Making sense of child, early and forced marriage among Syrian refugee girls: a mixed methods study in Lebanon.

INTRODUCTION: The Syrian conflict has resulted in over 2.3 million child refugees in the Middle East and the prevalence of early marriage has reportedly increased among displaced Syrian families. This study explores the underlying factors contributing to child marriage among Syrian refugees in Lebanon with the goal of informing community-based strategies to address the issue. METHODS: In July-August 2016, trained interviewers collected self-interpreted stories in Lebanon using Cognitive Edge's SenseMaker, a mixed-method data collection tool. Participants included married and unmarried Syrian girls, Syrian parents as well as married and unmarried men. Each participant shared a story about the experiences of Syrian girls and then interpreted the story by plotting their perspectives on a variety of questions. Patterns in the responses were analysed in SPSS and the accompanying qualitative narratives were reviewed to facilitate interpretation of the quantitative results. RESULTS: 1422 self-interpreted stories from 1346 unique participants were collected with 40% of shared stories focused on (n=332) or mentioning (n=245) child marriage. Quantitative data summarised the different perspectives of female and male participants. Syrian girls and mothers were more likely to share stories about protection/security and/or education and were more likely to report that girls were overprotected. Male participants were more likely to share stories about financial security as well as sexual exploitation of girls and more often reported that girls were not protected enough. Despite these gendered perspectives, many of the shared narratives highlighted similar themes of financial hardship, lack of educational opportunities and safety concerns around sexual and gender-based violence (SGBV). CONCLUSIONS: A complex myriad of factors contribute to early marriage including poverty, lack of educational opportunities and concerns about SGBV. Sexual exploitation under the guise of marriage is a reality for some Syrian girls. Gender-specific strategies to address child marriage might be more effective in reducing this harmful practice.

Status and drivers of maternal, newborn, child and adolescent health in the Islamic world: a comparative analysis.

BACKGROUND: The Millennium Development Goal (MDG) period saw dramatic gains in health goals MDG 4 and MDG 5 for improving child and maternal health. However, many Muslim countries in the south Asian, Middle Eastern, and African regions lagged behind. In this study, we aimed to evaluate the status of, progress in, and key determinants of reproductive, maternal, newborn, child, and adolescent health in Muslim majority countries (MMCs). The specific objectives were to understand the current status and progress in reproductive, maternal, newborn, child, and adolescent health in MMCs, and the determinants of child survival among the least developed countries among the MMCs; to explore differences in outcomes and the key contextual determinants of health between MMCs and non-MMCs; and to understand the health service coverage and contextual determinants that differ between best and poor or moderate performing MMCs. METHODS: In this country-level ecological study, we examined data from between 1990 and 2015 from multiple publicly available data repositories. We examined 47 MMCs, of which 26 were among the 75 high-burden Countdown to 2015 countries. These 26 MMCs were compared with 48 non-Muslim Countdown countries. We also examined characteristics of the eight best performing MMCs that had accelerated improvement in child survival (ie, that reached their MDG 4 targets). We estimated adolescent, maternal, under-5, and newborn mortality, and stillbirths, and the causes of death, essential interventions coverage, and contextual determinants for all MMCs and comparative groups using standardised methods. We also did a hierarchical multivariable analysis of determinants of under-5 mortality and newborn mortality in low-income and middle-income MMCs. FINDINGS: Despite notable reductions between 1990 and 2015, MMCs compared with a global esimate of all countries including MMCs had higher mortality rates, and MMCs relative to non-MMCs within Countdown countries also performed worse. Coverage of essential interventions across the continuum of care was on average lower among MMCs, especially for indicators of reproductive health, prenatal care, delivery, and labour, and childhood vaccines. Outcomes within MMCs for mortality and many reproductive, maternal, newborn, child, and adolescent health indicators varied considerably. Structural and contextual factors, especially state governance, conflict, and women and girl's empowerment indicators, were significantly worse in MMCs compared with non-MMCs within the high-burden Countdown countries, and were shown to be strongly associated with child and newborn mortality within low-income and middle-income MMCs. In adjusted hierarchical models, among other factors, under-5 mortality in MMCs increased with more refugees originating from a country (ß=23·67, p=0·0116), and decreased with better political stability or absence of terrorism (ß=-0·99, p=0·0285), greater political rights or government effectiveness (ß=-1·17, p<0·0001), improvements in log gross national income per capita (ß=-4·44, p<0·0001), higher total adult literacy (ß=-1·69, p<0·0001), higher female adult literacy (ß=-0·97, p<0·0001), and greater female to male enrolment in secondary school (ß=-16·1, p<0·0001). The best performing MMCs were Azerbaijan, Bangladesh, Egypt, Indonesia, Kyrgyzstan, Morocco, Niger, and Senegal, which had higher coverage of family planning interventions and newborn or child vaccinations, and excelled in many of the above contextual determinants when compared with moderate or poorly performing MMCs. INTERPRETATION: The status and progress in reproductive, maternal, newborn, child, and adolescent health is heterogeneous among MMCs, with little indication that religion and its practice affects outcomes systemically. Some Islamic countries such as Niger and Bangladesh have made great progress, despite poverty. Key findings from this study have policy and programmatic implications that could be prioritised by national heads of state and policy makers, development partners, funders, and the Organization of the Islamic Cooperation to scale up and improve these health outcomes in Muslim countries in the post-2015 era. FUNDING: US Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn, and Child Survival, the Centre for Global Child Health, Hospital for Sick Children, and the Aga Khan University.

Implementation of a SenseMaker® research project among Syrian refugees in Lebanon.

The Syrian conflict has displaced over 1.2 million Syrians into Lebanon. As a result of displacement, some Syrian families are turning to child marriage as a coping mechanism. The prevalence of early marriage has reportedly increased and the average age of marriage decreased during the crisis. The aim of the project was to understand the underlying factors contributing to child marriage among Syrian refugees in Lebanon using Cognitive Edge's SenseMaker®. This manuscript explores the process of implementing this novel research tool in a humanitarian setting. Twelve interviewers conducted SenseMaker® interviews with married and unmarried Syrian girls, Syrian parents, as well as married and unmarried men. Participants were asked to share a story about the lives of Syrian girls in Lebanon and to self-interpret the narratives by answering follow-up questions in relation to the story provided. Data collection occurred across three locations: Beirut, Beqaa, and Tripoli. In total 1422 narratives from 1346 unique participants were collected over 7 weeks. Data collection using SenseMaker® was efficient, capable of electronically capturing a large volume of quantitative and qualitative data. SenseMaker® limitations from a research perspective include lack of skip logic and inability to adjust font size on the iOS app. SenseMaker® was an efficient mixed methods data collection tool that was well received by participants in a refugee setting in Lebanon. The utility of SenseMaker® for research could be improved by adding skip logic and by being able to adjust font size on the iOS app.