The economic and social dimension of parental mental illness

Authors: Christoph Strohmaier (1^st author; AIHTA), Laura Hölzle (2^nd author; VILLAGE project)
Quality Assurance lead: Ingrid Zechmeister-Koss (AIHTA; Co-Investigator VILLAGE project); COIs VILLAGE project (Jean Paul, Annette Bauer, Melinda Goodyear, Hanna Christiansen)
Duration: April until September 2021
Language: English with German summary

Dieses Projekt ist Teil des ‚Village Projekts‘ 

Publication: HTA Project Report No. 142: https://eprints.aihta.at/1351/

Background: Thirty years ago, the UN Convention on the Rights of the Child (CRC) was approved, setting out the civil, political, economic, social, cultural and health rights of children [1]. Also in Austria in 2012, the Federal Health Commission (“Bundesgesundheitskommission”) and the Council of Ministers agreed upon 10 Austrian Health Targets (“Gesundheitsziele”) including the commitment to shape healthy growing up for children and adolescents while ensuring health equity and fostering psychosocial health in the best possible way [2].

50 to 60% of people with a severe mental illness (SMI) live with one or more children, and furthermore, according to international estimates, approximately one in five minor children lives with a parent who experiences a SMI [3-6]. Children who grow up with a parent who has a mental health problem are at increased risk for adverse child development, for developing physical and mental health problems themselves [7], learning difficulties, long-term dependence on public welfare, or reduced prospects with regard to personal fulfilment [6]. This may result in long-term health and socio-economic effects for the child and affected parent. Socio-economic inequalities in society reinforce these health inequalities [8].

Multidisciplinary health and social care interventions in the context of children of parents with a mental illness (COPMI) such as the VILLAGE project in Austria [9]do not only have the potential to improve the quality of life of individual COPMI and lead to a better understanding of the parental mental illness. Public investments in such interventions for COPMI, which are often preventive in nature, also offer an opportunity to embrace public health targets and assure health in all policies, while simultaneously creating a positive public impact in the broader community that goes beyond individual health outcomes. Hence, these interventions may support health equity goals and offer other values for the individual and society (participation, empowerment, feeling safe, dignity, self-respect, social support, improve help-seeking).

Although there is some evidence on the costs [10]or cost-effectiveness [11, 12]of family-oriented complex interventions for COPMIs, comprehensive social impact assessments are rare and may not be adequately incorporated in current HTA processes and methods [13]. In most of the cases, analyses focus on health economic evaluations and follow a resource oriented micro-economic approach which often fail to capture socio-economic benefits beyond health outcomes or benefits and costs outside the health sector [13]– so-called inter-sectoral costs and benefits (ICBs) [14, 15]. Reasons for this are difficulties to evaluate such interventions with the appropriate evaluation tool and metric [16, 17], but also because decision-makers usually ask for cost-effectiveness ratios rather than broader economic consequences. Furthermore, the complexity of the social system in which the interventions operate, makes it difficult to accurately capture impacts that go beyond short-term economic consequences. Hence, such complexities challenge the traditional economic evaluation methods [18]. Some methods to assess societal value of an intervention exist (e.g. the concept of Social Return on Investment (SROI) [19]). Furthermore, methodological development of new standards of economic evaluation that capture impacts beyond health-related outcomes or multi-sectoral impacts from a societal perspective is an on-going agenda [13, 16, 20-23]. Although those methods have their own limitations, they may be useful to capture the economic dimension of COPMI relevant aspects and long-term opportunity costs.

The project is divided into two parts:

Part I: Systematic literature review on the economic and social impact of family-oriented complex interventions for children who have a parent with a mental disorder

Aims and research questions: Part I is supposed to give a (systematic) overview of the cost-effectiveness and the broader social and economic impact of family-oriented complex interventions focussing on prevention or early intervention in the field of COPMI. We aim to raise general awareness in health planners and decision makers on the economic dimensions of mental health problems in families. Furthermore, the overview aids as an information source for health (economic) researchers in order to conduct social and economic evaluation and impact assessments for similar interventions such as the VILLAGE project.

The following research questions (RQ) will guide this part:

RQ1: What is the international evidence on the cost-effectiveness and on the broader economic and social impact of family-oriented complex interventions for COPMI focussing on prevention or early intervention in children? Which methods are used to evaluate health economic and social impacts? What programmes, cost categories, and outcomes can be identified?

RQ2: What is the quality of the identified health economic studies and to what extent is the data (effects, population, services, costs etc.) of the studies generalizable for the Austrian context?

RQ3: What are the additional impacts of the intervention beyond health related outcomes that may be associated with (socio-)economic impacts (e.g. participation, empowerment, feeling safe, dignity, self-respect, social support, improve help-seeking), and what are opportunity costs or possible sustained negative effects of refraining the intervention? Which frameworks/methods are applied to capture these consequences?

Methods: RQ1 to RQ3 will be addressed by a systematic review of the evidence of economic and social impacts of internationally implemented family-oriented complex interventions focussing on prevention or ‘early’ intervention in the field of COPMI. For this task, a systematic literature search in selected databases is conducted to identify economic and social impact assessments (EconLit, PubMed, Medline, Medline, NHS EED etc.). The systematic approach is accompanied by a hand search.

Furthermore, in the course of answering RQ2, we critically appraise the quality of the identified studies by applying the CHEC [24]checklist for assessing economic evaluations.

In addition, long-term economic impact measures, the potential (cross-sectoral) economic and social impact of family-oriented complex interventions for COPMI, and (societal) opportunity costs or negative effects from refraining the intervention are discussed in a narrative discourse from a realist evaluation vantage point [25, 26]to answer RQ3. An underlying logic model (drawing on earlier results from the VILLAGE project) and the guidance for assessing complex technologies from the INTEGRATE-HTA project [18]will help as a theoretical underpinning in order to describe the causal pathway by which the intervention is thought to impact health and non-health related outcomes. Social and economic impacts relating to the following categories are considered in form of a qualitative evidence synthesis (QES): Impact on individuals, impact on families, impact on communities, and broad societal impacts. We refrain from conducting a cost-benefit analysis, since the benefits of social innovations such as community-based interventions cannot always be expressed in monetary terms.

PICO-Analysis for the literature search:

Part II: Economic evaluation of the ‘VILLAGE program’ to support children of parents with a mental illness: Unit cost analysis

Aims and research questions:

Using the information on methods and approaches from part I, part II aims to deliver preparatory work for an economic analysis of the program piloted in the VILLAGE project for COPMI and their families. The focus will be on one specific component of the economic analysis, which is to retrieve unit costs on the services used by the children supported in the VILLAGE project. The second aim of this part will be to collect experience from applying a newly developed Pan-European unit cost calculation tool– PECUNIA [22]–for the unit cost retrieval.

The following research questions will guide this part:

RQ1: What are the unit costs for the individual services utilised by the children who participated in the VILLAGE project?
RQ2: What are the advantages and limitations of using the unit cost calculation methods and tools developed in the EU-project PECUNIA for retrieving the unit costs and to what extent is this approach feasible for the economic evaluation of a family-oriented complex intervention in the field of COPMI?

Method:

Unit costs for services which are included in the service receipt inventory (a questionnaire which children who participate in the VILLAGE project fill in at baseline and follow up) will be retrieved by searching for relevant unit costs in existing Austrian unit cost data sources (e.g. DHE unit cost database, Tyrol-specific costs) and by applying the standardised costing tools from the PECUNIA project [22]. A list of unit costs will be created. The application of the tool will be critically assessed for practicability in the field of COPMI. Furthermore, health cost/benefit categories and ICBs identified by the PECUNIA project [14, 15]and health and non-health related impacts identified from part I will be contrasted. Differences, commonalities and contradictions are discussed narratively.

Schedule and milestones:

References:

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