Development Economics

Einleitung / Introduction

Uncontrolled hypertension is the leading risk factor cardiovascular disease and premature mortality in many low- and middle-income countries (LMICs). There is growing policy interest in using home- and community-based screening to improve hypertension control in LMIC settings where awareness and diagnosis of hypertension is poor. The main assumption is that once individuals are made aware that they may have uncontrolled hypertension, they will act by seeking formal care and initiating and adhering to cost-effective treatments. Yet, there is a lack of rigorous evidence on whether individuals actually seek care and treatment following a home-based screening. Our study provides the first causal evaluation of whether home-based screening and providing health information about the need for hypertension control leads to a behavioural change in India and whether certain population groups are more likely to respond to this information.

Methode / Method

We used data from six waves of the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) survey, which are representative of adults aged 20 years and older living in Chennai and New Delhi. As part of CARRS, survey enumerators conducted a home-based hypertension screening. We employed the regression discontinuity design (RDD) to evaluate the causal impact of this screening intervention on two outcomes: (1) whether an individual became diagnosed with hypertension; and (2) whether they report initiating treatment for high blood pressure. We estimated the RDD separately by sex and educational attainment to determine whether the intervention had greater effects for some groups compared to others.

Ergebnisse / Results

We find no evidence of an effect of home-based screening on hypertension diagnosis in the total population (0.1pp, 95% CI -1.4 – 1.7), among men (-1.6pp, 95% CI -3.9 - 0.7) or women (1.3pp, 95% CI -2.2 - 4.1). We similarly find no evidence that the intervention improved hypertension treatment. When disaggregating by sociodemographic groups, we find that home-based screening increased hypertension diagnosis by 4.7pp (95%CI 1.0 – 9.2) among women with higher education but no other groups. These results are robust to several sensitivity analyses.

Zusammenfassung / Conclusion

Hypertension causes a major health burden to the Indian population. Previous evidence shows that most people living with hypertension are unaware of their condition and, thus, do not receive any treatment. While home-based screening provides an appealing solution, we find that in two cities in India, it did not increase formal hypertension diagnosis nor treatment uptake for most people. Understanding why individuals do not seek care or treatment despite being made aware of their condition will be critical for improving hypertension control and cardiovascular disease prevention.

AutorInnen

Michaela Theilmann

Sneha Mani

Pascal Geldsetzer

Nikkil Sudharsanan

Einleitung / Introduction

Despite the recent move towards universal health insurance schemes, barriers to effective health care utilization remain. We focus on the barrier of incomplete information, and suppose that uncertainty about the costs and benefits of seeking health care is one of the pathways through which it can prevent individuals from seeking appropriate health care. We hypothesize that facing an uncertain medical and financial outcome, the utility evaluation of individuals may lead to not seeking appropriate health care. This is especially plausible in a low-income environment where uncertain costs are potentially catastrophic and information access is limited. We operationalize and measure uncertainties in both the medical and financial domain and examine their role in health care decisions, including the role of information seeking. By this, we contribute to the literature by first extending the concept of uncertainty in health care seeking to the cost dimension and by proposing a novel measurement tool for medical and cost uncertainty. Besides, understanding such information barriers better is highly policy relevant to tailor information provision accordingly.

Methode / Method

We designed a respective survey tool and fielded it in an in-person survey among low-income households in Khybher Pakhthunkhwa province in Pakistan in early 2022. The two-day survey tool builds on three hypothetical health scenarios of varying severity (vignettes), which we employ to simulate an actual care-seeking decision. For the expected benefits, we asked the respondent to assess the likelihood to get substantially better when visiting four types of health facilities and, to gauge uncertainty, we asked about this probability in the best and in the worst thinkable case. For the expected costs, we follow an established literature to measure subjective expectation and elicit subjective cost distributions for each scenario-facility-combination.

Ergebnisse / Results

We find that respondents are indeed unsure about the benefits of seeking care, which differ in level, but not uncertainty across scenarios and facilities. Benchmarking with medical expert judgements show that respondent guesses are more stationary, which leads them to overestimate the probability to get better for the primary care facilities for the more severe scenarios and underestimate it for the light vignette. We also detect substantial uncertainty regarding costs, which differs across facilities and scenarios. Cost benchmarking with user experiences shows that the hypothetical guesses are in a realistic range. Information-seeking between the day 1 and day 2 measure does not alter the uncertainties.

Zusammenfassung / Conclusion

We find preliminary evidence that medical and cost uncertainty is present in our target population, and might pose a barrier to health care decisions.

AutorInnen

Alina Imping

Andreas Landmann

Lisa Rogge