Transcript Module 1: General Introduction to Quality Improvement Programs

National Family Safety Program, NGHA
January 28th and 29th 2013
Presentation 9. Step 4 of the Public Health
Approach to Child Maltreatment Prevention:
Scaling Up and Economic Analysis of Child
Maltreatment Prevention
Presented by
Alaa Sebeh, MD Ph.D.
Independent International Consultant,
Child Protection & Disability.
[email protected]
Violence and Injury Prevention Short Course
Objective
The core learning objective of this module is to apply step 4 of the
public health model to child maltreatment prevention by focusing
on scaling up programmes which have been demonstrated to be
effective and the basics of economic analysis of child maltreatment
prevention, including evaluating the costs and cost-benefits of
programmes.
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Outline
1.
Disseminating Information About Effective Interventions
2.
Scaling Up Effective Interventions
3.
Economic Analysis of Child Maltreatment Prevention
4.
Costs of Child Maltreatment and its Prevention
5.
Cost-Benefit Analysis of Child Maltreatment Prevention Programmes
6.
The Heckman Curve
7.
A Shift in Approach in Early Childhood Interventions from Treatment to
Prevention
8.
Summary and Conclusion
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Disseminating Information About
Effective Interventions
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Preventing child maltreatment: A guide to taking
action and generating evidence
• English
• Chinese
• Arabic
• French
A central objective of WHO’s publication Preventing child maltreatment: A guide to taking action and generating
evidence is to disseminate information as widely as possible about an evidence-based approach to child
maltreatment prevention.
"The 2006 WHO report on prevention of child maltreatment drew attention to the need for this topic to achieve the
prominence and investment in prevention and epidemiological monitoring that is given to other serious publichealth concerns with lifelong consequences affecting children” (Gilbert, R. Kemp, A. Thoburn, J. et al. (2008).
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Systematic Reviews
The evidence base for programmes to prevent child maltreatment is mainly
disseminated through systematic reviews.
The aim of systematic reviews is to disseminate the results in an easily
understandable way to interested audiences, including those making
decisions on what programmes to develop.
The availability of systematic reviews greatly increases the ability to
successfully argue for increased political and financial commitment to a
strategy shown to be effective.
New outcome evaluation studies of interventions are continually appearing,
and systematic reviews are therefore regularly updated.
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Scaling Up Effective Interventions
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The Public Health Model
Systematic, evidence-based
approach with 4 steps:
1.Define &
describe
What is the
Problem?
2.Identify risk
What are the risk
factors and
causes?
4. Scaling up and
cost-effectiveness
Implement on
large scale & cost
3.Develop and
evaluate
interventions
What works
and for whom?
1. Define and Describe
2. Identify Risk
3. Develop and Evaluate
Interventions
4. Scaling Up and CostEffectiveness
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Scaling Up Programmes
Scaling up is the process of reaching larger numbers of a target audience in a
broader geographic area by institutionalizing programmes which have been
demonstrated to be effective on smaller samples.
Evidence-based child maltreatment is still a relatively new field, and to date,
there are only a few programmes that have been demonstrated to be
effective.
Hence, there are currently only a handful of programmes that have been or
are in the process of being scaled up.
One of these is the Nurse-Family Partnership, a nurse home-visiting
programme.
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Scaling up the Nurse-Family Partnership (NFP): USA
April 2010
Source: Mikton, C. (2010). Module 9 PowerPoint Presentation. Geneva, World Health Organization.
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Home Visiting Program Legislation in the USA
The Home Visiting Program, inspired by the NFP, is funded at US$ 1.5 Billion
over five years and allows states, territories and tribes, and nonprofit entities
to apply for funding for three types of home visiting models:
• Programmes with significant, sustained and positive outcomes
• Programmes with significant and positive outcomes
• Programmes developed or identified that represent a promising and
new approach
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Home Visiting Program Targets
The programmes will target the following areas:
• Improvements in maternal and newborn health
• Childhood injury or maltreatment prevention and reduced emergency
room visits
• School readiness and achievement
• Crime or domestic violence
• Family self-sufficiency
• Coordination with community resources and supports
The Nurse-Family Partnership National Service Office will provide technical
support to implementing agencies and states.
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Scaling Up the Nurse-Family Partnership:
Australia and UK
In 2009, the UK government published a Child Health Strategy
which announced the expansion of the NFP from 30 to 70 sites
by 2011.
On a smaller scale, Australia has established an international
collaboration to undertake an implementation of the NFP
model of home visiting in Australia across seven sites.
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Scaling up the Positive Parenting Programme (Triple P)
These are the countries and institutions currently conducting trials of Triple P:
• Belgium (University of Antwerp)
• Canada (University of Manitoba)
• England (University of Manchester, Oxford University, Cambridge University,
University of East Anglia)
• Germany (University of Braunschweig; University of Bielefeld)
• Hong Kong (DOH)
• Iran (Medical University of Tehran)
• Japan (University of Tokyo, Medical University of Wakayama)
• The Netherlands (Trimbos Institute)
• New Zealand (University of Auckland, University of Waikato, University of
Canterbury)
• Sweden (University of Uppsala)
• Switzerland (University of Fribourg)
• USA (Oregon Research Institute, USC)
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Scaling Up: Shaken Baby Syndrome Prevention
Building on the evaluation of the parent education programme to prevent shaken baby
syndrome in New York State, similar interventions are being scaled up in a number of
locations in the USA.
Keeping Babies Safe in North Carolina, is funded to provide the statewide implementation
of the Period of PURPLE Crying programme for the prevention of Shaken Baby
Syndrome/Abusive Head Trauma (SBS/AHT) among infants in the state of North Carolina.
The programme is a universal prevention programme and will be provided to approximately
125,000 families of new babies born in North Carolina over the course of a five-year period.
A new study will test the programme to determine if it can now reduce the incidence of
SBS/AHT in the state of North Carolina.
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Economic Analysis of
Child Maltreatment Prevention
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Economic Analysis of Child Maltreatment
Prevention
Economic analysis includes a variety of methods to assess systematically the impact
that interventions, policies, and programs have on outcomes and costs (Haddix,
Teutsch, & Corso, 2003).
The most common type of economic analysis is the cost of illness/injury (COI) analysis.
COI analyses are used to quantify the economic burden of an outcome of interest, such
as child maltreatment, by quantifying:
• The (direct) medical expenditures resulting from a condition
• The resulting (indirect) value of lost productivity
But economic analysis also includes methods such as programme cost analyses and
cost-effectiveness and cost-benefit analyses.
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Economic Analysis of Child Maltreatment
Prevention: Why it Is Important
Economic analysis provides guidance for the task of allocating scarce resources
among competing demands, which applies to child maltreatment prevention.
Results of economic analysis are critical for:
• Mobilizing political will to address the problem
• Lobbying and persuading policy-makers for more prevention funding
• Resource allocation and priority-setting
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Health Policy Questions that Can be Addressed by
Economic Impact Studies of Violence
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Costs of Child Maltreatment
and its Prevention
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Costs of Child Maltreatment
In addition to the health and social costs, child maltreatment has a huge economic impact.
The economic costs include:
• Direct medical costs
• Lost earnings and tax revenue due to premature death
• Special education
• Psychological and welfare services
• Protective services
• Foster care
• Preventive services
• Adult criminality and subsequent incarceration related to child maltreatment
A study in the United States reviewed a range of sources and calculated the selected annual
direct and indirect costs resulting from child maltreatment to total US$ 94 billion – 1% of the
country’s gross domestic product.
The largest single component was adult criminality related to child abuse, which was estimated
to amount to an annual sum of US$ 55.4 billion.
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The Short-Term and Long-Term
Costs of Child Maltreatment
Source: Corso PS, Fertig, AR. (2010). The economic impact of child maltreatment in the United States. Are the estimates credible?
Child Abuse and Neglect
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The Direct and Indirect
Costs of Child Maltreatment
When categorizing the costs of violence, it is useful to distinguish
between direct and indirect costs.
• Direct costs arise directly from acts of violence and require actual
payments by individuals or institutions.
• Indirect costs refer to lost resources and opportunities resulting
from violence.
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Examples of Direct and Indirect Costs of Child Maltreatment
Direct Costs
Indirect Costs
• Hospitalization
• Special education
• Chronic health problems
• Mental health and health care
• Mental health care system
• Juvenile delinquency
• Child welfare system
• Lost productivity to society
• Law enforcement
• Adult criminality
• Judicial system
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Cost-Benefit Analysis of Child Maltreatment
Prevention Programmes
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Cost-Benefit Analysis
Cost-benefit analyses answer the question what is the return on every dollar
invested in a child maltreatment intervention.
Some outcomes that are examined in monetary terms in cost-benefit studies
include crime, victimization, criminal justice expenses, lost work due to illness,
and receipt of social welfare benefits.
A prerequisite for cost-benefit analyses is that impact or outcome evaluations
have been conducted.
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Outcome Evaluations in Low-and MiddleIncome Countries
Evidence of effectiveness:
• Home visiting
• Parent education
• Abusive head trauma
prevention
• Multi-component
interventions
Source: Mikton C, Butchart A. (2009). Child maltreatment prevention: a systematic review of reviews. WHO Bulletin, 87, 353-361.
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Problems Reduced and Benefits of Early
Childhood Intervention Programmes
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Cost-Benefit Studies in High-Income Countries
Few studies countries have specifically examined the costbenefits of child maltreatment prevention programmes, even
in high-income countries.
However, a number of studies have examined the costs and
cost-benefits or early child and youth intervention
programmes, including several targeting child maltreatment.
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The Heckman Curve
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Rates of Return of Interventions at Different Ages
The analyses of James Heckman and colleagues have shown that
the earlier one intervenes with early childhood programmes to
prevent or reduce various forms of adversity, the greater the
return to the individual and society on every dollar invested.
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Economic Returns of Interventions
Heckman and colleagues have shown that:
• Economic returns on early investments in children are high.
• Early investments promote efficiency and reduce inequality.
• Returns on later interventions are much lower.
• Technology of skill formation is at work here: Skill begets skill and early
skill makes later skill acquisition easier.
• Remedial programmes in the adolescent and young adult years are much
more costly than early interventions in producing the same level of skill
attainment in adulthood; most are economically inefficient.
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The Heckman Curve
Rate of return to investment in human capital
Programs targeted towards the earliest years
Preschool programs
Schooling
Job training
0-3
4-5
Preschool
0
School
Post-school
Age
Source: Heckman, J. (2008). The case for investing in disadvantaged young children. In First Focus (Ed.), Big ideas for children:
Investing in our nation's future (pp. 49-58). Washington, DC: First Focus.
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Shifting from Treatment to Prevention
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Learning from Research
Results from early childhood–programme evaluations show that primary
prevention may yield better outcomes and financial returns than treating
individuals for the consequences of childhood adversity.
In fact, an increasing number of studies document that these programmes can
save so much money in terms of future reductions in treatment costs that they
more than pay for themselves.
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Shifting Towards Prevention
Increasingly, there have been calls for a reorientation of child and human
services – including of child protection services – toward investment and
prevention and away from attempting to “treat” poor outcomes, including those
due to child maltreatment, that manifest themselves later in the life cycle.
Shifting towards an approach in which resources are invested in early human
capital, including by preventing child maltreatment, might produce better
outcomes, save taxpayers money, and improve the quality of life for the people
in whom we invest (What does economics tell us about early childhood policy.
Rand Corporation. 2008).
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Summary and Conclusion
Violence and Injury Prevention Short Course
Summary and Conclusion
This module reviewed:
1. Disseminating Information About Effective Interventions
2. Scaling Up Effective Interventions
3. Economic Analysis of Child Maltreatment Prevention
4. Costs of Child Maltreatment and its Prevention
5. Cost-Benefit Analysis of Child Maltreatment Prevention Programmes
6. The Heckman Curve
7. A Shift in Approach in Early Childhood Interventions from Treatment to Prevention
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References
Brownson, R. Gurney, J. Land, G. (1999). Evidence-based decision making in public health, Journal of Public Health Management and
Practice. 5, 86-97.
Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva,
World Health Organization.
Wang, C. Holton, J. (2007). Total estimated cost of child abuse and neglect. Prevent Child Abuse America. Retrieved June 11, 2010 from
http://www.preventchildabuse.org/about_us/media_releases/pcaa_pew_economic_impact_study_final.pdf
Corso, P. Fertig, A. (2010). The economic impact of child maltreatment in the United States. Are the estimates credible? Child Abuse and
Neglect. 34(5), 296-304.
Gilbert, R. Kemp, A. Thoburn, J. et al. (2008). Recognising and responding to child maltreatment. Lancet; published online
Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child maltreatment in highincome countries. Child Maltreatment 1. 373 (9667), 1-14.
The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 169-194.
Haddix, A. Teutsch, S. Corso, P. (2003). A Guide to Decision Analysis and Economic Evaluation. New York, NY. Oxford Press.
Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization.
Lynn, A. Kilburn, R. Cannon, J. (2008). Early Childhood Intervention: Proven Results, Future Promise. Santa Monica, CA. RAND Distribution
Services
Mikton, C. Butchart, A. (2009). Child maltreatment prevention: A systematic review of reviews. Bulletin of the World Health Organization.
87, 353–361
Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization.
What does economics tell us about early childhood policy. (2008). Rand Corporation.
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Activity: Scaling Up and the Cost Benefit of Child
Maltreatment Prevention Programmes
Participants will be assigned to one of three groups:
1.
Panel members
2.
Group 1 (Scaling up)
3.
Group 2 (Cost-benefit analysis)
Panel members: Discuss concerns or issues which would need to be taken into account in
order to support a scaled-up child maltreatment programme.
Group 1: Discuss what some of the challenges and promises of scaling up a local child
maltreatment prevention programme would be. Based on this discussion prepare an
argument to the panel for scaling up such a local programme.
Group 2: Discuss the potential cost-benefit of implementing and scaling up child
maltreatment prevention programmes. Based on this discussion prepare an argument to
the panel for scaling up such a local programme.
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