ResearchBRIEF Health Screening for Emerging and Non-Communicable Disease Burdens Among the Global Poor Evidence From Sub-Saharan Africa Alberto Ciancio, Fabrice Kämpfen, Hans-Peter Kohler, and Iliana V. Kohler Journal of Health Economics — published January 2021 KEYFINDINGS Among adults in rural Malawi, population health screening for high blood pressure (BP) led to a 22-percentage point drop in the likelihood of being hypertensive four years later. Individuals with elevated BP received a referral letter upon initial screening; at follow-up, they had lower BP and higher self-reported mental health than individuals with similar BP who were just below the threshold for referral. Population health screenings can reduce the burden of non-communicable diseases in low-income countries. THE QUESTION hypertensive by 22 percentage points (Figure 1) and lowered both systolic and diastolic BP. Compared to similarly at-risk people who did Health screenings are an important tool to improve population health. not receive a letter, those who received a letter were 20-percentage In high and middle-income nations, blood pressure (BP) screening can points more likely to be diagnosed with hypertension after their reduce risk of cardiovascular disease, the leading cause of death and screening and 13-percentage points more likely to be taking BP disability for adults 50 and older. However, population-based screenings medication, suggesting that many saw a health care provider (Figure 1). remain limited in rural and low-income contexts. In this study, the authors examined the sustained impact of BP screening Health Knowledge, Behaviors, and Subjective Health for adults in rural Malawi, a low-income country in sub-Saharan Africa. Receiving a referral letter did not affect participants’ knowledge of Each participant had three BP measurements taken. Those with high BP high BP treatments and symptoms. Further, it increased participants’ received a letter referring them to a health care provider. likelihood of engaging in certain unhealthy behaviors. At follow-up, participants who received a referral letter consumed, on average, 1 more teaspoon of sugar in their tea or coffee. They were also more likely THE FINDINGS to reduce their physical activity (by over 8 hours of vigorous physical activity per week) than their counterparts who did not receive a letter. Blood Pressure & Hypertension However, there was no effect on the likelihood of adding extra salt to About 19% of adults in the study received a referral letter. At four- their plate or consuming sweet drinks. One possible explanation for this year follow-up, receiving a letter reduced the probability of being increase in certain unhealthy behaviors could be that some participants LDI.UPENN.EDU | @PENNLDI | AGING.UPENN.EDU | @PENNPARC ResearchBRIEF Figure 1. Effects of receiving referral letter on health outcomes three times. The study included 1,075 adults with an average age of 62 years. The survey also captured participants’ knowledge of hypertension-related health behaviors, treatments, diagnoses, and OUTCOME FOUR PERCENTAGE-POINT subjective health. YEARS LATER CHANGE IN PROBABILITY Participants were “at risk” for hypertension if they had at least one BP measurement above a threshold of 160 millimeters of mercury Being hypertensive1 -22 (mmHg) systolic and/or at least one measurement above 110 mmHg diastolic. At-risk participants received a short referral letter for further assessment by a nurse or doctor. Receiving hypertension The authors used regression discontinuity and matching to evaluate +20 diagnosis the health effects of receiving a referral letter. First, they compared health outcomes of individuals with a maximum BP measurement Taking BP medication +13 right above the threshold (i.e., who received a letter) to those right below the threshold (i.e., who did not receive a letter, but had similar BP). Second, they calculated individuals’ “true” systolic BP BP measurement of at least 140 mmHg systolic and 90 mmHg diastolic. 1 by averaging participants’ three systolic BP measurements. They matched individuals based on their average BP at baseline (i.e., some of whom received a letter, and some of whom did not) and compared their health outcomes at follow-up. Both analyses controlled for sex, who received a letter may have substituted medication for exercise age, and regional variables. and diet change. Notably, receiving a referral letter positively impacted participants' mental health. At follow-up, those who received a letter were more likely to report favorable mental health than their counterparts who did not receive a letter. However, receiving a letter did not substantially Ciancio, A., Kämpfen, F., Kohler, H.-P. , and Kohler, I.V. (2021). Health affect participants’ assessments of their physical health or projected Screening for Emerging Non-Communicable Disease Burdens Among five-year survival. the Global Poor: Evidence From Sub-Saharan Africa. Journal of Health Economics. doi: 10.1016/j.jhealeco.2020.102388. This brief is supported THE IMPLICATIONS by the Penn Population Aging Research Center, funded by the National Institute on Aging (2P30AG012836-26). Among adults at risk of hypertension in rural Malawi, providing a simple referral letter effectively reduced BP and hypertension over four years. It also had positive effects in other health dimensions, including subjective mental health and probability of taking BP medication. AUTHORS Alberto Ciancio, PhD is a Postdoctoral Fellow in the Department This is one of the first studies to document long-term health effects of Economics at the University of Lausanne and an affiliate of the of a simple screening for non-communicable disease in sub-Saharan Population Studies Center of the University of Pennsylvania. Africa. Overall, the findings suggest that while individuals are willing Fabrice Kämpfen, PhD is a Postdoctoral Fellow at the Population to spend time and effort to treat non-communicable disease, they Studies Center of the University of Pennsylvania. Dr. Kämpfen is the are less willing to modify their habits and daily routines to prevent coordinator of a research for development (r4d) project funded by the it. Importantly, rural, low-income populations may have different Swiss Programme for Research on Global Issues for Development, modifiable risk factors for disease than high or middle-income which finances projects in India, Sri Lanka, the Philippines, and Malawi. populations. Future research should examine the pathways through Hans-Peter Kohler, PhD is the Frederick J. Warren Professor of which participants in rural and low-income contexts achieve a Demography in the Department of Sociology and co-director of the reduction in BP and how this differs from other settings. Population Aging Research Center at the University of Pennsylvania. Dr. Kohler is also Research Associate in the Population Studies Center THE STUDY at the University of Pennsylvania. The authors analyzed data from the Mature Adults Cohort of the Iliana V. Kohler, MA, PhD is Research Assistant Professor of Population Malawi Longitudinal Study of Families and Health (MLSFH-MAC, Studies and Associate Director of the Population Studies Center at the 2012-2018), which includes adults ages 45+ in rural areas of three University of Pennsylvania. Dr. Kohler spearheaded the extension of the Malawi Longitudinal Study of Families and Health (MLSFH) and Malawi districts. All participants received a BP screening in 2013 and established the Mature Adults Cohort (MAC) of MLSFH in 2012. again in 2017, in which their diastolic and systolic BP was recorded