CSIRO PUBLISHING
Australian Journal of Primary Health, 2015, 21, 438–443 http://dx.doi.org/10.1071/PY14066
Research
Building evidence for peer-led interventions: assessing the cost of the Adolescent Asthma Action program in Australia Michael E. Otim A,B,D, Ranmalie Jayasinha A, Hayley Forbes A and Smita Shah A,C A
Poche Centre for Indigenous Health, Sydney Medical School, Edward Ford Building A27, University of Sydney, NSW 2006, Australia. B School of Allied Health, Faculty of Health Sciences, Australian Catholic University, PO Box 968, North Sydney, NSW 2059, Australia. C Primary Health Care Education and Research Unit, Western Sydney Local Health District, PO Box 533, Westmead, NSW 2145, Australia. D Corresponding author. Email: [email protected]
Abstract. Asthma is the most common chronic illness among adolescents in Australia. Aboriginal and Torres Strait Islander adolescents, in particular, face substantial inequalities in asthma-related outcomes. Triple A (Adolescent Asthma Action) is a peer-led education intervention, which aims to improve asthma self-management and reduce the uptake of smoking among adolescents. The aim of this study was to determine the cost of implementing the Triple A program in Australia. Standard economic costing methods were used. It involved identifying the resources that were utilised (such as personnel and program materials), measuring them and then valuing them. We later performed sensitivity analysis so as to identify the cost drivers and a stress test to test how the intervention can perform when some inputs are lacking. Results indicate that the estimated cost of implementing the Triple A program in five schools was $41 060, assuming that the opportunity cost of all the participants and venues was accounted for. This translated to $8212 per school or $50 per target student. From sensitivity analysis and a stress test, it was identified that the cost of the intervention (in practice) was $14 per student. This appears to be a modest cost, given the burden of asthma. In conclusion, the Triple A program is an affordable intervention to implement in high schools. The potential asthma cost savings due to the program are significant. If the Triple A program is implemented nation-wide, the benefits would be substantial. Additional keywords: Aboriginal and Torres Strait Islander health, asthma self-management, economic assessment, health education, health promotion. Received 17 April 2014, accepted 19 August 2014, published online 18 September 2014
Introduction Asthma in Australia Asthma continues to be a significant health problem in Australia, accounting for 2.4% of the total burden of disease (Australian Institute of Health and Welfare 2009). In 2004–05, the total expenditure on asthma was ~$606 million, representing ~1.2% of all health expenditure (Australian Institute of Health and Welfare 2010). In 1989, the economic cost of asthma in New South Wales was estimated to be $209 million, which represented a cost to the Australian community of $769 per asthmatic (Mellis et al. 1991). The Boston Consulting Group (1992) estimated the cost of asthma in 1991 at $585–$720 million in Australia. Children aged 0 to 14 years disproportionately bear the largest share (61%) of the total burden of asthma (Australian Institute of Health and Welfare 2009). A study by Toelle et al. (1995) found that the mean annual cost of asthma to a family with an asthmatic child was $212.48 per asthmatic child and that 13.4 h was spent Journal compilation Ó La Trobe University 2015
seeking treatment. The cost of absenteeism for parents has been estimated to be ~12.8 million child-care hours (Wang et al. 2005). Adolescent asthma self-management Asthma is the most common chronic illness among adolescents, who poorly understand it (Elizur et al. 2007; Jenkins et al. 2009; Yang et al. 2010). This is partly because adolescence can be a time for health-related risk-taking behaviour. This may lead to poor adherence to medications, which can result in school absences, poor social skills and lack of physical activity (Chen et al. 2007). Adolescents also have a significantly higher prevalence of nearfatal episodes of asthma, and episodes that require hospitalisation, incubation and cardiopulmonary resuscitation, compared with younger aged children (Elizur et al. 2007). Aboriginal and Torres Strait Islander adolescents, in particular, are twice as likely to have hospital visits for asthma, and three times as likely to die from asthma compared with non-Aboriginal adolescents (Jenkins et al. www.publish.csiro.au/journals/py
Cost of implementing Triple A program to address asthma
What is known about the topic? *
Asthma is the most common chronic illness among adolescents in Australia. Triple A, a peer-led education program, improves adolescent asthma selfmanagement. An economic analysis has not yet been undertaken.
What does this paper add? *
Triple A is an affordable peer-led education program to improve asthma self-management in adolescents. Investing in this intervention will most likely result in significant cost savings in the long term.
2009). Thus, Aboriginal and Torres Strait Islander adolescents are particularly disadvantaged. Asthma self-management takes on an additional dimension during adolescence, with the responsibility for health care shifting from parents to adolescents (Beal et al. 2001; Elizur et al. 2007). This shift is commonly mediated through external influences, with an increase in the importance of peer friendships (Bruzzese et al. 2004). Social support plays an important role in asthma self-management during adolescence and has a considerable influence on adolescent risky health behaviour (Beal et al. 2001; Chen et al. 2007; Yang et al. 2010). Despite the need for greater social support and asthma awareness during adolescence, there are a limited number of interventions designed for this age group (Beal et al. 2001). Effective peer-led interventions that target asthma self-management could equip adolescents with the necessary skills to manage their asthma (Ayala et al. 2006). Schools are a suitable location to implement peer-led interventions.
Australian Journal of Primary Health
439
disadvantaged students, such as Aboriginal and Torres Strait Islander peoples, and those with a refugee or migrant background. The intervention uses slightly older students to deliver the program. The Triple A program has undergone rigorous scientific review and testing (Gibson et al. 1998; Shah et al. 2001). The results show that participation in the program encourages a sense of personal responsibility. Furthermore, it leads to significant improvement in quality of life of asthmatic students by an average of 0.12 (95% CI = 0.05–0.18). Participating students experienced fewer asthma attacks and reduced school absenteeism. A recent randomised trial undertaken in Jordanian schools resulted in significant improvement of asthmatic quality-of-life by ~1.35 (95% CI = 1.15–2.19) (Al-sheyab et al. 2012). Thus, the Triple A program is effective in improving asthma self-management and preventing smoking in adolescents in high school settings (Shah et al. 2001; Al-sheyab et al. 2012). The program follows a three-step process (Shah and Jayasinha 2013). First, trained university students (Triple A Educators) coach senior high school students between the ages of 15–16 years to be Triple A Peer Leaders during a 1-day workshop. The Peer Leaders learn about asthma and its management and acquire skills in facilitation and leadership. Second, the Peer Leaders deliver three Triple A lessons to their younger peers, between the ages of 12–13 years, the target group. Finally, wider dissemination of asthma information and prevention of smoking occurs when the target students relay what they have learnt to the wider school community, through creative student actions such as posters, songs, dances, drama and/or performances. However, the cost of implementing Triple A has not been estimated. This study estimates the cost of implementing the Triple A program in high schools in Australia over a 1 year period. Ethics approval to use secondary data for this study was obtained from the University of Sydney Human Ethics Committee.
Peer-led education in schools
Methods
By facilitating the implementation of peer-led interventions in schools, it allows easy access to the target asthmatic students who need it most, allows intervention outcomes to be measured and allows contact with the wider community (Shah et al. 2001; Al-sheyab et al. 2013). It has also been noted as a key setting for peer group influences on health behaviours in adolescence (Alexander et al. 2001). Peer-led health education is a potential alternative to health professional- or teacher-delivered health education in the school context (Mellanby et al. 2000). Peers are often seen by adolescents as more credible sources of information (Harden et al. 2001). Peer-led education programs have been found to be effective in a range of health behaviours (Campbell et al. 2008; Flay 2009). This paper focuses on the Adolescent Asthma Action (Triple A) program, a peer-led school-based intervention, which aims to improve asthma self-management and prevent smoking uptake by high school students.
Standard economic costing methods were used to estimate the cost of implementing the Triple A program over a 1-year period, following three basic steps: identification of intervention activities; measurement of resource use; and valuation of the resources (Drummond et al. 2005). To identify Triple A activities for costing purposes, an activity pathway (Fig. 1) was used. The individual cost components of the interventions and unit costs of the activities were identified from the literature (Kernick 2000; Chapko et al. 2009; Doran et al. 2012). Input costs were estimated according to the requirements for each activity and their unit cost (Fig. 2). Estimating the economic cost of the intervention involved identifying the opportunity costs (the best alternatives foregone) of the required inputs (Kernick 2000), including volunteer labour and venue hire costs. Typically, inputs include 20 university medical and pharmaceutical students who are trained as Triple A educators in a 1-day workshop. In collaboration with five high schools in Western Sydney, which have high numbers of Aboriginal students (10–20%), Triple A Educators in groups of three or four, mainly volunteer students from Years 10 or 11, were trained as Triple A Peer Leaders. They learnt about asthma and its management, and how to resist smoking through videos,
The Triple A program The Triple A program is based on psychosocial theory (Shah et al. 1998, 2001) and it is implemented in high schools located in low socioeconomic areas. As such, the intervention targets
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games and activities (Shah et al. 1998). School staff, including Aboriginal Education Officers, helped to promote the program and encouraged students to volunteer. When available, volunteers provide their labour at no cost. The high school students receive training, which contributes to their education and the university students receive credit towards their university course depending on the relevance of the activity to their study program. High school teachers provide their time during the school day to support classroom management. Additionally, the university and high school venues are usually provided free of charge as an in-kind gesture for receiving the program. A sensitivity analysis stress test was therefore undertaken to assess the impact of including or excluding the volunteers and venue hire costs in order to identify the cost drivers. Due to a lack of complete data to aid the costing of Triple A, assumptions had to be made, as outlined in Table 1. Fig. 1. Triple A intervention pathway.
Fig. 2. Triple A identification of input requirement.
Cost of implementing Triple A program to address asthma
Results Overall, the cost of implementing the Triple A program in five high schools was ~$41 060, assuming the opportunity cost of all the participants had been accounted for. This translated to ~$8212 per school or $50 per target student. This estimate, as outlined in Table 2, is the figure before sensitivity analysis and stress testing was undertaken. Sensitivity analysis and stress testing of the results was undertaken (Table 3). The effect of the volunteers and/or venue hire being included or excluded on the overall cost of the program was assessed. Results indicate that excluding both the cost of volunteers and venues more than halves the cost of the intervention per student, which translates to a cost of $14 per student, although there is still an opportunity cost, in spite of the financial savings. Discussion The primary aim of the study was to estimate the cost of implementing the Triple A program in Australia. Results indicate that high schools require an investment of $50 per target student with asthma. With such an investment, there are potential savings that can be achieved in terms of reduced school absenteeism and related costs of parental leave, as well as hospital admissions (Shah et al. 2001; Al-sheyab et al. 2012). This may, in turn, prevent further asthma-related costs among adults in the future
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(Australian Institute of Health and Welfare 2010). This study provides evidence of the affordability of Triple A to improve adolescent asthma-self management. The use of the activity pathway to identify and map intervention activities allowed us to estimate the key component costs at each stage of the program (Chapko et al. 2009). Additionally, by using a sensitivity analysis and stress testing of the intervention, we were able to identify the key cost drivers that affected the affordability of the program. As such, we were able to determine that, while the intervention costs $50 per target student in the study, in practise, the program financial costs is $14 per target student, which makes a significant difference in terms of affordability. Such costing has important implications for the future implementation of Triple A. We had also planned to estimate the potential savings due to the program using the reported improvement of health-related quality of life proposed by Shah et al. (2001) as the primary outcome measure of the effectiveness of the program. However, we were unable to do so due to a lack of recent estimates of the social cost of asthma data that used recent prevalence or incidence rates of asthma to reflect the current situation in Australia. For example, Mellis et al. (1991) determined the social cost of asthma to be $769 per person based on 1989 data and the Boston Consulting Group (1992) estimated the cost of asthma to be between $585 and $720 million based on 1991 prevalence data of 7%. Today, the prevalence of asthma in Australia among
Table 1. Assumptions for the costing of the Triple A intervention Assumptions Participants
*
*
*
*
*
*
*
Salary
The average number of student (11–12 year olds) was estimated to be 165 students, which was based on average class size at a typical government-funded high school in Western Sydney, New South Wales, Australia (Office of Education 2013). The Shah et al. (2001) and Al-sheyab et al. (2012) studies on the Triple A intervention did not specify the number of health workers and project staff used to train the senior high school students (15–16 year olds). As such, we contacted the Triple A intervention leader in Australia to determine participant numbers for the current implementation of the program in Sydney. Twenty university students (Triple A Educators) are required to coach 20 senior high students (15–16 year olds) as Peer Leaders in each school (n = 100) in a 5-h workshop. Twenty senior school students (15–16 year olds) train ~165 junior students (11–12 year olds) in each school over three lessons. As there are five schools that participated, with an average of 165 junior students, there was a total of 825 junior students (11–12 year olds). One teacher was present at each Peer Leader workshop and at each of the junior student lessons to assist with class management. Four facilitators are required to train 20 university students in a 5-h workshop. The possibility of drop-outs from the program was not accounted for.
All salaries for Triple A project staff were based on 2013 professional salaries at The University of Sydney (2013): The salary of the Project Officer was $35 per hour, Level 5/Step 1, pro rata (2 days per week). The Salary of the Project Leader was $44 per hour, Level 7, Step 1. The wage of the two external facilitators was $44 per hour, Level 7, Step 1. On-cost of salaries were calculated at 30% as per University of Sydney standard practice. In principle, the labour and time given by the volunteers, the university, senior high school students and teachers, should be costed because there is an ‘opportunity cost’ to each of them. An average wage for student volunteers was based on the Australian Department of Labour website. The estimated wage per hour for university and senior high school students was $16.37 and $9.46 respectively (Fair Work Ombudsman 2013). Teacher salary was based on a graduate starting salary of $60 000, which translates to approximately $35 per hour (NSW Teachers Federation 2013). In practise, volunteers are usually provided at no cost during the intervention, which was accounted for in the stress test, because in remote areas, such volunteers may not be present. *
*
*
*
*
*
*
*
Resources
*
*
*
In theory, the venues for the workshops used in the Triple A intervention should be costed, as there is an ‘opportunity cost’ to each of them. However, in practise, venues are usually provided at no cost during the intervention as an in-kind gesture. Where venue hire charge was costed in the sensitivity analysis, the $88 per hour room charge was based on advice regarding the base per hour hire fee of a tutorial room at the University of Sydney, Camperdown campus. 20% for incidentals includes the cost of office resources and transport.
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Table 2. Cost of intervention Cost Salary Venue Resources Subtotal Incidentals Grand total Per school Per student
$20 563 $11 660 $1994 $34 217 $6843 $41 060 $8212 $50
Table 3. Sensitivity and stress tests
Salary Venue Resources Subtotal Incidentals Grand total Per student Per school
Full costA
Without volunteers
Without venue
Without volunteers and venueA,B
$20 563 $11 660 $720 $32 943 $6589 $39 532 $50 $8212
$8694 $11 660 $720 $21 074 $4215 $25 288 $31 $5058
$21 838 $0 $720 $22 558 $4512 $27 069 $33 $5414
$8694 $0 $720 $9414 $1883 $11 296 $14 $2259
A B
Values used in economic analysis. Usual practise.
adolescents is ~17% (Australian Centre for Asthma Monitoring 2011), which means that the social cost of asthma may have significantly changed. Additionally, a study by Toelle et al. (1995), based on 1991–92 data from NSW, calculated the cost of asthma to a family with a child with asthma as $212. Thus, available historic data require updating in order for the savings due to the Triple A program and other interventions to be accurately estimated. With increased need for efficient approaches in the health system to address increasing healthcare needs, determining the economic cost of interventions is important for ensuring sustainability of interventions (Kernick 2000). Furthermore, outlining the intervention costs and comparisons with other interventions (such as adult- or expert-led interventions) can be undertaken to demonstrate the cost benefits of implementing school-based peer-led education to improve adolescent asthma self-management. Conclusion Asthma is the most common chronic illness among adolescents, especially among Aboriginal and Torres Strait Islander adolescents, in Australia. Effective peer-led interventions that target asthma self-management are therefore urgently needed to equip adolescents with the skills to manage their asthma. The school context has also been noted as a key setting for peer group influences on health behaviours in adolescence or peer-led interventions. This study demonstrates that the Triple A program could lead to significant savings in asthma costs. If the Triple A intervention is implemented nationwide, the benefits would
be substantial. However, more updated figures on the effectiveness of the Triple A program and the social costs of existing asthma programs is needed for potential savings to be achieved. Conflicts of interest None declared. Acknowledgements We acknowledge the funding support received from the Poche Centre of Indigenous Health, Sydney Medical School, University of Sydney to undertake this project. We thank the Asthma Foundation of New South Wales for their support of the Triple A program in high schools. We acknowledge Ms Kylie Gwynne, Professor Stephen Jan and Shifra Waks for their comments on this manuscript.
References Australian Institute of Health and Welfare (2009) Burden of disease due to asthma in Australia 2003. Cat. no. ACM 16. AIHW, Canberra. Australian Institute of Health and Welfare (2010) Health system expenditure on disease and injury in Australia, 2004–05. Health and welfare expenditure series. AIHW, Canberra. Al-sheyab N, Gallagher R, Crisp J, Shah S (2012) Peer-led education for adolescents with asthma in Jordan: a cluster-randomized controlled trial. Pediatrics 129, e106–e112. doi:10.1542/peds.2011-0346 Al-sheyab N, Gallagher R, Gallagher P, Shah S (2013) Cigarette smoking in adolescents with asthma in Jordan: impact of peer-led education in high schools. Journal of Nursing and Practice 3(9), 13–22. doi:10.5430/jnep. v3n9p13 Alexander C, Piazza M, Mekos D, Valente T (2001) Peers, schools, and adolescent cigarette smoking. The Journal of Adolescent Health 29, 22–30. doi:10.1016/S1054-139X(01)00210-5 Australian Centre for Asthma Monitoring (2011) Asthma in Australia 2011. AIHW Asthma Series no. 4. Cat. no. ACM 22. AIHW, Canberra. Ayala GX, Miller D, Zagami E, Riddle C, Willis S, King D (2006) Asthma in middle schools: what students have to say about their asthma. The Journal of School Health 76, 208–214. doi:10.1111/j.1746-1561.2006.00098.x Beal AC, Ausiello J, Perrin JM (2001) Social influences on health-risk behaviors among minority middle school students. The Journal of Adolescent Health 28, 474–480. doi:10.1016/S1054-139X(01)00194-X Boston Consulting Group (1992) Report on the cost of asthma in Australia. National Asthma Campaign. National Asthma Council Australia, Melbourne. Bruzzese JM, Bonner S, Vincent EJ, Sheares BJ, Mellins RB, Levison MJ, Wiesemann S, Du Y, Zimmerman BJ, Evans D (2004) Asthma education: the adolescent experience. Patient Education and Counseling 55, 396–406. doi:10.1016/j.pec.2003.04.009 Campbell R, Starkey F, Holliday J, Audrey S, Bloor M, Parry-Langdon N, Hughes R, Moore L (2008) An informal school-based peer-led intervention for smoking prevention in adolescence: a cluster randomised trial. Lancet 371, 1595–1602. doi:10.1016/S0140-6736(08)60692-3 Chapko MK, Liu C-F, Perkins M, Li Y-F, Fortney JC, Maciejewski ML (2009) Equivalence of two healthcare costing methods: bottom-up and top-down. Health Economics 18, 1188–1201. doi:10.1002/hec.1422 Chen E, Chim LS, Strunk RC, Miller GE (2007) The role of the social environment in children and adolescents with asthma. American Journal of Respiratory and Critical Care Medicine 176, 644–649. doi:10.1164/ rccm.200610-1473OC Doran CM, Einfeld SL, Madden RH, Otim M, Horstead SK, Ellis LA, Emerson E (2012) How much does intellectual disability really cost? First estimates for Australia. Journal of Intellectual & Developmental Disability 37, 42–49. doi:10.3109/13668250.2011.648609
Cost of implementing Triple A program to address asthma
Drummond M, Sculpher M, Torrance G, O’Brien B, Stoddard G (2005) ‘Methods for the economic evaluation of health care programmes.’ (Oxford University Press: Oxford) Elizur A, Bacharier LB, Strunk RC (2007) Pediatric asthma admissions: chronic severity and acute exacerbations. The Journal of Asthma 44, 285–289. doi:10.1080/02770900701340445 Fair Work Ombudsman (2013) National minimum wage. Available at http:// www.fairwork.gov.au/pay/national-minimum-wage/pages/default.aspx [Verified 27 October 2013] Flay BR (2009) The promise of long-term effectiveness of school-based smoking prevention programs: a critical review of reviews. Tobacco Induced Diseases 5, 7. doi:10.1186/1617-9625-5-7 Gibson PG, Shah S, Mamoon HA (1998) Peer-led asthma education for adolescents: impact evaluation. The Journal of Adolescent Health 22(1), 66–72. doi:10.1016/S1054-139X(97)00203-6 Harden A, Oakley A, Oliver S (2001) Peer-delivered health promotion for young people: a systematic review of different study designs. Health Education Journal 60, 339–353. doi:10.1177/001789690106000406 Jenkins CR, Chang AB, Poulos LM, Marks GB (2009) Asthma in Indigenous Australians: so much yet to do for Indigenous lung health. The Medical Journal of Australia 190, 530–531. Kernick D (2000) Costing interventions in primary care. Family Practice 17, 66–70. doi:10.1093/fampra/17.1.66 Mellanby AR, Rees JB, Tripp JH (2000) Peer-led and adult-led school health education: a critical review of available comparative research. Health Education Research 15, 533–545. doi:10.1093/her/15.5.533
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Mellis CM, Peat JK, Bauman A, Woolcock AJ (1991) The cost of asthma in New South Wales. The Medical Journal of Australia 155, 522–528. NSW Teachers Federation (2013) Graduate teachers survival kit 2013. New South Wales Teachers Federation, Sydney. Office of Education (2013) Average class sizes. New South Wales Department of Education and Communities, Sydney. Shah S, Jayasinha R (2013) ‘Triple A peer leader manual.’ (Western Sydney Local Health District: Sydney) Shah S, Mahmoon AH, Gibson PG (1998) Peer led asthma education for adolescents: development and formative evaluation. Health Promotion Journal of Australia 8, 177–182. Shah S, Peat JK, Mazurski EJ, Wang H, Sindhusake D, Bruce C, Henry RL, Gibson PG (2001) Effect of peer led programme for asthma education in adolescents: cluster randomised controlled trial. British Medical Journal 322, 583doi:10.1136/bmj.322.7286.583 The University of Sydney (2013) The University of Sydney enterprise agreement 2013–2017. The University of Sydney, Sydney. Toelle BG, Peat JK, Mellis CM, Woolcock AJ (1995) The cost of childhood asthma to Australian families. Pediatric Pulmonology 19, 330–335. doi:10.1002/ppul.1950190604 Wang LY, Zhong Y, Wheeler L (2005) Direct and indirect costs of asthma in school-age children. Preventing Chronic Disease 2, A11 Yang TO, Sylva K, Lunt I (2010) Parent support, peer support, and peer acceptance in healthy lifestyle for asthma management among early adolescents. Journal for Specialists in Pediatric Nursing 15, 272–281. doi:10.1111/j.1744-6155.2010.00247.x
www.publish.csiro.au/journals/py
Australian Journal of Primary Health, 2015, 21, 438–443 http://dx.doi.org/10.1071/PY14066
Research
Building evidence for peer-led interventions: assessing the cost of the Adolescent Asthma Action program in Australia Michael E. Otim A,B,D, Ranmalie Jayasinha A, Hayley Forbes A and Smita Shah A,C A
Poche Centre for Indigenous Health, Sydney Medical School, Edward Ford Building A27, University of Sydney, NSW 2006, Australia. B School of Allied Health, Faculty of Health Sciences, Australian Catholic University, PO Box 968, North Sydney, NSW 2059, Australia. C Primary Health Care Education and Research Unit, Western Sydney Local Health District, PO Box 533, Westmead, NSW 2145, Australia. D Corresponding author. Email: [email protected]
Abstract. Asthma is the most common chronic illness among adolescents in Australia. Aboriginal and Torres Strait Islander adolescents, in particular, face substantial inequalities in asthma-related outcomes. Triple A (Adolescent Asthma Action) is a peer-led education intervention, which aims to improve asthma self-management and reduce the uptake of smoking among adolescents. The aim of this study was to determine the cost of implementing the Triple A program in Australia. Standard economic costing methods were used. It involved identifying the resources that were utilised (such as personnel and program materials), measuring them and then valuing them. We later performed sensitivity analysis so as to identify the cost drivers and a stress test to test how the intervention can perform when some inputs are lacking. Results indicate that the estimated cost of implementing the Triple A program in five schools was $41 060, assuming that the opportunity cost of all the participants and venues was accounted for. This translated to $8212 per school or $50 per target student. From sensitivity analysis and a stress test, it was identified that the cost of the intervention (in practice) was $14 per student. This appears to be a modest cost, given the burden of asthma. In conclusion, the Triple A program is an affordable intervention to implement in high schools. The potential asthma cost savings due to the program are significant. If the Triple A program is implemented nation-wide, the benefits would be substantial. Additional keywords: Aboriginal and Torres Strait Islander health, asthma self-management, economic assessment, health education, health promotion. Received 17 April 2014, accepted 19 August 2014, published online 18 September 2014
Introduction Asthma in Australia Asthma continues to be a significant health problem in Australia, accounting for 2.4% of the total burden of disease (Australian Institute of Health and Welfare 2009). In 2004–05, the total expenditure on asthma was ~$606 million, representing ~1.2% of all health expenditure (Australian Institute of Health and Welfare 2010). In 1989, the economic cost of asthma in New South Wales was estimated to be $209 million, which represented a cost to the Australian community of $769 per asthmatic (Mellis et al. 1991). The Boston Consulting Group (1992) estimated the cost of asthma in 1991 at $585–$720 million in Australia. Children aged 0 to 14 years disproportionately bear the largest share (61%) of the total burden of asthma (Australian Institute of Health and Welfare 2009). A study by Toelle et al. (1995) found that the mean annual cost of asthma to a family with an asthmatic child was $212.48 per asthmatic child and that 13.4 h was spent Journal compilation Ó La Trobe University 2015
seeking treatment. The cost of absenteeism for parents has been estimated to be ~12.8 million child-care hours (Wang et al. 2005). Adolescent asthma self-management Asthma is the most common chronic illness among adolescents, who poorly understand it (Elizur et al. 2007; Jenkins et al. 2009; Yang et al. 2010). This is partly because adolescence can be a time for health-related risk-taking behaviour. This may lead to poor adherence to medications, which can result in school absences, poor social skills and lack of physical activity (Chen et al. 2007). Adolescents also have a significantly higher prevalence of nearfatal episodes of asthma, and episodes that require hospitalisation, incubation and cardiopulmonary resuscitation, compared with younger aged children (Elizur et al. 2007). Aboriginal and Torres Strait Islander adolescents, in particular, are twice as likely to have hospital visits for asthma, and three times as likely to die from asthma compared with non-Aboriginal adolescents (Jenkins et al. www.publish.csiro.au/journals/py
Cost of implementing Triple A program to address asthma
What is known about the topic? *
Asthma is the most common chronic illness among adolescents in Australia. Triple A, a peer-led education program, improves adolescent asthma selfmanagement. An economic analysis has not yet been undertaken.
What does this paper add? *
Triple A is an affordable peer-led education program to improve asthma self-management in adolescents. Investing in this intervention will most likely result in significant cost savings in the long term.
2009). Thus, Aboriginal and Torres Strait Islander adolescents are particularly disadvantaged. Asthma self-management takes on an additional dimension during adolescence, with the responsibility for health care shifting from parents to adolescents (Beal et al. 2001; Elizur et al. 2007). This shift is commonly mediated through external influences, with an increase in the importance of peer friendships (Bruzzese et al. 2004). Social support plays an important role in asthma self-management during adolescence and has a considerable influence on adolescent risky health behaviour (Beal et al. 2001; Chen et al. 2007; Yang et al. 2010). Despite the need for greater social support and asthma awareness during adolescence, there are a limited number of interventions designed for this age group (Beal et al. 2001). Effective peer-led interventions that target asthma self-management could equip adolescents with the necessary skills to manage their asthma (Ayala et al. 2006). Schools are a suitable location to implement peer-led interventions.
Australian Journal of Primary Health
439
disadvantaged students, such as Aboriginal and Torres Strait Islander peoples, and those with a refugee or migrant background. The intervention uses slightly older students to deliver the program. The Triple A program has undergone rigorous scientific review and testing (Gibson et al. 1998; Shah et al. 2001). The results show that participation in the program encourages a sense of personal responsibility. Furthermore, it leads to significant improvement in quality of life of asthmatic students by an average of 0.12 (95% CI = 0.05–0.18). Participating students experienced fewer asthma attacks and reduced school absenteeism. A recent randomised trial undertaken in Jordanian schools resulted in significant improvement of asthmatic quality-of-life by ~1.35 (95% CI = 1.15–2.19) (Al-sheyab et al. 2012). Thus, the Triple A program is effective in improving asthma self-management and preventing smoking in adolescents in high school settings (Shah et al. 2001; Al-sheyab et al. 2012). The program follows a three-step process (Shah and Jayasinha 2013). First, trained university students (Triple A Educators) coach senior high school students between the ages of 15–16 years to be Triple A Peer Leaders during a 1-day workshop. The Peer Leaders learn about asthma and its management and acquire skills in facilitation and leadership. Second, the Peer Leaders deliver three Triple A lessons to their younger peers, between the ages of 12–13 years, the target group. Finally, wider dissemination of asthma information and prevention of smoking occurs when the target students relay what they have learnt to the wider school community, through creative student actions such as posters, songs, dances, drama and/or performances. However, the cost of implementing Triple A has not been estimated. This study estimates the cost of implementing the Triple A program in high schools in Australia over a 1 year period. Ethics approval to use secondary data for this study was obtained from the University of Sydney Human Ethics Committee.
Peer-led education in schools
Methods
By facilitating the implementation of peer-led interventions in schools, it allows easy access to the target asthmatic students who need it most, allows intervention outcomes to be measured and allows contact with the wider community (Shah et al. 2001; Al-sheyab et al. 2013). It has also been noted as a key setting for peer group influences on health behaviours in adolescence (Alexander et al. 2001). Peer-led health education is a potential alternative to health professional- or teacher-delivered health education in the school context (Mellanby et al. 2000). Peers are often seen by adolescents as more credible sources of information (Harden et al. 2001). Peer-led education programs have been found to be effective in a range of health behaviours (Campbell et al. 2008; Flay 2009). This paper focuses on the Adolescent Asthma Action (Triple A) program, a peer-led school-based intervention, which aims to improve asthma self-management and prevent smoking uptake by high school students.
Standard economic costing methods were used to estimate the cost of implementing the Triple A program over a 1-year period, following three basic steps: identification of intervention activities; measurement of resource use; and valuation of the resources (Drummond et al. 2005). To identify Triple A activities for costing purposes, an activity pathway (Fig. 1) was used. The individual cost components of the interventions and unit costs of the activities were identified from the literature (Kernick 2000; Chapko et al. 2009; Doran et al. 2012). Input costs were estimated according to the requirements for each activity and their unit cost (Fig. 2). Estimating the economic cost of the intervention involved identifying the opportunity costs (the best alternatives foregone) of the required inputs (Kernick 2000), including volunteer labour and venue hire costs. Typically, inputs include 20 university medical and pharmaceutical students who are trained as Triple A educators in a 1-day workshop. In collaboration with five high schools in Western Sydney, which have high numbers of Aboriginal students (10–20%), Triple A Educators in groups of three or four, mainly volunteer students from Years 10 or 11, were trained as Triple A Peer Leaders. They learnt about asthma and its management, and how to resist smoking through videos,
The Triple A program The Triple A program is based on psychosocial theory (Shah et al. 1998, 2001) and it is implemented in high schools located in low socioeconomic areas. As such, the intervention targets
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games and activities (Shah et al. 1998). School staff, including Aboriginal Education Officers, helped to promote the program and encouraged students to volunteer. When available, volunteers provide their labour at no cost. The high school students receive training, which contributes to their education and the university students receive credit towards their university course depending on the relevance of the activity to their study program. High school teachers provide their time during the school day to support classroom management. Additionally, the university and high school venues are usually provided free of charge as an in-kind gesture for receiving the program. A sensitivity analysis stress test was therefore undertaken to assess the impact of including or excluding the volunteers and venue hire costs in order to identify the cost drivers. Due to a lack of complete data to aid the costing of Triple A, assumptions had to be made, as outlined in Table 1. Fig. 1. Triple A intervention pathway.
Fig. 2. Triple A identification of input requirement.
Cost of implementing Triple A program to address asthma
Results Overall, the cost of implementing the Triple A program in five high schools was ~$41 060, assuming the opportunity cost of all the participants had been accounted for. This translated to ~$8212 per school or $50 per target student. This estimate, as outlined in Table 2, is the figure before sensitivity analysis and stress testing was undertaken. Sensitivity analysis and stress testing of the results was undertaken (Table 3). The effect of the volunteers and/or venue hire being included or excluded on the overall cost of the program was assessed. Results indicate that excluding both the cost of volunteers and venues more than halves the cost of the intervention per student, which translates to a cost of $14 per student, although there is still an opportunity cost, in spite of the financial savings. Discussion The primary aim of the study was to estimate the cost of implementing the Triple A program in Australia. Results indicate that high schools require an investment of $50 per target student with asthma. With such an investment, there are potential savings that can be achieved in terms of reduced school absenteeism and related costs of parental leave, as well as hospital admissions (Shah et al. 2001; Al-sheyab et al. 2012). This may, in turn, prevent further asthma-related costs among adults in the future
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(Australian Institute of Health and Welfare 2010). This study provides evidence of the affordability of Triple A to improve adolescent asthma-self management. The use of the activity pathway to identify and map intervention activities allowed us to estimate the key component costs at each stage of the program (Chapko et al. 2009). Additionally, by using a sensitivity analysis and stress testing of the intervention, we were able to identify the key cost drivers that affected the affordability of the program. As such, we were able to determine that, while the intervention costs $50 per target student in the study, in practise, the program financial costs is $14 per target student, which makes a significant difference in terms of affordability. Such costing has important implications for the future implementation of Triple A. We had also planned to estimate the potential savings due to the program using the reported improvement of health-related quality of life proposed by Shah et al. (2001) as the primary outcome measure of the effectiveness of the program. However, we were unable to do so due to a lack of recent estimates of the social cost of asthma data that used recent prevalence or incidence rates of asthma to reflect the current situation in Australia. For example, Mellis et al. (1991) determined the social cost of asthma to be $769 per person based on 1989 data and the Boston Consulting Group (1992) estimated the cost of asthma to be between $585 and $720 million based on 1991 prevalence data of 7%. Today, the prevalence of asthma in Australia among
Table 1. Assumptions for the costing of the Triple A intervention Assumptions Participants
*
*
*
*
*
*
*
Salary
The average number of student (11–12 year olds) was estimated to be 165 students, which was based on average class size at a typical government-funded high school in Western Sydney, New South Wales, Australia (Office of Education 2013). The Shah et al. (2001) and Al-sheyab et al. (2012) studies on the Triple A intervention did not specify the number of health workers and project staff used to train the senior high school students (15–16 year olds). As such, we contacted the Triple A intervention leader in Australia to determine participant numbers for the current implementation of the program in Sydney. Twenty university students (Triple A Educators) are required to coach 20 senior high students (15–16 year olds) as Peer Leaders in each school (n = 100) in a 5-h workshop. Twenty senior school students (15–16 year olds) train ~165 junior students (11–12 year olds) in each school over three lessons. As there are five schools that participated, with an average of 165 junior students, there was a total of 825 junior students (11–12 year olds). One teacher was present at each Peer Leader workshop and at each of the junior student lessons to assist with class management. Four facilitators are required to train 20 university students in a 5-h workshop. The possibility of drop-outs from the program was not accounted for.
All salaries for Triple A project staff were based on 2013 professional salaries at The University of Sydney (2013): The salary of the Project Officer was $35 per hour, Level 5/Step 1, pro rata (2 days per week). The Salary of the Project Leader was $44 per hour, Level 7, Step 1. The wage of the two external facilitators was $44 per hour, Level 7, Step 1. On-cost of salaries were calculated at 30% as per University of Sydney standard practice. In principle, the labour and time given by the volunteers, the university, senior high school students and teachers, should be costed because there is an ‘opportunity cost’ to each of them. An average wage for student volunteers was based on the Australian Department of Labour website. The estimated wage per hour for university and senior high school students was $16.37 and $9.46 respectively (Fair Work Ombudsman 2013). Teacher salary was based on a graduate starting salary of $60 000, which translates to approximately $35 per hour (NSW Teachers Federation 2013). In practise, volunteers are usually provided at no cost during the intervention, which was accounted for in the stress test, because in remote areas, such volunteers may not be present. *
*
*
*
*
*
*
*
Resources
*
*
*
In theory, the venues for the workshops used in the Triple A intervention should be costed, as there is an ‘opportunity cost’ to each of them. However, in practise, venues are usually provided at no cost during the intervention as an in-kind gesture. Where venue hire charge was costed in the sensitivity analysis, the $88 per hour room charge was based on advice regarding the base per hour hire fee of a tutorial room at the University of Sydney, Camperdown campus. 20% for incidentals includes the cost of office resources and transport.
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Table 2. Cost of intervention Cost Salary Venue Resources Subtotal Incidentals Grand total Per school Per student
$20 563 $11 660 $1994 $34 217 $6843 $41 060 $8212 $50
Table 3. Sensitivity and stress tests
Salary Venue Resources Subtotal Incidentals Grand total Per student Per school
Full costA
Without volunteers
Without venue
Without volunteers and venueA,B
$20 563 $11 660 $720 $32 943 $6589 $39 532 $50 $8212
$8694 $11 660 $720 $21 074 $4215 $25 288 $31 $5058
$21 838 $0 $720 $22 558 $4512 $27 069 $33 $5414
$8694 $0 $720 $9414 $1883 $11 296 $14 $2259
A B
Values used in economic analysis. Usual practise.
adolescents is ~17% (Australian Centre for Asthma Monitoring 2011), which means that the social cost of asthma may have significantly changed. Additionally, a study by Toelle et al. (1995), based on 1991–92 data from NSW, calculated the cost of asthma to a family with a child with asthma as $212. Thus, available historic data require updating in order for the savings due to the Triple A program and other interventions to be accurately estimated. With increased need for efficient approaches in the health system to address increasing healthcare needs, determining the economic cost of interventions is important for ensuring sustainability of interventions (Kernick 2000). Furthermore, outlining the intervention costs and comparisons with other interventions (such as adult- or expert-led interventions) can be undertaken to demonstrate the cost benefits of implementing school-based peer-led education to improve adolescent asthma self-management. Conclusion Asthma is the most common chronic illness among adolescents, especially among Aboriginal and Torres Strait Islander adolescents, in Australia. Effective peer-led interventions that target asthma self-management are therefore urgently needed to equip adolescents with the skills to manage their asthma. The school context has also been noted as a key setting for peer group influences on health behaviours in adolescence or peer-led interventions. This study demonstrates that the Triple A program could lead to significant savings in asthma costs. If the Triple A intervention is implemented nationwide, the benefits would
be substantial. However, more updated figures on the effectiveness of the Triple A program and the social costs of existing asthma programs is needed for potential savings to be achieved. Conflicts of interest None declared. Acknowledgements We acknowledge the funding support received from the Poche Centre of Indigenous Health, Sydney Medical School, University of Sydney to undertake this project. We thank the Asthma Foundation of New South Wales for their support of the Triple A program in high schools. We acknowledge Ms Kylie Gwynne, Professor Stephen Jan and Shifra Waks for their comments on this manuscript.
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