Title: Age at First Marriage and Women’s Psychosocial Wellbeing in the Amhara Region,
Ethiopia
Version: 3 Date: 22 Nov 2023
Reviewer's report:
The strength of this manuscript lies in its application of both quantitative and qualitative methods
to examine the association between age at marriage and women’s psychosocial wellbeing. This
mixed methods approach makes for a rich discussion of the findings and promotes a better
understanding of social norms around child marriage in the setting in which the study was
conducted. The manuscript is well written.  However, there are several issues that need to be
addressed to strengthen the acceptability of the researchers’ conclusions. Comments are outlined
below.
1. 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.
2. The Methods and Tools section would benefit from having a separate Measures sub-section
describing how indicators were defined. Was the RSES previously validated in Ethiopia? If so,
what were the results of these validation studies? In the present analysis, what was Cronbach’s
alpha coefficient for the global RSES score? This information was presented in the discussion
but should be moved to the Measures sub-section.  Was principal component or factor analysis
used to identify the most important components of the RSES for the Amhara region sample?
If not, why not?
3. In the recommended Measures subsection, the authors should include a description of how
women’s social capital was defined and present Cronbach’s alpha coefficient for the resulting
index.
4. 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 wellbeing, 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.
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?
6. Lumping all child brides into one category may not adequately capture the psychosocial
effects of child marriage. The authors are encouraged to divide child brides into two groups –
those married before age 15 and those married at ages 15-17 – to shed light on the experiences
of very young adolescent brides.
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 wellbeing 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.
8. Duration since marriage was not considered by the authors as a factor that could potentially
affect the validity of the conclusions. Women’s psychosocial wellbeing was measured at
the time of the survey even though marriage could have occurred ten years earlier. As
psychosocial wellbeing can change over time due to the interaction of psychological processes
and life events, the authors should acknowledge this limitation in the discussion section and
highlight the importance of conducting prospective studies and analyzing family dynamics and
coping strategies. This study would have been more valuable if information was presented
on psychosocial factors at the time the individual got married and if comparisons were made
between child brides and unmarried children (< 18 years).