Abstract
Recent improvements in adult life expectancies in high HIV-prevalence sub-Saharan African (SSA) low-income countries (LICs) have reversed previous adverse trends in adult survival during the 1990s and early 2000s when the HIV/AIDS epidemic considerably reduced life expectancies. Despite these improvements, there is widespread evidence that many individuals have distorted survival and disease perceptions (SDPs) and are overly pessimistic about their own survival and disease environment. For example, rural Malawians underestimate their chances to survive five years by 33–45%, which is consistent with considerable overestimation of local HIV prevalence and morbidity. These distorted SDPs are likely to affect mental health and influence a wide range of behaviors, including sexual behaviors, labor supply, human capital investments, and preparations for old-age. Despite the recent strong evidence about the benefits of more accurate SDPs, however, there are no population-based randomized controlled trials (RCTs) that have directly evaluated this hypothesis. The RCT proposed as part of this R21 project, which builds on separately-funded collection for mature adults in Malawi, is designed to (i) explore possibilities to improve the accuracy of SDPs by providing information about current health and mortality risks through a health-information intervention, and (ii) test whether more accurate SDPs improve mental health, life-course decision-making and a broad range of social/economic outcomes among mature adults (= individuals aged 45+). If our hypotheses are supported, this research will provide strong support for cost-effective health-information programs that are highly pertinent in SSA LICs, where mortality levels and disease conditions/treatments have changed rapidly in recent years, and more generally, among older individuals who are likely to underestimate their longevity given recent progress in reductions of old-age mortality. The Specific Aims of this project include: (1) Conduct exploratory research in 2016 on how to effectively convey evidence-based information about recent mortality levels and trends to mature adults to increase the accuracy of survival and disease perceptions (SDPs) in Malawi, and subsequent to the already-funded 2016 data collection for mature adults, conduct a health-information intervention that randomizes 50\% of the study population (700+ individuals in 65+ villages) in a treatment group that will receive detailed information about recent mortality and health trends. (2) Collect new data in 2017 on (a) SDPs (including subjective expectations about survival, health, local HIV prevalence), (b) health (including mental health and cognitive function), (c) health behaviors and expenditures, (d) life-cycle behaviors and preparations for old age. (3) Using existing data, already-funded data collection and new data collection funded through this project on SDPs, health and life-cycle behaviors for the period 2006–18, (a) evaluate the causal impacts of health information on (i) SDPs, (ii) mental health and health behaviors, and (iii) labor supply, savings, intergenerational transfers and other life-cycle behaviors, (b) investigate the pathways through which SDPs affect these behaviors and outcomes.