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

Manahil Siddiqi; Margaret E. Greene; Alexandra Stoppel; Charles Allegar

doi:10.9745/GHSP-D-23-00425

Figures & Tables

Figures

Tables
Additional Files

Download figure
Open in new tab
Download powerpoint
FIGURE 1
Flow Chart of Studies Included in Review of Interventions to Respond to Needs of Married Adolescents
Download figure
Open in new tab
Download powerpoint
FIGURE 2
Conceptual Framework Guiding Analysis of Interventions to Respond to Needs of Married Adolescents

View popup

TABLE 1.

Inclusion and Exclusion Criteria for Systematic Review of Interventions to Address Married Adolescents’ Needs

Category	Included	Excluded
Study types and design	Impact evaluations of programming using experimental or quasi-experimental designs (including mixed methods approaches)	Publications that describe process evaluations, use only qualitative methods, use nonexperimental research designs, or theoretical or conceptual articles
Focus area	Interventions that seek to improve health and/or social outcomes for individuals married as children—study sample must have included individuals married or in union before the age of 18 years	Publications that include only unmarried individuals
Publication type	Peer-reviewed journal articles and project reports	Policy briefs, programmatic literature that does not describe study results and effectiveness in detail
Publication date	January 2000 to January 2022	Documents published before 2000
Language	English	Languages other than English

View popup

TABLE 2.

Interventions and Their Objectives Mapped to Conceptual Framework

Conceptual Framework	Program Activity Areas Addressed by Interventions
Health	Physical¹⁵^,²⁰
	Mental³⁷
	Sexual and reproductive¹⁵^–³⁶^,⁴²^,⁴³
	Maternal¹⁵^–¹⁷^,²⁰^,²²^,²³^,²⁵^–²⁷^,²⁹^,³¹^–³⁶^,⁴²^,⁴³
Relationships and roles	Marital relationship and decision-making¹⁵^,¹⁸^,¹⁹^,²¹^,²³^–²⁶^,²⁹^,³³^,³⁶
	Household roles and responsibilities¹⁵^,²⁴^,³⁸
	Violence prevention and mitigation, including sexual consent¹⁵^,²⁴^,²⁷^,³⁸^,³⁹^,⁴⁰
	Social network²⁰^,²²^,²³^,²⁶^,³⁰^,³⁹
Life choices	Schooling¹⁸^,²²^,³⁰^,⁴¹
	Employment and livelihoods¹⁵^,¹⁶^,¹⁸^,²¹^,²²^,³⁸^,⁴⁰
	Rights, access to legal support²⁶
	Agency¹⁵^,²⁰^,²²^,²⁶^,³⁰^,³²^,³³^,³⁸
Norms	Health and choice²⁰^–²²^,²⁴^,²⁶^,³¹^,³³^,³⁴
	Gender equity²³^,²⁴^,²⁶^,³⁶^,³⁸
	Attitudes toward age at marriage³⁶^,³⁹

View popup

TABLE 3.

Characteristics of Included Studies Addressing the Needs of Married Girls and Results

Study, Year, and Country	Study Objective and Interventions	Evaluation Design	Quality	Key Findings
Erulkar and Tamrat,¹⁵ 2014Ethiopia	Provided girls with peer groups on SRH topics, financial literacy, safe motherhood, and self-esteem. Partner program provided training for husbands on partner communication, nonviolent and respectful relationships, caring for wives and children, and SRH topics.	Midline and endline population-based surveys	Low	Increased FP use, voluntary counseling and treatment, and husbands’ likelihood of helping with household, and mild increase in husbands’ likelihood of accompanying wife to clinic. However, if husbands were not also program participants, increased likelihood of being forced into sex and mild increase in wives’ likelihood of being beaten.
Handa et al.,¹⁶ 2015Kenya	Provided monthly unconditional cash transfers to poor females aged 12–24 years to measure impact on pregnancy and early marriage.	Cluster RCT	Medium	Decreased odds of pregnancy, especially among out-of-school girls.
Pathfinder International,¹⁷ 2015Burkina Faso	Trained CHWs to reach young married women and first-time parents with SRH information to increase contraceptive use and conducted small group discussions to engage community.	Qualitative monitoring data	Low	Increased contraceptive use.
Luseno et al.,¹⁸ 2017Zimbabwe	Provided school support (payment of school fees, uniforms, exercise books, and other supplies) to young orphaned women to examine effects on pathways to and experiences with marriage and use of maternal and child health services.	Quasi-experimental pre-and post-test with control; IDIs with sampled girls	High	Although quantitative results are not significant due to low sample size, women showed a decrease in positive attitudes toward SRH services and use of SRH services, as well as being less likely to use FP, get HIV testing, and immunize children. There was an increase in HIV positivity. Decreased happiness in marriage. Increase in +1 year education and food security. Equal perceptions of having resources compared to others.
Shattuck et al.,¹⁹ 2011Malawi	Provided peer-delivered (“male motivator”) educational and motivational intervention to examine effect on couples’ contraceptive uptake.	RCTIn-depth interviews	Medium	Increased contraceptive use, higher scale score for general communication with partners, and increased communication frequency with partners.
CREHPA,²⁰ 2004Nepal	Held monthly peer group meetings for youth community action groups and mothers’ groups to improve access to and use of RH services and information by young married couples, ages 24 years and younger.	Quasi-experimental pre-post-test with 2 intervention arms (youth, mother’s groups) and 1 control	Medium	Increased awareness, knowledge, and acceptance of contraception, HIV/AIDS, and ANC, as well as increased knowledge of danger signs in pregnancy, labor, and delivery. Increased vitamin A consumption and deliveries assisted by traditional birth assistants in the youth community action group area.
Edmeades et al.,²¹ 2016Ethiopia	Group-based peer education meetings on SRH, economic empowerment, and conflict resolution and combination of those topics on contraceptive use and STI knowledge.	Quasi-experimental pre-post-test with 3 treatment arms plus controlNonrandom selection of eligible districts but random selection of implementation sites	High	Increased reported use of SRH services, basic knowledge of STIs, HIV testing, use of modern contraceptives, percentage of women who discussed FP with their husbands, as well as increased personal financial savings, intention to invest savings, and economic self-sufficiency.
Erulkar and Muthengi,²² 2009Ethiopia	A combination of peer group and safe social space, education support, and referrals to health services for girls to remain in school and community awareness to reduce the prevalence of child marriage in rural Ethiopia.	Quasi-experimental pre-post- with control, controlling for age, socioeconomic status, marital status, and years of schooling	Medium	Increased use of contraceptives; likelihood of talking with a friend about FP, condoms, HIV/AIDS, STIs; awareness of condoms; and knowledge that one can’t always tell if a man has an STI. Increase in discussion about violence in the community and problems in marriage and increase in new friendships. Increased enrollment in school and literacy.
Huda et al.,²³ 2019Bangladesh	Peer groups of married adolescent girls aged 14–19 years in urban slums of Dhaka to discuss SRH topics combined with group leader training, community health volunteer SRH service promotion, FP material distribution, and counseling.	Quasi-experimental design using population-based surveys; IDIs and FGDs with wife participants and their husbands	Medium	Increase in odds of FP awareness and belief that FP is joint responsibility of husbands and wives.
Institute for Reproductive Health et al.,²⁴ 2016Uganda	Used collective dialogue and action implemented by community leaders and mobilizers through community action groups, radio dramas, and village health teams to promote and sustain change related to social norms and attitudes toward gender, RH, and violence.	Quasi-experimental pre- and post- with control, propensity score analysis with difference-in-difference estimates	Medium	Increase in partner communication about FP, FP seeking behavior, use of FP, and intended future FP use. Increase in equitable partner-decision-making score and couple communication score. Increase in household role sharing score, men’s involvement in sharing of household roles, men involvement in at least 2 childcare tasks, as well as decrease in violent response to partner conflict.
Khan et al.,²⁵ 2008India	Trained community workers to promote lactational amenorrhea and postpartum contraception among pregnant women with a parity of 0 or 1, distributed information and education materials, and conducted household visits.	Quasi-experimental pre-and post- with control, clustered by village, baseline and 2 endlines	Medium	Increased postpartum contraception use, postpartum lactational amenorrhea use, and knowledge of methods for spacing pregnancy.
Santhya and Haberland,²⁶ 2007India	Provided health education and information to first-time parents on SRH topics, communication, and join decision-making, provide education to service providers on first-time parent needs, and form married girl peer groups to reduce isolation and increase agency.	Quasi-experimental study, 2 villages, baseline and endline surveys, no pre-assignment to treatment/controlIDIs at baseline.	Medium	Increase in RH knowledge (both Vadodara and Diamond Harbor villages)Diamond Harbor: increased number of women who had comprehensive antenatal check-ups, made delivery preparations, had a postpartum check-up, breastfed babies immediately after birth, and fed their babies colostrum.Vadodara: Increased number of women who had routine postpartum check-ups and increase in contraceptive use for delaying the first birth.Increased say in household decision-making, freedom of movement, friends in whom to confide, discussion of contraceptives with partners.Vadodara: Increase in egalitarian gender role attitudes and discussion of timing of first pregnancy with partners; Diamond Harbor: increase in openly disagree with husband.
Silverman et al.,²⁷ 2019Niger	Used monthly household visits, peer group sessions, and community dialogues on healthy timing and spacing of pregnancy and SRH topics to increase use of modern spacing contraception among married adolescent girls (ages 13–19 years) and their husbands in the Dosso region.	Four-arm cluster RCT, difference in difference	High	Increase contraceptive use (household visit and combined arms only) and decreased intimate partner violence (small group sessions and combined arms only).
Subramanian et al.,²⁸ 2018India	Conducted outreach to married young women and husbands of young women in Bihar on SRH and gender to delay the age at first birth by delaying the age at marriage, increase voluntary contraceptive use among young nulliparous married women, and to space second and subsequent births by at least 3 years.	Multiple quantitative population-based quasi-experimental evaluations from 3 project phases	Medium	Increased contraceptive use.
Undie et al.,²⁹ 2014Kenya	Conducted a media campaign, CHW training, and distribution of information to promote the uptake of comprehensive RH (including FP) and HIV prevention services and information among married adolescent girls and expand access to these services among this population.	Pre- and post-intervention design without control, some measurement of exposure on select indicators	Low	Increased use of FP and postpartum use of implants and condoms, number of married girls decreased whose first ANC visit was at month 7-8 of pregnancy and who delivered babies at home and number of married girls increased who had 4 total ANC visits during pregnancy Increased proportion of girls whose husbands: provided transportation or transportation money to ANC services; provided money to pay for delivery; provided money for delivery services.
Mehra et al.,³⁰ 2018India	Provided youth safe spaces, peer educator training, and community mobilization focusing on SRH information and education and assess effects on early marriage, early pregnancy, and school retention among young people in 2 states.	Cross-sectional post-test	Low	Delayed pregnancy.
Dyalchand et al.,³¹ 2021India	Behavior change communication through CHW visits to improve the RH of married adolescent girls and avert the adverse consequences of early motherhood	Quasi-experimental with pre- and post-test, difference-in-difference	Medium	Increased use of full ANC, consumption of at least 3 meals/day in the third trimester of pregnancy, safe and institutional delivery, use of postnatal care, and treatment of postnatal complications.
Engebretsen and Kaboré,³² 2011Burkina Faso	Mother educators provided information and support to married adolescents during their first pregnancy and birth and provided Vitamin A and iron supplements to those who were pregnant	Cross-sectional surveys of households and adolescent girls at baseline and endline	Low	Increased knowledge of obstetric fistula, use of SRH services, particularly delivery assistance, and knowledge of the minimum legal age of marriage.
Foundation for Research in Health Systems,³³ 2006India	Through social mobilization and strengthening government RH services aimed to improve married adolescents’ SRH knowledge and to increase their access to and use of health services.	Quasi-experimental design pre- and post- with control, social mobilization arm, government services arm, and combined arm	Medium	Increased knowledge of maternal health and contraceptive side effects; increased postnatal check-ups, contraceptive acceptance, treatment of gynecological disorders, RTIs, and STIs; and increased husbands’ awareness of maternal health needs.
Mathur et al.,³⁴ 2005Nepal	Used community mobilization and participatory approaches to improve services and outcomes for youth RH, focusing on youth aged 14–21 years.	Quasi-experimental pre-and post- with control; cross-sectional (not panel) data; IDIs and FGDs	Medium	Increased knowledge of serious problems during childbirth, use of ANC, and use of facilities for delivery.
Pande et al.,³⁵ 2006India	Provided youth-friendly, accessible, affordable and effective diagnosis and treatment for RTIs and STIs among adolescents and young women and men through 2 different community-based approaches.	Quasi-experimental design with 2 study arms (community- based health aid, female doctor, control); FGDs with young men	Medium	Increased contraceptive use.
The ACQUIRE Project,³⁶ 2008Nepal	Increased access to and use of RH information and services among married adolescents in Parsa and Dhanusha districts through peer education and network building.	Cross-sectional quasi-experimental with household surveys, no control; qualitative FGDs	Low	Increased use of ANC care and deliveries attended by a skilled birth attendant and decreased deliveries taking place at home. Increased communication and joint decision-making and awareness of needs and rights of married adolescents.
Malak et al.,³⁷ 2021Jordan	Provided mental health counseling and evaluated depression, anxiety, and stress symptoms among adolescent married girls in Palestinian refugee camps.	Cross-sectional survey with convenience sample (no follow-up)	Low	Decreased depression, anxiety, and stress with previous trauma and father’s education; decreased anxiety and stress with age at marriage; and decreased stress with husband’s education and family income after marriage.
Falb et al.,³⁸ 2015Côte d’Ivoire	Used group savings program and women’s discussion groups to promote gender equality, and violence prevention, improve livelihoods, and increase agency.	RCT	High	Decreased economic abuse for married girls and violence for unmarried girls.
Stark et al.,³⁹ 2018 Ethiopia	Conducted adolescent girl life skills session in safe spaces and caregiver sessions to improve communication and raise awareness of GBV among refugee adolescent girls.	Two-arm, single-blinded, cluster RCT	High	No effect of intervention on reports of sexual violence, physical violence, emotional violence or transactional sex in the previous 12 months or on perceived feelings of safety.Increased perceptions of social support increased attitudes around ideal ages of marriage and motherhood.
Muthengi et al.,⁴⁰ 2016Kenya	Intervention program aimed at building social, health, and economic assets for vulnerable married adolescent girls.	Cross-sectional secondary analysis of survey data coupled with content analysis of in-depth interviews	Low	Increased odds of experiencing physical violence for girls who worked compared to not-working, odds of experiencing physical violence for girls who worked with no regular saving compared to girls who did not work, and odds of experiencing physical violence for girls earning a higher (≥ median) income with no regular saving compared to not working.Decreased odds of experiencing violence for girls who reported their partner trusting them with money compared to those not having partner trust.
Walgwe et al.,⁴¹ 2016Kenya	Conducted interactive media campaign, advocacy, and policy dialogues to increase demand for secondary school education among teenage mothers.	Cross-sectional baseline and endline data	Low	Increased % out-of-school girls who reentered school.
Jacobs et al.,⁴² 2017Burkina Faso; Senegal	Used generic FP messaging through media campaigns to reach married adolescent women in West Africa to examine whether such messaging is associated with increased contraceptive use.	Cross-sectional, secondary analysis of DHS data using propensity score matching	Low	Increased odds of contraceptive knowledge and odds of intended future contraceptive use (Burkina Faso only).
KEM Hospital Research Centre,⁴³ 2004India	Provided an integrated package of RH information, clinical referrals, and SRH couples counseling to married youth in a rural context.	Quasi-experimental pre- and post- without control plus quantitative and qualitative monitoring	Low	Increased couples’ knowledge of SRH (even if only 1 person participated).

Abbreviations: ANC, antenatal care; CHW, community health worker; DHS, Demographic and Health Survey; FGD, focus group discussion; FP, family planning; GBV, gender-based violence; IDI, in-depth interview; RCT, randomized controlled trial; RH, reproductive health; RTI, reproductive tract infection; SRH, sexual and reproductive health; STI, sexually transmitted infection.