International migration of unaccompanied minors: trends, health risks, and legal protection.

The global population of unaccompanied minors-children and adolescents younger than 18 years who migrate without their legal guardians-is increasing. However, as data are not systematically collected in any region, if collected at all, little is known about this diverse group of young people. Compared with adult migrants, unaccompanied minors are at greater risk of harm to their health and integrity because they do not have the protection provided by a family, which can affect their short-term and long-term health. This Review summarises evidence regarding the international migration and health of unaccompanied minors. Unaccompanied minors are entitled to protection that should follow their best interests as a primary consideration; however, detention, sometimes under the guise of protection, is a widespread practice. If these minors are provided with appropriate forms of protection, including health and psychosocial care, they can thrive and have good long-term outcomes. Instead, hostile immigration practices persist, which are not in the best interests of the child.

Fault Lines of Refugee Exclusion: Statelessness, Gender, and COVID-19 in South Asia.

Despite widespread recognition of the right to a nationality, statelessness and its attendant vulnerabilities continue to characterize the lives of millions in South Asia. During the onset of the COVID-19 pandemic, when states turned inward to protect their own citizens, refugees and de facto stateless persons found themselves excluded from humanitarian services and health care and were denied the ability to claim rights. Stateless women faced the additional burden of gender-based violence, a hostile labor market, and the threat of trafficking. This paper analyzes gender and statelessness as vectors of exclusion in South Asia, where asylum seekers are neither recognized by law nor protected by social institutions. We argue that citizenship constitutes an unearned form of social capital that is claimed and experienced in distinctively gendered ways. The pandemic has shone a bright light on the perils of statelessness, particularly for women, who face exacerbated economic inequities, the forced commodification of their sexuality, and exclusion from mechanisms of justice.

Defining and deconstructing girl child marriage and applications to global public health.

An estimated 650 million girls and women alive today married before their 18th birthday. Referred to as girl child marriage, the formal or informal union of the girl-child before age 18, the practice is increasingly recognized as a key roadblock to global health, development, and gender equality. Although more research than ever has focused on girl child marriage, an important gap remains in deconstructing the construct. Through an extensive review of primary and secondary sources, including legal documents, peer-reviewed articles, books, and grey literature across disciplines, we explore what the term "girl child marriage" means and why it more accurately captures current global efforts than other terms like early, teenage, or adolescent marriage. To do this, we dive into different framings on marriage, children, and gender. We find that there has been historical change in the understanding of girl child marriage in published literature since the late 1800s, and that it is a political, sociocultural, and value-laden term that serves a purpose in different contexts at different moments in time. The lack of harmonized terminology, particularly in the global public health, prevents alignment amongst different stakeholders in understanding what the problem is in order to determine how to measure it and create solutions on how to address it. Our intent is to encourage more intentional use of language in global public health research.

Establishing Good Practice for Human Rights-Based Approaches to Mental Health Care and Psychosocial Support in Kenya.

A human rights-based approach (HRBA) to health has long been seen as an important way in which to address public health needs in a manner that is equitable and conducive to social justice. Yet the actual content of an HRBA to health remains unspecific, and therefore implementation remains heterogeneous. This situation is even more challenging in the field of mental health, where human rights considerations are particularly complex and have emerged out of a history of myriad violations. Even when research has been conducted into mental health, it has focused predominantly on the Global North, raising questions of contextual and cultural relevance. Accordingly, this study examined the issue from the perspectives of stakeholders in Kenya who consider their work or the services they use to be rights based. It explored the key principles and interventions deemed to constitute an HRBA to mental health care and psychosocial support, the perceived benefits of such approaches, and the main barriers and supports relevant for implementation. The results produced seven key principles and corresponding interventions. Among other things, it highlighted the importance of economic well-being and self-efficacy, as well as the reduction of barriers to implementation, such as stigma and lack of adequate resourcing. Two key tensions were apparent-namely, the un/acceptability of coercion and the role of traditional and faith-based modalities in an HRBA to mental health care and psychosocial support.

Analyzing and improving national and local child protection data in Nepal: A mixed methods study using 2014 Multiple Indicator Cluster Survey (MICS) data and interviews with 18 organizations.

BACKGROUND: Globally, progress to improve data on child protection outcomes has been slower than efforts to improve data on child nutrition, vaccination and development outcomes in the under-five age group. The Sustainable Development Goals included several child protection targets further necessitating the need to track progress on child protection, but few studies have examined the varied data landscape for child protection within countries. OBJECTIVE: This mixed-methods study aims to examine (1) the prevalence of child protection outcomes in Nepal, (2) the types of data the child protection sector uses, and (3) recommendations to improve the collection, analysis and use of child protection data. PARTICIPANTS AND SETTING: We used: (a) secondary data from the nationally-representative 2014 Nepal MICS which surveyed over 13,000 households to measure the national prevalence of child labor, child marriage, and violent discipline, and (b) primary data from 18 qualitative key informant interviews with organizations in Nepal's child protection sector. METHODS: We conducted descriptive quantitative analyses of the secondary data and thematic inductive and deductive qualitative analyses of transcripts of key informant interviews. RESULTS: The burden of violent discipline (82%), child labor (37%), child marriage (12%), and their co-occurrence is high in Nepal. Respondents described using a range of data sources which included: large-scale surveys, case data from the police, court system, newspapers, community consultations, and child participation. Recommendations to improve data included developing a national child protection information system, ensuring the definitions of child protection outcomes were comparable across data sources, and improving the dissemination of data.

Girl child marriage, socioeconomic status, and undernutrition: evidence from 35 countries in Sub-Saharan Africa.

BACKGROUND: Girl child marriage, a formal union of a female before age 18, and undernutrition remain common in Sub-Saharan Africa. The aim of this study is to establish the extent to which girl child marriage contributes to socioeconomic status and underweight, a measure of undernutrition, among adult women. METHODS: We used data from 103 Demographic and Health Surveys (DHS), representing 35 African countries from 1991 to 2014. Girl child marriage was coded both as a binary variable (before 18 years) and categorical variable (before 14, 14 to 15 years, 16 to 17 years). The primary outcome was underweight (body mass index less than 18·5). Secondary outcomes were early and multiple childbearing, secondary education completion, and wealth index. Logistic regression models were used to estimate associations. RESULTS: Fifty-five percent of women married before age 18. Girl child marriage was associated with reduced risk of being underweight both in models adjusted for basic confounders (risk difference = - 0.020, 95% CI [- 0.026, - 0.014], p < 0.01) and in models adjusted for childbearing, women's relative status, and socioeconomic outcomes (risk difference = - 0.018, 95% CI [- 0.024, - 0.011], p < 0.01). Conditional on completing primary education and community fixed-effects, women married before 18 years had an increased risk of early motherhood (risk difference = 0.38, 95% CI [0.38, 0.38], p < 0.01) and of being in the poorest quintile (risk difference = 0.024, 95% CI [0.012, 0.036], p < 0.01), and were 27 percentage points less likely to complete secondary education (risk difference = - 0.27, 95% CI [- 0.28, - 0.26)], p < 001), compared to women married as adults. CONCLUSIONS: Though associated with substantially reduced socioeconomic status, girl child marriage appears to be associated with slightly reduced risk of being underweight in the population studied. Further research is needed to understand the determinants of undernutrition in this context as well as the broader relationship between socioeconomic status and nutritional outcomes.

Girl child marriage as a risk factor for early childhood development and stunting.

This paper quantitatively examines the intergenerational effects of girl child marriage, or the developmental and health outcomes of children born to women who marry before age 18. The overall objective is to understand the mechanisms through which girl child marriage affects the health and well-being of children in sub-Saharan Africa, as well as the relative magnitude and impact of these mechanisms. We used data from 37,558 mother-child pairs identified through 16 national and sub-national cross-sectional surveys across sub-Saharan Africa conducted between 2010 and 2014 by the UNICEF Multiple Indicator Clusters Survey program. The Early Childhood Development Index was used to measure child development, and stunting was used to measure health. Using logistic regression, we found that the odds of being off-track for development and being stunted were 25% and 29% higher, respectively, for children born to women who married before age 18 compared to those whose mothers married later (p < 0.001). Geographic location and primary education, which were conceptualized as contextual factors, explained most of this relationship, controlling for country fixed-effects. In adjusted models, we found that early childbearing was not the sole pathway through which girl child marriage affected child development and health. Our final models revealed that disparities in advanced maternal education and wealth explained child development and stunting. We conclude that there are intergenerational consequences of girl child marriage on her child's well-being, and that through association with other contextual, socioeconomic, and biological factors, marrying early does matter for child development and health. Our findings resonate with existing literature and point toward important policy considerations for improving early childhood outcomes.

Paying for antiretroviral adherence: is it unethical when the patient is an adolescent?

With the expansion of antiretroviral treatment programmes, many children and adolescents with HIV in sub-Saharan Africa could expect to live healthy lives. Yet adolescents have the highest levels of poor antiretroviral adherence and of loss to follow-up compared with other age groups. This can lead to increased morbidity and mortality, to the development of drug-resistant strains, and to high societal costs. While financial incentives have been extensively used to promote medication adherence among adults, their use among adolescents remains rare. And while there is a large body of ethical literature exploring financial incentives among adults, little philosophical thought has gone into their use among adolescents. This paper explores three oft-mentioned ethical worries about financial incentives for health behaviours and it asks whether these concerns are more serious in the context of incentives for improving adolescent adherence. The three worries are that such incentives would unduly coerce adolescents' decision-making, would compromise distributive justice and would crowd out intrinsic motivations and non-monetary values. Our tentative conclusion is that more empirical investigation of these concerns is necessary, and that at this point they are not compelling enough to rule out trials in which adolescents are incentivised for antiretroviral adherence.

Sex work and sexually transmitted infections in Asia: a biosocial analysis.

The Harvard University Asia Center hosted a symposium in October 2010 focused on sex work and sexually transmitted infections in Asia, engaging a biosocial approach to promote sexual health in this region. Asia has an estimated 151 million cases of curable sexually transmitted infections (STIs; eg, syphilis, gonorrhea, chlamydia) each year, with commercial sex interactions playing a large role in ongoing transmission. Substantial human movement and migration, gender inequalities, and incipient medical and legal systems in many states stymie effective STI control in Asia. The articles in this supplement provide theoretical and empirical pathways to improving the sexual health of those who sell and purchase commercial sex in Asia. The unintended health consequences of various forms of regulating commercial sex are also reviewed, emphasizing the need to carefully consider the medical and public health consequences of new and existing policies and laws.