Access to Care for Cardiometabolic Diseases in Low- and Middle-Income CountriesKumulative Dissertation
Datum der mündl. Prüfung:2022-09-19
Betreuer:Prof. Dr. Sebastian Vollmer
Gutachter:Prof. Dr. Sebastian Vollmer
Gutachter:Prof. Dr. Renate Hartwig
Gutachter:Prof. Dr. Jennifer Asst. Manne-Goehler
EnglischThe objective of this dissertation is to contribute to evidence on access to care for cardiovascular disease (CVD) – the most common cause of death globally – by a) describing the state of hypercholesterolemia care in a large range of low-and middle-income countries (LMICs) and b) testing the effectiveness of two individual-level interventions aimed at increasing CVD screening behavior in Indonesia and South Africa. This dissertation describes that access to CVD care is poor in many LMICs. We showed that especially for diabetes and hypercholesterolemia, large shares of affected individuals are never screened for their conditions. Furthermore, across all diabetes, hypercholesterolemia, and hypertension, we found large drops along diagnosis, treatment, and control stages of care. As a marker for integrated CVD care, the analysis of statin use for primary and secondary prevention of CVD additionally showed that no examined LMIC met World Health Organization treatment targets. These findings suggest that large population shares remain without appropriate care for the global leading cause of death – calling for greater policy and research attention towards facilitating improved CVD care in LMICs. Highlighting opportunities for improvement, we found that substantial heterogeneities in access to care across regions and countries exist. Some countries, such as Costa Rica, were found to consistently perform better across multiple studies and conditions, potentially offering important policy lessons upon closer inspection. Also at the individual level, patterns in the associations with care outcomes suggest that targeting mechanism for identifying respondent at higher risk of presenting with CVD may partially be in place; with older individuals and those presenting with comorbidities being more likely to achieve care outcomes. At the same time, also differences in key socioeconomic characteristics, such as education, became apparent – requiring solutions that expand on efficient, but equitable target mechanisms. While solutions must be found on all levels of the health system, this dissertation specifically points to two interventions aimed at increasing individual-level screening demand for CVD risk factors, namely SMS reminder and survey-based referral letters. Both interventions aimed at increasing the salience of CVD risk factors by instructing and reminding individuals to seek care; as well as aimed at altering risk perceptions of individuals by offering different degrees of personalized risk information. They showed that health behavior can be affected by such light-touch interventions, as SMS reminders induced greater screening uptake, and survey-based referral letters induced small changes in health outcomes in certain population groups (yet left no impact on others). In the SMS intervention, this seemed to have worked primarily through a reminder effect. In the referral letter intervention, impact varied by physical and mental health status, potentially addressing perceptions of risk of illness and of screening and treatment benefits. Overall, these interventions show that CVD health behavior can be affected by such light-touch interventions, but to an extent that still left large care gaps remaining.
Keywords: Global Health; Cardiovascular Diseases; Access to Care; RCT; Indonesia; South Africa; LMIC