Health Decision-Making in the Aftermath of Disaster

摘要 灾害对卫生决策有何影响？灾难影响是否至少在一定程度上是通过变化来产生的 在经济偏好和心理因素上？公共卫生计划能否帮助保护社区免受 灾难的影响？我们通过研究发生在一场大灾难中的一场大灾难来探索这些问题 我们正在对莫桑比克的一个社区公共卫生项目进行随机评估。在.之前 这场灾难，在2017-2018年，这个研究小组进行了大约4500人的基线调查 家庭，并促进随机分配方案，forçaàcomunidade e Crianças(FCC， “加强社区和儿童”)。在76个社区中，有一半被分配到治疗中 组，接受FCC程序；其余的作为对照组。2019年3月，飓风艾达， 非洲有史以来最具破坏性的龙卷风袭击了我们的研究地区。FCC计划实现了一个 一套相互关联的健康、教育和经济干预措施。家庭连接到社区 支持网络，鼓励访问和使用当地公共卫生诊所，提供信息以改善 卫生决策，并参与小额信贷计划。我们首先估计人类和经济 损失以及对危险性行为(包括交易性行为)、性传播感染的影响 性传播感染检测、性传播感染发生率和新冠肺炎相关结局。我们在调查样本中估计影响 在灾难发生之前确定的，因此能够处理选择偏差(例如，差异样本 根据灾害暴露情况纳入)，否则会影响治疗效果估计。影响评估 将利用研究社区飓风暴露的异质性。然后，我们将研究对 可能中介灾害影响健康决策的个体偏好和心理因素-- 制作。检查动机信念偏差(在这种情况下，通过否认健康风险而保持的过度乐观)是 尤其新颖；它是行为经济学的一个新前沿，但尚未在健康领域得到实证评估-- 相关上下文。我们的测量工具是试验性的、经过改进的，并已准备好大规模实施。最后， 我们将评估FCC计划是否有助于保护社区免受灾难的负面影响 危险性行为暴露；性传播感染检测、流行和治疗；以及与新冠肺炎相关的 结果。因果推断将依赖于灾前随机分配的FCC程序。我们还将 审查该计划实现其保护效果的机制。该项目的发现可以 帮助指导未来公共卫生项目的设计。对经济学和心理学的洞察 灾后决策可以提出新的干预措施，以减轻灾害导致的疾病恶化 健康决策。公共卫生项目是否以及如何保护人们免受灾难的证据 为他们的最佳设计提供指导。

Abstract How do disasters affect health decision-making? Do disaster impacts operate, at least in part, through changes in economic preferences and psychological factors? Can public health programs help shield communities from the impacts of disasters? We pursue these questions by studying a major disaster that struck in the midst of a randomized evaluation we are conducting of a community-level public health program in Mozambique. Prior to the disaster, in 2017-2018, this study team had administered a baseline survey of approximately 4,500 households, and had facilitated random assignment of the program, Força à Comunidade e Crianças (FCC, “Strengthening Communities and Children”). Out of 76 communities, half were assigned to the treatment group, receiving the FCC program; the remainder serve as the control group. In March 2019, Cyclone Idai, the most destructive cyclone ever recorded in Africa, struck our study areas. The FCC program implements an interrelated set of health, educational, and economic interventions. Households are connected to community support networks, encouraged to visit and use local public health clinics, provided with information to improve health decision-making, and participate in microfinance programs. We first estimate human and economic losses, as well as impacts on risky sexual behaviors (including transactional sex), sexually transmitted infection (STI) testing, STI incidence, and COVID-19-related outcomes. We estimate impacts in a survey sample determined prior to the disaster, and are thus able to deal with selection biases (e.g., differential sample inclusion based on disaster exposure) that otherwise compromise treatment effect estimates. Impact estimates will exploit heterogeneity in hurricane exposure across study communities. Then, we will study impacts on individual preferences and psychological factors that may mediate the effects of disasters on health decision- making. Examining motivated belief biases (in this context, over-optimism maintained by health risk denial) is particularly novel; it is a new behavioral economics frontier but has not been empirically evaluated in health- related contexts. Our measurement tools are piloted, refined, and ready for large-scale implementation. Finally, we will assess whether the FCC program helps shield communities from the negative impacts of disaster exposure on risky sexual behaviors; STI testing, prevalence, and treatment; and on COVID-19-related outcomes. Causal inference will rely on the pre-disaster random assignment of the FCC program. We will also examine mechanisms through which the program achieves its protective effects. This project's findings can help guide the design of public health programs in the future. Insights into the economics and psychology of post-disaster decision-making can suggest novel interventions to mitigate disaster-induced deterioration of health decisions. Evidence on whether and how public health programs shield people from disasters can provide guidance on their optimal design.