Economic Evaluation of Universal Programmes to Promote Healthy Behaviours: Challenges and Possible Solutions with an Application to Physical Activity
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Economic evaluation of universal programmes to promote healthy behaviours: challenges and possible solutions with an application to physical activity Francesco Paolo Candio University of Leeds School of Medicine Submitted in accordance with the requirements for the degree of Doctor of Philosophy June 2019 Declaration I confirm that the work submitted is my own and that appropriate credit has been given where reference has been made to the work of others. This copy has been supplied on the understanding that it is copyright material and that no quotation from the thesis may be published without proper acknowledgement. Francesco Paolo Candio June 2019 Acknowledgements I would like to thank my supervisors David Meads, Prof. Andrew Hill, Laura Bojke and Prof. Karen Bloor for the advice provided throughout this journey. I would also like to thank Prof. Chris Bojke and Prof. Robert West for their valuable input. I gratefully acknowledge the funding received towards my PhD from NIHR CLAHRC Yorkshire and Humber and Leeds Institute of Health Sciences. I must express my gratitude to have been given the opportunity to meet stakeholders, academics and PhD colleagues from the Universities of York, Sheffield and Bradford, and more recently Oxford, who have all contributed to my professional and personal development. Finally, I am indebted to my family and dearest friends Ambra and Gaetano, whose unconditional love and support has made this possible. Most importantly, I owe a debt of gratitude to my loving life partner Esme, who has always been by my side throughout all the ups and downs of this PhD, and to our daughter Ludovica, to give me joy in my heart. Abstract Several methodological challenges characterise the economic evaluation of public health interventions, especially universal programmes to promote healthy behaviours. While relevant guidance to support analysts exists, methodological shortcomings have been highlighted in recent reviews. The choice of evaluation method and assumptions can have profound impacts on cost-effectiveness, and consequently decision-making. Therefore, methods development and validation for public health interventions are needed. Narrowing the focus to physical activity, the first research question of this thesis was: if and how have the methodological challenges acknowledged in public health have been addressed in economic evaluations of PA promotion interventions? To address this question, a systematic review of the methods used for economic evaluation was conducted. This review revealed a paucity in the methods used and identified four outstanding issues to be addressed in this thesis: modelling of heterogeneity and inequality in population-level impact, assumptions regarding maintenance of behaviour change over time, longitudinal selection bias and perspective for economic evaluation. To address these four issues, this thesis was framed around two research questions: how to incorporate concerns regarding population-level impacts into the economic model? What is the impact of the key methodological assumptions that underpin the existing models on the economic decision? These questions are explored using a case study which focused on a local universal programme to promote physical activity. i A novel modelling approach is proposed to address the issues of population-level impact and behaviour change maintenance over time. Results show the choice of evaluation method can impact the cost-effectiveness decision. In particular, the choice of method and assumptions regarding selection mechanisms and maintenance of behaviour change over time have the potential to independently affect identification of the optimal strategy. Results also suggest that the case study programme can potentially be cost-neutral, but widen existing health inequalities in the short term, if its opportunity cost is considered. Findings highlight the importance of addressing the identified shortcomings to adequately inform decision-making. They provide support for change in implementation and research practices and pave the way to more robust and informative economic evaluations. The proposed modelling approach represents a simple modelling solution that can be replicated for evaluation of universal strategies to promote healthy behaviours. A summary of the lessons learnt, which could be useful for future evaluations, is presented. Keywords: economic evaluation, healthy behaviours, physical activity, public health economic modelling, universal promotion. ii Table of Contents List of Figures viii List of Tables ix Table of Acronyms and Abbreviations x 1 Chapter ............................................................................................................................................ 1 1.1 Background .............................................................................................................................. 1 1.1.1 What is economic evaluation? ........................................................................................ 1 1.1.2 What is health promotion? ............................................................................................. 8 1.1.3 Challenges in designing health promotion activities.....................................................17 1.1.4 Universal programmes ..................................................................................................18 1.1.5 Physical activity and health promotion .........................................................................19 1.1.6 Methods guidance for the economic evaluation of health promotion .........................20 1.1.7 Outstanding methodological challenges in economic evaluation of health promotion .....23 1.2 Thesis aims and objectives .................................................................................................... 26 1.3 Structure of the thesis ........................................................................................................... 27 2 Chapter ..........................................................................................................................................31 2.1 Chapter outline ...................................................................................................................... 31 2.2 Search strategy ...................................................................................................................... 31 2.2.1 Development .................................................................................................................32 2.2.2 Testing ...........................................................................................................................33 2.3 Review of existing reviews .................................................................................................... 34 2.3.1 Methods of review ........................................................................................................34 2.3.2 Results ...........................................................................................................................35 2.3.3 Conclusions ....................................................................................................................39 2.4 Systematic review.................................................................................................................. 40 2.4.1 Methods of review ........................................................................................................40 2.4.2 Overview of the included studies ..................................................................................43 2.4.3 Economic evaluation results .........................................................................................49 2.4.4 Critique of the analytical methods used for economic evaluation ...............................56 2.4.5 Main findings .................................................................................................................73 2.4.6 Limitation of the review ................................................................................................75 2.5 Identified methodological issues ........................................................................................... 76 iii 3 Chapter ..........................................................................................................................................78 3.1 Chapter outline ...................................................................................................................... 78 3.2 The case study ....................................................................................................................... 79 3.2.1 Decision-making context ...............................................................................................79 3.2.2 Programme contents .....................................................................................................80 3.2.3 Data collection process .................................................................................................82 3.3 Methods ................................................................................................................................ 85 3.3.1 Definitions .....................................................................................................................86 3.3.2 Identified variables ........................................................................................................87 3.3.3 Descriptive analysis .......................................................................................................89