How can we prevent millions of people with high blood pressure from going untreated? This question is at the heart of the international research project “Behavioral Science Strategies to Increase Hypertension Diagnosis and Treatment (Better Heart),” which is led by Prof. Dr. Nikkil Sudharsanan, head of the Assistant Professorship of Behavioral Science for Disease Prevention and Health Care at the Technical University of Munich (TUM), together with partner institutions in India and the US. The project is funded by the US National Heart, Lung, and Blood Institute (NHLBI). It aims to improve access to diagnosis and treatment of high blood pressure in low- and middle-income countries through the use of behavioral science strategies.
High blood pressure, medically known as hypertension, is one of the world's leading risk factors for cardiovascular disease and death. It is estimated that more than 1.2 billion people live with high blood pressure, over 80 percent of them in low- and middle-income countries. The problem is particularly pronounced in India: About one-third of the adult population is affected, but the majority of those affected are unaware of their condition and therefore do not receive treatment. Most of these deaths could be prevented through early diagnosis and simple, inexpensive therapies. In recent years, several Indian states have introduced programs in which health professionals make home visits, offer blood pressure measurements, and refer people with elevated readings to medical facilities. However, the crucial step – medical confirmation and the start of treatment – is often not taken. Many of those affected who show abnormal readings during home examinations do not visit the recommended clinic or do not initiate essential treatment.
“We see time and again that it is not just a question of the availability of health services,” explains Prof. Sudharsanan. “Often, it is behavioral factors – misconceptions, information gaps, or everyday obstacles – that prevent people from taking the next step.” This is precisely where the “Better Heart” project comes in. The research team is using insights from behavioral science to improve access to medical care and close the gaps in the care chain from diagnosis to treatment. There are two main hurdles in particular: widespread misconceptions about high blood pressure and the short-term costs and efforts associated with seeking medical care.
Many people in India believe that treatment is only necessary if they feel ill or experience symptoms such as headaches or dizziness. However, since high blood pressure is usually asymptomatic, it is often ignored – until serious health consequences arise. In addition, visits to the doctor require time, money, and organization. For many people, these immediate hurdles outweigh the long-term health benefits of treatment.
The “Better Heart” team is developing and testing two behavioral science approaches to address these challenges. On the one hand, new communication strategies and counseling approaches will be used that are specifically designed to correct common misconceptions about high blood pressure and raise awareness of the need for regular medical checkups. Second, small financial incentives – for example, 250 Indian rupees, equivalent to around three US dollars – will be tested to give those affected an additional incentive to visit a medical facility for a confirmatory measurement. The underlying idea is that an immediate positive incentive offsets the short-term costs and thus promotes healthier behavior in the long term.
To test the effectiveness of these strategies, a randomized controlled trial will be conducted in around 25 villages in the southern Indian state of Andhra Pradesh. This region has a particularly high prevalence of high blood pressure, while at the same time many people remain unconnected with care and treatment. Approximately 1,700 adults with elevated blood pressure but without a previous medical diagnosis will participate in the study. They will be divided into four groups, each receiving different combinations of counseling approaches and financial incentives. The team will then determine which combination of strategies has the greatest impact on seeing a physician, initiating treatment, and ultimately blood pressure control.
In addition to quantitative data collection, qualitative interviews will be conducted with participants, doctors, and other healthcare professionals. These interviews will provide insight into why certain strategies are more successful than others and which factors facilitate or hinder implementation in practice. The aim is to develop evidence-based recommendations that can also be applied to larger population groups and other countries.
“Better Heart” is a joint project of renowned institutions: In addition to TUM, the All India Institute of Medical Sciences (AIIMS), the University of Pennsylvania, Emory University, and J-PAL South Asia are also involved. The project will run for five years.
“This close international collaboration allows us to pool knowledge from various disciplines – from medicine and behavioral economics to public health and implementation research,” emphasizes Prof. Sudharsanan. “We want to develop strategies that are not only scientifically sound but also practical – both in India and in other countries facing similar challenges.”
The international research team hopes that the results of the project will make a decisive contribution to improving public health programs in India. If the strategies prove effective, they could be integrated into existing government screening programs, giving millions of people access to life-saving treatment. In addition, “Better Heart” provides valuable insights into how behavioral science and public health research can work together to make health interventions more effective.
“It's not just about imparting knowledge, but about changing behavior—in a way that is sustainable, respectful, and effective,” says Prof. Sudharsanan. “’Better Heart’ shows how interdisciplinary research can help make global health problems solvable.”
Contact:
Prof. Dr. Nikkil Sudharsanan
Rudolf Mößbauer Assistant Professorship for Behavioral Science for Disease Prevention and Health Care
Am Olympiacampus 11
80809 München
phone: 089 289 24990
e-mail: nikkil.sudharsanan(at)tum.de
Text: Romy Schwaiger
Photos: BEGIN Lab, University of Pennsylvania/Andreas Heddergott, TUM