1. Working With Community Health Workers to Increase Use of ORS and Zinc to Treat Child Diarrhea In Uganda: A Cluster Randomized Controlled Trial (Job Market Paper)
Many cost-effective health products are underused in poor countries, although the burden from diseases that could benefit from these products remains high. Using community health workers (CHWs) to increase utilization of essential health products is a promising strategy, yet little is known about how best to structure such programs to maximize coverage. In this study, I examine two key features of CHW program design: 1) charging vs. free distribution of health products and 2) home delivery vs. client retrieval of health products. I measure the impact of these different strategies in the context of distribution of oral rehydration salts (ORS) and zinc—highly effective but widely underused treatments for child diarrhea. In addition, I examine the role of two barriers that could contribute to low ORS and zinc utilization: price and convenience. I use a four-armed, village-clustered, randomized design across 118 villages in Uganda to experimentally vary the price and convenience of accessing ORS and zinc from CHWs. Villages were randomized to one of the following three intervention groups or a control group: 1) A novel preemptive home delivery intervention (Free+Delivery) makes ORS and zinc free and conveniently available inside the home when a child comes down with diarrhea; 2) A preemptive Home Sales intervention makes accessing ORS and zinc conveniently available at the home, but not free; 3) A free upon retrieval intervention (Vouchers) makes ORS and zinc free but not convenient; 4) A control group has CHWs carry out their normal activities. This design allows me to evaluate the impact of these different distribution strategies as well as to examine the role of price (Free+Delivery vs. Home Sales) and convenience (Free+Delivery vs. Vouchers) in underuse of ORS and zinc. The first result is that Free+Delivery increased the share of cases treated with ORS (primary outcome) by 20 percentage points (36%) and ORS+zinc by 33 percentage points (106%), relative to the control group. Second, Free+Delivery increased ORS use by 12 percentage points (18%) and ORS+zinc use by 18 percentage points (40%) relative to Home Sales, suggesting that price is an important barrier to use. Third, I find no difference in use between Free+Delivery and Voucher groups, suggesting that convenience is not a key barrier to use. Fourth, among households where a diarrhea episode occurred, I find little evidence that Free+Delivery did a worse job of targeting or increased wastage relative to the other groups. Finally, I find that Free+Delivery is extremely cost effective from a donor perspective in terms of cost per case treated with ORS ($2.20) and cost per DALY averted ($64), relative to the status quo. When household out-of-pocket costs are considered, Free+Delivery is cost saving relative to all other groups, implying that this is the preferred distribution strategy. The results of this study suggest that price is an important barrier to ORS and zinc use in Uganda, that substantial gains in ORS and zinc coverage can be made if CHWs distribute the products for free as opposed to charging, and that free distribution is highly cost effective.
2. A Cost-Effectiveness Analysis Of Different Approaches to Offering HIV Screening Services In Emergency Departments (With William H. Dow, Juan Carlos Montoy, and Emmanuel Drabo)
Many HIV positive individuals are still unaware of their infected status, which has led health systems to try many alternative approaches to expand HIV testing. The CDC, US Preventive Service Task Force, and others have encouraged the use of opt-out default screening regimens for patients, while some systems have implemented small incentives to increase testing uptake. We conducted a two-year randomized trial in the emergency room of a large safety net hospital to directly test the effectiveness of alternative default choices against the effectiveness of small incentives, as well as to test the degree to which defaults and incentives were complements or substitutes. In separately reported results, we found that defaults and incentives each had substantial effects on raising HIV testing rates. For example, with zero incentives, changing from opt-in to active choice raised testing rates from 38% to 51%, and changing to opt-out achieved a 66% rate. Small incentives by themselves could raise testing rates by as much as 20%, depending on the risk-group and default scenario. In the current paper we build on this analysis to quantify the cost-effectiveness of different combinations of defaults and incentives. The main benefit metric is the incremental number of new HIV diagnoses, estimated from a mathematical screening model exploiting survey information on the risk level of each patient. We also modeled the relative effectiveness in terms of future HIV infections averted. We find the highest incremental cost-effectiveness ratios (ICERs) when moving from opt-in to active choice or opt-out. When starting from a base case of opt-in with no incentives, changing the defaults dominates adding small incentives in terms of cost per new diagnosis. However, the effectiveness of the opt-out regimen is further enhanced by additional small incentives, though at a greater marginal cost per diagnosis. These results hold across a wide range of alternative parameter values. We suggest a research agenda to similarly compare competing incentive versus choice architecture effects for a wide range of behavioral change efforts in other domains.
3. The Impact of Prescription Drug Monitoring Programs On Opioid Use and Subsequent Employment Outcomes
Several studies have shown that prescription drug monitoring programs (PDMPs) result in reduced opioid use and opioid related mortality. However, such laws could also have the indirect effect improving employment outcomes that have been harmed by the opioid epidemic. We will use variation in state PDMP laws over time to assess the impact of these laws on employment outcomes. We will then use the PDMP laws as an instrument for opioid use to identify the causal impact of opioid use on employment outcomes.