Drivers of child marriages for girls: A prospective study in a low-income African setting.

Child marriage has adverse consequences for young girls. Cross-sectional research has highlighted several potential drivers of early marriage. We analyse drivers of child marriage using longitudinal data from rural Malawi, where rates of child marriage are among the highest in the world despite being illegal. Estimates from survival models show that 26% of girls in our sample marry before age 18. Importantly, girls report high decision-making autonomy vis-à-vis the decision to marry. We use multivariate Cox proportional hazard models to explore the role of 1) poverty and economic factors, 2) opportunity or alternatives to marriage, 3) social norms and attitudes, 4) knowledge of the law and 5) girls' agency. Only three factors are consistently associated with child marriage. First, related to opportunities outside marriage, girls lagging in school at survey baseline have significantly higher rates of child marriage than their counterparts who were at or near grade level. Second, related to social norms, child marriage rates are significantly lower among respondents whose caregivers perceive that members of their community disapprove of child marriage. Third, knowledge of the law has a positive coefficient, a surprising result. These findings are aligned with the growing qualitative literature describing contexts where adolescent girls are more active agents in child marriages.

Do tuition-free lower secondary education policies matter for antenatal care among women in sub-saharan African countries?

BACKGROUND: Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits. METHODS: To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries. RESULTS: Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics. CONCLUSIONS: The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

Pathways between adverse childhood experiences and viral suppression among male HIV-infected adolescents in South Africa.

Fewer adolescents achieve viral suppression compared to adults. One impediment may be a history of adverse childhood experiences (ACEs). To better develop targets and timeframes for intervention, this study created more robust estimates of the impact of cumulative adversity on viral suppression, tested whether the association is sensitive to the timing of adversity, and simultaneously tested several potential mechanisms. We focus on males, who have lower viral suppression than females and who may contribute to disproportionate incidence among young women. We recruited 251 male perinatally HIV-infected adolescents aged 15-19 from HIV clinics in Soweto, South Africa. Adversity was captured using the Adverse Childhood Experience - International Questionnaire (ACE-IQ). Viral load was measured using blood samples; viral suppression was defined as <20 copies/mL. Indicators of medication adherence, depression, post-traumatic stress disorder (, and substance misuse were captured. A series of pathway analysis were performed. Our sample experienced a median of 7 lifetime and 4 past-year adversities. Less than half (44%) exhibited viral suppression. Adversity demonstrated a significant association with suppression; depression mediated the association. Primary prevention of adversity among children living with HIV is paramount, as is addressing the subsequent mental and behavioral health challenges that impede viral suppression among adolescents.

Impact of laws prohibiting domestic violence on wasting in early childhood.

Intimate partner violence (IPV) affects an estimated 641 million women and girls globally with far-reaching consequences for the health of women and children. Yet, laws that prohibit domestic violence (DV) are not universal. Countries actively debate the effectiveness of DV laws in improving conditions given the inconclusive evidence on deterrent effects within households particularly in low- and middle-income countries that have limited infrastructure, and fewer resources to implement and enforce policy changes. This is the first study to rigorously examine the impact of DV laws on women's health decision-making and the intergenerational impact on children's wasting, a key predictor of mortality. We used the Demographic and Health Surveys (DHS) data collected between 2000-2020 across 23 African countries. Exploiting the staggered adoption of laws, we used a difference-in-differences study design to estimate the impact of DV laws in the treated countries compared to countries without such laws. We find that DV laws increased women's decision-making autonomy in healthcare by 16.7% as well as other measures of women's autonomy that matter for health such as financial autonomy by 6.3% and social mobility by 11.0%. The improvements in women's autonomy translated into reductions in the probability of wasting among children aged 0-23 months by 5.4% points, a 30.9% reduction from the mean. DV laws also reduced wasting among older children aged 24-59 months by 3.6% points, a 38.7% reduction from the mean. The laws were effective in all 6 countries analyzed individually that criminalized DV. A civil prohibition in the seventh country was not found to be effective. The effect was positive and significant for all wealth and geographical categories. Our findings demonstrate the value of enacting criminal laws that prohibit domestic violence as one important tool to reducing the profound health impacts of IPV, a critical health and human rights issue.

Implementing ecological momentary assessments to measure violence and adolescent HIV transmission risk: Lessons from Johannesburg, South Africa.

Ecological Momentary Assessment (EMA) is an important methodology to understand risky behaviour and holds promise for HIV research. EMA is still novel in sub-Saharan Africa. We describe challenges and lessons learned on a novel study implementing mobile phone EMAs with adolescent boys in South Africa. The Tsamaisano study was a longitudinal study from 2020-2023 to recruit adolescent boys aged 15-19 years; including those without HIV and those perinatally infected and living with HIV. Participants were prompted to complete 52 weekly mobile phone survey on emotional state, exposure to and perpetration of violence, and sexual risk behaviour. Surveys were delivered using a random algorithm to choose the day. We incorporated mechanisms to assess challenges and optimize survey completion: weekly team meetings with youth representation and real-time data monitoring. Additionally, 20 frequent vs infrequent survey submitters participated in qualitative interviews about barriers and recommendations. Real-time monitoring indicated low (defined as <50%) survey completion in the first months of study implementation. To ensure that both the adolescent participant and their caregiver understood the commitment required for successful EMA, we created and implemented a guided discussion around mobile phone access during the enrolment visit. We identified a need for increased and ongoing technical support; addressed by creating technical guides, implementing a standard two-week check-in call after enrolment, adding an automated request button for call-back assistance, creating a WhatsApp messaging stream, and reaching out to all participants failing to submit two sequential surveys. Entry-level smartphones, including those initially distributed by the study, did not have capacity for certain updates and had to be replaced with more expensive models. Participants struggled with randomly allocated survey days; completion improved with set completion days and targeted reminder messages. Together, these steps improved survey completion from 40% in December 2020 to 65% in April 2022. We describe key lessons learned to inform future study designs with mobile phone EMAs, drawing on our experience implementing such among adolescent boys, including persons living with HIV, in a low-and-middle income setting. The key lessons learned through the Tsamaisano study are important to inform future study designs with EMA utilizing mobile phone, electronic data collection among adolescent boys in low-and-middle-income settings.

The intergenerational effect of tuition-free lower-secondary education on children's nutritional outcomes in Africa.

One in five child deaths under age 5 are a result of severe wasting. Malnutrition at early ages is linked to lifelong consequences, such as reduced cognitive skills, reduced earnings in adulthood and chronic health conditions. Countries worldwide have committed to addressing child undernutrition, and ending hunger is foundational to the Millennium Development Goals. In this paper, we study the intergenerational effect of providing free tuition in secondary school on future children's nutrition. We combined a novel longitudinal dataset that captures educational policies for 40 African countries from 1990 to 2019 with the Demographic and Health Survey (DHS). We identified three countries that introduced free secondary education several years after implementing free primary education. Exploiting this variation in timing we estimate the additional impact of providing free secondary education over free primary education. Using a difference-in-difference approach, we find that introducing free secondary education significantly reduced wasting. Cohorts exposed to free secondary had an 18% relative decrease in wasting. The impact on cohorts exposed only to free primary was smaller and not statistically significant. Expanding free secondary education has long-term, intergenerational benefits and is an effective path to reducing malnutrition. Results are robust to different specifications.

Longitudinal Associations Between Childhood Adversity and Adolescent Intimate Partner Violence in Malawi.

Adverse childhood experiences (ACEs)-including child maltreatment, witnessing violence, and household dysfunction-have been robustly associated with poor health in later life. There is also increasing evidence that those who experience childhood adversity are more likely subsequently to be victims or perpetrators of intimate partner violence (IPV). Most evidence, however, is cross-sectional and concentrated in high-income settings, and cannot be generalized to more diverse contexts. In contrast, this study assessed longitudinal relations between ACEs and IPV in a low-income country. We interviewed 1,878 adolescents in rural Malawi between 2017 and 2018 (aged 10-16) and again in 2021 (aged 13-20). Adolescents completed the Adverse Childhood Experience-International Questionnaire. Past-year physical, sexual, and emotional IPV victimization and perpetration were measured using the WHO's Violence Against Women Instrument. We estimated multivariate regression models between cumulative adversity (0-13 adversities) at baseline and IPV at follow-up among respondents who reported any romantic or sexual partnerships. The cumulative ACEs score was associated with emotional IPV victimization for boys (OR = 1.12 per ACE) and sexual IPV victimization for girls (OR = 1.18). The ACEs score demonstrated a significant association with perpetration for girls only (OR = 1.33 for emotional IPV). By using longitudinal data, we more rigorously demonstrated the critical role of childhood adversity in shaping later IPV behavior. There are ongoing efforts toward primary prevention of childhood adversity. Given the burden that adolescents already carry (six ACEs on average in our sample), we also need secondary interventions that can help interrupt the pathway from adversity to IPV. This calls for increased collaboration between those working to address violence against children and violence against women.

Domestic violence calls for police service in five US cities during the COVID-19 pandemic of 2020.

BACKGROUND: When COVID-19 stay-at-home orders were instituted, there were concerns that isolation may lead to increases in domestic violence (DV). Reports of increased rates of DV during the stay-at-home period have been suggestive of this but inconsistent across different locations. We sought to complement the existing studies by characterizing changes in DV trends in US cities of Chicago, Los Angeles (LA), New York City (NYC), Philadelphia, and Phoenix using police call volume data from January 1st, 2018, through Dec 31st, 2020. METHODS: The stay-at-home orders were generally instituted for most US states in the second half of March 2020. We used the call volume for the pre-COVID-19 period (Jan. 2018 to Feb. 2020) to model a forecast against the stay-at-home order period (Mar. - May 2020) and the period after lifting the order (June - Dec. 2020) using the interrupted autoregressive integrated moving average (ARIMA) time series model. RESULTS: During the stay-at-home order, increases in mean DV calls relative to pre-COVID-19 were observed in Chicago (47.8%), Phoenix (18.4%), NYC (3.5%), and LA (3.4%), but a decrease in Philadelphia (-4.9%). After lifting the stay-at-home order, changes in mean calls relative to pre-COVID-19 remained elevated in Chicago, slightly elevated in Phoenix, and returned to baseline in NYC and LA. CONCLUSION: Results suggest that the stay-at-home orders may have contributed to an increase in DV calls in some cities (Phoenix, and to a smaller extent LA, NYC), but the increase seen in Chicago (and to some extent Phoenix) persisted beyond the stay-at-home order and therefore may not be attributable to the stay-at-home orders. Additional studies are needed to help explain why the association between stay-at-home orders and DV police call volume seems to only appear in some locations.

Global and regional estimates of orphans attributed to maternal cancer mortality in 2020.

Despite women being disproportionally affected by cancer deaths at young ages, there are no global estimates of the resulting maternal orphans, who experience health and education disadvantages throughout their lives. We estimated the number of children who became maternal orphans in 2020 due to their mother dying from cancer in that year, for 185 countries worldwide and by cause of cancer-related death. Female cancer deaths-by country, cancer type and age (derived from GLOBOCAN estimates)-were multiplied by each woman's estimated number of children under the age of 18 years at the time of her death (fertility data were derived from United Nations World Population Prospects for birth cohort), accounting for child mortality and parity-cancer risk associations. Globally, there were 1,047,000 such orphans. Over half of these were orphans due to maternal deaths from breast (258,000, 25%), cervix (210,000, 20%) and upper-gastrointestinal cancers (136,000, 13%), and most occurred in Asia (48%: India 15%, China 10%, rest of Asia 23%) and Africa (35%). Globally, there were 40 new maternal orphans due to cancer per 100,000 children, with a declining trend with a higher Human Development Index (range: 121 in Malawi to 15 in Malta). An estimated 7 million children were prevalent maternal orphans due to cancer in mid-2020. Accelerating the implementation of the World Health Organization's cervical and breast cancer initiatives has the potential to avert not only millions of preventable female cancer deaths but also the associated, often-overlooked, intergenerational consequences of these deaths.

A prospective study on adverse childhood experiences and HIV-related risk among adolescents in Malawi.

OBJECTIVE: Adverse childhood experiences have been robustly associated with poor sexual health in later life. In low-income countries, there is growing evidence that children experience greater adversity than those in higher income countries. Research suggests this may contribute to later sexual risk taking and HIV infection, though most studies to date have been cross-sectional. DESIGN: We use longitudinal data on adolescents to examine the temporal relationship between adversity and HIV-related behavioral and biological outcomes. METHODS: We interviewed 1878 adolescents living in Malawi in 2017-2018 (age 10-16) and again in 2021 (age 13-20). Adolescents completed the Adverse Childhood Experience - International Questionnaire. HIV-risk was assessed through both behavioral (e.g. condom use) and biological (HIV and herpes simplex virus 2 [HSV2] infection) outcomes. ordinary least squares (OLS) and logistic multivariate regression models are used to explore associations between adversity and HIV risk. RESULTS: In longitudinal analyses, adverse childhood experiences (ACEs) were significantly associated with intimate partner violence and girls' behavioral risk scores only. HIV incidence was too low to model; there were no significant associations with HSV2. In cross-sectional analyses, ACEs were additionally associated with an early sexual debut, lack of condom use, a greater number of sexual partnerships, and sexually transmitted infection symptoms. CONCLUSIONS: Our findings emphasize the importance of collecting prospective data: results from longitudinal and cross-sectional analyses drew qualitatively different conclusions. Cross-sectional analyses may not be accurate representations of longitudinal processes. However, they suggest that recent adversity and distress drives HIV-related behavior, perhaps more than early adversity. Interventions that combat emotional abuse or peer violence during adolescence could potentially reduce HIV risk.

Longitudinal consistency of self-reports of adverse childhood experiences among adolescents in a low-income setting.

A sizeable literature documents the associations between adverse childhood experiences (ACEs) and poor health in later life. By and large, ACEs are measured using retrospective self-reports. Little is known about the longitudinal consistency of these self-reports in panel data with multiple measurements. This is especially true in adolescence, as most studies using ACEs self-reports have been conducted among adults. Furthermore, very few studies have explored the consistency of ACEs self-reports in low- and middle-income countries, where the reported prevalence of ACEs tends to be higher than in high-income countries. Addressing these gaps, the current study examines the consistency of ACEs self-reports among a cohort of adolescents (N = 1,878, age 10 to 16 at survey baseline) in rural Malawi. We use data from two waves of the ACE project of the Malawi Longitudinal Study of Families and Health carried out in 2017-18 and 2021. In addition to the high prevalence of self-reported ACEs among adolescents in our sample, we document very low consistency of self-reports over time (average Kappa coefficient of 0.11). This low consistency is attributable not only to adolescents reporting more ACEs over time, which could be due to new exposures, but also to adolescents reporting fewer ACEs over time. Analyses of survey vignettes indicate that individual and sociocultural perceptions of abuse do not explain this low consistency. We find that external events (such as changes in socioeconomic status and negative economic shocks) and internal psychological states (such as depression and post-traumatic stress disorder) both predict inconsistencies in ACEs self-reports. Compared with results from prior studies, our findings indicate that the longitudinal consistency of ACEs self-reports may be lower in adolescence than in adulthood. Taken together, these findings suggest that ACEs self-reports provided by adults may be biased by key processes unfolding in adolescence.

Returning to school after COVID-19 closures: Who is missing in Malawi?

During the early stages of the COVID-19 pandemic, almost all countries implemented school closures to prevent disease transmission. However, prolonged closures can put children at risk of leaving school permanently, a decision that can reduce their long-term potential and income. This study investigated the extent to which the COVID-19 pandemic and associated school closures reduced school attendance in Malawi, a low-income African country. We used longitudinal data from a cohort of adolescents interviewed before (2017/18; at age 10-16) and after (2021; at age 13-20) the pandemic school closures. Of those students who had been attending school prior to school closures, we find that 86% returned when schools re-opened. Dropouts were more pronounced among older girls: over 30% of those aged 17-19 did not return to school. This resulted in further lowering the gender parity index to the greater disadvantage of girls. We also found that students already lagging behind in school were more likely to dropout. Thus, our data suggest that the COVID-19 pandemic has magnified gender inequalities in schooling, at least partially erasing recent progress towards inclusive education. Urgent investments are needed to find and re-enroll lost students now, and to create more resilient and adaptable educational systems before the next pandemic or other negative shock arrives.

The effects of negative economic shocks at birth on adolescents' cognitive outcomes and educational attainment in Malawi.

We provide new evidence of the association between moderate negative economic shocks in utero or shortly after birth and adolescents' cognitive outcomes and educational attainment in Malawi. This is one of the first studies to analyze the effect of not one, but multiple moderate negative economic shocks in a sub-Saharan African (SSA) low-income country (LIC). This focus is important as multiple economic shocks in early life are more representative of the experiences of adolescents in LICs. Combining data on adolescents aged 10-16 from the Adverse Childhood Experiences (ACE) project with the Malawi Longitudinal Study on Families and Health (MLSFH) (N = 1, 559), we use linear and probit regression models to show that girls whose households experienced two or more economic shocks in their year of birth have lower cognitive scores, which are measured using working memory, reading and mathematical tests. Girls also have lower educational attainment, conditional on age. These effects are gendered, as we do not observe similar effects among boys. Overall, our results point to lasting effects of early-life adversity on adolescents, and they highlight that, even in a LIC context where early-life adversity is common, policymakers need to intervene early to alleviate the potential long-term educational impacts of in utero or early life shocks among girls.

Social Norms, Agency, and Marriage Aspirations in Malawi.

OBJECTIVE: We evaluate whether community norms, caregiver beliefs, and adolescents' own beliefs and perceptions, focused on early marriage, predict adolescent marriage aspirations in a low-income context. BACKGROUND: The processes that contribute to adolescent marriage aspiration formation have received little attention in low-income contexts, particularly sub-Saharan Africa. Understanding how marriage aspirations are formed is important because they are associated with critical education and health outcomes. METHOD: Using data that links Malawian adolescents (N=2,089) with their caregivers (N=1,452), we analyze gender stratified ordered logistic regression models to examine key relationships. RESULTS: We show that community norms for youngest acceptable marriage age predict when boys want to marry, but do not find conclusive evidence that they predict when girls want to marry. We also show that adolescents who believe it is acceptable to marry at an early age are more likely to want to marry early themselves. CONCLUSION: Both community norms and adolescents' own beliefs are central to the formation of their marriage aspirations. IMPLICATIONS: We recommend that programs incorporate adolescent beliefs and perceptions when designing child marriage interventions and measuring their impact. We also recommend theory-driven measurement of community norms to better evaluate their impact on both marriage aspirations and marriage age.

Uptake of HIV testing among adolescents and associated adolescent-friendly services.

BACKGROUND: HIV testing remains low among adolescents. Making public health services more adolescent-friendly is one strategy used to encourage testing. However, it remains unclear whether government-led initiatives have a meaningfully impact. METHODS: The current study is observational and utilizes two sources of data (health-facility and adolescent-level) from one round of data collection of an on-going, longitudinal impact evaluation of a pilot cash plus program targeting adolescents. This study linked data from adolescent surveys (n = 2191) to data collected from nearby government-run health facilities (n = 91) in two rural regions of Tanzania. We used log binomial regression models to estimate the association between specific adolescent-friendly health service (AFHS) characteristics and adolescents' uptake of 1) HIV testing and 2) visiting a health care facility in the past year for sexual and reproductive health (SRH) services. RESULTS: Most adolescents (67%) lived in a village with a health facility, and all offered HIV services. We find, however, that AFHS have not been fully implemented. For example, less than 40% of facilities reported that they had guidelines for adolescent care. Only 12% of facilities had a system in place for referral and follow-up with adolescent clients, yet this was an important predictor of both past-year HIV testing (RR = 1.28, p < 0.1) and SRH visits (RR = 1.44, p < 0.05). Less than half (44%) offered services for survivors of gender-based violence (GBV), a significant predictor of past-year HIV testing (RR = 1.20, p < 0.05) and SRH visits (RR = 1.41, p < 0.01) among sexually-active adolescents. CONCLUSIONS: We find that national guidelines on AFHS have not been fully translated into practice at the local level. We highlight particular gaps in adolescent referral systems and GBV services. Scaling up these two essential services could encourage greater HIV testing among a high-risk population, in addition to providing much needed support for survivors of violence.

Emerging partner violence among young adolescents in a low-income country: Perpetration, victimization and adversity.

BACKGROUND: Intimate partner violence (IPV) is prevalent in high- as well as low-income contexts. It results in a substantial public health burden and significant negative socioeconomic and health outcomes throughout the life-course. However, limited knowledge exists about IPV during early adolescence. This period is critical during the transition to adulthood for at least two reasons: it is when the majority of adolescents in low-income countries first encounter dating, sexuality and partnerships, often with older adolescents or adults, and it is also the period when lifelong patterns of violence and norms about acceptable IPV are formed. The current study is one of the first to measure IPV prevalence among young adolescents in a low-income setting, examine the potential etiology, and investigate relationships with gender ideology, poverty, mental health and childhood adversity. METHODS: We surveyed 2,089 adolescents aged 10-16 in Malawi using standardized instruments. We estimated the prevalence of IPV, and use multivariate logistic regression to test potential correlates. RESULTS: More than a quarter (27%) of ever-partnered adolescents in Malawi report being victimized. A substantial proportion of both male and female adolescents (15%) report committing violence against their partner. Girls were more likely than boys to report being a victim of sexual IPV (24% versus 8%), and boys more likely to perpetrate such (9% versus 1%). Almost 10% of the sample had both committed and been a victim of IPV. Cumulative childhood adversity (e.g., physical abuse, witnessing domestic violence) was a consistent and strong correlate of IPV victimization (adjusted odds ratio (aOR) 1.30) and of perpetration (aOR 1.35). Depression and PTSD were likewise associated with IPV victimization in the overall sample. Notably, gender ideology was not predictive of either victimization or perpetration, even among boys. CONCLUSIONS: IPV is common for both male and female young Malawian adolescents, and includes both victimization and perpetration. IPV compounds other adversities experienced by adolescents in this low-income setting, and it is rarely alleviated through help from the health system or other formal support. These findings underscore the need to intervene early when interventions can still break destructive pathways and help foster healthier relationships. This focus on early adolescence is particularly critical in low-income countries given the early onset and rapid pace of the transition to adulthood, with sexual activity, dating and partnership thus being common already in young adolescence. Promising interventions would be those that reduce violence against or around children, as well as those that reduce the impacts of such trauma on mental health during adolescence.

Growing up positive: adolescent HIV disclosure to sexual partners and others.

Over three million youth live with HIV worldwide. Very little is known about whether youth disclose their HIV status to family, friends or sexual partners, and what risks and benefits may accrue from doing so. This study characterizes HIV disclosure among 250 youth with perinatally-acquired HIV (PHIV; age 13-24 years) living in Soweto, South Africa. A third had self-disclosed their HIV status to at least one person; similarly, only a third of sexually-active PHIV had disclosed their HIV status to their most recent partner. It is not clear whether HIV disclosure alone leads to positive impact: we found perceived social support from the family was negatively associated with disclosure (aOR 0.81, 95% 0.70-0.94). PHIV who spoke to a provider about disclosure were more likely to share their HIV status with a sexual partner (aOR 2.48; 95% CI 1.28-4.81). However, those PHIV who disclosed their status were no more likely to use a condom. The World Health Organization recommends that health providers advise adolescent patients on safe disclosure, but we still lack evidence on the consequences for young people and effective tools to help them weigh benefits and risks.