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In a context where pessimistic survival perceptions have been widespread as a result of the HIV/AIDS epidemic (Fig. 1A), we study vaccine uptake and other health behaviors during the recent COVID-19 pandemic. Leveraging a longitudinal cohort study in rural Malawi that has been followed for up to 25 y, we document that a 2017 mortality risk information intervention designed to reduce pessimistic mortality perceptions (Fig. 1B) resulted in improved health behavior, including COVID-19 vaccine uptake (Fig. 1C). We also report indirect effects for siblings and household members. This was likely the result of a reinforcing process where the intervention triggered engagement with the healthcare system and stronger beliefs in the efficacy of modern biomedical treatments, which led to the adoption of health risk reduction behavior, including vaccine uptake. Our findings suggest that health information interventions focused on survival perceptions can be useful in promoting health behavior and participation in the formal healthcare system, even during health crises--such as the COVID-19 pandemic--that are unanticipated at the time of the intervention. We also note the importance of the intervention design, where establishing rapport, tailoring the content to the local context, and spending time with respondents to convey the information contributed to the salience of the message. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

We investigate the impact of a randomised information intervention about population-level mortality on health investment and subjective health expectations. Our focus is on risky sex in a high-HIV-prevalence environment. Treated individuals are less likely to engage in risky sexual practices one year after the intervention, with, for example, an 8% increase in abstinence. We collected detailed data on individuals' subjective expectations about their own and population survival, as well as other important health outcomes. Our findings emphasise the significance of integrating subjective expectation data in field experiments to identify the pathways that lead to behavioural change. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Individuals age at vastly different rates resulting in significant within‐population heterogeneity in health and aging outcomes. This diversity in health and aging trajectories has rarely been investigated among low‐income aging populations that have experienced substantial hardships throughout their lifecourses. Utilizing 2006–2019 data from the Malawi Longitudinal Study of Families and Health and estimating group‐based trajectory models, our analyses identified three distinct lifecourse health trajectories: (1) comparatively good initial mental and physical health that persisted throughout the lifecourse ("resilient aging"), (2) relatively good initial mental and physical health that started to deteriorate during mid‐adulthood ("accelerated aging"), and (3) poor initial mental and physical health that further declined over the lifecourse ("aging with persistently poor health"). For both physical and mental health, men were more likely to enjoy resilient aging than women. Predictors other than gender of trajectory membership sometimes confirmed, and sometimes contradicted, hypotheses derived from high‐income country studies. Our analyses highlight the long arm of early life conditions and gender in determining aging trajectories and show that a nontrivial subpopulation is characterized by aging with persistently poor health. The study uncovers widening gaps in health outcomes between those who age with resilience and those who experience accelerated aging. [ABSTRACT FROM AUTHOR]

Network-based strategies and competencies are probably even more important in poor societies with limited means of communication and less effective formal structures than in developed economies. And they often deal with life and death matters. This paper presents lessons from and insights about the nature of and the impacts of informal social networks in reducing fertility and coping with HIV/AIDS in Kenya and Malawi based on analyses of quantitative longitudinal data and qualitative data that the authors and their collaborators have been collecting and analyzing for over a decade. Specific lessons include the relevance of social networks and informal interactions for many different domains related to health – and thus life and death – in developing countries, the importance of accounting for the endogeneity of network partners in analyzing network effects, that networks are important even with control for endogeneity, that network effects may be nonlinear, that there may be multiple equilibria, that which networks may either reinforce the status quo or help diffuse new options and behaviors, that both the context (e.g., the degree of market development) and the density of networks matter (possibly interactively), and that multiple approaches, including both qualitative and quantitative analyses, can be informative in providing more in-depth understanding of what networks do and how they function.

Objective: To examine the acceptance of repeat population-based voluntary counselingand testing (VCT) for HIV in rural Malawi.Methods: Behavioral and biomarker data were collected in 2004 and 2006 fromapproximately 3,000 adult respondents. In 2004, oral swab specimens were collected andanalyzed using enzyme-linked immunosorbent assay (ELISA) and confirmatory Westernblot tests while finger-prick rapid testing was done in 2006. We use cross-tabulationswith chi-square tests and significance tests of proportions to determine the statisticalsignificance of differences in acceptance of VCT by year, individual characteristics andHIV risk.Results: First, over 90% of respondents in each round accepted HIV test, despitevariations in testing protocols. Second, the percentage of individuals who obtained theirtest results significantly increased from 67% in 2004 when the results were provided inrandomly selected locations several weeks after the specimens were collected, to 98% in2006 when they were made available immediately within the home. Third, whereas therewere significant variations in the socio-demographic and behavioral profiles of those whowere successfully contacted for a second HIV test, this was not the case for those whoaccepted repeat VCT. This suggests that variations in the success of repeat testing mightcome from contacting the individuals rather than from accepting the test or knowing theresults.Conclusions: Repeat HIV testing at home by trained health care workers from outsidethe local area, and with either saliva or blood, is almost universally acceptable in ruralMalawi, and thus likely to be acceptable in similar contexts.

Network-based strategies and competencies are probably even more important in poor societies with limited means of communication and less effective formal structures than in developed economies. And they often deal with life and death matters. This paper presents lessons from and insights about the nature of and the impacts of informal social networks in reducing fertility and coping with HIV/AIDS in Kenya and Malawi based on analyses of quantitative longitudinal data and qualitative data that the authors and their collaborators have been collecting and analyzing for over a decade. Specific lessons include the relevance of social networks and informal interactions for many different domains related to health – and thus life and death – in developing countries, the importance of accounting for the endogeneity of network partners in analyzing network effects, that networks are important even with control for endogeneity, that network effects may be nonlinear, that there may be multiple equilibria, that which networks may either reinforce the status quo or help diffuse new options and behaviors, that both the context (e.g., the degree of market development) and the density of networks matter (possibly interactively), and that multiple approaches, including both qualitative and quantitative analyses, can be informative in providing more in-depth understanding of what networks do and how they function.

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. [ABSTRACT FROM AUTHOR]