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An economic model of school-based behavioral interventions to prevent sexually transmitted infections |
Cooper K, Shepherd J, Picot J, Jones J, Kavanagh J, Harden A, Barnett-Page E, Clegg A, Hartwell D, Frampton G, Price A |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary The objective was to assess the cost-effectiveness of behavioural interventions in school, for the prevention of sexually transmitted infections, in young people. The authors concluded that school-based interventions could improve knowledge and self-efficacy, but this had little impact on behaviour, and there was considerable uncertainty in the results. Some important method details were not given, but most of the methods were good, and it seems that the authors’ conclusions were appropriate for the scope of the analysis. Type of economic evaluation Study objective The objective was to assess the cost-effectiveness of behavioural interventions in school, for the prevention of sexually transmitted infections, in young people. Interventions There were three interventions: teacher led, peer led, and standard sexual health education. The teacher-led intervention was 20 sessions over two years, with 10 sessions for 13- to 14-year-olds, and 10 for 14- to 15-year-olds. The peer-led intervention was three sessions of one hour, over one school term. Methods Analytical approach:The authors adapted a developed Bernoulli statistical model, to assess the effect of changes in sexual behaviour, following the introduction of each intervention (Weinstein, et al. 1989, see Other Publications of Related Interest). The authors reported that the UK NHS and Personal Social Services (PSS) perspective was adopted. Effectiveness data:The clinical and effectiveness data were from published studies and UK reports, which were identified by systematic searches of databases and websites of relevant organisations, or from contact with experts on sexually transmitted infections. The main measure of effectiveness was condom use and this was estimated using a meta-analysis of studies identified by the searches. Monetary benefit and utility valuations:The utility data were from studies of groups of patients who had developed complications from sexually transmitted infections. Measure of benefit:The measures of benefit were the total number of sexually transmitted infections averted, and quality-adjusted life-years (QALYs). Cost data:The direct costs included those of treatment of the infections and provision of the interventions. The resource use for the teacher-led and peer-led interventions was based on the results of two UK trials, and was valued using UK primary and secondary sources. The direct costs of treating the infections were from published UK sources. All costs were updated, using the NHS multiplier for Hospital and Community Health Services, and were reported in Euros (EUR). Analysis of uncertainty:One-way sensitivity analyses were undertaken by varying all the model parameters across plausible ranges. A probabilistic sensitivity analysis was carried out, with input values sampled from probability distributions, using 1,000 Monte Carlo simulations. The results were presented as a cost-effectiveness acceptability curve. Results Compared with standard sexual health education, the teacher-led and peer-led interventions were each associated with QALY gains of 0.35. The additional cost per student was EUR 8,575 with the teacher-led intervention, and EUR 34,255 with the peer-led intervention. The additional cost per QALY gained was EUR 24,268 with the teacher-led intervention and EUR 96,938 with the peer-led intervention. The probabilistic sensitivity analysis showed that the teacher-led-intervention had an incremental cost-utility ratio of EUR 0 to EUR 36,000 in 48% of iterations, over EUR 36,000 in 28% of iterations, and it lost QALYs in 24% of iterations. The peer-led intervention had a ratio of EUR 0 to EUR 36,000 in 16% of iterations. Authors' conclusions The authors concluded that school-based interventions could improve knowledge and self-efficacy, but this had little impact on behaviour, and there was considerable uncertainty in the results. CRD commentary Interventions:The interventions were reported adequately. The comparator was standard sexual health education, which was the usual practice. Effectiveness/benefits:The clinical and effectiveness data were from published studies and reports. Websites of relevant organisations were searched and contact was made with experts to identify data. The systematic reviews to identify the clinical and effectiveness data were not described; the databases searched, search strategy, and inclusion and exclusion criteria, were not reported. The same effectiveness estimates appear to have been used for the teacher-led and peer-led interventions, and no justification was given for this. Sexually transmitted infections averted and QALYs were valid benefit measures. The sources for the utilities and their values were provided, and they appear to have been from appropriate patients, but the methods used to elicit them were not reported. Costs:The authors explicitly reported that an NHS and PSS perspective was adopted. For this perspective, all the relevant major cost categories and costs appear to have been analysed. The sources for these costs and the resource use were adequately reported, but neither the price year, nor the time horizon of the study, was explicitly stated, and it was unclear if discounting was required or not. Analysis and results:A published mathematical model was used to combine the costs and outcome information. The details of the model were provided, with supplementary information in appendices and another publication (Shepherd, et al. 2010, see Other Publications of Related Interest). Uncertainty in the model was adequately tested in one-way and probabilistic sensitivity analyses. As the main limitation to their study, the authors reported that their meta-analyses showed that the intervention had no statistically significant effect on the behavioural outcomes. Concluding remarks:Some important method details were not given, but most of the methods were good, and it seems that the authors’ conclusions were appropriate for the scope of the analysis. Funding Funding received from the UK NIHR Health Technology Assessment programme. Bibliographic details Cooper K, Shepherd J, Picot J, Jones J, Kavanagh J, Harden A, Barnett-Page E, Clegg A, Hartwell D, Frampton G, Price A. An economic model of school-based behavioral interventions to prevent sexually transmitted infections. International Journal of Technology Assessment in Health Care 2012; 28(4): 407-414 Other publications of related interest Weinstein M, Graham J, Siegel J. Cost effectiveness analysis of AIDS prevention programs: Concepts, complications and illustrations. In: Turner C, Miller H, Moses L, (eds). AIDS: sexual behaviour and intravenous drug use. Washington, DC, USA: National Academy Press. 1989: 471-499. Shepherd J, Kavanagh J, Picot J, Cooper K, Harden A, Barnett-Page E, Jones J, Clegg A, Hartwell D, Frampton GK, Price A. The effectiveness and cost-effectiveness of behavioural interventions for the prevention of sexually transmitted infections in young people aged 13–19: a systematic review and economic evaluation. Health Technology Assessment 2010; 14(7): 1-230. Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Cost-Benefit Analysis; Female; Great Britain /epidemiology; Health Behavior; Health Knowledge, Attitudes, Practice; Health Promotion /economics /methods; Humans; Life Style; Male; Models, Economic; Peer Group; Pregnancy; Public Health; Quality of Life; Risk-Taking; School Health Services /economics; Sexually Transmitted Diseases /economics /epidemiology /prevention & control AccessionNumber 22012040638 Date bibliographic record published 31/01/2013 Date abstract record published 26/02/2013 |
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