Drivers and consequences of child marriage in a context of protracted displacement: a qualitative study among Syrian refugees in Egypt

The sexual and reproductive healthcare challenges when dealing with female migrants and refugees in low and middle-income countries (a qualitative evidence synthesis)

BACKGROUND

Migrants and refugees face unprecedented inequalities in accessing sexual and reproductive health (SRH) in developed and developing countries. Most attention has focused on the rich world perspective, while there are huge numbers of migrants and refugees moving towards less developed countries. This article synthesizes the barriers to proper SRH care from low and middle-income countries perspective.

METHODS

We performed a systematic review of articles containing primary source qualitative and quantitative studies with thick qualitative descriptions. Articles from various databases, including PubMed, Science Direct, HINARI, and Google Scholar, published between 2012 and 2022 were included. Because the context differed, we excluded articles dealing with migrants and refugees from low- and middle-income countries living in high-income countries. To select articles, a preferred reporting item for systematic reviews and meta-analyses (PRISMA) was used. The articles' quality was assessed using the standard QASP checklist. We used a socio-ecological model to investigate barriers at various levels, and thematic analysis was used to identify the strongest themes at each level of the model. This synthesis is registered under PROSPERO number CRD42022341460.

RESULTS

We selected fifteen articles from a total of 985 for the final analysis. The results show that despite the diversity of the participants' homes and countries of origin, their experiences using SRH services were quite similar. Most female migrants and refugees claimed to have encountered discrimination from service providers, and linguistic and cultural obstacles played a significant role in their experiences. In nations lacking universal healthcare coverage, the cost of care was a barrier to the use of SRH services. Other main obstacles to using SRH services were a lack of knowledge about these programs, worries about privacy, inadequate communication, stigma in the community, and gender-related power imbalances.

CONCLUSION

To enhance the use of SRH by female migrants and refugees, it is vital to provide person-centered care and involve husbands, parents, in-laws, and communities in SRH coproduction. Training on cultural competency, compassion, and respect must be provided to healthcare personnel. Increasing financial access for migrant and refugee healthcare is crucial, as is meeting their basic requirements.

Socio-ecological factors of girl child marriage: a meta-synthesis of qualitative research

BACKGROUND

Child marriage of girls is one example of human rights violations, and is increasingly recognized as a key obstacle to global public health. Given the importance of a comprehensive understanding of the motivations for child marriage, this study aimed to identify socio-ecological factors contributing to gills child marriage.

METHODS

A comprehensive search was conducted of all English-language studies measuring causes of child marriage between 2000 and October 2022 in the Web of Science, PubMed, Scopus, PsycInfo, ProQuest, Poplin and Google Scholar databases. Girl child marriage is defined as a marriage under the age of 18. In this study, the CASP evaluation checklist was used to collect data. Two independent reviewers reviewed all articles.

RESULTS

A total of 34 eligible qualitative articles were included. The most salient causes of child marriage among girls include low skills and knowledge, internal and external beliefs and motivations, and physical advantages at the individual level. Family characteristics and structure contribute to child marriage at the interpersonal level, while environmental and economic factors play a role at the community level. Social factors and cultural norms, as well as the shortcomings and weaknesses of legislation, are also contributing factors at the society level.

CONCLUSION

The results showed that cultural beliefs supporting gender inequality and economic status were the most important causes of child marriage. These results can help policymakers and decision-makers implement strategies to reduce gender inequality to prevent child marriage.

Associations between child marriage and food insecurity in Zimbabwe: a participatory mixed methods study

BACKGROUND

Child marriage is a global crisis underpinned by gender inequality and discrimination against girls. A small evidence base suggests that food insecurity crises can be both a driver and a consequence of child marriage. However, these linkages are still ambiguous. This paper aims to understand how food insecurity influences child marriage practices in Chiredzi, Zimbabwe.

METHODS

Mixed methods, including participant-led storytelling via SenseMaker® and key informant interviews, were employed to examine the relationship between food insecurity and child marriage within a broader context of gender and socio-economic inequality. We explored the extent to which food insecurity elevates adolescent girls' risk of child marriage; and how food insecurity influences child marriage decision-making among caregivers and adolescents. Key patterns that were generated by SenseMaker participants' interpretations of their own stories were visually identified in the meta-data, and then further analyzed. Semi-structured guides were used to facilitate key informant interviews. Interviews were audio-recorded, and transcribed and translated to English, then imported into NVivo for coding and thematic analysis.

RESULTS

A total of 1,668 community members participated in SenseMaker data collection, while 22 staff participated in interviews. Overall, we found that food insecurity was a primary concern among community members. Food insecurity was found to be among the contextual factors of deprivation that influenced parents' and adolescent girls' decision making around child marriage. Parents often forced their daughters into marriage to relieve the household economic burden. At the same time, adolescents are initiating their own marriages due to limited alternative survival opportunities and within the restraints imposed by food insecurity, poverty, abuse in the home, and parental migration. COVID-19 and climate hazards exacerbated food insecurity and child marriage, while education may act as a modifier that reduces girls' risk of marriage.

CONCLUSIONS

Our exploration of the associations between food insecurity and child marriage suggest that child marriage programming in humanitarian settings should be community-led and gender transformative to address the gender inequality that underpins child marriage and address the needs and priorities of adolescent girls. Further, programming must be responsive to the diverse risks and realities that adolescents face to address the intersecting levels of deprivation and elevate the capacities of adolescent girls, their families, and communities to prevent child marriage in food insecure settings.

Participatory approaches and methods in gender equality and gender-based violence research with refugees and internally displaced populations: a scoping review

Using participatory approaches or methods are often positioned as a strategy to tackle power hierarchies in research. Despite momentum on decolonising aid, humanitarian actors have struggled to describe what 'participation' of refugees and internally displaced persons (IDPs) means in practice. Efforts to promote refugee and IDP participation can be tokenistic. However, it is not clear if and how these critiques apply to gender-based violence (GBV) and gender equality-topics that often innately include power analysis and seek to tackle inequalities. This scoping review sought to explore how refugee and IDP participation is conceptualised within research on GBV and gender equality. We found that participatory methods and approaches are not always clearly described. We suggest that future research should articulate more clearly what constitutes participation, consider incorporating feminist research methods which have been used outside humanitarian settings, take more intentional steps to engage refugees and IDPs, ensure compensation for their participation, and include more explicit reflection and strategies to address power imbalances.

Sexual and reproductive health (SRH) needs for forcibly displaced adolescent girls and young women (10-24 years old) in humanitarian settings: a mixed-methods systematic review

BACKGROUND

Globally, there are 42 million women and girls estimated to be forcibly displaced. Adolescent girls and young women in humanitarian settings have their sexual and reproductive health (SRH) neglected. This systematic review aimed to describe SRH obstacles that adolescent girls and young women (10-24 years old) face in humanitarian settings in line with the Sustainable Development Goals.

METHODS

We conducted a mixed-methods systematic review in six databases, focusing on migrant women ages 10 - 24and their SRH outcomes. The mixed-methods appraisal tool was used to evaluate the quality of the studies. This review follows PRISMA and the Systematic Review Guidelines from the Centre for Reviews and Dissemination recommendations.

RESULTS

Among the 1290 studies screened by abstracts, 32 met the eligibility criteria: 15 were qualitative, 10 were quantitative and seven were mixed-methods studies. Most studies were performed in the last four years, in African countries. They discussed the increased frequency of adolescent pregnancies (16-23%), lack of contraceptive use and access (8-32%), poor menstrual hygiene management (lack of water, shortage of menstrual hygiene supplies), ignorance and stigma about sexually transmitted infections and HIV, a higher number of child, early and forced marriage or partnership and sexual and gender-based violence, challenging to obtain SRH information/knowledge/access, and unmet SRH needs.

CONCLUSION

Migration is a current issue. Although there is a growing number of studies on adolescent girls and young women's SRH in humanitarian settings, this population remains overlooked, and face several challenges in SRH. There is a need for targeting interventions on SRH.

Identifying psychosocial problems, needs, and coping mechanisms of adolescent Syrian refugees in Jordan

Background

Refugees who have fled war zones are at a heightened risk of psychosocial problems that can impact their ability to function in day-to-day life and place a significant burden on the family structure. This study aimed to assess the psychosocial problems and needs and coping mechanisms of Adolescent Syrian refugees in Jordan.

Methods

Between October and December 2018, we conducted a qualitative study using semi-structured interviews with a sample of key and individual informants. Our sample included 20 primary healthcare professionals, 20 schoolteachers, 20 Syrian parents, and 20 adolescents aged 12-17 years. All interviews were transcribed verbatim, and we utilized thematic analysis to group, categorize, and analyze the original Arabic language transcripts. To ensure thorough analysis, we adopted a bottom-up inductive approach that covered the six-phase iterative process proposed by Braun and Clarke.

Results

The main psychosocial problems encountered by Syrian adolescents included stress, depression, loneliness, lack of a sense of security, isolation, aggressiveness, fear of war, and family disintegration. Almost all schoolteachers reported that they observed that Jordanian adolescents are more settled, self-confident, and financially stable relative to their Syrian peers. The Jordanian government and community were praised for their support, including education, recreational centers, health services, and awareness campaigns. Going to school, praying and reading the Holy Quran, listening to music, and talking to friends and engaging with them were reported as the main coping mechanisms. The majority of respondents said that more services are still needed for adolescents, including more places for entertainment, psychosocial support and psychological counseling, medical care, job creation, and providing health insurance.

Conclusion

Syrian refugees are aware of the psychological aspects of their situation, but they are not always able to access clinic-based humanitarian assistance for mental health and psychosocial support. Stakeholders must interact with refugees to learn about their needs and develop services that are appropriate for their culture.

Sexual and reproductive health knowledge among adolescent Syrian refugee girls displaced in Lebanon: The role of schooling and parental communication

Adolescent Syrian refugee girls living in Lebanon are vulnerable to poor sexual and reproductive health (SRH). Sociocultural norms, stigmatization, and limited educational opportunities in the context of forced displacement may impact adolescent girls' SRH. Little is known about how and where girls in this population access SRH information and services. This study aimed to: (1) assess knowledge of SRH topics among a population of adolescent Syrian refugee girls displaced in Lebanon, and (2) determine the association of schooling versus maternal SRH communication with SRH knowledge. A total of 418 11-17-year-old Syrian refugee girls displaced in the Beqaa region of Lebanon were recruited to participate in a cross-sectional survey. Bivariate logistic regression and ordinary least squares regression models were used to examine the associations between schooling, maternal SRH communication, and other covariates with SRH knowledge outcomes. Significant predictors (p<0.2) were included in multivariate analyses. The mean age of girls was 13.4 years. Approximately two thirds of our sample was enrolled in school, with enrollment rates dropping considerably around age 15. In bivariate and multivariate models, older age and participation in SRH programs were predictive of puberty knowledge. One in five girls enrolled in school had learned about menstruation in school, which was associated with higher puberty knowledge in bivariate models. Older age, current school enrollment, and reaching the 8th-11th grade were strongly associated with HIV knowledge. Schooling is more strongly associated with SRH knowledge among adolescent girls than is maternal communication. School-based SRH curricula should be administered on the basis of age and not grade, given significant age-for-grade heterogeneity in this population. Forced displacement and poverty are major barriers to education retention and may have long-term impacts on girls' health.

Girl child marriage and the social context of displacement: a qualitative comparative exploration of Syrian refugees in Jordan and Rohingya refugees in Bangladesh

BACKGROUND

There is growing global evidence that girl child marriage (CM) increases during humanitarian crises. Norms, attitudes, and policies that sustain CM are deeply entrenched within families and communities, and may be further exacerbated by conflict and displacement. The purpose of this study is to understand how the social and normative environment influences attitudes and practices related to CM in two diverse humanitarian settings.

METHODS

We held a total of eight focus group discussions, four in each country, with Syrian refugees in Jordan and Rohingya Refugees in Bangladesh. FGDs were conducted with fathers, mothers, and adolescent boys and girls.

RESULTS

Similar themes emerged from both settings. Participants discussed a desire to hold onto tradition in displacement and how norms are reinforced across generations. Social influence emerged in positive and negative ways, including peer pressure and conformity and the positive influence of host communities. In both settings, girls themselves described having little agency. Participants described resistance to change, which was exacerbated by conflict and displacement, though they discussed how social influence could be an effective way to challenge existing norms that drive the practice of girl child marriage.

CONCLUSIONS

Our findings represent a more robust understanding of how norms operate within the social ecological system, and how they are reinforced across social relationships, offering an opportunity to more effectively challenge norms that sustain the practice of girl child marriage.

Developing a sexual and reproductive health educational intervention for adolescent Syrian refugee girls: Challenges and lessons learned

In Lebanon, a country with the highest per capita refugee population in the world, roughly one in four persons is forcibly displaced. Early marriage is highly prevalent among Syrian refugees in Lebanon and qualitative studies suggest an unmet need for sexual and reproductive health (SRH) information and services in this community. Adolescent Syrian refugee girls in Lebanon are a vulnerable population at risk of negative SRH outcomes related to early sexual debut, which occurs primarily in the context of early marriage. Despite this need, cultural norms and gender roles generally restrict adolescent girls' access to SRH resources. To address this need for comprehensive sexuality education, our team developed a novel, rights-based, peer-led, adolescent SRH educational curriculum that is specific to the context of Syrian displacement in Lebanon. This curriculum was developed to be administered as part of Project Amenah, a community-based, multi-component intervention that aims to reduce early marriage and improve SRH among adolescent Syrian refugee girls displaced in Lebanon. The curriculum, which features eight discreet age-appropriate units, is based on extensive formative work conducted in this community, as well as adaptations of early marriage programs implemented in low-resource settings elsewhere. Topics covered include, but are not limited to, gender and human rights, communication, negotiation and decision-making, reproductive anatomy, puberty and menstruation, sexually transmitted infections, family planning and modern contraception, and adolescent pregnancy. We encountered several challenges when developing this curriculum, including those related to community acceptability, varying levels of literacy levels among participants, and limited engagement with married adolescents, who may experience mobility restrictions that preclude their participation. We recommend that investigators developing adolescent SRH interventions in similar settings utilize a behavior-determinant-intervention logic model to guide their study design, elucidate community priorities and capacity by conducting preliminary qualitative work and assembling a community advisory board, and follow a peer-led model, which has shown to be effective for adolescent SRH interventions.

Assessment of Risk Factors and Obstetric Outcome of Adolescent Pregnancies Through a Prospective Observational Analysis

Background Adolescence is the most crucial stage of life. Early marriage and teenage pregnancy infringe on adolescent girls' social and humanitarian rights. Moreover, it leads to school dropouts and decreased self-autonomy. Through this study, we aimed to analyze the risk factors and obstetric and neonatal outcomes resulting from adolescent pregnancies conceived by Indian girls less than 20 years of age. Materials and methods It was a prospective observational study conducted over a period of two years. Consecutive consenting adolescent mothers visiting the antenatal clinic or the delivery wards were recruited into the study. Adolescent pregnancies constituted all pregnancies where the maternal age was between 14 and 19 years at the time of presentation. Participants were followed prospectively till delivery and postpartum visit at six weeks to assess the obstetric and puerperal outcomes. Treating obstetricians asked about the causes responsible for current teenage pregnancy. At the time of delivery, data pertaining to antenatal complications, pregnancy outcome, mode of delivery, and birth weight were noted. All women were counseled for postpartum contraception at the time of delivery. Compliance with postpartum contraception was noted, and reasons for non-acceptance were asked. Results A total of 133 antenatal women in the adolescent age group were recruited during the study time frame. The mean age at the time of delivery was 18.4 years. Most of the women were educated between the sixth and 12th standards and belonged to the upper-lower economic class. Early marriage, increased family pressure, and school dropout at a young age were the predominant risk factors for teenage pregnancy in the study population. The majority of them suffered from anemia. Pregnancy-induced hypertension, hypothyroidism, fetal growth restriction, and oligohydramnios were a few other complications seen in adolescent pregnancies. Despite counseling, only 33.8% of adolescent mothers accepted postpartum contraception (any of the standard methods). Conclusion Pregnancy has concerning health consequences on adolescent girls and their babies. For example, adolescent mothers face increased risks of pregnancy-induced hypertension, obstructed labor, and puerperal sepsis. So, it is time to create awareness through mass educational campaigns and widespread family planning services.

Child Marriage in Relation to the Syrian Conflict: Jordanian and Syrian Adolescents' Perspectives

PURPOSE

Although the average age of marriage has increased in many countries in the Middle East in recent years, child marriage is thought to become more common among certain populations in Jordan, notably the refugees. This study explores the perspectives of Jordanian and Syrian adolescents on child marriage in relation to the Syrian conflict as members of refugee populations and host communities.

METHODS

This study used data from in-depth interviews with 64 Jordanian and Syrian adolescents between the ages of 15 and 19 years. Interviews consisted of a narrative, flexible dialog in which participants discussed their life histories using the creation of a visual timeline as a tool. Data analysis was iterative, inductive, and based on the grounded theory approach. Themes were identified through ongoing interaction with the data.

RESULTS

Three major themes emerged from the data relating to child marriage: (1) the influence of intermingling between Syrian and Jordanian communities, (2) vulnerability and control interact to fuel increases in child marriage in displacement, and (3) finding agency by rejecting child marriage.

CONCLUSIONS

The Syrian conflict has changed practices relating to child marriage, fostering a renewed reliance on child marriage in light of increasing instability, leaving both Jordanian and Syrian adolescents increasingly vulnerable. Many adolescents reject the practice, thus offering an opportunity for social change.

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.