Cohort profile: the Adverse Childhood Experiences cohort of the Malawi Longitudinal Study of Families and Health

PURPOSE

The Adverse Childhood Experiences (ACE) cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-ACE) is a study of adolescents surveyed during 2017-2021. It provides an important opportunity to examine the longitudinal impact of ACEs on health and development across the early life course. The MLSFH-ACE cohort provides rich data on adolescents, their children and adult caregivers in a low-income, high-HIV-prevalence context in sub-Saharan Africa (SSA).

PARTICIPANTS

The MLSFH-ACE cohort is a population-based study of adolescents living in three districts in rural Malawi. Wave 1 enrolment took place in 2017-2018 and included 2061 adolescents aged 10-16 years and 1438 caregivers. Wave 2 took place in 2021 and included data on 1878 adolescents and 208 offspring. Survey instruments captured ACEs during childhood and adolescence, HIV-related behavioural risk, mental and physical health, cognitive development and education, intimate partner violence (IPV), marriage and aspirations, early transitions to adulthood and protective factors. Biological indicators included HIV, herpes simplex virus and anthropometric measurements.

FINDINGS TO DATE

Key findings include a high prevalence of ACEs among adolescents in Malawi, a low incidence of HIV and positive associations between ACE scores and composite HIV risk scores. There were also strong associations between ACEs and both IPV victimisation and perpetration.

FUTURE PLANS

MLSFH-ACE data will be publicly released and will provide a wealth of information on ACEs and adolescent outcomes in low-income, HIV-endemic SSA contexts. Future expansions of the cohort are planned to capture data during early adulthood.

Surprising Gendered Age Differences in Rural Malawians' Early COVID-19 Pandemic Prevention Efforts

OBJECTIVES

We assess how age, the presence of mature adults aged 45+ years, and recent deaths in rural households are associated with coronavirus disease 2019 (COVID-19) preventative actions and the likelihood of getting vaccinated against the virus in Malawi during early stages of the pandemic.

METHODS

We draw upon data from 2,187 rural Malawians who participated in a 2020 COVID-19 Phone Survey. We estimate the log odds of engaging in "low-cost" and "high-cost" COVID-19 preventative actions based on age, gender, household composition, and recent household deaths. Low-cost prevention efforts were washing hands with soap and water frequently, avoiding close contact with people when going out, and avoiding shaking hands. High-cost actions included staying at home and decreasing time spent close to people not living in their household. We also estimate the chances of acquiring the COVID-19 vaccine in early stages of its availability.

RESULTS

Mature women (45+ years) in general and younger men (<45 years)-living with at least one mature adult in the household-were less likely than others to comply with low-cost actions. Mature men were more likely than younger men (<45 years) to take on high-cost actions. To some extent, individuals who experienced a recent family death were more likely to engage in high-cost COVID-19 preventative actions as well as getting vaccinated.

DISCUSSION

Gendered age differences in preventing the transmission of COVID-19 offer hints of larger social norms affecting protective efforts. The analyses also inform future COVID-19 public health outreach efforts in Malawi and other rural SSA contexts.

Drivers of child marriages for girls: A prospective study in a low-income African setting

Child marriage has adverse consequences for young girls. Cross-sectional research has highlighted several potential drivers of early marriage. We analyse drivers of child marriage using longitudinal data from rural Malawi, where rates of child marriage are among the highest in the world despite being illegal. Estimates from survival models show that 26% of girls in our sample marry before age 18. Importantly, girls report high decision-making autonomy vis-à-vis the decision to marry. We use multivariate Cox proportional hazard models to explore the role of 1) poverty and economic factors, 2) opportunity or alternatives to marriage, 3) social norms and attitudes, 4) knowledge of the law and 5) girls' agency. Only three factors are consistently associated with child marriage. First, related to opportunities outside marriage, girls lagging in school at survey baseline have significantly higher rates of child marriage than their counterparts who were at or near grade level. Second, related to social norms, child marriage rates are significantly lower among respondents whose caregivers perceive that members of their community disapprove of child marriage. Third, knowledge of the law has a positive coefficient, a surprising result. These findings are aligned with the growing qualitative literature describing contexts where adolescent girls are more active agents in child marriages.

Is experience of the HIV/AIDS epidemic associated with responses to COVID-19? Evidence from the Rural Malawi

INTRODUCTION

Starting in late 2019, the coronavirus "SARS-CoV-2", which causes the disease Covid-19, spread rapidly and extensively. Although many have speculated that prior experience with infectious diseases like HIV/AIDS, Ebola, or SARS would better prepare populations in sub-Saharan Africa for COVID-19, this has not been formally tested, primarily due to data limitations.

METHODS

We use longitudinal panel data from the Malawi Longitudinal Study of Families and Health (MLSFH, waves 2006, 2008, and 2020) to examine the association between exposure to the HIV/AIDS epidemic and perceptions of, and behavioral response to, the COVID-19 pandemic. We measured exposure to HIV infection through perceived prevalence of HIV/AIDS in the community, worry about HIV infection, perceived likelihood of HIV infection, and actual HIV status; and the experience of HIV/AIDS-related mortality through self-reports of knowing members of the community and extended family who died from AIDS (measured in 2006 or 2008). Our outcome measures were perceptions of COVID-19 presence in the community, perceptions of individual vulnerability to COVID-19, and prevention strategies to avoid COVID-19 collected through phone-interviews in 2020.

RESULTS

Based on our data analysis using multivariable regression models, we found that the experience of HIV-related mortality was positively associated with perceptions of COVID-19 prevalence in the community and preventive behaviors for COVID-19. However, perceived vulnerability to HIV-AIDS infection and actual HIV positive status 10-years prior to the COVID-19 pandemic are generally not associated with COVID-19 perceptions and behaviors.

CONCLUSIONS

Our results suggest that COVID-19-related behaviors are impacted more by experience of AIDS mortality instead of HIV/AIDS risk perceptions, and that individuals may be correctly viewing HIV/AIDS and COVID-19 transmission as distinct disease processes.

Pain Is Widespread and Predicts Poor Mental Health Among Older Adults in Rural Malawi

Background and Objectives

Pain is common among older persons and has been documented as an important predictor of disability, health, and economic outcomes. Evidence about its prevalence and relationship to well-being is scarce in rural sub-Saharan Africa (SSA), where work is frequently physically demanding, and pain prevention or treatment options are limited. We investigate the prevalence of pain and its association with mental health and subjective well-being in a population-based study of older adults in rural Malawi.

Research Design and Methods

We estimate the prevalence, severity, and duration of pain along with its sociodemographic distribution in a sample of 1,577 individuals aged 45 and older. We assess the association of pain with clinically validated measures of mental health, including depression and anxiety, and subjective well-being.

Results

Pain is widespread in this mature population with an average age of 60 years: 62% of respondents report the experience of at least minor pain during the last year, and half of these cases report severe or disabling pain. Women are more likely to report pain than men. Pain is a strong predictor of mental health and subjective well-being for both genders. More severe or longer pain episodes are associated with worse mental states. Individuals reporting pain are more likely to suffer from depression or express suicidal thoughts.

Discussion and Implications

Our study identifies key subpopulations such as older women in a SSA low-income context who are particularly affected by the experience of pain in daily life and calls for interventions targeting pain and its consequences for mental health and subjective well-being.

Curtailing Covid-19 on a dollar-a-day in Malawi: Role of community leadership for shaping public health and economic responses to the pandemic

Utilizing 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 focus on the crucial role that community leadership and trust in institutions played in shaping behavioral, economic and social responses to Covid-19 in this low-income sub-Saharan African context. We argue that the effective response of Malawi to limit the spread of the virus was facilitated by the engagement of local leadership to mobilize communities to adapt and adhere to Covid-19 prevention strategies. Using linear and ordered probit models and controlling for time fixed effects, we show that village heads (VHs) played pivotal role in shaping individuals' knowledge about the pandemic and the adoption 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.

Cohort profile: the mature adults cohort of the Malawi longitudinal study of families and health (MLSFH-MAC)

PURPOSE

The Mature Adults Cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-MAC) contributes to global ageing studies by providing a rare opportunity to study the processes of individual and population ageing, the public health and social challenges associated with ageing and the coincident shifts in disease burdens, in a low-income, high HIV prevalence, sub-Saharan African (SSA) context.

PARTICIPANTS

The MLSFH-MAC is an open population-based cohort study of mature adults aged 45+ years living in rural communities in three districts in Malawi. Enrolment at baseline is 1266 individuals in 2012. Follow-ups were in 2013, 2017 and 2018 when the cohort size reached 1626 participants in 2018.

FINDINGS TO DATE

Survey instruments cover ageing-related topics such as cognitive and mental health, non-communicable diseases (NCDs) and related health literacy, subjective survival expectations, measured biomarkers including HIV, grip strength, hypertension, fasting glucose, body mass index (BMI), broad individual-level and household-level social and economic information, a 2018 qualitative survey of mature adults and community officials, 2019 surveys of village heads, healthcare facilities and healthcare providers in the MLSFH-MAC study areas. Across many domains, MLSFH-MAC allows for comparative research with global ageing studies through harmonised measures and instruments. Key findings to date include a high prevalence of depression and anxiety among older adults, evidence for rapid declines in cognitive health with age, a low incidence of HIV among mature adults, rising prevalence of HIV due to increased survival of HIV-positive individuals and poor physical health with high NCD prevalence.

FUTURE PLANS

An additional wave of MLSFH-MAC is forthcoming in 2021, and future expansions of the cohort are planned. MLSFH-MAC data will also be publicly released and will provide a wealth of information unprecedented for ageing studies in a low-income SSA context that broadly represents the socioeconomic environment of millions of individuals in south-eastern Africa.

Using grip strength to compute physical health-adjusted old age dependency ratios

The standard approach for comparing the potential challenges of population aging across countries based on conventional old-age dependency ratios (OADR) does not account for cross-population differences in health, functional capacity or disability, despite their importance for labor force participation and dependency more broadly. We investigate how OADRs observed across selected low-, middle-, and high-income countries change if population differences in physical health measured by hand-grip strength are accounted for. Specifically, we propose and calculate an adjusted measure of the OADR based on hand-grip strength, which serves as an objective indicator of muscle function and has been shown to predict future morbidity, disability and mortality. We show that adjusting the OADR for differences in hand-grip strength results in substantial changes in country rankings by OADR compared to a ranking based on the conventional OADR definition. Accounting for cross-population differences in hand-grip strength, the estimated OADRs for low- and middle-income countries tend to increase compared to the conventional OADR approach based on age only, whereas the estimated OADRs in high-income countries decline substantially relative to the standard approach. Since hand-grip strength is an important prerequisite for maintaining functional capacity and productivity and preventing disability -especially in economies in low-income settings- our grip-strength-adjusted OADRs clearly show that population aging is not just a challenge in high-income countries but also an important concern for economies in the developing world.