Over a decade ago, the Society for Prevention Research endorsed the first standards of evidence for research in preventive interventions. The growing recognition of the need to use limited resources to make sound investments in prevention led the Board of Directors to charge a new task force to set standards for research in analysis of the economic impact of preventive interventions. This article reports the findings of this group’s deliberations, proposes standards for economic analyses, and identifies opportunities for future prevention science. Through examples, policymakers’ need and use of economic analysis are described. Standards are proposed for framing economic analysis, estimating costs of prevention programs, estimating benefits of prevention programs, implementing summary metrics, handling uncertainty in estimates, and reporting findings. Topics for research in economic analysis are identified. The SPR Board of Directors endorses the “Standards of Evidence for Conducting and Reporting Economic Evaluations in Prevention Science.”The online version of this article (10.1007/s11121-017-0858-1) contains supplementary material, which is available to authorized users. In the nineteenth and early twentieth centuries, many social programs were recognized as worthy endeavors simply because of their beneficent intent. As federal and state governments gradually took over the funding of large-scale social programs, calls for accountability in these public expenditures grew, with an initial focus on documenting the reach of interventions through service delivery . In particular, this work offers standards for the broad field of prevention science—the empirical investigation of preventive strategies and translation of findings to promote well-being. Economic evaluation may be conceptualized as a set of methodological tools for assessing and contextualizing the costs and benefits of an intervention. In this context, economic evaluation is a natural, yet underutilized, methodology of prevention science.Certain methodological, logistical, and ethical issues surrounding these evaluation approaches are unique or especially pertinent when employed to assess preventive interventions Beatty  in part Many federal, state, and local decisionmakers increasingly recognize and seek out high-quality economic evaluations that use consistent methods and reporting standards , and benefit-cost analyses . Cost analysis is used to determine the cost of implementing a prevention strategy. Cost-effectiveness analysis is a way of comparing the costs of two or more interventions to reduce or produce a single beneficial outcome. Benefit-cost analyses compare the difference in costs of two or more conditions against the differences in benefits of those conditions valued by a common metric . Budgetary impact analyses, a form of BCA, are the public-sector analog to private-sector return-on-investment analyses that are used to guide decisions about where to invest resources from the perspective of the government and a business, respectively. Public-sector decisions are often more complex than private-sector decisions because they must consider benefits and costs for The answers to these and other questions can support decisions about how best to allocate limited resources for prevention. This report focuses on standards for cost analysis and benefit-cost analysis, although likely informing work in cost-effectiveness analysis indirectly. For those interested in CEA, the Second Panel on Cost-Effectiveness in Health and Medicine has released complementary standards guiding cost-effectiveness analysis  the decisionmakers who are soliciting and who may benefit from economic evaluation, (2) the kinds of economic evaluation information that they request, (3) how economic evaluation contributes to evidence of effectiveness, and (4) examples from the field.Decisionmakers interested in economic evaluations of prevention programs include, but are not limited to, elected and politically appointed officials in both the executive and legislative branches of government; program administrators in government; for-profit, not-for-profit, and philanthropic agencies responsible for prevention funding; administrators and evaluators responsible for program implementation; and program developers interested in creating efficient interventions. Economic evaluations are relevant for policy-making and program funding at all levels of government, from city and county-level local jurisdictions, to state branches of government and agency heads, to the executive and legislative branches of the US federal government. Internationally, economic evaluation plays a substantial role in setting funding priorities within nations  and for making funding decisions by the World Bank, USAID, the United Nations, and many international nongovernmental organizations .Sometimes decisionmakers simply want to know the costs of a program. That is, they seek an accurate and comprehensive cost analysis of the total and component resources required to implement a prevention strategy—without an evaluation of the intervention’s impacts. They often compare costs of programs and seek consistent means for doing so. The standards proposed below provide a guideline for producing this kind of information. Sometimes decisionmakers may not know how to request the evidence they want. For instance, they may request evidence of cost-effectiveness when what they ultimately desire is a benefit-cost analysis. Cost-effectiveness analyses are most useful when comparing interventions that affect the same outcome. An example is a study that compares differences in costs between two programs designed to increase graduation rates where the increase in graduation is the only outcome measured. Guidelines for cost-effectiveness analyses are increasingly available , and the ranking Democrat on the Senate Budget Committee , the Commission is composed of 15 unpaid members, academic researchers, data management experts, and program administrators appointed by the President and Majority and Minority Leaders of the Senate and House of Representatives. The Commission is charged with three tasks:The Commission’s responsibility is to “determine the optimal arrangement for which administrative data on Federal programs and tax expenditures and related data series may be integrated and made available to facilitate program evaluation, policy-relevant research, and benefit-cost analyses.” It is not surprising that Commission members want to be sure that Congress knows how economic evaluations can be conducted with existing federal data, because members of Congress want to know the dollar value of benefits produced by federal programs. Based on the number of laws that now require rigorous evaluations and economic evaluations of social programs, combined with the attention that will be given to economic evaluation by the Ryan/Murray Commission, it is likely that the influence of economic evaluations in the federal government will continue to grow.This agency has long provided guidance to federal agencies on including economic evaluation as part of regulatory impact analyses for economically significant rules. The OMB circular explaining the use of economic evaluations in federal rule making provides guidance on how to: (1) quantify and monetize the benefits and costs of regulatory actions; (2) evaluate nonquantified and nonmonetized benefits and costs; and (3) characterize uncertainty in benefits, costs, and net benefits. The purpose of the guidance is to inform agency decisions in advance of regulatory actions and to ensure that regulatory choices are made after appropriate consideration of the likely consequences. To the extent permitted by law, agencies should proceed only on the basis of a reasoned determination that the benefits justify the costs (recognizing that some benefits and costs are difficult to quantify). Economic evaluation within regulatory analysis also has an important democratic function. It promotes accountability and transparency and is a central part of open government. Important goals of economic evaluations included as part of these regulatory analyses are to establish whether federal regulation is necessary and justified to achieve a social goal. Further, they are used to clarify how to design regulations in the most efficient, least burdensome, and most cost-beneficial manner.One of the major duties of the CBO is to “score” the cost of legislative proposals . Many of the proposals the CBO scores address social policy—either new social programs or reforms of old programs. In these cases, the CBO is sometimes willing to score savings against the cost of the program if there is strong evidence, usually from randomized controlled trials (RCTs), showing that the program results in government savings because some social problem is reduced in magnitude. If the study includes the kind of economic evaluation using standards we propose, and if the evaluation shows government savings, the CBO would be all the more likely to reduce its estimate of program costs to reflect the savings. In early drafts of the Affordable Care Act, for example, the CBO (as well as the OMB) scored savings as a result of an appropriation for spending on the Nurse Family Partnership home visiting program, a program with evidence from three RCTs of impacts that result in government savings in healthcare and other programs. The Coalition for Evidence-Based Policy summarized both the CBO and OMB positions on using evidence from social science research in scoring; their summary includes a CBO letter explaining their position and an outline of the OMB’s position , then Congress would need to identify only $800 million rather than $1 billion to offset the program cost. Thus, unlike most other types of spending, prevention programs that save government money have the potential to apply the saving directly to the estimated net costs of the program even during budget allocation.At the state level of policy-making, economic evaluation similarly plays an important role in the policy-making process. Created by the Washington State legislature in 1983, the Washington State Institute for Public Policy (WSIPP) is one of the earliest examples of using benefit-cost analysis to advise state policymakers on a systematic and routine basis. WSIPP is a nonpartisan agency governed by a board of directors with representatives from the legislature, the governor’s office, and public universities. The agency has a director and a staff to perform the policy analyses requested by the state legislature. In a typical analysis, the agency is asked by lawmakers to investigate a problem the legislature wants to address and provides them with an assessment of programs that research has shown to effectively attack the issue. The assessment includes an analysis of the costs and benefits produced by the programs the legislature may support. The agency provides state policymakers with a list (referred to as a “portfolio”) of programs and the costs and benefits they produce, which policymakers can use as a tool in fashioning legislation. The benefit-cost information provided to policy makers by WSIPP staff has become a major part of the legislative process in Washington, owing to the reliability of information WSIPP has provided over the years.Nongovernmental organizations (NGOs) also play an important role in the advancement of economic evaluation in policy making. Building on the WSIPP program, the Pew-MacArthur Results First Initiative is a large-scale attempt to help states develop a framework to bring evidence, especially benefit-cost studies, to bear on policy choice  while the other will focus on the impact on society . In this context, the question should be clear to avoid unintentionally conducting evaluations that fail to answer the intended question of interest.primary goal . If the program has multiple goals , all goals should be operationalized.The program’s theory of change. Identify the activities involved, stages over which these activities take place, and potential direct and indirect effects of the program as comprehensively as possible.The program’s nature of the program. Identify eligibility criteria , delivery setting , population served, specific services , protocols, duration, and other salient characteristics.The time period(s) in which the program was conducted and a description of the location(s) and context(s)  in which the program was implemented. If multiple sites were involved, describe any major differences in how the program was carried out, who was served, and how it was administered. Provide a rationale for whether the analysis should be conducted separately by site.The comparison condition, that is, whether the alternative to the focal program is no program, an alternative intervention, etc. Description of this comparator is just as important as the description of the program. A program’s economic evaluation results can change dramatically if the comparison condition changes.The An economic evaluation should describe or reference the prevention program in sufficient detail that readers who are not experts in the problem behavior or familiar with the specific program can understand its purpose and essential elements. The description should include at least the following:research design that yielded the effects to be monetized in the economic evaluation . See Gottfredson et al.  used in the analysis should be clearly described.potential impacts were measured and which were not, and the estimated size of each impact and its level of statistical significance. Discuss whether there is reason to believe that some unmeasured impacts could be substantial, so that their omission might skew the findings. Briefly describe methods and instruments used to measure impact.Which data quality used to measure the program’s effects should be outlined. This information includes whether the data come from surveys, administrative records, observational reports, or some other source(s). The quality of the data should be discussed .Information about the quality of the evaluation study, including follow-up and attrition rates by condition at each measurement time point should be outlined .The Limitations, if any, on the ability to draw causal inferences from the analysis.Concerns, if any, about the internal and external validity of the findings.For economic evaluations beyond cost analyses, decisionmakers need to understand what impact estimates are included in the economic evaluation . The full range of theoretically possible impacts as well as which ones were measured and whether they were monetized should be described. The information should address the following issues:The analytic perspective within an economic evaluation guides decisions around how cost and benefits are determined. For instance, the resources needed to implement a program may represent a substantial cost to the implementing agency but an inconsequential cost to the participant. The societal perspective, most common in benefit-cost analyses, considers the economic impact on society as a whole  or agency. In addition, when prevention programs have impacts that affect tax revenue , these economic benefits should account for the administrative costs . Sometimes, it is simply not feasible for an economic evaluation to consider distant-future time periods or particular public systems. In these cases, the evaluation should state explicitly which time periods and sectors are covered and acknowledge possibly relevant periods and sectors that are not addressed.The evaluation of program costs and resource needs is essential as a basis for benefit-cost analysis, but also because detailed analysis of costs can improve subsequent program planning and implementation. A comprehensive analysis of the cost of implementing a prevention program is important to decisionmakers’ efforts to determine whether to adopt a program. This information has utility even in the absence of a benefit-cost analysis. However, program costs are often calculated or estimated retrospectively, if at all. Additionally, program costs are often reported as a sum of direct expenditures and may neglect resources such as volunteer time, participant time, or program donations. Evaluations sometimes neglect an accounting of the infrastructure costs to adopt programs, integrate them with existing organizational activities, and sustain them over time. Finally, the methods used to calculate costs are highly variable, which reduces our ability to compare costs across programs or to generalize program costs to new settings.The process of understanding a program’s resource needs continues to be one of the most consistently neglected yet addressable areas of program evaluation  describe the theory of change or logic model guiding the program; (2) identify specific resources used to implement the program; (3) value the cost of those resources (see section III); and then (4) estimate the program’s total, average, and marginal costs. This method includes estimating resource needs related to both the “day of implementation” and intervention infrastructure as well as variable and fixed costs . This approach recognizes the importance of going beyond program budgets to include other measures of resource consumption that help illuminate how resources are used to achieve prevention goals . Free tools for implementing this approach to cost analyses are available, including the online CostOut tool available through Columbia University’s Center for Benefit-Cost Studies of Education.The ingredients method calls for a comprehensive assessment of all resources  needed to carry out the program  and the prices of those units. Sometimes the prices for different resources will be followed across many years. For analytic purposes, all prices should be converted to a common year using an appropriate price index. We recommend using the year when the report is issued (“today’s dollars”).Often the resources needed to implement a prevention program are consumed at different rates over a period of time . For example, capacity-building and training needs may be most intensive early on, whereas sustainability efforts are likely to increase over time. A robust understanding of when different resources will be needed  is key for program planning and project sustainability  and to ensure ongoing program quality  are also likely to be substantial but are conceptually distinct from the cost of implementing the program to achieve impact. As a result, these costs are not typically included in the cost analysis.The nature of human development is that early experiences in one domain can cascade across the lifespan into other domains  or from readily monetized outcomes . Observed outcomes during the course of the evaluation afford the opportunity for direct valuation. Some outcomes may have a direct monetary value , and some can be converted to a monetary value .The monetary value applied to a particular behavior may be computed by any of several methods, and so the researcher should report the behavior change in natural units  separately from the valued benefit  so that other researchers may recalculate benefits using alternative approaches. For instance, changes in public policy may affect the economic value from altering a behavior .Comprehensive economic valuation requires designing the evaluation to analyze all relevant domains of impact, both those measured during the evaluation as well as those not measurable in the timeframe of the evaluation. Program developers and evaluators should determine the course of intervention impact over time and assess impacts on persons in the comparison group. This measurement should include as much follow-up data collection as is feasible based on logistic and funding limitations. Measures of program impact that extend beyond participants should be based on the intervention’s logic model .The assignment of a monetary value to a behavior is made in a particular economic, social, and political context. Further, that context may vary across geographical regions or time. A program that serves to strengthen job skills may have differing economic benefits depending on how difficult it is to find a job. In a period of high employment, these skills may not be necessary to find a job, whereas in a recession, these skills may increase applicant competitiveness. A program that prevents psychiatric disorders with high utilization of welfare services may have differing economic benefits depending on the government’s funding for such services. For instance, a prevention program deemed cost-beneficial in a political environment of generous welfare services may become noncost-beneficial if a new government cuts funding for these services. By reporting behavior units separately from their estimated monetary value, researchers and policymakers will be able to compute updated benefit-cost ratios to estimate benefits for a programs offered in new contexts more easily. As described in section I, the evaluator should describe context in which estimates are made by noting the years covered, the geographical locale, and description of the participants .Whereas directly valuing outcomes provides the most straightforward approach to assessing benefits, sometimes logistic or analytic restrictions prevent direct valuation from occurring. Further, sometimes the outcomes that can be monetized directly do not represent the full impacts of the intervention. In such cases, evaluators often employ indirect valuation techniques to project program impacts into the future. Projecting impacts beyond those directly observed as part of the evaluation can enable a more accurate and complete estimate, but they also carry assumptions about the relations between present and future outcomes. Given the rich literature demonstrating the value of programs that yield long-term improvement in the developmental life course  or a more liberal valuation . In such a scenario, evaluators need to justify their decision and test the impact of choosing upper- and lower-bound estimates. Such tests, known as sensitivity analyses, are covered in section V (handling estimate uncertainty).The quality and consensus on shadow prices can vary by substantive area. As such, it is important to consider carefully the utility of using shadow prices given the purpose of the evaluations. Sometimes the shadow price is imperfect but may currently be the best estimate and appropriate for indirect valuation. Sometimes an estimate is only appropriate for projections in certain circumstances and should not be generalized . Sometimes a shadow price estimate is outdated and should be replaced with newer estimates . For instance, a somewhat controversial source of benefits in some prevention programs is quality-of-life improvements, as indexed by measures such as a disability-adjusted life year (DALY). The DALY is a measure of the burden of disease or disorder, computed by summing the value of life years lost prematurely plus the proportion of the quality of life lost each year while still surviving . These quantitative figures are based on qualitative judgments of the value of life and the suffering experienced by surviving persons afflicted with a disorder, automobile crash, or other adverse outcome—typically judged by stakeholders or evaluated from historical jury awards. As an example, based on surveys with caregivers and pediatricians, Miller et al.  estimateSometimes an outcome variable will carry both positive and negative monetary benefits. An example is college attendance. As an outcome of a prevention program, college attendance carries immediate negative benefits , but also longer-term positive benefits in later income and better health and overall welfare. Another example is employment. As an outcome of a skills-training program for single mothers, employment brings negative benefits in the form of increased childcare and transportation expenditures and positive benefits in the form of higher income. Some analyses place the negative benefits on the cost side—others, on the benefits side. We suggest that the field adopts a standard for placing all monetary values that accrue as a direct part of the intervention and during the intervention period into the cost “bin” and all monetary values that accrue after the intervention ends into the benefits “bin,” acknowledging that some outcomes will have negative value. Doing so functionally deducts the negative outcomes from the positive outcomes instead of inflating the cost of the program. We suggest this standard because it brings clarity to these terms and will reduce confusion in interpreting results. Specifically, costs are average monetary values that are assumed to occur for every participant by definition of being assigned to an intervention. Benefits are monetary values that follow from outcomes that may or may not occur as a function of the experience of being assigned to intervention, with a higher or lower probability for recipients. Like the college attendance example above, numerous other outcomes carry both positive and negative monetary values that are best summarized as a single net value rather than a negative cost and a positive benefit.p value. For example, cost estimates can be disaggregated both according to different program elements or phases  and according to who bears the costs . Similarly, benefits can be disaggregated according to source  and to beneficiary . The metrics reported ultimately summarize the evaluation’s findings. When well done, they provide an evaluation that is transparent and highly useful for program planning and budgeting. When done poorly, the metrics reported can obscure important issues and misinform decisionmakers.The final step of modeling the costs and benefits of an intervention is to compute a net-benefit score for intervention recipients . Yet, costs and benefits of prevention are not static. Thus, to increase the clarity and utility of the information provided, it is important to calculate and report a broad spectrum of metrics that describe program costs and benefits from multiple perspectives. Constructing these metrics differs from simply reporting a coefficient and One of the overarching considerations to be taken into account when constructing metrics is to characterize accurately the timing of the intervention’s benefits and costs. In evaluations of preventive interventions that span many years, this is of particular concern as the costs and benefits are subject to inflation. Inflation, the general rate at which prices for goods and services are rising, can be accounted for by simple conversion using a relevant consumer price index. For those unfamiliar, a multitude of free software and guides are available. Although the accuracy of an analysis will not be compromised by expressing benefits and costs in another year, using current dollars gives decisionmakers a better sense of the practical size of benefits and costs in the context of current purchasing power.Ignoring inflation, a dollar of future economic benefits is worth less than a dollar of current program costs , this variation is usually due to self-selection. In these cases, it is difficult to identify causal effects of the dose of participation on an outcome. Because it is often difficult to predict self-selection patterns in future implementations, it is problematic to assume that different cost estimates can be assigned to different groups in a reliable way. When selection is correlated with a group characteristic such as gender or income, it may make the assignment of different cost estimates to different groups meaningful. For example, perhaps females, on average, show up for more individual counseling sessions in a voluntary prevention program than do males, leading the researcher to estimate the average program cost to be higher for females than males.Sometimes when researchers disaggregate the average cost according to whether an assigned participant actually participates, they compute two different impact estimates—one for the total sample  and one for the participating subsample . The validity of the TOT estimate depends on participation being exogenous to any characteristic of the assigned participants .The marginal cost of a program is the cost of adding participants. Consumers of reports of program cost estimates often want to extrapolate the estimated cost for a future implementation with a different sample size. Extrapolations usually cannot be made linearly because some costs are fixed and some are variable. Fixed costs are required for a future implementation no matter how individuals participate, at least within a certain range. Variable costs depend on the number of participants. For example, perhaps a group intervention has a fixed cost for the group leader’s salary and variable costs for food and transportation for each participant. Adding another participant increases the fixed cost by nothing and the variable cost by the food and transportation cost for that participant. When such nonlinearities occur, the average and marginal cost of a program will differ. We recommend disaggregating costs according to fixed and variable costs and also reporting the marginal cost of serving an additional participant.Economic evaluators typically identify program impacts, estimate an economic benefit for impacts that are monetizable, and then sum these values to reach a total benefit. When summing benefits, it is essential that evaluators not double-count benefits  is the difference between present value benefits and present value costs Boardman . It is tThe NPV can be estimated on a per-participant basis or for the entire sample for which the BCA was conducted. The per-participant value is easier to grasp and usually the level at which model testing and statistical significance are computed, but the sample-based value provides a more complete picture of the overall loss or gain resulting from the program.In addition to the NPV, BCA results can be summarized in terms of the benefit-cost ratio, payback period, return on investment (ROI), internal rate of return (IRR), and investment risk. Each has potential drawbacks that should be understood and communicated alongside results where applicable Boardman .The benefit-cost ratio (BCR), which divides present value benefits by present value costs, has intuitive appeal as a summary of the “dollar returned per dollar invested” heuristic. However, because it is a ratio, the BCR does not provide information about the magnitude of present value benefits or present value costs. As a hypothetical example, a high BCR could follow from a program that returns $1000 in benefits per $100 in costs or $10 in benefits per $1 in costs. In both cases, the BCR is $1:$10, but the former program leads to a far greater welfare gain. For this reason, the BCR is most useful when offered in conjunction with the NPV.The payback period, breakeven point, return on investment, and IRR can provide useful supplemental information under certain conditions. The payback period summarizes the point at which cumulative discounted benefits equal cumulative discounted costs. This information may be sought by stakeholders wanting to understand the time horizon over which program investments break even. The concept is most relevant for programs and policies that require investments for a single, discrete period of time. The premise of many prevention programs is that benefits will continue after the termination of the intervention, although many programs experience fadeout of impacts over time. In a hypothetical example, a program costs $100 per individual and causes $20 in discounted annual benefits for the foreseeable future. The breakeven point, that is, the date at which the net benefits equal the costs, would be just over 5 years, depending on the rate of inflation and the discount rate applied ($100 Cost < 5+ Years * $20).The payback period can be applied to programs for which benefits are negative for a temporary period. Temporary negative benefits in this case refer to expenditures incurred outside of program costs that are related to a program outcome. One example is a middle school program designed to prevent high school dropout that leads to temporary negative benefits when more program students remain enrolled in high school. The logic model of this program is that ultimately the benefits will become positive through enhanced employment and other outcomes. A second example is a prevention program targeting a high-risk sample of youth and their families that leads to temporary negative benefits when participating families ask for, or are referred to, mental health or healthcare services they otherwise would not receive. A program with temporary negative benefits could achieve a positive cumulative net benefit at a later point in time. These cases illustrate that the payback period should be estimated and reported with care, particularly when there is a period of negative benefits.The IRR is the discount rate at which the NPV is 0 and can be interpreted as an annualized effective rate of return on an investment. An IRR larger than the discount rate that reflects the opportunity cost of the investment in the program indicates a favorable investment. The IRR is problematic under the same conditions that lead to problems for the payback period. Under these conditions, there are multiple possible IRRs, resulting in a lack of clarity about the “true” rate of return. In such cases, the IRR should be used with caution.Program costs and benefits can be estimated on a per-participant basis for the entire sample on whom the estimates were based, or both. Each choice offers valuable information about the economic impact of the implemented program, as shown in Table Presenting information on a total and per-participant basis helps illustrate why a program’s net present benefit should not be the ultimate driver of resource allocation decisions. In the example above, both programs pass the benefit-cost test and, from a BCA perspective, reflect investments that should be “on the table” from an economic perspective. Both could have a place in a portfolio of investments devised to achieve an overall set of goals.Because each measurement at each step of an economic analysis is made with some degree of unreliability , the final estimate of economic impact will have some uncertainty. Standards are needed for estimating, resolving, and reporting that uncertainty.Intervention cost and benefit estimates are based on a variety of assumptions, and the impact of uncertainty in those assumptions should be modeled , costs and resource use, the discount rate, the time horizon over which benefits are projected, and other factors of import to a given economic evaluation and/or prevention program implementation, such as decisions to account for equity concerns  through weighting or other procedures  program costs, (b) prevention impacts on behavior, (c) prevention impacts on economic benefits (without regard to program costs), and (d) the intervention’s net benefits as appropriate. Best practices for transparent reporting include comprehensive enumeration of the assumptions and decision rules used in analysis, models and sources of price information for valuing benefits , quality of information used to project benefits , and description of the conditions under which results are likely to replicate. Finally, to be useful to policymakers, program administrators, and other consumers, reporting should be clear, concise, and easy to understand.A challenge in reporting economic evaluation results is maintaining transparency while avoiding reporting complexity that can ultimately lessen the comprehension of findings. Achieving this balance can be difficult due to the many decisions and factors driving economic evaluation, particularly BCA, some of which are highly technical. We recommend implementing a two-tiered reporting system that includes a consumer-focused summary accompanied by a technical description  that details the modeling and assumptions made to estimate costs and benefits. The objective is to offer cost analyses and BCA bottom lines that succinctly address the questions driving the analysis in a summary report, including concise presentation of the elements in Table As described above, sensitivity analyses using Monte Carlo methods involve many simulations of the likely NPV. The predicted NPV for each simulation can be represented in a histogram that gives a sense of the distribution. Further, the proportion of simulations that achieve a positive NPV can be calculated. These two pieces of information capture in a simple straightforward way the implications of uncertainty for the NPV of a BCA and can communicate information to potential funders about the riskiness of investing in a program. As shown in Fig. The proposed standards aim to address the ability of economic evaluations to offer consistent, high-quality, transparent estimates while also providing the flexibility essential to evaluating the many forms of prevention. The MAPS III Committee believes that it is important to recognize the limitations of economic evaluation methods—even when conducted in a high-quality manner consistent with the above standards  or experience  and later outcomes that carry monetary value , but these relations are typically reported in basic science journals as regression coefficients rather than shadow prices. High-quality estimates of the shadow prices of childhood behaviors and experiences could enhance economic evaluations of prevention. In particular, efforts to strengthen our ability to project future economic outcomes accurately are of particular importance. Such work likely necessitates employing models to strengthen the ability to draw causal inferences about the relation between proximal and distal outcomes. Such shadow prices will need to be updated as the social context changes.An illustrative example related to prevention in early life might consider the economic value attached to school readiness as an outcome measure. This outcome is not directly measured in dollars, nor is there a natural direct valuation method. An indirect approach would utilize empirical research that establishes a causal link between observed readiness and another outcome that can be more readily valued in monetary terms. Research could link school readiness to later school performance  and then link school performance to labor market earnings, which may be valued. Such published shadow price estimates can provide important information on outcomes commonly targeted in prevention.Shadow prices for behaviors targeted by prevention programs also may inform the upper bounds of what an intervention may cost to still be cost-beneficial. They may drive prevention scientists to develop new interventions that target behaviors and experiences whose benefits have particularly high shadow prices, and with parameters for creating prevention programs that are likely (or not) to be cost-beneficial if effective. For example, knowing that one case of career criminality has a shadow price of several million dollars . Prorating the space costs based on proportional use would overestimate actual costs. Research is needed to understand the implications of various models of costing prevention programs when implemented in other service contexts.A prevention program may have different impacts on subgroups of intervention targets. Such heterogeneity in intervention response is common in prevention programs. For example, a universal preschool program may have stronger economic impacts on lower-income children than middle-income children. Understanding these patterns can guide policy-making, future prevention design for those groups for whom cost-beneficial interventions have not yet been identified, and funding plans. However, statistical testing on the moderation of economic benefit is still relatively crude. Furthermore, the detection of moderation within an implementation that included multiple groups does not imply that the positively affected group would continue to enjoy benefits in a future implementation that excludes unaffected groups. It may be that implementation is less costly per child in the larger context or that the positive impact for one group is contingent on inclusion of the unaffected group, particularly in an implementation context in which intervention is administered in a group format. These issues call for new empirical inquiry, specifically, a more focused effort to understand the economic implications of heterogeneity in response—particularly in universal programs. Of key importance is to understand whether any detected differential responsiveness is likely to change not only the intervention’s effectiveness but also its costs, benefits, and overall return-on-investment. Such analyses are key to assisting policymakers, budget makers, and program planners in making the best use of limited resources.Research is needed to understand the life course of behavior and economic benefit that occurs as a result of preventive intervention in contrast to the same behavior that occurs naturally, without intervention. Consider the example of increasing high school graduation, estimated to have an economic benefit of more than $200,000 per graduate across the lifespan  are multidisciplinary task forces commissioned by the Society for Prevention Research and funded by the National Institute on Drug Abuse. They are designed to address prevention research and practice in areas deemed especially important to advancing the state of the field. The MAPS I task force focused on the role of biological factors in prevention research, and MAPS II focused on type 2 translational research. The current MAPS III focuses on the economic costs and benefits of preventive interventions and policies. The charge of the MAPS III task force was to (1) provide guidance regarding current standards and best practices in the economic evaluation of preventive interventions and policies, (2) recommend actions to increase the field’s capacity to conduct and report high-quality economic evaluations, and (3) identify research gaps and policy needs specific to economic evaluation of prevention. This report summarizes the findings and recommendations of the MAPS III Task Force.The MAPS III report and recommendations are the result of an iterative process, incorporating input from the members of the task force who were selected to represent diverse disciplines, areas of expertise, and perspectives. Members sought input from representatives of key federal agencies , private foundations , policy institutes , the interdisciplinary Prevention Economic Planning and Research Network (PEPR), and attendees of annual conferences for both the Society for Prevention Research and the Society for Benefit-Cost Analysis. After deliberation, the task force reached consensus about standards of quality that should be endorsed in evaluating the economic costs and benefits of prevention interventions and policies. The current document summarizes those standards.ESM 1(DOCX 14 kb)


The health outcomes of men continue to be poorer than women globally. Challenges in addressing this problem include difficulties engaging men in weight loss programs as they tend to view these programs as contrary to the masculine narrative of independence and self-reliance. Researchers have been turning towards sports fans to engage men in health promotion programs as sports fans are typically male, and tend to have poor health habits.Developed from the highly successful gender-sensitized Football Fans in Training program, Hockey Fans in Training (Hockey FIT) recruited 80 male hockey fans of the London Knights and Sarnia Sting who were overweight or obese into a weekly, 90-minute classroom education and group exercise program held over 12 weeks; a 40-week minimally-supported phase followed. A process evaluation of the Hockey FIT program was completed alongside a pragmatic randomized controlled trial and outcome evaluation in order to fully explore the acceptability of the Hockey FIT program from the perspectives of coaches delivering and participants engaged in the program. Data sources included attendance records, participant focus groups, coach interviews, assessment of fidelity (program observations and post-session coach reflections), and 12-month participant interviews.Coaches enjoyed delivering the program and found it simple to deliver. Men valued being among others of similar body shape and similar weight loss goals, and found the knowledge they gained through the program helped them to make and maintain health behaviour changes. Suggested improvements include having more hockey-related information and activities, greater flexibility with timing of program delivery, and greater promotion of technology support tools.We confirmed Hockey FIT was an acceptable “gender-sensitized” health promotion program for male hockey fans who were overweight or obese. Minor changes were required for optimization, which will be evaluated in a future definitive trial.NCT02396524 . Date of registration: Feb 26, 2015. In 2014, 62% of Canadian men self-reported being overweight or obese versus 46% of women . Up to 7Men are continually underrepresented and underserved in health promotion interventions , 7. Men eSteps™ lifestyle prescription program . I’ve been coaching since I was 15 so it’s easy for me now that I can try to motivate people and I have a better idea of the body in a physical aspect than I do in a nutritional aspect” (C1–1).Some coaches felt they were “lecturing” participants at the beginning of the program in part due to the greater amount of classroom content and becoming familiar with the flow of the sessions. This changed as the program progressed, “that was a barrier to overcome because a lot of the program is interaction and you want guys to be talking and coming up with ideas so if you only have 9 in a group and you only have one group of 5, one group of 4, it’s a lot harder than if you had 4 groups of 4 or 5, where you have more ideas coming out” (CI-1).As indicated by Figure “…I didn’t feel like I was giving them the exercises that they needed and again that was because we didn’t really take into account the environment that we’d be doing those exercises in.” (CI-4). Timing was a common difficulty noted by coaches throughout the post-session reflections and interviews, “I wish it was longer, not only number of weeks but I wish it was a 2 hour program instead of an hour and a half because sometimes they had a lot more questions than we anticipated” (CI-3). More hockey-related content was also suggested by coaches to take greater advantage of the men’s common interest, “…if we did more [hockey] drills with balls and sticks and things like that because they were all such big hockey fans…maybe incorporating more of what they all had in common, which was hockey, would have been nice” (CI-2).The coaches did have suggestions for improving the program. One coach expressed concern about participants exercising on the concrete surface of the arena as this can exacerbate previous injuries, 2 and an average step count of 6859.6 (SD 3253.8) steps per day. Further information on the baseline characteristics of participants has been discussed elsewhere  in the class” (FG-1). Others noted that the variation of exercise activities supported the range of physical abilities present in the group, “I liked the variation because I am not as fit as some of the other guys here, I used to be, but I’m not…” (FG-2).Most men appreciated how other members of the group were similar in size, shape, and desire to lose weight and improve their lifestyle, “…understanding exercise and target heart rate, its impact on obviously your fitness or your calorie burn, those are the things I didn’t know” (FG-1). One of the men explained how this new knowledge led to actual behaviour changes, “I never ate breakfast for 51 years, and now I haven’t missed breakfast in probably six weeks” (FG-1).The classroom content was valued by participants as this information both reinforced and added new knowledge to help participants make lifestyle changes, “They really had a genuine interest in health and well-being and us” (FG-2). The men felt accountable to show up for the program and their coaches as they considered themselves a team, “It’s that whole teamwork…you’ve got to show up for the team” (FG-2). The men’s experience with the program left them eager to attend the next session, “The combination of everything, I wanted to learn, the next week I wanted to see what else. And the competition and everything. Everybody said they just wanted to come back” (FG-2).Participants felt the coaches were invested in their success in the program, “I found that with the class and the exercise it was almost you know, 3 hours squeezed into an hour and a half” (FG-1). Others were disappointed with the lack of hockey-related content and support from the OHL team personnel, “I thought that maybe the [OHL] trainer would come out and talk to us a bit about the training, and health, and sports, and exercise” (FG-2). Some participants suggested involving a dietitian or a chef in a session, “I can only cook so many types of food, so why not have a chef come in and go over different things to show us how to do it properly” (FG-1). Lastly, some of the men would have enjoyed competition between sites, “It would have been nice to see the competition between the Sarnia Sting and the London Knights” (FG-2).Some participants felt the program was rushed to cover all of the content, “…the lessons I learned during Hockey Fit continued to follow me, in the sense of the water, the fruits and the vegetables” . The emphasis on making simple lifestyle changes helped participants continue to be physically active, “I think the attention to the simple thing as walking and staying somewhat fit has helped me stay focused on maintaining what I learned in the program and keep it going” . Others noted the skills they learned through the handbook was helpful in maintaining their weight loss goals, “it was plain and simple, it was on paper, this is what you should do and if you follow this you’re probably going to lose weight” . The pedometer was also cited as helpful for maintaining physical activity levels after the program was completed, “…even the pedometer, it’s a really good thing because every day I was very cognizant of that thing and I always made sure that I was watching it…” .Interviews conducted with the men at 12 months informed the participants experience maintaining their healthy lifestyle during the minimally-supported phase. Participants found the skills they had gained through the active phase of the program helped them to maintain their health behaviour changes, “I was out in [rural city], out in nowhere at a hockey arena and just walking and walking and then I ran into one of our guys, he was playing with the other team and so it was funny, and are you getting your steps in, so it was just part of the program…” .Participants found they were encountering each other at community events, hockey games, and arenas and found it helpful to talk about their progress, I’ve seen these results, but I don’t want to regress” . Participants did identify barriers in maintaining their healthy lifestyles including medical conditions, injuries, and difficulties being active in the winter, “I would say the biggest challenge that I faced is winter. I think it’s tough to move in the winter and that tends to pack on weight.” .Men indicated the fear of regressing back into old habits as a reason for continuing with their healthy lifestyle changes, “eSteps™ smartphone app was introduced to the men during session 11. It was not used by participants due to technical challenges experienced by the men . Based on the 12 month interviews, the Hockey FIT social network was used passively with men only accessing the network when they received a message/post from their coach or another participant. Men admitted their own and other participants lack of interaction on the social network limited the potential of the network to support their progress during the minimally-supported phase, “It might help if more people were active on it, but I wasn’t active on it either so I can’t complain about it. I’m just saying if there’s more interaction going on than it might have inspired more people,” .The Health“They don’t shame you into doing it but they give you a good reminder of what you’re doing, makes you think about what you’re not doing” . Some participants would have valued more personal messages from the coaches as they felt left behind once the program ended.Nevertheless, many men found the standardized messages (see Table n = 5), family commitments (n = 3), too far to travel (n = 4), not aware of the event/what it entailed (n = 2), or other commitments (n = 7). Participants noted this event was held on Super Bowl weekend, during the winter, and only in London making it difficult for some to attend.Eight out of 40 participants from the intervention group  attended the booster session/reunion. Participants were asked at the 12 month interview why they could not attend. Reasons participants did not attend included work . Some of the men found this session/reunion set them back on track with their goals, “It actually brought me back from a couple of weeks of falling off the wagon if you can call it that. Really because of the timing of it, it was towards the middle of winter, it really helped to actually say okay, yea you can still find some ways to do it…” .The eight who attended enjoyed seeing each other again and found it highly motivating to hear about others’ success, Based on the interviews with coaches and participants, a number of areas were identified for optimizing the program for future delivery. These items included improving mid-program attendance, coach training, nutrition education, timing, exercise modifications, amount of hockey skills and drills, app usability, the booster session/reunion, and the Hockey FIT social network  out of 30 invited participants attended the focus groups limiting the generalizability of these findings to the wider group. Moderators noted one of the focus group participants was more vocal about his experiences with the program than others in the group. This may have swayed the results of the focus group more heavily in favour of this participants’ experience rather than the entire group. Data were only collected from the intervention group; collecting data from the wait-list group could have deepened our understanding of participants’ experience with the program. Lastly, there was a low turn-out for the booster session due to a variety of factors  limiting the amount of data collected about this event.This study supports the findings of other gender-sensitized programs targeting sports fans  and prov


The epidemic of obesity and diabetes in the United States poses major challenge to the prevention and management of chronic diseases. Furthermore, when this is viewed in other components of the metabolic syndrome , the prevalence of the metabolic syndrome continues to rise in the USA continued challenge is how to deal with this epidemic from a medical and public health standpoint. Community Based Participatory Research (CBPR) is a unique approach and offers a novel perspective for answering this challenge. A critical set of goals for CBPR is to address health disparities and social inequalities while getting community members engaged in all aspects of the research process. Utilizing the West Virginia Diabetes Prevention and Management Program and trained Health Coaches as a model, we discuss topics of consideration related to CBPR, involving trained health coaches, optimizing early adoption of healthy lifestyle behaviors, and enhancing participation. Through careful project planning and design, questions regarding disparities increasing susceptibility and preventive efforts within the community can be addressed successfully. These topics are part of a broader integration of theories such as participatory research, community engagement, and outcomes measurement. The understanding of the pathophysiology and epidemiology of the metabolic syndrome can help frame an appropriate strategy for establishing long-term community-wide changes that promote health. In order to continue to improve investigations for preventing the metabolic syndrome, it will be necessary to have aggressive efforts at the individual and population level for developing culturally sensitive programs that start early and are sustainable in practical environments such as the workplace. In this comprehensive review, we will discuss practical considerations related to project design, implementation, and how to measure effectiveness in regards to reducing the burden of the metabolic syndrome. Type II diabetes is increasing worldwide with upwards of 58% of patients with diabetes developing the metabolic syndrome . Early iIn this review, we highlight our own experiences with a community-based program for diabetes prevention and management that focuses on participatory research, community engagement, and careful monitoring of clinical outcomes. Using this program as a reference, important principles are discussed including the selection site of the study, the importance of participant feedback, successful implementation of health coaches, and how to optimize the adoption of the interventions. These principle components will be addressed under the broader framework of lifestyle adjustments that were designed to decrease the risk associated with the metabolic syndrome, and associated diabetes and CVD risk. To understand how these interventions are intended to function within the community, we will briefly review the pathophysiology and epidemiology that contributes to the metabolic syndrome. Finally, future advancements will be suggested for the diabetes prevention and management program with the intention of improving avenues that reduce the burden of the metabolic syndrome, diabetes, and cardiovascular disease within at-risk communities.Insulin resistance is the underlying pathophysiological process defining the metabolic syndrome . Recent Furthermore, high stress exacerbates the risk for getting the metabolic syndrome among adults. Recently, a longitudinal study found that increased work-related stress had negative effects on four of the five metabolic syndrome diagnostic criteria: Blood pressure, HDL cholesterol, lipid profiles, and fasting blood glucose. Participants with work-related stress had 2.68 the odds for developing the metabolic syndrome compared to non-stressed controls ,13. In aApproximately 25% of United States adults have been diagnosed with the metabolic syndrome . Insulinth in the nation), obesity (1st in the nation), hypertension (2nd in the nation), cardiovascular disease (2nd in the US) and the metabolic syndrome. West Virginia is an Appalachian rural environment that has a culture of independence and historically does not trust outsiders. Additionally, they may not know how to take care of their health due to low education and social economic status. The utilization of the CBPR approach helps participants to “own” and contribute to program success. As Cargo and colleagues emphasize, the primary goal of CBPR is to address health disparities [Interventions that target a change in lifestyle habits thereby offer the best solution for reducing the risk factors via dietary, lifestyle and behavior modifications as a means of reducing the likelihood of developing metabolic syndrome, as associated risk for diabetes, obesity, hypertension and cardiovascular disease. The primary dilemma is addressing the gap between available knowledge and effectively applying that knowledge to lower the risk. A chronic disease such as diabetes, metabolic syndrome, and cardiovascular disease predominately affects those in the lowest social economic class and rural communities . Women iparities . DesigniThe Diabetes Prevention and Management program is an evidence-based program that is being implemented at two-sites: Morgantown and Charleston West Virginia, and it are currently in its second year of implementation. The program consists of twenty-two sessions taught by trained health coaches and community experts. The recruitment target was enrollment of 60 participants into the study for year 2; the study team reached 100% of their recruitment target in October 2015, with 70 participants recruited into the study. Participants voluntarily agreed to participate in the 1-year DPM program. In order to be eligible for the program, participants had to be over 18 years of age and have dysglycemia . The participants were eager to engage in a program with a focus on non-pharmaceutical lifestyle modification through education and group support. Data is being collected on multiple factors including demographics, anthropometrics, clinical outcomes, satisfaction with the program, and calorie consumption as well as step tracking. In this review, we will use the ongoing program as a basis for evaluating implementation strategies to address the metabolic syndrome .One of the most critical components for CBPR is selecting appropriate community partners and sites . PartnerChurches in West Virginia and other places of worship nationally often offer unique advantages in that many have an attached kitchen for cooking demonstrations and space for physical activity demonstrations. This is highly important for programs dealing with prevention of chronic diseases such as diabetes, obesity, metabolic syndrome etc. Prevention programs that show demonstrations of healthy food preparation and physical activity are more effective in changing lifestyle habits than programs without these demonstrations . Many diOnce the site was selected and the program is underway, it is important to garner feedback from participants. The key to a successful diabetes prevention and management program is ensuring sustainability. Focus groups offer an interesting and valuable means by which feedback can be obtained. A CBPR program for diabetes prevention in Harlem used mid-program focus group surveys to help restructure the second half of the program . SimilarA local community champion was selected for the site located 3 hrs away from the university. The community champion is a local female student and a health coach who grew up in the region and works for the state department. Adeniyi et al. found that enlisting the help of community champions was essential for decreasing risk factors for the metabolic syndrome . CommuniThe health coaches attended 20 hrs of training using a curriculum developed by the program team; undergraduate, master and doctoral students enrolled in professional programs and other majors , College of Physical Activity and Sports Sciences, Exercise Physiology, Human Nutrition and Department of Communication. The health coaches were provided opportunity to participate in the planning, participant recruitment, and screening of participants.For preventing chronic diseases and syndromes such as the one focused for this paper (metabolic syndrome), healthy lifestyle changes depend on three important components: Change in mindset, change in physical activity, and change in eating habits. A primary way to encourage these changes is through education. Health coaches trained in diabetes education have been shown to be highly effective ,32. SessThe use of advanced technology such as texting and email makes the feasibility of contact between coaches and participants efficient and productive. Texting has emerged as an effective way for coaches to provide positive feedback and important reminders to participants . In addiIn order to help participants' stay on track, calorie-tracking books and pedometer step counts were used in addition to weigh-ins at each session. Participants were encouraged to record their daily food intake by hand in the food logs provided. They were instructed to be honest, accurate, and complete it each week to build awareness of their eating behaviors. Food logs and dairies increase awareness of extra calories and have been shown to be a powerful tool in prior research . The heaA key component for participant adoption is to move CBPR from the margins to mainstream . One of The educational component provides valuable support and dissemination of ideas that allow participants to incorporate new habits. In addition to improving participant's knowledge of healthy lifestyle, other important educational pieces focused upon dealing with small setbacks, coping with stress, and how to get back on track after a perceived slip up. To address these hurdles, the systematic approach of consistent sessions with weekly feedback has been shown to be more effective than single interventions or unconventional approaches . Since tMaintaining a healthy diet and increasing physical activity will reduce the prevalence of metabolic syndrome by decreasing risk factors, such as diabetes and obesity. Many participants are knowledgeable of individual conditions such as increased blood pressure, blood sugar, and abnormal cholesterol, but have trouble understanding how the clustering of these factors increases the risk for cardiovascular disease. The more important struggle is that participants have to implement their knowledge into behavioral modifications. Green and colleagues argue that although knowledge is present, it is not readily being implemented into preventive programs by public health researchers . TherefoOne of the underlying core principles of participatory research is empowering people for change. Altman and colleagues showed that the combination of education, health screenings, and discussions about changing attitude and perceptions was successful in reducing the cardiovascular risk factors associated with the metabolic syndrome . InterviCollective solutions generated by participants of the DPM program in West Virginia include changing where they eat lunch, avoiding negative co-workers, and establishing better habits in the workplace. One successful action-based habit is parking the car further from the entrance to inspire increased physical activity throughout the day. Survey responses collected at baseline, 6 months, and 1 year will be analyzed and the data used to disseminate knowledge for the implementation of future programs . On a la2 [Another example of a successful participatory approach for metabolic syndrome prevention was pioneered in the Healthy Lifestyle Change Program. They emphasized the significance of increasing knowledge, skills, and self-efficacy. Programs are normally effective at increasing knowledge but potentially lack in the transfer of skills and self-efficacy. By employing peer mentors to help encourage walking and healthy diets, participants in the Healthy Lifestyle Change Program had an average BMI reduction of 0.5 kg/m2 . Peer me2 . ParticiCommunity engagement differs in its primary focus. For the lifestyle programs to address chronic diseases and metabolic syndrome, the community engagement approach would emphasize changes that benefit the collective community and not necessarily individual participants. The Vida Sana community engagement program translated the available diabetes and metabolic syndrome prevention literature into Spanish . By provFor the West Virginia Diabetes Prevention and Management program, pre-screenings were utilized at local mall, restaurants, and churches. The pre-screenings increase awareness about diabetes prevention and management, provided potential participants with important health information, and the posted fliers in clinics, hospitals, restaurants, grocery stores, and churches provided a community-wide reminder about improving health. Screening is an example of community engagement especially when it addresses an area of health disparities on a larger scale . AnotherA novel strategy for approaching diabetes prevention is to consider social environment, culture, and local values in designing programs . Values Uncontrolled metabolic syndrome can lead to life threatening cardiovascular events, diabetes complications, cognitive decline, and kidney failure . One of In order to track the effectiveness of preventing the metabolic syndrome throughout the course of a program, biometrics and blood work must be collected. Waist circumference has a high correlation with body mass index and can be used as a measure of obesity . ResearcHealth metrics such as dietary consumption and physical activity level can be correlated to changes in outcomes. Although not a randomized-control trial, the Diabetes Prevention and Management program in West Virginia tracks outcomes from baseline to completion of the program. This allows for careful tracking of metabolic changes at various times throughout the program and correlating changes to the educational intervention. A national consensus meeting in Canada just announced a renewed focus on implementing diabetes prevention programs that track long-term clinical outcomes . WeinholThe metabolic syndrome is quickly emerging as a global pandemic as both obesity and diabetes increase in prevalence . This syWoolf argues however that this heavily weighted T1 research focus is limiting translation. T3 research focuses on practice-based research, which has high practicality . RecentlFor the West Virginia Diabetes Prevention and Management program, Rotary International and the Eye Foundation of America were co-sponsors. Rotarians in West Virginia are heavily invested in the Action Group for Diabetes. Eliciting the help and funding support of co-sponsors is essential for sustainability. Israel describes the process of working with co-sponsors as a mutual learning and empowering environment that fosters unique changes that address social inequalities . By usinA key goal of CBPR is participant involvement in all stages of the research process. As data is gathered from the West Virginia Diabetes Prevention and Management program, it will be important to collect qualitative information from participants for inclusion in outgoing manuscripts and reports. Participants should also be offered positions on a community panel to decide appropriate targets of investigation for the community. Through relationship building during the course of the program, it will be possible to recruit and encourage research participants to take an active role in data analysis and program advocacy .Program improvement should be at the forefront of every CBPR study. Several of the first year participants decided to join the cohort for the subsequent year. Through feedback and guidance from these participants, sessions were improved to meet the needs of the community. Israel describes this process as both cyclical and iterative . The proResults regarding study effectiveness must be distributed to a larger audience as a whole. In order to maintain funding, it is necessary to demonstrate that prevention is more cost-effective than treatment. Healthy individuals are better able to contribute to the community through volunteering, work, philanthropy, and social activities. Koh in Vision for Healthy People 2020 proposes that environments must be established where people can contribute to advancing life quality and quantity . ReducinAs outlined in the pathophysiology section, workplace stress is a primary contributor to insulin resistance due to glucocorticoid signaling. Westfall encourages researchers to meet participants in settings where they are most likely to benefit . WorkplaAnother potential challenge is comfort level of the participants. Places of worship such as churches, synagogues, temples and mosques as well as community centers, such as the local YMCA/YWCA, offer safe and constructive learning environments. Working environments are typically stressful and filled with time constraints. The lack of comfort is offset by practicality. If participants can learn to implement changes in stressful environments, the changes will be more likely to endure over time. Adam pioneered a stress reduction component into a community-based prevention program, which was very successful and associated with significant improvement in health outcomes . Work enThe metabolic syndrome poses a unique problem for public health professionals as the prevalence continues to rise. Insulin resistance is the primary underlying pathophysiologic change associated with the metabolic syndrome. Diabetes, obesity, and cardiovascular disease prevention through a CBPR approach offers to be the most cost-effective solution for widespread community change. In this review, metabolic syndrome prevention was discussed in the broader context of the West Virginia Diabetes Prevention and Management program. The program incorporates important aspects of participatory research such as participant feedback, health coaches' weekly feedback and calls to participants, a localized church setting, use of weekly food logs and pedometers to track dietary habits and physical activity, and changes in behavioral, anthropometric and clinical outcomes over the program period. These aspects were part of a broader approach that contains elements of participatory research, community engagement, and health outcomes research. Going forward it will be critical to engage participants in evaluation and dissemination of the data. To maximize sustainability, it will be important to advocate for increased funding and to role out programs in practical environments such as the workplace. In future programs, it will be important to identify factors that contribute to successful implementation of lifestyle modifications in real-world community settings. Overall CBPR programs that are focused on diabetes prevention or prevention of chronic diseases can produce substantial results if applied vigorously across the nation.