Context Matters—One Size Does Not Fit All When Designing Interventions to Prevent Child Marriage

Abstract

Child marriage continues to be an important public health and social challenge even in the 21st century. Globally, approximately 12 million girls are married as children annually and, prior to the COVID-19 pandemic, it was estimated that over 120 million additional girls would be married as children by 2030 if programs to prevent child marriage are not accelerated [[1]UNICEFChild marriage is a violation of human rights, but is all too common.2020https://data.unicef.org/topic/child-protection/child-marriage/Date accessed: August 5, 2021Google Scholar]. Sub-Saharan Africa carries the greatest prevalence of child marriage, with approximately 35% of women married before the age of 18, followed by South Asia with nearly 30% [[1]UNICEFChild marriage is a violation of human rights, but is all too common.2020https://data.unicef.org/topic/child-protection/child-marriage/Date accessed: August 5, 2021Google Scholar]. Although child marriage rates are declining globally, the decline is uneven across regions, between countries and within countries [[2]Koski A. Clark S. Nandi A. Has child marriage declined in sub-Saharan Africa? An Analysis of trends in 31 countries.Popul Dev Rev. 2017; 43: 7-29Crossref Scopus (57) Google Scholar]. The greatest reductions have been observed in South Asia and the least in sub-Saharan Africa, but the situation could well be exacerbated by the COVID-19 pandemic, which threatens to slow down progress [[3]Szabo G. Edwards J. The global girlhood report 2020: How COVID-19 is putting progress in peril. Save the Children, London2020Google Scholar,[4]UNICEF. COVID-19A threat to progress against child marriage.2021https://data.unicef.org/resources/covid-19-a-threat-to-progress-against-child-marriage/Date accessed: August 5, 2021Google Scholar]. Child marriage has far-reaching impacts. Low- and middle-income countries are estimated to lose trillions of dollars because of child marriage by 2030 [[5]Wodon Q. Male C. Nayihouba A. et al.Economic impacts of child marriage: Global synthesis report. The World Bank Group, Washington, DC2017Google Scholar], the date set by the Sustainable Development Goals for the elimination of the practice [[6]United NationsAchieve gender equality and empower all women and girls. Sustainable Development Goals, 2015https://sdgs.un.org/goals/goal5Date accessed: August 5, 2021Google Scholar]. There has been a huge increase in research and in concerted program implementation efforts to prevent child marriage; as a result, a range of effective interventions have been identified [[7]Plesons M. Travers E. Malhotra A. et al.Updated research gaps on ending child marriage and supporting married girls for 2020–2030.Reprod Health. 2021; 18: 152Crossref PubMed Scopus (3) Google Scholar]. However, more needs to be done to ensure that proven interventions are appropriately selected to match local contexts and implemented at scale with quality and equity to achieve the desired impacts. This supplement brings together a body of evidence on child marriage drivers and impacts from different contexts. It responds to a recently published call for further research at the subnational and subpopulation levels examining determinants and correlates of child marriage across macro-, meso-, and micro-level social and economic trends [[7]Plesons M. Travers E. Malhotra A. et al.Updated research gaps on ending child marriage and supporting married girls for 2020–2030.Reprod Health. 2021; 18: 152Crossref PubMed Scopus (3) Google Scholar]. The writing team consisted of researchers who are part of the Bill and Melinda Gates Foundation Child Marriage Learning Partners Consortium. The editorial team consists of a diverse set of Southern voices including a medical student from Uganda, a mid-career professional from Kenya who has worked with research institutions and funding bodies, and a seasoned adolescent health professional who has worked both at the local level with community-based organizations and at the global level with an intergovernmental agency. We collaboratively reviewed and provided feedback on each of the supplement articles and commentaries and prepared this editorial commentary. There is a growing recognition of the importance of context in child marriage prevention, based on decades of research showing that interventions that are successful in one population may not have the same impact in a different setting [8Cislaghi B. Nkwi P. Mackie G. Shakya H. Why context matters for social norms interventions: The case of child marriage in Cameroon.Glob Public Health. 2020; 15: 532-543Crossref PubMed Scopus (11) Google Scholar, 9Petroni S. Steinhaus M. Fenn N.S. et al.New findings on child marriage in sub-Saharan Africa.Ann Glob Heal. 2017; 83: 781Crossref PubMed Scopus (41) Google Scholar, 10McDougal L. Shakya H. Dehingia N. et al.Mapping the patchwork: Exploring the subnational heterogeneity of child marriage in India.SSM - Popul Heal. 2020; 12: 100688Crossref PubMed Scopus (3) Google Scholar, 11Girls Not BridesNew research identifies what works best to delay marriage in Ethiopia and Tanzania.2015Date accessed: July 29, 2021Google Scholar]. This supplement adds to the evidence base by providing a more nuanced understanding of why we need to consider contextual factors in the design of child marriage policies and programs. Psaki et al. [[12]Psaki S. Misunas C. Patel S. et al.What are the drivers of child marriage? A conceptual framework to guide policies and programs.J Adolesc Health. 2021; 69: S13-S22Abstract Full Text Full Text PDF Scopus (5) Google Scholar] present a streamlined conceptual framework for understanding the drivers of child marriage, illustrated by three case studies drawn from studies in Bangladesh, Niger, and Malawi. The framework provides a starting point to guide more targeted interventions and policies that address the complex combinations of drivers in each setting. Misunas et al. [[13]Misunas C. Erulkar A. Apicella L. et al.What influences girls’ age at marriage in Burkina Faso and Tanzania? Exploring the contribution of individual, household, and community level factors.J Adolesc Health. 2021; 69: S46-S56Abstract Full Text Full Text PDF Scopus (2) Google Scholar] use this framework to examine individual, household, and community-level drivers of child marriage in rural settings in Burkina Faso and Tanzania, illustrating the complexity and intersections of the drivers in different contexts. Several papers in this supplement use data on married girls to provide useful insights for child marriage interventions in specific contexts. Zahra et al. explore the impacts of specific marriage drivers on the health and well-being of married girls in Malawi, Zambia, and India, while Raj et al. demonstrate the role of progressive gender role beliefs in expanding girls’ freedom of movement and digital connectivity [[14]Zahra F. Austrian K. Gundi M. et al.Drivers of marriage and health outcomes among adolescent girls and young women: Evidence from sub-Saharan Africa and South Asia.J Adolesc Health. 2021; 69: S31-S38Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,[15]Raj A. Johns N. Bhan N. et al.Effects of gender role beliefs on social connectivity and marital Safety: Findings from a cross Sectional Study among married adolescent girls in India.J Adolesc Health. 2021; 69: S65-S73Abstract Full Text Full Text PDF Scopus (2) Google Scholar]. Tomar et al. [[16]Tomar S. Johns N. Raj A. et al.Associations of age at marriage with marital decision-making agency among adolescent Wives in rural Niger.J Adolesc Health. 2021; 69: S74-S80Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar] also show that marriage during early adolescence has an impact on girls’ marital agency and decision-making power in rural Niger. In addition, Soler-Hampejsek et al. [[17]Soler-Hampejsek E. Johns N. Challa S. et al.Education, child marriage and work outcomes among young people in rural Malawi.J Adolesc Health. 2021; 69: S57-S64Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar] find that child marriage curtails education, but the challenges of poor learning also affect girls’ ability to translate education into productive employment in Malawi. Two of the papers have broader implications for child marriage prevention efforts. Yukich et al. [[18]Yukich J. Worges M. Gage A. et al.Projecting the impact of the COVID-19 pandemic on child marriage.J Adolesc Health. 2021; 69: S23-S30Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar] provide timely and relevant estimates of the potential impact of the COVID-19 pandemic on child marriage. The findings indicate that the number of excess child marriages attributed to the pandemic could be as high as 7–10 million globally. Finally, Makino et al. [[19]Makino M. Ngo T. Psaki S. et al.Heterogeneous impacts of interventions Aiming to delay girls’ marriage and pregnancy across girls’ backgrounds and social contexts.J Adolesc Health. 2021; 69: S39-S45Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar] use data from Bangladesh and Zambia to show that differing levels of vulnerability can affect the effectiveness of interventions to delay marriage and pregnancy, with recommendations for tailoring interventions for specific subgroups. Overall, the papers in this supplement highlight the fact that child marriage is influenced by contextual factors at the individual level, family/household level, and the community level, as well as the wider society [[11]Girls Not BridesNew research identifies what works best to delay marriage in Ethiopia and Tanzania.2015Date accessed: July 29, 2021Google Scholar,[20]Singh R. Vennam U. Factors Shaping Trajectories to early marriage: Evidence from Young Lives.2016https://ora.ox.ac.uk/objects/uuid:14005c76-8e23-4817-b74f-64578861af18/download_file?file_format=pdf%26safe_filename=YL-WP149-Trajectories%2Bto%2Bearly%2BMarriage.pdf%26type_of_work=General+itemDate accessed: August 5, 2021Google Scholar,[21]Biswas R.K. Khan J.R. Kabir E. Trend of child marriage in Bangladesh: A reflection on significant socioeconomic factors.Child Youth Serv Rev. 2019; 104: 104382Crossref Scopus (5) Google Scholar]. As a result, a package of interventions working across levels and across sectors is needed to address these intersecting drivers. Furthermore, the choice of interventions must be tailored to address the realities of each context. Despite the growing attention to child marriage, inequalities continue to persist, and certain groups of adolescents are being left behind, particularly girls living in the most marginalized communities [[22]Melesse D.Y. Cane R.M. Mangombe A. et al.Inequalities in early marriage, childbearing and sexual debut among adolescents in sub-Saharan Africa.Reprod Health. 2021; 18: 117Crossref PubMed Scopus (4) Google Scholar]. On the one hand, there is a need to step up global implementation efforts to achieve SDG targets [[7]Plesons M. Travers E. Malhotra A. et al.Updated research gaps on ending child marriage and supporting married girls for 2020–2030.Reprod Health. 2021; 18: 152Crossref PubMed Scopus (3) Google Scholar]. On the other hand, the differing drivers of child marriage in different settings point to the need for local responses. How can we ensure that our response is tailored to local contexts, yet coordinated at the global level to address resource limitations in the regions with the highest rates of child marriage? We believe that there is much we can learn from the HIV model of “know your epidemic, tailor your response” [[23]UNAIDSPractical Guidelines for Intensifying HIV prevention. UNAIDS, Geneva2007Google Scholar]. For HIV prevention, this meant a recognition that there was no single global HIV epidemic, but rather, a multitude of diverse epidemics. The strategy thus involved the following: understanding the drivers in each setting, prioritizing or phasing responses accordingly, setting measurable targets, tailoring prevention plans, and using strategic information to stay on course. For child marriage prevention, this would similarly require a recognition that there are many child marriage hotspots, each with its own complicated set of intersecting drivers. At the same time, as Wilson and Halperin [[24]Wilson D. Halperin D.T. “Know your epidemic, know your response”: A useful approach, if we get it right.Lancet. 2008; 372: 423-426Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar] have stressed, the approach should seek to avoid the following pitfalls of the HIV model: (1) overcomplicating tailored approaches to the point where we are unable to act decisively, (2) an overreliance on mathematical modeling without careful triangulation, (3) ensuring that responses are grounded in evidence so we do not compromise rigor, and (4) knowing how to bring about social and normative change to address cross-cutting drivers. Nevertheless, the model provides useful lessons for developing child marriage prevention strategies that include clear targets for different scenarios or patterns of child marriages at the local level, with transparent leadership, coordination, and accountability at national and global levels. Less than 10 years to the Sustainable Development Goal target date, we have much more knowledge and understanding about child marriage than we did 10 years ago. We have stronger global commitment and investment. We have stronger country-level policies and programs. Substantial, though uneven progress has been made in reducing child marriage, and relatively less in addressing the needs of child brides. To address this, child marriage interventions should be multisectoral and aligned with the broader adolescent agenda in mind, to ensure that we are addressing the root causes of child marriage, while also achieving goals related to education, health, livelihoods, violence prevention, and so on. We are under pressure to step up our response in the face of the COVID-19 pandemic which is increasing poverty and is likely to lead to increased levels of child marriage in some places. We need to do this by knowing our child marriage hotspots, drivers, and contexts, and tailoring our response.

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