Cost-Effectiveness of Installing Water Dispensers in Massachusetts' Schools to Improve Nutrition Environments, Health, and Health Equity

Abstract

Background: Evidence suggests that providing children with water on school lunch lines promotes healthy weight and is cost-effective.

Objective: Estimate reach, cost, cost-effectiveness, and impact on weight status and obesity-related health equity of a strategy to install chilled, filtered water dispensers on school lunch lines in Massachusetts' schools.

Design: A cost-effectiveness analysis was conducted in 2022-2023 using the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model (2020-2029), estimates from published studies, publicly available national and state surveillance, programmatic, administrative data, and experts' assumptions.

Participants/setting: Schools participating in Massachusetts' school drinking water lead testing program with elevated lead concentrations in areas with disproportionate health risks MAIN OUTCOME MEASURES: Reach, cost, cost per quality-adjusted life year (QALY) gained, and cases of obesity prevented overall and by income, race, and ethnicity STATISTICAL ANALYSES: Means and 95% uncertainty intervals (UIs) for outcomes were estimated by running the model 1000 times, accounting for uncertainty from data sources and population projections.

Results: This strategy is projected to improve drinking water access for 265 000 (95% UI, 259 000-273 000) students in 304 schools, prevent 525 (95% UI, 192-880) cases of childhood obesity in 2029, cost $4.48/student/year (95% UI, $3.54-$5.43) to implement, and is likely cost-effective ($72 700 (95% UI, $40 000-$234 000) per QALY). Larger projected reductions in obesity prevalence for Hispanic/Latino and Black students compared with white students were observed (7.2 [95% UI, 5.2-10.3], and 4.7 [95% UI, 2.9-7.4], respectively), and among students from families with lowest incomes (<130% Federal Poverty Level) compared with the highest incomes (>350% Federal Poverty Level) (2.6 [95% UI, 1.9-3.5]).

Conclusions: A strategy to provide chilled, filtered water dispensers on lunch lines in Massachusetts schools is projected to improve school nutrition environments, increase water consumption, prevent excess weight gain, improve health equity, and be cost-effective.

Keywords: Cafeteria; Hydration; Lead; Obesity; Water filter.