Extrinsic goals and time tradeoff

Comparing heuristic valuation processes between health state valuation from child and adult perspectives

OBJECTIVES

Health state valuation assumes that respondents trade off between all aspects of choice tasks and maximize their utility. Yet, respondents may use heuristic valuation processes, i.e., strategies to simplify or avoid the trade-offs that are core to health state valuation. The objective of this study is to explore if heuristic valuation processes are more prevalent for valuation from a 10-year-old child's perspective compared to the use of an adult perspective.

METHODS

We reused existing data in which EQ-5D health states were valued from adult and child perspectives with composite time trade-off (cTTO) and discrete choice experiment (DCE) tasks. Our analyses focused on comparing completion time and responding patterns across both perspectives. We also explored how reflective of a set of heuristic strategies respondents' choices were in both perspectives.

RESULTS

We found no evidence for systematic differences in completion time across perspectives. Generally, we find different responding patterns in child perspectives, e.g., more speeding, dominance violations, and clustering of utilities at 1.0, 0.8, and 0. Very few heuristic strategies provide a coherent explanation for the observed DCE responses.

CONCLUSION

Our results provide some, albeit indirect, evidence for differences in heuristic valuation processes between perspectives, although not across all data sources. Potential effects of heuristic valuation processes, such as transfer of responsibility, may be identified through studying responding patterns in cTTO and DCE responses.

Do Misconceptions About Health-Related Quality of Life Affect General Population Valuations of Health States?

OBJECTIVES

Healthcare resource allocation decisions are often informed by the expected gains in patients' quality-adjusted life-years. Misconceptions about ill-health's consequences for quality of life (QOL) may however affect evaluations of health states by the general population and hence affect resource allocation decisions informed by quality-adjusted life-years. We examine whether people selectively misestimate the QOL consequences of moderate anxiety or depression compared with other dimensions of health, and we test whether informing people of actual changes in QOL associated with health states changes appraisals of their relative undesirability.

METHODS

UK general population participants (N = 1259; in 2017) expressed preferences over moderate problems: anxiety or depression, self-care, and pain or discomfort. A randomized control trial design was used whereby a control group was given a functional description of each health state, and 2 intervention groups were additionally given information on the actual differences in either life satisfaction (LS) or day affect (DA) associated with experiencing each health state.

RESULTS

The LS (DA) group reported a higher preference for avoiding living with moderate anxiety or depression, being 13.4% (13.9%) more likely to choose it as most undesirable.

CONCLUSION

Informing people of the change in LS or DA associated with health states before they appraise them is a feasible way to obtain informed preferences.

EQ-5D-Y Value Set for Germany

BACKGROUND

Demand is increasing for youth-specific preference-based health-related quality-of-life measures for inclusion in evaluations of healthcare interventions for children and adolescents. The EQ-5D-Youth (EQ-5D-Y) has the potential to become such a preference-based measure.

OBJECTIVE

This study applied the recently published EQ-5D-Y valuation protocol to develop a German EQ-5D-Y value set and explored the differences between values given to youth health by parents and non-parents.

METHODS

To elicit EQ-5D-Y health state preferences, a representative sample of 1030 adults of the general population completed a discrete choice experiment (DCE) online survey, and 215 adults participated in face-to-face interviews applying composite time trade-off (cTTO). Respondents were asked to consider a 10-year-old child living in the health states. DCE data were modelled using a mixed logit model. To derive the value set, DCE latent scale values were anchored onto adjusted mean cTTO values using a linear mapping approach.

RESULTS

Adult respondents considered pain/discomfort and feeling worried/sad/unhappy as the two most important dimensions in terms of youth health. Adjusted mean cTTO values ranged from - 0.350 for health state 33333 to 0.970 for health state 21111. The EQ-5D-Y value set showed a logical order for all parameter estimates, and predicted values ranged from - 0.283 to 1. Differences in preferences by parental status were mainly observed for cTTO results, where mean values were larger for parents than for non-parents.

CONCLUSIONS

Applying the valuation protocol, a German EQ-5D-Y value set with internally consistent coefficients was developed. This enables the instrument to be used in economic evaluations of paediatric healthcare interventions.

Expect Nothing: The (Lack of) Influence of Subjective Life Expectancy on Valuation of Child Health States

Objective

Earlier research has shown that individuals' subjective life expectancy (SLE) affects health state valuation with time trade-off (TTO). Individuals with longer expected life durations are less willing to trade-off life duration, which yields higher utilities. In this article, the influence of SLE is explored in the valuation of EQ-5D-Y-3L with a proxy perspective, i.e., adults' valuation of health states considering the life of a 10-year-old child. As SLE for children is likely higher, this might explain earlier findings suggesting that individuals are less willing to trade-off years of life for children than for adults.

Methods

A total of 197 respondents were recruited to take part in digital TTO interviews, facilitated by trained interviewers. TTO interviews were implemented in accordance with the recommended protocol for the valuation of EQ-5D-Y-3L. Respondents valued 10 EQ-5D-Y-3L health states for a 10-year-old child, after which they were asked to report how old they themselves expected to become and also how old they expected a 10-year-old child to become.

Results

Generally, adult respondents reported higher SLE for children than for themselves. Neither SLE was systematically associated with the willingness to trade lifetime or the number of life years traded off in TTO tasks. This null-result was substantiated by regression analyses per health state.

Conclusion

The results of this study suggest that individuals' expectations about longevity are not associated with EQ-5D-Y-3L valuation. This lack of association is in contrast to earlier work and might be explained by the psychological distance introduced with proxy perspective valuation, or by the methodological differences with earlier work.

Impact of Including Carer Information in Time Trade-Off Tasks: Results from a Pilot Study

INTRODUCTION

Carer quality of life (QoL) can be included in economic evaluations and captured using EQ-5D. Traditional valuation tasks require participants to imagine living in a health state for a number of years, without being told what to consider. This pilot study sought to investigate whether participants implicitly consider the impact of the health state on others, and the extent to which this may impact health state valuations.

METHODS

Composite time trade-off (TTO) interviews were conducted with a convenience sample. Each interview included a 'traditional' TTO exercise to value three health states, and a 'combined' TTO exercise, where participants valued the same health states again, having been informed that they would require a carer living in a particular health state. Qualitative feedback was collected after each exercise. Paired t-test comparisons of the utilities elicited in each exercise were made.

RESULTS

Thirty-three participants enrolled in the pilot. Mean differences between exercises were not statistically significant and differed in direction, although considerable heterogeneity was observed in individual response trajectories. Overall, 36% (n = 12) of participants expressed an unprompted concern about being a burden on others in the traditional exercise, and 67% (n = 22) of participants would have responded differently had the carer been in full health in the combined exercise.

CONCLUSION

Providing contextual information about carers may impact valuations. Further research is required to better understand the reasons behind the variation in individual response trajectories observed in this pilot study. The insights from this study may be useful for informing the design of related future studies.

Time trade-off with someone to live for: impact of having significant others on time trade-off valuations of hypothetical health states

Background

The TTO task involves giving up life years, i.e. living a shorter life, to avoid an undesirable health state. Despite being a hypothetical task, some respondents take other life factors into account when completing the task. This study explored the effect of having children and/or a partner on TTO valuations of hypothetical EQ-5D-5L health states in a valuation study of the general population.

Methods

The study used TTO data collected in a Norwegian EQ-5D-5L valuation study in 2019–2020, by one-to-one pc-assisted interviews following the EQ-VT protocol. We used regression modelling to determine the effect of significant others (having children or a partner) on disutility per health state from the TTO valuations.

Results

430 respondents were included [mean age 43.8 (SD 15.9) years, 58% female, 48% with children, 68% with a partner, 25% with neither children nor partner]. Having children and/or a partner was associated with lowered willingness to trade life years translating to higher elicited health state utilities (p < 0.01).

Conclusion

Having significant others, or the lack of having significant others, was associated with respondents’ valuation of hypothetical health states using TTO, more so than traditional sampling variables such as age and sex. Inadequate representativeness in terms of having significant others could bias health state preference values in valuation studies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-03026-6.

Think of the Children: A Discussion of the Rationale for and Implications of the Perspective Used for EQ-5D-Y Health State Valuation

OBJECTIVES

The recently published EQ-5D-Y valuation protocol prescribes the general public values EQ-5D-Y health states for a 10-year-old child. This child perspective differs from the individual perspective applied for valuation of adult EQ-5D instruments. This article discusses the rationale for and implications of applying a child perspective for EQ-5D-Y health state valuation.

METHODS

This article was informed by an exploration of the normative and empirical literature on health state valuation. We identified and summarized key discussion points in a narrative review.

RESULTS

Although valuing EQ-5D-Y health states from an individual perspective is feasible, it may be problematic for several reasons. The use of a child perspective implies that-rather than valuing one's own health-someone else's health is valued. This may require the projection of one's own beliefs, expectations, and preferences on others, which could change the decision processes underlying the elicited preferences. Furthermore, because preferences are obtained for a 10-year-old child, it is unclear if this given age as well as other (missing) information on the described child beneficiary (should) affect valuation of EQ-5D-Y health states.

CONCLUSIONS

The change from an individual to a child perspective in the valuation of EQ-5D-Y will likely lead to differences in utilities. This has implications for the estimation of incremental health-related quality-of-life gains in economic evaluations of health technologies for children and adolescents and therefore might affect reimbursement decisions. Further research is necessary for gaining insight into the extent to which this impact is normatively and empirically justified.

What drives differences in preferences for health states between patients and the public? A qualitative investigation of respondents' thought processes

Cost-effectiveness analyses using quality-adjusted life-years (QALYs) are used in decision-making regarding which interventions are available via many national healthcare systems. QALYs are calculated based on health state values provided by preference elicitation techniques. Several national decision-making bodies recommend that health state values should be based on preferences elicited from general populations, rather than from patients. Previous studies have shown systematic differences between health state values elicited from members of the general population and from patients. Various explanations for this phenomenon have been proposed, however empirical evidence for these is scarce. We aimed to explore possible reasons for discrepancies between public and patient valuations by undertaking qualitative cognitive interviews, asking 14 members of the general population and 12 people with multiple sclerosis (MS) to think aloud while completing a preference elicitation task (time trade-off) for MS-related health states. The interviews were undertaken between December 2016 and October 2017 in the South West region of England, and were analysed using the Framework Method. As anticipated, we found that participants with MS had more experience of health problems and used this experience to consider how they might adapt to the health states over time, and which dimensions of health-related quality of life were most important to them. We found no evidence that participants with MS were less affected by framing effects and focusing illusions, more likely to prioritise non-physical dimensions of health, or more prone to loss aversion, endowment effects and non-compensatory decision-making. These findings contribute to our understanding of how patients and members of the general population respond to preference elicitation exercises, and why their preferences may differ, and may help to inform developing areas of research, such as the joint presentation of cost-effectiveness results from multiple perspectives, and the use of preferences elicited from patients for experienced health states.

Elicitation of Norwegian EQ-5D-5L values for hypothetical and experience-based health states based on the EuroQol Valuation Technology (EQ-VT) protocol

INTRODUCTION

Norway is one of several European countries that lacks a national value set and scoring algorithm for the EuroQol five dimensions (EQ-5D). Recent studies have found differences between countries in terms of health values or preferences for health states described by instruments such as the EQ-5D. The project aims to model a national value set for the five level version of the EQ-5D based on values elicited from a representative sample of the Norwegian adult general population in terms of region, age, sex and level of education. Using a sampling strategy supporting the collection of values for both hypothetical and experienced health states, the study will have the additional aim of assessing the feasibility of collecting experience-based values in accordance with the latest EQ-5D valuation study protocol, and comparing values with those given for hypothetical health states.

METHODS AND ANALYSIS

Multistage random sampling and quota-sampling will contribute to representativeness. To increase the number of valuations of experienced health states, those with less than perfect health will be oversampled, increasing the total number of interviews from 1000 to 1300-1500. The most recent EQ-5D valuation protocol will be followed which includes computer assisted face-to-face, one-to-one interviews and use of composite time trade-off and discrete choice experiments.

ETHICS AND DISSEMINATION

The study has been reviewed and found to be outside of the scope of the ethics committee and thus not in need of ethical approval. The study findings will be disseminated through peer-reviewed publications, conference presentations and summaries for key stakeholders and partners in the field. The scoring algorithms will be available for widely used statistical software.

Effect of Reflection and Deliberation on Health State Values: A Mixed-Methods Study

BACKGROUND

Health economists ask members of the general public to value health states, but it is recognized that individuals construct their preferences during the valuation tasks. Conventional methods rely on one-off interviews that do not give participants time to reflect and deliberate on their preferences.

OBJECTIVE

This study investigates the effect of reflection and deliberation on health state preferences using the EQ-5D questionnaire and time trade-off valuation method.

METHODS

A novel concurrent explanatory mixed-methods design is used to investigate the explanation for the quantitative findings.

RESULTS

A total of 57 participants in the United Kingdom valued health states before and after a group-based deliberation exercise. There were large changes in health state values at the individual level, but the changes canceled out at the aggregate level. The mixed-methods findings suggest deliberation did not reveal new information or reduce inconsistencies in reasoning but rather focused on an exchange of personal subjective beliefs. In cases of disagreement, the participants accepted but did not adopt other participants' opinions. Participants remained uncertain about the relevance of their experiences and about their values.

CONCLUSIONS

The evidence suggests that reflection and deliberation, as designed in this study, are unlikely to result in large systematic changes of health state values. The uncertainties expressed by participants means future research should investigate whether preferences are informed or whether providing participants with more information helps them construct their preferences with more certainty. The mixed-methods design used is a promising design to help elucidate the reasons for quantitative findings.

Overview, Update, and Lessons Learned From the International EQ-5D-5L Valuation Work: Version 2 of the EQ-5D-5L Valuation Protocol

A standardized 5-level EuroQol 5-dimensional questionnaire (EQ-5D-5L) valuation protocol was first used in national studies in the period 2012 to 2013. A set of problems encountered in this initial wave of valuation studies led to the subsequent refinement of the valuation protocol. To clarify lessons learned and how the protocol was updated when moving from version 1.0 to the current version 2.1 and 2.0, this article will (1) present the challenges faced in EQ-5D-5L valuation since 2012 and how these were resolved and (2) describe in depth a set of new challenges that have become central in currently ongoing research on how EQ-5D-5L health states should be valued and modeled.

Measuring health utility in varying pregnancy contexts among a diverse cohort of pregnant women

OBJECTIVE

To contribute to decision analysis by estimating utility, defined as an individual's valuation of specific health states, for different pregnancy contexts.

STUDY DESIGN

Cross-sectional analysis of data from pregnant women recruited at pregnancy testing clinics during June 2014-June 2015. Utility was measured using the visual analog scale (VAS), PROMIS GSF-derived utility, standard gamble (SG), and time-trade-off (TTO) approaches. Six dimensions of pregnancy context were assessed including: intention, desirability, planning, timing, wantedness, and happiness. Multivariable regression modeling was used to examine the associations between pregnancy context and utility while controlling for women's sociodemographic and health characteristics.

RESULTS

Among 123 participants with diverse characteristics, aged 27±6 years, with mean gestation of 7.5±3 weeks, few reported optimal pregnancy contexts. Mean utility of the pregnancy state varied across contexts, whether measured with VAS (0.28-0.91), PROMIS GSF-derived utility (0.66-0.75), SG (0.985-1.00) or TTO (0.9990-0.99999). The VAS-derived mean utility score for unintended pregnancy was 0.68 (95% CI 0.59, 0.77). Multivariable regression analysis demonstrated significant disutility of unintended pregnancy, as well as all other unfavorable pregnancy contexts, when measured by VAS. In contrast, PROMIS GSF-derived utility only detected a significant reduction in utility among ambivalent compared to wanted pregnancy, while SG and TTO did not show meaningful differences in utility across pregnancy contexts.

CONCLUSIONS

Unintended pregnancy is associated with significant patient-reported disutility, as is pregnancy occurring in other unfavorable contexts. VAS-based measurements provide the most nuanced measures of the utility for pregnancy in varying contexts.

IMPLICATIONS

Decision analyses, including assessments of the cost-effectiveness of pregnancy related interventions, should incorporate measures of the utility of pregnancy in various contexts.

Are preferences over health states informed?

Background

The use of preference-elicitation tasks for valuing health states is well established, but little is known about whether these preferences are informed. Preferences may not be informed because individuals with little experience of ill health are asked to value health states. The use of uninformed preferences in cost-effectiveness can result in sub-optimal resource allocation. The aim of this study was to pilot a novel method to assess whether members of the public are informed about health states they value in preference-elicitation tasks.

Methods

The general public was said to be informed if the expectations of the public about the effect of ill health on people’s lives were in agreement with the experience of patients. Sixty-two members of the public provided their expectations of the consequences of ill health on five life domains (activities, enjoyment, independence, relationships, and avoiding being a burden). A secondary dataset was used to measure patient experience on those five consequences.

Results

There were differences between the expectations of the public and the experience of patients. For example, for all five life consequences the public underestimated the effects of problems in usual activities compared to problems in mobility. They also underestimated the effect of ‘anxiety or depression’ compared to physical problems on enjoyment of life and on the quality of personal relationships.

Conclusions

This proof-of-concept study showed that it is possible to test whether preferences are informed. This study should be replicated using a larger sample. The findings suggest that preferences over health states in this sample are not fully informed because the participants do not have accurate expectations about the consequences of ill health. These uninformed preferences may not be adequate for allocation of public resources, and research is needed into methods to make them better informed.

How do individuals value health states? A qualitative investigation

Despite the importance of health state values in informing resource allocation in health care, there is arguably little known about how individuals value health. Previous studies have shown that a variety of non-health factors and beliefs are important in valuing health, but there is less evidence in the literature about how individuals' beliefs affect their preferences or what role non-health factors play in the process of forming preferences. This study investigated the thought processes of 21 U.K. based participants in March 2013 who valued health states using semi-structured interviews and a think-aloud protocol, with the aim to better understand the relationship between health states, the individual's underlying beliefs, and the individual's preferences. Participants followed several stages in valuing health. First, participants interpreted the health states more concretely, relying on their imagination and their experience of ill health. Participants judged how the concrete health problems combined with their personal interests, circumstances, and environment would affect them personally. Ultimately, participants valued health by estimating and weighing the non-health consequences of the health states. Six consequences were most frequently mentioned: activities, enjoyment, independence, relationships, dignity, and avoiding being a burden. At each stage participants encountered difficulties and expressed concerns. The findings have implications for methods of describing health, for example, whether the focus should be on health or a broader notion of well-being and capability. This is because the consequences are similar to the domains of broader measures such as the ICECAP measures for adults and older people, and the Warwick-Edinburgh Mental Wellbeing Scale. The findings suggest the need for testing whether individuals are informed about the health states they are valuing. Participants valued health by estimating the non-health consequences of health states and these estimates relied on individuals' beliefs about the interaction of the health state and their personal and social circumstances.

"Married with children" the influence of significant others in TTO exercises

Background

Which responder characteristics influence TTO scores remains underexplored. More research is needed in order to understand (differences in) TTO scores, but also in the context of generating representative health state valuations for some population. Previous studies have found age, gender, marital status and subjective life expectancy to influence the number of years traded off.

Objective

This study aimed to investigate which other responder characteristics influence TTO responses, with an emphasis on consideration of significant others, such as partners and children.

Methods and Design

We performed a web-based survey in a representative sample of the Dutch general public (aged 18–65). Data on demographics, health status and expectations about future length and quality of life were gathered. Respondents valued three distinct health states using TTO.

Results

A total of 1067 respondents completed the questionnaire. Sixty percent of respondents had children and 49 % were married. The mean number of years traded off increased with severity of health states. Higher age and living together were positively associated with number of years traded off. Increases in subjective life expectancy, having children and being male (were negatively associated with the number of years traded-off.

Conclusion

Age, gender and subjective life expectancy, living together and having children were significantly associated with TTO responses. Consideration of significant others in TTO exercises thus may be important in understanding (differences in) TTO responses and when drawing representative samples from the general public.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-015-0276-7) contains supplementary material, which is available to authorized users.

Impact of caregiver and parenting status on time trade-off and standard gamble utility scores for health state descriptions

Background

The purpose of this study was to examine the effect of caregiver status on time trade-off (TTO) and standard gamble (SG) health state utility scores. Respondents were categorized as caregivers if they reported that either children or adults depended on them for care.

Methods

This study was a secondary analysis of data from three studies in which general population samples rated health state descriptions. Study 1: UK; four osteoarthritis health states. Study 2: UK; three adult ADHD health states. Study 3: US; 16 schizophrenia health states. All three studies included time trade-off assessment. Study 1 also included standard gamble. Descriptive statistics were calculated to examine willingness to trade in TTO or gamble in SG. Utilities for caregivers and non-caregivers were compared using t-tests and ANCOVA models.

Results

There were 364 respondents including 106 caregivers (n = 30, 47, and 29 in Studies 1, 2, and 3) and 258 non-caregivers. Most caregivers were parents of dependent children (78.3%). Compared to non-caregivers, caregivers had more responses at the ceiling (i.e., utility = 0.95), indicating less willingness to trade time or gamble. All utilities were higher for caregivers than non-caregivers (mean utility difference between groups: 0.07 to 0.16 in Study 1 TTO; 0.03 to 0.17 in Study 1 SG; 0.06 to 0.10 in Study 2 TTO; 0.11 to 0.22 in Study 3 TTO). These differences were statistically significant for at least two health states in each study (p < 0.05). Results of sensitivity analyses with two caregiver subgroups (parents of dependent children and parents of any child regardless of whether the child was still dependent) followed the same pattern as results of the primary analysis. The parent subgroups were generally less willing to trade time or gamble (i.e., resulting in higher utility scores) than comparison groups of non-parents.

Conclusions

Results indicate that caregiver status, including being a parent, influences responses in time trade-off health state valuation. Caregivers (i.e., predominantly parents) were less willing than non-caregivers to trade time, resulting in higher utility scores. This pattern was consistent across multiple health states in three studies. Standard gamble results followed similar patterns, but with less consistent differences between groups. It may be useful to consider parenting/caregiving status when collecting, interpreting, or using utility data because this demographic variable could influence results.

Development of Goal-Sensitive Health-Related Utility Assessment Procedures

Purpose. To measure the degree to which people express willingness to trade life or health for nonmedical goals. Method. In 3 studies, outpatients provided important life goals. In study 1, patients performed time-tradeoff between life-years and goal achievement and chose between states that varied in goal achievement, life expectancy, and disability; in study 2, patients made choices that traded off health state and goal achievement; in study 3, patients performed time-tradeoff assessments in 3 different goal achievement contexts. Results. In study 1 (n = 58), participants were eager to trade life-years for goal achievement, trading, on average, 71% of their remaining life for certain achievement v. certain nonachievement or 54% of their remaining life for their expected likelihood of achievement v. nonachievement. Life expectancy, disability status, and goal achievement each had a significant main effect on utility. In study 2 (n = 54), participants equally preferred a moderately impaired health state with goal achievement to perfect health without goal achievement and more strongly preferred the moderately impaired state with goal achievement than other less impaired states without goal achievement. Study 3 (n = 62) demonstrated that the mere discussion of goals and goal achievement or nonachievement in the context of a standard time-tradeoff assessment (without trading off goals) did not impact the assessment. Conclusions. Nonmedical life goals are important determinants of quality of life. People express willingness to trade off life and health in pursuit of these goals, which are extrinsic to the standard quality-adjusted life-year model.

Incorporating extrinsic goals into decision and cost-effectiveness analyses

It has not been widely recognized that medical patients as individuals may have goals that are not easily expressed in terms of quality-adjusted life years (QALYs). The QALY model deals with ongoing goals such as reducing pain or maintaining mobility, but goals such as completing an important project or seeing a child graduate from college occur at unique points in time and do not lend themselves to easy expression in terms of QALYs. Such extrinsic goals have been posited as explanations for preferences inconsistent with the QALY model, such as unwillingness to trade away time or accept gambles. In this article, the authors examine methods for including extrinsic goals in medical decision and cost-effectiveness analyses. As illustrations, they revisit 2 previously published analyses, the management of unruptured intracranial arteriovenous malformations (AVMs) and the evaluation of preventive strategies for BRCA + women.

Measuring the effects of unintended pregnancy on women's quality of life

BACKGROUND

This study was conducted to assess the potential impact of an unintended pregnancy on women's quality of life.

STUDY DESIGN

We asked 192 nonpregnant women to report how they would feel if they learned that they were pregnant using a visual analog scale (VAS), a time trade-off (TTO) metric, a standard gamble (SG) metric and a willingness-to-pay (WTP) metric.

RESULTS

Women's anticipated responses to an unintended pregnancy varied widely. Using a VAS, 8% reported pregnancy would make them feel like they were dying. To avoid pregnancy, 28% of women were willing to trade time from the end of their life (TTO), 16% of women were willing to accept an immediate risk of death (SG) and 60% of women were willing to pay some amount of money (WTP). On average, women, using the VAS, TTO and SG metrics, reported that an unintended pregnancy would create a health utility state (where 0 represents death and 1 represents perfect health) of 0.487, 0.992 and 0.997, respectively.

CONCLUSION

The anticipated effects of pregnancy on women's quality of life should be integrated into cost-effectiveness analyses of family planning services.