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.

Eliciting Survival Expectations of the Elderly in Low-Income Countries: Evidence From India.

We examine several methodological considerations when eliciting probabilistic expectations in a developing country context using the Longitudinal Ageing Study in India (LASI). We conclude that although, on average, individuals are able to understand the concept of probability, responses are sensitive to framing effects and to own versus hypothetical-person effects. We find that overall, people are pessimistic about their survival probabilities compared with state-specific life tables and that socioeconomic status does influence beliefs about own survival expectations as found in previous literature in other countries. Higher levels of education and income have a positive association with survival expectations, and these associations persist even when conditioning on self-reported health. The results remain robust to several alternative specifications. We then compare the survival measures with objective measures of health. We find that activities of daily life, height, and low hemoglobin levels covary with subjective expectations in expected directions.

Monetary costs of dementia in the United States.

BACKGROUND: Dementia affects a large and growing number of older adults in the United States. The monetary costs attributable to dementia are likely to be similarly large and to continue to increase. METHODS: In a subsample (856 persons) of the population in the Health and Retirement Study (HRS), a nationally representative longitudinal study of older adults, the diagnosis of dementia was determined with the use of a detailed in-home cognitive assessment that was 3 to 4 hours in duration and a review by an expert panel. We then imputed cognitive status to the full HRS sample (10,903 persons, 31,936 person-years) on the basis of measures of cognitive and functional status available for all HRS respondents, thereby identifying persons in the larger sample with a high probability of dementia. The market costs associated with care for persons with dementia were determined on the basis of self-reported out-of-pocket spending and the utilization of nursing home care; Medicare claims data were used to identify costs paid by Medicare. Hours of informal (unpaid) care were valued either as the cost of equivalent formal (paid) care or as the estimated wages forgone by informal caregivers. RESULTS: The estimated prevalence of dementia among persons older than 70 years of age in the United States in 2010 was 14.7%. The yearly monetary cost per person that was attributable to dementia was either $56,290 (95% confidence interval [CI], $42,746 to $69,834) or $41,689 (95% CI, $31,017 to $52,362), depending on the method used to value informal care. These individual costs suggest that the total monetary cost of dementia in 2010 was between $157 billion and $215 billion. Medicare paid approximately $11 billion of this cost. CONCLUSIONS: Dementia represents a substantial financial burden on society, one that is similar to the financial burden of heart disease and cancer. (Funded by the National Institute on Aging.).

Candidate preferences and expectations of election outcomes.

Analysis of data from the American Life Panel shows that in the presidential election of 2008 and in multiple statewide elections in 2010, citizens exhibited large differences in their expectations of election outcomes. Expectations were strongly positively associated with candidate preferences, persons tending to believe that their preferred candidate is more likely to win the election. Committed supporters of opposing candidates regularly differed by 20-30% in their assessments of the likelihood that each candidate would win. These findings contribute evidence on the false consensus effect, the empirical regularity that own preferences tend to be positively associated with perceptions of social preferences. We used unique measures of preferences and perceptions that enabled respondents to express uncertainty flexibly. We studied a setting that would a priori seem inhospitable to false consensus--one where persons have little private information on social preferences but substantial common knowledge provided by media reports of election polls.

Using Elicited Choice Probabilities in Hypothetical Elections to Study Decisions to Vote.

This paper demonstrates the feasibility and usefulness of survey research asking respondents to report voting probabilities in hypothetical election scenarios. Posing scenarios enriches the data available for studies of voting decisions, as a researcher can pose many more and varied scenarios than the elections that persons actually face. Multiple scenarios were presented to over 4,000 participants in the American Life Panel (ALP). Each described a hypothetical presidential election, giving characteristics measuring candidate preference, closeness of the election, and the time cost of voting. Persons were asked the probability that they would vote in this election and were willing and able to respond. We analyzed the data through direct study of the variation of voting probabilities with election characteristics and through estimation of a random utility model of voting. Voting time and election closeness were notable determinants of decisions to vote, but not candidate preference. Most findings were corroborated through estimation of a model fit to ALP data on respondents' actual voting behavior in the 2012 election.

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.

Dementia and out-of-pocket spending on health care services.

BACKGROUND: High levels of out-of-pocket (OOP) spending for health care may lead patients to forego needed services and medications as well as hamper their ability to pay for other essential goods. Because it leads to disability and the loss of independence, dementia may put patients and their families at risk for high OOP spending, especially for long-term care services. METHODS: We used data from the Aging, Demographics, and Memory Study, a nationally representative subsample (n = 743) of the Health and Retirement Study, to determine whether individuals with dementia had higher self-reported OOP spending compared with those with cognitive impairment without dementia and those with normal cognitive function. We also examined the relationship between dementia and utilization of dental care and prescription medications-two types of health care that are frequently paid for OOP. Multivariate and logistic regression models were used to adjust for the influence of potential confounders. RESULTS: After controlling for demographics and comorbidities, those with dementia had more than three times the yearly OOP spending compared with those with normal cognition ($8216 for those with dementia vs. $2570 for those with normal cognition, P < .01). Higher OOP spending for those with dementia was mainly driven by greater expenditures on nursing home care (P < .01). Dementia was not associated with the likelihood of visiting the dentist (P = .76) or foregoing prescription medications owing to cost (P = .34). CONCLUSIONS: Dementia is associated with high levels of OOP spending but not with the use of dental care or foregoing prescription medications, suggesting that excess OOP spending among those with dementia does not "crowd out" spending on these other health care services.

Subjective expectations in the context of HIV/AIDS in Malawi.

In this paper we present a newly developed interactive elicitation methodology for collecting probabilistic expectations in a developing country context with low levels of literacy and numeracy, and we evaluate the feasibility and success of this method for a wide range of outcomes in rural Malawi. We find that respondents' answers about their subjective expectations take into account basic properties of probabilities, and vary meaningfully with observable characteristics and past experience. From a substantive point of view, the elicited expectations indicate that individuals are generally aware of differential risks. For example, individuals with lower incomes and less land rightly feel at greater risk of financial distress than people with higher socioeconomic status (SES), and people who are divorced or widowed rightly feel at greater risk of being infected with HIV than currently married individuals. Meanwhile many expectations-including the probability of being currently infected with HIV-are well-calibrated compared to actual probabilities, but mortality expectations are substantially overestimated compared to life table estimates. This overestimation may lead individuals to underestimate the benefits of adopting HIV risk-reduction strategies. The skewed distribution of expectations about condom use also suggests that a small group of innovators are the forerunners in the adoption of condoms within marriage for HIV prevention.

Changes in Spending and Labor Supply in Response to a Social Security Benefit Cut: Evidence from Stated Choice Data.

We investigate how individuals in the U.S. expect to adjust their labor force participation and savings if Social Security benefits were cut by 30 percent. Respondents were asked directly what they would do under this scenario. Using the resulting stated choice data we find that respondents would on average reduce spending by 18.2 percent before retirement and 20.4 percent after retirement. About 34.1% of respondents state they would definitely work longer and they would postpone claiming Social Security by 1.1 years. We investigate how working longer and claiming Social Security later would compensate partially for the loss in benefits among the individuals who are currently working, under the assumption that individuals retire and claim at the same time. Individuals would increase their Social Security benefits from the post-reform level due to additional earnings entering the benefit calculation and a smaller early claiming penalty (or higher delayed claiming credit). As a result, the Social Security benefit people would receive would drop on average by 21 rather than 30 percent. Still, the net financial loss, even after accounting for additional earnings, is sizeable for individuals in the lowest wealth tertile.

The Impact of Repeat HIV Testing on Risky Sexual Behavior: Evidence from a Randomized Controlled Trial in Malawi.

A significant proportion of HIV-positive adults in sub-Saharan Africa are in serodiscordant relationships. Identification of such serodiscordant couples through couple HIV testing and counseling (HTC) is thought to promote safe sexual behavior and reduce the probability of within couple seroconversion. However, it is possible HTC benefits are not sustained over time and therefore repeated HTC may be more effective at preventing seroconversion than one time HTC. We tested this theory in Zomba, Malawi by randomly assigning 170 serodiscordant couples to receive repeated HTC and 167 serodiscordant couples to receive one time HTC upon study enrollment (control group). We used linear probability models and probit model with couple fixed effects to assess the impact of the intervention on risky sexual behavior. At one-year follow-up, we found that couples that received repeated HTC reported significantly more condom use. However, we found no difference in rate of seroconversion between groups, nor did we find differences in subjective expectations about seroconversion or false beliefs about HIV, two expected pathways of behavior change. We conclude that repeated HTC may promote safe sexual behavior, but this result should be interpreted with caution, as it is inconsistent with the result from biological and subjective outcomes.

HIV-related social intolerance and risky sexual behavior in a high HIV prevalence environment.

Although most countries state that fighting social intolerance against persons with HIV is part of their national HIV strategy, the impact of reducing intolerance on risky sexual behavior is largely unknown. In this paper, we estimate the effect of social intolerance against HIV+ persons on risky sexual behavior in rural Malawi using data from roughly 2000 respondents from the 2004 and 2006 waves of the Malawi Longitudinal Study of Families and Health (MLSFH). The effect of social intolerance on risky behavior is a priori ambiguous. On the one hand, higher social intolerance or stigma can lead people to disassociate from the stigmatized group and hence promote risky behavior. On the other hand, intolerance can be viewed as a social tax on being HIV+ and thus higher intolerance may reduce risky behavior. We find that a decrease in social intolerance is associated with a decrease in risky behavior, including fewer partners and a lower likelihood of having extra-marital relations. This effect is mainly driven by the impact of social intolerance on men. Overall the results suggests that reducing social intolerance might not only benefit the HIV positive but might also forestall the spread of HIV.

The impact of HIV testing on subjective expectations and risky behavior in Malawi.

We investigate the causal impact of learning HIV status on HIV/AIDS-related expectations and sexual behavior in the medium run. Our analyses document several unexpected results about the effect of learning one's own, or one's spouse's, HIV status. For example, receiving an HIV-negative test result implies higher subjective expectations about being HIV-positive after two years, and individuals tend to have larger prediction errors about their HIV status after learning their HIV status. If individuals in HIV-negative couples also learn the status of their spouse, these effects disappear. In terms of behavioral outcomes, our analyses document that HIV-positive individuals who learned their status reported having fewer partners and using condoms more often than those who did not learn their status. Among married respondents in HIV-negative couples, learning only one's own status increases risky behavior, while learning both statuses decreases risky behavior. In addition, individuals in sero-discordant couples who learned both statuses are more likely to report some condom use. Overall, our analyses suggest that ensuring that each spouse learns the HIV status of the other, either through couple's testing or through spousal communication, may be beneficial in high-prevalence environments.

Individuals' Uncertainty about Future Social Security Benefits and Portfolio Choice.

Little is known about the degree to which individuals are uncertain about their future Social Security benefits, how this varies within the U.S. population, and whether this uncertainty influences financial decisions related to retirement planning. To illuminate these issues, we present empirical evidence from the Health and Retirement Study Internet Survey and document systematic variation in respondents' uncertainty about their future Social Security benefits by individual characteristics. We find that respondents with higher levels of uncertainty about future benefits hold a smaller share of their wealth in stocks.

Differential survival in Europe and the United States: estimates based on subjective probabilities of survival.

Cross-country comparisons of differential survival by socioeconomic status (SES) are useful in many domains. Yet, to date, such studies have been rare. Reliably estimating differential survival in a single country has been challenging because it requires rich panel data with a large sample size. Cross-country estimates have proven even more difficult because the measures of SES need to be comparable internationally. We present an alternative method for acquiring information on differential survival by SES. Rather than using observations of actual survival, we relate individuals' subjective probabilities of survival to SES variables in cross section. To show that subjective survival probabilities are informative proxies for actual survival when estimating differential survival, we compare estimates of differential survival based on actual survival with estimates based on subjective probabilities of survival for the same sample. The results are remarkably similar. We then use this approach to compare differential survival by SES for 10 European countries and the United States. Wealthier people have higher survival probabilities than those who are less wealthy, but the strength of the association differs across countries. Nations with a smaller gradient appear to be Belgium, France, and Italy, while the United States, England, and Sweden appear to have a larger gradient.

Probabilistic Polling And Voting In The 2008 Presidential Election: Evidence From The American Life Panel.

This article reports new empirical evidence on probabilistic polling, which asks persons to state in percent-chance terms the likelihood that they will vote and for whom. Before the 2008 presidential election, seven waves of probabilistic questions were administered biweekly to participants in the American Life Panel (ALP). Actual voting behavior was reported after the election. We find that responses to the verbal and probabilistic questions are well-aligned ordinally. Moreover, the probabilistic responses predict voting behavior beyond what is possible using verbal responses alone. The probabilistic responses have more predictive power in early August, and the verbal responses have more power in late October. However, throughout the sample period, one can predict voting behavior better using both types of responses than either one alone. Studying the longitudinal pattern of responses, we segment respondents into those who are consistently pro-Obama, consistently anti-Obama, and undecided/vacillators. Membership in the consistently pro- or anti-Obama group is an almost perfect predictor of actual voting behavior, while the undecided/vacillators group has more nuanced voting behavior. We find that treating the ALP as a panel improves predictive power: current and previous polling responses together provide more predictive power than do current responses alone.

Eliciting Subjective Probabilities in Internet Surveys.

Individuals' subjective expectations are important in explaining heterogeneity in individual choices, but their elicitation poses some challenges, in particular when one is interested in the subjective probability distribution of an individual. We have developed an innovative visual representation for Internet surveys that has some advantages over previously used formats. In this paper we present our findings from testing this visual representation in the context of individuals' Social Security expectations. Respondents are asked to allocate a total of 20 balls across seven bins to express what they believe the chances to be that their future Social Security benefits would fall into any one of those bins. Our data come from the Internet Survey of respondents to the Health and Retirement Study, a representative survey of the U.S. population age 51 and older. To contrast the results from the visual format with a previously used format we divided the sample into two random groups and administered both, the visual format and the more standard percent chance format. Our findings suggest that the main advantage of the visual format is that it generates usable answers for virtually all respondents in the sample while in the percent chance format a significant fraction (about 20 percent) of responses is lost due to inconsistencies. Across various other dimensions the visual format performs similarly to the percent chance format, leading us to conclude that the bins-and-balls format is a viable alternative that leads to more complete data.