Students and brides: a qualitative analysis of the relationship between girls' education and early marriage in Ethiopia and India

A Social-Ecological Model to Explore Multi-Faceted Drivers of Child Marriage: An Iterative Qualitative Study in Southern Bangladesh

Despite national priorities, legal reforms, and increased investment in interventions, child marriage (CM) remains a significant public health risk, leading to violence, intergenerational nutritional depletion, and poor health outcomes in Bangladesh. Using the social-ecological model (SEM), this iterative qualitative study aimed to understand the drivers of CM at the individual, familial, social/community, and institutional levels to inform policy and programs. A total of 29 focus group discussions (with community members, married and unmarried adolescent girls, and their parents and grandmothers), 44 in-depth interviews (with married and unmarried adolescent girls, and their parents), and 10 key informants' interviews (influential community leaders) were conducted. Findings were drawn through thematic analysis employing both inductive and deductive coding. Identified CM drivers are aligned with the SEM framework. Girls' agency, collective efficacy, self-initiated marriage, and educational performance were individual-level drivers. Family-associated drivers were household poverty, parents' lack of awareness, and intra-household gendered preferences. Social/community drivers include norms about the "ideal" bride, girls' readiness for marriage, control over girls' sexuality and mobility, fear of violence, family honor, and religious norms. Weak enforcement to prevent CM, limited opportunities for girls, ecological conditions, and long school closures during COVID-19 were key institutional drivers. Findings suggest CM drivers are interconnected across levels of the SEM, implying the need for multi-level interventions. Coordinated efforts to reduce CM may include addressing the harmful CM norms and systemic factors leading to CM, raising community awareness about the adverse outcomes of CM, and offering poverty alleviation and economic opportunities for girls.

Intimate partner violence and quality of life of young women in urban slum and non-slum communities, Ibadan, Nigeria

BACKGROUND

Intimate partner violence (IPV) is a prevalent public health problem and a significant contributor to morbidity and mortality among women and girls. IPV significantly interferes with individual's quality of life (QoL). This study examined and compared the relationship between experience of IPV and QoL of young women in urban slums and non-slums communities of Ibadan, Nigeria.

METHODS

The study was conducted in the five Local Government Areas (LGAs) of Ibadan municipal, Oyo State, and employed a cross-sectional design. The study population were 1,050 young women aged between 18 and 24 years, who had ever been or currently was in a relationship. Data were collected using semi-structured and close-ended 97-items questionnaire, adapted from standardized instruments of the WHO VAW study (WHO, 2013) and WHOQOL BREF. Data were analysed using STATA 16. hierarchical multiple regression model was used to describe relationship between the outcome and independent variables.

RESULTS

The age (21.0 ± 2.1 years) of respondents was the same in both communities. Prevalence of physical (31.4%, 13.4%), psychological (58.6%, 31.5%) and sexual IPV (37.1%, 18.3%) were (p < 0.05) higher in the slums than non-slums, respectively. Overall QoL score was lower among IPV victims than non-victims in both non-slum (67.3 ± 23.4; 72.2 ± 19.8) and slum communities (67.3 ± 23.1 versus 72.4 ± 21.1). Physical and psychological QoL scores were lower (p < 0.05) among IPV victims in both settings. The predictors of overall QoL were experience of any IPV, perceived social support, partner's age, while experience of sexual IPV and partner's age were predictors of psychological QoL. Lastly, the predictors of physical QoL were experience at sexual debut and perceived social support.

CONCLUSION

Experience of IPV was common in both communities, with a consequential reduction in the QoL of young women. Measures to improve the QoL of young women need to target reduction of IPV and available social support in both settings.

Generational trends in education and marriage norms in rural India: evidence from the Pune Maternal Nutrition Study

Introduction

Globally in 2024, 1 in 5 women aged 20-24 years worldwide had been married before the age of 18 years. One reason for this persistent prevalence of underage marriage may be the slow change in social norms relating to education levels and women's marriage age. However, we know little about how norms change, and whether they vary by socio-demographic characteristics. We aimed to investigate changes in social norms across generations in rural Maharashtra, India.

Methods

To understand the status quo, we identified education levels and marriage ages typical of contemporary young adults in rural Maharashtra using the National Family Health Survey. To see if norms have shifted across generations, we analysed data on education and marriage age in 659 parent-adolescent dyads from the Pune Maternal Nutrition Study (PMNS) in rural Maharashtra. To ascertain if norms might shift in the future, we investigated adolescents' aspirations for their future hypothetical children's education and marriage, and classified adolescents as wanting (a) their children to decide themselves, (b) more education and later marriage age, or (c) the status quo. We assessed whether these aspirations differed by socio-demographic characteristics.

Results

Compared to the status quo and PMNS adults, PMNS adolescents had substantially more education, and girls were marrying slightly later. About 70% of the adolescents wanted their children to themselves decide their schooling. The remainder of both sexes wanted their children to have the same education as them (15 years). Only 10% of adolescent girls and 14% of boys wanted their child to decide their own marriage age. Most adolescents wanted a later marriage age for their children than their own experience. Lower educated and early married girls aspired for greater education for their children. More educated boys aspired for later marriage for their children.

Discussion

Education norms have changed by a larger magnitude than marriage age norms. Adolescents are already attaining their education aspirations, but aspire for later marriage of their children, more so for their hypothetical sons than daughters. Since senior household members remain influential in marriage decisions, it may take time before adolescents' aspirations for their children become a new norm.

Distribution and determinants of early marriage and motherhood: a multilevel and geospatial analysis of 707 districts in India

BACKGROUND

Early marriage and motherhood have long been prevalent in India, with 44.5% of women aged 20-24 reporting marriage before 18 in NFHS 3 (2005-2006), dropping to 26.8% in NFHS 4 (2015-2016). Early motherhood has also seen a significant decline, with first births by age 18 decreasing from 34.3% in NFHS I to 8.2% in NFHS V. Despite these improvements, significant regional disparities persist due to social, normative, and legal factors. This study investigates the spatial heterogeneity of early marriage and motherhood across Indian districts, offering a multilevel analysis that reveals critical local variations often obscured at broader levels. Understanding these patterns is crucial for targeted policy interventions and addressing the root causes of early marriage and motherhood.

METHODS

Utilizing data from the fifth round of National Family Health Survey, this study employs multilevel logistic regression and geospatial analysis to assess the determinants and spatial distribution of early marriage and early motherhood among ever-married women in India. The analysis incorporates individual, household, and community-level variables, complemented by spatial analysis techniques, including Empirical Bayes Bivariate Moran's I values and LISA cluster maps, to identify regional patterns and hotspots.

RESULTS

This study revealed that educational attainment emerged as a critical determinant, with uneducated women significantly more likely to marry early. Socioeconomic factors, such as poverty and limited mass media exposure, also heightened the risk of early marriage and motherhood. Caste and religion were significantly associated with these events, with marginalized groups facing higher prevalence. Spatial analysis revealed significant geographic disparities, with central and eastern regions showing higher concentrations of early marriage and motherhood. District-level characteristics and the influence of neighboring districts were also significant, highlighting the importance of localized interventions.

CONCLUSIONS

The findings underscore the critical role of education, economic empowerment, and media literacy in mitigating early marriage and motherhood risks. The study calls for multi-sectoral interventions in geographical hotspots to break the cycle of early family formation and promote reproductive health. Policies enhancing educational opportunities, addressing economic disadvantages, and considering district-specific factors are essential. Comprehensive strategies are necessary to empower women, foster reproductive health, and address the multifaceted nature of early marriage and motherhood in India.

Child marriage and quality of marriage among young married women in a rural district, Lorestan Province, Iran

PURPOSE

Child marriage remains a significant socio-cultural phenomenon with profound implications for the quality of marital relationships, particularly among young women. This study investigates the association between child marriage and the quality of marriage among young married women in Iran.

METHODS

This study employed a population-based cross-sectional research design. A total of 70 young women, aged 18-20 years, who had married before reaching 18 years of age, were selected from four primary health care (PHC) centers in Papi District, Lorestan Province, Iran, employing a systematic random sampling approach. Subjects were categorized into women experiencing relationship distress and those without such distress using the Quality of Marriage Index (QMI). Concurrently, their level of sexual satisfaction was assessed utilizing the Hudson's Index of Sexual Satisfaction (ISS). Furthermore, Social Support was evaluated using the Social Support Questionnaire (SSQ).

RESULTS

The mean age (SD) of women was 18.9 (0.7) years, and their mean age (SD) of marriage was 15.2 (2.1) years. Women experiencing distress showed significant differences in age of menarche (P = 0.006), education levels (P = 0.039), spouses' education (P = 0.025), spouses' occupations (P = 0.004), household income satisfaction (P = 0.041), and household structure (P = 0.045). Pearson's correlation coefficient analysis revealed significant and positive correlations between sexual self-efficacy and social support with marital quality (r = 0.73, p < 0.001 and r = 0.55, p < 0.001, respectively). Conversely, there was a significant negative correlation between the score of indexes of sexual satisfaction and marital quality (r = -0.65, p < 0.001).

CONCLUSION

These findings emphasize the complex factors affecting marital quality and underscore the urgent need for interventions to support young women in early marriages. It is essential to reinforce policies aimed at reducing child marriage to improve the quality of marriage among young married women.

A bivariate Poisson regression to analyse impact of outlier women on correlation between female schooling and fertility in Malawi

BACKGROUND

Women's levels of education and fertility are commonly associated. In Sub-Saharan Africa, the pace of decreasing fertility rates varies greatly, and this is linked to women's levels of education. However, this association may be influenced by unusual females who have uncommon measurements on both variables. Despite this, most studies that researched this association have only analysed the data descriptively, without taking into account the effect of potential outliers. This study aimed to examine the presence and impact of outlier women on the relationship between female education and fertility in Malawi, using regression methods.

METHODS

To analyse the correlation between women's schooling and fertility and evaluate the effect of outliers on this relationship, a bivariate Poisson model was applied to three recent demographic and health surveys in Malawi. The R software version 4.3.0 was used for model fitting, outlier computations, and correlation analysis. The STATA version 12.0 was used for data cleaning.

RESULTS

The findings revealed a correlation of -0.68 to -0.61 between schooling and fertility over 15 years in Malawi. A few outlier women were identified, most of whom had either attended 0 or at least 9 years of schooling and had born either 0 or at least 5 children. The majority of the outliers were non-users of modern contraceptive methods and worked as domestic workers or were unemployed. Removing the outliers from the analysis led to marked changes in the fixed effects sizes and slight shifts in correlation, but not in the direction and significance of the estimates. The woman's marital status, occupation, household wealth, age at first sex, and usage of modern contraceptives exhibited significant effects on education and fertility outcomes.

CONCLUSION

There is a high negative correlation between female schooling and fertility in Malawi. Some outlier women were identified, they had either attended zero or at least nine years of schooling and had either born zero or at least five children. Most of them were non-users of modern contraceptives and domestic workers. Their impact on regression estimates was substantial, but minimal on correlation. Their identification highlights the need for policymakers to reconsider implementation strategies for modern contraceptive methods to make them more effective.

Is parental engagement associated with subsequent delayed marriage and marital choices of adolescent girls? Evidence from the Understanding the Lives of Adolescents and Young Adults (UDAYA) survey in Uttar Pradesh and Bihar, India

Objective

This study examines the association between parental engagement and subsequent delayed marriage of adolescent girls and, secondarily, to assess whether parental engagement is positively associated with girls' involvement in marital decision-making regarding husband selection.

Methods

The study used longitudinal survey data from the Understanding the Lives of Adolescents and Young Adults (UDAYA) in Uttar Pradesh and Bihar, India. We analysed 6168 unmarried adolescent girls aged 15-19 years at wave 1 (2015-16) who were interviewed in wave 2 (2018-19). Our outcomes were delayed marriage of girls (unmarried vs. married at 20-22 vs. married at 18-19 vs. married at <18) and, among those married at <18 years, girls' involvement in husband selection (alone vs. with parents vs. not involved). Parental discussion around school performance, friendships, menstruation, pregnancy, free time, and personal issues were the exposure variables. We applied unadjusted and adjusted multinomial regression models to assess associations between our exposure variables and each outcome variable.

Results

From wave 1 to wave 2, 1551 girls (31.2%) married; 567 girls (12.5%) married as minors (<18 years). We found that parental discussion around school performance (relative risk ratio [RRR]: 1.33), friendship (RRR: 1.37) and personal matters (RRR: 1.29) were positively associated with remaining unmarried relative to early marriage of girls. However, discussion with parents about menstruation was negatively associated with marriage at 20-22 (RRR: 0.67) and remaining unmarried (RRR: 0.80), compared to early marriage. Discussing school performance was negatively associated with marriage at 18-19 (RRR: 0.62) and at 20-22 (RRR: 0.50), relative to early marriage. Discussing personal issues with parents was positively associated with joint parent-girl decision-making regarding husband selection, relative to parents alone selecting the husband (RRR: 1.43).

Conclusions

Parental engagement on school performance, friendship, and personal issues in early adolescence may help delay marriage and support marital choice for girls in India.

Continuation of education after marriage and its associated factors among young adult women: findings from the Bangladesh Demographic and Health Survey 2017-2018

OBJECTIVE

To identify the individual and community-level variables associated with the continuation of education among currently married young adult women in Bangladesh.

DESIGN

Cross-sectional data extracted from the Bangladesh Demographic and Health Survey (BDHS), 2017-2018. The BDHS is a stratified cluster sample of households conducted in two and three stages in both rural and urban settings. A multilevel multinomial logistic regression analysis was employed to identify the associated factors.

SETTING

Bangladesh.

PARTICIPANTS

Currently married young adult women aged 15-29 years (n=4595).

PRIMARY OUTCOME

Continuation of education after marriage was measured in the BDHS by asking respondents, 'Did you continue your studies after marriage?' with the response options: no; yes, less than a year; yes, for 1-2 years; yes, for 3-4 years; and yes, for 5+ years.

RESULTS

Among young adult women, 28.2% continued education after marriage for different durations of years (<1 year to 5+ years). The odds of continuing education after marriage for <1 year (adjusted OR (aOR): 0.68; 95% CI 0.50 to 0.90), 1-2 years (aOR: 0.67; 95% CI 0.47 to 0.96) and ≥5 years (aOR: 0.38; 95% CI 0.17 to 0.85) were lower among women who justified wife beating compared with women who did justify it. Compared with the high-literate community, women from the low-literate community were less likely to continue education after marriage for <1 year (aOR: 0.53; 95% CI 0.42 to 0.66), 1-2 years (aOR: 0.47; 95% CI 0.36 to 0.61), 3-4 years (aOR: 0.32; 95% CI 0.22 to 0.46), and for ≥5 years (aOR: 0.29; 95% CI 0.17 to 0.48). Several other individual-level and community-level variables, such as age at marriage, first birth interval, partner educational status, household wealth index, community economic status and region, were found to be associated with the continuation of education after marriage for different durations.

CONCLUSIONS

The proportion of women continuing their education after marriage in this sample is low. This study provides insight into the individual-level and community-level barriers women encounter in continuing their education after marriage. The identification of these barriers helps policy-makers develop effective intervention programmes to promote women's educational attainment.

Domestic Violence in Cross-Border Marriages: A Systematic Review

Cross-border marriages have been found to be associated with domestic violence due to the migration experiences of the couples concerned and the stress experienced before, during, and after migration, despite local and international legislation on domestic violence. A systematic review using the PRISMA Statement was conducted to examine the relationship between domestic violence and cross-border marriages among cross-border wives from Asian countries. Six databases-Taylor & Francis Online, Wiley Online, Scopus, Web of Science, Sage Journals, and Springer Online library, were used in the research which found 179 articles for eligibility and 58 articles were finally used in the review. To be included, studies must have addressed domestic violence and cross-border marriage among Asians, report qualitative, quantitative, or mixed methods, addressed the RQs, been published in polished English between 2010 and 2020 and published in a reputable journal with high impact factor. The systematic review found that immigration status, citizenship, culture, language barrier, diversity/intersectionality, age, and economic dependence are the risk factors for domestic violence, which leads effects such as divorce or separation, racism, loneliness, loss of identity & inheritance, stigma, abandonment, and discrimination. Yet these cross-border wives resorted to NGOs, social & religious groups, and traditional beliefs as coping strategies. The review suggests that legislations on domestic violence should be amended to include a definition of the rights of immigrant women, and the plight of cross-border wives, which should be protected. It is also imperative to propose favorable laws and policies regarding immigration status and citizenship for these cross-border couples.

Gender differences in HIV knowledge among adolescents and young people in low-and middle-income countries: a systematic review

Objectives

This review seeks to critically analyze studies assessing gender differences in HIV-related knowledge among adolescents and young people in low- and middle-income countries.

Methods

Using PRISMA guidelines and searching Pubmed and Scopus online databases, the search strategy combined search keywords with Boolean operators: (HIV OR AIDS) AND (knowledge) AND (gender) AND (adolescents). AC and EG conducted the search and independently reviewed all articles in Covidence software; conflicts were resolved by GC. Articles were included if they evaluated differences in HIV knowledge in at least two groups ages 10-24 and were implemented in a low or middle-income country.

Results

The search resulted in 4,901 articles, of which fifteen studies, implemented in 15 countries, met selection criteria. Twelve evaluated differences in HIV knowledge in school settings; three evaluated participants in clinic settings. Adolescent males consistently scored higher in composite knowledge scores, as well as knowledge of HIV transmission, prevention, attitudes and sexual decision-making.

Conclusion

We found gender-based discrepancies between knowledge, perception of risk and HIV prevalence among youth globally, with boys consistently scoring higher in HIV knowledge. However, there is significant evidence that social and cultural contexts render girls at high risk of HIV infection, and the gaps in girls' knowledge and boys' roles in HIV risk must be addressed urgently. Future research should consider interventions that facilitate discussion and HIV knowledge building across genders.

Epidemiology of neonatal mortality: a spatial and multilevel analysis of the 2019 mini-Ethiopian demographic and health survey data

BACKGROUND

Sub-Saharan African countries are a high-burden region of neonatal mortality and showed slow progress in its reduction. In developing countries, as long as the current trend of mortality persists, achieving a sustainable development target for neonatal mortality would be challenging. The aim of this study was to detect significant geographic areas and identify community and individual-level predictors of neonatal mortality in Ethiopia to draw attention to a policy.

METHODS

A weighted total sample of 24,136 mothers from the 2019 mini-Ethiopian demographic and health survey data were included in the analysis. Global Moran's I statistics was run to check the clustering of neonatal mortality and then kriging interpolation was done to predict the magnitude of neonatal mortality in Ethiopia. In addition, SaTScan analysis was also executed to identify hot spot clusters of neonatal mortality. Finally, a multilevel mixed-effect logistic regression model was used to identify community and individual-level predictors of early neonatal and neonatal mortality.

RESULTS

The lifetime early neonatal and neonatal mortality among mothers in Ethiopia was 5.08 (95% CI: 4.13-6.03) and 6.54 (5.55, 7.52) per 1000 births respectively. Neonatal mortality was spatially clustered in the country and the SaTScan analysis identified significant hotspot areas of neonatal mortality in the Amhara and Afar regions and some areas of the Somali and Oromia regions. Its predicted magnitude was > 8 per 1000 births in wide areas of the Amhara and Benishangul regions. A multilevel mixed-effect logistics regression analysis identified that a lower level of maternal education, being a twin neonate, and being a male neonate were predictors of both early neonatal and neonatal mortality. Whereas, the younger age of mothers predicted neonatal mortality.

CONCLUSIONS

Neonatal mortality in Ethiopia is geographically clustered and sociodemographic and obstetric factors played a significant role. Policy direction should focus on evidence-based practices like midwives-led community and facility-based continuum of care from preconception to postnatal periods to possibly reduce neonatal mortality.

Child Marriage in South Asia: A Systematic Review

Background: Child marriage is a serious public health issue with dire implications at the individual and societal level. Almost half of all child marriages globally originate from South Asia. The aim of this study is to identify consistent factors associated with and resulting from child marriage in South Asia through a review of available evidence. Methods: This systematic review adhered to the 2015 Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. Six computerized bibliographic databases, namely PsycINFO, CINAHL, EMBASE, Ovid Medline, PUBMED, and Scopus were searched. Retrieved studies were exported to EndNote and screened for eligibility using pre-determined criteria. The quality of the included studies was rated using 14 quality appraisal criteria derived from the National Institutes of Health (NIH) Tool. Results: A total of 520 articles were retrieved from six databases. Of these, 13 articles met the eligibility criteria and were included in this study. Factors consistently associated with child marriage in South Asia were rural residence, low level of education, poor economic background, low exposure to mass media and religion (Hindu and Muslim in particular countries). Maternal health care factors resulting from child marriage included: low utilization of antenatal care services, low institutional delivery, and low delivery assistance by a skilled birth attendant. Conclusions: Child marriage results from an interplay of economic and social forces. Therefore, to address the complex nature of child marriage, efforts targeting improvement in education, employment, exposure to health information via mass media, and gender egalitarianism are required. This systematic review was registered with PROSPERO [CRD42020190410].

Reflections of the after processes in early and forced marriages: A meta-synthesis study

PURPOSE

To develop analytical themes through a descriptive synthesis of qualitative studies to create a broader and more conscious understanding of after processes in early and forced marriages.

METHODS

This study is a meta-synthesis study.

FINDINGS

The analytical themes of the main theme "The process after early and forced marriages" were divided into four groups: cognitive, affective, behavioral, and cultural reflections.

PRACTICE IMPLICATIONS

Effective social norm interventions should be adapted to people's cognitive, affective, behavioral, and cultural understanding to change attitudes and practices toward early marriages.

Food Insecurity among Adolescent Students from 95 Countries Is Associated with Diet, Behavior, and Health, and Associations Differ by Student Age and Sex

Background

Adolescents' developmental tasks and challenges vary based on age, sex, and social context. Food insecurity affects adolescents, but existing research has been limited to a few country contexts and has treated adolescence as a singular developmental moment with limited consideration of potential differences in how food insecurity relates to developmental experiences based on adolescent age and sex.

Objectives

We aimed to describe relations between student-reported food insecurity and students' profiles of nutritional, physical activity, school absenteeism, health/mental health, and victimization experiences, and how these differ by student age and sex.

Methods

Using cross-sectional data from the Global School-based Student Health Survey, we examined adolescent reports of their food security among 337,738 students 11-18 y old from 95 countries. We identified their profiles of focal experiences, and used mixed-effects linear and logistic regression models to examine differences in these profiles by student food insecurity and how these differ by student age and sex.

Results

Of students, 25.5% aged 11-14 y compared with 30% aged 15-18 y reported food insecurity in the past 30 d. Food insecurity was associated with less frequent fruit and vegetable intake; more frequent soft drink intake; worse mental health; less physical activity; more missed school; higher odds of smoking, drinking, and using drugs; and more bullying victimization and sexual partners. Food insecurity was associated with reduced age- and sex-specific protection: greater substance use among younger adolescents, more sexual partners among older females, and greater worry among younger males. Food insecurity was also associated with increased age-specific risk: greater soft drink consumption among younger adolescents.

Conclusions

Across countries, adolescent food insecurity was associated with poorer nutritional, mental health, behavioral, and relationship profiles; these associations differed with student age and sex. Food insecurity interventions should attend to adolescent developmental stage and the gendered contexts through which adolescents navigate daily life.

Adolescent girls trapped in early marriage social norm in rural Ethiopia: A vignette-based qualitative exploration

Background

Early marriage is not uncommon in Ethiopia, particularly for adolescent girls in rural settings. Social norms are among the factors believed to perpetuate early marriage practices. This qualitative study explores social norms surrounding adolescent girls’ marriage practices in West Hararghe, Ethiopia.

Methods

This study used the qualitative inquiry method to explore social norms in rural Ethiopia. Focus group discussions were conducted with purposively sampled married and unmarried adolescent girls, adolescent boys, and parents. A total of 158 individuals participated in the study, comprising 95 adolescents and 63 parents. Data were collected using locally developed vignettes. A thematic framework analysis approach using the Social Norms Analysis Plot (SNAP) was employed to diagnose and understand social norms.

Results

Adolescent girls’ marriage was found to be mainly influenced by their peers who conform to prevailing social norms. Marrying one’s first suitor was considered an opportunity not to be missed and a symbol of good luck. Relatives, neighbors, and marriage brokers facilitate adolescent girls’ marriage in accordance with the local social norms. Girls usually accept the first marriage proposal regardless of their age, and they are highly expected to do so by their peers, parents, and influential others. Exceptions from the early marriage social norm include adolescent girls determined to continue their education and those having supportive teachers.

Conclusions

In this study context, social norms strongly encourage early marriage and are mainly perpetuated by peers of adolescent girls and influential adults. A strong determination to continue education on the part of girls, strong school performance, and supportive schoolteachers are important conditions for circumventing social norms on early marriage. As social norms evolve slowly, we recommend periodical assessment in order to develop locally appropriate interventions against early marriage.

Impact of the COVID-19 pandemic on student' sleep patterns, sexual activity, screen use, and food intake: A global survey

Background

The education sector experienced substantial impacts during the COVID-19 pandemic resulting from worldwide restrictions.

Purpose

To examine differences in the sleep patterns, sexual activity, screen use, and food intake of students and non-students during the COVID-19 pandemic.

Methods

This was a global cross-sectional study conducted in the second half of 2020 using multiple social media platforms to recruit study participants globally. A close-ended questionnaire was administered anonymously in English, French, Spanish, Portuguese, and Arabic to adults ages 18 and older. The outcome variables considered in analyses were changes in sleep pattern, sexual activity, screen use, and food intake. The explanatory variable was student status categorized as students vs. non-student. T-test, chi-square, and Mann Whitney U tests were used to assess differences between student and non-student populations. One logistic regression model was built for each outcome variable. Country of residence and country income level were included in the adjusted models.

Results

There were 17,008 participants of which 3,793 (22.3%) were students. Of the total sample, 4,889 (28.7%) reported changes in sleep, 4,642 (31.8%) reported increases in sexual activity, 10,278 (70.7%) reported increases in screen use, and 5,662 (40.2%) reported increases in food intake during the pandemic. Compared to non-students, students had significantly higher odds of reporting changes in sleep (AOR = 1.52), increases in sexual activity (AOR = 1.79), and increases in screen use (AOR = 1.36) but lower odds of reporting increase in food intake (AOR = 0.87).

Conclusion

Students displayed higher risk of experiencing changes in sleep, sexual behavior, and screen use during the COVID-19 pandemic. This has the potential to lead to broader adverse effects on students’ overall wellbeing. The findings and implications raise further obligations on the education sector to put extra-curricular support systems in place that address COVID-19 related behavior changes that have the potential to adversely impact students’ wellbeing.

Women's empowerment and fertility preferences of married women: analysis of demographic and health survey'2016 in Timor-Leste

A recently independent state, Timor-Leste, is progressing towards socioeconomic development, prioritizing women empowerment while its increased fertility rate (4.1) could hinder the growth due to an uncontrolled population. Currently, limited evidence shows that indicators of women's empowerment are associated with fertility preferences and rates. The objective of this study was to assess the association between women empowerment and fertility preferences of married women aged 15 to 49 years in Timor-Leste using nationally representative survey data. The study was conducted using the data of the latest Timor-Leste Demographic and Health Survey 2016. The study included 4040 rural residents and 1810 urban residents of Timor-Leste. Multinomial logistic regression has been performed to assess the strength of association between the exposures indicating women's empowerment and outcome (fertility preference). After adjusting the selected covariates, the findings showed that exposures that indicate women empowerment in DHS, namely, the employment status of women, house and land ownership, ownership of the mobile phone, and independent bank account status, contraceptive use, and the attitude of women towards negotiating sexual relations are significantly associated with fertility preferences. The study shows higher the level of education, the less likely were the women to want more children, and unemployed women were with a higher number of children. Our study also found that the attitude of violence of spouses significantly influenced women's reproductive choice. However, employment had no significant correlation with decision-making opportunities and contraceptive selection due to a lack of substantial data. Also, no meaningful data was available regarding decision-making and fertility preferences. Our findings suggest that women's empowerment governs decision-making in fertility preferences, causing a decline in the fertility rate.

Biosocial life-course factors associated with women's early marriage in rural India: The prospective longitudinal Pune Maternal Nutrition Study

OBJECTIVES

By convention, women's early marriage is considered a sociocultural decision sensitive to factors acting during adolescence such as poverty, early menarche, and less education. Few studies have examined broader risk factors in the natal household prior to marriage. We investigated whether biosocial markers of parental investment through the daughters' life-course were associated with early marriage risk in rural India. We used an evolutionary perspective to interpret our findings.

MATERIALS AND METHODS

A prospective cohort recruited mothers at preconception. Children were followed from birth to age 21 years. Multivariable logistic regression models estimated odds ratios of marrying early (<19 years) associated first with wealth, age at menarche and education, and then with broader markers of maternal phenotype, natal household characteristics, and girls' growth trajectories. Models adjusted for confounders.

RESULTS

Of 305 girls, 71 (23%) had married early. Early married girls showed different patterns of growth compared to unmarried girls. Neither poverty nor early menarche predicted early marriage. Girls' non-completion of lower secondary school predicted early marriage, explaining 19% of the variance. Independent of girls' lower schooling, nuclear household, low paternal education, shorter gestation, and girls' poor infant weight gain were associated with marrying early, explaining in combination 35% of the variance.

DISCUSSION

Early marriage reflects "future discounting," where reduced parental investment in daughters' somatic and educational capital from early in her life favors an earlier transition to the life-course stage when reproduction can occur. Interventions initiated in adolescence may occur too late in the life-course to effectively delay women's marriage.

Adolescent pregnancy and young motherhood in rural Zimbabwe: Findings from a baseline study

Pregnant adolescents and young mothers comprise a vulnerable group, particularly in low and middle income countries, yet there is limited research describing this population, particularly in rural Zimbabwe. Using tablet-administered questionnaires concerning maternal and child health, sexual and reproductive health, psychosocial well-being and parenting, we recruited 442 pregnant and young mothers (14-24 years) with the support of social workers from health facilities. We found high levels of poverty amidst increased rates of marriage, including child marriage (almost 20%). Participants had poor sexual and reproductive health knowledge and uptake of contraception was low (only 35% respondents reported current use). Although almost 60% girls had completed Form 2, 24% had only completed Grade 1 and just 4% were still engaged in schooling. Girls reported inadequate social support amidst high caretaking responsibilities and change in relocation for marriage, compromising mental health. Most of the pregnancies were unintended (approximately 60%) which had consequences on attachment and parenting where roughly 40% of our sample reported difficulties and lack of enjoyment in caring for their babies. Investments in interventions that address these vulnerabilities for pregnant adolescents and young mothers, and capitalise on available resources, are critical to improve health and interrupt cycles of risk for the next generation.

New estimations of child marriage: Evidence from 98 low- and middle-income countries

The Sustainable Development Goals include a target on eliminating child marriage, a human rights abuse. Yet, the indicator used in the SDG framework is a summary statistic and does not provide a full picture of the incidence of marriage at different ages. This paper aims to address this limitation by providing an alternative method of measuring child marriage. The paper reviews recent data on nuptiality and captures evidence of changes in the proportion married and in the age at marriage, in 98 low- and middle-income countries (LMICs). Using data collected from nationally representative Demographic and Health Surveys and Multiple Indicator Cluster Surveys, survival analysis is applied to estimate (a) age-specific marriage hazard rates among girls before age 18; and (b) the number of girls that were married before age 18 in 2020. Results show that the vast majority of girls remain unmarried until age 10. Child marriage rates increase gradually until age 14 and accelerate significantly thereafter at ages 15-17. By accounting for both single-year-age-specific child marriage hazard rates and the age structure of the population with a survival analysis approach, lower estimates in countries with a rapid decrease in child marriage and higher estimates in countries with constant or slightly rising child marriage rates relative to the direct approach are obtained.

Contraceptive use among sexually active female adolescents in Ethiopia: trends and determinants from national demographic and health surveys

BACKGROUND

Sexual and reproductive health and right of adolescents is a global priority as the reproductive choices made by them have a massive impact on their health, wellbeing, education, and economy. Teenage pregnancy is a public health issue and a demographic challenge in Ethiopia. Increasing access to contraceptive services for sexually active adolescents will prevent pregnancies and related complications. However, little is known about the trends in contraceptive use and its determinants among adolescent girls in Ethiopia. Therefore, this study was designed to examine the trends and factors associated with contraceptive use among sexually active girls aged 15-19 years in Ethiopia by using Ethiopian demographic and health survey data.

METHODS

Four Ethiopian demographic and health survey data were used to examine trends of contraceptive methods use. To identify factors associated with contraceptive use, the 2016 Ethiopian demographic and health survey data were used. The data was downloaded from the demographic and health survey program database and extracted for sexually active adolescent girls. Data were weighted for analysis and analyzed using SPSS version 21. Descriptive analysis was used to describe the independent variables of the study. A multivariable logistic regression model was used to identify factors associated with contraceptive use and adjusted odds ratios with 95% confidence interval were presented for significant variables. Variables with a p-value less than 0.05 were considered as significantly associated with contraceptive use.

RESULTS

Contraceptive method use had increased significantly from 6.9% in 2000 to 39.6% in 2016 among sexually active adolescent girls in Ethiopia. The odds of contraceptive use were lower among female adolescents who had no formal education (AOR 0.044; 95% CI 0.008-0.231) and attended primary education (AOR 0.101; 95% CI 0.024-0.414). But the odds were higher among adolescents from a wealthy background (AOR 3.662; 95% CI 1.353-9.913) and those who have visited health facilities and were informed about family planning (AOR 3.115; 95% CI 1.385-7.007).

CONCLUSION

There is an increment in the trend of contraceptive use among sexually active female adolescents in Ethiopia between 2000 and 2016. Significant variations in the use of modern contraception by wealth status, educational level and visited a health facility, and being informed about family planning were observed. Improving the economic and educational status of young women, and provision of information may help in improving contraceptive use in Ethiopia.

Is early marriage practice a problem for women living in Istanbul? A qualitative study

Early marriages (EM) adversely affect women's physical and mental health, education, and social status. The current study aimed to analyze effects of EM through the thoughts, experiences, and suggestions of women who were married under the age of eighteen in Istanbul, Turkey, and the key informants (e.g., social worker, psychologist, obstetrician) who have encountered EM. In-depth interviews were conducted with fifteen women who were married before age 18, recruited from psychiatry outpatient department and eleven key informants. Thematic analysis was used. Low educated, poor family environment with domestic violence and neglect of children, loss of parents, lack of access to education, and traditional social structure were stated as causes for EM. Families' attitudes about EM were characterized as their daughter's reputation would be tarnished which implied the daughter's premarital relationships would be perceived as immoral by community. All women experienced traditional, aggressive rituals for the first night of marriage, husbands were mostly insensitive, and coercive resulting a traumatic experience. Women were subjected to physical, sexual, psychological, and emotional violence; most of them were socially isolated after marriage with restrictions imposed by their spouses and spouses' family that limited communication with their loved ones. The women generally felt unprepared for adult sexual life and motherhood. In order to prevent EM, raising parents' awareness about EM, supporting girls' education, and enforcing legitimate regulations were recommended. Early marriages violate human rights, cause negative consequences for health both physically and mentally, and deepen social inequality for women. All the participants suggested a better functioning legislative arrangement. The male dominated society that legitimizes child marriages and other harmful traditional practices should be addressed.

Planning for work: Exploring the relationship between contraceptive use and women's sector-specific employment in India

While the health-related benefits of contraceptive use for women are well documented, potential social benefits, including enabling women’s employment, have not been well researched. We examine the relationship between contraceptive use and women’s employment in India, a country where both factors have remained relatively static over the past ten years. We use data from India’s 2015–16 National Family Health Survey to test the association between current contraceptive use (none, sterilization, IUD, condom, pill, rhythm method or withdrawal) and current employment status (none, professional, clerical or sales, agricultural, services or production) with multivariable, multinomial regression; variable selection was guided by a directed acyclic graph. More than three-quarters of women in this sample were currently using contraception; sterilization was most common. Women who were sterilized or chose traditional contraception, relative to those not using contraception, were more likely to be employed in the agricultural and production sectors, versus not being employed (sterilization adjusted relative risk ratio [aRRR] = 1.5, p<0.001 for both agricultural and production sectors; rhythm aRRR = 1.5, p = 0.01 for agriculture; withdrawal aRRR = 1.5, p = 0.02 for production). In contrast, women with IUDs, compared to those who not using contraception, were more likely to be employed in the professional sector versus not being employed (aRRR = 1.9, p = 0.01). The associations between current contraceptive use and employment were heterogeneous across methods and sectors, though in no case was contraceptive use significantly associated with lower relative probabilities of employment. Policies designed to support women’s access to contraception should consider the sector-specific employment of the populations they target.

Prevalence, Patterns and Predictors of Chronic Complications of Diabetes Mellitus at a Large Referral Hospital in Ethiopia: A Prospective Observational Study

PURPOSE

Diabetes mellitus complications are responsible for increased disability, morbidity, and mortality. This study aimed to assess prevalence, patterns, and predictors of chronic complications of diabetes among people with diabetes.

PATIENTS AND METHODS

The study was conducted using a prospective observational study design which was done on people with diabetes attending the ambulatory clinic of Mettu Karl Referral Hospital. The data were collected using a consecutive type of sampling technique from April 15 to August 9, 2019. The data were entered into Epidata manager version 4.4.2. Logistic regression analysis was done to identify predictors of chronic complications of diabetes.

RESULTS

A total of 330 participants were included in this study. The mean age of participants was 49.9±14.2, and 156 (47.3%) were 41 to 60 years old. About 127 (38.5%) had one or more chronic complications. The predictors of chronic diabetes complications were resident in urban areas [AOR: 1.94; 95% CI: (1.17, 3.20); p = 0.010], duration of diabetes 10 years [AOR: 2.05, 95% CI: (1.21, 3.47); p = 0.007], hypertension [AOR: 4.19; 95% CI: (2.54, 6.91); p < 0.001] and poor glycemic control [AOR: 2.82; 95% CI: (1.53, 5.21); p = 0.001].

CONCLUSION

Almost two-fifth of the study participants had chronic complications of diabetes. Residents in urban areas, longer duration of diabetes, hypertension and poor glycemic control were predictors of chronic diabetes complications. It is important to achieve good glycemic control and manage comorbid diseases like hypertension to minimize the risk of chronic diabetes complications.

Mapping the patchwork: Exploring the subnational heterogeneity of child marriage in India

Despite dramatic reductions in child marriage over the past decade, more than one in four girls in India still marry before reaching age 18. This practice is driven by a complex interplay of social and normative beliefs and values that are inadequately represented in national- or even state-level analyses of the drivers of child marriage. A geographic lens was employed to assess variations in child marriage prevalence across Indian districts, identify hot and cold spots, and quantify spatial dependence and heterogeneity in factors associated with district levels of child marriage. Data were derived from the 2015-16 National Family Health Survey and the 2011 India Census, and represent 636 districts in total. Analyses included global Moran's I, LISAs, spatial Durbin regression and geographically weighted regression. This study finds wide inter- and intra-state heterogeneity in levels of child marriage across India. District levels of child marriage were strongly influenced by geographic characteristics, and even more so by the geographic characteristics of neighboring districts. Districts with higher levels of female mobile phone access and newspaper use had lower levels of child marriage. These relationships, however, were all subject to substantial local spatial heterogeneity. The results indicate that characteristics of neighboring districts, as well as characteristics of a district itself, are important in explaining levels of child marriage, and that those relationships are not constant across India. Child marriage reduction programs that are targeted within specific administrative boundaries may thus be undermined by geographic delineations that do not necessarily reflect the independent and interdependent characteristics of the communities who live therein. The geographic, social and normative characteristics of local communities are key considerations in future child marriage programs and policies.

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Child marriage prevalence is highly heterogeneous across Indian districts.

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Districts near state border districts tend to have higher levels of child marriage.

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Characteristics of districts and their neighbors influence child marriage.

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Geography affects the relationship between social normative factors and child marriage.

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Child marriage interventions may require joint action across states.

Spousal violence and its determinants among married adolescent girls in Upper Egypt

INTRODUCTION

In Egypt, many girls are still married before the age of 18, which is a fundamental violation of the girls' human rights. Early marriage is associated with an alarmingly elevated risk of all types of intimate partner violence that have various negative consequences. The purpose of this study was to identify the predictors of exposure to spousal violence among the early married girls in rural Upper Egypt.

METHODS

A household survey was carried out and covered 23 villages in Assiut and Sohag governorates reaching to a sample of 729 married girls before the age of 20. Listing and enumeration of 4 districts was done to identify the study participants. Data was collected by personal interviews using a structured questionnaire. Bivariate and stepwise regression analyses were performed to identify the predictors of exposure to spousal violence.

RESULTS

It was found that 15.2% of the study participants were exposed to physical violence while 17.8% were exposed to sexual violence and 7.3% were exposed to both types. Girls married before the age of 18 were more exposed to spousal violence. Stepwise regression analysis found that girls' acceptance to get married was a protective factor against exposure to physical (β = - 1.07, OR 0.34) and sexual (β = - 0.68, OR 0.51) violence. The perceived attitude of husbands and mothers-in-law about considering wife beating "a husband's right" was found to be a risk factor of exposure to physical and sexual violence. Longer duration till the first pregnancy was also associated with more exposure to sexual violence (β = 0.04, OR 1.04).

CONCLUSION

Married adolescent girls (MAGs) are highly exposed to physical and sexual violence. This is mainly due to ignoring girls' preference to postpone their marriage, cultural concepts of accepting violence against women, and low sexual satisfaction. This study shows that most determinants of spousal violence were related to culture issues. Identifying these determinants is required to combat such a crucial public health problem that has serious consequences on adolescent health.

Do the prevalence and correlates of adverse reproductive health outcomes differ by marriage cohorts? Evidence from a study of two marriage cohorts in Nigeria

The researchers examined the prevalence and correlates of adverse reproductive health outcomes among two cohorts of married women in Nigeria based on the 2018 Nigeria Demographic and Health Survey. A weighted sample size of 8,704 and 6,076 women were analyzed respectively for the child and delayed marriage cohorts. Our results showed differences in adverse reproductive health outcomes by marriage cohorts with higher prevalence in the child marriage cohort and also differences in the correlates of adverse reproductive health outcomes. Strategies to promote the uptake of reproductive health services, gender equity and women's empowerment across the different marriage cohorts are required.