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PublicationAssessing (and Addressing) Reporting Heterogeneity in Visual Analogue Scales (VAS) with an Application to Gender Difference in Quality of Life(2019-07-30) Huang, Zhiyong; Kämpfen, Fabrice; Huang, Zhiyong; Kämpfen, FabriceIn this study, we propose several new methods to account for reporting heterogeneity in self-reported data coming from Visual Analogue Scales (VAS) using corresponding VAS-based anchoring vignettes. Compared to usual Likert scale measures, VAS have the advantage that they lead to more nuanced assessments. Yet, like responses to Likert scale, VAS may suffer from individual-specific reporting heterogeneity. To the best of our knowledge, such reporting heterogeneity and potential solutions to solve this problem in the context of VAS measures have not yet been addressed in the literature. Using VAS-based anchoring vignettes and standard vignettes assumptions (vignette equivalence and response consistency), we show how standard fixed-effect approaches and double-index models can be used to address individual-specific reporting heterogeneity in VAS. We also show that several other methods such as Generalized Ordered Response models and Hierarchical Ordered Probit (HOPIT) models can be used to meaningfully adjust for potential reporting heterogeneity under the weaker assumption that VAS responses should be interpreted as ordered rather than cardinal data. We then apply our methods to real data assessing gender differences in Quality of Life (QoL) among students in Switzerland. While female students report higher levels of QoL than male students -as commonly found in the literature- we also show that female students tend to rate the QoL of corresponding comparable anchoring vignettes higher than male students. Accounting for these gender differences in response behaviors, we show that female students actually appear to be worse off in terms of QoL than male students. This finding suggests that reporting heterogeneity may be important in assessing gender differences in QoL and that the commonly found female advantage in QoL assessments may at least be partially due to differences in reporting behavior. PublicationHealth Screening for Emerging and Non-Communicable Disease Burdens Among the Global Poor(2021-01-26) Ciancio, Alberto; Kämpfen, Fabrice; Kohler, Hans-Peter; Kohler, Iliana V.; Ciancio, Alberto; Kämpfen, Fabrice; Kohler, Hans-Peter; Kohler, Iliana V.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. PublicationThe Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC)(2020-01-28) Kohler, Iliana V.; Bandawe, Chiwoza; Ciancio, Alberto; Kämpfen, Fabrice; Payne, Collin F.; Mwera, James; Mkandawire, James; Kohler, Hans-Peter; Kohler, Iliana V.; Bandawe, Chiwoza; Ciancio, Alberto; Kämpfen, Fabrice; Payne, Collin F.; Mwera, James; Mkandawire, James; Kohler, Hans-PeterCohort purpose: The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) contributes to global aging studies by providing a rare opportunity to study the processes of individual and population aging, the public health and social challenges associated with aging and the coincident shifts in disease burdens, in a low-income, high HIV prevalence, sub-Saharan African (SSA) context. Design and Measures: The MLSFH-MAC is a population-based cohort study of mature adults aged 45 years and older living in rural communities in three districts in Malawi (Mchinji, Balaka and Rumphi). Initial enrollment at baseline is 1,266 individuals in 2012. MLSFH-MAC follow-ups were in 2013, 2017, and 2018. Survey instruments cover aging-related topics such as cognitive and mental health, NCDs and related health literacy, subjective survival expectations, measured biomarkers including HIV, grip strength, hypertension, fasting glucose, BMI, a broad range of individual- and household-level social and economic information, a 2018 qualitative survey of mature adults and community officials, 2019 surveys of village heads, health care facilities and health care providers in the MLSFH-MAC study areas. Unique features: MLSFH-MAC is a data resource that covers 20 years of the life course of cohort members and provides a wealth of information unprecedented for aging studies in a low-income SSA context that broadly represents the socioeconomic environment of millions of individuals in south-eastern Africa. Among these are the longitudinal population-based data on depression and anxiety using clinically-validated instruments. MLSFH-MAC is also vanguard in measuring longitudinal changes in cognitive health among older individuals in SSA. Complemented by contextual and qualitative information, the extensive MLSFH-MAC data facilitate a life-course perspective on aging that reflects the dynamic and distinct settings in which people reach older ages in SSA LICs. Across many domains, MLSFH-MAC also allows for comparative research with global aging studies through harmonized measures and instruments. Collaboration and data access: Public-use version of the 2012 (baseline) MLSFH-MAC data can be requested at http://www.malawi.pop.upenn.edu. Sharing of additional MLSFH-MAC data is currently possible as part of collaborative research projects (if not overlapping with ongoing research projects, and subject to a Data Use Agreement). PublicationCurtailing COVID-19 on a Dollar-a-Day in Malawi: Implications for the Ongoing Pandemic(2021-03-15) Kohler, Iliana V.; Kämpfen, Fabrice; Ciancio, Alberto; Mwera, James; Kohler, Hans-Peter; Kämpfen, Fabrice; Ciancio, Alberto; Mwera, James; Mwapasa, Victor; Kohler, Hans-PeterUtilizing 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 investigate behavioral, economic and social responses COVID-19 and focus on the crucial role that community leadership and trust in institutions play towards shaping these responses. We argue that the effective response of Malawi to limit the spread of the virus was facilitated by the engagement of local leaders to mobilize communities to adapt and adhere to COVID-19 prevention strategies. Village heads (VHs) played pivotal role in shaping individual's knowledge about the pandemic and the adaption 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. PublicationKnow Your Epidemic, Know Your Response: COVID-19 in the United States(2020-03-31) Ciancio, Alberto; Kämpfen, Fabrice; Kohler, Iliana V.; Ciancio, Alberto; Kämpfen, Fabrice; Kohler, Iliana V.; Bennett, Daniel; Kohler, Hans-Peter; Darling, Jill; Kapteyn, Arie; Maurer, Jürgen; Kohler, Hans-PeterWe document that during the week of March 10-16, the Covid-19 pandemic fundamentally affected the perceptions of U.S. residents about the health risks and socioeconomic consequences entailed by the pandemic. During this week, it seems, "everything changed." Not only did the pandemic progress rapidly across the United States, but U.S. residents started to realize that the threat was real: increasing Covid-19 caseloads heightened perceptions of infection risks and excess mortality risks, concerns about the economic implications increased substantially, and behavioral responses became widespread as the pandemic expanded rapidly in the U.S. In early to mid-March 2020, average perceptions about the coronavirus infection risks are broadly consistent with projections about the pandemic, while expectations about dying conditional on infection and expectations about Covid-19-related excess mortality during the next months are possibly too pessimistic. However, some aspects of Covid-19 perceptions are disconcerting from the perspective of implementing and sustaining an effective societal response to the pandemic. For instance, the education gradient in expected infection risks entails the possibility of having different perceptions of the reality of the pandemic between people with and without a college education, potentially resulting in two different levels of behavioral and policy-responses across individuals and regions. Unless addressed by effective health communication that reaches individuals across all social strata, some of the misperceptions about Covid-19 epidemic raise concerns about the ability of the United States to implement and sustain the widespread and harsh policies that are required to curtail the pandemic. Our analyses also reveal perceptions of becoming infected with the virus, and dying from Covid-19, were driven upwards by a rapidly increasing national caseload, and perceptions of the economic consequences and the adaptation of social distancing were affected by both national and state-level cases. PublicationThe Effects of Negative Economic Shocks at Birth on Child Health in Sub-Saharan Africa(2020-01-01) Kämpfen, Fabrice; Kämpfen, FabriceIn this study, I estimate the effects that mothers' experience of negative economic shocks during pregnancy or shortly after childbirth has on children's subjective and objective health measures in Malawi. Using data from the Malawi Longitudinal Study on Families and Health (MLSFH), I find that children whose mothers were hit by such economic shocks were about 7 percentage points less likely to be reported to be in excellent health and 8 percentage points less likely to be reported to be in much better health compared to children of the same age and sex in the same village by their mothers. They were also about 300 grams lighter and 0.3 centimeters shorter than others, although the latter estimate is relatively imprecise and not statistically significant at conventional significance levels. These results are robust to various econometric specifications and sample selection rules. In addition, I propose a simple model to account for the fact that economic shocks are self-reported and show that my results are likely to continue to hold under reasonable assumptions about the rates of false positive and false negative reports of these economic shocks. PublicationThe Effects of Negative Economic Shocks at Birth on Adolescents’ Cognitive Health and Educational Attainment in Malawi(2021-10-30) Kämpfen, Fabrice; Zahra, Fatima; Kohler, Hans-Peter; Kidman, Rachel; Kämpfen, Fabrice; Zahra, Fatima; Kohler, Hans-Peter; Kidman, RachelWe provide new evidence of the association between moderate negative economic shocks in utero or shortly after birth and adolescents’ cognitive outcomes and educational attainment in Malawi. This is one of the first studies to analyze the effect of not one, but multiple moderate negative economic shocks in a sub-Saharan African (SSA) low-income country (LIC). This focus is important as multiple economic shocks in early life are more representative of the experiences of adolescents in LICs. Combining data on adolescents aged 10-16 from the Adverse Childhood Experiences (ACE) project with the Malawi Longitudinal Study on Families and Health (MLSFH) (N = 1; 559), we use linear and probit regression models to show that girls whose households experienced two or more economic shocks in their year of birth have lower cognitive skills as measured by working memory, reading and mathematical skills. Girls also have lower educational attainment, conditional on age. These effects are gendered, as we do not observe similar effects among boys. Overall, our results point to lasting effects of early-life adversity on adolescents, and they highlight that, even in a LIC context where early-life adversity is common, policymakers need to intervene early to alleviate the potential long-term educational impacts of in utero or early life shocks among girls. PublicationHealth Screening for Emerging Disease Burdens Among the Global Poor(2020-02-14) Ciancio, Alberto; Kämpfen, Fabrice; Kohler, Hans-Peter; Kohler, Iliana V.; Ciancio, Alberto; Kämpfen, Fabrice; Kohler, Hans-Peter; Kohler, Iliana V.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. 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.