Winter 1988 // Volume 26 // Number 4 // Feature Articles // 4FEA4

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An Ounce of Prevention


Paula Keefe
Extension Home Economist
Iowa State University
Black Hawk County

Even skeptical and hard-nosed critics will become supporters of Extension, when we show how our programs prevent costly problems to society.

It's not enough to do a good job, reach the program objectives, or keep statistics and evaluations. It's not even enough to get testimonials to the right legislators at the right time. We must document unacceptable situations that would occur if our programs didn't exist. Only then will we have the impact to create the support we need.

Using the Expanded Food and Nutrition Education Program (EFNEP) as an example, this article reviews prevention concepts and shows how prevention is cost-effective in public fund expenditures.

EFNEP as Prevention

Nutrition affects a person's health and productivity in many things. A good breakfast may help a child remain alert and behave more appropriately at school. Good nutrition will also reduce susceptibility to infections and other diseases. A woman's nutritional status during pregnancy has irreversible effects on her unborn child. Eating habits developed in childhood are factors in cardiovascular disease, diabetes, and even cancer.1 As adults, people who experienced mild malnutrition in childhood are far more likely to miss days from work or to have medical conditions that prevent them from holding regular jobs.2

EFNEP fosters appropriate food purchase, preparation, sanitation, and nutrition before problems occur. It creates new knowledge, skills, and attitudes that make misuse of limited nutritional resources far less likely.

Recent studies consistently show that children living in low-income households continue to be at risk from chronic nutritional deficiencies.3 Adult EFNEP targets the adult responsible for food purchase and preparation for such children. 4-H EFNEP organizes after-school groups for children in low-income neighborhoods. Thus, EFNEP is primary prevention targeted to a "population at risk."

Cost Effectiveness

During fiscal year 1985, 224,609 families were enrolled in adult EFNEP nationwide. The total federal budget for adult EFNEP that year was $60,354,000, averaging $268.71 per family.4

Nearly all EFNEP clientele are eligible for Medicaid. In other words, their poor health is a direct expense to our government.

Poor nutrition is known to predispose children to infections. Lead poisoning in children is usually caused by eating paint chips due to pica - a symptom of long-term anemia. Indeed, it's lead poisoning and chronic infections that "consistently show greater severity and higher prevalence among poor children."5

Of Medicaid children under six, 90.3% visit a physician at least once annually. The mean is 5.5 visits, with 4.8 prescriptions per child annually. For Medicaid children 6-17, the mean is 6.0 visits to physicians and 3.8 prescriptions each year.6 Nearly a third of Medicaid AFDC recipients had at least one hospital admission in 1980, with an average stay of 4.1 days.7

In other words, one child is likely to cost taxpayers more per year in Medicaid payments than the entire family's participating in EFNEP would cost. If, over their lifetimes, the members of an enrolled family avoid one hospitalization or 10 office visits, EFNEP will have paid for itself.

Evaluation of EFNEP

According to Lofquist, a well-designed prevention program is oriented toward practical, specific, and measurable results. Thus, evaluation is planned from the beginning as integral to the program.8 Since its beginning, adult EFNEP has used a 24-hour food recall. An adequate diet is defined as at least two servings of dairy products, two servings from the meat group, four servings of fruit and vegetables, and four servings from the bread and cereal group. In Black Hawk County, Iowa, between October 1, 1985 and September 30, 1986 only three percent of clients entering adult EFNEP had adequate diets. Of those exiting the program, 26% did.

Another measure is the minimally adequate diet consisting of at least one serving from each of the nutritious food groups. Forty-seven percent of entering clientele met this standard, compared with 95% of those leaving the program. Nationwide, similar results are documented every year.

Follow-up studies of the nutrition practices of former EFNEP participants find that their nutrition practices are maintained. Some graduates developed their nutritional skills for employment and many made positive changes in managing other personal resources. This shows EFNEP families developed the habit of continuing to learn and EFNEP benefits are long-term.9


Like EFNEP, most Extension programs emphasize primary prevention, self-reliance, and management skills. Often, the problems addressed aren't yet urgent, perhaps not even evident to people lacking an indepth understanding. But, it's at this early, nebulous stage that the best, most cost-effective solutions can be found for a wide range of problems.

As in the example given, it can be useful to document facts that can be used to infer the implicit benefits and cost-effectiveness of an Extension program. Those in authority over potential funds may consider the program as a luxury. When they see the larger, more expensive problem that the program prevents, they may be far more willing to allocate funds.


1. E. M. Hamilton and E. Whitney, Nutrition: Concepts and Controversies (St. Paul, Minnesota: West Publishing Co., 1979), pp. 376-78.

2. S. L. Manocna, Malnutrition and Retarded Human Development (Springfield, Illinois: Charles C. Thomas, 1972), pp. 78-83.

3. Physican Task Force on Hunger in America, Hunger in America: The Growing Epidemic (Middletown, Connecticut: Wesleyan University Press, 1985), pp. 111-15.

4. U.S., Office of Management and the Budget, Appendix to Budget of the United States (Washington, D.C.: Government Printing Office, 1986).

5. Judith D. Kasper, "Health Status and Utilization: Differences by Medicaid Coverage and Income," Health Care Financing Review, VII (Summer 1986), 13.

6. Ibid., p. 8.

7. Ibid., p. 16.

8. William A. Lofquist, Discovering the Meaning of Prevention: A Practical Approach to Positive Change (Tucson, Arizona: Associates for Youth Development, Inc., 1983).

9. Cora G. Vowell, ""Long-Term Effects of EFNEP on Program Homemakers," The Reporter, XLII (Fall 1985), 22-23.