Mortality risk information and health-seeking behavior during an epidemic.

In a context where pessimistic survival perceptions have been widespread as a result of the HIV/AIDS epidemic (Fig. 1 A), we study vaccine uptake and other health behaviors during the recent COVID-19 pandemic. Leveraging a longitudinal cohort study in rural Malawi that has been followed for up to 25 y, we document that a 2017 mortality risk information intervention designed to reduce pessimistic mortality perceptions (Fig. 1 B) resulted in improved health behavior, including COVID-19 vaccine uptake (Fig. 1 C). We also report indirect effects for siblings and household members. This was likely the result of a reinforcing process where the intervention triggered engagement with the healthcare system and stronger beliefs in the efficacy of modern biomedical treatments, which led to the adoption of health risk reduction behavior, including vaccine uptake. Our findings suggest that health information interventions focused on survival perceptions can be useful in promoting health behavior and participation in the formal healthcare system, even during health crises-such as the COVID-19 pandemic-that are unanticipated at the time of the intervention. We also note the importance of the intervention design, where establishing rapport, tailoring the content to the local context, and spending time with respondents to convey the information contributed to the salience of the message.

MORTALITY RISK INFORMATION, SURVIVAL EXPECTATIONS AND SEXUAL BEHAVIOURS.

We investigate the impact of a randomised information intervention about population-level mortality on health investment and subjective health expectations. Our focus is on risky sex in a high-HIV-prevalence environment. Treated individuals are less likely to engage in risky sexual practices one year after the intervention, with, for example, an 8% increase in abstinence. We collected detailed data on individuals' subjective expectations about their own and population survival, as well as other important health outcomes. Our findings emphasise the significance of integrating subjective expectation data in field experiments to identify the pathways that lead to behavioural change.

Status (in)consistency in education and violent parenting practices towards children.

Violent childrearing practices represent an invisible threat for global health and human development. Leveraging underused information on child discipline methods, this study explores the relationship between parental educational similarity and violent childrearing practices, testing a new potential pathway through which parental educational similarity may relate to child health and wellbeing over the life course. The study uses data from Multiple Indicator Cluster Surveys (MICS) and Demographic and Health Surveys (DHS) covering 27 sub-Saharan African (SSA) countries. Results suggest that couples where partners share the same level of education (homogamy) are less likely to adopt violent childrearing practices relative to couples where partners face status inconsistency in education (heterogamy), with differences by age of the child, yet less so by sex and birth order. Homogamous couples where both partners share high levels of education are also less (more) likely to adopt physically violent (non-violent) practices relative to homogamous couples with low levels of education. Relationships are stronger in countries characterized by higher GDP per capita, Human Development Index, and female education, yet also in countries with higher income and gender inequalities. Besides stressing the importance of female education, these findings underscore the key role of status concordance vs discordance in SSA partnerships. Tested micro-level mechanisms and country-level moderators only weakly explain result heterogeneity, calling for more research on the topic.

Barker's Hypothesis Among the Global Poor: Positive Long-Term Cardiovascular Effects of in Utero Famine Exposure.

An influential literature on the Developmental Origins of Health and Disease (DOHaD) has documented that poor conditions in utero lead to higher risk of cardiovascular disease at older ages. Evidence from low-income countries (LICs) has hitherto been missing, despite the fact that adverse in utero conditions are far more common in LICs. We find that Malawians exposed in utero to the 1949 Nyasaland famine have better cardiovascular health 70 years later. These findings highlight the potential context specificity of the DOHaD hypothesis, with in utero adversity having different health implications among aging LIC individuals who were exposed to persistent poverty.

Trends in psychological distress in Great Britain, 1991-2019: evidence from three representative surveys.

BACKGROUND: Previously improving UK mortality trends stalled around 2012, with evidence implicating economic policy as the cause. This paper examines whether trends in psychological distress across three population surveys show similar trends. METHODS: We report the percentages reporting psychological distress (4+ in the 12-item General Health Questionnaire) from Understanding Society (Great Britain, 1991-2019), Scottish Health Survey (SHeS, 1995-2019) and Health Survey for England (HSE, 2003-2018) for the population overall, and stratified by sex, age and area deprivation. Summary inequality indices were calculated and segmented regressions fitted to identify breakpoints after 2010. RESULTS: Psychological distress was higher in Understanding Society than in SHeS or HSE. There was slight improvement between 1992 and 2015 in Understanding Society (with prevalence declining from 20.6% to 18.6%) with some fluctuations. After 2015 there is some evidence of a worsening in psychological distress across surveys. Prevalence worsened notably among those aged 16-34 years after 2010 (all three surveys), and aged 35-64 years in Understanding Society and SHeS after 2015. In contrast, the prevalence declined in those aged 65+ years in Understanding Society after around 2008, with less clear trends in the other surveys. The prevalence was around twice as high in the most deprived compared with the least deprived areas, and higher in women, with trends by deprivation and sex similar to the populations overall. CONCLUSION: Psychological distress worsened among working-age adults after around 2015 across British population surveys, mirroring the mortality trends. This indicates a widespread mental health crisis that predates the COVID-19 pandemic.

Pain Is Widespread and Predicts Poor Mental Health Among Older Adults in Rural Malawi.

Background and Objectives: Pain is common among older persons and has been documented as an important predictor of disability, health, and economic outcomes. Evidence about its prevalence and relationship to well-being is scarce in rural sub-Saharan Africa (SSA), where work is frequently physically demanding, and pain prevention or treatment options are limited. We investigate the prevalence of pain and its association with mental health and subjective well-being in a population-based study of older adults in rural Malawi. Research Design and Methods: We estimate the prevalence, severity, and duration of pain along with its sociodemographic distribution in a sample of 1,577 individuals aged 45 and older. We assess the association of pain with clinically validated measures of mental health, including depression and anxiety, and subjective well-being. Results: Pain is widespread in this mature population with an average age of 60 years: 62% of respondents report the experience of at least minor pain during the last year, and half of these cases report severe or disabling pain. Women are more likely to report pain than men. Pain is a strong predictor of mental health and subjective well-being for both genders. More severe or longer pain episodes are associated with worse mental states. Individuals reporting pain are more likely to suffer from depression or express suicidal thoughts. Discussion and Implications: Our study identifies key subpopulations such as older women in a SSA low-income context who are particularly affected by the experience of pain in daily life and calls for interventions targeting pain and its consequences for mental health and subjective well-being.

Curtailing Covid-19 on a dollar-a-day in Malawi: Role of community leadership for shaping public health and economic responses to the pandemic.

Utilizing population-based data from the Covid-19 phone survey ( N = 2 , 262 ) of the Malawi Longitudinal Study of Families and Health (MLSFH) collected during June 2nd-August 17th, 2020, we focus on the crucial role that community leadership and trust in institutions played in shaping behavioral, economic and social responses to Covid-19 in this low-income sub-Saharan African context. We argue that the effective response of Malawi to limit the spread of the virus was facilitated by the engagement of local leadership to mobilize communities to adapt and adhere to Covid-19 prevention strategies. Using linear and ordered probit models and controlling for time fixed effects, we show that village heads (VHs) played pivotal role in shaping individuals' knowledge about the pandemic and the adoption of preventive health behaviors and were crucial for mitigating the negative economic and health consequences of the pandemic. We further show that trust in institutions is of particular importance in shaping individuals' behavior during the pandemic, and these findings highlight the pivotal role of community leadership in fostering better compliance and adoption of public health measures essential to contain the virus. Overall, our findings point to distinctive patterns of pandemic response in a low-income sub-Saharan African rural population that emphasized local leadership as mediators of public health messages and policies. These lessons from the first pandemic wave remain relevant as in many low-income countries behavioral responses to Covid-19 will remain the primary prevention strategy for a foreseeable future.

Health screening for emerging non-communicable disease burdens among the global poor: Evidence from sub-Saharan Africa.

Evidence for the effectiveness of population health screenings to reduce the burden of non-communicable diseases in low-income countries remains very limited. We investigate the sustained effects of a health screening in Malawi where individuals received a referral letter if they had elevated blood pressure. Using a regression discontinuity design and a matching estimator, we find that receiving a referral letter reduced blood pressure and the probability of being hypertensive by about 22 percentage points four years later. These lasting effects are explained by a 20 percentage points increase in the probability of being diagnosed with hypertension. There is also evidence of an increase in the uptake of medication, while we do not identify improvements in hypertension-related knowledge or risk behaviors. On the contrary, we find an increase in sugar intake and a decrease in physical activity both of which are considered risky behaviors in Western contexts. The health screening had some positive effects on mental health. Overall, this study suggests that population-based hypertension screening interventions are an effective tool to improve health in low-income contexts.

Predictors of mental health during the Covid-19 pandemic in the US: Role of economic concerns, health worries and social distancing.

Despite the profound health and economic implications of Covid-19, there is only limited knowledge to date about the role of economic concerns, health worries and social distancing for mental health outcomes during the pandemic. We analyze online survey data from the nationally representative "Understanding America Study" (UAS) covering the period of March 10-31st 2020 (sample size: 6,585). Mental health is assessed by the validated PHQ-4 instrument for measuring symptoms of depression and anxiety. About 29% (CI:27.4-.30.4%) of the US adult population reported some depression/anxiety symptoms over the study period, with symptoms deteriorating over the month of March. Worsening mental health was most strongly associated with concerns about the economic consequences of the pandemic, while concerns about the potential implications of the virus for respondents' own health and social distancing also predicted increases in symptoms of depression and anxiety during the early stages of the pandemic in the US, albeit less strongly. Our findings point towards the possibility of a major mental health crisis unfolding simultaneously with the pandemic, with economic concerns being a key driving force of this crisis. These results highlight the likely importance of economic countermeasures and social policy for mitigating the impact of Covid-19 on adult mental health in the US over and above an effective public health response.

Cohort profile: the mature adults cohort of the Malawi longitudinal study of families and health (MLSFH-MAC).

PURPOSE: The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) contributes to global ageing studies by providing a rare opportunity to study the processes of individual and population ageing, the public health and social challenges associated with ageing and the coincident shifts in disease burdens, in a low-income, high HIV prevalence, sub-Saharan African (SSA) context. PARTICIPANTS: The MLSFH-MAC is an open population-based cohort study of mature adults aged 45+ years living in rural communities in three districts in Malawi. Enrolment at baseline is 1266 individuals in 2012. Follow-ups were in 2013, 2017 and 2018 when the cohort size reached 1626 participants in 2018. FINDINGS TO DATE: Survey instruments cover ageing-related topics such as cognitive and mental health, non-communicable diseases (NCDs) and related health literacy, subjective survival expectations, measured biomarkers including HIV, grip strength, hypertension, fasting glucose, body mass index (BMI), broad individual-level and household-level social and economic information, a 2018 qualitative survey of mature adults and community officials, 2019 surveys of village heads, healthcare facilities and healthcare providers in the MLSFH-MAC study areas. Across many domains, MLSFH-MAC allows for comparative research with global ageing studies through harmonised measures and instruments. Key findings to date include a high prevalence of depression and anxiety among older adults, evidence for rapid declines in cognitive health with age, a low incidence of HIV among mature adults, rising prevalence of HIV due to increased survival of HIV-positive individuals and poor physical health with high NCD prevalence. FUTURE PLANS: An additional wave of MLSFH-MAC is forthcoming in 2021, and future expansions of the cohort are planned. MLSFH-MAC data will also be publicly released and will provide a wealth of information unprecedented for ageing studies in a low-income SSA context that broadly represents the socioeconomic environment of millions of individuals in south-eastern Africa.

Know your epidemic, know your response: Early perceptions of COVID-19 and self-reported social distancing in the United States.

As COVID-19 is rapidly unfolding in the United States, it is important to understand how individuals perceive the health and economic risks of the pandemic. In the absence of a readily available medical treatment, any strategy to contain the virus in the US will depend on the behavioral response of US residents. In this paper, we study individual's perceptions on COVID-19 and social distancing during the week of March 10-16, 2020, a week when COVID-19 was officially declared to be a pandemic by WHO and when new infections in the US were more than doubling every three days. Using a nationally representative sample of 5,414 respondents 18+ years of age from the Understanding America Study (UAS), we find that perceptions about COVID-19 health risks and economic consequences in the US population were largely pessimistic and highly variable by age and education. US residents who are young and do not have a college degree perceived a lower risk of getting infected but a higher probability of running out of money than others. Most individuals reported taking some steps to distance themselves from others but important differences emerge by gender and by source of information on COVID-19. Using state and day fixed-effect regressions, we show that perceptions of the health risks closely followed the number of COVID-19 cases in the country, and perceptions of the economic consequences and the prevalence of social distancing were driven upwards by both national and state-level cases. Unless addressed by effective health communication that reaches individuals across all social strata, variations in perceptions about COVID-19 epidemic raise concerns about the ability of the US to implement and sustain the widespread and restrictive policies that are required to curtail the pandemic.