Health in developing countries

Einleitung / Introduction

This paper aims to empirically test whether a channel proposed by sociologists and psychologists – spiritual-cultural displacement – can help explain the substantially worse mental health outcomes of indigenous peoples. Employing a lab-in-the-field experiment in rural Indonesia that involves the administration of psychological, fear-inducing primes, we examine the role of this channel in a context in which a local indigenous ethnic group has recently lost much of its religious environment – sacred rain forest – due to widespread rural transformation processes. Overall, we find evidence in support of the spiritual-cultural displacement mechanism. In contrast, we observe no significant effects regarding the role of various plausible alternative channels such as discrimination, conflict, differential wealth, and changes in the nature of work tasks.

Methode / Method

Conducting a lab-in-the-field experiment with about 2,700 individuals in 90 villages in rural Indonesia, we adopt two distinct empirical strategies to shed light on the spiritual-cultural displacement vs. mental health channel. First, we provide quasi-experimental evidence on the impact of the palm oil expansion process on indigenous people's mental health (anxiety and depression). The approach rests on a matched pair design in which we sample neighboring villages that nowadays show remarkable differences in deforestation and palm oil exposure patterns but that were still highly comparable with respect to a large set of observables (including primary forest coverage, mental health proxies, and ethnic composition) only 2-3 decades ago (start of the rapid oil palm expansion process). Second, we generate experimental evidence from applying psychological primes using a between-subject-design. More specifically and following the earlier work of Callen et al (2014) and Cohn et al (2015), we aimed at inducing temporary trauma within study subjects that comes from stimulating the recollection of fearful episodes in their lives. The applied primes are associative in nature and are meant to provide small cues to stimulate individuals into thinking about the rapid loss of primary rain forest in their environment. Our results suggest that people from the indigenous ethnic group are more likely to temporarily become anxious and depressed in response to the administered prime. Moreover, this effect is particularly driven by indigenous people that live in villages with a high exposure to the palm oil expansion process.

Ergebnisse / Results

Overall, we find evidence in support of the spiritual-cultural displacement mechanism. In contrast, we observe no significant effects regarding the role of various plausible alternative channels such as discrimination, conflict, differential wealth, and changes in the nature of work tasks.

Zusammenfassung / Conclusion

This paper aims to empirically test whether a channel proposed by sociologists and psychologists – spiritual-cultural displacement – can help explain the substantially worse mental health outcomes of indigenous peoples. Employing a lab-in-the-field experiment in rural Indonesia that involves the administration of psychological, fear-inducing primes, we examine the role of this channel in a context in which a local indigenous ethnic group has recently lost much of its religious environment – sacred rain forest – due to widespread rural transformation processes. Overall, we find evidence in support of the spiritual-cultural displacement mechanism. In contrast, we observe no significant effects regarding the role of various plausible alternative channels such as discrimination, conflict, differential wealth, and changes in the nature of work tasks.

Authors

Jan Priebe, BNITM

Einleitung / Introduction

Individual and area-level socio-economic conditions significantly affect access to essential goods and services that promote physical and psychological well-being, and ultimately impact health equity. While interrelations between regional area deprivation and socio-economic inequalities in non-communicable diseases are well explored in high income countries, evidence on low-and-middle-income countries is still scarce. We developed an index of multiple regional deprivation for the Indian state of Punjab at the district level, tested its efficacy by analyzing inequalities in diabetes associated with regional deprivation and individual-level wealth, and measured deprivation-specific wealth-related inequalities in diabetes.

Methode / Method

We used data from multiple official sources and applied factor analysis to derive the Punjab Index of Multiple Deprivation (PIMD), following the established approaches from Germany and the UK. Individual-level data were taken from the Indian Demographics and Health Survey (DHS). Domains and indicators were adapted to the Indian context to account for the differences between high and low-and-middle income countries. Deprivation-related and wealth-related inequalities in diabetes were measured using the concentration index, and PIMD-specific wealth-related inequalities in diabetes were measured using a non-parametric extension of the concentration index.

Ergebnisse / Results

Our results suggest a statistically significant concentration of diabetes among richer individuals and in better-off areas, with wealth-related health inequality being significantly stronger than the deprivation-related health inequality. The throughout positive estimates of the varying inequality index indicate that diabetes is significantly concentrated among richer individuals at all levels of regional deprivation, but the socio-economic gradient barely varies with the degree of area-level deprivation.

Zusammenfassung / Conclusion

Unlike findings from high income countries, diabetes is concentrated in better-off regions and among better-off individuals in the Indian state of Punjab. Our findings suggest that regional deprivation represents an important determinant of the prevalence and of socio-economic gradients in diabetes. Policymakers should address the regionally unequal burden when allocating resources to prevent or mitigate the spread of diabetes in India. Efforts should be made to increase awareness and promote healthy lifestyles, particularly in affluent areas where the prevalence of diabetes is higher. Public health campaigns and initiatives aimed at encouraging physical activity and reducing the consumption of unhealthy foods could be implemented in better-off regions and may be particularly effective when addressing economically better-off households in India.

Authors

Martin Siegel, TU Berlin

Sujata Sujata, IIT Mandi

Ramna Thakur, IIT Mandi

Einleitung / Introduction

Regular follow-up visits are a crucial component of prevention and care for many important non-communicable diseases. Yet, across low- and middle-income countries (LMICs), there is low demand for follow-up visits despite their large expected health benefits. In this study, we conducted a randomized evaluation of an enhanced reminder intervention that sought to improve follow-up visits for preventive hypertension care among individuals with high blood pressure (BP) in two Indian public facilities. Our enhanced reminders combined a traditional reminder targeting low salience with debunking information aimed at correcting misconceptions around preventive healthcare that arise from incorrect mental models of healthcare seeking. Our primary hypothesis was that simultaneously addressing low salience and misconceptions would boost the effectiveness of reminder messages and improve demand for preventive care visits.

Methode / Method

We conducted a randomized controlled trial in two public sub-district hospitals in Punjab, India, among 851 patients with high BP. Prior to randomization, we measured hypertension-related beliefs to identify how widespread false beliefs derived from mismatched mental models are. Participants were then randomly assigned to either receive usual care or an enhanced reminder message through either WhatsApp or a phone call. The enhanced reminder included brief debunking statements seeking to correct commonly held false beliefs about hypertension care. Our primary outcome was attendance of a physician-requested follow-up visit. We also assessed mechanisms by estimating the effect of the reminder on changes in false beliefs.

Ergebnisse / Results

Our study has four main findings. First, we observe extremely low levels of follow-up attendance, with only 29.7% of participants returning for their appointments. Second, we document widely prevalent false beliefs around hypertension care. Third, we find that the two different modes of delivering our reminders had different effects on follow-up attendance. Reminders delivered through phone calls increased follow-up attendance by 10.4 percentage points (p-value=0.061) compared to a null effect for reminders delivered through WhatsApp. Fourth, neither of the reminders successfully corrected false beliefs related to hypertension care.

Zusammenfassung / Conclusion

Our study reveals that phone-call reminders are effective at improving preventive healthcare seeking. Our findings also implicate false beliefs as a contributor to the low demand for preventive health services in LMICs and highlight the challenges associated with correcting false beliefs. Interventions that combine phone-call reminders with more effective strategies for updating individuals' mental models will be important for improving health outcomes and encouraging preventive care seeking in LMICs.

Authors

Caterina Favaretti, Technical University of Munich

Vasanthi Subramonia Pillai, Technical University of Munich

Nikkil Sudharsanan, Technical University of Munich

Einleitung / Introduction

Cervical cancer is one of the leading causes of mortality among women in low- and middle-income countries (LMIC). Early detection through screening is the key to cervical cancer prevention. HPV testing is promising in resource-constrained settings, because it has the potential to increase screening uptake among hard-to-reach women in the rural areas with a community-based self-sampling approach. However, costs are unclear for implementing the community-based HPV self-sampling (HPV-SS) approach in the local context of LMIC. A micro-costing study was conducted alongside the ongoing cluster randomized trial in Siem Reap province in rural Cambodia comparing facility-based versus community-based primary HPV test and triage testing. The objectives of the micro-costing study were to estimate the average cost per woman tested, per positive case identified using the community-based HPV-SS strategy, and per triage testing (VIA-DC, VIA with naked eye, and dual stain cytology) following a positive HPV primary test.

Methode / Method

Using activity-based costing and a healthcare system’s perspective, we estimated the cost in US$ (2023) from January 2022 to November 2023. The unit costs and the quantities of the resources consumed were identified by observation, semi-structured interviews, and review of program budgets and financial reports. We identified four cost categories (human resources, consumables, equipment and administration), and eight activities (management, training in start-up phase, management, supplies and samples transportation, monitoring and evaluation, community HPV-SS, lab testing, and triage in the implementation phase).

Ergebnisse / Results

During the implementation phase between March 2023 and November 2023, 7795 women were recruited from the catchment area, 7621 underwent primary HPV-SS, yielding 352 HPV positives. The total cost of the program between January 2022 and November 2023 was $261,366.4 with an average cost of $27.6 per woman screened with HPV-SS, $726.4 per positive case, and $16.5 per triage test. Training was the biggest cost driver in the start-up phase, attributing 70.8% of the start-up costs. Lab testing and community-based HPV-SS counted for 57.0% and 33.5% of the programmatic costs. Human resources cost and administration costs were the two major cost categories for most of the activities.

Zusammenfassung / Conclusion

Policymakers need to consider how to financially sustain the HPV-based cervical cancer screening strategies, especially training and lab testing within the healthcare system in Cambodia. A comprehensive economic evaluation on cost-effectiveness is essential to inform future decisions regarding the potential adoption or adaption, and scale-up of HPV-based cervical cancer screening in Cambodia.

Authors

Ziyue Zhang, Heidelberg University

Kavita Singh, Heidelberg University

Manuela De Allegri, Heidelberg University

Hermann Bussmann, Heidelberg University

Hero Kol, Cambodia Ministry of Health

Sathiarany Vong, Cambodia Ministry of Health