While there is a growing interest in transporting evidence-based interventions developed and tested in one country to other countries, research in Sweden suggests new challenges for researchers, policy makers and practitioners.

In 2002 the rising costs of dealing with youth with behavior problems in the childcare system prompted several municipal child welfare authorities in Sweden to adopt MST, an intensive family- and community-based treatment for adolescents with serious clinical problems, including criminal behavior, violence, substance abuse and serious emotional disturbance. Research in the USA has consistently shown MST to be more effective than alternative interventions at reducing rates of recidivism and conduct problems for offending and substance abuse.

Studies in Sweden have shown that MST is just as effective as other treatments in treating youth with behavior problems in the short- and long-term. However, a study of the use MST in Sweden, by Tine Olsson, represents the first cost-benefit analysis to be conducted within the Swedish social welfare system using a randomized trial.

Yong people aged 11 to 17 years of age, with a clinical diagnosis of conduct disorder, were randomly assigned to MST (79) and a control group that received treatment as usual (77). Sixty seven per cent were from single parent families, 61 per cent were boys and 47 per cent were not of Swedish heritage and spoke a language other than Swedish at home. They completed assessments at referral and seven and 24 months hence.

MST was provided by six teams, each comprising a clinical supervisor and three to four therapists. Weekly expert consultation was provided to ensure quality and fidelity, and there were three to six families in each therapist’s caseload. Therapists worked with families for between three and five months, depending on severity of need and effectiveness of treatment.

Five of the six teams provided detailed information about the resources used and families served over the two years (2004-2005). These were categorized as personnel costs and overheads. In the participating teams, personnel costs averaged 75 per cent of total operating costs.

MST significantly reduced the use of non-placement interventions over the two-year study, resulting in a benefit of 62,100 Swedish krona (SEK) for each young person. With savings in travel costs included, this came to 63,100 SEK. However, after inclusion of the cost of providing of MST to these families (105,400 SEK) and discounting both costs and benefits, MST resulted in a net loss to society of 44,500 SEK for each young person. Critically, it was not associated with a reduction in the use of placement intervention costs.

These results are contrary to a prior study in the USA that showed MST to have favorable economic outcomes when compared to usual treatments.

One explanation for the discrepancy is the relative high average cost of providing MST in Sweden. According to Olsson, it cost more than double that estimated in two studies in the USA. Differences in employer contributions to social policies and labor costs lead to variations in costs between different countries and make cross-cultural comparisons difficult.

Another explanation concerns the different roles that MST plays in the USA and Swedish services. MST is an intervention designed to reduce the placement of young people in out-of-home care. In Sweden, however, MST may be used as an alternative to such interventions. This is because in Sweden young offenders are traditionally aided through child welfare, with placements used rarely and as a last resort. In the USA, youth offenders are processed within the juvenile justice system and the placement of youth with severe behavior problems may be the default way in which courts choose to deal with young offenders.

For Olsson the message is clear: “With the increasing focus on evidence-based interventions and the transfer of interventions between cultural contexts, care needs to be taken in understanding that treatment effectiveness and cost-effectiveness is always relative. Developing an understanding of the current status of efforts before introducing a new intervention has been identified as an important first step in the implementation process.

“In Sweden, little was known about the effectiveness or efficiency of social service interventions prior to the importation of MST to Sweden. Therefore, it would have been difficult at that time to assess the ability of MST to strengthen the system of services already in place and improve cost-effectiveness.

“Resources within social welfare are scarce and choices need to be made regarding the most efficient interventions to maximize the overall societal benefit achieved with those scare resources. However, the effectiveness of an intervention is insufficient evidence on which to base these choice decisions, as the cost of the intervention may outweigh its benefits or an alternative intervention may achieve the same outcome for a lower cost.”

Reference:
Olsson, T. (2010) ‘MST with conduct disordered youth in Sweden: costs and benefits after 2 years’, Research on Social Work Practice, 20 (6), 561-571.