Economic evaluation of population health interventions aimed at children and delivered at school

Boyer, Nicole Renée Soldner (2018) Economic evaluation of population health interventions aimed at children and delivered at school. PhD thesis, University of Glasgow.

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Background: Population health interventions by their nature affect an entire population and are typically delivered outwith of health services and within the community, such as in schools. An example of such interventions are those that aim to improve children’s social and emotional wellbeing, which have demonstrated effectiveness in the short-term and potentially the long-term. However, challenges arise when conducting economic evaluations of population health interventions, most notably the difficulties of identifying, measuring, and valuing broader intersectoral costs, health, and non-health outcomes. Economic evaluation in an education context is relatively novel, but could provide decision-makers with information to help them make transparent and consistent decisions about how to allocate limited funds. This thesis examined the role for economic evaluation in school-based interventions and sought to determine appropriate methods for its implementation in addition to examining appropriate child-focused outcome measures. Thus, the overarching research question asked, ‘How should the cost-effectiveness of school-based, population health interventions aimed at children be determined?’

Methods: A mixed methods approach to this thesis was used:
(i) a systematic literature review and narrative synthesis to determine which evaluation methods (economic and non-economic) are currently being used in school-based population health interventions;
(ii) a case study to illustrate an economic evaluation (including cost-utility and cost-effectiveness analysis) of a school-based intervention to reflect on the advantages and disadvantages for decision making in this context; and
(iii) an exploration of outcome measures (through mapping validation) for valuing child health and social and emotional wellbeing in school-based programmes to support future evaluation work in this context.
Data for the economic evaluation and mapping validation study were available from a cluster randomised controlled trial of the Roots of Empathy programme in Northern Ireland (Ref: 10/3006/02).

Results: The systematic review found that the methods currently being utilised to evaluate school programmes are varied (including economic evaluation, cost only, and effectiveness only studies), with poor quality reporting for the economic evaluations. Of the few cost-utility analyses in school-based settings identified, none had directly measured health-related quality of life using child measures or values. The case study cost-utility analysis using Child Health Utility 9D of a school-based intervention was found to be cost-effective from the National Health Service perspective with an incremental cost-effectiveness ratio of £11,000 per quality-adjusted life year (confidence interval: -£95,500 to £147,000), however the wide confidence interval demonstrates considerable uncertainty. This uncertainty is likely due to a lack of statistically significant effect that remained at the 36-month follow-up. Cost-effectiveness analysis using child behavioural descriptive measure, the Strengths and Difficulties Questionnaire, resulted in an incremental cost-effectiveness ratio of £197 per unit decrease in total difficulties score (confidence interval: £77 to £471). The Strengths and Difficulties Questionnaire is suitable for measuring social and emotional wellbeing, but is less advantageous for cost-effectiveness decision-making as no consensus has been reached as to what a clinically meaningful change in score represents, nor has a cost-effectiveness threshold been defined. It remains uncertain how these cost-effectiveness results will be interpreted in an education decision-making context where cost-effectiveness thresholds have not been set up. The mapping validation study validated a mapping algorithm to convert the Strengths and Difficulties Questionnaire into child health utility. Using this algorithm provides an option for valuing incremental changes in health-related quality of life against a generally accepted cost-effectiveness threshold from a health service perspective.

Conclusions: Given the findings from the various aspects of work undertaken for this thesis to address population health issues, this thesis identified cost-benefit analysis as currently the most comprehensive method for determining the value for money of school-based public health interventions. Cost-benefit analysis incorporates monetary valuation of multisector outcomes in a final net benefit/loss result allowing clear, consistent, decision-making criteria to be set. Other methods such as cost-consequence analysis, cost-utility analysis, and multi-criteria decision analysis may also be suitable depending on the decision-making context and problem. This thesis demonstrates a lack of clear decision-making criteria in place for funding allocation decisions in education (e.g. education specific cost-effectiveness thresholds). Furthermore, there is no equitable method currently in place for apportioning the cost of funding public health interventions that generate benefits for multiple sectors. From a health service perspective, directly measuring child health utility using the Child Health Utility 9D is preferred as it is the only preference-based measure developed specifically for children and valued by young people. Mean child health utility can be predicted by mapping from the Strengths and Difficulties Questionnaire. This affords the opportunity to estimate longer-term utility by utilising long-term cohort data that routinely collects the Strengths and Difficulties Questionnaire, as long-term cost-effectiveness of school-based preventive programmes is an area in need of further research. The school setting plays an important role in shaping our young people’s futures. Economic evaluation of school-based population health interventions is justified, as schools need to maximise their existing resources in order to give children the best start in life.

Item Type: Thesis (PhD)
Qualification Level: Doctoral
Additional Information: Chapters 4 and 5 have been published in Public Health research: Connolly P, Miller S, Kee F, Sloan S, Gilda A, McIntosh E, Boyer N, and Bland M (2018). A cluster randomised controlled trial evaluation and cost-effectiveness analysis of the Roots of Empathy schools-based programme for improving social and emotional wellbeing outcomes among 8-9 year olds in Northern Ireland. Public Health Research. 6:4, DOI: 10.3310/phr06040. Chapter 6 has been published in Quality of Life Research: Boyer, N. R., Miller, S., Connolly, P., and McIntosh, E. (2016). Paving the way for the use of the SDQ in economic evaluations of school-based population health interventions: an empirical analysis of the external validity of SDQ mapping algorithms to the CHU9D in an educational setting. Qual Life Res, doi:10.1007/s11136-015-1218-x.
Keywords: Economic evaluation, population health, children, school, social and emotional wellbeing.
Subjects: R Medicine > RA Public aspects of medicine
Colleges/Schools: College of Medical Veterinary and Life Sciences > Institute of Health and Wellbeing > Health Economics and Health Technology Assessment
Supervisor's Name: McIntosh, Professor Emma and Boyd, Dr. Kathleen A.
Date of Award: 2018
Depositing User: Dr Nicole R.S. Boyer
Unique ID: glathesis:2018-9012
Copyright: Copyright of this thesis is held by the author.
Date Deposited: 30 Apr 2018 14:02
Last Modified: 19 Nov 2018 16:06
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