Community-Based Interventions for Preventing Child Marriage in Low- and Middle-Income Countries: A Systematic Review.

India grapples with its child marriage challenge

Changes in state legal norms regarding the age limit for marriage have been implemented to reduce the number of child marriages in Indonesia. However, child marriage is still practised, especially in rural areas of Central Java. This paper discusses three main problems, namely the prevalence of child marriage in rural areas, the dominance of tradition and dogmatic understanding of religion, the impact of poverty and social media technology as factors influencing child marriage in rural communities, and the transformation of social engineering through education and economic improvement to overcome the problem. child marriage in rural areas. This legal sociology research uses a qualitative approach. Data analysis techniques use interactive models. The study shows that the prevalence of child marriage increased by 300% after changes in norms regarding the age limit for marriage, especially in rural communities. This happens because child marriage in rural communities is a tradition passed down through generations. Traditions and religious norms understood by rural communities as allowing child marriage have become an unwritten legal system implemented by the community. Changes in state legal norms regarding marriage age limits have the potential to disrupt established social institutions, so that sociologically they are not binding as norms for rural communities, giving rise to an apathetic public response. Therefore, efforts to improve the education and economic systems with a holistic approach are very effective in overcoming the problem of child marriage in rural communities.

Suicide Prevention in an International Context.

IntroductionChild marriage remains a prevalent issue in low- and middle-income countries (LMIC) despite global declines. Girls are disproportionately affected, facing health risks, limited education, and restricted decision-making power. We aim to provide insights for child marriage prevalence across LMIC from 1990 to 2020, with a focus on sexual violence and early sexual intercourse for public health policy interventions.MethodsThis study used World Bank datasets to assess progress in addressing child marriage in LMIC countries. Statistical analyses, including trend analysis and compound annual growth rate (CAGR), were conducted to evaluate indicators of first marriage, sexual violence, and sexual intercourse. Countries with sufficient data were categorized based on prevalence rates and trends, and detailed analysis focused on significant indicators.ResultsWhile significant reductions were observed in the prevalence of child marriage before the age of 15 and 18 and early sexual intercourse in most countries, few countries show increasing trends, and others could not demonstrate statistical trends due to data limitations, such as scarcity of data for boys. Overall, many countries showed a decline in sexual violence and early sexual intercourse before the age of 15, but some exhibited increasing trends. For instance, Zambia and Senegal showed a decreasing trend of sexual violence, while Nigeria exhibited an increasing trend. Notably, Uganda, Cameroon, and Sierra Leone for women, and Namibia, Zambia, and Kenya for men, experienced substantial decline in early sexual intercourse.ConclusionThere is a decline in child marriage, sexual violence, and early sexual intercourse in most countries independent from the income group. Only a few countries show slight increasing trends. The improvements confirm that policies that address education, employment, and deep-rooted gender inequality at the societal level seem to be effective and help reach the SDG. However, better data are needed to enhance the understanding of the development of child marriage in these countries to improve the effectiveness of policy intervention. Therefore, we recommend that policymakers not only include existing evidence that continues progress but also increase and improve the monitoring of relevant indicators.

BackgroundChild marriage is a human rights violation disproportionately impacting girls in low- and middle-income countries. In the Middle East region, conflict and displacement have prompted concerns that families are increasingly resorting to child marriage to cope with economic insecurity and fears from sexual violence. This study set out to examine child marriage among Syrian refugees residing in Egypt with the aim of understanding drivers of child marriage in this context of displacement as well as how child marriage affects refugee girls’ wellbeing.MethodsThis analysis draws from 15 focus group discussions (FGD) conducted with married and unmarried girls, as well as parents of adolescent girls in three governorates in Egypt. FGDs included a participatory ranking exercise and photo-elicitation. Additionally, we conducted 29 in-depth interviews with girls and mothers, as well as 28 key informant interviews with health providers, community leaders, and humanitarian actors. The data was thematically analyzed using a combination of inductive and deductive coding.ResultsA prevalent phenomenon in pre-war Syria, child marriage has been sustained after the influx of Syrian refugees into Egypt by pre-existing cultural traditions and gender norms that prioritize the role of girls as wives and mothers. However, displacement into Egypt engendered different responses. For some families, displacement-specific challenges such as disruptions to girls’ education, protection concerns, and livelihood insecurity were found to exacerbate girls’ vulnerability to child marriage. For others, however, displacement into urban areas in Egypt may have contributed to the erosion of social norms that favored child marriage, leading to marriage postponement. Among girls who were married early, we identified a range of negative health and social consequences, including lack of family planning use, disruption to schooling and curtailment of girls’ mobility as well as challenges with marriage and birth registration which accentuated their vulnerability.ConclusionEfforts to address child marriage among Syrian refugees must acknowledge the different ways in which displacement can influence child marriage attitudes and practices and should capitalize on positive changes that have the potential to catalyze social norm change. Moreover, targeted, focused and contextualized interventions should not only focus on preventing child marriage but also on mitigating its impacts.

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.

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.

Preventing gender-based violence victimization in adolescent girls in lower-income countries: Systematic review of reviews

Surgeons practicing in high-income countries (HIC) like the United States, which spends an estimated 765 billion dollars per year on unnecessary healthcare costs, are generally not accustomed to resource limitations.1 However, the coronavirus disease 2019 (COVID-19) pandemic has strained the usually robust healthcare system in HIC. Lack of adequate testing, small reserves of ventilators and global supply chain disruptions, among other causes, have led to shortages affecting care for critically ill patients – most notably human resources, ventilators, and personal protective equipment (PPE).2 This has transformed hospitals in HIC to a "resource variable environment" with uncertainty of the supplies, intensive care unit (ICU) beds, and staff available at any given time. Although this challenging environment is novel for many providers in HIC, these constraints are commonplace for providers in low- and middle-income countries (LMIC). Only 12% of the world's specialist surgical and anesthesia workforce practice in the world's poorest regions in Africa and Southeast Asia, where a third of the world's population lives and the majority of the world's surgical burden lies.3,4 LMIC also face a severe shortage of ICU capacity, for example, Uganda has only 0.1 ICU beds per 100,000 population, compared with 20 beds per 100,000 in the United States.5,6 Approximately 1 in every 4 hospitals in LMIC do not have access to oxygen, rendering them unable to provide timely, basic care for many patients.3 At most hospitals in LMIC, PPE shortages are the norm and essential care is provided by family members at the bedside.3,7 To overcome these and other daily challenges, LMIC providers must often improvise, adapt, and innovate. Many hospitals in HIC rely on just-in-time inventory management, which can be an effective method to cut down on costs, as it calls for minimal reserves of healthcare supplies. However, the widespread use of such strategies, which are reliant on consistent and tightly controlled supply chains, have made HIC vulnerable to PPE and supply shortages should demand sharply increase, as has been seen with the COVID-19 pandemic. In some HIC hospitals, healthcare workers facing PPE shortages have already had to adopt common practices from LMIC, such as using bin liners instead of gowns and wearing reusable cloth masks. HIC providers have also implemented evidence based adaptations, such as creating reusable elastomeric respirators, the development of open source ventilators, and reprocessing N95 masks using the hydrogen peroxide vapor sterilization technique.8–11 In many LMIC, healthcare supply chains are vulnerable at baseline, and providers are regularly faced with shortages of supplies and PPE. Items that are considered disposable in HIC, such as endotracheal (ET) tubes and electrocautery tips and pads, are often reused after high level disinfection. Equipment shortages in LMIC have led to the expanded use of regional anesthesia with intravenous (IV) sedation, and most surgeries are performed open rather than via laparoscopy. Operating room supplies are opened only as-needed and evaluated after each case; only the most essential available instruments for every case are opened, and key instruments are prioritized for sterilization throughout the day. Similar strategies towards the pragmatic use of operating room resources could be considered in HIC and may even decrease perioperative costs.12 Public private partnerships and innovative local production strategies have emerged in LMIC in response to widespread oxygen shortages.13,14 Such strategies may be considered in HIC should there be an oxygen shortage during the COVID-19 pandemic. Additionally, surgical gowns, head covers, and surgical drapes in LMIC are cloth, requiring washing and reuse, whereas such supplies are disposable in the majority of hospitals in HIC, particularly in the US. The use of disposable surgical textiles is largely driven by reimbursements to hospitals based on volume of purchases, and there is a lack of evidence to suggest that the use of disposables have an overall cost or safety benefit.15 Transitioning to increased use of reusable products where possible would make HIC hospitals less vulnerable to supply chain disruptions and would additionally have a substantial sustainability benefit. Amid the COVID-19 pandemic, the number of patients requiring mechanical ventilation in the US could range between 1.4 and 31 patients per available ventilator, which would necessitate thoughtful resource allocation should HIC face a ventilator shortage.16 Even outside the setting of pandemics, LMIC face a constant shortage of ventilators and ICU care, even in national referral hospitals.17 As a result, many young patients die from reversible etiologies, such as surgical disease, postsurgical complications, infectious diseases, trauma, and peripartum maternal or neonatal complications.18 Providers in these settings routinely make difficult ethical and practical decisions about the allocation of ICU care, often informed by the local context and cultural factors. This extends through the entirety of the perioperative journey, from who can be offered surgery, to operative approaches and postoperative care. Scoring systems appropriate for the LMIC context have been developed, and take into account some of these factors.19,20 Other mitigation strategies include the development of high-dependency units, which have increased capacity for monitoring and oxygen delivery, and training programs for the limited numbers of ward nurses emphasizing early recognition and intervention for critically ill patients.21 Should ventilator shortages become apparent, a planning exercise for this type of scenario in HIC may be worthwhile given the current reality of ventilator shortages to potential need. A large volume of critically-ill patients combined with potentially high rates of healthcare worker infections and exposures has led to staffing shortages in both HIC and LMIC during COVID-19. LMIC already face severe staffing shortages due to a variety of factors, including low numbers of graduates, poor salaries and working conditions, and high attrition rates.22 Addressing such shortages has required a number of innovations, some of which could potentially be adapted for use in HIC. A program to engage family members in multiple aspects of patient care has been used successfully by Narayana Health in India. Family members were trained to perform tasks such as monitoring fluid balance, taking and recording vital signs, and assisting with incentive spirometry, which not only cut costs and addressed staffing shortages, but reduced postoperative complication rates.23 Due to social distancing guidelines and visitor restrictions in hospitals this may be most effectively utilized for post-hospitalization care and rehabilitation programs as support staff and rehab centers are also part of the overwhelmed healthcare community. In LMIC, both physician and nonphysician general practitioners are commonly called upon to perform essential surgery.24 Such task sharing, where healthcare workers are reorganized and required to work in alternative roles to meet changes in workforce demands, is a common solution to staffing shortages in LMIC. During the COVID-19 pandemic, this practice been a necessary adaptation in HIC as the imminent need for many specialties declined, whereas intensivists and generalists have been in high demand. In our own HIC institutions we have seen the re-allocation of surgical critical care physicians and surgeons into roles assisting in the medical intensive care units and medical floors helping care for both COVID and non-COVID medical patients. This crisis has brought attention to the need to address the shortage of more broadly trained personnel and generalist physicians, which is largely attributed to the high costs of medical school and procedure-based reimbursement strategies, resulting in higher salaries for specialist physicians.25 Going forward, the expansion of policies to incentivize young doctors to enter general practice, such as tuition reimbursement and a transition to value-based payment strategies in both HIC and LMIC may be necessary. The widespread, immediate implications of the acute shortages during the COVID-19 pandemic have highlighted the need for systems strengthening in both HIC and LMIC and have forced us to re-examine our approach to healthcare delivery. Telemedicine is being optimized globally more than ever before to prevent surges through forward triage, minimize healthcare worker exposures and address workforce shortages.26 The widespread implementation of telehealth interventions can be leveraged long after the pandemic ends to overcome challenges of distance and patient access in both HIC and LMIC. This will need to be done thoughtfully to ensure that alternatives are developed when necessary for vulnerable populations that may have challenges in technology use. Disruption in the global supply chain for healthcare supplies has underscored the importance of building redundancies into the system, and has led to the opening up of new local supply chains by linking local stakeholders.27 Shortages of PPE and other essential equipment have also highlighted the need for a transparent, centrally controlled strategic reserve of medical supplies. Hospitals have had to rapidly scale up ICU capacity, which has underlined the value of redundant capacities and flexibility within the healthcare system. These lessons have highlighted the need for long-term investment to build flexible, resilient health systems and are sure to help providers in both HIC and LMIC care for more patients safely and effectively both during this pandemic and long after it ends. Learning how LMIC providers manage resource limitations through global surgery collaborations can give surgeons working in HIC valuable perspective that has become increasingly relevant during the COVID-19 pandemic. The rapid expansion of social media has facilitated such collaborations, and is a valuable tool for networking, mentorship, and information sharing. Additionally, the rapid sharing of research findings via social media is enhancing our ability as a global health community to respond to this pandemic in a strong evidence based manner. However, it is essential that social media be used responsibly, and that precautions are taken to prevent the spread of misinformation. For surgeons working in HIC, there is much to learn from counterparts in LMIC. Healthcare systems in many LMIC, particularly in Africa, have more experience responding to infectious disease pandemics, especially in contact tracing and community mobilization. The extensive network of community health workers in LMIC is an essential component of grass roots public health infrastructure that HIC may be able to emulate.28 Triage systems, finite resources, and limited personnel in LMIC require constant thoughtfulness regarding testing, treatment, and disposition. More importantly, working in a resource-variable environment requires fostering a set of soft skills that LMIC practitioners utilize on a daily basis. These include adaptability, resourcefulness, frugality of supplies, humility, and leadership among others. These lessons highlight the importance of fostering bilateral partnerships and increasing relevance of global health competencies to surgical training. Examples such as task sharing illustrate that HIC can adapt and can respond to these challenges with resilience.29 This requires vigilant monitoring of the situation and constant improvisation in the face of unpredictable challenges. These and other nontechnical skills are always essential to ensure safe and high quality surgical care but become especially pertinent during this trying time. The most vulnerable populations, often linked to the underlying social determinants of health such as poverty, food security, literacy, sex, and racial and ethnic factors, are most at risk of adverse outcomes during these health and social shocks. There is already data demonstrating that racial and ethnic minorities in the US and UK are at increased risk of death from COVID-19.30 Difficulty in accessing care for emergent conditions exists at baseline for these populations, and extensive backlogs for essential operations are commonplace, especially in LMIC. This is likely only to get worse during the current crisis and underscores the importance of our professional commitment to health equity – regardless of geography. New estimates of the "collateral damage" caused by the pandemic are very concerning and also illustrate the urgent need to mitigate this impact through local and global coordinated action.31 The overall lack of collective and individual health equity around the globe dramatically weakens our global heath security and without addressing this disparity, the even the best attempts by HIC to ensure safeguard domestic health will always be undermined.32 The grave reality is in both LMIC and now in HIC, population needs vastly outpace our resources, and it is the patients who are affected unless we too improvise, adapt, and innovate. Global surgery collaborations with reciprocity between partners, with trainees and faculty working together, enhance our capacity to share our collective expertise and navigate this pandemic resiliently.

Community-based health promotion interventions to reduce risk factors of non-communicable diseases among adolescent and young adults in low- and middle-income countries: A systematic review and meta-analysis.

Age at marriage is rising throughout sub-Saharan Africa. The singulate mean age at marriage is now greater than 18 in the vast majority of countries in the region and in all of the countries included in our analysis (United Nations Department of Economic and Social Affairs Population Division 2015). Even so sub-Saharan Africa has the highest rates of child marriage in the world and previous studies have estimated that more than half of girls marry before age 18 in many countries in the region (Singh and Samara 1996; Mensch Singh and Casterline 2006). Measuring trends in the prevalence of child marriage over time is important for understanding where the practice is most common and for evaluating the effectiveness of efforts to eliminate it. However measuring age at marriage in sub-Saharan Africa is difficult. Unlike Western marriages which are often unambiguously dated by a ceremony the signing of legal documents and civil registration marriage in sub-Saharan Africa is often described as a process consisting of multiple stages including legitimized sexual relations cohabitation and ceremonies. The process can be lengthy and the various stages occur in different sequences across ethnic and social groups (van de Walle and Meekers 1994; Locoh 1994; Arnaldo 2004). If several events are required to solidify a union it may be unclear when the union was formalized. (excerpt)

Child marriage is a violation of human rights and it is illegal according to the Kenyan laws. Child marriage is a barrier to personal and community growth and development in the 21st century. The victims of child marriage are denied a chance to education, economic empowerment, and safety among other excellent opportunities and this leads to perpetual poverty cycles from one generation to the next. In Maasai community, the government and many NGO's have put forward many strategies to mitigate child marriages. These strategies include economic and social empowerment, community mobilization, education and awareness and enforcement of laws. However, in spite of having these strategies in place, cases of child marriages are still going on hence prompting the need to understand the reason why these strategies have not managed to end this vice among Maasai community in Ill Bissil Division in Kajiado County. The purpose of the study was to analyse the effects of the employed mitigating strategies in child marriages among the Maasai community in Kajiado County, Kenya. The study specifically aimed evaluating the influence of community mobilization strategy on preventing child marriages among the Maasai community in Kajiado County. The study adopted descriptive research design to collect both qualitative and quantitative primary data. The study targeted a population of 252 drawn from victims, parents, law enforcement officers, education officer; teachers, church leaders and NGO administrators. A sample size of 126 individuals was enrolled for the study. Purposive sampling method was used to select all key informants while complete census was used to select police officers. A simple random sampling technique was used to select the individual victims who were enrolled in the study. The parents were paired with the selected victims. Teachers were purposively selected from each class. Questionnaires and interview schedule were employed as data collection instruments. Collected data was analysed using descriptive and inferential statistics. The study established that there was lack of coordination between the government and stakeholders who are involved in mitigating child marriages. Religious organisations and professionals were not largely involved in mitigating child marriages. The findings of this study will inform the government and stakeholders of the reasons why mitigating strategies adopted in I'll Bissil Division have not succeeded in preventing child marriages. This in turn will assist government and stakeholders to develop policies and intervention strategies that are relevant to curb child marriage in I'll Bissil Division in Kajiado County. The study recommends that policies be developed to guide on the community mobilization implementation of strategies for mitigating child marriages.

Hypertension in reproductive age women, particularly in low-and-middle income countries (LMICs) is an area that is less explored. This study assesses the risk of hypertension in relation to two critical women's health issues in the LMICs - child marriage and adolescent childbearing. The health consequences of these issues have been primarily studied in the context of reproductive health. There is a dearth of evidence on the long-term health outcomes associated with these early life events. The current study, by linking child marriage and adolescent motherhood with hypertension in young adult and early middle-aged women, is commensurate with the body of literature that examines the link between potentially early adversity and later life risk of chronic health outcomes. Using the most recent data on 582,358 women aged 20 to 49 years from India, this study examined whether child brides and adolescent mothers at age 20 s, 30 s, and 40 s had a higher risk of having hypertension compared to women who were not married before age 18 years or did not give birth by age 19 years in respective age groups. Estimating multivariable logistic regressions, we found that child brides and adolescent mothers were about 1.2 times more likely to have hypertension later in life. The elevated risk of hypertension among child brides and adolescent mothers were evident at every age group. These results were robust after controlling for various sociodemographic, anthropometric, and behavioral characteristics as well as across urban and rural, and poor and non-poor subgroups.

The role of child marriage and marital disruptions on hypertension in women - A nationally representative study from India

Musculoskeletal and lifestyle-related health conditions often co-occur, which presents a major physical and psychological burden on individuals and may have socioeconomic implications in society. Rural communities in low- and middle-income countries often have limited access to regular, in-person health and healthy lifestyle supportive services and facilities. As an alternative, digital and community-based interventions should be considered. A scoping review was conducted to investigate digital and community-based health interventions for exercise and education in the management of musculoskeletal and lifestyle-related health conditions in rural communities in low- and middle-income countries. The JBI methodology for scoping reviews was utilised. A three-step search strategy was implemented to identify articles. Following an initial exploratory search, the strategy was adapted. The full search was conducted using PubMed, Scopus, Web of Science, and EBSCOhost. Reference lists of included articles and grey literature searches were also performed. Titles and abstracts were screened followed by full-text evaluations against the eligibility criteria by two independent reviewers. Studies in the past 20 years involving digital or community-based health interventions aimed at the management of musculoskeletal and/or lifestyle-related health conditions through exercise or education for participants aged over 18 years and conducted in rural settings in low- or middle-income countries were included in the review. The search identified 1323 articles (following removal of duplicates). Nineteen studies meeting the eligibility criteria were included. Most studies (n=16) focused on community-based interventions with (n=8) or without (n=8) digital components, with one study involving a digital intervention only for lifestyle-related health conditions. Only two studies focused on musculoskeletal conditions. All interventions included a health education component and some studies included screening, monitoring, and exercise components. Digital health components included mobile health messages and apps, videos, and websites to assist health practitioners and patients. Many studies relied on community health workers for the implementation of interventions. Improvements in various health parameters were reported following the interventions. Barriers related to the digital components such as technical faults and concerns related to message content were reported. Community engagement during development and implementation of interventions and finding cost-saving strategies may be important to assist with the feasibility of interventions in rural under-resourced settings. The findings of the review demonstrate that community-based health interventions with and without digital components for the management of lifestyle-related health conditions appear to have a positive impact and are feasible to implement in rural communities in low- and middle-income countries. The type of interventions utilised as well as associated facilitators and barriers should be considered during the development of future interventions to increase the likelihood of the value and feasibility thereof in rural, under-resourced settings. Community involvement should be encouraged during the development and implementation of interventions to ensure the appropriateness thereof to local communities.