Selected Publications

Adverse childhood experiences (ACEs)—including child maltreatment, witnessing violence, and household dysfunction—have been robustly associated with poor health in later life. There is also increasing evidence that those who experience childhood adversity are more likely subsequently to be victims or perpetrators of intimate partner violence (IPV). Most evidence, however, is cross-sectional and concentrated in high-income settings, and cannot be generalized to more diverse contexts. In contrast, this study assessed longitudinal relations between ACEs and IPV in a low-income country. We interviewed 1,878 adolescents in rural Malawi between 2017 and 2018 (aged 10–16) and again in 2021 (aged 13–20). Adolescents completed the Adverse Childhood Experience—International Questionnaire. Past-year physical, sexual, and emotional IPV victimization and perpetration were measured using the WHO’s Violence Against Women Instrument. We estimated multivariate regression models between cumulative adversity (0–13 adversities) at baseline and IPV at follow-up among respondents who reported any romantic or sexual partnerships. The cumulative ACEs score was associated with emotional IPV victimization for boys (OR = 1.12 per ACE) and sexual IPV victimization for girls (OR = 1.18). The ACEs score demonstrated a significant association with perpetration for girls only (OR = 1.33 for emotional IPV). By using longitudinal data, we more rigorously demonstrated the critical role of childhood adversity in shaping later IPV behavior. There are ongoing efforts toward primary prevention of childhood adversity. Given the burden that adolescents already carry (six ACEs on average in our sample), we also need secondary interventions that can help interrupt the pathway from adversity to IPV. This calls for increased collaboration between those working to address violence against children and violence against women.

PDRI affiliates Hans-Peter Kohler and Iliana Kohler recently co-authored a study, published in the Journal of Health Economics that investigates the effectiveness of health screenings to reduce the burden of non-communicable diseases in Malawi.

Evidence for the effectiveness of population health screenings to reduce the burden of non-communicable diseases in low-income countries remains very limited. We investigate the sustained effects of a health screening in Malawi where individuals received a referral letter if they had elevated blood pressure. Using a regression discontinuity design and a matching estimator, we find that receiving a referral letter reduced blood pressure and the probability of being hypertensive by about 22 percentage points four years later.

These lasting effects are explained by a 20 percentage point increase in the probability of being diagnosed with hypertension. There is also evidence of an increase in the uptake of medication, while we do not identify improvements in hypertension-related knowledge or risk behaviors. On the contrary, we find an increase in sugar intake and a decrease in physical activity both of which are considered risky behaviors in Western contexts.

The health screening had some positive effects on mental health. Overall, this study suggests that population-based hypertension screening interventions are an effective tool to improve health in low-income contexts.

Adverse childhood experiences (ACEs)-including child maltreatment, witnessing violence, and household dysfunction-have been robustly associated with poor health in later life. There is also increasing evidence that those who experience childhood adversity are more likely subsequently to be victims or perpetrators of intimate partner violence (IPV). Most evidence, however, is cross-sectional and concentrated in high-income settings, and cannot be generalized to more diverse contexts. In contrast, this study assessed longitudinal relations between ACEs and IPV in a low-income country. We interviewed 1,878 adolescents in rural Malawi between 2017 and 2018 (aged 10-16) and again in 2021 (aged 13-20). Adolescents completed the Adverse Childhood Experience-International Questionnaire. Past-year physical, sexual, and emotional IPV victimization and perpetration were measured using the WHO’s Violence Against Women Instrument. We estimated multivariate regression models between cumulative adversity (0-13 adversities) at baseline and IPV at follow-up among respondents who reported any romantic or sexual partnerships. The cumulative ACEs score was associated with emotional IPV victimization for boys (OR = 1.12 per ACE) and sexual IPV victimization for girls (OR = 1.18). The ACEs score demonstrated a significant association with perpetration for girls only (OR = 1.33 for emotional IPV). By using longitudinal data, we more rigorously demonstrated the critical role of childhood adversity in shaping later IPV behavior. There are ongoing efforts toward primary prevention of childhood adversity. Given the burden that adolescents already carry (six ACEs on average in our sample), we also need secondary interventions that can help interrupt the pathway from adversity to IPV. This calls for increased collaboration between those working to address violence against children and violence against women.