Economic Evaluation of Implementation Strategies for School-Based Universal Prevention: Insights from a Pilot Study

Universal prevention can avert behavioral health consequences, including addiction, and is an excellent societal investment. However, school-based interventions are often delivered suboptimally. Implementation strategies, including Enhanced Replicating Effective Programs (REP), are needed to realize prevention benefits, but they can be resource-intensive in economically challenged environments. This study aimed to evaluate cost-effectiveness and utility for decision-making and resource allocation.

Data are from a pilot cluster randomized trial in eight low-resource Michigan high schools (four Enhanced REP, four standard implementation) during 2021-2022. Enhanced REP supported delivery of the Michigan Model for Health^™ (MMH), a universal school-based prevention curriculum. We used activity-based costing to estimate incremental costs. To assess effectiveness, we examined student anxiety symptoms using the GAD-7 and mapped them to utilities. We used probabilistic sensitivity analyses for one- and five-year horizons.

Enhanced REP cost per school was $8,659 (1-year) and $12,598 (5-year). Student GAD-7 scores (N=279) were lower for Enhanced REP versus standard implementation ( $\beta =\text{-}1.56$ , p = .046); we used entropy balancing to reduce bias from differential attrition. The cost for one unit GAD-7 decrease was $59.38/student for 1-year horizon and $17.34/student for 5-year horizon; cost per QALY was $39,648/1-year and $11,537/5-year horizon.

Implementation strategies, such as Enhanced REP, can help schools use resources efficiently and improve student well-being. This research highlights the importance of determining costs and outcomes associated with implementation strategies to enhance the public health impact of school-based prevention.

NCT04752189.