Effectiveness and Cost-Benefit of an Elementary School-Based Telehealth Program

Utilization of telehealth in school-based health centers (SBHCs) is increasing rapidly during the COVID-19 pandemic. This study used a quasi-experimental design to evaluate the effect on school absences and cost-benefit of telehealth-exclusive SBHCs at 6 elementary schools from 2015-2017. The effect of telehealth on absences was estimated compared to students without telehealth using negative binomial regression controlling for absences and health suite visits in 2014 and sociodemographic characteristics. The sample included 7,164 observations from 4,203 students. Telehealth was associated with a 7.7% (p = 0.025; 95% CI: 1.0%, 14%) reduction in absences (0.60 days/year). The program cost $189,000/yr and an estimated total benefit of $384,995 (95% CI: $60,416; $687,479) and an annual net benefit of $195,873 (95% CI: -$128,706; $498,357). While this cost-benefit analysis is limited by a lack of data on total healthcare utilization, the use of telehealth-exclusive SBHCs can improve student health and attendance while delivering cost savings to society.

School-Based Health Centers, Access to Care, and Income-Based Disparities

Importance

School-based health centers (SBHCs) are primary care clinics colocated at schools. SBHCs have the potential to improve health care access and reduce disparities, but there is limited rigorous evidence on their effectiveness at the national level.

Objective

To determine whether county-level adoption of SBHCs was associated with access, utilization, and health among children from low-income families and to measure reductions in income-based disparities.

Design, Setting, and Participants

This survey study used a difference-in-differences design and data from a nationally representative sample of children in the US merged with SBHC indicators from the National Census of School-Based Health Centers. The main sample included children aged 5 to 17 years with family incomes that were less than 200% of the federal poverty level observed in the National Health Interview Survey, collected between 1997 to 2018. The sample was restricted to children living in a county that adopted a center between 2003 and 2013 or that did not have a center at any time during the study period. Analyses of income-based disparities included children from higher income families (ie, 200% or higher than the federal poverty level). Data were analyzed between January 2020 and July 2023.

Exposure

County-by-year SBHC adoption.

Main Outcomes and Measures

Outcomes included access (usual source of care, insurance status, barriers), ambulatory care use (general physician, eye doctor, dental, mental health visits), and health (general health status, missed school days due to illness). P values were adjusted for multiple comparisons using the sharpened q value method.

Results

This study included 12 624 unweighted children from low-income families and 24 631 unweighted children from higher income families. The weighted percentage of children in low-income families who resided in counties with SBHC adoption included 50.0% aged 5 to 10 years. The weighted percentages of the race and ethnicity of these children included 36.7% Hispanic children, 25.2% non-Hispanic Black children, and 30.6% non-Hispanic White children. The weighted percentages of children in the counties that never adopted SBHCs included 50.1% aged 5 to 10 years. The weighted percentages of the race and ethnicity of these children included 20.7% Hispanic children, 22.4% non-Hispanic Black children, and 52.9% non-Hispanic White children. SBHC adoption was associated with a 6.4 percentage point increase in dental visits (95% CI, 3.2-9.6 percentage points; P < .001), an 8.0 percentage point increase in having a usual source of care (95% CI, 4.5-11.5 percentage points; P < .001), and a 5.2 percentage point increase in insurance (95% CI, 1.2-9.2 percentage points; P = .03). No other statistically significant associations were found with other outcomes. SBHCs were associated with relative reductions in income-based disparities to dental visits by 76% (4.9 percentage points; 95% CI, 2.0-7.7 percentage points), to insured status by 63% (3.5 percentage points; 95% CI, 1.3-5.7 percentage points), and to having a usual source of care by 98% (7.2 percentage points; 95% CI, 5.4-9.1 percentage points).

Conclusions and Relevance

In this survey study with difference-in-differences analysis of SBHC adoption, SBHCs were associated with access to care and reduced income-based disparities. These findings support additional SBHC expansion.

[Effects and costs of The Healthy Primary School of the Future]

OBJECTIVE

To study school lifestyle interventions for elementary school children (The Healthy Primary School of the Future).

RESEARCH QUESTION

What are the effects of the introduction of increased physical activity with or without healthy nutrition on health behaviour and BMI of young children and what are the costs of this program?

DESIGN

Prospective controlled non-randomized study with nearly 1700 children in Parkstad (South-East Netherlands).

RESULTS

Preliminary results after two years show that the combination of increased physical activity and healthy nutrition result in a decreased BMIz-score (-0.036), increased physical activity alone in hardly any change (-0.10) while in the control group the BMIz-score increased (0.052). The net societal costs of the combination of physical activity and health nutrition costs were 1 euro per child per day.

CONCLUSION

The study contributes to the increasing amount of evidence proving that lifestyle interventions are effective in reducing the obesity epidemic. Future studies will show whether a weight reduction in children will result in the prevention of chronic disease later on in life and what the cost reduction related to this result will be.

Cost-Utility Analysis of a Complex Intervention to Reduce School-Based Bullying and Aggression: An Analysis of the Inclusive RCT

OBJECTIVES

Bullying and aggression among children and young people are key public mental health priorities. In this study, we evaluated the cost-effectiveness of a complex school-based intervention to address these outcomes within a large-cluster randomized trial (Inclusive).

METHODS

Forty state secondary schools were randomly allocated (1:1) to receive the intervention or continue with current practice as controls. Data were collected using paper questionnaires completed in classrooms including measures of their health-related quality of life using the Childhood Utility Index and police and National Health Service resource use. Further detailed data were collected on the cost of delivering the intervention. We calculated incremental cost-effectiveness ratios following the intention-to-treat principle using multilevel linear regression models that allowed for clustering of pupils at the school level.

RESULTS

Overall, we found that the intervention was highly cost-effective, with cost-per quality-adjusted life year thresholds of £13 284 and £1875 at 2 years and 3 years, respectively. Analysis of uncertainty in the result at 2 years revealed a 65% chance of being cost-effective, but after 3 years there was a 90% chance that it was cost-effective.

CONCLUSION

This study provides strong evidence collected prospectively from a randomized study that this school-based intervention is highly cost-effective. Education- and health-sector policy makers should consider investment in scaling up this intervention.

Analyzing the Association between Student Weight Status and School Meal Participation: Evidence from the School Nutrition and Meal Cost Study

Childhood obesity remains a pressing public health concern. Children consume a substantial amount of their caloric intake while in school, making the passage of the Healthy Hunger-Free Kids Act (HHFKA) in 2010 and the subsequent improvements to the school meal standards a key policy change. Using data from the School Nutrition and Meal Cost Study, this paper seeks to re-examine the association between students' (N = 1963) weight status and participation in the National School Lunch Program (NSLP) and School Breakfast Program (SBP) since the implementation of these policy changes to determine whether, and how, this relationship has changed. After controlling for a wide array of student characteristics and school-level fixed effects, findings from the multivariate regression analyses indicate that usual participation in the school meal programs has no clear association with students' weight status, which contradicts findings from earlier studies conducted prior to the passage of the HHFKA. These findings are discussed in relation to changes in the demographic composition of usual NSLP participants over time.

Disparities in the Healthfulness of School Food Environments and the Nutritional Quality of School Lunches

The Healthy, Hunger-Free Kids Act (HHFKA), a public law in the United States passed in 2010, sought to improve the healthfulness of the school food environment by requiring updated nutrition standards for school meals and competitive foods. Studies conducted since the passage of the HHFKA indicate improvements in the food environment overall, but few studies have examined whether these improvements varied by the socioeconomic and racial/ethnic composition of students in schools. To better understand the extent of disparities in the school food environment after HHFKA, this paper examined differences in the healthfulness of school food environments and the nutritional quality of school lunches by the school poverty level and racial/ethnic composition of students using data from the School Nutrition and Meal Cost Study. Results from chi-square analyses showed lower proportions of high poverty, majority black, and majority Hispanic schools had access to competitive foods, while higher proportions of these schools had a school wellness policy in addition to a district wellness policy. The overall nutritional quality of school lunches, as measured by total Healthy Eating Index (HEI)-2010 scores, did not vary significantly across school types, although some HEI component scores did. From these findings, we concluded that there were disparities in the school food environment based on the socioeconomic and racial/ethnic composition of students in schools, but no significant disparities in the overall nutritional quality of school lunches were found.

Effectiveness and cost-effectiveness of the GoActive intervention to increase physical activity among UK adolescents: A cluster randomised controlled trial

BACKGROUND

Less than 20% of adolescents globally meet recommended levels of physical activity, and not meeting these recommended levels is associated with social disadvantage and rising disease risk. The determinants of physical activity in adolescents are multilevel and poorly understood, but the school's social environment likely plays an important role. We conducted a cluster randomised controlled trial to assess the effectiveness of a school-based programme (GoActive) to increase moderate-to-vigorous physical activity (MVPA) among adolescents.

METHODS AND FINDINGS

Non-fee-paying, co-educational schools including Year 9 students in the UK counties of Cambridgeshire and Essex were eligible for inclusion. Within participating schools (n = 16), all Year 9 students were eligible and invited to participate. Participants were 2,862 13- to 14-year-olds (84% of eligible students). After baseline assessment, schools were computer-randomised, stratified by school-level pupil premium funding (below/above county-specific median) and county (control: 8 schools, 1,319 participants, mean [SD] participants per school n = 165 [62]; intervention: 8 schools, 1,543 participants, n = 193 [43]). Measurement staff were blinded to allocation. The iteratively developed, feasibility-tested 12-week intervention, aligned with self-determination theory, trained older adolescent mentors and in-class peer-leaders to encourage classes to conduct 2 new weekly activities. Students and classes gained points and rewards for engaging in any activity in or out of school. The primary outcome was average daily minutes of accelerometer-assessed MVPA at 10-month follow-up; a mixed-methods process evaluation evaluated implementation. Of 2,862 recruited participants (52.1% male), 2,167 (76%) attended 10-month follow-up measurements; we analysed the primary outcome for 1,874 participants (65.5%). At 10 months, there was a mean (SD) decrease in MVPA of 8.3 (19.3) minutes in the control group and 10.4 (22.7) minutes in the intervention group (baseline-adjusted difference [95% confidence interval] -1.91 minutes [-5.53 to 1.70], p = 0.316). The programme cost £13 per student compared with control; it was not cost-effective. Overall, 62.9% of students and 87.3% of mentors reported that GoActive was fun. Teachers and mentors commented that their roles in programme delivery were unclear. Implementation fidelity was low. The main methodological limitation of this study was the relatively affluent and ethnically homogeneous sample.

CONCLUSIONS

In this study, we observed that a rigorously developed school-based intervention was no more effective than standard school practice at preventing declines in adolescent physical activity. Interdisciplinary research is required to understand educational-setting-specific implementation challenges. School leaders and authorities should be realistic about expectations of the effect of school-based physical activity promotion strategies implemented at scale.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN31583496.

The Impact of a Gradual Healthier Assortment among Vocational Schools Participating in a School Canteen Programme: Evidence from Sales and Student Survey Data

Many adolescents have poor eating habits. As a major part of their caloric intake takes place at school, the present study aims to examine the effect of increasing the availability of healthier foods in school canteens on sales, student attitude and self-reported behaviour. A quasi-experimental study was carried out at two vocational schools in the Netherlands over a 10-month period, where the visible share of healthier products was gradually or abruptly increased from 60% to 80%. Outcome measures were sales data for healthier and less healthy foods and drinks in the canteens, as well as surveys. The proportion of healthier products sold increased from 31.1% during the baseline period to 35.9% in the final period. A gradual increase led to higher relative sales of healthier products (40%) than an abrupt change (34.5%). Survey data showed that students’ moderate satisfaction remained insensitive to the changes over time. Overall, results suggest that increasing the availability of healthier products in school canteens leads to small positive changes in sales of products, particularly in the product groups beverages and sandwiches. A gradual introduction may ensure that students slowly get used to assortment changes.

An Enhanced Approach for Economic Evaluation of Long-Term Benefits of School-Based Health Promotion Programs

Chronic diseases constitute a tremendous public health burden globally. Poor nutrition, inactive lifestyles, and obesity are established independent risk factors for chronic diseases. Public health decision-makers are in desperate need of effective and cost-effective programs that prevent chronic diseases. To date, most economic evaluations consider the effect of these programs on body weight, without considering their effects on other risk factors (nutrition and physical activity). We propose an economic evaluation approach that considers program effects on multiple risk factors rather than on a single risk factor. For demonstration, we developed an enhanced model that incorporates health promotion program effects on four risk factors (weight status, physical activity, and fruit and vegetable consumption). Relative to this enhanced model, a model that considered only the effect on weight status produced incremental cost-effectiveness ratio (ICER) estimates for quality-adjusted life years that were 1% to 43% higher, and ICER estimates for years with chronic disease prevented that were 1% to 26% higher. The corresponding estimates for return on investment were 1% to 20% lower. To avoid an underestimation of the economic benefits of chronic disease prevention programs, we recommend economic evaluations consider program effects on multiple risk factors.

The sustainability of public health interventions in schools: a systematic review

BACKGROUND

The sustainability of school-based health interventions after external funds and/or other resources end has been relatively unexplored in comparison to health care. If effective interventions discontinue, new practices cannot reach wider student populations and investment in implementation is wasted. This review asked: What evidence exists about the sustainability of school-based public health interventions? Do schools sustain public health interventions once start-up funds end? What are the barriers and facilitators affecting the sustainability of public health interventions in schools in high-income countries?

METHODS

Seven bibliographic databases and 15 websites were searched. References and citations of included studies were searched, and experts and authors were contacted to identify relevant studies. We included reports published from 1996 onwards. References were screened on title/abstract, and those included were screened on full report. We conducted data extraction and appraisal using an existing tool. Extracted data were qualitatively synthesised for common themes, using May's General Theory of Implementation (2013) as a conceptual framework.

RESULTS

Of the 9677 unique references identified through database searching and other search strategies, 24 studies of 18 interventions were included in the review. No interventions were sustained in their entirety; all had some components that were sustained by some schools or staff, bar one that was completely discontinued. No discernible relationship was found between evidence of effectiveness and sustainability. Key facilitators included commitment/support from senior leaders, staff observing a positive impact on students' engagement and wellbeing, and staff confidence in delivering health promotion and belief in its value. Important contextual barriers emerged: the norm of prioritising educational outcomes under time and resource constraints, insufficient funding/resources, staff turnover and a lack of ongoing training. Adaptation of the intervention to existing routines and changing contexts appeared to be part of the sustainability process.

CONCLUSIONS

Existing evidence suggests that sustainability depends upon schools developing and retaining senior leaders and staff that are knowledgeable, skilled and motivated to continue delivering health promotion through ever-changing circumstances. Evidence of effectiveness did not appear to be an influential factor. However, methodologically stronger primary research, informed by theory, is needed.

TRIAL REGISTRATION

The review was registered on PROSPERO: CRD42017076320, Sep. 2017.

Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake

OBJECTIVE

This study aimed to estimate the cost-effectiveness and impact on childhood obesity of installation of chilled water dispensers ("water jets") on school lunch lines and to compare water jets' cost, reach, and impact on water consumption with three additional strategies.

METHODS

The Childhood Obesity Intervention Cost Effectiveness Study(CHOICES) microsimulation model estimated the cost-effectiveness of water jets on US childhood obesity cases prevented in 2025. Also estimated were the cost, number of children reached, and impact on water consumption of the installation of water jets and three other strategies.

RESULTS

Installing water jets on school lunch lines was projected to reach 29.6 million children (95% uncertainty interval [UI]: 29.4 million-29.8 million), cost $4.25 (95% UI: $2.74-$5.69) per child, prevent 179,550 cases of childhood obesity in 2025 (95% UI: 101,970-257,870), and save $0.31 in health care costs per dollar invested (95% UI: $0.15-$0.55). In the secondary analysis, installing cup dispensers next to existing water fountains was the least costly but also had the lowest population reach.

CONCLUSIONS

Installating water jet dispensers on school lunch lines could also save almost half of the dollars needed for implementation via a reduction in obesity-related health care costs. School-based interventions to promote drinking water may be relatively inexpensive strategies for improving child health.

Four-year trajectory of Korean youth mental health and impacts of school environment and school counselling: a observational study using national schools database

OBJECTIVES

This study aimed to investigate changes in the mental health status of South Korean adolescents at a school level and identify school-related factors affecting these changes.

DESIGN

A retrospective data analysis, population study.

SETTING

South Korean high schools from 2013 to 2016.

PARTICIPANTS

Randomly sampled 827 schools (316 834 boys and 299 304 girls) PRIMARY OUTCOME MEASURES: Mean scores of the Adolescent Mental Health and Problem Behavior Questionnaire-II (AMPQ-II), a school-based mental health screening test, were used to explore changes in youth mental health. Data regarding the school environment and school counselling were gathered from the 'School info' website. A multilevel growth model was used to determine relationships between students' mental health and school-related factors.

RESULTS

Students' mental health statuses in South Korea gradually improved over time (coefficient=-1.46 to -1.70, p<0.001). School mobility rates (coefficient=0.93 to 1.00, p<0.05), school dropout rates (coefficient=0.38 to 0.40, p<0.001), school budgets per student (coefficient=-0.05 to -0.06, p<0.01) and number of school counselling sessions (coefficient=0.14, p<0.01) were significantly associated with baseline AMPQ-II scores. The rate of change in AMPQ-II score increased when the number of school counselling sessions was higher (coefficient=-0.03, p<0.05) or the school budget was lower (coefficient=0.02, p<0.001). School environment explained 21.6% of the AMPQ-II baseline score variance and 9.3% of the rate of change variance. School counselling further explained 2.0% of the variance in baseline AMPQ-II scores and 2.3% of the rate of change variance.

CONCLUSIONS

This study suggests that school environment stability and active provision of school-based mental health services have a positive impact on youth mental health.

Hands-Only Cardiopulmonary Resuscitation Training in Schools: Impact of Legislation on the Future of School Nurses

BACKGROUND

Bystander cardiopulmonary resuscitation (CPR) initiated before medical help arrives saves lives. Hands-Only CPR keeps the blood flowing to the brain and other organs, increasing a person's chance of survival.

METHODS

A literature review identified Hands-Only CPR as the preferred method of CPR performed in the community setting. Many states have passed legislation making CPR education a high school graduation requirement.

RESULTS

School nurses can play a pivotal role as school districts address these new CPR requirements. The school nurse involvement in these newly mandated CPR training requirements can support student success and improve the health of communities.

CONCLUSIONS

School nurses need to use these newly mandated CPR training requirements as an opportunity to showcase the profession of nursing to ensure the school nurse remains present in our schools.

Net Benefits of Recovery High Schools: Higher Cost but Increased Sobriety and Educational Attainment

BACKGROUND

Recovery high schools (RHS) provide a supportive educational and therapeutic environment for students subsequent to treatment for substance use disorders (SUDs). Most students served by RHSs have concurrent mental health disorders and are at risk for school failure or dropout and substance use relapse.

AIMS OF THE STUDY

The central question addressed is whether RHSs are economically efficient alternatives to other high school settings for students in recovery. The aim is to estimate the incremental cost-benefit of RHSs.

METHODS

A quasi-experimental non-equivalent pretest-posttest comparison group design was used. We compared substance use and educational outcomes for adolescents who had received specialty SUD treatment; 143 who enrolled in an RHS were compared to 117 who enrolled in a non-RHS school. Groups were balanced by use of a propensity score to drop students who were not similar to those in the other group. The propensity score was also used as a covariate in multiple regression to estimate cost and outcome parameters and standard errors. To take account of uncertainties in impacts and shadow prices, we used Monte Carlo simulations to estimate the distribution of incremental benefits of RHS relative to non-RHS schooling.

RESULTS

Two beneficial impacts of statistical and substantive importance were identified: increased probability of high school graduation and increased sobriety. RHS students had significantly (p<.05) less substance use during the study period -- at 12-month follow-up, 55% of RHS and 26% of comparison students reported 3 month abstinence from alcohol and drugs. Urinalysis confirmed abstinence from THC (cannabis) for 68% of RHS versus 37% of comparison students. RHS students' high school graduation rates were 21 to 25 percentage points higher than comparison students. Adopting a societal perspective, incremental benefits of RHSs were estimated by monetizing the increased probability of high school graduation and comparing it to incremental costs. Mean net benefits ranged from USD16.1 thousand to USD51.9 thousand per participant; benefit-to-cost ratios ranged from 3.0 to 7.2.

DISCUSSION

Monetizing the benefits and the incremental costs of RHS relative to conventional schooling show substantial positive net benefits from RHS participation. Two factors lend credibility to the results. First, the RHS improvement in substance use indicates a mechanism through which the increased probability of high school graduation can plausibly occur. Second, the estimated increases in the probability of high school graduation were large and statistically significant. As the productivity gains from high school graduation are also large, the dominant benefit category is very plausible. Limitations include the non-randomized design; selection bias into the study conditions not fully controlled by the propensity scores; generalizability only to young people with treated behavioral health disorders; lack of estimates for direct monetization of reduced substance use among adolescents; possible attenuation of the value of education among individuals with behavioral health issues; and uncertainty in calculation of school costs.

IMPLICATIONS FOR BEHAVIORAL HEALTH POLICIES

This research provides evidence that the recovery high school model provides cost beneficial support for high school students after primary SUD treatment. The students who enroll in RHSs typically have co-occurring mental health and substance use disorders, adding complexity to their continuing care. Funding policies recognizing the multiple systems of care (behavioral health, education, child and family services, juvenile justice) responsible for these young people are called for.

Economic evaluation of a childhood obesity prevention programme for children: Results from the WAVES cluster randomised controlled trial conducted in schools

Background

Childhood obesity is a serious public health challenge and schools have been identified as an ideal place to implement prevention interventions. The aim of this study was to measure the cost-effectiveness of a multi-faceted school-based obesity prevention intervention targeting children aged 6–7 years when compared to ‘usual activities’.

Methods

A cluster randomised controlled trial in 54 schools across the West Midlands (UK) was conducted. The 12-month intervention aimed to increase physical activity by 30 minutes per day and encourage healthy eating. Costs were captured from a public sector perspective and utility-based health related outcomes measured using the CHU-9D. Multiple imputation using chained equations was used to address missing data. The cost effectiveness was measured at 30 months from baseline using a hierarchical net-benefit regression framework, that controlled for clustering and prespecified covariates. Any uncertainty in the results was characterised using cost-effectiveness acceptability curves.

Results

At 30 months, the total adjusted incremental mean cost of the intervention was £155 (95% confidence interval [CI]: £139, £171), and the incremental mean QALYs gained was 0.006 (95% CI: -0.024, 0.036), per child. The incremental cost-effectiveness at 30 months was £26,815 per QALY and using a standard willingness to pay threshold of £30,000 per QALY, there was a 52% chance that the intervention was cost-effective.

Conclusions

The cost-effectiveness of the school-based WAVES intervention was subject to substantial uncertainty. We therefore recommend more research to explore obesity prevention within schools as part of a wider systems approach to obesity prevention.

Trial registration

This paper uses data collected by the WAVES trial: Controlled trials ISRCTN97000586 (registered May 2010).

Cost-effectiveness of a combined classroom curriculum and parental intervention: economic evaluation of data from the Steps Towards Alcohol Misuse Prevention Programme cluster randomised controlled trial

OBJECTIVES

This study aimed to assess the cost-effectiveness of the Steps Towards Alcohol Misuse Prevention Programme (STAMPP) compared with education as normal (EAN) in reducing self-reported heavy episodic drinking (HED) in adolescents.

DESIGN

This is a cost-effectiveness analysis from a public sector perspective conducted as part of a cluster randomised trial.

SETTING

This study was conducted in 105 high schools in Northern Ireland and in Scotland.

PARTICIPANTS

Students in school year 8/S1 (aged 11-12) at baseline were included in the study.

INTERVENTIONS

This is a classroom-based alcohol education curricula, combined with a brief alcohol intervention for parents/carers.

OUTCOME MEASURES

The outcome of this study is the cost per young person experiencing HED avoided due to STAMPP at 33 months from baseline.

RESULTS

The total cost of STAMPP was £85 900, equivalent to £818 per school and £15 per pupil. Due to very low uptake of the parental component, we calculated costs of £692 per school and £13 per pupil without this element. Costs per pupil were reduced further to £426 per school and £8 per pupil when it was assumed there were no additional costs of classroom delivery if STAMPP was delivered as part of activities such as personal, social, health and economic education. STAMPP was associated with a significantly greater proportion of pupils experiencing a heavy drinking episode avoided (0.08/8%) and slightly lower public sector costs (mean difference -£17.19). At a notional willingness-to-pay threshold of £15 (reflecting the cost of STAMPP), the probability of STAMPP being cost-effective was 56%. This level of uncertainty reflected the substantial variability in the cost differences between groups.

CONCLUSIONS

STAMPP was relatively low cost and reduced HED. STAMPP was not associated with any clear public sector cost savings, but neither did it increase them or lead to any cost-shifting within the public sector categories. Further research is required to establish if the cost-effectiveness of STAMPP is sustained in the long term.

TRIAL REGISTRATION NUMBER

ISRCTN47028486; Results.

Effects, equity, and cost of school-based and community-wide treatment strategies for soil-transmitted helminths in Kenya: a cluster-randomised controlled trial

BACKGROUND

School-based deworming programmes can reduce morbidity attributable to soil-transmitted helminths in children but do not interrupt transmission in the wider community. We assessed the effects of alternative mass treatment strategies on community soil-transmitted helminth infection.

METHODS

In this cluster-randomised controlled trial, 120 community units (clusters) serving 150 000 households in Kenya were randomly assigned (1:1:1) to receive albendazole through annual school-based treatment targeting 2-14 year olds or annual or biannual community-wide treatment targeting all ages. The primary outcome was community hookworm prevalence, assessed at 12 and 24 months through repeat cross-sectional surveys. Secondary outcomes were Ascaris lumbricoides and Trichuris trichiura prevalence, infection intensity of each soil-transmitted helminth species, and treatment coverage and costs. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02397772.

FINDINGS

After 24 months, prevalence of hookworm changed from 18·6% (95% CI 13·9-23·2) to 13·8% (10·5-17·0) in the annual school-based treatment group, 17·9% (13·7-22·1) to 8·0% (6·0-10·1) in the annual community-wide treatment group, and 20·6% (15·8-25·5) to 6·2% (4·9-7·5) in the biannual community-wide treatment group. Relative to annual school-based treatment, the risk ratio for annual community-wide treatment was 0·59 (95% CI 0·42-0·83; p<0·001) and for biannual community-wide treatment was 0·46 (0·33-0·63; p<0·001). More modest reductions in risk were observed after 12 months. Risk ratios were similar across demographic and socioeconomic subgroups after 24 months. No adverse events related to albendazole were reported.

INTERPRETATION

Community-wide treatment was more effective in reducing hookworm prevalence and intensity than school-based treatment, with little additional benefit of treating every 6 months, and was shown to be remarkably equitable in coverage and effects.

FUNDING

Bill & Melinda Gates Foundation, the Joint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, the Wellcome Trust, and the Children's Investment Fund Foundation.

Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trial

BACKGROUND

School environments affect health and academic outcomes. With increasing secondary school retention in low-income and middle-income countries, promoting quality school social environments could offer a scalable opportunity to improve adolescent health and wellbeing.

METHODS

We did a cluster-randomised trial to assess the effectiveness of a multi-component whole-school health promotion intervention (SEHER) with integrated economic and process evaluations in grade 9 students (aged 13-14 years) at government-run secondary schools in the Nalanda district of Bihar state, India. Schools were randomly assigned (1:1:1) to three groups: the SEHER intervention delivered by a lay counsellor (the SEHER Mitra [SM] group), the SEHER intervention delivered by a teacher (teacher as SEHER Mitra [TSM] group), and a control group in which only the standard government-run classroom-based life-skills Adolescence Education Program was implemented. The primary outcome was school climate measured with the Beyond Blue School Climate Questionnaire (BBSCQ). Students were assessed at the start of the academic year (June, 2015) and again 8 months later at the end of the academic year (March, 2016) via self-completed questionnaires. This study is registered with ClinicalTrials.gov, number NCT02484014.

FINDINGS

Of the 112 eligible schools in the Nalanda district, 75 were randomly selected to participate in the trial. We randomly assigned 25 schools to each of the three groups. One school subsequently dropped out of the TSM group, leaving 24 schools in this group. The baseline survey included a total of 13 035 participants, and the endpoint survey included 14 414 participants. Participants in the SM-delivered intervention schools had substantially higher school climate scores at endpoint survey than those in the control group (BBSCQ baseline-adjusted mean difference [aMD] 7·57 [95% CI 6·11-9·03]; effect size 1·88 [95% CI 1·44-2·32], p<0·0001) and the TSM-delivered intervention (aMD 7·57 [95% CI 6·06-9·08]; effect size 1·88 [95% CI 1·43-2·34], p<0·0001). There was no effect of the TSM-delivered intervention compared with control (aMD -0·009 [95% CI -1·53 to 1·51], effect size 0·00 [95% CI -0·45 to 0·44], p=0·99). Compared with the control group, participants in the SM-delivered intervention schools had moderate to large improvements in the secondary outcomes of depression (aMD -1·23 [95% CI -1·89 to -0·57]), bullying (aMD -0·91 [95% CI -1·15 to -0·66]), violence victimisation (odds ratio [OR] 0·62 [95% CI 0·46-0·84]), violence perpetration (OR 0·68 [95% CI 0·48-0·96]), attitude towards gender equity (aMD 0·41 [95% CI 0·21-0·61]), and knowledge of reproductive and sexual health (aMD 0·29 [95% CI 0·06-0·53]). Similar results for these secondary outcomes were noted for the comparison between SM-delivered intervention schools and TSM-delivered intervention schools (depression: aMD -1·23 [95% CI -1·91 to -0·55]; bullying: aMD -0·83 [95% CI -1·08 to -0·57]; violence victimisation: OR 0·49 [95% CI 0·35-0·67]; violence perpetration: OR 0·49 [95% CI 0·34-0·71]; attitude towards gender equity: aMD 0·23 [95% CI 0·02-0·44]; and knowledge of reproductive and sexual health: aMD 0·22 [95% CI -0·02 to 0·47]). However, no effects on these secondary outcomes were observed for the TSM-delivered intervention schools compared with the control group (depression: aMD -0·03 [95% CI -0·70 to 0·65]; bullying: aMD -0·08 [95% CI -0·34 to 0·18]; violence victimisation: OR 1·27 [95% CI 0·93-1·73]; violence perpetration: OR 1·37 [95% CI 0·95-1·95]; attitude towards gender equity: aMD 0·17 [95% CI -0·09 to 0·38]; and knowledge of reproductive and sexual health: aMD 0·06 [95% CI -0·18 to 0·32]).

INTERPRETATION

The multi-component whole-school SEHER health promotion intervention had substantial beneficial effects on school climate and health-related outcomes when delivered by lay counsellors, but no effects when delivered by teachers. Future research should focus on the evaluation of the scaling up of the SEHER intervention in diverse contexts and delivery agents.

FUNDING

John D. and Catherine T. MacArthur Foundation, USA and the United Nations Population Fund India Office.

Barriers and Enablers to the Implementation of School Wellness Policies: An Economic Perspective

BACKGROUND

Local wellness policies (LWPs) are mandated among school systems to enhance nutrition/physical activity opportunities in schools. Prior research notes disparities in LWP implementation. This study uses mixed methods to examine barriers/enablers to LWP implementation, comparing responses by student body income.

METHOD

Schools ( n = 744, 24 systems) completed an LWP implementation barriers/enablers survey. Semistructured interviews ( n = 20 random subsample) described barriers/enablers. Responses were compared by majority of lower (≥50% free/reduced-price meals; lower income [LI]) versus higher income (HI) student body.

RESULTS

In surveys, LI and HI schools identified common barriers (parents/families, federal/state regulations, students, time, funding) and enablers (school system, teachers, food service, physical education curriculum/resources, and staff). Interviews further elucidated how staffing and funding served as enablers for all schools, and provide context for how and why barriers differed by income: time, food service (HI schools), and parents/families (LI schools).

CONCLUSIONS

Findings support commonalities in barriers and enablers among all schools, suggesting that regardless of economic context, schools would benefit from additional supports, such as physical education and nutrition education resources integrated into existing curricula, additional funding, and personnel time dedicated to wellness programming. LI schools may benefit from additional funding to support parent and community involvement.

Cost-effectiveness analysis of a school-based dental caries prevention program using fluoridated milk in Bangkok, Thailand

BACKGROUND

This study modelled the cost-effectiveness, from a societal perspective, of a program that used fluoridated milk to prevent dental caries in children who were 6 years old at the beginning of the program, versus non-intervention, after 6 years.

METHODS

After 6 years, children in the milk-fluoridation program had a significant (34%) reduction in dental caries experience compared to those in the comparison community (i.e., received school milk without added fluoride) (DMFS: 1.06 vs. 1.60).

RESULTS

This improvement was achieved with an investment of Thailand Baht (THB) 5,345,048 over 6 years (or THB 11.88 per child, per year) (1 US$ = THB(2011) 30.0). When comparing the costs of the operation of the program and dental treatment in the test community with those of the comparison community, the program resulted in a net societal savings of THB 8,177,179 (range 18,597,122 to THB 7,920,711) after 6 years. This investment would result in 40,500 DMFS avoided in a community with a childhood population of 75,000 [DMFS avoided: 75,000 x (- 0.54)].

CONCLUSIONS

While the analysis has inherent limitations due to its dependence on a range of assumptions, the results suggest that, from a societal perspective, when compared with the non-intervention group, the Bangkok Metropolitan Administration intervention appeared to be a more cost-efficient option than current standard oral health care.

Improving access to school health services as perceived by school professionals

BACKGROUND

The organisation of health assessments by preventive health services focusing on children's health and educational performance needs to be improved due to evolving health priorities such as mental health problems, reduced budgets and shortages of physicians and nurses. We studied the impact on the school professionals' perception of access to school health services (SHS) when a triage approach was used for population-based health assessments in primary schools. The triage approach involves pre-assessments by SHS assistants, with only those children in need of follow-up being assessed by a physician or nurse. The triage approach was compared with the usual approach in which all children are assessed by physicians and nurses.

METHODS

We conducted a cross-sectional study, comparing school professionals' perceptions of the triage and the usual approach to SHS. The randomly selected school professionals completed digital questionnaires about contact frequency, the approachability of SHS and the appropriateness of support from SHS. School care coordinators and teachers were invited to participate in the study, resulting in a response of 444 (35.7%) professionals from schools working with the triage approach and 320 (44.6%) professionals working with the usual approach.

RESULTS

Respondents from schools using the triage approach had more contacts with SHS and were more satisfied with the appropriateness of support from SHS than respondents in the approach-as-usual group. No significant differences were found between the two groups in terms of the perceived approachability of SHS.

CONCLUSIONS

School professionals were more positive about access to SHS when a triage approach to routine assessments was in place than when the usual approach was used. Countries with similar population-based SHS systems could benefit from a triage approach which gives physicians and nurses more opportunities to attend schools for consultations and assessments of children on demand.

Urban-Rural Differences in School Nurses' Asthma Training Needs and Access to Asthma Resources

PURPOSE

Few studies have examined school nurses preferences' for asthma training. Our purpose was to: 1) assess school nurses' perceived asthma training needs, 2) describe nurses' access to asthma educational resources, and 3) identify urban-rural differences in training needs and access to resources in southern states.

DESIGN AND METHODS

A convenience sample of school nurses (n=162) from seven counties (two urban and five rural) in North Carolina and South Carolina completed an online, anonymous survey. Chi-square tests were used to examine urban-rural differences.

RESULTS

Although most nurses (64%) had received asthma training within the last five years, urban nurses were more likely to have had asthma training than rural nurses (χ2=10.84, p=0.001). A majority of nurses (87%) indicated they would like to receive additional asthma training. Approximately half (45%) of nurses reported access to age-appropriate asthma education materials, but only 16% reported that their schools implemented asthma education programs. Urban nurses were more likely than rural nurses to have access to asthma education programs (χ2=4.10, p=0.04) and age-appropriate asthma education materials (χ2=8.86, p=0.003).

CONCLUSIONS

Few schools are implementing asthma education programs. Rural nurses may be disadvantaged in terms of receiving asthma training and having access to asthma education programs and materials.

PRACTICE IMPLICATIONS

Schools are an ideal setting for delivering age-appropriate asthma education. By providing school nurses with access to age-appropriate asthma education resources and additional asthma training, we can help them overcome several of the barriers that impede their ability to deliver asthma care to their students.

Cost-effectiveness of a school-based health promotion program in Canada: A life-course modeling approach

Background

The Alberta Project Promoting active Living and healthy Eating in Schools (APPLE Schools) has been recognized as a “best practice” in preventing childhood obesity. To inform decision making on the economic implications of APPLE Schools and to justify investment, we evaluated the project’s cost-effectiveness following a life-course approach.

Methods

We developed a state transition model for the lifetime progression of body weight status comparing elementary school students attending APPLE Schools and control schools. This model quantified the lifetime impact of APPLE Schools in terms of prevention of excess body weight, chronic disease and improved quality-adjusted life years (QALY), from a school system’s cost perspective. Both costs and health outcomes were discounted to their present value using 3% discount rate.

Results

The incremental cost-effectiveness ratio(ICER) of APPLE schools was CA$33,421 per QALY gained, and CA$1,555, CA$1,709 and CA$14,218 per prevented person years of excess weight, obesity and chronic disease, respectively. These estimates show that APPLE Schools is cost effective at a threshold of ICER < CA$50,000.

In probabilistic sensitivity analysis, APPLE Schools was cost effective more than 64% of the time per QALY gained, when using a threshold of ICER<CA$50,000, and more than 93% of the time when using a threshold of ICER<CA$100,000.

Conclusion

School-based health promotion, such as APPLE Schools is a cost-effective intervention for obesity prevention and reduction of chronic disease risk over the lifetime. Expanding the coverage and allocating resources towards school-based programs like the APPLE Schools program, is likely to reduce the public health burden of obesity and chronic diseases.

The effectiveness and cost-effectiveness of a mindfulness training programme in schools compared with normal school provision (MYRIAD): study protocol for a randomised controlled trial

BACKGROUND

Mindfulness-based approaches for adults are effective at enhancing mental health, but few controlled trials have evaluated their effectiveness or cost-effectiveness for young people. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of a mindfulness training (MT) programme to enhance mental health, wellbeing and social-emotional behavioural functioning in adolescence.

METHODS/DESIGN

To address this aim, the design will be a superiority, cluster randomised controlled, parallel-group trial in which schools offering social and emotional provision in line with good practice (Formby et al., Personal, Social, Health and Economic (PSHE) Education: A mapping study of the prevalent models of delivery and their effectiveness, 2010; OFSTED, Not Yet Good Enough: Personal, Social, Health and Economic Education in schools, 2013) will be randomised to either continue this provision (control) or include MT in this provision (intervention). The study will recruit and randomise 76 schools (clusters) and 5700 school students aged 12 to 14 years, followed up for 2 years.

DISCUSSION

The study will contribute to establishing if MT is an effective and cost-effective approach to promoting mental health in adolescence.

TRIALS REGISTRATION

International Standard Randomised Controlled Trials, identifier: ISRCTN86619085 . Registered on 3 June 2016.

Cost-Effectiveness of Ready for Recess to Promote Physical Activity in Children

BACKGROUND

Many school-based recess interventions have been shown to be effective in increasing physical activity but their relative efficiency compared to other school-based programs are unknown. This study examined the cost-effectiveness of Ready for Recess, a program designed to increase students' physical activity in 2 elementary schools.

METHODS

Standard cost-effectiveness analysis method was used from a program's perspective for this study. Program effectiveness was measured as total metabolic equivalent (MET) hours gained. Program costs included equipment, training, and personnel costs during the 1-year intervention. The cost-effectiveness was measured as the ratio of program costs to total MET-hours gained.

RESULTS

Ready for Recess cost $27,643.97 for the 2 schools in the first year of implementation. Physical activity increased by 1.8 MET-hours per day per student. Approximately 32 cents were spent on Ready for Recess to produce an additional MET-hour per student per school day in the 2008-2009 school year.

CONCLUSIONS

Ready for Recess was cost-effective in its first year of implementation using 35 cents as a benchmark and it was cost-effective relative to other school-based physical activity interventions. The program may be more cost-effective if implemented for a longer time and on a larger scale.

Costs and effects of a state-wide health promotion program in primary schools in Germany - the Baden-Württemberg Study: A cluster-randomized, controlled trial

AIM

To evaluate the cost-effectiveness of the state-wide implementation of the health promotion program "Join the Healthy Boat" in primary schools in Germany.

METHODS

Cluster-randomized intervention trial with wait-list control group. Anthropometric data of 1733 participating children (7.1 ± 0.6 years) were taken by trained staff before and after a one year intervention period in the academic year 2010/11. Parents provided information about the health status, and the health behaviour of their children and themselves, parental anthropometrics, and socio-economic background variables. Incidence of abdominal obesity, defined as waist-to-height ratio (WHtR) ≥ 0.5, was determined. Generalized linear models were applied to account for the clustering of data within schools, and to adjust for baseline-values. Losses to follow-up and missing data were analysed. From a societal perspective, the overall costs, costs per pupil, and incremental cost-effectiveness ratio (ICER) to identify the costs per case of averted abdominal obesity were calculated.

RESULTS

The final regression model for the incidence of abdominal obesity shows lower odds for the intervention group after an adjustment for grade, gender, baseline WHtR, and breakfast habits (odds ratio = 0.48, 95% CI [0.25; 0.94]). The intervention costs per child/year were €25.04. The costs per incidental case of averted abdominal obesity varied between €1515 and €1993, depending on the different dimensions of the target group.

CONCLUSION

This study demonstrates the positive effects of state-wide, school-based health promotion on incidental abdominal obesity, at affordable costs and with proven cost-effectiveness. These results should support allocative decisions of policymakers. An early start to the prevention of abdominal obesity is of particular importance because of its close relationship to non-communicable diseases.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), Freiburg University, Germany, DRKS-ID: DRKS00000494.

Basic life support education in secondary schools: a cross-sectional survey in London, UK

OBJECTIVES

Basic life support (BLS) training in schools is associated with improved outcomes from cardiac arrest. International consensus statements have recommended universal BLS training for school-aged children. The current practice of BLS training in London schools is unknown. The aim of this study was to assess current practices of BLS training in London secondary schools.

SETTING, POPULATION AND OUTCOMES

A prospective audit of BLS training in London secondary schools was conducted. Schools were contacted by email, and a subsequent telephone interview was conducted with staff familiar with local training practices. Response data were anonymised and captured electronically. Universal training was defined as any programme which delivers BLS training to all students in the school. Descriptive statistics were used to summarise the results.

RESULTS

A total of 65 schools completed the survey covering an estimated student population of 65 396 across 19 of 32 London boroughs. There were 5 (8%) schools that provide universal training programmes for students and an additional 31 (48%) offering training as part of an extracurricular programme or chosen module. An automated external defibrillator (AED) was available in 18 (28%) schools, unavailable in 40 (61%) and 7 (11%) reported their AED provision as unknown. The most common reasons for not having a universal BLS training programme are the requirement for additional class time (28%) and that funding is unavailable for such a programme (28%). There were 5 students who died from sudden cardiac arrest over the period of the past 10 years.

CONCLUSIONS

BLS training rates in London secondary schools are low, and the majority of schools do not have an AED available in case of emergency. These data highlight an opportunity to improve BLS training and AEDs provision. Future studies should assess programmes which are cost-effective and do not require significant amounts of additional class time.

Ethnic Disparities in School-Based Behavioral Health Service Use for Children With Psychiatric Disorders

BACKGROUND

We examined racial/ethnic disparities in school-based behavioral health service use for children with psychiatric disorders.

METHODS

Medicaid claims data were used to compare the behavioral healthcare service use of 23,601 children aged 5-17 years by psychiatric disorder (autism, attention deficit hyperactivity disorder [ADHD], conduct/oppositional defiant disorder, and "other") and by race/ethnicity (African-American, Hispanic, white, and other). Logistic and generalized linear regression analyses were used.

RESULTS

Differences in service use by racial/ethnic group were identified within and across diagnostic groups, both for in-school service use and out-of-school service use. For all disorders, Hispanic children had significantly lower use of in-school services than white children. Among children with ADHD, African-American children were less likely to receive in-school services than white children; however, there were no differences in adjusted annual mean Medicaid expenditures for in-school services by race/ethnicity or psychiatric disorders. Statistically significant differences by race/ethnicity were found for out-of-school service use for children with ADHD and other psychiatric disorders. There were significant differences by race/ethnicity in out-of-school service use for each diagnostic group.

CONCLUSIONS

Differences in the use of school-based behavioral health services by racial and ethnic groups suggest the need for culturally appropriate outreach and tailoring of services to improve service utilization.

An Excel Spreadsheet Model for States and Districts to Assess the Cost-Benefit of School Nursing Services

This paper describes a user-friendly, Excel spreadsheet model and two data collection instruments constructed by the authors to help states and districts perform cost-benefit analyses of school nursing services delivered by full-time school nurses. Prior to applying the model, states or districts need to collect data using two forms: "Daily Nurse Data Collection Form" and the "Teacher Survey." The former is used to record daily nursing activities, including number of student health encounters, number of medications administered, number of student early dismissals, and number of medical procedures performed. The latter is used to obtain estimates for the time teachers spend addressing student health issues. Once inputs are entered in the model, outputs are automatically calculated, including program costs, total benefits, net benefits, and benefit-cost ratio. The spreadsheet model, data collection tools, and instructions are available at the NASN website ( http://www.nasn.org/The/CostBenefitAnalysis ).

Medicaid Managed Care: Unanswered Impact on School-Located Immunization Services

Managed care coordination for Medicaid beneficiaries is being implemented in states across the country. Recently, 1.5 million Medicaid beneficiaries in five regions of Illinois began this transition. This article presents the findings of a study to learn if immunizations would continue to be a reimbursable service if provided to beneficiaries outside of the designated primary care setting. The findings revealed a lack of clarity among health plan representatives and billing personnel in how to obtain coverage information. Five contacted plans (25%) stated they were unable to verify coverage and unclear where to acquire this information. Similarly, six (30%) representatives could not answer the question and recommended calling the Illinois Department of Healthcare and Family Services hot line. Despite the potential benefit of improved coordination of care gained by transitioning to managed care entity model, this infrastructure change may inadvertently introduce barriers to services obtained outside the medical home, like school-located immunization.

Increasing the Delivery of Preventive Health Services in Public Education

The delivery of prevention services to children and adolescents through traditional healthcare settings is challenging for a variety of reasons. Parent- and community-focused services are typically not reimbursable in traditional medical settings, and personal healthcare services are often designed for acute and chronic medical treatment rather than prevention. To provide preventive services in a setting that reaches the widest population, those interested in public health and prevention often turn to school settings. This paper proposes that an equitable, efficient manner in which to promote health across the life course is to integrate efforts from public health, primary care, and public education through the delivery of preventive healthcare services, in particular, in the education system. Such an integration of systems will require a concerted effort on the part of various stakeholders, as well as a shared vision to promote child health via community and institutional stakeholder partnerships. This paper includes (1) examination of some key system features necessary for delivery of preventive services that improve child outcomes; (2) a review of the features of some common models of school health services for their relevance to prevention services; and (3) policy and implementation strategy recommendations to further the delivery of preventive services in schools. These recommendations include the development of common metrics for health outcomes reporting, facilitated data sharing of these metrics, shared organization incentives for integration, and improved reimbursement and funding opportunities.

Cost effectiveness of a multi-component school-based physical activity intervention targeting adolescents: the 'Physical Activity 4 Everyone' cluster randomized trial

BACKGROUND

Few school-based interventions have been successful in reducing physical activity decline and preventing overweight and obesity in adolescent populations. As a result, few cost effectiveness analyses have been reported. The aim of this paper is to report the cost and cost effectiveness of the Physical Activity 4 Everyone (PA4E1) intervention which was a multi-component intervention implemented in secondary schools located in low-income communities. Cost effectiveness was assessed using both the physical activity and weight status trial outcomes.

METHODS

Intervention and Study Design: The PA4E1 cluster randomised controlled trial was implemented in 10 Australian secondary schools (5 intervention: 5 control) and consisted of intervention schools receiving seven physical activity promotion strategies and six additional strategies that supported school implementation of the intervention components. Costs associated with physical activity strategies, and intervention implementation strategies within the five intervention schools were estimated and compared to the costs of usual physical activity practices of schools in the control group. The total cost of implementing the intervention was estimated from a societal perspective, based on the number of enrolled students in the target grade at the start of the intervention (Grade 7, n = 837). Economic Outcomes: The economic analysis outcomes were cost and incremental cost effectiveness ratios for the following: minutes of moderate-to-vigorous physical activity (MVPA) per day gained, MET hours gained per person/day; Body Mass Index (BMI) unit avoided; and 10% reduction in BMI z-score.

RESULTS

The intervention cost AUD $329,952 over 24 months, or AUD$394 per student in the intervention group. This resulted in a cost effectiveness ratio of AUD$56 ($35-$147) per additional minute of MVPA, AUD$1 ($0.6-$2.7) per MET hour gained per person per day, AUD$1408 ($788-$6,570) per BMI unit avoided, and AUD$563 ($282-$3,942) per 10% reduction in BMI z-score.

CONCLUSION

PA4E1 is a cost effective intervention for increasing the physical activity levels and reducing unhealthy weight gain in adolescence, a period in which physical activity typically declines. Additional modelling could explore the potential economic impact of the intervention on morbidity and mortality.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000382875.

Economic Evaluation of School-Based Health Centers: A Community Guide Systematic Review

CONTEXT

A recent Community Guide systematic review of effectiveness of school-based health centers (SBHCs) showed that SBHCs improved educational and health outcomes. This review evaluates the economic cost and benefit of SBHCs.

EVIDENCE ACQUISITION

Using economic systematic review methods developed for The Community Guide, 6,958 papers were identified for the search period January 1985 to September 2014. After two rounds of screening, 21 studies were included in this review: 15 studies reported on cost and nine on benefit; three studies had both cost and benefit information. All expenditures in this review were presented in 2013 U.S. dollars.

EVIDENCE SYNTHESIS

Analyses were conducted in 2014. Intervention cost had two main components: start-up cost and operating cost. All but two of the cost studies reported operating cost only (ranging from $16,322 to $659,684 per SBHC annually). Benefits included healthcare cost averted and productivity and other loss averted. From the societal perspective, total annual benefit per SBHC ranged from $15,028 to $912,878. From healthcare payers' perspective, particularly Medicaid, SBHCs led to net savings ranging from $30 to $969 per visit. From patients' perspective, savings were also positive. Additionally, two benefit studies used regression analysis to show that Medicaid cost and hospitalization cost decreased with SBHCs. Finally, results from seven estimates in two cost-benefit studies showed that societal benefit per SBHC exceeded intervention cost, with the benefit-cost ratio ranging from 1.38:1 to 3.05:1.

CONCLUSIONS

The economic benefit of SBHCs exceeds the intervention operating cost. Further, SBHCs result in net savings to Medicaid.

The Medicaid "Free Care" Policy Change: What Is It, and What Does It Mean for School Nurses?

On December 15, 2014, the Centers for Medicare and Medicaid Services (CMS) issued guidance to state Medicaid Directors regarding Medicaid Payment for Services Provided without Charge (free care). This guidance may offer local education agencies the opportunity to receive Medicaid reimbursement for health related services when certain requirements are met. This article describes the considerations for local education agencies seeking this reimbursement and the integral role the school nurse could play in the implementation of these requirements.

A school-based intervention incorporating smartphone technology to improve health-related fitness among adolescents: rationale and study protocol for the NEAT and ATLAS 2.0 cluster randomised controlled trial and dissemination study

INTRODUCTION

Physical inactivity has been described as a global pandemic. Interventions aimed at developing skills in lifelong physical activities may provide the foundation for an active lifestyle into adulthood. In general, school-based physical activity interventions targeting adolescents have produced modest results and few have been designed to be 'scaled-up' and disseminated. This study aims to: (1) assess the effectiveness of two physical activity promotion programmes (ie, NEAT and ATLAS) that have been modified for scalability; and (2) evaluate the dissemination of these programmes throughout government funded secondary schools.

METHODS AND ANALYSIS

The study will be conducted in two phases. In the first phase (cluster randomised controlled trial), 16 schools will be randomly allocated to the intervention or a usual care control condition. In the second phase, the Reach, Effectiveness, Adoption, Implementation and Maintenance (Re-AIM) framework will be used to guide the design and evaluation of programme dissemination throughout New South Wales (NSW), Australia. In both phases, teachers will be trained to deliver the NEAT and ATLAS programmes, which will include: (1) interactive student seminars; (2) structured physical activity programmes; (3) lunch-time fitness sessions; and (4) web-based smartphone apps. In the cluster RCT, study outcomes will be assessed at baseline, 6 months (primary end point) and 12-months. Muscular fitness will be the primary outcome and secondary outcomes will include: objectively measured body composition, cardiorespiratory fitness, flexibility, resistance training skill competency, physical activity, self-reported recreational screen-time, sleep, sugar-sweetened beverage and junk food snack consumption, self-esteem and well-being.

ETHICS AND DISSEMINATION

This study has received approval from the University of Newcastle (H-2014-0312) and the NSW Department of Education (SERAP: 2012121) human research ethics committees. This study is funded by the Australian Research Council (FT140100399) and the NSW Department of Education.

TRIAL REGISTRATION NUMBER

ACTRN12615000360516; Pre-results.

Does Prevention Pay? Costs and Potential Cost-savings of School Interventions Targeting Children with Mental Health Problems

BACKGROUND

In Sweden, the local government is responsible for funding schools in their district. One funding initiative is for schools to provide students with mental health problems with additional support via extra teachers, personal assistants, and special education classes. There are evidence-based preventive interventions delivered in schools, which have been shown to decrease the levels of students' mental health problems. However, little is known about how much the local government currently spends on students' mental health support and if evidence-based interventions could be financially beneficial.

AIMS OF THE STUDY

The aim of this study was to estimate the costs of providing additional support for students' mental health problems and the potential cost-offsets, defined as reduced school-based additional support, if two evidence-based school interventions targeting children's mental health problems were implemented in routine practice.

METHODS

This study uses data on the additional support students with mental health problems received in schools. Data was collected from one school district for students aged 6 to 16 years. We modeled two Swedish school interventions, Comet for Teachers and Social and Emotional Training (SET), which both had evidence of reducing mental health problems. We used a cost-offset analysis framework, assuming both interventions were fully implemented throughout the whole school district. Based on the published studies, the expected effects and the costs of the interventions were calculated. We defined the cost-offsets as the amount of predicted averted additional support for students with ongoing mental health problems who might no longer require receiving services such as one-on-one time with an extra teacher, a personal assistant, or to be placed in a special education classroom. A cost-offset analysis, from a payer's perspective (the local government responsible for school financing), was conducted comparing the costs of both interventions with the potential cost-savings due to a reduction in the prevalence of mental health problems and averted additional support required.

RESULTS

The school district was comprised of 6,256 students, with 310 students receiving additional support for their mental health problems. Of these, 143 received support in their original school due to either having ADHD (n = 111), psychosocial problems (n = 26), or anxiety/depression (n = 6). The payers' total cost of additional support was 2,637,850 Euro per school year (18,447 Euro per student). The cost of running both interventions for the school district was 953,643 Euro for one year, while the potential savings for these interventions were estimated to be 627,150 Euro. The estimated effects showed that there would be a reduction of students needing additional support (25 for ADHD, eight for psychosocial problems, and one for anxiety/depression), and the payer would receive a return on their invested resources in less than two years (1.5 years) after implementation.

DISCUSSION

Preventive school interventions can both improve some children's mental health problems and be financially beneficial for the payer. However, they are still limited in their scope of reducing all students' mental health statuses to below clinical cut-offs; therefore, the preventive school interventions should be used as a supplement, but not a replacement, to current practices.

IMPLICATIONS FOR HEALTH POLICIES

The findings have political and societal implications, in that payers can reallocate their funds toward preventive measures targeting students' mental health problems, while reducing the costs.

IMPLICATIONS FOR FUTURE RESEARCH

When evaluating public health actions, it is necessary to consider their economic impact. The resources are scarce and the decision makers need knowledge on how to allocate their resources in an efficient way. Cost-offset analysis is seen as one way for decision makers to comprehend research findings; however, such analyses tend to not include the full benefits of the interventions, and actual impacts need to be fully evaluated in routine implementation.

Overcoming Medicaid Reimbursement Barriers to Funding School Nursing Services for Low-Income Children With Asthma

BACKGROUND

School nurses can provide direct services for children with asthma, educate, and reinforce treatment recommendations to children and their families, and coordinate the school-wide response to students' asthma emergencies. Unfortunately, school-based health services today depend on an unreliable patchwork of funding. Limited state and local funds lead to extremely low nurse-to-student ratios, resulting in missed opportunities for prevention and care of asthma and other health conditions.

METHODS

We carried out a nonsystematic review of legal, government, private health foundation, and medical literature.

RESULTS

Many health services for asthma and other conditions provided in school settings are services typically covered by Medicaid and the Children's Health Insurance Program (CHIP) when offered in other settings. However, complex reimbursement rules, questionable policy guidance establishing a "free care rule," and other barriers have limited the ability of schools to seek Medicaid/CHIP reimbursement for these services. Recent legal developments may help overcome some of these barriers, and new flexibilities in Medicaid law bring opportunities for increased reimbursement of school-based health services.

CONCLUSIONS

Policymakers should call on the Centers for Medicare and Medicaid Services to abandon the "free care rule" and issue other guidance that would enable schools to appropriately obtain Medicaid reimbursement for nursing services.

Projected economic evaluation of the national implementation of a hypothetical HIV vaccination program among adolescents in South Africa, 2012

BACKGROUND

Adolescents in South Africa are at high risk of acquiring HIV. The HIV vaccination of adolescents could reduce HIV incidence and mortality. The potential impact and cost-effectiveness of a national school-based HIV vaccination program among adolescents was determined.

METHOD

The national HIV disease and cost burden was compared with (intervention) and without HIV vaccination (comparator) given to school-going adolescents using a semi-Markov model. Life table analysis was conducted to determine the impact of the intervention on life expectancy. Model inputs included measures of disease and cost burden and hypothetical assumptions of vaccine characteristics. The base-case HIV vaccine modelled cost at US$ 12 per dose; vaccine efficacy of 50 %; duration of protection of 10 years achieved at a coverage rate of 60 % and required annual boosters. Incremental cost-effectiveness ratios (ICER) were calculated using life years gained (LYG) serving as the outcome measure. Sensitivity analyses were conducted on the vaccine characteristics to assess parameter uncertainty.

RESULTS

The HIV vaccination model yielded an ICER of US$ 5 per LYG (95 % CI ZAR 2.77-11.61) compared with the comparator, which is considerably less than the national willingness-to-pay threshold of cost-effectiveness. This translated to an 11 % increase in per capita costs from US$ 80 to US$ 89. National implementation of this intervention could potentially result in an estimated cumulative gain of 23.6 million years of life (95 % CI 8.48-34.3 million years) among adolescents age 10-19 years that were vaccinated. The 10 year absolute risk reduction projected by vaccine implementation was 0.42 % for HIV incidence and 0.41 % for HIV mortality, with an increase in life expectancy noted across all age groups. The ICER was sensitive to the vaccine efficacy, coverage and vaccine pricing in the sensitivity analysis.

CONCLUSIONS

A national HIV vaccination program would be cost-effective and would avert new HIV infections and decrease the mortality and morbidity associated with HIV disease. Decision makers would have to discern how these findings, derived from local data and reflective of the South African epidemic, can be integrated into the national long term health planning should a HIV vaccine become available.

Effectiveness and micro-costing of the KiVa school-based bullying prevention programme in Wales: study protocol for a pragmatic definitive parallel group cluster randomised controlled trial

BACKGROUND

Bullying refers to verbal, physical or psychological aggression repeated over time that is intended to cause harm or distress to the victims who are unable to defend themselves. It is a key public health priority owing to its widespread prevalence in schools and harmful short- and long-term effects on victims' well-being. There is a need to strengthen the evidence base by testing innovative approaches to preventing bullying. KiVa is a school-based bullying prevention programme with universal and indicated elements and an emphasis on changing bystander behaviour. It achieved promising results in a large trial in Finland, and now requires testing in other countries. This paper describes the protocol for a cluster randomised controlled trial (RCT) of KiVa in Wales.

METHODS/DESIGN

The study uses a two-arm waitlist control pragmatic definitive parallel group cluster RCT design with an embedded process evaluation and calculation of unit cost. Participating schools will be randomised a using a 1:1 ratio to KiVa plus usual provision (intervention group) or usual provision only (control group). The trial has one primary outcome, child self-reported victimisation from bullying, dichotomised as 'victimised' (bullied at least twice a month in the last couple of months) versus 'not victimised'. Secondary outcomes are: bullying perpetration; aspects of child social and emotional well-being (including emotional problems, conduct, peer relations, prosocial behaviour); and school attendance. Follow-up is at 12 months post-baseline. Implementation fidelity is measured through teacher-completed lesson records and independent school-wide observation. A micro-costing analysis will determine the costs of implementing KiVa, including recurrent and non-recurrent unit costs. Factors related to the scalability of the programme will be examined in interviews with head teachers and focus groups with key stakeholders in the implementation of school-based bullying interventions.

DISCUSSION

The results from this trial will provide evidence on whether the KiVa programme is transportable from Finland to Wales in terms of effectiveness and implementation. It will provide information about the costs of delivery and generate insights into factors related to the scalability of the programme.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN23999021 Date 10-6-13.

The Case for Adolescent HIV Vaccination in South Africa: A Cost-Effectiveness Analysis

Despite comprising 0.7% of the world population, South Africa is home to 18% of the global human immunodeficiency virus (HIV) prevalence. Unyielding HIV subepidemics among adolescents threaten national attempts to curtail the disease burden. Should an HIV vaccine become available, establishing its point of entry into the health system becomes a priority. This study assesses the impact of school-based HIV vaccination and explores how variations in vaccine characteristics affect cost-effectiveness. The cost per quality adjusted life year (QALY) gained associated with school-based adolescent HIV vaccination services was assessed using Markov modeling that simulated annual cycles based on national costing data. The estimation was based on a life expectancy of 70 years and employs the health care provider perspective. The simultaneous implementation of HIV vaccination services with current HIV management programs would be cost-effective, even at relatively higher vaccine cost. At base vaccine cost of US$ 12, the incremental cost effectiveness ratio (ICER) was US$ 43 per QALY gained, with improved ICER values yielded at lower vaccine costs. The ICER was sensitive to duration of vaccine mediated protection and variations in vaccine efficacy. Data from this work demonstrate that vaccines offering longer duration of protection and at lower cost would result in improved ICER values. School-based HIV vaccine services of adolescents, in addition to current HIV prevention and treatment health services delivered, would be cost-effective.

The NIHR Public Health Research Programme: responding to local authority research needs in the United Kingdom

The remit of the National Institute for Health Research Public Health Research (PHR) Programme is to evaluate public health interventions, providing new knowledge on the benefits, costs, acceptability and wider impacts of interventions, set outside of the National Health Service, intended to improve the health of the public and reduce inequalities. This paper illustrates how the PHR Programme is providing new knowledge for public health decision makers, based on the nine key areas for local authority public health action, described by the King's Fund. Many funded PHR projects are evaluating interventions, applied in a range of settings, across the identified key areas for local authority influence. For example, research has been funded on children and young people, and for some of the wider determinants of health, such as housing and travel. Other factors, such as spatial planning, or open and green spaces and leisure, are less represented in the PHR Programme. Further opportunities in research include interventions to improve the health of adolescents, adults in workplaces, and communities. Building evidence for public health interventions at local authority level is important to prioritise and implement effective changes to improve population health.

Cost-Effectiveness of School-Based Prevention of Cannabis Use

BACKGROUND

Cannabis is the most frequently used illicit drug globally. Despite increasing evidence that cannabis use is associated with adverse health effects, the knowledge on preventative strategies is still limited. This study stemmed from a systematic review of effective prevention in which school-based programmes were identified as promising. The primary objective was to evaluate the cost effectiveness of Project ALERT (Adolescent, Learning, Experiences, Resistance, and Training), compared with ordinary ATOD (Alcohol, Tobacco, and Other Drug) education, among Swedish students in the eighth grade of compulsory school.

METHODS

The cost-effectiveness analysis was performed from the societal perspective with quality-adjusted life-years (QALYs) as an outcome (willingness-to-pay threshold €50,000) and follow-up periods from 1 year to a lifetime, considering a discounting rate of 3%, and with costs inflated to 2013 levels. A Markov model was constructed on the basis of the 'states' of single use, regular use, daily use and use of other illicit drugs, which were associated with 'complications' of psychosis, schizophrenia, traffic accidents, depression and amotivational syndrome. Health and cost consequences were linked to both states and complications.

RESULTS

The programme was cost saving on the basis of evidence from the USA (ratio 1:1.1), and was cost effective (incremental cost-effectiveness ratio €22,384 per QALY) after reasonable adjustment for the Swedish context and with 20 years of follow-up. When the target group was restricted to boys who were neither studying nor working/doing work experience, the programme was cost effective after 9 years and cost saving (ratio 1:3.2) after 20 years.

CONCLUSION

School-based prevention such as Project ALERT has the potential to be cost effective and to be cost saving if implemented in deprived areas. In the light of the shifting landscape regarding legalization of cannabis, it seems rational to continue the health economic analysis of prevention initiated here.

Implementing a School-Located Vaccination Program in Denver Public Schools

BACKGROUND

School-located vaccination (SLV) offers an opportunity to deliver vaccines to students, particularly those without a primary care provider.

METHODS

This SLV program offered 2 clinics at each of 20 elementary schools (influenza vaccine) and 3 clinics at each of 7 middle/preschool-eighth-grade schools (adolescent platform plus catch-up vaccines) during the 2009-2010 and 2010-2011 school years. Established programmatic processes for immunization delivery in an outreach setting were used. Billing and vaccine inventory management processes were developed. Vaccines from the federal Vaccines for Children program were used for eligible students. Third-party payers were billed for insured students; parents were not billed for services.

RESULTS

The proportion of enrolled students who received at least 1 dose of vaccine increased from year 1 to year 2 (elementary: 28% to 31%; middle: 12% to 19%). Issues identified and addressed included program planning with partners, development and implementation of billing processes, development of a solution to adhere to the Family Educational Rights and Privacy Act requirements, development and utilization of an easy-to-comprehend consent form, and implementation of standard work procedures.

CONCLUSIONS

This SLV program offered an alternative approach for providing vaccinations to students outside of the primary care setting. To be successful, ongoing partnerships are needed.