This paper is based on data from a local neighbourhood project, which was conducted from January 2005 to December 2007. The development and evaluation of the primary preventive interventions was carried out in three different settings: “company,” “sports club,” and “residential district” in the area of Erlangen, Germany. The target population consisted of women “in difficult life situations” partly living in a residential district that was characterized by high rates of unemployment; social welfare recipients and migrants. The key characteristics of being “in a difficult life situation” included the receipt of low income or social welfare payments, low educational attainment, unemployed or in blue-collar occupation, and single parent or member of an ethnic minority. The project aimed to improve the opportunities for physical activity among this service population and define their interests at group meetings. Following the health assets concept and the participatory approach of project development, a setting group and a joint group were set up. The setting group mainly consisted of members of the target population, and the responsibilities within each setting included deciding on actions that should be taken for the promotion of physical activity among them; the joint group consisted of members of the target group, scientific experts, and setting-specific decision makers such as the management of the sports club; the mayor of Erlangen; other stakeholders and representatives of the company, who developed preventive exercise programmes suited to the target population and decided on instruments for evaluation in a cooperative work process. As these prevention programmes should be potentially transferable to other regions, the programmes were implemented and funded according to setting-specific arrangements.
The developed intervention programmes consisted of two different kinds of physical activity programmes, a 90-minute programme of moderate-to-high intensity (in the following called HI [high intensity] programme) and a 60-minute programme of low-to-moderate intensity (in the following called LI [low intensity] programme). Both programmes included a mix of different and from session-to-session changing elements of physical activity exercises such as endurance training, workout training, aerobic gymnastics, or relaxation exercises. The programmes took place as indoor programmes in gyms and once a week over a time period of three months, corresponding to a number of totally 11-12 sessions. The programmes were performed as group exercises, with a mean group size of 10–12 women. The exercise classes were directed by certified exercise instructors for grassroots sport and sport for all, being the first grade in the educational hierarchy of sport instructors and trainers and usually practised as a second-job activity. The acquisition of this certificate which is granted be the German public sport associations, is not restricted to an educational background in sport or healthcare; essentially, it requires the successful completion of a course consisting of regularly 120 hours of theoretical and practical training.
These two types of physical exercise programmes were offered in all three settings [22
]. Recruitment to the project was done by applying usual marketing techniques such as production and distribution of flyers, holding informative meetings, or publishing newspaper articles on project activities. Moreover, and much more importantly, three different types of “social catalysts” [35
] were effective in the process of recruiting women for the project. First, disadvantaged women themselves acted as social catalysts, leading to the involvement of other disadvantaged women in the implementation of the project. Second, informal social networks—particularly those of immigrant women—were especially helpful in initiating and sustaining women's participation and collaboration in project implementation. Third, a number of voluntary associations such as sports clubs, church communities, or cultural clubs of migrants which may be regarded as social institutions mediating between private and public life acted as social catalysts as well [35
Totally, 87 women could be recruited for participation in the physical exercise programmes. Recruitment to these programmes was not linked to the obligation to participate in the evaluation research activities of the project. In fact, only 57 women were willing to participate in these research activities. Moreover, recruitment to the programmes as well as to other project activities was done on a self-selection basis. Therefore, women not being in difficult life situations had the option to participate. However, survey results showed that more than 90 percent of the 57 study participants were women in difficult life situations as defined by the project. As the study should produce realistic estimates of the willingness to participate in health promotion activities, no financial incentives were offered to the women for acting as study participants or participating in the physical activity programmes. Quite the contrary, the programmes were offered as programmes liable to charges, even if the level of the fees was fixed somewhat below the customary prices of comparable programmes at the market place.
For the evaluation of the programmes, changes in health status and health-relevant behaviour of the women as well as the costs of all phases of the exercise programmes and changes in health care utilisation were measured. Medical and sport scientists estimated the intervention as not invasive for the participants. Medical parameters were examined during the regular consultations of general practitioners by the study participants. Therefore, the study leader did not apply for an approval of the study by the responsible Ethics Committee.
However, in this paper, only the costing dimension of this physical activity programme will be analysed and discussed with reference to the “health asset concept” and the “participatory approach” to programme development and according to the cost dimension of the conceptual framework for economic evaluations for physical activity programmes [32
2.2. Programme Setup
The project was divided into five phases: (1) assessment; (2) design of the preventive intervention programmes; (3) programme implementation; (4) programme optimisation; (5) dissemination of the preventive programmes.
In the first phase—the phase of health asset assessment—options, chances and resources within the three settings were identified according to the health assets concept of the WHO. Therefore, in the first phase, the tasks of the project were to make contact with project partners and decision makers and to conduct face-to-face interviews with women in the target groups (duration of phase 1: six months).
In the second phase—the design of the preventive intervention programmes—project partners, representatives of the target group, stakeholders in the related political field and scientific experts took part in establishing setting-specific planning groups as well as an overall joint group. In the setting and joint groups, the programmes were developed in accordance with the participatory approach of the WHO (duration of phase 2: six months).
During the third phase, the developed physical activity programmes were implemented and scientifically evaluated (duration of phase 3: twelve months).
The fourth phase—optimisation of the programme—aimed at improving the established programmes and initiated the first steps in the rollout of these programmes to other regions of Germany in order to expand these preventive intervention programmes beyond the end of the project (duration of phase 4: six months).
During the fifth phase—the phase of dissemination—the conditions for successful project transfer to other regions were to be created (duration of phase 5: six months).
In terms of assessing the costs and the cost-effectiveness of the physical activity intervention programme, only the first, second, and third phases are relevant for the health economic evaluation. Note, however, that subject of costing of the third phase of the project was only activities related to the implementation of the health promotion interventions, whereas resource consumption and costs related to the scientific evaluation of the effects of the project were not included in the cost analysis. Also excluded from costing were the last two phases of the project as the main focus of these phases was to publish, promote, and disseminate the programme.
As stated above, one purpose of the study was to answer the question of whether the costs of the health assets assessment and the participatory project development should be included in evaluating the programme costs. Therefore, a straightforward implication for the cost analysis is a careful splitting into these project phases of “asset assessment,” “programme design,” and “programme implementation,” thus taking into account the specific requirements of the health asset concept and the participatory approach. The cost measurement of this intervention is based on the development of a detailed cost inventory comprising all relevant cost categories. All these cost categories were assigned to their pertinent costing dimension in a conceptual framework for the economic evaluation of physical activity programmes [32
]. In general, the cost dimension of the framework consists of the programme development costs and programme implementation costs. The costs of the health asset assessment phase include a part of the programme development costs comprising the personnel and nonpersonnel costs of the scientists leading the assessment. During the design phase, another part of programme development cost in terms of personnel and nonpersonnel costs of the scientists, the stakeholders and representatives of the target group arose. During the implementation phase of the intervention programme, cost components such as the implementation costs including personnel and nonpersonnel costs of the scientists, stakeholders and members of the target group for implementation, organisation of the physical activities programmes and recruiting participants as well as the costs of running the programme occurred. The recruiting costs include the costs that are connected with the recruitment of the participants to the physical exercise programmes. Information and other marketing activities as well as costs of the pilot workout and health seminar are regarded in the context of the health economic evaluation as activities of recruiting. And finally, the costs of the programme itself include costs of personnel and nonpersonnel costs for the accomplishment of the programmes, participant time costs, and the costs of supervising women's children during the courses. The components of costs to be considered in each phase and according to the cost dimension of the conceptual framework are shown in .
Input-oriented subdivision of costs by project phases.
All quantities of resources consumed were assessed retrospectively by questionnaires and personnel telephone interviews for each setting separately. Stakeholders, trainers, members of the target group, and scientists were interviewed to get all utilisation and cost data.
All resources were valued using market prices or—if market prices were not available—using values derived from cost manuals in Euros and adjusted to the year 2005. Actual and imputed costs of resource use and (non-) personnel costs were calculated and shown for a physical activity programme lasting for three months.
Resources utilized by a productive activity may include fixed assets which by definition are not fully consumed during their short-term use. The resources used in the project under study include two types of these fixed assets: gyms and sport equipment. For both types, two different approaches were applied to calculate their costs. For using the gyms for the physical activity programme, first, the actual rents to be paid by the programme organisers were used; this approach would be appropriate for programme costing from an organiser's or programme payer's view. Second, the imputed rent of a new gym was calculated following the customary capital costs approach; the corresponding cost values would be appropriate for assessing the costs in a societal perspective. The details of calculating the imputed capital costs of the use of gyms are given in . The resulting unit cost estimate per square metre and hour has been used to calculate the total costs of utilizing the gyms for the two programmes in the three different settings.
Imputed capital costs of the gym.
Similarly, for the equipment used in the physical activity programmes, cost values based on actual expenses and imputed costs were calculated. The calculation of imputed costs was based on the costs of new equipment, which would be needed according to the recommended manual for these physical activity programmes. Apart from the stereo equipment, all equipment needs are defined as needs per capita of women attending the programmes. These costs were valued with market prices for the year 2005 and amortized over the years of possible usage. The total equipment costs are calculated as costs per person for all types of equipment (except for the stereo system) times the number of participants plus the costs of stereo equipment. Actual equipment expenses were assessed by questionnaire from the programme organisers of each setting from the joint group.
Personnel time costs of the scientists, which include, for example, interviews with members of the target group, identification of the assets and contact with decision makers, were valued by typical gross earnings of scientists as public sector employees [37
]. Time costs of representatives, for example time costs of attending the various meetings were valued by taking mean wage data of the lower social class (setting group) or by taking the mean wage rate of the German population (joint group) based on data published by the Federal Statistical Office of Germany [38
]. For calculating the personnel costs of exercise instructors, again two different methods were applied. First, the number of course hours was valued with the contracted compensation per course hour or the appropriate wage rate. Second, the number of course hours plus the additional time investment (e.g., for pre- and post-presence and preparation) was valued with the corresponding unit cost figure.
From a societal perspective, the valuation of the time costs of the participants who take part in physical exercise programmes should be based on the principle of opportunity cost. The valuation of these costs depends on whether the time occupied in physical exercise replaces leisure or labour time (including housekeeping and unpaid activities) and whether the participants regard the exercise itself as a leisure activity. In this study, the time consumed for participating in the programme courses was assumed to be substituted for another type of leisure activity. Hence, the time cost for physical activity was valued at zero costs.
2.4. Sensitivity Analysis
A sensitivity analysis was conducted to determine how “sensitively” the results of the cost analysis react to changes in the values of single-cost parameters. Several assumptions were varied, such as the amortisation of equipment, nonpersonnel and personnel costs. The average usage of a single piece of equipment was based on personnel information from a professional sports scientist. Variation in the usage of a single item cannot be excluded; therefore, ±1 year of amortisation of equipment was calculated. Additionally, ±50% of all nonpersonnel cost positions was calculated to reflect the uncertainty of the chosen market prices. Furthermore, the setting and the joint group are made up of different representatives who would incur different personnel time costs according to their work. Thus, ±10% of the average wage rate is added and subtracted to approximate the real average wage rate. The costs of exercise instructors were also calculated from the programme payer's perspective taking the actual wage rate and, for the societal perspective, calculating the additional time of pre- and post-preparation of the physical activity programme according to the questionnaire filled out retrospectively by trainers in the project. The personnel costs of trainers and child care were also calculated within ±10% to account for the uncertainty of the given hourly wage rate.
All costs were calculated and presented as minimum (min) costs, maximum (max) costs and personal information (PI) costs. The actual costs from the programme payer's perspective and the societal perspective (including imputed costs of the gym, equipment, and exercise instructors instead of the corresponding financial values) are calculated and reported separately.