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The Association Between Individual and Village Level Demographic The association between individual and village level demographic characteristics and age at first marriage among married adolescents in rural Niger: a spatial analysis. Holly B. Shakya, John Weeks, Paul Fleming, Lotus McDougal, Anne Scobel, Benjamin Cislaghi, Sabrina Boyce, Anita Raj, Jay Silverman Introduction Niger has the highest prevalence of child marriage in the world, with 76% of women aged 20-24 married by the age of 18; nearly 40% of these marriages occur before the girl reaches 15 years of age.(1) These child brides quickly become child mothers, with 74% of women aged 20-24 years having given birth as adolescents. As a result, Niger has the highest adolescent fertility rate in the world with 201 births per 1000 adolescents aged 15-19. Early childbearing in Niger leads to high levels of overall fertility: Niger also has the highest fertility in the world, with an average of 7.6 children born to each woman, a level of childbearing which has remained largely unchanged for the last 40 years.(2, 3). Unsurprisingly in this context of high fertility, contraceptive use is extremely low, with only one in eight married women reporting modern contraceptive use.(1) Research documents substantial linkages between early marriage, early childbearing, and adverse health consequences for both the mother and her children.(4, 5) To compound these vulnerabilities, the high levels of early marriage and fertility in Niger exist in a context of an extremely understaffed health system; the density of doctors, nurses and midwives serving its population of 21.5 million is among the lowest in the world.(2, 6) These factors all contribute to some of the most sobering health statics of any country. Niger ranks 17th globally in terms of maternal mortality ratio, at 553 maternal deaths/100,000 live births, and has the 10th highest under-five mortality rate, at 96 deaths/1,000 live births.(7, 8) Gender equity is extremely compromised in Niger, above and beyond elevated levels of early marriage and fertility. While education and literacy are low overall, they are substantially more depressed in women than men. Only 9% of women receive at least secondary education (compared with 20% of men), and only 14% of women are literate (compared with 42% of men).(1) 60% of women believe that wife-beating is justified (more than twice the number of men who report this belief). The demand for family planning satisfied by modern contraceptive methods is only 41% .(1) Lower levels of education are associated with child marriage both within Niger and across the region.(1, 9-11) A similar relationship is seen with household wealth. Over the last twenty-five years, West Africa has seen a decrease in child marriage among the wealthiest 20% of women, while levels of child marriage in the poorest 20% are actually increasing over time.(9) Residence is also strongly associated with child marriage in West Africa, where child marriage tends to be concentrated in rural, rather than urban, areas.(9-11) Child marriage also varies by ethnic group, with the highest prevalence in Niger seen among the Hausa.(11) These geographic and economic factors influence decisions on marriage via the traditio of goos’ failies offeig a ide pie, thus creating diet eooi ietie to gils’ failies fo eal aiage, i additio to the idiet benefits of one less family member to feed and care for, and the elimination of risk of social stigma associated with premarital sex or pregnancy (CITE HERE FOR W.A). Finally, migration experiences influence child marriage, as younger generations migrate away from their natal communities, especially toward urban areas in search of employment, in the process lessening their exposure to traditional norms regarding social rules and expectations (12). It is critical to recognize, however, that these statistics are not uniform throughout the country. Median age at aiage ages fo . to 9. aoss Nige’s ten regions, and similar variations are seen in other key health and equity measures.(1) Not only are child marriage and fertility influenced by myriad social and structural factors, these factors, and their relationships with one another, vary across social and geographic contexts suggesting social normative influences that transcend simple demographic associations.(13-16) Spatial demographers assume that place is an important determinant of attitudes and behaviors, both because geographic features can inhibit or facilitate behaviors (for instance distance to a health clinic) and perhaps, more importantly, because it is through spatial clustering of people that clustering of norms typically occurs. (17, 18) While people with similar characteristics typically choose to interact with each other, a concept known as homophily (19), people who are geographically proximal to each other can also become more alike due to shared exposures or direct social influence. From a spatial analytic perspective, an outcome of interest is spatially dependent when people in close proximity to each other are more likely to share certain characteristics in common with each other than with people who live at a greater distance.(17) Spatial heterogeneity (also known as spatially varying relationships), on the other hand, refers to situations in which relationships among variables differ according to place.(17) Both spatial dependence and spatial heterogeneity can be important markers for social norms. In norms theory, we understand individual behavior as being determined by the attitudes, expectations, and ehaios of ipotat othes, o those ithi a peso’s reference group. Ideally, in norms research, reference groups would be identified through the use of discrete social network ties (20, 21), but in much health and development research such data are lacking. Instead, researchers looking for evidence of norms generate data with measures across more crude social units, in which social ties are inferred, such as residents of the same village or neighborhood (the concept behind DHS clusters) to determine whether there is inter- cluster variation. High levels of variation across these spatial units are viewed as evidence of variability in norms (22). This is also true of spatial heterogeneity. If the impact of education on fertility levels, for example, varies by geographic area, this suggests that there may be geographic-specific social effects that are driving the behavior beyond the expected association of, for example, educational levels and fertility (23). These sorts of insights have important implications for policy applications, as varying levels of social reinforcement and expectations around behaviors of interest can mean very different strategies for engaging with behavioral change. Understanding these potential normative influences across geographic areas within a country is not only a critical next step in dissecting coverage of essential health services and determinants of health outcomes, but allows for a more nuanced and informed means of addressing those inequitable gaps.(24) The goal of this paper, therefore, is to test whether village level factors predict age of marriage for a group of married adolescent girls in rural Niger, accounting for her own demographics, and to then test whether the association of those village level factors varies geographically. We first consider the individual level demographic predictors of younger age of marriage. We then aggregate those significant factors at the village level to deteie hethe idepedet of a gil’s own demographic measure, the impact of that factor is strongly associated at the village level. Finally, we test for spatial heterogeneity. Do the village level associations we find differ geographically? Methods Study Setting Niger – a land-locked country in Francophone West Africa – is the second most gender inequitable country in the old aodig to the UN’s Gede Ieualit Ide aked out of outies (25, 26). While comprehensive data on Niger is limited, the Demographic and Health Survey is one of the main sources of information on socio-demographics, health, fertility, and gender equity (Institut National de la Statistique & ICF International Enquête, 2013). With the DHS data as a background, in this research we analyze data that were collected across 48 villages clustered within the Dosso, Doutchi, and Loga districts in the Dosso region of Niger as part of the baseline data collection (i.e., no intervention activities had been implemented at the time of data collection) for a cluster randomized control trial evaluating a family planning intervention (see Figure 1). Villages were randomly selected based on the following inclusion criteria: 1) having at least 1000 permanent inhabitants; 2) primarily Hausa or Zarma-speaking (the two major languages of Niger); and 3) no known recent intervention specifically around family planning or female empowerment with married adolescent wives or their husbands. Both intervention and control villages from the RCT are included in this analysis. Participants Twenty-five married female adolescents ages 13-19 years old from each of the 48 villages (N=1200) and their husbands (N=1200) were randomly selected from a list of all eligible married female adolescents provided by each village chief. Eligibility criteria for the married female adolescents include: 1) ages 13-19 years old; 2) married; 3) fluent in Hausa or Zarma; 4) residing in the village where recruitment was taking place with no plans to move away in next 18 months or plan to travel for more than 6 months during that period; 5) not currently sterilized; and 6) providing informed consent to participate in the study. Of those who were randomly selected, 81.6% participated in the baseline survey. No significant differences in wife age, husband age, or time spent away from the village were observed across those who did and did not participate. An equal number of respondents was chosen from each of the three districts. Data Collection Separate surveys with the young women and their husbands were conducted by sex-matched trained research assistants from the Dosso region who could fluently read and speak French and fluently speak Hausa and/or Zarma.
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