1. Violence and Injury Prevention Short Course National Family Safety Program, NGHA January 28 th and 29 th 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. alaa1234@gmail.com

2. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course Outline 1.Disseminating Information About Effective Interventions 2.Scaling Up Effective Interventions 3.Economic Analysis of Child Maltreatment Prevention 4.Costs of Child Maltreatment and its Prevention 5.Cost-Benefit Analysis of Child Maltreatment Prevention Programmes 6.The Heckman Curve 7.A Shift in Approach in Early Childhood Interventions from Treatment to Prevention 8.Summary and Conclusion

4. Violence and Injury Prevention Short Course Disseminating Information About Effective Interventions

5. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course Scaling Up Effective Interventions

8. Violence and Injury Prevention Short Course 1.Define & describe What is the Problem? 2.Identify risk What are the risk factors and causes? 4. Scaling up and cost-effectiveness Implement on large scale & cost 3.Develop and evaluate interventions What works and for whom? 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 The Public Health Model

9. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course Scaling up the Nurse-Family Partnership (NFP): USA April 2010 Source: Mikton, C. (2010). Module 9 PowerPoint Presentation. Geneva, World Health Organization.

11. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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 2011. 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course Economic Analysis of Child Maltreatment Prevention

17. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course Health Policy Questions that Can be Addressed by Economic Impact Studies of Violence

20. Violence and Injury Prevention Short Course Costs of Child Maltreatment and its Prevention

21. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course Examples of Direct and Indirect Costs of Child Maltreatment Direct Costs 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. Violence and Injury Prevention Short Course Cost-Benefit Analysis of Child Maltreatment Prevention Programmes

26. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course Outcome Evaluations in Low-and Middle- Income Countries Source: Mikton C, Butchart A. (2009). Child maltreatment prevention: a systematic review of reviews. WHO Bulletin, 87, 353-361. Evidence of effectiveness: Home visiting Parent education Abusive head trauma prevention Multi-component interventions

28. Violence and Injury Prevention Short Course Problems Reduced and Benefits of Early Childhood Intervention Programmes

29. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course The Heckman Curve

31. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course The Heckman Curve 0 Age Rate of return to investment in human capital Preschool programs Schooling Job training 0-34-5 Preschool SchoolPost-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. 49-58). Washington, DC: First Focus.

34. Violence and Injury Prevention Short Course Shifting from Treatment to Prevention

35. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course 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. Violence and Injury Prevention Short Course Summary and Conclusion

38. Violence and Injury Prevention Short Course Summary and Conclusion This module reviewed: 1.Disseminating Information About Effective Interventions 2.Scaling Up Effective Interventions 3.Economic Analysis of Child Maltreatment Prevention 4.Costs of Child Maltreatment and its Prevention 5.Cost-Benefit Analysis of Child Maltreatment Prevention Programmes 6.The Heckman Curve 7.A Shift in Approach in Early Childhood Interventions from Treatment to Prevention

39. Violence and Injury Prevention Short Course References Brownson, R. Gurney, J. Land, G. (1999). Evidence-based decision making in public health, Journal of Public Health Management and Practice. 5, 86-97. 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 http://www.preventchildabuse.org/about_us/media_releases/pcaa_pew_economic_impact_study_final.pdf 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), 296-304. 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 1. 373 (9667), 1-14. The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 169-194. 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. Violence and Injury Prevention Short Course Activity: Scaling Up and the Cost Benefit of Child Maltreatment Prevention Programmes Participants will be assigned to one of three groups: 1.Panel members 2.Group 1 (Scaling up) 3.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.