Article Text

Cohort profile
Cohort profile: the Adverse Childhood Experiences cohort of the Malawi Longitudinal Study of Families and Health
  1. Rachel Kidman1,
  2. James Mwera2,3,
  3. Yang (Tingting) Rui4,
  4. Etienne Breton4,5,
  5. Andrew Zulu2,3,
  6. Jere Behrman6,
  7. Hans-Peter Kohler7
  1. 1 Program in Public Health and Department of Family Population and Preventive Medicine, Stony Brook University (The State University of New York), Stony Brook, New York, USA
  2. 2 Compelling Works, Blantyre, Malawi
  3. 3 Invest in Knowledge (IKI), Zomba, Malawi
  4. 4 Department of Sociology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  5. 5 University of Minnesota, Minneapolis, Minnesota, USA
  6. 6 Departments of Economics and Sociology, Population Aging Research Center and Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  7. 7 Department of Sociology and Population Aging Research Center and Population Studies Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Rachel Kidman; Rachel.Kidman{at}stonybrook.edu

Abstract

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.

  • Adolescent
  • EPIDEMIOLOGY
  • Health Equity
  • PUBLIC HEALTH
  • HIV & AIDS

Data availability statement

Data are available upon reasonable request. An anonymised public-use version of the MLSFH-ACE data is being prepared for release via the Interuniversity Consortium for Political and Social Research (ICPSR) at the University of Michigan. These public-use data will include the MLSFH-ACE wave 1 and wave 2 survey data, health measures, and HIV status collected as part of this project. Selected sensitive information and data potentially allowing for identification of study participants are excluded from these public use data. Data will be linkable to other MLSFH data that has been collected as part of the overall MLSFH (including data collected for the caretakers during the 2008-2010 MLSFH rounds). Use of these public-use data is restricted to research purposes consistent with the overall aims of the project described in this cohort profile, but otherwise no restrictions apply. In addition to providing public-use data, the MLSFH-ACE team also encourages collaboration with the project team. To initiate discussions about potential collaborations, researchers interested in collaborating with the MLSFH-ACE team can submit a two-page proposal (including an analysis plan and IRB plan) to the MLSFH-ACE principal investigators (Rachel.Kidman@stonybrook.edu and hpkohler@pop.upenn.edu). For more information on MLSFH research, please visit https://www.mlsfhresearch.org/.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • The Adverse Childhood Experiences cohort of the Malawi Longitudinal Study of Families and Health (MLSFH-ACE) provides longitudinal, prospective cohort data on adolescents in a low-income, high-HIV context.

  • The MLSFH-ACE may capture the relationship between ACEs and key adolescent outcomes (eg, early sexual initiation, mental health) more accurately than studies that rely on retrospective recall in adult populations.

  • The MLSFH-ACE collects and links data from caregivers, adolescents and their offspring, thus facilitating a three-generation perspective on health and development.

  • The study relies on self-reported data; adversities might be inconsistently reported or under-reported due to social desirability bias.

  • The study did not collect data on the specific ages at which adversities occurred, which hampers investigation into sensitive developmental periods.

Introduction

Globally, more than 1.7 million adolescents (aged 10–19) are living with HIV, representing a growing share of HIV infections around the globe.1 Reducing HIV infections among adolescents requires a greater focus on early life determinants of HIV risk during the transition to adulthood. Adverse childhood experiences (ACEs) capture a broad array of individual, family, peer and community factors that are potentially important determinants of health and HIV risks in later life.2–4 However, little research has been conducted to measure current and past ACEs among adolescents in HIV-endemic, low-income and middle-income countries, and even fewer studies have used standardised instruments for the measurement. To gain deeper insights into the linkages between adversity and later HIV risk trajectories, it is important to capture data during adolescence since this developmental stage allows for more accurate reporting due to relatively shorter recall periods.5

Malawi has more than 2.2 million adolescents aged 10–19, accounting for 24% of the population.6 As a country with a $645 GDP per capita, Malawi offers an important low-income context, particularly since existing evidence on ACEs is derived mostly from high-income and middle-income countries.7 With the urgent need for new evidence, in 2017, we established the Adverse Childhood Experiences Project of the Malawi Longitudinal Study of Families and Health (MLSFH), or in short, the MLSFH-ACE cohort. The MLSFH is a long-running population-based cohort study in rural Malawi established in 1998; it has been extensively documented in prior cohort profiles.8–10 The MLSFH-ACE was designed to collect two new waves of longitudinal, prospective data in order to investigate the influence of ACEs on the emergence of risk behaviours and social trajectories during early and middle adolescence. Data collected during adolescence may be less prone to the recall bias inherent in retrospective reporting of childhood adversity by adults.11 12

Longitudinal studies have unique potential to clarify dynamic and potentially bidirectional relationships, to highlight modifiable mediators along the pathways and to capture the interplay between ACEs and social determinants at different ages. However, there are few existing longitudinal studies that focus on African adolescents. Young Lives tracks two cohorts of children through adolescence in Ethiopia (as well as in India, Peru and Vietnam), with a focus on understanding childhood poverty, health, education and inequality, but without emphasis on HIV.13 The Birth to Twenty study enrolled infants born in 1989 in Johannesburg, South Africa and has provided exceptional data on adolescent health, but is distinct from ours in that it was conducted in a rapidly urbanising and relatively more-affluent context.14 The Young Carers Project collected prospective data on adolescents in South Africa but was focused more narrowly on AIDS-affected children.15 Compared with these datasets, the MLSFH-ACE has the advantage of linking child and adolescent data to several earlier waves of prospective data collected from their parents. It also captures HIV risk behaviours and generates population-based estimates of HIV incidence in adolescents.

The MLSFH-ACE project is uniquely suited to integrate a life-course perspective into the study of how early life experiences and adversities in childhood affect later life outcomes. The current data focus on adolescent outcomes, with plans to continue following the cohort into adulthood. It represents a collaboration between the University of Pennsylvania, Stony Brook University, the Kamuzu University of Health Sciences (formerly College of Medicine), and Invest in Knowledge Initiative, the latter two in Malawi.

In establishing the MLSFH-ACE cohort, our aims were to (1) estimate the prevalence, co-occurrence and re-occurrence of ACEs among adolescents in a highly HIV-endemic country; (2) understand the impact of ACEs on the emergence of HIV risk trajectories during adolescence; (3) identify causal mediators between ACEs and adolescent health, social and cognitive outcomes to highlight potential intervention points and (4) discover protective factors that moderate the impact of ACEs on HIV risks. This cohort profile describes the study population, data collection and design of the MLSFH-ACE cohort study, and presents findings to date from the cohort.

Cohort description

Study population

The MLSFH-ACE Project was created by enrolling children of existing respondents in the MLSFH (see online supplemental materials for more information on the larger MLSFH cohort). The MLSFH-ACE, like the MLSFH itself, is primarily based in three rural districts in Malawi: Rumphi in the north, Mchinji in the central region and Balaka in the south. To establish the MLSFH-ACE cohort, household rosters of MLSFH respondents participating in the 2008 and 2010 rounds of data collection were reviewed to identify children of MLSFH respondents who would be expected to be 11–15 years old in 2017, the year of the first planned MLSFH-ACE data collection. MLSFH-ACE was designed to include sibling pairs to allow the identification of family versus individual influences, and all age-eligible adolescents in each MLSFH household roster were included in the MLSFH-ACE target sample. Moreover, to provide sibling matches in households with only one age-eligible adolescent, the age range was extended by 1 year in both directions10 16 and the adolescent closest in age to the index child was selected. We chose to establish the MLSFH-ACE cohort based on the 2008–2010 MLSFH surveys for the reason that the earlier data, provided by existing MLSFH respondents, provide information on the early-life contexts of the adolescents, including anthropometric measures.

Supplemental material

Once the MLSFH-ACE target population was established, efforts were made to find the 3317 potential adolescent respondents using identifying information provided during the 2008–2010 MLSFH surveys. When adolescents no longer lived at their original locations, attempts were made to trace them if their new locations were within the same district or in a major city. Ultimately, a total of 2061 adolescents were enrolled in the MLSFH-ACE Project and surveyed in 2017–2018. Only 13 (<1%) of those adolescents we located did not consent to participate. The study also interviewed the adolescents’ primary caregivers (n=1438). Primary caregivers were most often the original MLSFH respondents who provided survey data in 2008–2010. If someone else was currently caring for the adolescent, however, they were identified as the primary caregiver and surveyed. There were often several adolescents living with the same caregiver (1016 adolescents in pairs; 136 in larger sibling groups). Figure 1 presents enrolment in the MLSFH-ACE 2017–2018 (wave 1) and attrition in 2021 (wave 2).

Figure 1

MLSFH-ACE sample flow. MLSFH-ACE, Adverse Childhood Experiences cohort of the Malawi Longitudinal Study of Families and Health.

The MLSFH-ACE study anticipated that the 2008–2010 MLSFH household roster information might include insufficient or inaccurate information for some potential participants; it also anticipated that some adolescents might have been listed on household rosters by multiple MLSFH respondents (eg, parents who live apart). Once the MLSFH-ACE team located adolescents in the target sample, some were found to be ineligible because of misreporting of their ages in 2008–2010. Other adolescents were identified as duplicates because more than one MLSFH respondent listed them in their 2008–2010 household rosters. A further subset of adolescents in the target sample had moved out of the study catchment area or their current location was unknown.

Table 1 presents the summary statistics for the MLSFH-ACE cohort. Among the 2061 adolescents at wave 1, 1878 were then interviewed again in 2021. The attrition rate was less than 10% and was mainly due to migration outside of the catchment areas covered by the survey. Respondents lost in wave 2 were slightly more likely to be girls, to live in Balaka, and to have lower school enrolment rates (83% vs 92%) at wave 1 than adolescents interviewed at both waves. Among all the adolescents located in 2021, only three declined to take part in the wave 2 survey.

Table 1

Summary statistics for the MLSFH-ACE study population

MLSFH-ACE data collection

All interviews were conducted face-to-face at the adolescents’ homes and in their native language (chiChewa, chiTumbuka or chiYao) by trained interviewers. The interviewer team was a fairly even mix of men and women. We attempted to match the gender of the interviewer to the potential adolescent participant, but this was not always possible. All interviewers were trained and followed Institutional Review Board-approved interview protocols. Adolescents under 18 years old provided written assent after guardian consent; adolescents 18 and over provided consent. Caregivers provided their own consent for an interview at wave 1. Interviews were halted immediately if there was any risk to ensuring privacy. Given the focus on ACEs, interviewers were trained to monitor distress during interviews and protocols were in place to arrange any necessary support. In addition, the field team operated a 24-hour hotline during and for 2 months after the study period.

Adolescents were also surveyed by a separate team of trained HIV testing services (HTS) counsellors. The counsellors tested adolescents for HIV and herpes simplex virus type 2 (HSV-2) and collected anthropometric measures including height, weight, hip and waist circumference and grip strength. A separate consent and assent process was used for this element, and adolescents could opt out of any or all of these tests.

Throughout wave 2 data collection in 2021, a strict COVID-19 protocol was in place to ensure safety for both staff and participants. This included periodic COVID-19 testing, daily screening procedures for staff, symptoms check of respondents prior to interviews and physical distancing during interviews—which were carried out outdoors by masked interviewers. To further limit the risk of COVID-19 transmission to more vulnerable populations, caregivers were not interviewed at wave 2. Moreover, the HTS survey only focused on testing for HIV and HSV-2, omitting collection of anthropometric data that required additional contacts between respondents and counsellors. HSV-2 tests were also halted during data collection at wave 2 due to supply-chain disruptions.

MLSFH-ACE measurements

The MLSFH-ACE relied on a combination of newly developed and previously validated survey instruments (table 2). It is one of the first studies to systematically measure ACEs among adolescents in a high HIV prevalence context using the WHO Adverse Childhood Experiences International Questionnaire (ACE-IQ). Data on ACEs cover exposure to 13 domains as specified in the ACE-IQ.16 The survey questionnaire also covered multiple domains relevant to adolescent transitions to adulthood, including marriage and sexual health, educational outcomes and socio-emotional well-being. Adolescents who reported either sexual debut and/or having current or past romantic partners were asked about intimate partner violence (IPV). Lifetime and past-year IPV victimisation and perpetration were captured using questions adapted from the WHO’s Violence Against Women instrument.17 Measures of normative beliefs about marriage age, decision making and child marriage for both adolescents and caregivers were also collected. As mentioned previously, adolescents were tested for HIV (both waves) and HSV-2 (at wave 2), in addition to various anthropometric measures (at wave 1). Lastly, Global Positioning System (GPS) data were collected to permit aggregation at the community level and linkages to external data sources on community resources.16 More detailed information on the MLSFH-ACE measurements is provided in the online supplemental materials.

Table 2

Selected MLSFH-ACE measurements

Findings to date

Measurement and prevalence of ACEs

We conducted a psychometric evaluation of the ACE-IQ and found that it was appropriate for use on adolescents in Malawi.18 Principal component analyses revealed that the ACE-IQ is structured along three dimensions: household disruption, abuse and neglect. Further regression analyses revealed that additional information on the timing of ACEs (‘last year’ vs ‘ever’) improved the predictive power of the ACE-IQ for poor mental health.

Adolescents in the MLSFH-ACE cohort reported a high prevalence of childhood adversities at both rounds of data collection (figure 2). The most frequently reported adversities were witnessing community violence and emotional neglect, whereas reports of sexual abuse and household mental illness were the least frequently reported domains. On average, adolescents reported 5.1 lifetime ACEs at wave 1, compared with 5.9 at wave 2. Subsequent multivariate analyses on longitudinal consistencies of self-reported ACEs found that both external events (eg, economic shocks) and internal psychological states (eg, depression and post-traumatic stress disorder (PTSD)) predict inconsistencies in ACEs self-reports. Furthermore, these findings suggest that adult self-reported ACEs might be biased by processes unfolding in adolescence.12

Figure 2

Lifetime adversities at wave 1 (2017–2018) and wave 2 (2021). HH, household.

HIV risk factors

We found a low prevalence of HIV infection (11 HIV-positive adolescents) at wave 1. We examined the dose–response relationship between cumulative adversity and HIV-related behaviours using multivariate logistic regression. We found that cumulative ACEs were associated with a significant rise in the odds of both sexual debut and HIV testing at wave 1. We then conducted separate logistic regressions for each type of adversity. Eight of the 13 types of adversities were significantly associated with sexual debut. Five of the 13 adversities were associated with HIV testing.19

By wave 2 (2021), an additional six adolescents had seroconverted and were HIV-positive; this meant that the HIV incidence was far too low to power analyses examining this outcome. HSV-2 was more common: one in five adolescents tested positive for HSV-2 at wave 2. We used ordinary least squares (OLS) and logistic multivariate regression models to examine the impact of ACEs on this and other HIV-related risk factors at wave 2. Models were built separately to examine longitudinal associations (the impact of wave 1 factors on wave 2 outcomes) as well as cross-sectional associations. To account for the sampling frame, we used standard errors clustered by early-childhood caregiver.

Stratified by gender, we found a significant longitudinal association between wave 1 ACEs and wave 2 composite HIV risk scores (an additive score summing early sexual debut, sex without a condom, multiple partnerships and age-disparate partnerships) for girls, though not for boys. However, no significant associations were found between ACEs and HSV-2. In cross-sectional analyses, ACEs were positively associated with composite scores of HIV behavioural risks for both genders at both waves. ACEs were also associated with early sexual debut, lack of condom use, a greater number of sexual partnerships and STI symptoms at wave 2. The discrepancy between longitudinal and cross-sectional analyses raises interesting questions both about measurement and about the relative influence of more recent versus distal adversities.20

Intimate partner violence

At wave 1, over a quarter (28%) of ever-partnered adolescents (or 8% of all adolescents in the cohort) reported having been a victim of physical, sexual or emotional IPV in their lifetime, with only modest differences by gender. Among adolescents who reported being victims of IPV, a quarter reported seeking help. Female respondents were slightly more likely to seek help compared with males.21 At wave 2, almost a third of ever-partnered girls reported being victimised during their lifetime, while 24% reported being victimised in the last year. For boys, these numbers were only slightly lower (23% and 19%, respectively), which mainly resulted from lower rates of sexual IPV victimisation among boys. As above, we performed logistic regressions in both longitudinal and cross-sectional analyses to understand the relationships between ACEs and IPV, adjusting for key confounders. Cumulative exposure to ACEs at survey wave 1 was significantly associated with sexual IPV victimisation and perpetration for girls and emotional IPV victimisation for boys at survey wave 2. Once again, cross-sectional associations at wave 2 were much stronger across virtually all types of both IPV victimisation and perpetration.22

Mental and physical health

We also examined the relationship between adversity and a range of key mental and physical health indicators. As earlier, we used OLS regressions for continuous outcomes and logistic regressions for dichotomous outcomes, adjusting for age, gender, socioeconomic status and home district; standard errors accounted for the correlation at the caregiver level. At wave 1, adolescents reporting a greater number of ACEs had greater odds of reporting symptoms of PTSD and depression; they were also more likely to report worse self-rated health and higher expected likelihoods of dying in the next 5 years. However, ACEs did not demonstrate a graded relationship with more objective indicators of physical health, including obesity, stunting or grip strength.23

Marriage and aspirations

At wave 1, roughly 90% of adolescents (age 10–16 years old at the time) and caregivers knew that the law prohibited marriage below the age of 18. More than 55% of adolescent respondents and 70% of caregivers declared that the youngest age acceptable for girls to marry was 18 years or older. Critically, 97% of sampled girls declared that they aspired to marry at age 18 and above.24

However, nearly 50% of respondents aged 18 and above were married by wave 2, with half of them married before age 18. We used multivariate Cox proportional hazards models to understand the drivers of early marriage. Findings show that girls who had been lagging behind in school at wave 1 had higher rates of early marriage at wave 2 compared with girls who had been at or near grade level.25 Moreover, multivariate regression analyses revealed that adolescent girls who experienced physical IPV at wave 1 were more likely to enter early marriages at wave 2. Experiencing sexual IPV was also significantly associated with early pregnancy.26

Schooling and cognitive outcomes (before and during COVID-19)

External shocks appear to have a greater influence on girls’ education as compared with boys. We used linear and probit regression models to show that experiencing two or more negative economic shocks at birth was associated with lower cognitive and educational outcomes for adolescent girls; no corresponding associations were found for boys.27 Wave 2 (2021) was conducted after a long COVID-19 school disruption which resulted in many adolescents leaving school. In multivariate descriptive analyses, we found that only 86% of students who had been attending school prior to COVID-19-related school closures returned when schools reopened. Those who did not return were disproportionately older girls: over 30% of girls aged 17–19 did not return to school. Students who were already lagging behind in school before COVID-19 were also more likely to drop out.28

Strengths and limitations

The MLSFH-ACE Project provides longitudinal, prospective cohort data on adolescents in a low-income, high-HIV context. The large sample size enables sufficient statistical power to analyse associations, and the sibling design facilitates causal analyses. The use of standardised instruments on indicators such as ACEs and IPV allows for comparisons with similar studies across the globe. Compared with other studies of the life-course influences of ACEs, a major advantage of the MLSFH-ACE is the focus on adolescents who may more accurately report ACEs than adults, as the latter suffer from longer recall periods and a lack of clarity about whether adversities happened before age 18. Hence, this adolescent cohort is likely to capture the relationship between ACEs and key outcomes (eg, early sexual initiation, mental health) more accurately than studies that survey adults. Future data collections will allow for analyses of lasting effects into early adulthood.

An important feature of the MLSFH-ACE cohort is that it collects data from multiple generations. The original MLSFH respondents contributed data on their children’s health and household conditions in the 2008–2010 waves, and most of these original MLSFH respondents have themselves been followed until 2019–2022 as part of a separate MLSFH project. The data on parents/original caretakers can be linked to the MLSFH-ACE data, enabling analyses of early predictors of adolescent health and other intergenerational analyses of the transmission of adversities. In addition, the MLSFH-ACE surveyed the 2017–2018 primary caregivers of the adolescent participants who partially overlap, and partially differ from the 2008–2010 caregiver/parents. Combined, this caregiver information provides key data to allow a more comprehensive understanding of the contextual factors that influence child and adolescent development.

There are limitations of the MLSFH-ACE Project. First, attrition in MLSFH-ACE could be selective as is the case in many other cohort studies, with selection occurring due to reasons such as non-response, mortality and mobility.29 Nevertheless, additional analyses detailed in the online supplemental materials (S3.2) indicate that this selective attrition did not bias relationships between key outcomes and determinants. Second, the study relies heavily on self-reported data: adversities might be under-reported due to social desirability bias. This also affects reliability, as questions about why we observed inconsistent reporting remain unanswered.12 Yet, in Malawi as in most contexts, verification of self-reports via linkages to register or other data is generally not feasible, and self-reports are the only viable way of collecting data on ACEs. Finally, the study did not collect data on the specific ages at which adversities occurred, which hampers investigation into sensitive developmental periods.

Future plans

In wave 2, the project began collecting data on the offspring of the MLSFH-ACE cohort, including data on infant/child health and development. This facilitates a three-generation perspective on health and development in a low-income context. Future expansions of the cohort will continue the collection of data from both parents and offspring, building a database that can trace the intergenerational transmission of adversity and resilience.

Patient and public involvement

The MLSFH-ACE study involves eligible study participants from the general population in Malawi and does not include patients or clinic-based study populations. Our research team collaborated closely with study partners in Malawi to develop the study instruments and elicited feedback directly from pilot participants. The MLSFH is deeply integrated into its study communities, with long-standing ties with local stakeholders. Additionally, interviewers recruited from the local communities were able to ensure a high acceptance of the study team by the local communities. Key study findings are communicated to local stakeholders, the research community in Malawi and relevant stakeholders in the government.

Data availability statement

Data are available upon reasonable request. An anonymised public-use version of the MLSFH-ACE data is being prepared for release via the Interuniversity Consortium for Political and Social Research (ICPSR) at the University of Michigan. These public-use data will include the MLSFH-ACE wave 1 and wave 2 survey data, health measures, and HIV status collected as part of this project. Selected sensitive information and data potentially allowing for identification of study participants are excluded from these public use data. Data will be linkable to other MLSFH data that has been collected as part of the overall MLSFH (including data collected for the caretakers during the 2008-2010 MLSFH rounds). Use of these public-use data is restricted to research purposes consistent with the overall aims of the project described in this cohort profile, but otherwise no restrictions apply. In addition to providing public-use data, the MLSFH-ACE team also encourages collaboration with the project team. To initiate discussions about potential collaborations, researchers interested in collaborating with the MLSFH-ACE team can submit a two-page proposal (including an analysis plan and IRB plan) to the MLSFH-ACE principal investigators (Rachel.Kidman@stonybrook.edu and hpkohler@pop.upenn.edu). For more information on MLSFH research, please visit https://www.mlsfhresearch.org/.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved. The data collection and research were approved by the Institutional Review Board (IRB) at Stony Brook University (IRB-ID: 1008094) and the National Health Science Research Committee (NHSRC) in Malawi (NHSRC ref. number: 1805). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We thank the respondents for sharing their time and lived experiences with the study team. We also thank the staff (field supervisors, interviewers, counselors and many others) at the MLSFH implementation partner, Invest in Knowledge, for their commitment to this project.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Contributors RK and HK designed the MLSFH-ACE cohort; oversaw data collection, collaborated on all analyses, and serve as guarantors. YR drafted the manuscript. EB conducted the analysis and drafted some sections. RK, HK and JB collaborated on the content, structure and refinement of the manuscript. JM and AZ directed the data collection. All authors critically reviewed the manuscript.

  • Funding Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Numbers R01HD090988. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We also gratefully acknowledge support for the MLSFH through grants NICHD R01HD087391 and R01HD053781.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Patient and public involvement section for further details.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.