Cost-benefit and extended cost-effectiveness analysis of a comprehensive adolescent pregnancy prevention program in Zambia: study protocol for a cluster randomized controlled trial

Amani Thomas Mori, Linda Kampata, Patrick Musonda, Kjell Arne Johansson, Bjarne Robberstad, Ingvild Sandøy, Amani Thomas Mori, Linda Kampata, Patrick Musonda, Kjell Arne Johansson, Bjarne Robberstad, Ingvild Sandøy

Abstract

Background: Early marriages, pregnancies and births are the major cause of school drop-out among adolescent girls in sub-Saharan Africa. Birth complications are also one of the leading causes of death among adolescent girls. This paper outlines a protocol for a cost-benefit analysis (CBA) and an extended cost-effectiveness analysis (ECEA) of a comprehensive adolescent pregnancy prevention program in Zambia. It aims to estimate the expected costs, monetary and non-monetary benefits associated with health-related and non-health outcomes, as well as their distribution across populations with different standards of living.

Methods: The study will be conducted alongside a cluster-randomized controlled trial, which is testing the hypothesis that economic support with or without community dialogue is an effective strategy for reducing adolescent childbearing rates. The CBA will estimate net benefits by comparing total costs with monetary benefits of health-related and non-health outcomes for each intervention package. The ECEA will estimate the costs of the intervention packages per unit health and non-health gain stratified by the standards of living. Cost data include program implementation costs, healthcare costs (i.e. costs associated with adolescent pregnancy and birth complications such as low birth weight, pre-term birth, eclampsia, medical abortion procedures and post-abortion complications) and costs of education and participation in community and youth club meetings. Monetary benefits are returns to education and averted healthcare costs. For the ECEA, health gains include reduced rate of adolescent childbirths and non-health gains include averted out-of-pocket expenditure and financial risk protection. The economic evaluations will be conducted from program and societal perspectives.

Discussion: While the planned intervention is both comprehensive and expensive, it has the potential to produce substantial short-term and long-term health and non-health benefits. These benefits should be considered seriously when evaluating whether such a program can justify the required investments in a setting with scarce resources. The economic evaluations outlined in this paper will generate valuable information that can be used to guide large-scale implementation of programs to address the problem of the high prevalence of adolescent childbirth and school drop-outs in similar settings.

Trial registration: ClinicalTrials.gov, NCT02709967. Registered on 2 March 2016. ISRCTN, ISRCTN12727868. Registered on 4 March 2016.

Keywords: Adolescent pregnancy; Cash transfer; Catastrophic health expenditure; Cluster randomized controlled trial; Cost-benefit analysis; Early marriage; Extended cost-effectiveness analysis; School drop-out.

Conflict of interest statement

Ethics approval and consent to participate

The main trial protocol was approved by the University of Zambia Biomedical Research Ethics Committee (Ref. number. 021-06-15) and the Regional Ethics Committee of Western Norway (Ref. number. 2015/895). The trial was registered with ClinicalTrials.gov registry on 2 March 2016 (identifier NCT02709967) and the ISRCTN registry on 4 March 2016 (registration number ISRCTN12727868).

Permission to conduct the trial in schools in the study districts and to engage teachers and CHAs/CHWs in the community component was obtained from the Ministry of General Education and Ministry of Health and district education offices in Zambia. All girls and their parents/guardians gave consent/assent to participate in the trial.

For the planned costing sub-studies and the household survey, we will apply for ethical approval from the University of Zambia Biomedical Research Ethics Committee and the Regional Ethics Committee of Western Norway. We will also apply for permission from the relevant authorities in Zambia to conduct studies in the hospitals. All patients and care providers will be interviewed after giving written or verbal informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
SPIRIT figure. Schedule of enrolment, interventions and assessments
Fig. 2
Fig. 2
Transition states. Adolescent girls enter the model i.e. were enrolled into the RISE trial at grade 7 in primary school. At primary school and lower secondary school it is expected that a certain proportion of girls will drop out of school due to pregnancy and other reasons while the majority progress to higher levels. It is expected that the interventions provided will have direct effect of increasing the proportion of girls that progress from primary school to junior secondary and indirect effect from junior to senior secondary. It is assumed that girls dropping out of school at each level will eventually enter into the labor market where they will be paid a certain amount of wage that corresponds to their level of education

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