Economic evaluation of a multi-strategy intervention that improves school-based physical activity policy implementation

Abstract

Background Internationally, government policies mandating schools to provide students with opportunities to participate in physical activity are poorly implemented. The multi-component Physically Active Children in Education (PACE) intervention effectively assists schools to implement one such policy. We evaluated the value of investment by health service providers tasked with intervention delivery, and explored where adaptations might be targeted to reduce program costs for scale-up. Methods A prospective trial-based economic evaluation of an implementation intervention in 61 primary schools in New South Wales (NSW), Australia. Schools were randomised to the PACE intervention or a wait-list control. PACE strategies included centralised technical assistance, ongoing consultation, principal's mandated change, identifying and preparing in-school champions, educational outreach visits, and provision of educational materials and equipment. Effectiveness was measured as the mean weekly minutes of physical activity implemented by classroom teachers, recorded in a daily log book at baseline and 12-month follow-up. Delivery costs (reported in $AUD, 2018) were evaluated from a public finance perspective. Cost data were used to calculate: total intervention cost, cost per strategy and incremental cost (overall across all schools and as an average per school). Incremental cost-effectiveness ratios (ICERs) were calculated as the incremental cost of delivering PACE divided by the estimated intervention effect. Results PACE cost the health service provider a total of $35,692 (95% uncertainty interval [UI] $32,411, $38,331) to deliver; an average cost per school of $1151 (95%UI $1046, $1236). Training in-school champions was the largest contributor: $19,437 total; $627 ($0 to $648) average per school. Educational outreach was the second largest contributor: $4992 total; $161 ($0 to $528) average per school. The ICER was $29 (95%UI $17, $64) for every additional minute of weekly physical activity implemented per school. Conclusion PACE is a potentially cost-effective intervention for increasing schools implementation of a policy mandate. The investment required by the health service provider makes use of existing funding and infrastructure; the additional cost to assist schools to implement the policy is likely not that much. PACE strategies may be adapted to substantially improve delivery costs. Trial registration Australia New Zealand Clinical Trials Registry ACTRN12617001265369; Prospectively registered 1st September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373520

A systematic review of economic evaluations of interventions targeting childhood overweight and obesity

“…114 Thirty-eight studies evaluated interventions with the main components cutting across multiple intervention categories. 31,38,[52][53][54]60,61,[63][64][65][66][67][68]70,73,75,76,79,80,83,94,[99][100][101][102][107][108][109][110][111]123,125,130,131,134,137,139,140 All but three of these multi-category interventions involved behavioral components: Of the three that did not, one intervention targeted food standards across English schools, 83 while two others sought to change the school drinking water environment in the United States. 73,76 One study considered hypothetical scenarios of reduction in the prevalence of obesity, and no intervention was specified.…”

“…The volume of published studies tended to increase over 5‐year periods from 2001, with the greatest number of studies published between 2016 and 2020. Only 9 studies of the 151 included studies were conducted in low and middle‐income countries (LMICs) 30–38 compared with 143 studies from high‐income countries 31,39–180 . One study published in 2010 was set in a high‐income country and six LMICs 31 …”

“…Of all the included studies, 18 reported variations of non-anthropometric measures as the primary outcome. 53,[57][58][59]66,72,85,92,113,114,132,133,135,[139][140][141]179,180 In two studies, consequences were measured primarily as a change in the proportion of schools that adhered to a canteen policy, 108 [33][34][35][66][67][68][69][70][71][72][73][74][75][76][77][78][79][84][85][86][87][88][89][90][91][92][93][94][95][96]…”

Systematic Review of the Economics of School-Based Interventions for Dating Violence and Gender-Based Violence

“…As with evaluations of other school-based interventions (e.g., for physical activity policy [ Lane et al, 2022 ]), the largest cost of interventions related to staff costs, including training and/or hiring of external organizations to deliver interventions. Costs were shown to increase in settings where staff turnover is high due to the need to re-train staff, and costs were shown to reduce where these could be shared among a larger group of students.…”

Implementation fidelity, student outcomes, and cost-effectiveness of train-the-trainer strategies for Masters-level therapists in urban schools: a cluster randomized trial

“…Other important outcomes related to TT implementation strategies are the cost of training a trainer compared to traditional direct training of therapists [20] and the cost-effectiveness of training a trainer vis-à-vis implementation and child outcomes [20]. The literature about cost and cost-effectiveness of TT in schools is very limited [21][22][23]. In general, the application of TT in the mental health eld is seen as being more cost-effective than training by expert trainers because the initial costs of preparing therapists as trainers are often offset by lower clinician training and supervision costs for those trained by the new trainers [21].…”