Cost-Effectiveness of Digital Preventive Parent Training for Early Childhood Disruptive Behaviour.

BACKGROUND: Childhood disruptive behaviour disorder associates with various, also costly problems. Parent training is effective in reducing childhood disruptive behaviour. Only a few studies have evaluated the cost-effectiveness of digital parent training in reducing children's disruptive behaviour. AIMS OF THE STUDY: We evaluated the two-year cost-effectiveness of an Internet and telephone assisted parent training intervention called the Strongest Families Smart Website (SFSW) for prevention of children's disruptive behaviour compared to education control (EC) from the combined perspective of the health care funder and parents. METHODS: This study used data from a randomized controlled trial (RCT). The trial screened a population-based sample of 4,656 four-year-olds at annual child health clinic check-ups in Finnish primary care. A total of 464 disruptively behaving children participated in the RCT; half received the SFSW and half EC. We evaluated intention-to-treat based incremental net monetary benefit with a range of willingness to pay values. Costs contained the interventions' and parents' time-use costs. The effectiveness measure was the Child Behavior Checklist (CBCL/1.5-5) externalizing score. The trial is registered at Clinicaltrials.gov (NCT01750996). RESULTS: From the health care funder's perspective, SFSW costs per family were €1,982 and EC €661, and from the parents' perspective SFSW costs per family were €462 and EC €77. From the combined health care funder and parents' perspective, costs were €1,707 higher in the SFSW intervention than in EC. The SFSW decreased the CBCL externalizing score (1.94, SE=0.78, p=0.01) more in comparison to the EC group. In cost-effectiveness analysis using the combined perspective, the incremental net monetary benefit was zero [95% CI €-1,524 to €1,524] if the willingness to pay for one extra point of CBCL externalizing score reduced was €879. If the willingness to pay was more than €879, the average incremental net monetary benefit was positive. DISCUSSION: The cost-effectiveness of the SFSW depends on the decision makers' willingness to pay, which is not stated for CBCL outcomes. Also, the decision maker should consider the uncertainty of cost-effectiveness estimates. The lack of other service use information and micro-costing of SFSW and EC intervention costs weakens our conclusions. However, our study had multiple strengths, such as population-based screening, high sample size, 2-year follow-up, and use of proper methods to conduct a full economic evaluation. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The SFSW is effective in reducing children's disruptive behaviour. Although digitally provided, the SFSW intervention included professional time and, thus, costs. The costs of intervention to the healthcare provider and time cost to families should be taken into account when interventions are implemented. The cost-effectiveness of SFSW interventions depends on the willingness to pay of health care decision makers. IMPLICATIONS FOR HEALTH POLICIES: Investment decisions should require high-quality economic evaluation of interventions and independent evaluation research of interventions should be financed. IMPLICATIONS FOR FURTHER RESEARCH: Decision makers need more economic evaluations of digital interventions. Research should use similar high-quality methods to allow comparison between studies. In an early planning phase of research, health economists should be consulted to enable usability of data and high-quality research.

Physical activity as an investment or consumption good-a mixed methods approach.

Studying individuals' motivation to engage in physical activity raises the question of whether physical activity is a consumption good (enjoyment) or an investment good (a health investment). The aims of the study were: (i) What kind of motivational background is it possible to identify for different forms of physical activity among adults, and (ii) Is there an association between different motivational factors and the form and amount of physical activity among adults. A mixed methods approach was applied using interviews (n = 20) and a questionnaire (n = 156). The qualitative data was analysed using content analysis. The quantitative data were analysed using factor and regression analysis. Among the interviewees, different types of motivation were found: 'enjoyment', 'health reasons' and 'mixed motivations', and from the quantitative data: (i) mixed motivation, a combination of enjoyment and investment, (ii) dislike of physical activity, (iii) social, (iv) goal focused, (v) appearance focused and (vi) exercising only within the comfort zone. Mixed-motivational background, with both enjoyment and investment in health, increased weekly physical activity hours significantly (ß = 1.733; p = 0.001). Personal appearance-based motivation increased weekly muscle training (ß = 0.540; p = 0.000) and brisk physical activity hours (ß = 0651; p = 0.014). Conducting such physical activity which provides enjoyment during the performance of the activity, increased weekly balance-focused exercise hours (ß = 0.224; p = 0.034). People have different kind of motivational backgrounds for engaging in physical activity. Mixed motivational background, including enjoyment and investment in health, yielded more physical activity in hours than if the person had only one of these motivations.

Pairing physical activity with pleasant associations could be a direction for effective physical activity promotion. It is important to enable people to test different physical activity types in order to find the type of physical activity which gives them most joy and pleasure. If one is conducting physical activity purely as an investment in health, the amount of activity is less than when the activity is combined with enjoyment. Getting pleasure from physical activity should be the main target when we try to increase physical activity among people who have previously not enjoyed physical activity.

The long-term cost of childhood conduct problems: Finnish Nationwide 1981 Birth Cohort Study.

BACKGROUND: Commonly recognized childhood conduct problems often lead to costly problems in adulthood. This study aimed to evaluate the long-term cumulative cost of childhood conduct problems until the age of 30. The costs included inpatient care, nervous system medicine purchases, and criminal offences. METHODS: The study used population-based nationwide 1981 birth cohort data. Families and teachers assessed the conduct problems of the eight-year-olds based on Rutter questionnaires. We grouped 5,011 children into low-level of conduct problems (52%), intermediate-level of conduct problems (37%), and high-level of conduct problems (11%) groups, based on combined conduct symptoms scores. The analysis included the cohort data with the Care Register for Health Care, the Drug Prescription Register, and the Finnish Police Register. The cost valuation of service use applied national unit costs in 2016 prices. We used Wilcoxon rank-sum test to test the differences between groups and gender. RESULTS: During 1989-2011, average cumulative costs of the high-level (€44,348, p < .001) and the intermediate-level (€19,405, p < .001) of conduct problems groups were higher than the low-level of conduct problems group's (€10,547) costs. In all three groups, the boys' costs were higher than girls' costs. CONCLUSIONS: The costs associated with conduct problems in childhood are substantial, showing a clear need for cost-effective interventions. Implementation decisions of interventions benefit from long-term cost-effectiveness modelling studies. Costing studies, like this, provide cost and cost offset information for modelling studies.

Municipal resources to promote adult physical activity - a multilevel follow-up study.

BACKGROUND: In Finland, local authorities (municipalities) provide many services, including sports and physical activity facilities such as pedestrian and bicycle ways and lanes, parks, sports arenas and pools. This study aimed to determine whether local authorities can promote physical activity by allocating resources to physical activity facilities. METHODS: The data on municipality expenditure on physical activity and sports, number of sports associations receiving subsidies from the municipality, kilometers of ways for pedestrians and bicycles and hectares of parks in 1999 and 2010 were gathered from national registers. These data were combined using unique municipal codes with individual survey data on leisure-time physical activity (N = 3193) and commuting physical activity (N = 1394). Panel data on physical activity originated from a national health survey, the Health 2000 study, conducted in 2000-2001 and 2011-2012. We used the data of persons who answered the physical activity questions twice and had the same place of residence in both years. In the data, the individuals are nested within municipalities, and multilevel analyses could therefore be applied. The data comprised a two-wave panel and the individuals were followed over 11 years. RESULTS: The resources for physical activity varied between municipalities and years. Municipal expenditure for physical activity and total kilometers of pedestrian ways increased significantly during the 11 years, although a clear decrease was observed in individuals' physical activity. In our models, individual characteristics including higher education level (OR 1.87) and better health status (OR 7.29) increased the odds of increasing physical activity. Female gender was associated with lower (OR 0.83) leisure-time physical activity. Living in rural areas (OR 0.37) decreased commuting physical activity, and age (OR 1.05) increased it. Women (OR 3.16) engaged in commuting physical activity more than men. CONCLUSIONS: Individual-level factors were more important for physical activity than local resources. A large part of the variation in physical activity occurs between individuals, which suggests that some factors not detected in this study explain a large part of the overall variation in physical activity.

Cost-effectiveness of physical activity intervention in children - results based on the Physical Activity and Nutrition in Children (PANIC) study.

BACKGROUND: We assessed the cost-effectiveness of a 2-year physical activity (PA) intervention combining family-based PA counselling and after-school exercise clubs in primary-school children compared to no intervention from an extended service payer's perspective. METHODS: The participants included 506 children (245 girls, 261 boys) allocated to an intervention group (306 children, 60 %) and a control group (200 children, 40 %). The children and their parents in the intervention group had six PA counselling visits, and the children also had the opportunity to participate in after-school exercise clubs. The control group received verbal and written advice on health-improving PA at baseline. A change in total PA over two years was used as the outcome measure. Intervention costs included those related to the family-based PA counselling, the after-school exercise clubs, and the parents' taking time off to travel to and participate in the counselling. The cost-effectiveness analyses were performed using the intention-to-treat principle. The costs per increased PA hour (incremental cost-effectiveness ratio, ICER) were based on net monetary benefit (NMB) regression adjusted for baseline PA and background variables. The results are presented with NMB and cost-effectiveness acceptability curves. RESULTS: Over two years, total PA increased on average by 108 h in the intervention group (95 % confidence interval [CI] from 95 to 121, p < 0.001) and decreased by 65.5 h (95 % CI from 81.7 to 48.3, p < 0.001) in the control group, the difference being 173.7 h. the incremental effectiveness was 87 (173/2) hours. For two years, the intervention costs were €619 without parents' time use costs and €860 with these costs. The costs per increased PA hour were €6.21 without and €8.62 with these costs. The willingness to pay required for 95 % probability of cost-effectiveness was €14 and €19 with these costs. The sensitivity analyses revealed that the ICER without assuming this linear change in PA were €3.10 and €4.31. CONCLUSIONS: The PA intervention would be cost-effective compared to no intervention among children if the service payer's willingness-to-pay for a 1-hour increase in PA is €8.62 with parents' time costs. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01803776. Registered 4 March 2013 - Retrospectively registered, https://clinicaltrials.gov/ct2/results?cond=&term=01803776&cntry=&state=&city=&dist= .

Total cost of care increases significantly from early to mild Alzheimer's disease: 5-year ALSOVA follow-up.

INTRODUCTION: We studied the costs of formal and informal care in relation to Alzheimer's disease (AD) progression. METHODS: 231 persons with AD with a family caregiver were followed up for 5 years. The Clinical Dementia Rating Scale-Sum of Boxes (CDR-SB) was used to measure AD progression. Health and social care unit costs were used for formal care costs. An opportunity cost method for lost leisure time was applied to analyse the cost of informal care. RESULTS: Total cost of care in early stage AD (CDR-SB ≤ 4) was 16,448€ (95% CI 13,722-19,716) annually. In mild (CDR-SB 4.5-9), moderate (CDR-SB 9.5-15.5) and severe (CDR-SB ≥ 16) AD, the total costs were 2.3, 3.4 and 4.4 times higher, respectively. A one-unit increase in CDR-SB increased the total, formal and informal costs by 15, 11 and 18%, respectively. CONCLUSIONS: Compared to early AD, the costs of total, formal and informal care are remarkably higher already in mild AD. This finding emphasises early diagnosis, interventions and family support for persons with AD and their caregivers.

Nutrition-focused group intervention with a strength-based counseling approach for people with clinical depression: a study protocol for the Food for Mind randomized controlled trial.

BACKGROUND: Depression is a highly prevalent mental disorder with major public health effects globally. It impairs the quality of life and reduces the ability to work and function, leading to increasing costs of sick leaves and disability pensions. Current treatment strategies focus on biological and psychological pathways while understating the role of lifestyle factors. Epidemiological studies have shown convincing evidence of an inverse relationship between diet quality and depression. However, only limited data are available on the therapeutic effects of diet quality improvement on depression. Using a randomized controlled trial design, our primary aim is to investigate the effectiveness and cost-effectiveness of a behavioral nutrition group intervention compared to a social support intervention in the treatment of depression. METHODS: Participants (N=144, aged 20-65 years) with a diagnosis of moderate or severe depression recruited in collaboration with outpatient care units will be randomized into two arms: Food for Mind (FM) nutrition intervention (n=72) or Bring Good Mood (BGM) social support control group (n=72). Both arms will be provided with 6 group sessions over an 8-week period. FM involves improving diet quality by applying strength-based behavioral nutrition counseling and activities facilitated by a registered dietitian. The control arm comprises a befriending protocol. During the interventions, all participants will continue their treatment for depression as usual. Longitudinal data are collected at baseline, at 8 weeks, and at 6- and 12-month follow-ups. Depressive symptoms, diet quality, eating behavior, ability to work and function, and quality of life are assessed by self-reported questionnaires. A treatment expectancy questionnaire will be administered at baseline and an acceptability questionnaire at 8 weeks. The Center for Epidemiologic Studies Depression Scale is used as the primary endpoint at 1 year. The results will be analyzed with linear mixed-effects models. Economic evaluation includes both cost-effectiveness and cost-utility analysis. Two incremental cost-effectiveness ratios will be calculated to evaluate the incremental cost per QALY and the incremental cost per improvement in CES-D. DISCUSSION: If the intervention proves to be cost-effective and acceptable, it be can be implemented in healthcare to support the treatment of depression. TRIAL REGISTRATION: ClinicalTrials.gov NCT03904771 . Retrospectively registered on 5 April 2019.

Randomised controlled trial (RCT) study design for a large-scale municipal fall prevention exercise programme in community-living older women: study protocol for the Kuopio Fall Prevention Study (KFPS).

INTRODUCTION: Falls are a substantial health problem in seniors, causing fractures and being the leading cause of fatal injuries. The benefits of physical activity in fall prevention have been shown in randomised controlled trials (RCTs) in small cohorts (eg, ≤200 persons), but there is a gap between the known health effects of exercise and the large-scale implementation of effective activity in communities. Mental health and subjective well-being (SWB) should also be studied since they are strongly related to healthy ageing. Thus far, the proven efficacy of communal strategies to reduce falls and improve healthy ageing is sparse. METHODS AND ANALYSIS: In 2016, a 2-year RCT was launched in Kuopio, Finland to estimate the efficacy of a large, population-based, fall prevention exercise programme in community-living older women (born 1932-1945). Both the intervention and control group (n=457+457) receive health education. The intervention group is also offered free 6-month supervised training courses (weekly gym training and Taiji sessions), followed by a free 6-month unsupervised use of exercise facilities, as well as unsupervised low-cost exercise is also offered for another 12 months. During the whole 24-month follow-up, controls are free to pursue all their normal physical activities. Both study groups undergo the study measurements three times. Outcome measures include recording of falls, injuries, bone mineral density, changes in health and functional status and cognitive performance, deaths and SWB. Finally, the cost-effectiveness and cost-utility analysis will be conducted from the societal view. The main analyses comparing outcomes between study groups will be conducted using the intention to treat principle. ETHICS AND DISSEMINATION: The study has been reviewed and approved by the Research Ethics Committee of the Hospital District of North Savo. All regulations and measures of ethics and confidentiality are handled in accordance with the Declaration of Helsinki. TRIAL REGISTRATION NUMBER: NCT02665169; Pre-results.

Cost-effectiveness of population-level physical activity interventions: a systematic review.

OBJECTIVE: This systematic review synthesizes the evidence on the cost-effectiveness of population-level interventions to promote physical activity. DATA SOURCE: A systematic literature search was conducted between May and August 2013 in four databases: PubMed, Scopus, Web of Science, and SPORTDiscus. STUDY INCLUSION AND EXCLUSION CRITERIA: Only primary and preventive interventions aimed at promoting and maintaining physical activity in wide population groups were included. An economic evaluation of both effectiveness and cost was required. Secondary interventions and interventions targeting selected population groups or focusing on single individuals were excluded. DATA EXTRACTION: Interventions were searched for in six different categories: (1) environment, (2) built environment, (3) sports clubs and enhanced access, (4) schools, (5) mass media and community-based, and (6) workplace. DATA SYNTHESIS: The systematic search yielded 2058 articles, of which 10 articles met the selection criteria. The costs of interventions were converted to costs per person per day in 2012 U.S. dollars. The physical activity results were calculated as metabolic equivalent of task hours (MET-hours, or MET-h) gained per person per day. Cost-effectiveness ratios were presented as dollars per MET-hours gained. The intervention scale and the budget impact of interventions were taken into account. RESULTS: The most efficient interventions to increase physical activity were community rail-trails ($.006/MET-h), pedometers ($.014/MET-h), and school health education programs ($.056/MET-h). CONCLUSION: Improving opportunities for walking and biking seems to increase physical activity cost-effectively. However, it is necessary to be careful in generalizing the results because of the small number of studies. This review provides important information for decision makers.

The impact of time cost of physical exercise on health outcomes by older adults: the DR's EXTRA Study.

When the motivation for exercise is high and people are retired, the cost of time used for physical exercise may be lower and individuals may exercise more compared to individuals with a low motivational level and in working life. The aim was to study the effect of time cost of physical exercise on the amount of physical exercise and on health-related quality of life. We used 2-year data (n = 1,292) from a 4-year randomised controlled trial in a population-based sample of Eastern Finnish men and women, 57-78 years of age at baseline, in 2005-2006. In the statistical analysis, physical exercise and health outcomes were assumed to be endogenous variables explained with a set of exogenous variables. The statistical modelling was done by panel data instrumental variable regressions. Health-related quality of life was evaluated by the RAND 36-item survey and motives for exercise with a questionnaire. Joy as the motivation for physical exercise and retirement increased the amount of physical exercise per week (p < 0.001). A higher amount of exercise was associated with physical (p < 0.001) and mental (p < 0.001) components of quality of life. Moreover, a higher amount of physical exercise decreased the metabolic risk factor score (p < 0.001). The motivation and extra time, i.e. retirement, have a significant impact on the time spent on physical exercise (p < 0.001). Our data agree with the theory that high motivation and retirement lower the time cost of physical exercise. The results emphasise that motivation and the labour market position are important in determining the cost of physical exercise.