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The approval letter is attached and available for review. The original data collection was carried out with ethical approval from the Tropical Disease and Research Center (TDRC) and the Research Ethics Review Board of the Centers for Disease Control and Prevention (CDC) Atlanta. As this study utilized secondary data sources, no additional ethical approval was needed. However, the process of collecting data for the Zambia Demographic and Health Survey (ZDHS) involved obtaining consent from individuals aged 18 and above. For participants aged 15\u201317 years, assent was obtained in addition to consent from their parents or legal guardians, as mandated by the DHS protocol. No identifying data or images were used in the analysis.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"1005"}}