Aligning Cost Assessment With Community-Based Participatory Research

Method

Black (N = 147), Latino (N = 33), and Arab (N = 126) women aged 19 to 88 years served by CHWs in the DDHWP and ACCESS public health programs were the focus of this intervention, with 210 women in the control group. The participants are served by 16 CHWs of the same race/ethnicity who, on average, had a caseload of 23 clients per month (Ford et al., 2014). The Kin Keeper intervention consisted of two cancer education home visits that included educational sessions and discussions led by a CHW, one focusing on breast and the other on cervical cancer. The control group received one education visit covering both breast and cervical cancer. For ethical reasons, the control group received one visit and the same written information as the intervention group, but the key difference was that the information was not presented nor discussed by the CHW. More details are available elsewhere (Williams et al., 2013). This cost analysis was performed from the perspective of a health organization with established community partnerships offering the Kin Keeper intervention in the future as an addition to an existing CHW program. Costs in each category were reported in year 2011 dollars.

As others, we assessed the costs of delivering the Kin Keeper intervention during a 12-month “steady state” period of operation. The study period was intended to represent a typical operating year, during which the partner health agencies operated at a relatively constant level in terms of participants visited, with no major organizational changes (Burwick et al., 2014; Burwick, Strong, Xue, & Daro, 2012). The intervention included two home visits. CHW time was allocated separately to training, recruitment, and delivering the intervention. Calculation of the CHW training costs assumed reinforcement-training after each 33 visits (approximately 100 visited participants), a conservative estimate. CHW supervision cost was estimated based on the percentage of a supervisor’s time allocated to supervising the Kin Keeper CHW. Ten percent full-time equivalent of a supervisor position was allocated to direct CHW supervision, an appropriate share for the needs of the intervention. Transportation costs for a home visit were calculated based on the fixed transportation stipend the CHWs were provided for the two intervention visits, regardless of the mean of transportation. The amount per visit ($12.50) was decided by the CHW supervisors based on their experiences with the CHWs and to get the CHWs motivated. Materials costs were separated between durable goods that could be used for a number of visits (e.g., breast model included in a breast cancer educational kit) and consumable goods that were given to participants at each home visit (health brochures). The sources of information were the Susan G. Komen for the Cure Foundation and the State of Michigan Breast and Cervical Cancer Control Program. For durable goods, we conservatively assumed that each item had a useful life for 33 home visits (approximately 100 visited participants) before it had to be replaced.

As described above, we present the cost analyses from the perspective of “piggybacking” Kin Keeper on an existing CHW program, and therefore we chose not to report the costs associated with delivering the control condition (available from the authors). As with other CBPR projects, the Kin Keeper trial incurred costs related to the development and maintenance of the CBPR partnerships with the community organizations. Because the CBPR relationships were already established at the time of the “steady state” period we analyzed, we only report costs associated with maintaining the CBPR partnerships, represented by meetings with the community organizations leaders. Each meeting included the travel cost (160 miles round trip at $.55/mile) and the opportunity cost of the time spent by the Kin Keeper principal investigator and a partner organization leader (estimated at $300/day × two persons).

The intervention was designed to be delivered in a family setting of between three and five related females in this trial. This trial enrolled and delivered the intervention almost exclusively to families of three related female members. We assumed the intervention costs did not vary with family size because, by design, the CHWs recruited only the initial family member, who then recruited additional family members, and all other components of the intervention were delivered in a family setting. We did not include in our analyses additional organizational costs (e.g., share of fixed and other operating costs allocated to Kin Keeper) because discussions with our DDHWP and ACCESS partners revealed that the added costs related to Kin Keeper were minimal and would not influence our analyses and results. In addition, while participant incentives were distributed during the randomized trial, we did not include these costs in the total cost of the intervention because these were research costs and would not be a part of the Kin Keeper future adoption in health organizations. We report the average cost for delivering the intervention to a family, while acknowledging the fact that costs for recruiting and delivering the intervention to individual families may vary with the specifics of each family and visit (e.g., ease of reach, scheduling, and longer than average home visits).

Results

Figure 1 presents the recruitment and randomization process. Of the initial 121 recruited intervention clients from among the CHWs’ existing caseload, 101 remained in the study and recruited additional family members. CHW training costs included training manuals ($9/manual) and 22 hours of training at a CHW hourly labor cost of $16.15, for a total of $22.06 per family ($11.03 per visit, two visits). On average, CHWs spent 4 hours to deliver the Kin Keeper intervention to each family, including the recruitment of the initial client in the study (0.5 hours), breast cancer education home visit (2 hours), and cervical cancer education home visit (1.5 hours) for a total of $64.60. CHW supervision costs per family home visit were estimated by dividing the yearly cost of $5,350 (10% of a CHW supervisor salary, including benefits) by 434 home visits, the number of visits delivered in the 12-month steady-state of the intervention, for a total of $24.64 per intervention ($12.32/visit). The transportation cost associated with the two intervention visits was $25 (the CHWs were provided with a $12.50 transportation stipend per visit). The cost associated with the breast and cervical cancer educational kits was estimated at $6 per visit ($200 per kit more than 33 visits, approximately 100 participants) for a total of $12 per intervention. The total cost of delivering the Kin Keeper intervention, including two cancer education home visits, was approximately $151 per family (Table 1). Not included in the total intervention costs were expenses related to the maintenance of the CBPR relationships, estimated at $2,752, divided by the 434 home visits, for a total of $12.7 per intervention ($6.34/visit). These included the costs of four meetings during the analyzed “steady-state” period (each meeting: $88 travel and 2 × $300 estimated opportunity cost of time).

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Figure 1.

Randomization for Kin Keeper^SM cancer prevention intervention program.

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Table 1.

Costs of Delivering the Kin Keeper^SM Intervention to a Family, Including Two Cancer Education Home Visits.

Costs of the intervention, including two home visits	Kin KeeperSM
CHW training costs	$22.06
CHW (recruitment, CHW home visits)	$64.60
CHW supervision	$24.64
Transportation costs	$25.00
Durable goods
Cancer educational kits	$12.00
Flipcharts	$0.45
Consumable goods
Health brochures (breast and cervical cancer)	$2.16
Total cost per intervention	$150.91

Note. CHW = community health worker. The intervention costs reported in the table include the costs incurred by a health organization to add Kin Keeper^SM with an existing CHW program and with established community partnerships.

Discussion

To our knowledge, this is one of the few prospective cost assessments of an intervention that uses CBPR. Doing this assessment encourages the practice of prospective reporting costs of interventions and providing early information for replication in diverse settings and populations (Glasgow et al., 2006). Kin Keeper is an inexpensive educational intervention to promote breast and cervical screening compared with other interventions delivered by community or lay health workers. The intervention was designed to be delivered in a family setting of between three and five related females in this trial. While this trial enrolled and delivered the intervention almost exclusively to families of three related members, potentially, the intervention could be delivered to larger family groups at virtually the same cost per family. For approximately $151/family (the equivalent of $50/participant), the participants received two in-home CHW educational visits, one focused on breast and the other on cervical cancer. In addition, Kin Keeper is establishing a trained network of CHWs with breast and cervical cancer knowledge. We are limited in the comparisons we can make with the existing literature because there are very few cost assessments of community-based cancer education interventions similar with Kin Keeper. For perspective, another community-based randomized trial relied on health educators (promotoras de salud) to teach cancer screening/prevention classes at a cost of approximately $103/participant when delivered in group settings (Larkey et al., 2012). To further put the Kin Keeper cost in perspective, the United States spends more than $100 billion on cancer care every year, of which more than $15 billion on breast cancer treatment, according to the American Cancer Society. American Cancer Society estimates that 12% of all women will develop invasive breast cancer at some point during their life, with lifetime cost of treatment between $20,000 and $100,000 (Campbell & Ramsey, 2009).

Prior research showed that the Kin Keeper model has strong intervention fidelity and quality, indicated both by participants and CHWs (Ford et al., 2014). Reporting prospective cost assessment in real time can help organizations make decisions about whether to adopt, adapt, adjust, or expand an intervention without waiting for retrospective reporting on completion of a study. Reporting also responds to the recent call for reporting information about the external validity and replicability of a study (Glasgow et al., 2006).

The intervention was designed to be attached to public health delivery systems that already employ CHWs who have a caseload of underserved clients. The fact that the CHWs are already employed and have ongoing contacts with clients minimizes the need and added cost of training and supervision. Providing health education to their existing clients is one of the CHWs’ responsibilities. With a broad scale-up potential, the intervention will be implemented and evaluated in partnerships with additional public health agencies employing CHWs to serve diverse populations in various United States locations in future research projects. While there are no specific funding provisions for CHWs in the Affordable Care Act, the new environment under the Affordable Care Act expands the opportunities to develop the CHW workforce and integrate CHWs into the health system. This would increase the appeal of the Kin Keeper Model.

Strengths of this study include the analysis using a “steady-state” period of implementation, a typical operating year, during which the partner health agencies operated at a relatively constant level in terms of participants visited. This allowed assessing the cost of adding the Kin Keeper intervention to an existing CHW program and the examination of individual program components, including CHW training, home visiting time, and supervision. A potential limitation was the fact that the “steady state” analysis perspective did not fully account for start-up costs. However, we did include the initial CHW training costs. In addition, using the perspective of a health organization that would add the Kin Keeper intervention to an existing CHW program minimizes the potential start-up costs. Another potential limitation, present in cost studies in general, is that we reported the average cost for delivering the intervention to a family. We acknowledge the fact that costs for recruiting and delivering the intervention to individual families vary with the specifics of each family and visit (e.g., ease of reach, scheduling). For example, the costs could be higher for families hard to reach, but such increases may not be very large. For example, an additional trip ($12.50) and additional hour of CHW’s time ($16.15) would increase the cost per family to $179 (the equivalent of $60/per participant). An additional potential limitation was our choice not to include in the intervention costs the expenses related to the maintenance of the CBPR partnerships (approximately $12.7 per intervention for a family), which included travel and opportunity cost of the time to talk to the leaders of the Kin Keeper community partner organizations. We made this choice because the costs will likely not be incurred by a health organization with established community partnerships adding Kin Keeper to an existing CHW program.

To conclude, Kin Keeper is an inexpensive educational intervention delivered by CHWs to promote breast and cervical screening, with strong fidelity and quality. The intervention had strong fidelity and quality and was well received by participants and CHWs. Prospecting cost evaluations of community-based interventions are needed for making informed timely decisions on the adaptation and expansion of such programs. Future research at the end of the randomized trial follow-up will assess the cost-effectiveness of the intervention. Planned research of the Kin Keeper scale-up will assess intervention costs in other populations and in different organizational settings and may include additional costs incurred by the specific health organizations. Kin Keeper is a relatively small investment that could prove effective if it will reduce even a small fraction of the cancer-related costs through earlier detection of breast and cervical cancer that could decrease treatment costs and mortality.