Browsing by Author "Van Doorslaer, Eddy"

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    The rise and fall of mortality inequality in South Africa in the HIV era
    (Elsevier, 2018-08) Haal, Karel; Smith, Anja; Van Doorslaer, Eddy
    Post-apartheid South Africa has seen an unprecedented rise and fall of mortality in less than two decades as a result of the HIV/AIDS epidemic and the subsequent rollout of free antiretroviral therapy (ART). Since the incidence of both was not equal for rich and poor, it is likely to also have affected disparities in health and survival chances by income. We use large nationwide surveys for 2001, 2007 and 2011 to obtain estimates of average income and mortality at the aggregate level of a municipality, and then to examine changes in mortality – and in inequality in mortality by income ─ over time. Using concentration indices to measure health inequality, we demonstrate that both the mean mortality level and absolute inequality in mortality by income rose rapidly until 2006, and declined again sharply since the rollout of free ART. Relative inequalities in mortality by income, however, remained fairly stable over the 2001–2011 period. The analysis of age-sex-specific mortality rates shows that it was in particular for adults aged 18–59 years that mortality and absolute inequality increased substantially between 2001 and 2006, followed by a rapid drop thereafter. These trends were far more pronounced for males than females. This means that the HIV/AIDS epidemic has taken a serious death toll, which was concentrated disproportionately among the poorest segments of the population and especially affected (older) males. While South Africa has been very successful in curbing the overall mortality trend since 2006, large disparities in survival prospects by income, race and gender continue to exist. Targeted efforts are required if it wants to further reduce the very unequal chances of living to old age for richer and poorer population groups of all ages.
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    SMS nudges as a tool to reduce tuberculosis treatment delay and pretreatment loss to follow-up. A randomized controlled trial
    (Public Library of Science, 2019) Wagstaff, Adam; Van Doorslaer, Eddy; Burger, Ronelle
    Background: TB persists despite being relatively easy to detect and cure because the journey from the onset of symptoms to cure involves a series of steps, with patients being lost to follow-up at each stage and delays occurring among patients not lost to follow-up. One cause of drop-off and delay occurs when patients delay or avoid returning to clinic to get their test results and start treatment. Methods: We fielded two SMS interventions in three Cape Town clinics to see their effects on whether people returned to clinic, and how quickly. One was a simple reminder; the other aimed to overcome “optimism bias” by reminding people TB is curable and many millions die unnecessarily from it. Recruits were randomly assigned at the clinic level to a control group or one of the two SMS groups (1:2:2). In addition to estimating effects on the full sample, we also estimated effects on HIV-positive patients. Results: SMS recipients were more likely to return to clinic in the requested two days than the control group. The effect was smaller in the intent-to-treat analysis (52/101 or 51.5% vs. 251/405 or 62.0%, p = 0.05) than in the per-protocol analysis (50/97 or 51.5% vs. 204/318 or 64.2%, p = 0.03). The effect was larger among HIV-positives (10/35 or 28.6% vs. 97/149 or 65.1%, p<0.01). The effects of SMS messages diminished as the interval increased: significant effects at the 5% level were found at five and 10 days only among HIV-positives. The second SMS message had larger effects, albeit not significantly larger, likely due in part to lack of statistical power. Conclusions: At 2 U.S. cents per message, SMS reminders are an inexpensive option to encourage TB testers to return to clinic, especially when worded to counter optimism bias.