MLSFH: 25+ Years of Research in Malawi

The Malawi Longitudinal Study of Families and Health (MLSFH) is one of very few long-standing publicly-available longitudinal cohort studies in a sub-Saharan African (SSA) context. It is a long-term collaboration between the University of Pennsylvania (Penn, USA), the Kamuzu University of Health Sciences (KUHeS, Malawi) and Compelling Works (CW, Malawi), and it provides a rare record of more than a quarter-century of demographic, socioeconomic and health conditions in one of the world’s poorest countries.

The origins of the MLSFH are in studies of social networks and fertility decision, with initial data collection in 1998 being conducted under the pioneering Malawi Diffusion and Ideational Change project directed by Susan Watkins.

While this initial study population is still followed up, the scope of the project, the research team and the study population has expanded. In 2007, under the leadership of Hans-Peter Kohler, the project became the Malawi Longitudinal Study of Families and Health (MLSFH) to reflect the project's broad focus on social and contextual determinants of health across the lifecourse. Iliana Kohler spearheaded in 2012 the expansion of the MLSFH into aging and ADRD research, and Rachel Kidman was instrumental for establishing in 2016 the MLSFH adolescent cohort. Lauren Schmitz joined the MLSFH team in 2023 to develop a biosocial focus that includes the collection of genetic and epigenetic focus, and Philip Anglewicz initiated in 2007 the systematic follow-up of migrants as part of the MLSFH. Victor Mwapasa and James Mwera for many years have been the lead MLSFH collaborators in Malawi, having made invaluable contributions to the collection of complex MLSFH data, the building of strong Penn-Malawi collaborative ties, and the dissemination of MLSFH findings to study communities and stake holders. 

With more than one dozen data collection rounds including more than 8,000 individuals, the MLSFH data 1998-2023 has been used to investigate a very broad range of topics, including for instance:

• the influence of social networks on HIV-related behaviors and perceptions,

• the HIV prevention strategies employed by individuals in rural high-HIV prevalence contexts,

• the relationship between life-course transitions and HIV infection risks,

• the acceptability of HIV testing and counseling (HTC) and the consequences of HTC on subsequent behaviors

• the health and well-being across the life-course of individuals facing multiple challenges resulting from high disease burdens and widespread poverty

• intergenerational relations and transfers,

• determinants of cognition and cognitive decline at older ages,

• the prevalence of hypertension and the consequences of screening for hypertension,

• adolescent HIV risk and adverse childhood environments,

• the impacts of the Covid-19 pandemic, and determinants of Covid-19 risks,

• the demography of mental health and the impact of life-course adversities on depression and anxiety

• the long-term consequences of in-utero famine exposure on health at older ages,

• the implications of mortality misperceptions and sexual behavior and life-course decisions-making, and

• many other research questions (see MLSFH projects and publications for further details)

MLSFH Team, Partners and Funding

The MLSFH research team is global and multidisciplinary, with long-term collaborators on all continents and across the social, health and biomedial sciences.

Penn, KUHeS and other graduate and undergraduate students regularly join MLSFH fieldwork and conduct dissertation research using the MLSFH, and alumni of the MLSFH hold leading academic, policy and research positions around the world, and often continue to collaborate with the MLSFH.

The MLSFH embraces an open and collaborative spirit to which it owes its longevity and success. The MLSFH is keen on growing its network of collaborators, and add additional strengths and expertise to its team. Interested scholars can connect with the MLSFH at @MLSFHresearch, and reach out at info@MLSFHresearch.org.

Partner-institutions of the MLSFH include Stony Brook University, University of Wisconsin Madison, the Perelman School of Medicine, University of British Columbia, Princeton University, University of Lausanne, University of Glasgow, University of Technology Sydney, and John Hopkins University. Invest in Knowledge (IKI) was the MLSFH implementation partner in Malawi for many years.

Ethics oversight and approval for the MLSFH is provided by the National Health Sciences Research Committee (NHSRC) in Malawi, and the IRB at the University of Pennsylvania (augmented with reliance agreements were appropriate). Additional IRB approvals are obtained at MLSFH partner institutions when necessary, and earlier MLSFH research was sometimes approved by the KUHeS Research Ethics Board (KUREC, formerly COMREC).

Funding for the MLSFH has been generously provided by the U.S. National Institutes of Health and other organizations.

MLSFH Cohort PRofiles

MLSFH Cohort Profiles with extensive Supplemental Materials, published in the International Journal of Epidemiology (2015), BMJ Open (2017, 2020) and SocArXive (2023), summarize the key findings of the MLSFH. The MLSFH Cohort Profiles also provides information about the sampling for the MLSFH, the refreshment and extensions of the MLSFH sample over time, the procedures for HIV testing and counseling, and other study procedures that were implemented as part of the MLSFH. The MLSFH cohort profiles also reports comparisons of the MLSFH study populations with nationally representative datasets, analyses of attrition in the MLSFH sample, and it includes discussions of some specific features of the MLSFH data that have been widely used across many MLSFH-based papers.

MLSFH Data & Data Availability

MLSFH data encompass more than a dozen major data collection waves of the MLSFH Cohort during 1998-2023, supplemented smaller data collection on specific topics  (see MLSFH Data for details).

Public-use version of the MLSFH data without identifying individual or village information are made publicly available with some delay after data collection. MLSFH data up to 2017 (MLSFH 9) can currently be requested by emailing a short project description and a signed copy of the MLSFH data use agreement to info@MLSFHreseaerch.org. A public-use version of the data is also being prepared for inclusion in the ICPSR at the University of Michigan.

Researchers interested in using MLSFH data that have not (yet) been made available as part of the MLSFH public use data files can submit a two-page proposal (including an analysis plan and IRB plan) to info@MLSFHreseaerch.org. If deemed scientifically sound and not overlapping with ongoing MLSFH research projects, researchers will then be asked to sign a Data Use Agreement to be able to access and utilize the MLSFH data that are not part of the public-use data sets. All analyses of the restricted MLSFH data are conducted in collaboration with members of the MLSFH study team.

MLSFH Study areas

The MLSFH is primary based in three districts in rural Malawi that have been the study sites since 1998: Rumphi in the north, Mchinji in the center, and Balaka in the south, with about 15% of the sample spread out across Malawi and followed as part of migration follow-up procedures. 

In all three MLSFH study regions, the primary source of livelihood for MLSFH respondents is subsistence agriculture, augmented with smallholder cash crops, small-scale trade of agricultural products and other goods, and casual labor. Transportation networks are relatively rudimentary with paved primary roads and generally unpaved secondary roads, which may be impassable during the rainy season. Communication infrastructure has importantly changed during the period observed by the MLSFH. Cell phones were absent when the MLSFH was initiated in 1998, but have spread rapidly since.

While the broad demographic, socioeconomic and epidemiological conditions are fairly similar across the three MLSFH study regions, and also across other parts of rural Malawi, some noteworthy differences across the MLSFH regions include the following. Rumphi District, located in the northern region of the country, follows the patrilineal system of kinship and lineage where residence is primarily patrilocal, inheritance is traced through sons, and parents of a groom pay bridewealth. The northern district, inhabited primarily by Tumbukas, is predominantly Protestant. Mchinji District, located in the central region, follows a less rigid matrilineal system whereby residence may be matrilocal or patrilocal or neither (among MLSFH participants in Mchinji, about 75% follow a patriolocal tradition). The Center is primarily inhabited by Chewas, with almost equal proportions of Catholics and Protestants. Balaka District, which is located in the southern region, is primarily inhabited by Lomwes and Yaos and has the highest proportion of Muslims. The region follows a matrilineal system of kinship and lineage system where residence is ideally matrilocal, although it is not uncommon for wives to live at least some period of time in their husband's village. The Balaka region also exhibits a lower age of sexual debut and larger numbers of lifetime sexual partners than the other MLSFH study regions, and residents tend to be less educated and poorer than those living in the north, leading to higher levels of migration. HIV/AIDS prevalence in the southern region is significantly higher than in the northern and central region.