1. National Family Safety Program, NGHA
January 28th and 29th 2013
Presentation 9. Step 4 of the Public Health Approach to Child Maltreatment Prevention:
Scaling Up and Economic Analysis of Child Maltreatment Prevention
Presented by
Alaa Sebeh, MD Ph.D.
Independent International Consultant,
Child Protection & Disability.

2. Objective
The core learning objective of this module is to apply step 4 of the public health model to child maltreatment prevention by focusing on scaling up programmes which have been demonstrated to be effective and the basics of economic analysis of child maltreatment prevention, including evaluating the costs and cost-benefits of programmes.

3. Outline Disseminating Information About Effective Interventions
Scaling Up Effective Interventions
Economic Analysis of Child Maltreatment Prevention
Costs of Child Maltreatment and its Prevention
Cost-Benefit Analysis of Child Maltreatment Prevention Programmes
The Heckman Curve
A Shift in Approach in Early Childhood Interventions from Treatment to Prevention
Summary and Conclusion

4. Disseminating Information About Effective Interventions

5. Preventing child maltreatment: A guide to taking action and generating evidence
English
Chinese
Arabic
French
A central objective of WHO’s publication Preventing child maltreatment: A guide to taking action and generating evidence is to disseminate information as widely as possible about an evidence-based approach to child maltreatment prevention.
"The 2006 WHO report on prevention of child maltreatment drew attention to the need for this topic to achieve the prominence and investment in prevention and epidemiological monitoring that is given to other serious public-health concerns with lifelong consequences affecting children” (Gilbert, R. Kemp, A. Thoburn, J. et al. (2008).

6. Systematic Reviews
The evidence base for programmes to prevent child maltreatment is mainly disseminated through systematic reviews. The aim of systematic reviews is to disseminate the results in an easily understandable way to interested audiences, including those making decisions on what programmes to develop. The availability of systematic reviews greatly increases the ability to successfully argue for increased political and financial commitment to a strategy shown to be effective. New outcome evaluation studies of interventions are continually appearing, and systematic reviews are therefore regularly updated.

7. Scaling Up Effective Interventions

8. The Public Health Model
1.Define & describe
What is the Problem?
2.Identify risk What are the risk factors and causes?
Systematic, evidence-based approach with 4 steps:
1. Define and Describe
2. Identify Risk
3. Develop and Evaluate Interventions
4. Scaling Up and Cost-Effectiveness
4. Scaling up and cost-effectiveness
Implement on large scale & cost
3.Develop and
evaluate interventions
What works and for whom?

9. Scaling Up Programmes
Scaling up is the process of reaching larger numbers of a target audience in a broader geographic area by institutionalizing programmes which have been demonstrated to be effective on smaller samples. Evidence-based child maltreatment is still a relatively new field, and to date, there are only a few programmes that have been demonstrated to be effective. Hence, there are currently only a handful of programmes that have been or are in the process of being scaled up. One of these is the Nurse-Family Partnership, a nurse home-visiting programme.

10. Scaling up the Nurse-Family Partnership (NFP): USA
April 2010
Source: Mikton, C. (2010). Module 9 PowerPoint Presentation. Geneva, World Health Organization.

11. Home Visiting Program Legislation in the USA
The Home Visiting Program, inspired by the NFP, is funded at US$ 1.5 Billion over five years and allows states, territories and tribes, and nonprofit entities to apply for funding for three types of home visiting models:
Programmes with significant, sustained and positive outcomes
Programmes with significant and positive outcomes
Programmes developed or identified that represent a promising and new approach

12. Home Visiting Program Targets
The programmes will target the following areas:
Improvements in maternal and newborn health
Childhood injury or maltreatment prevention and reduced emergency room visits
School readiness and achievement
Crime or domestic violence
Family self-sufficiency
Coordination with community resources and supports
The Nurse-Family Partnership National Service Office will provide technical support to implementing agencies and states.

13. Scaling Up the Nurse-Family Partnership: Australia and UK
In 2009, the UK government published a Child Health Strategy which announced the expansion of the NFP from 30 to 70 sites by On a smaller scale, Australia has established an international collaboration to undertake an implementation of the NFP model of home visiting in Australia across seven sites.

14. Scaling up the Positive Parenting Programme (Triple P)
These are the countries and institutions currently conducting trials of Triple P:
• Belgium (University of Antwerp)
• Canada (University of Manitoba)
• England (University of Manchester, Oxford University, Cambridge University, University of East Anglia)
• Germany (University of Braunschweig; University of Bielefeld)
• Hong Kong (DOH)
• Iran (Medical University of Tehran)
• Japan (University of Tokyo, Medical University of Wakayama)
• The Netherlands (Trimbos Institute)
• New Zealand (University of Auckland, University of Waikato, University of Canterbury)
• Sweden (University of Uppsala)
• Switzerland (University of Fribourg)
• USA (Oregon Research Institute, USC)

15. Scaling Up: Shaken Baby Syndrome Prevention
Building on the evaluation of the parent education programme to prevent shaken baby syndrome in New York State, similar interventions are being scaled up in a number of locations in the USA. Keeping Babies Safe in North Carolina, is funded to provide the statewide implementation of the Period of PURPLE Crying programme for the prevention of Shaken Baby Syndrome/Abusive Head Trauma (SBS/AHT) among infants in the state of North Carolina. The programme is a universal prevention programme and will be provided to approximately 125,000 families of new babies born in North Carolina over the course of a five-year period. A new study will test the programme to determine if it can now reduce the incidence of SBS/AHT in the state of North Carolina.

16. Child Maltreatment Prevention
Economic Analysis of
Child Maltreatment Prevention

17. Economic Analysis of Child Maltreatment Prevention
Economic analysis includes a variety of methods to assess systematically the impact that interventions, policies, and programs have on outcomes and costs (Haddix, Teutsch, & Corso, 2003).
The most common type of economic analysis is the cost of illness/injury (COI) analysis.
COI analyses are used to quantify the economic burden of an outcome of interest, such as child maltreatment, by quantifying:
The (direct) medical expenditures resulting from a condition
The resulting (indirect) value of lost productivity
But economic analysis also includes methods such as programme cost analyses and cost-effectiveness and cost-benefit analyses.

18. Economic Analysis of Child Maltreatment Prevention: Why it Is Important
Economic analysis provides guidance for the task of allocating scarce resources among competing demands, which applies to child maltreatment prevention.
Results of economic analysis are critical for:
Mobilizing political will to address the problem
Lobbying and persuading policy-makers for more prevention funding
Resource allocation and priority-setting

19. Health Policy Questions that Can be Addressed by Economic Impact Studies of Violence

20. Costs of Child Maltreatment
and its Prevention

21. Costs of Child Maltreatment
In addition to the health and social costs, child maltreatment has a huge economic impact.
The economic costs include:
Direct medical costs
Lost earnings and tax revenue due to premature death
Special education
Psychological and welfare services
Protective services
Foster care
Preventive services
Adult criminality and subsequent incarceration related to child maltreatment
A study in the United States reviewed a range of sources and calculated the selected annual direct and indirect costs resulting from child maltreatment to total US$ 94 billion – 1% of the country’s gross domestic product.
The largest single component was adult criminality related to child abuse, which was estimated to amount to an annual sum of US$ 55.4 billion.

22. The Short-Term and Long-Term Costs of Child Maltreatment
Source: Corso PS, Fertig, AR. (2010). The economic impact of child maltreatment in the United States. Are the estimates credible? Child Abuse and Neglect

23. The Direct and Indirect Costs of Child Maltreatment
When categorizing the costs of violence, it is useful to distinguish between direct and indirect costs.
Direct costs arise directly from acts of violence and require actual payments by individuals or institutions.
Indirect costs refer to lost resources and opportunities resulting from violence.

24. Examples of Direct and Indirect Costs of Child Maltreatment
Hospitalization
Chronic health problems
Mental health care system
Child welfare system
Law enforcement
Judicial system
Indirect Costs
Special education
Mental health and health care
Juvenile delinquency
Lost productivity to society
Adult criminality

25. Cost-Benefit Analysis of Child Maltreatment Prevention Programmes

26. Cost-Benefit Analysis
Cost-benefit analyses answer the question what is the return on every dollar invested in a child maltreatment intervention. Some outcomes that are examined in monetary terms in cost-benefit studies include crime, victimization, criminal justice expenses, lost work due to illness, and receipt of social welfare benefits. A prerequisite for cost-benefit analyses is that impact or outcome evaluations have been conducted.

27. Outcome Evaluations in Low-and Middle-Income Countries
Evidence of effectiveness:
Home visiting
Parent education
Abusive head trauma
prevention
Multi-component
interventions
Source: Mikton C, Butchart A. (2009). Child maltreatment prevention: a systematic review of reviews. WHO Bulletin, 87,

28. Problems Reduced and Benefits of Early Childhood Intervention Programmes

29. Cost-Benefit Studies in High-Income Countries
Few studies countries have specifically examined the cost-benefits of child maltreatment prevention programmes, even in high-income countries. However, a number of studies have examined the costs and cost-benefits or early child and youth intervention programmes, including several targeting child maltreatment.

30. The Heckman Curve

31. Rates of Return of Interventions at Different Ages
The analyses of James Heckman and colleagues have shown that the earlier one intervenes with early childhood programmes to prevent or reduce various forms of adversity, the greater the return to the individual and society on every dollar invested.

32. Economic Returns of Interventions
Heckman and colleagues have shown that:
Economic returns on early investments in children are high.
Early investments promote efficiency and reduce inequality.
Returns on later interventions are much lower.
Technology of skill formation is at work here: Skill begets skill and early skill makes later skill acquisition easier.
Remedial programmes in the adolescent and young adult years are much more costly than early interventions in producing the same level of skill attainment in adulthood; most are economically inefficient.

33. The Heckman Curve Age Preschool programs Schooling Job training 0-3
Age
Rate of return to investment in human capital
Preschool programs
Schooling
Job training
0-3
4-5
Preschool
School
Post-school
Programs targeted towards the earliest years
Source: Heckman, J. (2008). The case for investing in disadvantaged young children. In First Focus (Ed.), Big ideas for children: Investing in our nation's future (pp ). Washington, DC: First Focus.

34. Shifting from Treatment to Prevention

35. Learning from Research
Results from early childhood–programme evaluations show that primary prevention may yield better outcomes and financial returns than treating individuals for the consequences of childhood adversity. In fact, an increasing number of studies document that these programmes can save so much money in terms of future reductions in treatment costs that they more than pay for themselves.

36. Shifting Towards Prevention
Increasingly, there have been calls for a reorientation of child and human services – including of child protection services – toward investment and prevention and away from attempting to “treat” poor outcomes, including those due to child maltreatment, that manifest themselves later in the life cycle. Shifting towards an approach in which resources are invested in early human capital, including by preventing child maltreatment, might produce better outcomes, save taxpayers money, and improve the quality of life for the people in whom we invest (What does economics tell us about early childhood policy. Rand Corporation. 2008).

37. Summary and Conclusion

38. Summary and Conclusion
This module reviewed:
Disseminating Information About Effective Interventions
Scaling Up Effective Interventions
Economic Analysis of Child Maltreatment Prevention
Costs of Child Maltreatment and its Prevention
Cost-Benefit Analysis of Child Maltreatment Prevention Programmes
The Heckman Curve
A Shift in Approach in Early Childhood Interventions from Treatment to Prevention

39. References
Brownson, R. Gurney, J. Land, G. (1999). Evidence-based decision making in public health, Journal of Public Health Management and Practice. 5, Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva, World Health Organization. Wang, C. Holton, J. (2007). Total estimated cost of child abuse and neglect. Prevent Child Abuse America. Retrieved June 11, 2010 from Corso, P. Fertig, A. (2010). The economic impact of child maltreatment in the United States. Are the estimates credible? Child Abuse and Neglect. 34(5), Gilbert, R. Kemp, A. Thoburn, J. et al. (2008). Recognising and responding to child maltreatment. Lancet; published online Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. Child Maltreatment (9667), The Future of Children. (2009) Preventing Child Maltreatment. 119(2), Haddix, A. Teutsch, S. Corso, P. (2003). A Guide to Decision Analysis and Economic Evaluation. New York, NY. Oxford Press. Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization. Lynn, A. Kilburn, R. Cannon, J. (2008). Early Childhood Intervention: Proven Results, Future Promise. Santa Monica, CA. RAND Distribution Services Mikton, C. Butchart, A. (2009). Child maltreatment prevention: A systematic review of reviews. Bulletin of the World Health Organization. 87, 353–361 Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization. What does economics tell us about early childhood policy. (2008). Rand Corporation.

40. Activity: Scaling Up and the Cost Benefit of Child Maltreatment Prevention Programmes
Participants will be assigned to one of three groups:
Panel members
Group 1 (Scaling up)
Group 2 (Cost-benefit analysis)
Panel members: Discuss concerns or issues which would need to be taken into account in order to support a scaled-up child maltreatment programme.
Group 1: Discuss what some of the challenges and promises of scaling up a local child maltreatment prevention programme would be. Based on this discussion prepare an argument to the panel for scaling up such a local programme.
Group 2: Discuss the potential cost-benefit of implementing and scaling up child maltreatment prevention programmes. Based on this discussion prepare an argument to the panel for scaling up such a local programme.