Interventions to Address the Health and Well-Being of Married Adolescents: A Systematic Review

"The lack of evidence on responses to married girls points to a need to pay greater attention to the issue of agency and to the participation of married girls and boys in the design, development, and evaluation of programs."

The 2030 Agenda for Sustainable Development includes a specific target for eliminating child marriage (marriage before the age of 18 years) and includes goals related to quality education, gender inequality, and good health and well-being. Yet limited attention to the needs and vulnerabilities of married girls has historically led to limited resources and programming tailored for this population. This paper systematically reviewed academic and gray literature to learn what is known about the current state of the evidence for interventions to respond to the needs of married adolescents.

This systematic review builds on a comprehensive scoping review of child marriage studies, published between 2000 and 2019. In addition, the researchers searched 6 databases to include literature from January 2020 to January 2022. Ultimately, 29 articles met the eligibility criteria for this systematic review. Five randomised control trials were represented among the studies; the remaining studies used pre-test/post-test with comparison group design and/or quasi-experimental design or used cross-sectional data without comparison groups.

The researchers mapped outcomes to a conceptual framework we developed before initial searches and then refined the framework as they reviewed the literature. This conceptual model captures the range of potential intervention areas that may support married adolescents, organised by 3 broad dimensions:
 

• Health: Programme activities addressing health include physical health, mental health, sexual and reproductive health (SRH), and maternal health (MH).
• Relationships and roles: Activities included in this dimension address the marital relationship and decision-making, household roles, and violence (including sexual coercion), as well as social networks to overcome social isolation and a lack of mobility.
• Life choices: Activities included efforts to increase or support schooling, build livelihoods, support an understanding of a person's rights, provide legal support (for instances, where a child might wish to seek a divorce, for example), and build their agency or empowerment.

Work to transform norms cuts across all 3 of these dimensions, since a wide variety of normative expectations regarding the management of sexuality, transition to adulthood, deference to elders, future roles, and so on drive the pressure on girls, and sometimes boys, to marry and have children early.

The analysis of the 29 included intervention studies found that interventions occur mostly at a small scale, are carried out in relatively short periods of time, and focus on SRH and MH (25 of 29 articles), to the neglect of other sectors. There is also a remarkable geographic concentration of these interventions in South Asia and East Africa, with somewhat fewer in West and Southern Africa and a single programme in the Middle East and North Africa region. Not a single study surfaced on Latin America and the Caribbean, North America, East Asia, or Europe and Central Asia. This may partly reflect the researchers' omission of research on informal unions but also exposes a lack of attention to married girls in these regions. And boys, by virtue of the fact that they marry as children at lower rates and may experience fewer harmful consequences, are virtually invisible throughout the literature.

The analysis indicates that for most outcome categories for married girls, no single programme approach emerges as the most effective. For example, 13 studies demonstrated improved rates of contraceptive use, yet their respective programmes conducted activities as diverse as peer-based education, household visits, healthcare referrals, and media campaigns. Eight studies with a similar mix of programme activities each reported improved marital communication. However, at least 3 studies concluded that single intervention approaches produced stronger effects than multicomponent programming, which they attributed to the more focused effort. It seems that robust and well-funded programming is more important than the specific programme approach.

Per the researchers, there is a need for programmes to focus on improving educational and economic outcomes among married girls, as well as increased efforts to support equitable marital relations and to engage men and boys. Because married girls face more social and cultural constraints than unmarried girls, it may be more important to engage their broader social networks. Indeed, the mobilisation of married girls' families and communities is logically central to many interventions' mechanisms of change. Most interventions organised married girls into peer groups, and many also relied on household visits from community workers. These types of activities, in addition to explicit community mobilisation, strengthened married girls' social networks in service of other outcomes of interest.

The researchers argue that understanding how social norms vary across groups will also be useful in planning interventions, as it can guide investment to groups where norms are most entrenched or catalyse efforts for larger normative change in areas where norms are weaker or more contested. Longer intervention timeframes and more intensive engaging of influential family and community members will be needed to affect cultural beliefs and behaviours that negatively impact youth reproductive health decision-making and outcomes. They also recommend more attention to measuring social and legal support for individuals married as children.

Key implications:
 

• Programme designers and implementers must identify and address the needs of married adolescents through targeted evidence-based interventions that: encompass timely identification and referral of adolescents affected by child marriage; foster collaboration between child protection, education and social protection sectors; and employ evidence-based design and delivery.
• Policymakers should invest in and scale up programmes and services that not only prevent child marriage but also mitigate the harmful consequences faced by survivors of child marriage, particularly girls who remain disproportionately affected by the harmful effects of child marriage.