Financing Prevention: Opportunities for Economic Analysis Across the Translational Research Cycle
Prevention advocates often make the case that preventive intervention not only improves public health and welfare but also can save public resources. Increasingly, evidence-based policy efforts considering prevention are focusing on how programs can save taxpayer resources from reduced burden on health, criminal justice, and social service systems. Evidence of prevention’s return has begun to draw substantial investments from the public and private sector. Yet, translating prevention effectiveness into economic impact requires specific economic analyses to be employed across the stages of translational research. This work discussed the role of economic analysis in prevention science and presented key translational research opportunities to meet growing demand for estimates of prevention’s economic and fiscal impacts.
Crowley, D. M., & Jones, D. Financing prevention: opportunities for economic analysis across the translational research cycle. Translational Behavioral Medicine, 1-8.
The Power of a Collaborative Relationship between Technical Assistance Providers and Community Prevention Teams
Historically, the effectiveness of community collaborative prevention efforts has been mixed. Consequently, research has been undertaken to better understand the factors that support their effectiveness; theory and some related empirical research suggest that the provision of technical assistance is one important supporting factor. The current study examined one aspect of technical assistance that may be important in supporting coalition effectiveness: the collaborative relationship between the technical assistance provider and site lead implementer. Four and one-half years of data were collected from technical assistance providers and prevention team members from the 14 community prevention teams involved in the PROSPER project. Spearman correlation analyses with longitudinal data showed that the levels of the collaborative relationship during one phase of collaborative team functioning were associated with characteristics of internal team functioning in future phases. Results suggested that community collaborative prevention work should consider the collaborative nature of the technical assistance provider-prevention community team relationship when designing and conducting technical assistance activities, and it may be important to continually assess these dynamics to support high-quality implementation.
Chilenski, S. M., Perkins, D. F., Olson, J., Hoffman, L., Feinberg, M. E., Greenberg, M., Welsh, J., Crowley, M. & Spoth, R. (2016). The power of a collaborative relationship between technical assistance providers and community prevention teams: A correlational and longitudinal study. Evaluation and Program Planning, 54, 19-29.
Considering Valuation of Noncognitive Skills in Benefit-Cost Analysis of Programs for Children
The prospect of improving "noncognitive" skills through intervention increases the need to understand how to represent them in evaluations. Economic assessment of such efforts rarely incorporates these factors, especially when a benefit-cost approach is employed. Programs targeting such skills are more likely to be assessed through approaches that do not monetize noncognitive ability (e.g., using cost-effectiveness analysis). This could lead to ineffective policy formulations in situations where policy is swayed toward programs that can show monetized effects. Benefit-cost analyses (BCAs) that are employed for programs that target noncognitive competencies currently may underestimate the true economic impact if such skills are left out of the equation. The limitations in valuing these skills impede thorough economic assessment for important and effective programs that target noncognitive competencies. This is especially the case for programs for younger children where readily monetized outcomes are few. The targeted outcomes in programs for children are often noncognitive skills, skills that are perceived as vital to healthy human development and valued by parents, teachers, and educators. In this paper, we reviewed the state of valuation of key noncognitive skills that are often targeted in social policy intervention directed toward children and youth. We examined the state of valuation of noncognitive skills through a summary of the frameworks in research for characterizing noncognitive ability and by considering the measurement approaches for noncognitive skills in terms of origin (interpersonal versus intrapersonal) and measurement type (observed versus assessed). We reviewed examples of recent BCAs that have employed shadow prices for certain noncognitive skills. Finally, we considered what research is necessary to facilitate valuation in BCA in the future. Shadow price methodology should be carried out in a rigorous manner that recognizes uncertainty in cost projections. Improved methodologies in this area will increase the potential for more comprehensive BCA in evaluations of programs for children and youth.
Jones, D. E., Karoly, L. A., Crowley, D. M., & Greenberg, M. T. (2015). Considering Valuation of Noncognitive Skills in Benefit-Cost Analysis of Programs for Children. Journal of Benefit-Cost Analysis, 6(3), 471-507.
Early Social-Emotional Functioning and Public Health: The Relationship Between Kindergarten Social Competence and Future Wellness
In the study that is the focus of this paper, we examined whether kindergarten teachers' ratings of children's prosocial skills, an indicator of noncognitive ability at school entry, predict key adolescent and adult outcomes. Our goal was to determine unique associations over and above other important child, family, and contextual characteristics. Data came from the Fast Track study of low-socioeconomic status neighborhoods in 3 cities and 1 rural setting. We assessed associations between measured outcomes in kindergarten and outcomes 13 to 19 years later (1991-2000). Models included numerous control variables representing characteristics of the child, family, and context, enabling us to explore the unique contributions among predictors. We found statistically significant associations between measured social-emotional skills in kindergarten and key young adult outcomes across multiple domains of education, employment, criminal activity, substance use, and mental health. A kindergarten measure of social-emotional skills may be useful for assessing whether children are at risk for deficits in noncognitive skills later in life and, thus, help identify those in need of early intervention. These results demonstrate the relevance of noncognitive skills in development for personal and public health outcomes.
Jones, D. E., Greenberg, M., & Crowley, M. (2015). Early social-Emotional functioning and public health: The relationship between kindergarten social competence and future wellness. American Journal of Public Health, 105(11), 2283-2290.
Developmental mediation of genetic variation in response to the Fast Track prevention program
We conducted a developmental analysis of genetic moderation of the effect of the Fast Track intervention on adult externalizing psychopathology. The Fast Track intervention enrolled 891 children at high risk of developing externalizing behavior problems when they were in kindergarten. Half of the enrolled children were randomly assigned to receive 10 years of treatment, with a range of services and resources provided to the children and their families, and the other half to usual care (controls). We previously showed that the effect of the Fast Track intervention on participants' risk of externalizing psychopathology at age 25 years was moderated by a variant in the glucocorticoid receptor gene. Children who carried copies of the A allele of the single nucleotide polymorphism rs10482672 had the highest risk of externalizing psychopathology if they were in the control arm of the trial and the lowest risk of externalizing psychopathology if they were in the treatment arm. In this study, we test a developmental hypothesis about the origins of this for better and for worse Gene × Intervention interaction (G × I): that the observed G × I effect on adult psychopathology is mediated by the proximal impact of intervention on childhood externalizing problems and adolescent substance use and delinquency. We analyzed longitudinal data tracking the 270 European American children in the Fast Track randomized control trial with available genetic information (129 intervention children, 141 control group peers, 69% male) from kindergarten through age 25 years. Results show that the same pattern of for better and for worse susceptibility to intervention observed at the age 25 follow-up was evident already during childhood. At the elementary school follow-ups and at the middle/high school follow-ups, rs10482672 predicted better adjustment among children receiving the Fast Track intervention and worse adjustment among children in the control condition. In turn, these proximal G × I effects early in development mediated the ultimate G × I effect on externalizing psychopathology at age 25 years. We discuss the contribution of these findings to the growing literature on genetic susceptibility to environmental intervention.
Albert, D., Belsky, D. W., Crowley, D. M., Bates, J. E., Pettit, G. S., Lansford, J. E., ... & Dodge, K. A. (2015). Developmental mediation of genetic variation in response to the Fast Track prevention program.Development and psychopathology, 27(01), 81-95.
The Role of Social Impact Bonds in Pediatric Health Care
Pay for success financing and SIB development have the potential to provide the resources needed for large-scale dissemination trials with the explicit goal of demonstrating effective pediatric service’s capacity for downstream savings.8 Such demonstrations of savings from scaled prevention programs provide powerful evidence to public and private insurers about which services are and are not cost-effective. While engaging private investors to support pediatric services is likely to be foreign to many and risky to some, these models are growing rapidly—driven not by health researchers, but by philanthropic business leaders. The pediatrics community cannot afford to ignore this new development. Leveraging this new financing tool to accelerate dissemination of evidence-based prevention requires careful stewardship in order to ensure the health and safety of all children.
Crowley, D. M. (2014). The role of social impact bonds in pediatric health care. Pediatrics, 134(2), e331-e333.
Can Genetics Predict Response to Complex Behavioral Interventions? Evidence from a Genetic Analysis of the Fast Track Randomized Control Trial
Early interventions are a preferred method for addressing behavioral problems in high-risk children, but often have only modest effects. Identifying sources of variation in intervention effects can suggest means to improve efficiency. One potential source of such variation is the genome. We conducted a genetic analysis of the Fast Track randomized control trial, a 10-year-long intervention to prevent high-risk kindergarteners from developing adult externalizing problems including substance abuse and antisocial behavior. We tested whether variants of the glucocorticoid receptor gene NR3C1 were associated with differences in response to the Fast Track intervention. We found that in European-American children, a variant of NR3C1 identified by the single-nucleotide polymorphism rs10482672 was associated with increased risk for externalizing psychopathology in control group children and decreased risk for externalizing psychopathology in intervention group children. Variation in NR3C1 measured in this study was not associated with differential intervention response in African-American children. We discuss implications for efforts to prevent externalizing problems in high-risk children and for public policy in the genomic era.
Albert, D., Belsky, D. W., Crowley, D. M., Latendresse, S. J., Aliev, F., Riley, B., ... & Dodge, K. A. (2015). Can genetics predict response to complex behavioral interventions? Evidence from a genetic analysis of the Fast Track Randomized Control Trial. Journal of Policy Analysis and Management,34(3), 497-518.
Can We Build an Efficient Response to the Prescription Drug Abuse Epidemic? Assessing the Cost Effectiveness of Universal Prevention in the PROSPER Trial
Prescription drug abuse has reached epidemic proportions. Nonmedical prescription opioid use carries increasingly high costs. Despite the need to cultivate efforts that are both effective and fiscally responsible, the cost-effectiveness of universal evidence-based-preventive-interventions (EBPIs) is rarely evaluated. This study explores the performance of these programs to reduce nonmedical prescription opioid use.Sixth graders from twenty-eight rural public school districts in Iowa and Pennsylvania were blocked by size and geographic location and then randomly assigned to experimental or control conditions (2002–2010). Within the intervention communities, prevention teams selected a universal family and school program from a menu of EBPIs. All families were offered a family-based program in the 6th grade and received one of three school-based programs in 7th-grade. The effectiveness and cost-effectiveness of each school program by itself and with an additional family-based program was assessed using propensity and marginal structural models.This work demonstrates that universal school-based EBPIs can efficiently reduce nonmedical prescription opioid use. Further, findings illustrate that family-based programs may be used to enhance the cost-effectiveness of school-based programs. Universal EBPIs can effectively and efficiently reduce nonmedical prescription opioid use should be further considered when developing comprehensive responses to this growing national crisis..
Crowley, D. M., Jones, D. E., Coffman, D. L., & Greenberg, M. T. (2014). Can we build an efficient response to the prescription drug abuse epidemic? Assessing the cost effectiveness of universal prevention in the PROSPER trial. Preventive medicine, 62, 71-77.
Research Priorities for Economic Analyses of Prevention: Current Issues and Future Direction
In response to growing interest in economic analyses of prevention efforts, a diverse group of prevention researchers, economists, and policy analysts convened a scientific panel, on "Research Priorities in Economic Analysis of Prevention" at the 19th annual conference of the Society for Prevention Research. The panel articulated four priorities that, if followed in future research, would make economic analyses of prevention efforts easier to compare and more relevant to policymakers and community stakeholders. These priorities are: (1) increased standardization of evaluation methods, (2) improved economic valuation of common prevention outcomes, (3) expanded efforts to maximize evaluation generalizability and impact as well as (4) enhanced transparency and communicability of economic evaluations. In this paper, we define three types of economic analyses in prevention, provide context and rationale for these four priorities as well as related sub-priorities, and discuss the challenges inherent in meeting them.
Crowley, D. M., Hill, L. G., Kuklinski, M. R., & Jones, D. E. (2014). Research priorities for economic analyses of prevention: Current issues and future directions. Prevention Science, 15(6), 789-798.
Evaluating the Impact of Implementation Factors on Family-Based Prevention Programming: Methods for Strengthening Causal Inference
Despite growing recognition of the important role implementation plays in successful prevention efforts, relatively little work has sought to demonstrate a causal relationship between implementation factors and participant outcomes. In turn, failure to explore the implementation-to-outcome link limits our understanding of the mechanisms essential to successful programming. This gap is partially due to the inability of current methodological procedures within prevention science to account for the multitude of confounders responsible for variation in implementation factors (i.e., selection bias). The current paper illustrates how propensity and marginal structural models can be used to improve causal inferences involving implementation factors not easily randomized (e.g., participant attendance). We first present analytic steps for simultaneously evaluating the impact of multiple implementation factors on prevention program outcome. Then, we demonstrate this approach for evaluating the impact of enrollment and attendance in a family program, over and above the impact of a school-based program, within PROSPER, a large-scale real-world prevention trial. Findings illustrate the capacity of this approach to successfully account for confounders that influence enrollment and attendance, thereby more accurately representing true causal relations. For instance, after accounting for selection bias, we observed a 5 % reduction in the prevalence of 11th grade underage drinking for those who chose to receive a family program and school program compared to those who received only the school program. Further, we detected a 7 % reduction in underage drinking for those with high attendance in the family program.
Crowley, D. M., Coffman, D. L., Feinberg, M. E., Greenberg, M. T., & Spoth, R. L. (2014). Evaluating the impact of implementation factors on family-based prevention programming: Methods for strengthening causal inference.Prevention science, 15(2), 246-255.
Hurting, Helping, or Neutral? The Effects of Parental Permissiveness Toward Adolescent Drinking on College Student Alcohol Use and Problems
To enhance prevention efforts to reduce college drinking, parents have been identified as an important source of influence that can be modified with brief interventions. Research suggests parental permissiveness toward drinking in adolescence is positively related to college student drinking, though existing studies have not comprehensively accounted for potential confounders (e.g., parental drinking). The present study used propensity modeling to estimate the effects of pre-college parental permissiveness on college student drinking and consequences while accounting for an inclusive range of confounders. A random sample of 1,518 incoming students at a large university completed baseline measures of parental permissiveness and a list of confounders (e.g., parental drinking, family history). At follow-up 15 months later, participants reported on their drinking and alcohol-related consequences. To control for potential confounders, individuals were weighted based on their propensity scores to obtain less biased estimates of the effects of parental permissiveness on drinking and consequences. Analyses revealed parental permissiveness was consistently and positively associated with college drinking and consequences when the confounders were not accounted for, but these effects were attenuated after weighting. Parents' allowance of drinking was not related to college drinking or consequences after weighting. Students' perceived parental limits for consumption were related to drinking and consequences in the weighted models. Prevention efforts may benefit from targeting parents' communication of acceptable limits for alcohol consumption.
Varvil-Weld, L., Crowley, D. M., Turrisi, R., Greenberg, M. T., & Mallett, K. A. (2014). Hurting, helping, or neutral? The effects of parental permissiveness toward adolescent drinking on college student alcohol use and problems.Prevention Science, 15(5), 716-724.
The aftermath of the global recession has encouraged policy makers to confront the staggering public burden of crime. In this context, there is growing acceptance that many “tough-on-crime” policies have become primary drivers of crime’s increasing societal cost. Policy makers have responded with growing interest in making strategic investments in youth that prevent the development of lifetime offenders, instead of continuing to institute harsher punishments that lead to costly mass incarceration. In response, innovative strategies for preventing crime and controlling costs are being engaged. At the forefront are developmental prevention programs that intervene early in life to reduce risk factors for delinquent and criminal behaviors ). As a growing body of evidence illustrates, when implemented appropriately, these developmental prevention efforts not only effectively prevent crime but also are cost-effective solutions that save public resources.
Crowley, D. M. (2013). Building efficient crime prevention strategies.Criminology & public policy, 12(2), 353-366.
Resource Consumption of a Diffusion Model for Prevention Programs: The PROSPER Delivery System
To prepare public systems to implement evidence-based prevention programs for adolescents, it is necessary to have accurate estimates of programs' resource consumption. When evidence-based programs are implemented through a specialized prevention delivery system, additional costs may be incurred during cultivation of the delivery infrastructure. Currently, there is limited research on the resource consumption of such delivery systems and programs. In this article, we describe the resource consumption of implementing the PROSPER (PROmoting School-Community-University Partnerships to Enhance Resilience) delivery system for a period of 5 years in one state, and how the financial and economic costs of its implementation affect local communities as well as the Cooperative Extension and University systems. We used a six-step framework for conducting cost analysis, using a Cost-Procedure-Process-Outcome Analysis model (Yates, Analyzing costs, procedures, processes, and outcomes in human services: An introduction, 1996; Yates, 2009). This method entails defining the delivery System; bounding cost parameters; identifying, quantifying, and valuing systemic resource Consumption, and conducting sensitivity analysis of the cost estimates. Our analyses estimated both the financial and economic costs of the PROSPER delivery system. Evaluation of PROSPER illustrated how costs vary over time depending on the primacy of certain activities (e.g., team development, facilitator training, program implementation). Additionally, this work describes how the PROSPER model cultivates a complex resource infrastructure and provides preliminary evidence of systemic efficiencies. This work highlights the need to study the costs of diffusion across time and broadens definitions of what is essential for successful implementation.
Crowley, D. M., Jones, D. E., Greenberg, M. T., Feinberg, M. E., & Spoth, R. L. (2012). Resource consumption of a diffusion model for prevention programs: The PROSPER delivery system. Journal of Adolescent Health,50(3), 256-263.
The Effect of the PROSPER Partnership Model on Cultivating Local Stakeholder Knowledge of Evidence-Based Programs: A Five-Year Longitudinal Study of 28 Communities
A substantial challenge in improving public health is how to facilitate the local adoption of evidence-based interventions (EBIs). To do so, an important step is to build local stakeholders' knowledge and decision-making skills regarding the adoption and implementation of EBIs. One EBI delivery system, called PROSPER (PROmoting School-community-university Partnerships to Enhance Resilience), has effectively mobilized community prevention efforts, implemented prevention programming with quality, and consequently decreased youth substance abuse. While these results are encouraging, another objective is to increase local stakeholder knowledge of best practices for adoption, implementation and evaluation of EBIs. Using a mixed methods approach, we assessed local stakeholder knowledge of these best practices over 5 years, in 28 intervention and control communities. Results indicated that the PROSPER partnership model led to significant increases in expert knowledge regarding the selection, implementation, and evaluation of evidence-based interventions. Findings illustrate the limited programming knowledge possessed by members of local prevention efforts, the difficulty of complete knowledge transfer, and highlight one method for cultivating that knowledge.
Crowley, D. M., Greenberg, M. T., Feinberg, M. E., Spoth, R. L., & Redmond, C. R. (2012). The effect of the PROSPER partnership model on cultivating local stakeholder knowledge of evidence-based programs: A five-year longitudinal study of 28 communities. Prevention Science, 13(1), 96-105.
Economic Analysis of Methamphetamine Prevention Effects and Employer Costs
The goal of this research was to evaluate economically three interventions designed to prevent substance use in general populations of adolescents, specifically focusing on the prevention of methamphetamine use and its subsequent benefits to employers.
In a randomized, controlled trial, three preventive interventions were delivered to 6th- or 7th-grade youth in 58 Iowa school districts, with 905 of these youth (449 girls) providing follow-up assessments as 12th graders. Intervention conditions included the family-focused Iowa Strengthening Families Program (ISFP), the school-based Life Skills Training (LST) program, and a combined condition of both the Strengthening Families Program: For Parents and Youth 10-14 (SFP10- 14; an ISFP revision) plus LST (LST + SFP10-14). Analyses based on intervention costs, 12th-grade methamphetamine use rates, and methamphetamine- related employer costs yielded estimates of intervention cost, cost-effectiveness, benefit-cost ratio, and net benefit. The ISFP lowered methamphetamine use by 3.9%, cost $25,385 to prevent each case, and had a benefit-cost ratio of 3.84, yielding a net benefit of $2,813 per youth. The LST program reduced methamphetamine use by 2.5%, required $5,122 per prevented case, and had a benefit-cost ratio of 19.04, netting $2,273 per youth. The combined LST + SFP10-14 prevention condition lowered methamphetamine use rates by 1.8%, cost $62,697 to prevent each case, had a benefit-cost ratio of 1.56, and netted $620 per youth. Findings were robust after varying a number of key parameters across a range of plausible values. Substance use prevention programming is economically feasible, particularly for effective interventions that have lower per person treatment delivery costs.
Guyll, M., Spoth, R., & Crowley, D. M. (2011). Economic Analysis of Methamphetamine Prevention Effects and Employer Costs*. Journal of Studies on Alcohol and Drugs, 72(4), 577-585.