Title: Age at First Marriage and Women’s Psychosocial Wellbeing in the Amhara Region,
Ethiopia
Version: 4 Date: 20 Nov 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
Yes - the author's interpretation is reasonable
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: I acknowledge the authors for their efforts toward ensuring that the
issues raised during the last round of review were addressed. However, some of these issues are
yet to be resolved as expected.
REQUESTED REVISIONS:
The identified issues yet to be resolved are:
Reviewer 1 (Question 1): Excerpt: “The introduction presents no information on the existing
literature about the psychosocial effects of early marriage. Despite the dearth of literature on this
topic, it would be useful for the authors to summarize the findings of the few published studies
that exist and their relative strengths and weaknesses”.
The authors are expected to present studies where the association between age at first marriage
and women’s psychosocial well-being has been examined beyond and within Africa. A
paragraph can be dedicated to this as its inclusion will provide insights into the gaps in an existing
body of knowledge in this research area where the current study was designed to fill. There are
numerous similar studies that the authors can explore. I have included three such studies here
as information for authors.
Hajara Baba, Joana Salifu Yendork, Samuel Atindanbila, Exploring married girls’ subjective
experiences of well-being and challenges, Journal of Adolescence, Volume 79, 2020, Pages
193-207
Hynek, K.A., Abebe, D.S., Liefbroer, A.C. et al. The association between early marriage and
mental disorder among young migrant and non-migrant women: a Norwegian register-based
study. BMC Women's Health 22, 258 (2022). https://doi.org/10.1186/s12905-022-01836-5
Uecker JE. Marriage and mental health among young adults. J Health Soc Behav. 2012
Mar;53(1):67-83. doi: 10.1177/0022146511419206. Epub 2012 Feb 9. PMID: 22328171;
PMCID: PMC3390929.
Reviewer 1 (Question 4): Excerpt: “My primary concern is that the authors’ conclusions cannot
be supported by bivariate tabulations alone. Multivariable analysis should be conducted to get a
deeper understanding of the strength of the association between age at marriage and psychosocial
well-being, after controlling for confounding factors. The qualitative data pointed to several
factors that would need to be controlled in a multivariable regression analysis. These factors
included education, school dropout, partner choice, duration since marriage, employment, type
of place of residence (urban versus rural), girls’ perceptions of alternative opportunities available
to them (other than marriage), the power dynamics between spouses, perceived social norms,
etc. Overall, I found the quantitative analysis to be superficial”.
From the public health perspective, the inclusion of multivariate analysis would be essential
to track the influence of age at first marriage on women’s psychosocial well-being amidst
other independent variables. A bivariate analysis with only age at first marriage and women’s
psychosocial well-being in the model should be conducted first. Thereafter, the inclusion of
other variables in the model would be necessary to see if the strength of the association between
the age at first marriage and women’s psychosocial well-being would be sustained at this level
of analysis.
Reviewer 1 (Question 5): Reviewer 2 (5): “There should be a separate section on statistical
methods. A related question has to do with the treatment of observations with missing values. It
is rare to find surveys that have no missing values on variables that are included in the analysis.
What percentage of participants had missing values on variables analyzed in the present study?
How were missing values handled? Please describe in more detail the statistical procedures
performed on the data in the methods”
The analysis section in the method section needs to be provided. The statistical methods
used during the data analysis processes and what they were applied to should be included
in the section. For instance, regression analysis was used to ……. The assumptions of the
models should be provided and all the diagnostic mechanisms involved before the choice of the
model for the analysis be included. Additionally, how is the women’s psychosocial well-being
transformed into different domains? What are the questions constituting each domain and how
are the questions integrated to generate for instance the global score (low, moderate, high)?
Reviewer 1 (Question 7): “While it is useful to frame the analysis around the social context of
child marriage in Amhara region, the discussion is less about psychosocial wellbeing among
child brides and more about factors underlying child marriage. I would like to propose that the
discussion section be revised to focus on women’s psychosocial well-being and to include a
summary of how the authors’ findings are similar to or different from the findings of previous
studies and potential reasons for observed differences, if any”
A more thorough revision might be necessary while addressing this concern.
ADDITIONAL REQUESTS/SUGGESTIONS:
Emerging concerns:
The outcome variable was ‘Women’s Psychosocial Wellbeing’, while the explanatory variable
was ‘Age at First Marriage’. Therefore, age at first marriage influences women’s psychosocial
well-being, not vice versa. The title should be reframed as Age at First Marriage and Women’s
Psychosocial Wellbeing in the Amhara Region, Ethiopia
The conceptual framework is expected to provide the linkages between the independent,
intervening, and dependent variables by defining the relevant objectives for a research process
and mapping out how they come together to draw coherent conclusions. A single conceptual
framework is sufficient for a study. I am not convinced that what the authors referred to as
a conceptual framework in this study truly represents it. A revision is therefore suggested. A
chart that depicts the linkages between the variables is strongly recommended. Meanwhile, this
study would require a strong theoretical foundation and its underlying assumptions that the
authors engage while examining the relationship between age at first marriage and women’s
psychosocial well-being within the study’s context.
To maintain the international practice, age at first marriage should be regrouped as <15, 15-17,
18-24, and 25+ Those <15 are younger adolescent children, 15-17 (older adolescent children),
18-24 (adult youths), 25+ (older adults)
Provide the statistical output that led to the generation of this equation
Y2=18.67-.02x1+.05x2-.08x3-.19x4-.03x5-.12x6
As earlier raised by the first reviewer, marital duration is an important variable while examining
the relationship between age at first marriage and women’s psychosocial well-being. Therefore,
the descriptive and inferential components of the study should include this important variable.
Age at First Marriage and Women’s Psychosocial Wellbeing in the Amhara Region, Ethiopia
To bring out more clearly the public health importance of this study, a generalized linear
regression model could be used to examine the relationship between the age at first marriage and
women’s psychosocial well-being. In this approach, women’s psychosocial well-being will be
used in quantitative terms, while the age at first marriage will appear in the model categorically
(i.e in groups <15, 15-17, 18-24, and 25+). Other independent variables that the authors can
use as control include age at first marriage (<15, 15-17, 18-24, and 25+), husband’s age at first
marriage (<15, 15-17, 18-24, and 25+), age at first sex (<15, 15-17, 18-24, and 25+), age at first
pregnancy (<15, 15-17, 18-24, and 25+), number of marriages (1, 1+), annual household income
(classify based on Ethiopians’ standard), birthplace (Rural, Urban), current residence (Rural,
Urban), education at first marriage (None, Primary, Secondary, Tertiary), and marital duration
(0-4, 5-9, #10 years). This subgroup analysis will reveal the segment of the population that is
affected by women’s psychosocial well-being. However, the multicollinearity effect should be
established before including the variables in the model.
Why do we have empty statistics for the participants in age group <15 and 15-17 years as
presented in Table 3?"