Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13059 Interventions for early marriage in low- and middle-income nations: a systematic review Yulia Yunara,1 Andi Safutra Suraya,2,3,4 Neisya Pratiwindya Sudarsiwi,2 Hayatus Sa’adah Ayu Lestari,1 Ananda Patuh Padaallah,5 Dina Istiana,6 Fitri Kurnia Rahayu3,7 1School of Nursing, Faculty of Medicine and Health Sciences, Universitas Lambung Mangkurat; 2Faculty of Nursing, Universitas Airlangga; 3Research Center in Advancing Community Healthcare (REACH), Surabaya; 4Faculty of Health Sciences, Universitas Muhammadiyah Gorontalo; 5Faculty of Health Sciences, Universitas Medika Suherman; 6STIKES Rajekwesi Bojonegoro; 7Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia Abstract Early marriages result in the emergence of a harmful intergen- erational cycle. Various policies and programs have been imple- mented to address the issue of early marriage at both global and local levels. However, early marriages continue to occur world- wide. The purpose of this systematic review was to analyze inter- ventions in early marriage in an effort to offer different interven- tions. This systematic review used MeSH-based keywords from Scopus, ScienceDirect, Web of Sciences, and PubMed databases. The PRISMA and The JBI checklists were used as guidelines. Data searches were conducted using Scopus, ScienceDirect, Web of Sciences, and PubMed databases for articles published in the last five years. Fifteen articles mentioned interventions to delay early marriage, such as cash transfers, community-identified pro- grams, mentorship initiatives, youth clubs, youth information cen- ters, and interventions targeting married adolescents. To effective- ly delay early marriage and improve adolescent well-being, multi- level interventions targeting economic, social, psychological, and health-related factors are needed. Future programs should inte- grate economic support with educational and SRH services, ensure sustained engagement with communities and families, and include long-term evaluations to assess the impact over time. Introduction An intergenerational cycle of disadvantage is created by early marriage, which is a violation of human rights and has numerous effects on children or adolescents who marry young people as well as on their future children.1 Any marriage that is consummated before the age of 18 is considered early marriage.2 Adolescents are not psychologically or physically mature enough to handle the duties of marriage, pregnancy, delivery, and raising children before the age of 18. They have also not been able to accept responsibility for their sexual behavior.3 One of the Sustainable Development Goals (SDGs) indicators for gender equality, indica- tor point 5, states that by 2030, “ensure the elimination of all harmful practices, such as child marriage, early marriage, forced marriage, and female circumcision.” Early marriage is one of the targets in this indicator.4 Globally, 29% of young women are mar- ried before 18 years of age.5 Around 1.2 million women in Indonesia marry before the age of 18, according to the prevalence of early marriage, while 61.3 thousand women marry before the age of 15. According to these statistics, in Indonesia, one in nine women between the ages of 20 and 24 was married before turning 18 years old.6 Typically, early marriage is seen as a barrier to possibilities in education, the economy, and society, due to poverty and gender imbalance.7 The prevalence of early marriages is highly correlated with societal culture and values. Early marriage is more likely to result from the effects of poverty, violence, and a lack of commu- nity structure.8 Due to social standards, including the expectation that adolescents should be protected, parents believe that marrying off their children at a young age can protect them from sexual vio- lence, unintended pregnancies, and sexually transmitted diseases.1 Early marriage is affected by economic variables, including poor family income and unemployment.9 Early marriage is indicated by a lack of sexual education regarding topics such as contraception, pregnancy, childbirth, and access to sexual health care.8 In addi- Correspondence: Andi Safutra Suraya, Faculty of Nursing, Universitas Airlangga, Indonesia. E-mail: andisuraya90@gmail.com Key words: adolescent; early marriage; interventions; low-and middle- income nations. Contributions: YY, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ASS, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; NPS, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; HSAL, resources, investigation, formal analysis, and writing –review & editing; APP, resources, supervision, and writing – review & editing; DI, resources, investigation, and writing –review & editing; FKR, resources, investigation, and writing –review & editing. Conflict of interest: the authors declare no conflicts of interest. Ethical approval and consent to participate: not applicbale. Funding: this research did not receive external funding. Availability of data and materials: all data generated or analyzed in this study are included in this published article. Received: 9 September 2024. Accepted: 20 March 2025. Early view: 18 June 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13059 doi:10.4081/hls.2025.13059 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 18] [Healthcare in Low-resource Settings 2025;13(s2):13950] tion, early marriage is influenced by premarital sexual activity and unintended pregnancies.10,11 Therefore, it is important to have accu- rate information on and perceptions of early marriage among ado- lescents.12 Early marriage can lead to a wide range of issues that affect not only the individuals involved but also the health of fam- ilies and society as a whole.13 Early marriage can result in poor health, high infant mortality rates, and severe household poverty.1 A significant issue is how early marriage affects health. Early mar- riage contributes to infant mortality, stunting, and low birth weights. Early marriage has an impact on the loss of a teenager’s mobility, unpreparedness for household roles, premature sex, unpreparedness to give birth to children, and domestic violence that ends in divorce. In recent decades, several policies, strategies, and programs have been explored to address the issue of early mar- riage at the global, regional, and local levels. However, early mar- riage is still prevalent throughout the world.2 Several studies have been conducted with a focused on interventions to deal with early marriages and their implications. This systematic review aimed to analyze interventions in early marriage to offer different approach- es to problems. Materials and Methods Study design This study was a systematic literature review conducted to address this research question. This research was carried out sys- tematically following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on qualitative synthesis without performing a meta-analysis of quan- titative data (Figure 1). Search strategy We searched for secondary data sources in the form of rep- utable journal articles in four databases: Scopus, ScienceDirect, Web of Sciences, and PubMed. Key words used Medical Subject Headings (MeSH) terms such as ((adolescent) OR (teenager) AND (early marriage) OR (child marriage)) AND (Intervention) OR (methods)). Eligibility criteria This systematic review included original research articles pub- lished in English between 2018 and 2024 that focused on interven- tions designed to address early marriage in low- and middle- income nations, as defined by the World Bank at the time of data collection. We used the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework to guide our inclusion criteria. Specifically, the population of interest was ado- lescents affected by early marriage. The included interventions aimed at preventing, delaying, or mitigating the negative conse- quences of early marriage, encompassing a range of approaches such as educational programs, economic empowerment initiatives, legal reforms, and community-based interventions. While a com- parison group wasn’t a strict requirement, studies had to present outcomes demonstrating the effects of early marriage or the inter- vention’s impact. Studies solely focused on descriptive epidemiol- ogy or conducted in high-income nations were excluded (Table 1). Study selection Article selection was examined for keyword suitability, abstract, full text, study type, and article duplication. 5.583 studies were obtained from the databases during the initial search. Duplicates were removed. Screening of titles and abstracts was then performed to evaluate how well the article content matched the keywords in the research topic. These articles were considered relevant for review if they met the inclusion criteria. Risk of bias All search results were organized in Mendeley Desktop and reviewed to determine whether they met the inclusion criteria. Results that were identical or irrelevant to the research articles were excluded. The assessment of article quality and risk of bias was conducted independently by researchers using the Joanna Briggs Institute (JBI) critical appraisal tools provided in Table 2.14-26 Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13950] [page 19] Figure 1. The PRISMA flow diagram Data extraction Full-text articles were then read, organized, and explored based on author name, year of publication, country, sample size, Age, QA Score, type of intervention, and duration (Supplementary Materials, Table 1). Results Based on a search using keywords across four databases (Scopus, Science Direct, Web of Science, and PubMed, 5.583 arti- cles were found. After screening, 1.731 open-access articles were identified. Duplicate articles were removed, resulting in a total of 848 articles based on relevant titles. After further selection based on abstracts, 161 articles were selected. These articles were then matched against the PICOS criteria, and 15 met the desired crite- ria. Based on the results of the Critical Appraisal using the JBI instrument, 15 selected articles achieved a cumulative score above 50%, indicating the quality and suitability of the articles included in this review. Based on the systematic review, the reviewed arti- cles had the following research characteristics: cross-sectional study (n=1), quasi-experimental study (n=3), qualitative study (n=5), and Randomized Controlled Trial (RCT) (n=6). This sys- tematic review originated from studies conducted in various coun- tries worldwide, and the total number of samples in the systematic review was 2.591. The geographical distribution of the studies was multi-regional, with nine articles from Africa, four from South Asia, and two from the Middle East. The respondents in these stud- ies were adolescents aged 10-24 years. Discussion This review identifies various interventions aimed at delaying early marriage and improving adolescent well-being, including cash transfers, community engagement programs, mentorship ini- tiatives, youth clubs, youth information centers, and interventions targeting married adolescents. While these interventions demon- strate positive outcomes, their effectiveness varies based on the sociocultural and economic contexts. Economic interventions, such as cash transfers and school fee support, have proven effective in enhancing school attendance, delaying marriage, and reducing early pregnancies by reducing girls’ financial dependence on men.14,15,16 In a study by Malhotra et al. (2021), economic interventions, particularly cash transfers, had a significant impact on reducing child marriage rates or increasing the age at marriage.17 These findings align with economic empow- erment theories, which suggest that increasing financial autonomy strengthens women’s agency and decision-making power.18 However, these programs alone may not challenge the deeply root- ed gender norms that perpetuate early marriage. Community-based programs, including forums and safe spaces for girls, parental education, and boys’ sports groups have addressed the structural and social norms surrounding early mar- riage.19,16 Initiatives such as AGEP and GHD have demonstrated shifts in gender attitudes, increased family support for girls’ educa- tion, and reduced early marriages and pregnancies.20,21 These find- Pathways of Change, Part II Table 1. PICOS framework. PICOS framework Inclusion criteria Exclusion criteria Population Adolescent Not adolescent Intervention Consisted of early marriage Not relevant to intervention of early marriage Comparation No comparison Outcome Showing the intervention of early marriage Not showing the intervention of early marriage Study design Original research articles Review articles Table 2. Critical appraisal results for included studies using the JBI Critical Appraisal Checklist. Author Design Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Total Category Mehra et al. (2018)16 Cross-sectional study Y Y Y Y Y Y Y Y N/A N/A N/A N/A N/A 8/8 (Good) Kohli et al. (2021)17 Quasi-experimental Y Y Y Y Y Y Y Y Y N/A N/A N/A N/A 9/9 (Good) Sieverding et al. (2022)18 Quasi-experimental Y Y Y Y Y Y N Y Y N/A N/A N/A N/A 8/9 (Good) Huda et al. (2019)26 Quasi-experimental Y Y Y Y Y Y Y Y Y N/A N/A N/A N/A 9/9 (Good) Banda et al. (2019)15 Qualitative Y Y Y Y Y Y Y Y Y Y N/A N/A N/A 10/10 (Good) Chirwa-Kambole et al. (2020)21 Qualitative Y Y Y Y Y Y Y Y Y Y N/A N/A N/A 10/10 (Good) Zulu et al. (2022)22 Qualitative Y Y Y Y Y Y Y Y Y Y N/A N/A N/A 10/10 (Good) Milimo et al. (2021)23 Qualitative Y Y Y Y Y Y Y Y Y Y N/A N/A N/A 10/10 (Good) Bankar et al. (2018)25 Qualitative Y Y Y Y Y Y Y Y Y Y N/A N/A N/A 10/10 (Good) Prakash et al. (2019)14 RCT Y Y Y Y Y Y N Y Y Y Y Y Y 12/13 (Good) Austrian et al. (2022)19 RCT Y Y N Y N Y N Y Y Y Y Y Y 10/13 (Good) Zulaika et al. (2019)20 RCT Y Y Y N N Y N Y Y Y Y Y Y 10/13 (Good) Austrian et al. (2020)24 RCT Y Y Y N N Y N Y Y Y Y Y Y 10/13 (Good) Challa et al (2019)27 RCT Y Y Y Y Y Y N Y Y Y Y Y Y 12/13 (Good) Gholami et al. (2021)28 RCT Y Y Y Y Y Y N Y Y Y Y Y Y 12/13 (Good) [page 20] [Healthcare in Low-resource Settings 2025;13(s2):13950] ings support the social norms theory, emphasizing the role of col- lective community change in modifying behaviors and expecta- tions.22 Mentorship and youth empowerment interventions also contribute to positive long-term outcomes. Programs incorporating life skills training, financial literacy, and reproductive health edu- cation enhanced girls’ decision-making, self-efficacy, and ability to negotiate gender roles.23,24 Sport-based mentorship in particular fostered empowerment and reshaped household expectations.23 The effectiveness of these approaches aligns with Bandura’s social cognitive theory, which highlights how observational learning and self-efficacy influence behavioral change.25 Youth clubs and information centers provided peer education and interactive learning, increasing adolescents’ knowledge of Sexual and Reproductive Health (SRH) and reducing risky behav- iors.26,27,28 Interactive teaching methods, such as role-playing and group discussions, have proved to be more effective than tradition- al education, reinforcing the importance of participatory learning models. Interventions targeting married adolescents, including married adolescent girl clubs, household visits, counseling, improved con- traceptive use, delayed childbirth, and promoted gender-equitable decision-making within marriages.29,30 Programs such as Reaching Married Adolescents (RMA) addressed social norms and increased the demand for modern contraceptive methods through community engagement and counseling.30 Psychological interventions, such as Functional Emotional Coping Therapy (FECT), further support married adolescents in navigating their sexual and reproductive health.31 These findings underscore the need for integrated inter- ventions beyond economic and educational support to address the psychological and social dimensions of adolescent well-being. Conclusions To effectively delay early marriage and improve adolescent well-being, multi-level interventions are needed targeting econom- ic, social, psychological, and health-related factors. Future pro- grams should integrate economic support with educational and SRH services, ensure sustained engagement with communities and families, and include long-term evaluations to assess the impact over time. Strengthening the quality of family planning services and counseling is crucial for sustaining positive behavioral changes. References 1. De Groot R, Kuunyem MY, Palermo T, et al. Child marriage and associated outcomes in northern Ghana: A cross-sectional study. BMC Public Health 2018;18:285. 2. Aychiluhm SB, Tesema AK, Tadesse AW. Early marriage and its determinants among married reproductive age group women in amhara regional state, ethiopia: a multilevel analy- sis. Biomed Res Int 2021;2021:18–21. 3. World Health Organization. WHO guidelines on preventing early pregnancy and poor reproductive outcomes. 2011; 4. United Nations General Assembly. Global indicator frame- work for the Sustainable Development Goals and targets of the 2030 Agenda for Sustainable Development. Work Stat Comm Pertain to 2030 Agenda Sustain Dev 2020;1–21. 5. UNFPA, UNICEF. Child marriage: A mapping of programmes and partners in twelve countries in East and Southern Africa. 2017;1–88. 6. Badan Pusat Statistik. Pencegahan Perkawinan Anak Percepatan yang Tidak Bisa Ditunda. Badan Pus Stat. 2020;6– 10. 7. Kohan S, Allahverdizadeh S, Farajzadegan Z, Ghojazadeh M, Boroumandfar Z. Transition into the sexual and reproductive role: a qualitative exploration of Iranian married adolescent girls’ needs and experiences. Reprod Health 2021;18:157. 8. Elnakib S, Hunersen K, Metzler J, et al. Child marriage among Somali refugees in Ethiopia: a cross sectional survey of adoles- cent girls and adult women. BMC Public Health 2021;21:1051. 9. Fakhari A, Allahverdipour H, Esmaeili ED, et al. Early mar- riage, stressful life events and risk of suicide and suicide attempt: a case–control study in Iran. BMC Psychiatry 2022;22:71. 10. Septiarum R, Suwarni L, Alamsyah D. Unwanted pregnancies and early marriage child aged 13-18 years. Indian J Public Heal Res Dev 2019;10:1792–7. 11. UNICEF. Early marriage: child spouses. Innocenti Digest 2001;(7). Available from: https://www.girlsnotbrides.org/learning-resources/resource- centre/early-marriage-child-spouses-unicef-innocenti-digest/ 12. Ferdous Z, Zeba Z. Knowledge and perception of early mar- riage among adolescent girls in a selected community of Rangpur district, Bangladesh. Am J Public Heal Res 2019;7:9– 13. 13. UNICEF. Leveraging large-scale sectoral programmes to pre- vent child marriage. UNICEF; 2022. Available from: https://www.unicef.org/documents/leveraging-large-scale-sec- toral-programmes-prevent-child-marriage-0 14. Prakash R, Beattie TS, Javalkar P, et al. The Samata interven- tion to increase secondary school completion and reduce child marriage among adolescent girls: results from a cluster-ran- domised control trial in India. J Glob Health 2019;9:10430. 15. Banda E, Svanemyr J, Sandøy IF, et al. Acceptability of an eco- nomic support component to reduce early pregnancy and school dropout in Zambia: a qualitative case study. Glob Health Action 2019;12:1685808. 16. Mehra D, Sarkar A, Sreenath P, et al. Effectiveness of a com- munity based intervention to delay early marriage, early preg- nancy and improve school retention among adolescents in India. BMC Public Health 2018;18:732. 17. Kohli A, Shaw B, Guntzberger M, et al. Transforming social norms to improve girl-child health and well-being: a realist evaluation of the Girls’ Holistic Development program in rural Senegal. Reprod Health 2021;18:243. 18. Sieverding M, Bteddini D, Mourtada R, et al. Design and implementation of the amenah early marriage pilot interven- tion among Syrian refugees in Lebanon. Glob Heal Sci Pract 2022;10:e2100079. 19. Austrian K, Soler-Hampejsek E, Kangwana B, et al. Impacts of multisectoral cash plus programs on marriage and fertility after 4 years in pastoralist Kenya: a randomized trial. J Adolesc Heal Off Publ Soc Adolesc Med 2022;70:885–94. 20. Zulaika G, Kwaro D, Nyothach E, et al. Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls: study protocol of a cluster-randomised controlled trial in western Kenya. BMC Public Health 2019;19:1317. 21. Chirwa-Kambole E, Svanemyr J, Sandøy I, et al. Acceptability of youth clubs focusing on comprehensive sexual and repro- ductive health education in rural Zambian schools: a case of Central Province. BMC Health Serv Res 2020;20:42. Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13950] [page 21] 22. Zulu IZ, Zulu JM, Svanemyr J, et al. Application of communi- ty dialogue approach to prevent adolescent pregnancy, early marriage and school dropout in Zambia: a case study. Reprod Health 2022;19:30. 23. Milimo J, Zulu JM, Svanemyr J, et al. Economic support, edu- cation and sexual decision making among female adolescents in Zambia: a qualitative study. BMC Public Health 2021;21:1360. 24. Austrian K, Soler-Hampejsek E, Behrman JR, et al. The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia. BMC Public Health 2020;20:349. 25. Bankar S, Collumbien M, Das M, et al. Contesting restrictive mobility norms among female mentors implementing a sport based programme for young girls in a Mumbai slum. BMC Public Health 2018;18:471. 26. Huda FA, Mahmood HR, Ahmmed F, et al. The effect of a club in making differences in knowledge, attitude, and practices on family planning among married adolescent girls in urban slums in Bangladesh. Int J Environ Res Public Health 2019;16:40-37. 27. Challa S, Delong SM, Carter N, et al. Protocol for cluster ran- domized evaluation of reaching married adolescents - A gen- der-synchronized intervention to increase modern contracep- tive use among married adolescent girls and young women and their husbands in Niger. Reprod Health 2019;16:180. 28. Gholami M, Ahmadi A, Taebi M, et al. Effectiveness of coun- seling based on functional analytic psychotherapy with enhanced cognitive therapy on the sexual quality of life of married adolescent women. Rev Bras Ginecol e Obstet Rev da Fed Bras das Soc Ginecol e Obstet 2021;43:513–21. 29. Malhotra A, Ph D, Elnakib S, H MP. 20 Years of the evidence base on what works to prevent child marriage : a systematic review. J Adolesc Heal 2021;68:847–62. 30. Cislaghi B, Heise L. Theory and practice of social norms inter- ventions: Eight common pitfalls. Global Health 2018;14:83. 31. Nabavi RT, Bijandi MS. A literature review on Bandura’s social learning theory & social cognitive learning theory. Theory of Developmental Psychology. 2012. Available from: https://scholar.google.com/scholar?oi=bibs&cluster=2564486 135348341917&btnI=1&hl=en Pathways of Change, Part II [page 22] [Healthcare in Low-resource Settings 2025;13(s2):13950] Online supplementary materials Table 1. Summary of the articles.