Background
In public health, there is an economic case for targeted and universal preventative interventions to prevent depression. There is a growing evidence-base for Mindfulness Based Programmes (MBPs) but less evidence of their cost-effectiveness. Within the context of a translational research framework, which aims to increase the transferability of research findings into practice, there are lessons to be learnt from early-stage trials to develop robust methodologies to evaluate MBPs as complex interventions delivered within complex systems. This thesis aims to explore the economic case for investment in MBPs with both targeted and universal prevention of poor health considered by identifying the evidence, conducting feasibility research, and appraising methodological guidance and health economic tools.
Methods
Multiple methods are employed through this thesis including a societal perspective systematic review (PROSPERO 2017 CRD42017074848) (Chapter 2); a micro-costing study to establish intervention costs across 9 MBPs (Chapter 3); a randomised feasibility trial (ISRCTN23380065) and concurrent service evaluation study of MBCT-Ca, a targeted MBP for cancer patients (Chapter 4); and a non-randomised matched cohort feasibility study (ISRCTN89407829) of a universal Mindfulness in Schools project programme for Sixth Form students aged 16-18 years (Chapter 5).
Results
Chapter 2: 25 economic evaluations of MBPs were identified in a societal perspective systematic review of major medical and economics literature databases and grey literature. Cost-utility analysis (N=8) was the most common form of economic evaluation (converted and inflated to 2019 pounds results ranged from £3,125 to £54,327 per QALY), closely followed by cost-effectiveness analysis (N=7). Social return on investment study results (N=2) indicated between £3.65 and £10.12 of social value is generated for every £1 investment in MBPs.
Chapter 3: MBP group courses in the UK (consisting of between 4-10 sessions, with between 8 and 30 group participants) costed between £2,786.48 and £6,301.70 per course (between £111 - £645 per participant per course).
Chapter 4: Mixed methods evaluation of a randomised feasibility trial of targeted MBCT-Ca (N=39) and concurrent service evaluation (N=24) indicated that MBCT-Ca was acceptable to patients who attended however there are important barriers to recruitment identified. Clinical and economic outcome
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measures were piloted including the EQ-5D-3L (this study was conducted prior to the availability of value sets for the EQ-5D-5L), as a preference-based health related quality of life measure and the ICECAP-A as a measure of capabilities.
Chapter 5: A non-randomised matched cohort study of a universal Mindfulness in Schools program (N=98; complete case N=38) explores ceiling effects of measures such as the EQ-5D-5L as a primary economic outcome and the General Health Questionnaire as a screening tool for early signs of mental health problems. Feasibility of collecting resource use information from participants including school absenteeism and GP attendance was confirmed. However wider reaching resource use data is needed for a full societal perspective analysis.
Chapter 6: This methodological discussion chapter highlights the extensive health economics toolkit available to researchers looking to conduct economic evaluations of MBPs. This chapter offers a checklist for health economics within the feasibility stage and offers some insights about where public health practitioners might intervene to promote better mental health at a population level
Discussion
This thesis provides the first substantive review of MBP economic evaluations across public and private sectors. There is a need for more evidence on the economics of targeted and universal prevention interventions and future research which considers a precision public health approach should justify the approach taken. Embedding health economics into the entire translational process of complex intervention evaluation can help bridge the gaps to improve evidence-based practice.