroots initiative by parents and school staff at two elementary schools who had become increasingly concerned about the poor eating habits, physical inactivity and consequent health of their children and students. The initial project brought together partners from education, health, recreation, and food industry sectors to change the school environment and to make "the healthy choice the easy choice" for students. This included developing of healthy policies and practices, creating supportive environments, enabling strong community leadership and partnerships as well as providing personal skill development through education. As a result of these changes, students in these schools received more physical activity, had a variety of healthy food choices and were more educated on health and nutrition matters. (15)

In 2003, the Children's Lifestyle and School Performance Study (CLASS) revealed that students attending the AVHPS schools had healthier diets, were more active, and were 59% less likely to be over-weight or 72% less likely to be obese relative to their peers attending schools with no prevention programs. (9) These findings were instrumental to expanding the AVHPS program to a school-boardwide program including 44 schools. The AVHPS program addresses a range of health issues, however, the present study focuses on those related to the promotion of healthy eating and active living.

Economic evaluation methods

The AVHPS program, like other primary prevention initiatives, differs from health interventions as health benefits and health care cost savings are expected to happen in the future, for the most part decades later. This creates challenges related to estimating health benefits, valuing future costs and discounting rates, and to whether one should take a health care or societal perspective. (16,17) Additional challenges may also originate from the fact that CSH has more diverse incoming monetary and in-kind resources that include those from the health sector, the education sector, parents, the school community and local businesses.

Funding for the AVHPS program comes from several sources. The school board receives government funding earmarked for CSH, for Breakfast programs and for the School Food Policy. The school board distributes these to their schools based on the schools' CSH plan. The AVHPS program approves these plans and their budgets. The AVHPS also receives support by individuals, firms and charitable organizations either in the form of monetary donations or of free products, labour or services. The monetary donations that supported healthy eating and physical activity were tracked using data from school-based transaction reports for the 2008-2009 school year. In most cases, these reports had specified the intended use of the donation.

The funds were used mainly for two purposes: to enhance student physical activity (during or after school) and to support school nutritional programs. Although some of the costs incurred were from investments in school kitchen equipment (like microwave ovens, refrigerators) and physical education equipment, these costs were relatively small and therefore not distinguished from operating costs.

In the fall of 2009, we reviewed the program cost accounts from all schools of the Annapolis Valley Regional School Board (AVRSB) for the 2008-2009 school year. We also reviewed resources coming to the program from the parents and the larger community using the AVHPS program documents for each of the schools. There was no systematic record-keeping of volunteer hours in support of CSH. We therefore interviewed four schools at varying stages of implementation on volume of volunteerism. We valued voluntary work using $10 per hour as an estimate based on local wages for non-skilled persons. We expressed all monetary values in Canadian dollars in 2009 values, but did not apply discounting as all costs occurred in a single school year. We calculated costs by school, per student and school-board wide.

RESULTS

The direct public funding to implement and maintain CSH totaled $344,515, which translates to an average of $7,830 per school and $22.67 per student (Table 1). The public funding by the province constituted $140,500 earmarked for CSH funds, $86,250 from the Provincial Breakfast Program funds, $28,750 from the School Food Policy Program funds and $17,545 from other public sources. The AVRSB also received $70,000 per year in federal funding through the Sport Animator Program to support a physical activity coordinator.

The AVHPS program further received $127,235 in the form of grants, donations and fundraising, of which approximately 20% was for physical activity and 80% for nutrition programs. The mean funding from grants, donations and fundraising was $2,892 per school or $8.37 per student. Two of the 44 AVRSB schools did not report incoming funding through grants, donations and fundraising. The single largest donation received was $11,216.

Each of the AVHPS schools reported to be supported by volunteer time of staff and teachers. School facilities were reportedly used for nutritional and after-school activities. The value of these resources is not included in this analysis.

Table 2 summarizes volunteer activities along with acquired funding in four AVHPS schools. The estimated value of volunteer work ranged from $875 to $7,000 per year. On average, the value of volunteer activities ($3,368) approximated that of acquired grants, donations and fundraising ($3,561). In the estimation of the value of volunteer work, we considered an hourly wage of $10. If we had used the minimum wage of $8.60 in Nova Scotia in 2009, the value of the volunteer work would be 14% less. And if the volunteer work were valued at the average hourly wage of $19.24, the value of the volunteer work would exceed the value of the public funding.

All funds listed in Table 2 were acquired locally with the exception of one school that obtained a $1,500 external grant in support of physical activity. All four schools reportedly accepted food donations with a mean value of about $2,000 per school (not including renovations). On average, the combined grants, donations and fundraising were about $7,000 per school, of which approximately 75% was for nutritional programs. These may represent under-estimations as food donations were not consistently reported or did not have any monetary value.

DISCUSSION

Declines in diet quality and activity levels with consequent increases in body weights have resulted in an urgent need for preventive actions. CSH addresses both education and health in a planned, integrated and holistic way, and has been shown to benefit healthy eating and active living. (9,11) Healthy eating and active living, in turn, have been demonstrated to benefit learning. (11,18) This has sparked increasing interests in CSH. However, a dearth of information on costs associated with the implementation and maintenance of CSH may keep public health decision makers from making the investment. The present study describes the costs of the AVHPS program for which the benefits of CSH had been described previously. (9) The study revealed annual public costs of $344,515 for the school board, or on average, $7,830 per school and $22.67 per student. Locally acquired grants, donations and fundraising contributed $127,235, and the monetary value of volunteer work was estimated to double this. The cost of CSH is estimated to be approximately $10,700 per school and $31 per student. When further considering the value of volunteer work, this became $13,600 per school and $39 per student.

The costs for the AVHPS program seem similar to those of the Planet Health study (19) and CATCH (20) that estimated costs of US $14 and US $35 per student, respectively. As both the Planet Health study (19) and CATCH (20) were found to be cost effective, the AVHPS program will likely be as well if their school-board-wide expansion appears effective in preventing overweight and obesity. The costs of the MCG FitKid Project (21) and the New Zealand Apple project (14,22) were substantially higher at US $956 and NZ $1,281 per student, respectively.

Our cost analysis was greatly facilitated by the systematic financial documentation of amount and purpose of incoming funds by the school board and AVHPS program. However, not all donations, and particularly smaller donations, had been put on file. As such, we may have underestimated those contributions. Similarly, the value of donated foods like fresh vegetables and fruits, and breakfast cereals, were often not given a dollar value. Also, none of the schools had a systematic recording of volunteers contributing to in- and after-school activities. We had therefore captured these for the four sample schools. One may argue that revenues for schools and school jurisdictions may change with the introduction of healthful foods. Studies have shown both increases and declines in overall sales of foods. (23,24) Another study showed that of 17 schools and school districts that tracked revenue from fundraising after switching to healthier foods, 12 increased revenue and 4 reported no change. The one school district that did lose revenue in the short term experienced a subsequent revenue increase after the study was completed. (25) If the latter study findings would apply to the AVHPS program, the costs to the schools and school jurisdiction would be less than estimated in this study.

The Nova Scotia Government provides funding to the AVRSB to support CSH in their schools. Other public funding supports breakfast programs, the implementation of a school food policy and the organization of physical activity in schools. As the school board's financial management team has understanding and appreciation for the integrated and holistic nature of CSH, the funds are pooled such that the implementation of CSH is facilitated while ensuring that the purposes of the funds are met.

The AVHPS program is recognized as a 'best practice'. (15) It is a 'real world' example of a grassroots approach and gradually evolved into an ongoing school-board-wide program. This 'real-world' program differs from most obesity prevention programs that are researcher initiated. (12-14,19,20) Data collection in researcher-initiated studies are generally most systematic, providing better-quality data. However, 'real world' practice-based evaluations are important as they provide better judgement of feasibility, political acceptability and sustainability and they also provide better estimates of actual cost of the CSH program. (11) The combination of 'real world' practice-based evaluations and researcher-initiated studies provides public health decision makers with broader perspectives on costs and effectiveness that will facilitate their consideration and decision making.

Acknowledgements: We thank the schools and the Annapolis Valley Regional School Board for their valuable contributions to this work. The present study was supported through a grant to Dr. Veugelers from the Canadian Institutes of Health Research, The Heart and Stroke Foundation of Canada, and the Canadian Population Health Initiative. Dr. Veugelers is supported through a Canada Research Chair in Population Health and an Alberta Innovates--Health Solutions Scholarship. Jessie-Lee Langille is funded through a Vanier Canadian Institutes of Health Research Graduate Scholarship. All interpretations and opinions in the present study are those of the authors.

Conflict of Interest: None to declare.

Received: February 12, 2011

Accepted: May 24, 2011

REFERENCES

(1.) Shields M. Overweight and obesity among children and youth. Health Rep 2006;17(3):27-42.

(2.) Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 2002;26(4):538-43.

(3.) Ball GD, McCargar LJ. Childhood obesity in Canada: A review of prevalence estimates and risk factors for cardiovascular diseases and type 2 diabetes. Can J Appl Physiol 2003;28:117-40.

(4.) Williams J, Wake M, Hesketh K, Maher E, Waters E. Health-related quality of life of overweight and obese children. JAMA 2005;293:70-76.

(5.) Katzmarzyk PT, Janssen I. The economic costs associated with physical inactivity and obesity in Canada: An update. Can J Appl Physiol 2004;29(1):90-115.

(6.) Birmingham CL, Muller JL, Palepu A, Spinelli JJ, Anis AH. The cost of obesity in Canada. CMAJ 1999;160(4):483-88.

(7.) Ohinmaa A, Jacobs P, Simpson SH, Johnson JA. The projection of prevalence and cost of diabetes in Canada: 2000 to 2016. Can J Diabetes 2004;28:116-23.

(8.) Baranowski T, Mendlein J, Resnicow K, Frank E, Cullen KW, Baranowski J. Physical activity and nutrition in children and youth: An overview of obesity prevention. Prev Med 2000;31(2):S1-S10.

(9.) Veugelers PJ, Fitzgerald AL. Effectiveness of school programs in preventing childhood obesity: A multilevel comparison. Am J Public Health 2005;95(3):432-35.

(10.) Stewart-Brown S. What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Copenhagen: WHO Regional Office for Europe, 2006. Health Evidence Network Report. Available at: http://www.euro.who.int/document/e88185.pdf (Accessed September 16, 2010).

(11.) Veugelers PJ, Schwartz M. Comprehensive school health in Canada. Can J Public Health 2010;101(Supp. 2):S4-S8.

(12.) Wang LY, Gutin B, Barbeau P, Moore JB, Hanes J, Johnson MH, et al. Costeffectiveness of a school-based obesity prevention program. J School Health 2008;78(12):619-24.

(13.) Haby MM, Vos T, Carter R, Moodie M, Markwick A, Magnus A, et al. A new approach to assessing the health benefit from obesity interventions in children and adolescents: The assessing cost-effectiveness in obesity project. Int J Obesity 2006;30(10):1463-75.

(14.) McAuley KA, Taylor RW, Farmer VL, Hansen P, Williams SM, Booker CS, et al. Economic evaluation of a community-based obesity prevention program in children: The APPLE project. Obesity 2010;18(1):131-36. DOI:10.1038/oby.2009.148.

(15.) Public Health Agency of Canada. Canadian Best Practice Portal. Available at: http://cbpp-pcpe.phac-aspc.gc.ca/ (Accessed January 2011).

(16.) Drummond M, Weatherly H, Claxton K, Cookson R, Ferguson B, Godfrey C, et al. Assessing the challenges of applying standard methods of economic evaluation to public health interventions. York: Public Health Research Consortium, 2007.

(17.) Phillips CJ, Fordham R, Marsh K, Bertranou E, Davies S, Hale J, et al. Exploring the role of economics in prioritization on public health: What do stakeholders think? Eur J Public Health 2010; (online September, 2010).

(18.) Wang F, Veugelers PJ. Self-esteem and cognitive development in the era of the childhood obesity epidemic. Obes Rev 2008;9(6):615-23.

(19.) Wang LY, Yang Q, Lowry R, Wechsler H. Economic analysis of a school-based obesity prevention program. Obes Res 2003;11(11):1313-24.

(20.) Brown H, Perez A, Li YP, Hoelscher D, Kelder S, Rivera R. The cost-effectiveness of a school-based overweight program. Int J Behav Nutr Phys Activity 2007;4:47.

(21.) Yin Z, Gutin B, Johnson MH, Hanes J, Moore JB, Cavnar M, et al. An environmental approach to obesity prevention in children: Medical College of Georgia FitKid Project year 1 results. Obes Res 2005;13(12):2153-61.

(22.) Taylor RW, McAuley KA, Barbezat W, Farmer VL, Williams SM, Mann JI, et al. Two-year follow-up of an obesity prevention initiative in children: The APPLE project. Am J Clin Nutr 2008;88(5):1371-77.

(23.) French SA. Public health strategies for dietary change: Schools and work-places. J Nutr 2005;135(4):910-12.

(24.) Callaghan C, Mandich G. Healthier snacks in school vending machines: A pilot project in four Ontario high schools. Can J Dietet Pract Res 2010;71(4):186-91.

(25.) Johanson J, Wootan MG. Sweet Deals: School Fundraising Can Be Healthy and Profitable. Center for Science in the Public Interest. Available at: http://www.cspinet.org/schoolfundraising.pdf (Accessed May 2011).

Correspondence: Arto Ohinmaa, School of Public Health, Department of Public Health Sciences, University of Alberta, 3-50M University Terrace, 8303--112 Street, Edmonton, AB T6G 2T4, E-mail: arto.ohinmaa@ualberta.ca

Arto Ohinmaa, PhD, [1] Jessie-Lee Langille, MSc, [1] Stuart Jamieson, [2] Caroline Whitby, [3] Paul J. Veugelers, PhD [1]

Author Affiliations

[1.] School of Public Health, University of Alberta, Edmonton, AB

[2.] Annapolis Valley Regional School Board, Berwick, NS

[3.] Annapolis Valley Health Promoting Schools Program, Berwick, NS

Table 1. Total Direct Public Funding for the Annapolis Valley Health
Promoting Schools Program Schools During the 2008-2009 School Year

Programs                       Schools         Students          Total
                                (n=44)        (n=15,195)
                            Range   Mean      Range   Mean
CSH funds
Direct funding to          0-5041   1107   0-175.76     3.21    48,725
schools
Program administration *       --   2086         --     6.04    91,775
School Food Policy         0-2250    610    0-13.55     1.77    26,847
Provincial Breakfast       0-5364   2037   0-107.99     5.90    89,623
Program
Sport Animator Program         --   1591         --     4.61    70,000
Other public funding           --    399         --     1.15    17,545
([dagger])
Total direct public            --   7830         --    22.67   344,515
funding

* includes liability insurance costs, and funds for some school
meetings and professional development.

([dagger]) includes matched funding for after-school program from
municipalities and from the Nova Scotia government.

Table 2. Costs Reported by Four Schools in the Annapolis Valley
Health Promoting Schools Program on Volunteer Work, External
Grants, Donations and Fundraising in the 2008-2009 School Year

           Volunteers

School 1   Nutrition: 30 persons/week,
           30 min/person = 15 hours
           Value: 15 x $10 x 35 = $5,250
           Physical activity: 1 person 5 days
           a week; 1 hour/person = 5 hours
           Value: 5 x $10 x 35 = $1,750
           Total Value: 20 x $10 x
           35 weeks =$7,000

School 2   Nutrition: 1 person/day,
           30 min = 2 h 30 min
           Value: 2.5 x $10 x 35 = $875
           Physical activity: 0
           Total Value: $875

School 3   Nutrition: 2 persons/day;
           30 min each;
           Value: 5 x $10 x 35 = $1,750
           Physical activity: 0
           Total Value: $1,750

School 4   Nutrition: 2 persons/day;
           30 min each;
           Value: 5 x $10 x 35 = $1,750
           Physical activity: 1 person/day
           lunch hour, 1 person one
           morning/week = 6 hours
           Value: 6 x $10 x 35 = $2,100
           Total Value: $3,850

Overall    Nutrition: $2,406
mean       Physical activity: $962
           Total Value: $3,368

           Grants                    Donations

School 1   Nutrition:                Nutrition:
           Lunchtime program $400    Food donations $750
           Physical activity:        Money donations $3,568
           Girls program $1,500      Other: Kitchen Facility $2,016
           Total: $1,900             Physical activity: None
                                     Total: $6,334

School 2   Nutrition: None           Nutrition: Occasional food
           Physical activity: None   donation; value unknown (+)
           Total: 0                  Physical activity: None
                                     Total: unknown

School 3   Nutrition: None           Nutrition:
           Physical activity: None   Food donations $900
           Total: 0                  Money donations $295
                                     Physical activity: None
                                     Total: $1,195

School 4   Nutrition: None           Nutrition:
           Physical activity: None   Food donations;
           Total: 0                  value unknown
                                     Physical activity: None
                                     Total: unknown

Overall    Nutrition: None           Nutrition: $1,882 (+)
mean       Physical activity: $475   Physical activity: None
           Total: $475               Total: $1,882 (+)

           Fundraising

School 1   Nutrition: $3,542
           Physical activity: None
           Total: $3,542

School 2   Nutrition: None
           Physical activity: $936
           Total: $936

School 3   Nutrition: $335
           Physical activity:
           Significant sports teams
           fund raising (+)
           Total: $335 (+)

School 4   Nutrition: None
           Physical activity: None
           Total: 0

Overall    Nutrition: $970
mean       Physical activity: $234 (+)
           Total: $1,204 (+)

           Total

School 1   Nutrition: $15,126
           Physical activity: $3,650
           Total: $18,776

School 2   Nutrition: $875 (+)
           Physical activity: $936
           Total: $1,811

School 3   Nutrition: $3,280
           Physical activity: (+)
           Total: $3,280 (+)

School 4   Nutrition: $1,750
           Physical activity: $2,100
           Total: $3,850 (+)

Overall    Nutrition: $5,258
mean       Physical activity: $1,671 (+)
           Total: $6,929 (+)
           (Total per student: $20.1)

(+) Includes donations/fundraising that were not expressed in monetary
value by the schools.