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Costs and cost-effectiveness of a mental health intervention for war-affected young persons: decision analysis based
Ryan K McBain1, Carmel Salhi2, Katrina Hann3
1Department of Global Health and Population, Harvard School of Public Health, 651 Huntington Avenue, 7th Floor, Boston, 02115 MA, USA, Research Center on Children and Global Adversity, FXB Center for Health and Human Rights, Harvard University, Boston, MA, USA and rmcbain@hsph.harvard.edu.
Insights
The Youth Readiness Intervention (YRI) improved school outcomes for war-affected youth but was not cost-effective for improving overall functional impairment. Further modifications may enhance its cost-effectiveness in future trials.
Area of Science:
- Global Mental Health
- Public Health Interventions
- Child and Adolescent Psychology
Background:
- One billion children worldwide reside in war-affected regions.
- War-affected youth experience significant psychological distress and functional impairment.
- There is a critical need for effective interventions in these vulnerable populations.
Purpose of the Study:
- To conduct the first cost-effectiveness analysis of the Youth Readiness Intervention (YRI) for war-affected youth in sub-Saharan Africa.
- To evaluate the broader costs associated with the YRI.
- To assess the intervention's impact on functional impairment, mental health, and schooling.
Main Methods:
- A randomized controlled trial (RCT) in Sierra Leone involving 436 participants aged 15-24.
- Participants were randomized to the YRI or care as usual.
- Functional impairment measured by WHO Disability Assessment Scale, converted to Quality-Adjusted Life Years (QALYs); cost analysis used an 'ingredients approach'.
Main Results:
- The YRI showed a cost of $104 per participant, with an Incremental Cost-Effectiveness Ratio (ICER) of $7260 per QALY gained for functional impairment.
- Significant improvements were observed in school enrollment (ICER $431 per school year gained), attendance, and performance at 8-month follow-up.
- The intervention was more cost-effective for participants with the worst baseline conditions (ICER $3564 per QALY gained).
Conclusions:
- The YRI did not meet the standard cost-effectiveness threshold for improving functional impairment.
- The intervention demonstrated significant benefits in school enrollment and performance, which are not fully captured by QALYs.
- Recommendations are provided for modifying the YRI to improve future cost-effectiveness.
Background:
One billion children live in war-affected regions of the world. We conducted the first cost-effectiveness analysis of an intervention for war-affected youth in sub-Saharan Africa, as well as a broader cost analysis.
Methods:
The Youth Readiness Intervention (YRI) is a behavioural treatment for reducing functional impairment associated with psychological distress among war-affected young persons. A randomized controlled trial was conducted in Freetown, Sierra Leone, from July 2012 to July 2013. Participants (n = 436, aged 15-24) were randomized to YRI (n = 222) or care as usual (n = 214). Functional impairment was indexed by the World Health Organization Disability Assessment Scale; scores were converted to quality-adjusted life years (QALYs). An 'ingredients approach' estimated financial and economic costs, assuming a societal perspective. Incremental cost-effectiveness ratios (ICERs) were also expressed in terms of gains across dimensions of mental health and schooling. Secondary analyses explored whether intervention effects were largest among those worst-off (upper quartile) at baseline.
Results:
Retention at 6-month follow-up was 85% (n = 371). The estimated economic cost of the intervention was $104 per participant. Functional impairment was lower among YRI recipients, compared with controls, following the intervention but not at 6-month follow-up, and yielded an ICER of $7260 per QALY gained. At 8-month follow-up, teachers' interviews indicated that YRI recipients observed higher school enrolment [P < 0.001, odds ratio (OR) 8.9], denoting a cost of $431 per additional school year gained, as well as better school attendance (P = 0.007, OR 34.9) and performance (P = 0.03, effect size = -1.31). Secondary analyses indicated that the intervention was cost-effective among those worst-off at baseline, yielding an ICER of $3564 per QALY gained.
Conclusions:
The YRI is not cost-effective at a willingness-to-pay threshold of three times average gross domestic product per capita. However, results indicate that the YRI translated into a range of benefits, such as improved school enrolment, not captured by cost-effectiveness analysis. We also outline areas for modification to improve cost-effectiveness in future trials.
Trial Registration:
clinicaltrials.gov Identifier: RPCGA-YRI-21003.
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