Background: Optimal tuberculosis (TB) treatment remains the backbone of effective TB control programmes. However, TB drugs are often associated with adverse drug reactions (ADR) that affect treatment adherence and cure. Cutaneous adverse drug reactions (CADR) are more commonly associated with Human Immunodeficiency Virus (HIV)/TB co-infection, occurring in up to 7% of patients. If severe, CADR require treatment interruption and hospitalisation. There are no standardised guidelines for managing CADR to TB therapy. Current practice in South Africa involves drug rechallenge, a process, which aims to identify the offending drug and modify the treatment regimen. This practice can carry significant risks that need to be weighed against the benefits. Despite significant resources required to manage CADR, there is no available data regarding their economic impact. Alternate strategies to manage TB therapyassociated CADRs and their cost have never been evaluated. The purpose of this study is to evaluate the economic impact of TB therapy-associated CADRs in South Africa and compare the cost of drug rechallenge with alternative strategies. Methods: Data was obtained from 97 patients, admitted to the Groote Schuur Hospital dermatology ward with TB therapy-associated CADR. Clinical data pertaining to hospitalisation, diagnostic/monitoring tests and drug prescriptions was extracted from patient medical records. Healthcare and patient-related costs were obtained from financial department records, interviews and hospital admission records. Alternative drug regimens for CADR management were derived from literature and expert clinical advice. Costs were estimated using an ingredient's approach in 2016 US dollars. A cost-comparative analysis was performed comparing the cost of the current practice with alternative options. Univariate sensitivity analysis was used to investigate the uncertainties around cost components. Results: The cost of managing a TB therapy-associated CADR was $6,525 per patient. Within this population the average cost of managing a CADR in a patient with DS-TB was $5,831 (95% CI: 8438; 10727). The main contributor of CADR costs was hospitalisation amounting to $3,638/patient (62% of total cost). Alternative CADR management strategies using outpatient-initiated second-line regimens containing rifabutin, bedaquiline and delamanid cost 44-55% less than drug rechallenge depending on the drug regimen used ($2,651/patient to $3,276/patient). Sensitivity analyses indicated that drug rechallenge was most sensitive to hospitalisation costs, whereas second-line treatment strategies were sensitive to TB drug costs. The average total loss experienced by patients as a result of the CADR was $530 (25% of their annual income), as compared to an estimated loss in the alternate regimens of $154 (10% of their annual income). Societal costs with alternate regimens were also lower at 46-66% that of current cost of $6,134. Conclusion: CADR to TB treatment represent a significant economic burden to the healthcare system and affected patient. The alternate strategy of outpatient-initiated second-line therapy provides an economically feasible option by implementing an ambulatory practice of care despite using more expensive drugs. Shorter hospitalisation reduces patient and healthcare costs. This data should inform policy makers on optimal resource use within the healthcare system. Once the effectiveness and risk of drugresistance of these strategies has been determined, further research should estimate their cost-effectiveness.

The link between family social capital and child health has not been well investigated in developing countries. This study assessed socioeconomic inequalities in child health and in family social capital in South Africa. It also assessed the relationship between family social capital and child health. Four waves of the National Income Dynamics Study panel data were used to investigate the relationship between family social capital and child health. Socioeconomic inequalities were assessed using the concentration index. To assess the relationship between family social capital and child health, regressions models were fitted using a selected set of explanatory variables, including an index of family social capital. Child health in this study was operationalized to include: stunting, wasting, and parent-reported health of a child. Results showed that children from the poorest families bear the largest burden of stunting, wasting, and ill health. Similarly, children from poorer households possessed more family social capital when compared to children from more affluent families. Although family social capital was expected to improve child health, the study findings suggest that in South Africa, the socioeconomic status of a family has a greater effect on child health than family social capital.

Includes bibliographical references. / Following recommendations laid down by a consensus conference in 1986, the policy of the Norwegian government has been to offer a routine ultrasound scan to all pregnant women at 18 weeks of gestation, i.e. in the second trimester (weeks 14-27) of pregnancy . This form of antenatal screening is also provided in other European countries, though several countries have gone further and now offer universal screening in the first trimester (weeks 1-13), between the 11th and 13th week of gestation, as well as in the second. In 2006, the Norwegian Directorate for Health contemplated a revision of its antenatal care guidelines, and in the process, sought to determine whether anexpansion of the programme to incorporate universal first trimester screening would be a rational step with regard to the anticipated extra benefits and costs. Except for a relatively small patient co-payment charge, antenatal screening is publicly financed as is the case with most other healthservices. Norway has however, a small but thriving private healthcare sector, and first trimester ultrasound scanning has been offered by private providers in recent years. The are many potential benefits of antenatal ultrasound screening and some of them are undoubtedly controversial. The information gained from a scan may, depending on its timing, assist in determining the pregnancy term, the number of foetuses in the uterus, the location of the placenta and the condition of the foetus. If the foetus is found to suffer from a particular disease, it may sometimes be treated prior to birth. Invariably however, ultrasound scanning in pregnancy is often associated with the detection of foetal anomalies or defects, such as Down syndrome, congenital heart defects or neural tube defects. The detection can in some cases lead to the pregnancy being terminated, whilst in other cases it may prepare the parents for a life with a child who may requiremore attention and care than others. This provision of information may be considered beneficial, however one may choose to act upon it, although it also invites an active decision which could induce negative feelings. On the other hand, the potential stress and anxiety involved in the screening and diagnostic process may be viewed as disadvantageous. This study will focus on two of the most important anomalies, at least in terms of the attention they are given in the literature: Down syndrome (DS) and serious congenital heart defects (SCHD).

Background: The Western Cape province of South Africa has the highest recorded prevalence rates of Fetal Alcohol Spectrum Disorders (FASD) in the world. In the last decade rates of fetal alcohol syndrome (FAS) and partial fetal alcohol syndrome (PFAS) prevalence of 68.0 - 89.2 per 1000 (May et al., 2007), 67.2 per 1000 (Urban et al., 2008), and 59.3 - 91.0 per 1000 (May et al., 2013) have been published after research was conducted in towns in the Western Cape (WC). Educating learners with FASD is a challenge as a result of the large range of cognitive impairments associated with heavy prenatal alcohol exposure. Determining a burden of cost to the education system may be one way to motivate for the development of prevention and intervention strategies. Methods: I designed questionnaires that were distributed to the educator and principal of a cohort of learners including learners with FAS and PFAS. Data were collected on educational impacts of variables associated with educator time use. Additional costs as a result of the use of educator's time by learners with FAS/PFAS were scaled up using risk differences and published statistics to reflect a cost burden to the WC Education Department. Results: The additional cost burden of disruptions caused by learners with FAS and PFAS for the WC Education Department is USD 7,010,166 in educator time for one academic year. The additional burden for learners with FAS/PFAS requiring additional assistance with lesson content to the WC is USD 5,754,885 in educator time for one academic year. The additional cost burden of public primary school learners with FAS/PFAS who had repeated a year of schooling was USD 3,876,565 in educator time based on 2012 salaries. Conclusions: These findings indicate that there is a large burden of cost to the education system when educator time is viewed as an economic input in education. Efforts need to be directed towards prevention programs to reduce the prevalence of learners with FAS/PFAS in the classroom. Educator training programs must be created to ensure that educators are equipped to manage the challenges posed by learners with FAS/PFAS in the classroom.

Background: The increased smoking prevalence in some parts of the world, particularly in Low and Middle Income Countries (LMICs) is a major concern among tobacco control advocates and governments. The higher smoking-related disease prevalence associated with this is expected to fall among the sub-populations least able to pay for healthcare services in LMICs. This, in turn, will perpetuate the vicious cycle of poverty and disease. The current study contributes to developing an understanding of the socioeconomic disparities in smoking in Namibia and their potential association with per capita health-related expenditures. Method: Data from the Namibia 2013 Demographic and Health Survey, a nationally representative survey, are used in the study. Three main variables for healthcare costs are constructed, namely out-patient disease (OPD) costs, inpatient disease (IPD) costs and total out of pocket (OOP) payments. Concentration curves and indices are estimated for all three variables as well as for smoking intensity and smoking prevalence. Further, three Tobit regression models are run to examine the associations of the different healthcare costs with smoking intensity. Results: The concentration index of smoking prevalence is estimated at -0.05 compared to -0.18 for smoking intensity. Thus, both smoking prevalence and smoking intensity, in relation to their socioeconomic status, are concentrated among the poor. In contrast, the concentration index of OPD healthcare costs is calculated at 0.34 compared to 0.65 for IPD healthcare costs reflecting disproportionately higher healthcare costs among the rich. The concentration index of the overall total annual OOP payments is 0.55. Tobit regression analysis, however, does not find any statistically significant relationship between the smoking intensity and the amount spent on health care costs, regardless of whether these were IPD, OPD healthcare costs or total OOP payments. Conclusion: Namibia's current policies on demand reducing tobacco control policies can be strengthened by these findings. Smoking is an important determinant of several non-communicable diseases and has the potential to exacerbate health care costs across socioeconomic strata. Understanding the socioeconomic disparities in smoking is imperative for developing appropriate interventions against smoking.

This thesis consists of three chapters that investigate issues related to health economics, health behaviours, and labour outcomes. Using the longitudinal data from the National Population Health Survey (NPHS), Chapter 1 examines the association between minimum wage increases and a wide range of health outcomes and behaviours, such as physical health, mental health, chronic conditions, unmet health need, obesity, insurance, smoking, drinking, food insecurity and fruit and vegetable consumption using Difference-in-Difference (DD) and Difference-in-Difference-in-Difference (DDD) models. There is no evidence that minimum wage increases are associated with most health outcomes and behaviours, including better health. There is an association for low-education females with a higher probability of reporting overall fair or poor health, and excess drinking but a lower probability of work absences due to illness and being physically inactive. For low-education men, there is an association with improved mental health and less drinking and smoking. Broadly there is more evidence that minimum wage increases lead to healthier behaviours than evidence of an actual improvement in health, perhaps because of lags effects that are not captured in this analysis. Chapter 2 links the survey data from 2015-16 Canadian Community Health Survey (CCHS) to job characteristics from O*Net to explore the role of job characteristics in explaining the positive association between drinking alcohol and income, which is commonly found in the literature. The study finds that controlling for job characteristics reduces “income return to drinking” substantially (by between one fifth and one half, depending on gender and the measure of alcohol consumption). Last, using data from the Ontario sample of the 2020 CCHS, Chapter 3 estimates the marginal effects of an index of social capital (at the individual or aggregated level) on changes in intentions to get vaccinated. Results show that individual-level social capital is associated with a greater willingness to get vaccinated against Covid-19 at all ages, while aggregate-level social capital is associated with higher vaccination willingness only among older adults. / Dissertation / Doctor of Philosophy (PhD)

Understanding the role of social and cultural factors play in promoting smoking and helping smokers to stop is a challenge that has major implications for health of black and other minority populations. Smoking is a major contributor to preventable and premature cancer mortality among blacks. Their higher rate of tobacco-related cancer is tied to a lower quitting rate, greater smoking prevalence, and greater relapse rates. The focus on racial differences in smoking has provided only a limited understanding of these disparities. Findings research on racial difference in smoking typically point to a lack of understanding of sociocultural factors as an obstacle to determining racial difference in smoking. This research is a secondary data analysis of the University of Massachusetts, School of Public Health project on "Cancer Prevention (Smoking) in Black Populations" conducted from 1986 to 1991. This research analyzed a survey administered in four major US cities to approximately fourteen hundred respondents, all black smokers. The analysis defined the networks of smokers as structural characteristics (composition and size); and in terms of socially supportive relationships. Guiding this study was the assumption that a well-defined social network model would guide researchers toward a better understanding of the influence of sociocultural factors on smoking behavior. The principal hypothesis that guided this research was that social network characteristics would be significantly related to intentions. There were three sets of study variables including demographic, network structure, and social support variables. Univariate and multivariate logistic regression models examined the independent and joint contribution of these three sets of study variables to explaining the dependent variable--intention to stop smoking in one year. Network structure and social support variables were shown to have a significant influence on smokers' intentions to stop smoking. These positive results need replication and validation with a more precise survey instrument and method for examining individuals among empirical systems.

Cardiac arrest is a major cause of mortality and morbidity including recurring cardiac events, cognitive impairments, and mental health issues. This thesis is on empirical analyses of cardiac arrest patients in Ontario, Canada using administrative health data sources. Chapter 1 is a retrospective population surveillance study, which employs logistic regression analysis to examine short-term and long-term survival trends for adult patients in acute care hospitals. The 1-year adjusted odds ratio for initial successful resuscitation is 1.049 (95% CI: 1.022-1.076) when controlling for demographics, pre-admission comorbidities, and hospital of arrest. In stark contrast, there was no evidence of a trend in survival at discharge, 30 days, or 1 year. Results suggest further research into post-resuscitation care in Ontario care may be useful. However, we also find evidence of measurement error coding in successful resuscitation that is trending in magnitude in way that could bias trend estimates. Chapter 2 takes a serious look at the nonclassical measurement error problem in resuscitation success coding identified in the previous chapter. We employ a combination of credible assumptions from within the partial identification econometrics literature to nonparametrically bound the trend is resuscitation while allowing misclassification rates to trend. We also develop a novel approach which weakly restricts asymmetry between false positive and negative rates. We find that restricting false positives and negative to be within 10% and 90% of misclassified observations, in combination with monotonicity assumptions is enough to identify a trend. Chapter 3 follows survivors of cardiac arrest after discharge and investigates follow-up patterns in primary care. These patients remain at high risk of death, recurrence of cardiac events, cognitive impairment, and mental health issues. They may benefit from ongoing monitoring of cardiac risk factors, early mental health screening, and co-ordination of specialist care. This requires continuity of primary care. Primary care reforms in Ontario, Canada have led to the majority of general practitioners (GP) switching from fee-for-service remuneration to enhanced patient enrolment models, which encourage or require GPs to formally enroll most patients attached to their practice. To understand continuity of care across payment models, we use semi-parametric duration models to analyze time to first GP outpatient follow-up visit, distinguishing visits a patient’s own regular GP, and other GPs. We find enrolled patients visit their own (other) GP earlier (later) compared to patients whose regular GP is fee-for-service. / Thesis / Doctor of Philosophy (PhD)

<p>Formal economic analysis of tobacco products dates back to the middle of the 20^th century. At the beginning, most of the research was done by the tobacco industry itself. Later, research interests switched to the public health perspective following the publication of British and American reports on smoking and health. Many papers consistently demonstrate that smoking significantly damages health and that the cigarette tax is a popular policy tool to reduce smoking. My first two essays focus on the issue of the cigarette excise tax and smoking. In the first essay, we analyze a possible tax avoidance behaviour measured by pack versus carton purchasing behaviour, since carton purchasing is associated with a substantial quantity discount. We find that smokers who intend to quit switch to packs in response to tax increases, while smokers who do not want to quit smoking systematically switch to cartons when taxes increase. In the second essay, we investigate whether the smoking participation of relatively older smokers is sensitive to cigarette taxes. The consensus in the literature is that older smokers are not price-responsive. Medical research, however, suggests quitting smoking even at an older age can still generate substantial health benefit for the old smokers. Using the most recent large tax increases across US, we find that both the older smokers’ desire to quit and actual smoking participation rate are responsive to tax increases. These results run contrary to most of the literature and may suggest that tax increases generate substantial health benefits for older smokers. In the last essay, we extend the model specification test proposed by Fan et al. (2006) to the extent that we also smooth the discrete dependent variable. We derive the null distribution of the test and also show that the test is consistent even when the null hypothesis fails to hold. Finally, a Monte Carlo simulation study shows that by smoothing the categorical dependent variable, our test enjoys substantial power gains.</p> / Doctor of Philosophy (PhD)

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