Cost-effectiveness of the Self-Help Plus Intervention for Adult Syrian Refugees Hosted in Turkey

Abstract

Importance: The cost-effectiveness of the Self-Help Plus (SH+) program, a group-based, guided, self-help psychological intervention developed by the World Health Organization for people affected by adversity, is unclear.

Objective: To investigate the cost-utility of providing the SH+ intervention combined with enhanced usual care vs enhanced usual care alone for Syrian refugees or asylum seekers hosted in Turkey.

Design, setting, and participants: This economic evaluation was performed as a prespecified part of an assessor-blinded randomized clinical trial conducted between October 1, 2018, and November 30, 2019, with 6-month follow-up. A total of 627 adults with psychological distress but no diagnosed psychiatric disorder were randomly assigned to the intervention group or the enhanced usual care group.

Interventions: The SH+ program was a 5-session (2 hours each), group-based, stress management course in which participants learned self-help skills for managing stress by listening to audio sessions. The SH+ sessions were facilitated by briefly trained, nonspecialist individuals, and an illustrated book was provided to group members. Th intervention group received the SH+ intervention plus enhanced usual care; the control group received only enhanced usual care from the local health care system. Enhanced usual care included access to free health care services provided by primary and secondary institutions plus details on nongovernmental organizations and freely available mental health services, social services, and community networks for people under temporary protection of Turkey and refugees.

Main outcomes and measures: The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained from the perspective of the Turkish health care system. An intention-to-treat analysis was used including all participants who were randomized and for whom baseline data on costs and QALYs were available. Data were analyzed September 30, 2020, to July 30, 2021.

Results: Of 627 participants (mean [SD] age, 31.3 [9.0] years; 393 [62.9%] women), 313 were included in the analysis for the SH+ group and 314 in the analysis for the enhanced usual care group. An incremental cost-utility ratio estimate of T£6068 ($1147) per QALY gained was found when the SH+ intervention was provided to groups of 10 Syrian refugees. At a willingness to pay per QALY gained of T£14 831 ($2802), the SH+ intervention had a 97.5% chance of being cost-effective compared with enhanced usual care alone.

Conclusions and relevance: This economic evaluation suggests that implementation of the SH+ intervention compared with enhanced usual care alone for adult Syrian refugees or asylum seekers hosted in Turkey is cost-effective from the perspective of the Turkish health care system when both international and country-specific willingness-to-pay thresholds were applied.

Figure 1.. Stochastic Uncertainty Based on Nonparametric Bootstrapping With 10 000 Replications and 95% CI of the Incremental Cost-Utility Ratio (ICUR) for Provision of the Self-Help Plus Program for Syrian Refugees in Turkey

The 95% CI estimated for the ICUR represents the fraction of 95% of the bootstrap samples defined by cutting the highest 2.5% and the lowest 2.5% of the ICUR values simulated by the 10 000 bootstrap samples. Orange data point represents the ICUR point estimate; Reps, bootstrap replications of the ICUR; LL, lower limit of the 95% CI; UL, upper limit of the 95% CI; and T£, Turkish lira. PE (point estimate) line represents the slope of the cost-utility point estimator; vertical line, cost difference between treatment alternatives; horizontal line at 0, quality-adjusted life-year difference between treatment alternatives.

Figure 2.. Cost-effectiveness Acceptability Curve (CEAC) of the Cost-Utility for Providing the Self-Help Plus Program for Syrian Refugees in Turkey

On the horizontal line at 0, the CEAC shows the potential values for the maximum willingness to pay (MWTP) in increasing order, and the vertical axis shows the percentages of the estimated incremental cost-utility ratio values that are located below the MWTP curve. Similar to the statistical CI, the CEAC indicates at which MWTP a particular percentage of the estimated incremental cost-utility ratio falls below the MWTP curve. A percentage of acceptance of 95% is equivalent to a 1-sided statistical significance of 2.5%. T£ represents Turkish lira.

Figure 3.. Net Monetary Benefit (NMB) and 95% CI for Providing the Self-Help Plus Intervention vs Enhanced Usual Care for Syrian Refugees in Turkey at the Willingness-to-Pay (WTP) Range of Turkish Lira (T£)0 to T£125 000 (US $0-$23 623)

The NMB regression curve represents the monetary gain that the decision-maker may expect from implementing the intervention along a defined range of maximum WTP values between T£0 and T£125 000. A positive NMB may be expected from the maximum WTP value where the lower limit (LL) of the 95% CI of the NMB regression curve passes the x-axis representing the maximum WTP. UL represents upper limit of the 95% CI.