Turkish civil code permits child marriages at 16–17 years of age, but if a child is 16 years old judicial consent is needed. Before making a final decision on marriage consent, the judges refer these children to the doctor, and ask whether they are psychologically and physically ready for marriage. While the literature on child marriage in Turkey is rich, little is known about the underlying factors leading 16-year-old girls to request legal child marriage. This study examined the socio-demographic and clinical characteristics of girls applying to the courts for judicial marriage consent. Hospital records of girls admitted to a hospital in the Istanbul province of Turkey between January 2015 and December 2018 for the assessment of their physical and mental readiness for marriage were scanned. Of the 122 girls admitted to hospital for this purpose, eight were excluded as they had incomplete data, leaving 114 participating girls. All girls were Turkish citizens and had been referred from the law courts. Being pregnant/having a child (54.4%), having had a religious (non-legal) marriage (49.1%) and having an intelligence score of less than 90 (91.2%) were common among the participants. Among those who had a religious marriage, 78.6% were pregnant/had a child at the time of evaluation and 32.1% reported that they were pregnant before their religious marriage took place. None of the participants reported being forced to marry, but many had run away from home to marry (33.3%). Among those running away to marry, the major reason for deciding to do this was being pregnant (63.2%). Running away from home to marry was found to be related to lower parental educational levels (p<0.05). Contrary to the literature, the findings indicate that girls who request judicial consent for legal child marriage in Turkey are not being forced to marry. However, lower educational level seems to be an important factor. Below-average intelligence of the girl and her parents, running away from home to marry and early unsafe sexual intercourse, leading to child pregnancy, were found to be closely associated with legal child marriage in Turkey.

The World Health Organization set a target of a 15% relative reduction in the prevalence of insufficient physical activity (IPA) by 2025 among adolescents and adults globally. In Bangladesh, there are no national estimates of the prevalence of IPA among adolescents. The aim of this study was to estimate the prevalence of and risk factors associated with IPA among adolescent girls and boys. Data for 4865 adolescent girls and 4907 adolescent boys, collected as a part of a National Nutrition Surveillance in 2018–19, were analysed for this study. A modified version of the Global Physical Activity Questionnaire (GPAQ) was used to collect physical activity data. The World Health Organization recommended cut-off points were used to estimate the prevalence of IPA. Bivariate and multivariable logistic regression was performed to identify factors associated with IPA. Prevalences of IPA among adolescent girls and boys were 50.3% and 29.0%, respectively, and the prevalence was significantly higher among early adolescents (10–14 years) than late adolescents (15–19 years) among both boys and girls. The IPA prevalence was highest among adolescents living in non-slum urban areas (girls: 77.7%; boys: 64.1%). For both boys and girls, younger age, non-slum urban residence, higher paternal education and increased television viewing time were significantly associated with IPA. Additionally, residing in slums was significantly associated with IPA only among the boys. Higher maternal education was associated with IPA only among the girls. This study identified several modifiable risk factors associated with IPA among adolescent boys and girls in Bangladesh. These factors should be addressed through comprehensive public health interventions to promote physical activity among adolescent girls and boys.

The study investigates sex differences in the prevalence of undernutrition in sub-Saharan Africa. Undernutrition was defined by Z-scores using the CDC-2000 growth charts. Some 128 Demographic and Health Surveys (DHS) were analysed, totalling 700,114 children under-five. The results revealed a higher susceptibility of boys to undernutrition. Male-to-female ratios of prevalence averaged 1.18 for stunting (height-for-age Z-score <−2.0); 1.01 for wasting (weight-for-height Z-score <−2.0); 1.05 for underweight (weight-for-age Z-score <−2.0); and 1.29 for concurrent wasting and stunting (weight-for-height and height-for-age Z-scores <−2.0). Sex ratios of prevalence varied with age for stunting and concurrent wasting and stunting, with higher values for children age 0–23 months and lower values for children age 24–59 months. Sex ratios of prevalence tended to increase with declining level of mortality for stunting, underweight and concurrent wasting and stunting, but remained stable for wasting. Comparisons were made with other anthropometric reference sets (NCHS-1977 and WHO-2006), and the results were found to differ somewhat from those obtained with CDC-2000. Possible rationales for these patterns are discussed.

Malaria is a major public health concern in Malawi. This study explored the patterns and correlates of ownership and utilization of ITNs for malaria control among women of reproductive age in Malawi. Data were derived from the multi-stage cross-sectional Malaria Indicator Survey (MIS) conducted in 2017, which followed ITN distribution in 2012 and 2015. Of the 3860 sampled women aged 15–49 years, 88% (3398/3860) and 64% (2473/3860) reported that they owned and utilized ITNs, respectively. Adjusted multivariate logistic regression analysis showed that the odds of ownership of ITNs were significantly low among women with no education (AOR = 0.36, CI = 0.18–0.72), those with primary education (AOR = 0.50, CI = 0.27–0.94) and poor women (AOR = 0.70, CI = 0.51–0.97). Similarly, the odds of utilization of ITNs were significantly low among women with no education, (AOR = 0.40, CI = 0.26–0.63), primary education (AOR = 0.53, CI = 0.36–0.78) and poor women (AOR = 0.70, CI = 0.51–0.97). Furthermore, the odds of utilization of ITNs were significantly low among women living in households without a radio (AOR = 0.79, CI = 0.67–0.93) and those who have not seen or heard a malaria message in the last 6 months (AOR = 0.74, CI = 0.64–0.87). In order to prevent malaria morbidity and mortality among women of reproductive age, especially those from poor households, the Malawi government and relevant stakeholders need to continue the free distribution of ITNs to the poor and encourage social behaviours that promote the ownership and utilization of ITNs.

Transition to the role of mothering is one of the most important events in a woman’s life. While childbirth is a biological event, pregnancy and the experiences around it are more influenced by social structure, which is shaped by cultural perceptions and practices. The aim of this study was to explore cultural context during maternal role attainment in neonatal intensive care units (NICUs) in Iran. The study was part of a grounded theory study on how the mothers of preterm neonates go through maternal role attainment. Data collection was carried out by purposeful sampling from 20 participants (15 mothers of preterm neonates and 5 NICU nurses). Data were analysed according to Corbin and Strauss’s (2015) approach. Four categories of childbearing culture emerged: ‘The necessity of childbearing’, ‘Childbearing rituals’, ‘Maternal persistent presence’ and ‘Attitudes and religious beliefs’. The findings showed that the special beliefs and practices in Iranian culture affected all of the participants’ reactions to mothering process. Culture is one of the most important factors affecting the development of motherhood in Iran. In order to provide sensitive and culturally appropriate care, nurses should be aware of the general impact of cultural norms and values on the process of maternal role attainment and strive to meet the cultural needs of all mothers.

The aim of this study was to examine the differences between selected lifestyle and socioeconomic parameters among preschool (3–7 years of age) children of differing adiposity status. The study was conducted from February to June 2018 in 20 randomly selected kindergartens in Kraków, Poland. Triceps, biceps, subscapular, suprailiac, abdominal and calf skinfold thicknesses were measured. The sum of all six skinfolds was calculated and the children were subsequently characterized by low (≤–1 SD [standard deviation]), normal (–1 to 1 SD) or high body fat (≥1 SD). Socioeconomic and lifestyle characteristics were obtained using a questionnaire filled out by the children’s parents or legal guardians. Preschool children in the high adiposity category had, on average, fewer siblings and longer screen time; additionally, their parents had lower education and more often worked in manual jobs, in comparison to the children in the low and average adiposity categories. In conclusion, it was observed that children in different adiposity categories varied in terms of some socioeconomic as well as lifestyle characteristics. Knowledge regarding the influence that those factors can have on the metabolic health of children is essential for children’s present as well as future well-being. Moreover, it can help health care professionals and parents decide what intervention and/ or preventive measures should be undertaken to ensure the best possible outcomes, as the development of successful obesity prevention strategies should rely on evidence-based information. Nonetheless, future research examining the issue of factors influencing the metabolic health of children, as well as these outcomes later in life, is crucial. Well-planned studies including a large number of individuals, as well as longitudinal research, will be particularly beneficial in this regard.

There has been a drastic decline in the child sex ratio (number of females per 1000 males between ages 0 and 4) in India and many of its states. This study aimed to examine if prenatal factors, such as change in sex ratio at birth, or postnatal factors, such as change in relative mortality of females and males, contribute to this more by analysing the dynamics of the child sex ratio. Changes in the child sex ratio during 2001–2011 were decomposed into a ‘fertility’ component attributable to prenatal sex selection and a ‘mortality’ component attributable to sex differentials in postnatal survival at the country as well as the state level. Between the prenatal factor and the postnatal factor, the contribution of the latter to the declining child sex ratio has been greater than the former in India as a whole and in most of the states. By focusing on both prenatal and postnatal factors, the imbalance in the child sex ratio in the country can be reduced to a large extent.

Leg length in humans is considered to be an indicator of the long-term impact of quality of childhood living conditions and nutritional status. The main objective of this study was to evaluate the magnitude of association of percentage body fat (PBF) with relative subischial leg length (RSLL), adjusting for age, sex and body mass index (BMI), among adolescents and adults in a population of poor socioeconomic background in India. Data were taken from a cross-sectional study conducted in 2010–2014 among the Limbu community of Darjeeling, West Bengal – an indigenous community with poor socioeconomic background, low literacy rate, low income and inadequate living conditions. The study villages were located in the Himalayan and sub-Himalayan regions of Darjeeling. The present study sample comprised 97 adolescents aged 16–19 years (47 boys, 50 girls) and 260 adults aged 20–39 years (135 men, 125 women). Anthropometric measurements of stature/height (cm), weight (kg), sitting height (cm) and skinfold thicknesses (biceps, triceps, subscapular, suprailiac) (mm) were recorded. Derived variables were BMI (kg/m2), subischial leg length (SLL) (cm), RSLL (%), sum of four skinfolds (mm) and PBF (%). Significant sex differences at p<0.05 were observed for all anthropometric characteristics, except for body weight among adolescents and RSLL, subscapular and sum of four skinfolds in adults. The linear regression models adjusting for age and sex showed that RSLL had a negative relationship with PBF (p<0.05) among adolescents and adults. Higher body fat, independent of BMI, was correlated with lower RSLL among both adolescents and adults from the Limbu community, indicating a possible association with poor quality living conditions in childhood. However, this may also have been due to the allometry of total body fat with body proportions – a relatively larger trunk results in more body fat.

This paper investigates the relationship between women’s education and desire for additional children across the six economic regions of Vietnam. The study employed data from the nationally representative Vietnam Multiple Indicator Cluster Survey (MICS) 2014. Probit regression results showed that for women with one child, higher levels of education were associated with higher fertility desire in two out of six regions. Similar results were found for women with two or more children. Children’s sex composition played a role in the desire for additional children, reflecting both son preference and mixed-gender preference. In Vietnam overall, among women with at least one boy, those with lower levels of education were more likely not to want another child. The results, however, differed by region. The findings suggest that the social and economic context of each region, particularly sex ratio at birth and total fertility rate, should be taken into account when designing population policies in Vietnam.

Non-communicable diseases (NCDs), which can largely be prevented by controlling avoidable lifestyle-related risk factors, are rapidly penetrating the entire world, including developing countries. The present study aimed to assess NCD lifestyle risk factors among the adult population in Bangladesh. The data used in the study were collected as part of a population-based cross-sectional survey covering rural and urban areas of Bangladesh conducted in 2015–16 (N=11,982 adults aged ≥35 years). The lifestyle factors considered were diet (daily fruit and vegetable consumption and extra salt intake with meals), sleeping patterns, smoking, smokeless tobacco consumption, and physical activity. The study found that approximately 18.5% of participants had a non-daily consumption of fruit or vegetables, 46.6% used extra salt with their meals, 11.8% reported sleeping <7 hours daily, 25.7% smoked tobacco, 60.9% used smokeless tobacco and 69.7% were less physically active. The prevalence of improper lifestyle practices relevant to NCDs, such as an inadequate diet, poor sleeping pattern, tobacco consumption, and low physical activity, was significantly higher among older adults, women, the uneducated, the unemployed, urban dwellers, and people from rich households. The study found that NCD-related lifestyle characteristics were poorly compliant with standard guidelines among many adult populations in Bangladesh. The findings can inform preventative strategies to control the overwhelming NCD burden in Bangladesh, such as the promotion of physical exercise, healthy eating, and the cessation of the use of tobacco products.

The fertility–development relationship is bi-directional, context-specific, multi-phased and inconsistent over time. Indian districts provide an ideal setting to study this association due to their size, diversity and disparity in socioeconomic development. The objective of this study was to understand the association of fertility and socioeconomic development among the 640 districts of India. Data were drawn from multiple sources: Censuses of India 2001 and 2011; DLHS-2; NFHS-4; and other published sources. A district-level data file for Total Fertility Rate (TFR) and a set of developmental indices were prepared for the 640 districts for 2001 and 2016. Computation of a composite index (District Development Index, DDI), Ordinary Least Squares, Two Stage Least Squares and panel regressions were employed. By 2016, almost half of all Indian districts had attained below-replacement fertility, and 15% had a TFR of above 3.0. The DDI of India increased from 0.399 in 2001 to 0.511 by 2016 and showed large variations across districts. The correlation coefficient between TFR and DDI was –0.658 in 2001 and –0.640 in 2016. Districts with a DDI of between 0.3 and 0.6 in 2001 had experienced a fertility decline of more than 20%. The fertility–development relationship was found to be strongly negative, convex and consistent over time, but the level of association varied regionally. For any given level of DDI, fertility in 2016 was lower than in 2001; and the association was stronger in districts with a DDI below 0.45. The negative convex association between the two was prominent in the northern, central and eastern regions and the curves were flatter in the west, south and north-east. The increasing number of districts with low fertility and low development draws much attention. Some outlying districts in the north-eastern states had high TFR and high DDI (>0.6). Based on the findings, a multi-layered strategy in districts with low socioeconomic development is recommended. Additional investment in education, child health, employment generation and provisioning of contraceptives would improve the human development to achieve India’s demographic goals.

With the onset of the demographic transition in sub-Saharan Africa, couples’ desired number of children and the sex composition of offspring may become conflicted, with potential effects on future fertility. While intuitively expected, this effect has not been observed in studies in sub-Saharan Africa, where the level of fertility is higher than in other African regions. In this study, the hypothesis of a conflicted situation was examined by assessing the effect of sex composition of offspring on women’s intentions regarding additional children and their use of modern contraceptives. A mixed-method analysis was performed using quantitative data regarding 2567 women aged 35–49 years drawn from a 2012 Demtrend retrospective longitudinal population survey, supplemented by qualitative data collected through 23 in-depth interviews of men and women in Ouagadougou. Results showed that the absence of one sex (boy or girl) in the existing offspring was associated with additional demand for children and lower contraceptive use. These results suggest that a desire for a combination of both girls and boys may be the driving factor contributing to larger family size; that is, continued fertility may not be determined by son preference, but rather by overall composition of offspring, when existing children are all girls or all boys. This could explain the stalling of the fertility decline observed in recent years in Ouagadougou.

The multiple realities around the sexual and reproductive health of Ghanaian adolescents are explored in this paper. Female and male adolescents (aged 10–19 years, N=298) participated in 40 focus group discussions in 20 communities. A comparative inductive approach has been used to present, analyse and document the sexual and reproductive realities of adolescents in their communities. The findings reveal commonalities as well as differences in the realities among participants. Common realities, regardless of age and sex, were teenage pregnancy and abortion, sexual violence (defilement, rape and coercive sex) and parental neglect. These aside, there were divergent realities for older adolescent girls in particular, e.g. lack of access to contraceptives and understanding of the fertility cycle, and the influences and pressures of social media and varied notions about sexual harassment between female and male adolescents. The findings, overall, underscore the complexity and nuanced lives of adolescents in traversing the sexual and reproductive maturation processes. These events unfold in communities where adolescents are ‘required’ to be silent and ‘play’ innocent regardless of their daily struggles, compounded by limited opportunities to learn and unlearn embedded norms about sexual and reproductive functioning. Some implications for sexual health promotion programmes are outlined.

Morbidities and mortalities caused by malaria are still a serious issue in Nigeria, with the country accounting for 25% of malaria morbidities and 24% of malaria mortalities globally in 2018. Treated bed nets reduce the incidence of malaria, but not all Nigerians use them. This study aimed to examine the factors associated with treated bed net usage, including perceived severity of malaria, and the rural–urban differences in the relationship between socio-demographic factors and use of treated bed nets in Nigeria. The analytic sample size comprised 40,693 women aged 15–49 years. Poisson regression and bivariable and multivariable analyses were used to test the study hypothesis that women who agreed that malaria could potentially lead to death would be more likely to adopt malaria preventive measures, including treated bed net use. About 48% of the women slept under a treated mosquito net the night before the survey. Those who perceived that malaria could lead to death had a higher likelihood of using a treated bed net in the urban, rural and combined samples. However, in the multivariable model, the association between perceived malaria severity and use of a treated bed net was only significant for rural women (APR=0.964, 95% CI: 0.933, 0.996). The results unexpectedly suggest that rural Nigerian women who perceive malaria to be severe have a lower likelihood of using treated bed nets. Also, rural–urban variations in the relationship between the socio-demographic variables and use of treated bed nets were observed. Policies should consider the observed rural–urban dichotomy in the influence of perceived severity of malaria and other socio-demographic factors on women’s use of treated bed nets in Nigeria.

The co-existence of under- and overweight at population level around the globe is well documented. However, this has yet to be explored using suitable statistical techniques in the context of Bangladesh. This study aimed to examine the prevalence and risk factors for being underweight and overweight or obese compared with normal weight in ever-married non-pregnant women aged 15–49 years in Bangladesh using data from the most recent Bangladesh Demographic and Health Survey conducted in 2014. Multilevel multinomial logistic regression (MLMLR) and quantile regression models were fitted to examine the associations of socioeconomic and individual-, household- and community-level factors on the nutritional status of women as measured by BMI. Overall, the prevalences of underweight, normal weight, overweight and obese women were 19%, 58%, 19% and 4%, respectively, in 2014. The MLMLR analysis revealed that women of young age, widowed/divorced/separated, having a larger family size and children aged ≤5 years in the household, currently amenorrhoeic and members of non-government organizations were at significantly increased risk of being underweight; those of older age, having higher parity, more educated, frequently watched TV and non-poor were more likely to be overweight or obese relative to normal BMI. Women from more affluent communities and urban areas were more likely to be overweight or obese relative to normal BMI than their counterparts from less-affluent and rural communities. Women’s nutritional status was found to be heterogeneous across the regions of the country. The findings indicate that, along with individual-level factors, community-level characteristics are also important in explaining women’s BMI in Bangladesh. The issue of under- and overweight or obesity among women in Bangladesh requires the immediate adoption of a public health policy for its mitigation. When developing intervention programmes, important determinants and uniform development of regions should be taken into consideration to combat the dual burden of under- and overweight among women in Bangladesh.

Little is known about the relationship between socioeconomic position (SEP) and duration and patterning of objectively measured sedentary time (ST) among adults, especially adults at high risk of diabetes. The aim of this study was to examine cross-sectional associations of SEP with ST (total, prolonged ST, breaks in ST) and self-reported TV time among pregnant women at risk of gestational diabetes in the UK. At 20 weeks’ gestation, pregnant women (n=174) wore an activPAL accelerometer and reported their usual TV time. Generalized linear mixed models were used to test associations of education, household income and area-level deprivation (separately and with mutual adjustment) with total ST, prolonged ST and breaks in ST. Logistic regression models were used to test associations between SEP indicators and high (≥2h/day) TV time. Those with the lowest education, lowest household income and highest area-level deprivation had the lowest ST and lowest prolonged ST. After mutual adjustment, area-level deprivation remained associated with total ST (β=0.10 [0.01, 0.20]). There was an inverse association between area-level deprivation and breaks in sedentary time (exp(b)=1.11 [1.01, 1.22]). Education was the only SEP correlate of high TV time, with more of those with least education reporting high TV time; this association persisted after adjustment for household income and area-level deprivation. The association between SEP and total and prolonged ST (positive) was the opposite of the association between education and high TV time (negative) in this sample of high-risk pregnant women. These findings should inform interventions to reduce sedentary time.

In Cameroon, two-fifths of the population is between the age of 15 and 24. Adolescents and youths are an important social group for the development of the country and the realization of the demographic dividend. The promotion of sexual and reproductive health will enable youth to transform their potential into development. This study aimed to identify the determinants of condom use at last sexual intercourse among single youths, highlight gender differences in the factors associated with condom use and identify the characteristics of youths who were less likely to use condoms. Data were taken from the 2018 Cameroon Demographic and Health Survey. The study sample comprised 1464 single females and 989 single males age 15–24. Multivariate logistic regression analysis was used to test the study hypotheses. Overall, 51% of the female and 66% of the male youths reported using condoms at last sexual intercourse. For both sexes, the protective factor was not having children. Among the females, belonging to the Bamileke or Mbo ethnic groups and delaying first sexual intercourse were also protective, while working in the modern or service sectors was the main risk factor. Among male youths, residing in households whose heads had a higher educational level was protective and household poverty was the main risk factor. These findings support Cameroon’s multi-sectoral approach to HIV/AIDS prevention among youths, and emphasize the importance of involving parents, teachers and youths in prevention strategies.

Income inequality is associated positively with disease prevalence and mortality. Digit ratio (2D:4D) – a negative proxy for prenatal testosterone and a positive correlate of prenatal oestrogen – is related to several diseases. This study examined the association of income inequality (operationalized as relative parental income) and children’s 2D:4D. Participants self-measured finger lengths (2D=index finger, and 4D=ring finger) in a large online survey conducted in July 2005 (the BBC Internet Study) and reported their parents’ income. Children of parents of above-average income had low 2D:4D (high prenatal testosterone, low prenatal oestrogen) while the children of parents of below-average income had high 2D:4D (low prenatal testosterone, high prenatal oestrogen). The effects were significant in the total sample, present among Whites (the largest group in the sample), in the two largest national samples (UK and USA) and were greater for males than females. The findings suggest a Trivers-Willard effect, such that high-income women may prenatally masculinize their sons at the expense of the fitness of their daughters. Women with low income may prenatally feminize their daughters at the fitness expense of their sons. The effect could, in part, explain associations between low income, high 2D:4D (low prenatal testosterone) and some major causes of mortality such as cardiovascular disease.

The aim of this study was to assess gender differences in the prevalence non-communicable diseases (NCDs) and in associated health-related habits, weight status and common risk factors in Botswana. Data were from the cross-sectional, population-based Botswana STEPS Survey II conducted in 2014. A total sample of 2947 survey participants aged 25–64 years were included the study. The results showed that a statistically significant higher percentage of men used tobacco compared with women (34.4%, 95% CI: 33.5–35.1 vs 4.4%, 95% CI: 4.3–4.5). Men also had consistently and statistically significantly greater heavy alcohol consumption and lower fruit and/or vegetable consumption than women. Physical inactivity among women was higher than in men. Controlling for other factors, men had a higher probability of being overweight (28.7%, 95% CI: 28.6–28.8 vs 18.3%, 95% CI: 18.0–18.6) and obese (25.8%, 95% CI: 25.4–26.2 vs 10.2%, 95% CI: 9.9–10.5) than women. Women were at a greater risk of developing NCDs compared with men since their adjusted prevalence of having at least three common risk factors was higher than men’s. Women had a higher adjusted predicted prevalence of suffering from hypertension than men (39.4%, 95% CI: 38.9–40.0 vs 26.1%, 95% CI: 25.5–26.8). Appropriate policies and programmes need to be adopted to urgently address the problem of NCDs in Botswana.

The early detection of anaemia is important for its subsequent control and incidence among women of childbearing age. This study aimed to assess the anaemia status of preconception young married women in India using National Family Health Survey-4 data collected in 2015–16. A total 65,238 sample preconception young married women were analysed using univariate, bivariate and multivariate techniques. A majority belonged to the Hindu religion (81.7%), lived in rural areas (64.5%) and had secondary level education (51.8%), and 41.7% had not yet given birth. The percentage suffering from anaemia was 51.3%. The prevalence of anaemia was higher among younger women (55.3%), those from Scheduled Tribes (59.0%), those living in rural areas (52.8%), the non-educated (55.9%), those in the poorest wealth quintile (56.9%), those from the East region (57.0%) and those with a low body mass index (BMI) (58.4%). The adjusted odds ratios indicated that, after controlling for significant background factors, Hindu, Scheduled Tribe, Scheduled Caste, East region, already having a child, too thin for their height and poorer and poorest wealth quintiles had higher odds of suffering from anaemia compared with the reference groups. The odds of suffering from anaemia decreased with age and education. The study showed a high burden of anaemia and associated risk factors among preconception young married women in India. The finding will inform decision-makers when planning interventions to decrease anaemia among women of childbearing age in India.