Girl Child Marriage, Health, and Well-Being in Sub-Saharan Africa: A Mixed Methods Investigation The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:37925669 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA GIRL CHILD MARRIAGE, HEALTH, AND WELL-BEING IN SUB-SAHARAN AFRICA: A MIXED METHODS INVESTIGATION YVETTE OLUSEYI EFEVBERA A Dissertation Submitted to the Faculty of The Harvard T.H. Chan School of Public Health in Partial Fulfillment of the Requirements for the Degree of Doctor of Science in the Department of Global Health and Population Harvard University Boston, Massachusetts November 2018 Dissertation Advisor: Prof. Jacqueline Bhabha Yvette Oluseyi Efevbera Girl Child Marriage, Health, and Well-Being in Sub-Saharan Africa: A Mixed Methods Investigation Abstract Nearly 650 million girls and women alive today have experienced girl child marriage, a formal union before age 18. Yet gaps exist in understanding its health consequences for women and children in African contexts. The objective of this multi-study dissertation was to use a mixed methods research approach to improve our understanding of the complex relationships between girl child marriage and the health and well-being of women and their children in sub- Saharan Africa. Aim 1 estimates associations between girl child marriage and women’s undernutrition in sub-Saharan Africa. Using household data from Demographic and Health Surveys (DHS), representing 35 African countries (N=249,269 women), this study revealed that girl child marriage was associated with increased odds of early motherhood and being in the poorest versus wealthiest quintile as well as decreased odds of completing secondary school, controlling for contextual factors. Despite these relationships, girl child marriage was associated with reduced odds of being underweight (body mass index less than 18.5). Aim 2 estimates associations between girl child marriage and children’s development and stunting to examine intergenerational impacts. Using household data from UNICEF Multiple Indicator Clusters Survey (MICS) for 16 African countries (N=37,558 child-mother pairs), this study showed increased odds being off-track for development (measured using the Early Childhood Development Index) and stunted (height-for-age z score less than -2) among children born to women who married before age 18, compared to those whose mothers married as adults. ii Adjusted models revealed that contextual factors, maternal education, and wealth explained these associations. Aim 3 qualitatively explores how women married as children in Conakry, Guinea see their marriages as related to their health and their children’s health. Rooted in grounded theory, this study used data from in-depth interviews, brief ethnographic interviews, observation, and participant observation (N=19 women). Open coding was used to identify key themes. In the context of their child marriages, women perceived health disadvantages, categorized under four themes. Women also perceived health advantages in their marriages, categorized under five themes. Further analysis identified three factors influenced women’s perceptions. In combination with a theoretical chapter that deconstructs the term “girl child marriage,” research findings provide evidence to guide population policies designed to ensure that women and children can achieve their developmental potential. iii Table of Contents Abstract .......................................................................................................................................... ii List of Figures ............................................................................................................................. viii List of Tables ................................................................................................................................ ix Preface ............................................................................................................................................ x Acknowledgments ...................................................................................................................... xiii Chapter 1: Introduction ............................................................................................................... 1 Background on Girl Child Marriage ........................................................................................... 1 Girl Child Marriage and Women’s Health and Well-Being ....................................................... 3 Girl Child Marriage and Children’s Health and Well-Being ...................................................... 5 Investigating Girl Child Marriage and Health Consequences in Sub-Saharan Africa ................ 6 Gaps ......................................................................................................................................... 6 Purpose .................................................................................................................................... 7 Contributions of This Study .................................................................................................... 8 Research Design and Frameworks .............................................................................................. 9 Mixed Methods Research Design ............................................................................................ 9 Other Frameworks Considered .............................................................................................. 12 Bioecological Framework .................................................................................................. 13 Biosocial Approach ............................................................................................................ 15 Conceptual Map ..................................................................................................................... 16 Chapter 2: Defining and Deconstructing “Girl Child Marriage” and Its Applications to Public Health Research .............................................................................................................. 22 A Historical Journey on Terminology ....................................................................................... 23 Parsing Out “Marriage” ............................................................................................................. 26 Parsing Out “Child” .................................................................................................................. 31 The Need to Focus on Girls....................................................................................................... 35 Overlaps and Distinctions with Forced Marriage ..................................................................... 37 Measuring Girl Child Marriage ................................................................................................. 38 Conclusions and Implications for Public Health ....................................................................... 39 Chapter 3: Girl Child Marriage and Undernutrition: Evidence from 35 Countries in Sub- Saharan Africa ............................................................................................................................ 41 Summary ................................................................................................................................... 41 Background ............................................................................................................................... 41 iv Methodology ............................................................................................................................. 45 Data source ............................................................................................................................ 45 Participants ............................................................................................................................ 45 Measures ................................................................................................................................ 46 Girl child marriage ............................................................................................................. 46 Underweight ....................................................................................................................... 46 Secondary outcomes .......................................................................................................... 46 Other covariates ................................................................................................................. 47 Statistical analysis ................................................................................................................. 47 Ethical approval ..................................................................................................................... 50 Results ....................................................................................................................................... 50 Discussion ................................................................................................................................. 59 Interpretation ........................................................................................................................