CAUSES AND EFFECTS OF CHILD MARRIAGE IN UGANDA

Table of Contents

Abstract......................................................................................................................................4
Introduction................................................................................................................................5
Literature Review.......................................................................................................................6
Epidemiology of Child Marriage...........................................................................................6
Child Marriage in Uganda......................................................................................................6
Causes of Child Marriage in Uganda.....................................................................................7
Harms of Child Marriage.......................................................................................................8
Summary and Research Question........................................................................................10
Methodology Informing the Protocol......................................................................................11
Research Protocol....................................................................................................................12
Identification of Studies.......................................................................................................12
Search Strategy....................................................................................................................13
Study Selection....................................................................................................................14
Management of Studies........................................................................................................14
Quality Assessment..............................................................................................................15
Ethical Appraisal..................................................................................................................16
Data Extraction....................................................................................................................18
Data Analysis.......................................................................................................................18
Limitations...............................................................................................................................19
Dissemination...........................................................................................................................20
References................................................................................................................................20
Appendix 1 Schedule of Work.................................................................................................26
Appendix 2 Example Data Extraction Tool.............................................................................27
Appendix 3 Quality Appraisal Tool.........................................................................................28
Abstract

Child marriage in Uganda remains a significant problem, contributing to both health and
social inequalities. The practice persists despite the Ugandan governments agreement with
several international declarations, and local legislation prohibiting marriage of boys or girls
before they reach the age of majority (18yrs). The drivers of child marriage are suggested to
be rooted in extreme financial poverty allied with long standing local customs. The
consequences for the child are severe and frequently include the cessation of school and
education, early sexual initiation and pregnancy, increased risk of HIV and other infections,
and early mortality. This protocol outlines a strategy for a systematic review of qualitative
research. The review will undertake a systematic search of research databases to identify
suitable studies. Those studies which meet the inclusion criteria will be assessed for quality
and ethical practices, and finally undergo data extraction. The final meta synthesis will be
based on the interpretivist analysis of the themes identified and combined from individual
studies.
Introduction

Child marriage is generally defined as occurring when at least one of the partners in the union
is below the age of 18 and is explicitly prohibited under a variety of specific covenants of the
United Nations. The Convention on the Elimination of the Discrimination against Women
(CEDAW) describes in article 16 that the marriage of a child, or promise of marriage to a
child, has no legal basis (United Nations 1979). Furthermore, the Convention of Rights of
the Child (CRC) also prevents nations States from providing legal validity to any marriage
where the child is under 18 years of age (United Nations, 1989). In addition, despite claims
of cultural imperialism, the CRC also admonishes governments to abolish all practices that
contravene these principles regardless of whether they are considered as traditional practices
or not. Finally, and most recently, during the International Conference on Population and
Development (ICPD) an international consensus was agreed by 180 countries, and included a
measure to eliminate child marriage, as well as effectively preventing betrothal of children
(or adults) against the wishes of the individuals involved (United Nations 1994).

These agreements represent almost four decades of effort, and are a pervasive and
comprehensive set international agreements and policy directives, specifically aimed at the
elimination of child marriage. Given the timeframe and wide ranging political agreement, it
is surprising that child marriage persists, with indications that the number of children affected
has not fallen as anticipated (UNICEF, 2014). Indeed, child marriage has received increasing
attention from a wide variety of international actors including the World Health Organisation,
UNICEF and the United Nations. Furthermore, twenty years after the ICPD agreement
(United Nations, 1994), data from UNICEF (2014) indicated that worldwide, more than 700
million women are currently alive were first married prior to their eighteenth birthday.
Moreover, the evidence is that this is far from being eradicated and is predicted to continue
to increase in the coming decade (UNFPA, 2012).

Given both the breadth of policies and the number of signatory countries which have
condemned child marriage, it is universally accepted that forcing children into marriages
which they are unable to consent to, is unquestionable and a violation of their human rights.
However, there is strong evidence that it is also causes severe deleterious effects on the
child’s health. Child marriage has been associated with increased child morbidity and
mortality resulting from adverse effects on the child’s biological, psychological and social
well-being (Nour 2006, African Union 2014, Sarich et al. 2016). Consequently, child
marriage is not only worthy of legal and ethical investigation, it is also important to assess the
causes and consequences of the practice from a healthcare perspective.

While individual incidents of child marriage have been recorded in all countries, the practice
is most prevalent in low and middle income countries of South America, India, and Africa
(Brides 2015). This proposal for a systematic review will set out a protocol for assessing
what drivers continue to promote child marriage, and what health care consequences result
from the practice. These aspects of child marriage will be investigated using the African
nation of Uganda, where rates of child marriage are typical of the region (UNICEF, 2014,
UNICEF 2016) as an exemplar.

Literature Review

Epidemiology of Child Marriage

Most recent estimates suggest that worldwide there are over 700 million individuals alive
who became married before they were 18 years old, the large majority of which are women
(UNICEF, 2014). In addition, the practice is generally considered to be one that occurs
primarily in low and middle income countries, however within this there are wide variations
depending on population density and the frequency of child marriage. For example, the areas
where child marriage is most common are focussed around Sub-Saharan Africa (UNICEF
2016). Within this region, the highest rates of child marriage are in Niger, with 75% of girls
married before they turn 18 years of age As a region, Sub-Saharan Africa has a child
marriage rate of 14% by 15 years of age and 39% by the age of 18 (UNICEF, 2016). In
contrast, while the rates of child marriage are lower in South Asia, the high population
density of the area means that there are more child marriages in total in South Asia than in
Africa (ICRW 2012).

Child Marriage in Uganda

The Republic of Uganda, formerly part of the British Empire, gained independence in 1962
and has functioned as an independent nation state since then. As with many areas of Africa,
child marriage remains a serious issue, despite the government claims of that much has been
done to reverse the problem (Government of Uganda and UNICEF 2015). The most recent
report in child marriage by UNICEF (2016), reported that 10% of the country’s children are
married by 15 years of age, while 40% are married by 18 years of age. In addition, UNICEF
assess a countries overall status for child marriage by determining the number of 20-24 year
olds who married (or in an equivalent union) before the age of 18, and therefore is also
partially a historical measure of the rates of child marriage. Nevertheless, using this measure
Uganda ranks as 18th in the World for rates of child marriage.

It is also worth noting that Uganda’s history regarding child marriage is despite the countries
own legislation stating that the minimum age for marriage is 18 years of age, although girls
may also marry at 16 with their parents’ consent (UNFPA 2010). In addition Uganda is a
signatory to the relevant international human rights legislation including, CEDAW (United
Nations 1979), CRC (United Nations 1989), and the IPCD consensus (United Nations 1994).
More recently, the government has reaffirmed its commitment to ending child marriage.
Uganda was a co-signatory to the London Girls Summit in 2014 which pledged to end early
and forced marriage (UK Government, and UNICEF 2014). It is a member of the African
Union Campaign to end Child Marriage in Africa (African Union 2014). More recently, the
Government implemented the first Ugandan strategy, specifically aimed at ending child
marriage and teenage pregnancy (Government of Uganda and UNICEF 2015). It seems clear
therefore, that the countries government is attempting to address the issues of child marriage,
albeit imperfectly.

Causes of Child Marriage in Uganda

As outlined above, the Ugandan Constitution provides the right to family and marriage with
the minimum age of consent limited to 18 years of age (The Republic of Uganda 1995).
However, despite this constitutional framework, child marriage is both persistent and widely
practiced (Government of Uganda and UNICEF 2015). A common explanation for the
continued practice is that in traditional ethnic groups, parents view the practice as a way of
protecting their daughters, against premarital sex and pregnancy. In this context, child
marriage may appear to have some advantages. First it protects both the daughter’s and the
family’s honour by preventing pregnancy and child birth outside of marriage (UNICEF
2007). In addition, in many cases, unmarried mothers will find it difficult to find partner for
future marriage and financial security (considered a necessity in a highly patriarchal
society(Gordon 1996)). Consequently, child marriage prevents unwanted pregnancy outside
of wedlock while simultaneously securing a girl’s security (Rubin et al. 2009). The concern
that this ‘benefit’ may be at the cost of the child’s, mental and physical health, education, and
their future development is a lesser concern in areas where child marriage forms part of the
local tradition (Vogelstein 2013).

However, it would be overly simplistic to simply attribute regional traditions as the sole
driver for underage marriage in Uganda. The range of contributory factors underpinning the
practice is far more diverse, and related to the environment in which the children find them
themselves. For example, Uganda has had ongoing conflicts over the last two decades with
the Democratic Republic of Congo, and more recently has been involved with the South
Sudanese Civil war (Insight on Conflict 2016). Such conflict between nation states increases
the number of individuals with refugee status and the number of children missing one or both
parents, and as a result tend to be associated with increases in child marriage (Schlecht et al.
2013, Neal et al. 2016). In addition, conflict will exacerbate poverty and deprivation already
prevalent throughout Uganda (UNFPA 2010). and poverty per se, has been suggested as a
powerful driver of child marriage both in Uganda (Rubin et al. 2009, Lubaale 2013) as well
as other low to middle income countries (UNFPA, 2012).

In addition, for those families with the scarcest resources, child marriage may be seen as the
best option for both the girl and the family. The marriage of a female child can be a source of
significant income via dowry payments from prospective husbands, and parents may
therefore encourage their female offspring into early marriage (Bell and Aggleton 2014). In
addition, the presence of a female offspring may be seen as overly burdensome to a family
without the resources to meet their needs and reflects the relatively low value placed on the
education of a daughter who is expected to get married anyway (Amin et al. 2013).
Furthermore, because poverty will often persist in families for many generations, families and
villages will develop social norm’s that have resulted in the normalisation of child marriage.
As a consequence, during early socialisation, the practice becomes accepted by the child, who
may themselves aspire to getting married early; viewing it as both desirable and as part of
their duty to their parents (Amin et al. 2013).
Harms of Child Marriage

Despite the evidence that families may promote child marriage to protect the child from early
sexual encounters and therefore protects them from infection by sexually transmitted disease
or unwanted pregnancy, (STDs (Rubin et al. 2009)) the evidence suggests that this is
counterproductive, as married girls are more likely to contract HIV or human papilloma
virus (HPV) than their unmarried counterparts (Nour 2006). In addition, within Africa in
general, marriage by the age of 20 is a risk factor for HIV infection for girls (Nour 2006).
Given the prevalence of child marriage, this means that in Sub-Saharan Africa girls between
15-19 are up to 8 times more likely to have HIV than boys of the same age (Laga et al. 2001).
Work specific to Uganda has also similarly adverse results, for example while the HIV
infection rate in unmarried girls (15-19 yrs) is high at 66%, for those children who are
married this rises to a shocking 89% (Kelly et al. 2003). It is clear therefore, that despite the
prevalent poverty in many regions, and what in some cases, may be the best intentions of the
wider family, early marriage increases the risk of infection and early mortality. The reasons
for this appear to be related to the fact that in order to pay a dowry to the family of a child
bride, potential husbands may work for several years in order to accumulate sufficient
savings. Consequently, the partners of the child brides tend to be significantly older, with
correspondingly greater number of sexual partners (Laga et al. 2001). Indeed, Kelly et al.
(2003) reported that, not only was early marriage a significant risk factor for HIV infection,
but the incidence of HIV in child brides was positively associated with the age difference
between the bride and the husband.

In addition to risks of infection, there are a wide variety of other harms, both physical and
psychological, that may occur following marriage in children. There is evidence that child
marriage results in increased risk of cervical cancer through HPV infection (Perlman et al.
2014); a factor which, like HIV infection, is exacerbated by the greater sexual experience of
the children’s partner (Bayo et al. 2002). In addition, child brides are at a greater risk of
complications during pregnancy. For example, complications during pregnancy and delivery
are often among the leading causes of mortality in girls aged 15-19 years in countries where
child marriage is common (UNFPA, 2012). Similarly, because of the immunosuppression
that occurs during pregnancy, there is also a greater risk of the mother succumbing to other
types of infections (Nour 2006).
In terms of the future well-being and development of the married child, there is compelling
evidence that in Uganda, there is a strong negative relationship between school attendance
and marriage, with the majority of girls no longer attending or completing school once they
are married (Wodon et al. 2016). Married children are often financially reliant on their older
partners, yet there is also a strong relationship between a woman’s educational attainment and
income in low and middle income countries (UK Government, and UNICEF 2014).
Consequently, the likelihood of a married child failing to complete their education may have
consequences that persist long into adulthood, exacerbating their financial dependency.
Furthermore, there is also evidence that child marriage is also associated with lower levels of
wealth, reduced ability to generate income, lower educational levels and greater propensity
for the individual to be used for forced labour (Male and Wodon 2016). Indeed, several
commentators have indicated that in some cases, child marriage amounts to little more than
enforced slavery encompassing extreme physical labour and sexual gratification (Sarich et al.
2016).

Summary and Research Question

This scoping review was undertaken to inform the development of a research protocol to
assess the causes and consequences of child marriage in Uganda. The findings clearly
indicate that child marriage is not only condemned by the Ugandan government, but
demonstrably contravenes the regions legislation, as well as international agreements signed
by the government. Despite this, the practice of child marriage remains wide spread within
the country, and is exacerbated by recent conflicts and poverty, which may in turn have
resulted in ingrained local customs which promote early marriage, particularly for female
offspring. The practice is associated with significant harms to the child including financial,
emotional and physical; with risk of HIV infection a particular concern. Furthermore, the
scoping review found no evidence of any prior systematic reviews regarding either the causes
or consequences of child marriage in Uganda, and it is therefore an appropriate topic for
further academic consideration.

Therefore, the aim of the proposed review is to synthesise data, from multiple sources, which
discuss factors that contribute to the continuation of child marriage as a common occurrence
in Uganda, or which assess the effects that child marriage has on children and the wider
community where child marriage occurs. Consequently, the primary question that will be
addressed by this review is:

What are the individual and social drivers of child marriage in Uganda and what
consequences do they have on the individuals involved?

Methodology Informing the Protocol

In order to effectively undertake a meaningful review regarding the causes and consequences
of child marriage, it is important to first identify a suitable methodology by which the
research protocol can be informed. There are three broad approaches to addressing research
questions; quantitative, qualitative and mixed method investigations. Quantitative research is
a positivist approach based on the hypothetico-deductive method (Newman and Benz 1998).
It is concerned with measuring the phenomena of interest on a numerical scale such that the
resulting data is amenable to statistical analysis. Qualitative research is best used to assess
questions where the phenomena of interest relate to individual’s or group’s feelings, attitudes,
belief’s or behaviours (Creswell 2013) and often the data generated is narrative forming
themes, rather than numerical values. Mixed methods, as suggested by the name used,
consists of aspects of both quantitative and qualitative research, usually using the results of
one form of enquiry to better understand the results of the other (Schneider et al. 2012).

However, no single approach is universally superior, and it is important that the research
approach chosen is informed by, and relevant to, the intended research question (Schneider et
al. 2012). In the case of the proposed protocol, the research question aims to understand the
attitudes, beliefs and social constructs that perpetuate child marriage within communities in
Uganda. Consequently, this review will use a qualitative interpretivist approach. The
advantage of this approach is that in this case, is will support a rigorous and critical analysis
of the concepts and perspectives that are proposed in the literature, in a manner that is not
feasible using approaches based on quantitative positivism (Tobin and Begley 2004).
Moreover, interpretivism is based on very different ontological and epistemological premises,
and allows for a deeper understanding of the motivations and actions (Tobin and Begley
2004). In particular, interpretivism has been widely used within the social sciences, indeed
much of the literature included in the preceding review used an interpretivist approach. The
guiding tenet of interpretivism is that individual behaviours and beliefs need to be understood
in the context of the social structures relevant to their daily lives including, culture and
customs, peer groups, and institutions (Seale 2012).

In particular, interpretivist research accepts that individuals interpret the context in which
they find themselves in a subjective manner, consequently they must define their own
meanings, and it is this subjective reality that any investigator should seek to understand
(Markula and Silk 2011). In addition, this point is also extended to the researcher
themselves; interpretivism assumes that the researcher will similarly construct their own
reality from the data they collect and that any interpretation of the data will be influenced by
the researchers own experiences. In contrast, positivistic research attempts act objectively,
aiming to have little impact on the data collected, and assumes there is an underlying reality
that can be objectively measured (Scott and Morrison 2007).

The interpretivist approach also assumes that an individual’s construction of their social
reality is dynamic, and relies on iterative and bi-directional interactions with other individuals
and institutions (Biesta et al. 2011). This is often considered as a criticism of the qualitative
method as it suggests that any interpretation of the data is idiosyncratic, being specific to the
time and place of data collection, as well as to the researchers own experience. Therefore,
interpretivism may lack the generalisability of findings that makes quantitative approaches so
useful (Tushnet 1983). However, defenders argue that qualitative interpretivism examines
individuals in their own context and does not seek to be generalizable, only that where the
information has sufficient shared meaning, then others, in other contexts may find it useful to
apply the findings to their own context (Williams 2000). Consequently, since the protocol
proposed here aims to understand how individuals construct meaning and understanding
within their own context, as well as the consequences of their personal interpretations, a
qualitative interpretivist approach is most appropriate.

Research Protocol

Identification of Studies

The search strategy employed in the proposed review will aim to be as inclusive and as
comprehensive as possible. In order to accomplish this, a variety of strategies will be
employed. Online databases will be interrogated for relevant publications. These will
include PUBMED, SocIndex (EBSCO), CINAHL, Web of Science, the Directory of Open
Access Journals (DOAJ), PsycInfo, and Google Scholar. However, during the scoping
review, it became clear that a significant number of relevant publications were published
outside of traditional peer-review academic outlets. These included ‘grey’ literature
produced by governmental organisations, international humanitarian institutions, and
charities. Consequently, an important aspect to the search strategy in this protocol will be a
comprehensive search of grey literature sites, and of relevant non-academic sources. In this
case, searches will include the repositories of the United Nations, the United Nations
International Children's Emergency Fund (UNICEF), and the United Nations International
Children's Emergency Fund (UNFPA), as well as the specific grey literature repositories
OpenSIGLE and GreyLit.Org. In addition, a more general internet search will be used to
identify other charities and non-governmental organisations (NGOs) that investigate or report
on child marriage in Africa. Finally, a manual search of the reference lists of identified
research studies and reports will be undertaken to ensure that all possible, relevant
publications can be included in the analysis.

Search Strategy

While there are several studies assessing the most appropriate method of performing a
literature review in quantitative based research, there is less equivalent data regarding
qualitative reviews and the possible issues that may be encountered. Qualitative research is
by nature more diverse and can include a wide range of possible study designs and
methodologies (Markula and Silk 2011). In particular, there is evidence that narrowing
searches to titles or titles and abstracts, as is common in reviews of quantitative literature,
increases the number of papers that any specific search criteria may miss (Barroso et al.
2003). For example, Shaw et al., (2004) reported that qualitative research would commonly
have a title which may not directly relate to the subject matter of the study its-self. Similarly,
Evans (2002), reported that when searching for qualitative studies, databases that are
traditionally used for quantitative research classifications (e.g. PubMed) frequently miss-
classified records as quantitative research rather than qualitative.

As a result, the intended search strategy for this review will be deliberately broad, and will
rely on human analysis to identify studies that do not meet the inclusion criteria, rather than
use highly specialised search terms in an attempt to limit search results to only the most
relevant research. The search will combine 3 broad search criteria:

1� Location including; Uganda, ‘sub-Saharan Africa’ ‘Kampala’, ‘Gulu’ and ‘Lira’

2� Phenomena including; ‘child marriage’, ‘forced marriage’ ‘arranged marriage’ and
‘underage marriage’
3� Study type including; ‘qualitative’. ‘ethnogr*’, ‘narrative’, ‘grounded theory’,
‘phenomenolog*’, ‘case study’, ‘case report’, ‘stories’, ‘lived experience’, ‘attitudes’,
‘beliefs’

Study Selection

In order to identify suitable records for inclusion in the review, a selection of search terms
will be identified based on the SPIDER (Sample, Phenomenon of Interest, Design,
Evaluation, Research type) which was specifically designed to support systematic literature
searches of qualitative evidence synthesis (Cooke et al. 2012). In this case the sample will be
studies of children (boys or girls) who have married below the age of 18, or the parents or the
partners of children who have married below the age of 18. The phenomena of interest is in
child marriage, therefore studies must address some aspect of child marriage in the samples
outlined above. In addition, studies should be based on any recognized qualitative research
paradigm including interpretivist, ethnography including auto-ethnography, grounded theory,
action research, or phenomenological research. Given the overarching research question of
this protocol, to be included, the evaluation of data within studies must include some aspect
that describes the drivers of child marriage or the consequences of child marriage in terms of
physical, psychological, emotional, or social well-being. Finally, the research type will be
limited to qualitative studies, or mixed methods studies, but which have reported the results
of their qualitative component in such a way as to match the criteria outlined above. Studies
must be available and published in English.

In addition, specific exclusion criteria will also be applied. Studies that focus on adults will
not be included, this includes arranged or enforced marriages of men or women who are over
the age of 18. Studies assessing underage pregnancy, or the trafficking of underage children
for sexual exploitation, in the absence of any context of marriage, will also be excluded.
Studies assess the phenomena using quantitative methodologies will also be excluded.
Management of Studies

Studies identified from the literature searches will be imported into specific bibliographic
software (Endnote X7, Thompson Reuters, Philadelphia, USA). Once imported, the resulting
database will be scanned to remove duplicates. The remaining studies will be assessed by
title and abstract for suitability for inclusion in the review. Those excluded at this point will
be excluded as ‘clearly not relevant’. The remaining studies will undergo review of the full
published paper or report (in the case of grey literature). A full record will be kept at this
stage for the reasons for any further exclusions. Those studies that remain after this two-
stage process will be included in the review and meta-synthesis.

Quality Assessment

The role of quality assessment in qualitative research, and the most appropriate method of
any such assessment remains controversial (Hannes et al. 2010). A situation in stark contrast
to quantitative research, where there is broad agreement, not only on the use of such
assessments, but on the most appropriate tools to use. The disagreement regarding the role of
quality assessment covers several points. Both early (Smith 1984) and more contemporary
(Dixon-Woods et al. 2004) commentators have argued that the very act of undertaking a
quality assessment is inherently flawed due to the subjective nature of the researchers insight
and interpretation in qualitative research. Similarly, and precisely because of the
interpretation of qualitative data can be subjective, others have argued that any assessment of
qualitative research should focus exclusively on the methodological aspects of such research
(Dixon-Woods et al. 2007). However, such attempts to assess the methodological rigour
have also been problematic. As discussed earlier, there is extensive historical research, and a
strong consensus within qualitative research regarding the need for a systematic approach to
assessing study quality. This led some researchers to attempt to simply transfer the
conceptual underpinnings of the quantitative study assessment and apply it to qualitative
research (Hannes et al. 2010). However, the use of concepts such as reliability, validity and
systematic bias have not been widely accepted as either adequate or appropriate for use
within a qualitative framework (Hannes 2011). Early work (e.g. Eisner 1991) tried to
counter the use of quantitative assessment criteria, by ‘translating’ them into language that
may have greater resonance with qualitative researchers, such as rigor, trustworthiness,
plausibility and credibility, although this too has been criticised (Seale 1999). Indeed,
Hannes and Macaitis (2012) reported that of eighty two qualitative evidence synthesis
articles, a substantial number failed to mention any description of an appraisal framework,
and a minority explicitly indicated that no critical appraisal of study quality was undertaken.

More recently, attempts have been made to identify assessment of study quality that is rooted
in the work and traditions of qualitative research (Hannes et al. 2010). In order to accomplish
this, contemporary tools ask questions related to the type of work qualitative researchers
undertake in order to establish the validity of their own work (Attree and Milton 2006). The
most well-known of these include the Critical Appraisal Skills Programme (CASP) checklist
for assessing qualitative studies (Critical Appraisal Skills Programme (CASP) 2012), the
Joanna Briggs Institute Tool for assessing qualitative research (Joanna Briggs Institute 2011)
and the Evaluation Tool for Qualitative Studies (ETQS; (Long and Godfrey 2004). While all
three where designed to support the evaluation of studies when performing systematic
reviews of qualitative research, each has their own specific benefits. Hannes et al., (2010)
evaluated the validity of all three frameworks and concluded that each was valid, but that the
JBI framework was the most internally consistent, while the ECTS provided the most detailed
instructions for reviewers. Conversely, the CASP checklist was the most user-friendly and
provided a way to provide a simplified overview for prospective readers. In addition, case
studies by authors who have undertaken systematic meta-synthesis of qualitative research
also indicated that the CASP framework is both simple to use and provides easily understood
overviews (Newton et al. 2011).

Correspondingly, the review outlined in this protocol will use the CASP toolkit for qualitative
research (Critical Appraisal Skills Programme (CASP) 2012). This checklist includes 10
questions that aim to support reviewers in assessing the robustness and usefulness of
individual studies. The first two questions are screening questions to ensure that studies that
the tool is appropriate for the studies to be assessed; this includes checking if a study has a
clear aim and if qualitative research was an appropriate method to achieve any such aim. For
studies that satisfy these screening questions, the remaining questions assess different aspects
of the study design and conclusions including; was the design appropriate, was the
recruitment strategy appropriate, was data collected in a manner that could answer the
research question, has the relationship between the researcher and participants been
considered, is there due consideration for any ethical issues raised, was data analysis
sufficiently rigorous, where findings clearly states, and if the results are useful to expanding
existing knowledge.

Ethical Appraisal

As with assessment of study quality, ethical appraisal of qualitative research received less
attention and have similar issues inherent in quantitative research. Much of this failure to
assess the ethical implications of research stems back to early ethnography where, for
example, ethnographers observing remote populations would not consider such concepts as
informed consent (Sanjari et al. 2014). More recently, Richards and Scwartz (2002) report
that although ethical guidelines from institutions such as the Medical Research Council, and
the British Medical Association, and various research charities appear in the guidelines for
research ethics committees (Eckstein 2003) all deal almost exclusively with quantitative
research. More recently, the increasing focus on the role of qualitative research in healthcare
has led to a re-examination of the ethical scrutiny of healthcare based qualitative research,
with recent calls for the development of specific guidelines (Sanjari et al. 2014).

Systematic reviews are acknowledged as a key way to synthesise a broad body of information
(Moher et al. 2010) however it is rare for ethical issues to be considered (Weingarten et al.
2004). However, there is increasing concern that if ethical reviews of research is not
undertaken, it may compound several ethical issues within individual studies such as, using
research where the ethical considerations were insufficient, the surrogate reporting in the
review of unethical studies, and the assumed transfer of informed consent from the individual
study to the systematic review (Vergnes et al. 2010). Consequently, ethical review of studies
is an important part of the ethical conduct of a systematic review.

In assessing the ethical issues in qualitative research, four broad principles have been
suggested; causing anxiety and distress, misrepresentation, exploitation, and identification of
participants in the resulting published research (Richards and Schwartz 2002). These have
recently been further developed to encompass a wider range of ethical decisions that
researchers should consider including; justifiable research, researchers competence, study
quality and design, minimising harms, recruitment, information and consent, safety,
necessary deception, confidentiality, and dealing with vulnerable participants (Iphofen 2015).
However, those conducting systematic reviews can also reasonably expect that institutional
ethics review committee’s will be similarly aware of these areas of concern. In addition,
ethical assessment of studies is hampered by changes in ethical standards over time, such that
a study which may have been considered ethically sound at the time it was undertaken, may
not satisfy contemporary ethical scrutiny at the time of the systematic review.

Therefore, the review proposed in this protocol will assess the ethical aspects of each study in
line with the recommendations suggested by Vergnes et al. (2010). Thus, in order for the
paper to be included in this review, the ethical review will require that, as a minimum, each
study includes a statement that the research was scrutinised by and received approval from an
appropriate ethical body (e.g. University Ethics Committee). Furthermore, given the nature
of the proposed review and reports of high levels of domestic violence and servitude resulting
from child marriage (UNICEF 2007), studies that fail to anonymise participants, fail to report
seeking informed consent, or otherwise have manifested disregard regarding the safety of
their participants will be discounted. Failure to discount such research would be to provide
tacit support for such research methods.

Data Extraction

Data extraction will be performed using the Joanna Briggs Institutes Data Extraction
Template for Qualitative Evidence (Joanna Briggs Institute 2011). This includes collecting
basic bibliographic data for each study, a brief description of the method used and the
methodology that informed the study design. In addition, the extraction template also
includes assessment of the intervention used to collect data, what the setting for data
collection was, and the geographical location regarding the aims of the study. Cultural
reference points that are pertinent to the aims of the study are also extracted along with the
methods of data analysis. Finally, the template includes a brief summary of the authors
conclusions from the study, and a comment by the reviewer regarding the quality and
implementation of the study, and the coherence of the authors conclusions with the data
presented. The use of the template and the data that will be extracted under each heading will
be in line with those suggested for the tool by Munn et al., (2014).

Data Analysis

Once data extraction, quality evaluation, and ethical evaluations have been completed, studies
will be included in a qualitative synthesis. The aim of this synthesis will be to identify
recurrent themes that emerge from the studies that are pertinent to the aims of the review.
This will be accomplished using the process of meta synthesis outlined by Walsh and Downe
(2005). Briefly, meta synthesis is a technique that seeks to amalgamate the findings of a
series of related studies and was first described by Stern and Harris (1985). In contrast to
aggregating techniques used in quantitative meta-analysis, meta synthesis attempts to
integrate data and themes identified in related qualitative studies and uses an interpretive
framework (Walsh and Downe 2005). The approach is similar to thematic analysis used in
individual studies. Each paper is read and re-read to support a robust understanding of the
themes and methodologies used. Once completed, the findings of each study are reviewed
line-by-line and the key themes and explanatory sentences identified. The themes identified
from each paper are then extracted and grouped to develop broader interpretative themes
which represent the overarching nature attributes of the sub-themes. This interpretative
approach allows for the identification of common meanings between studies to emerge. It
should also be noted that meta synthesis (and systematic reviews of qualitative research in
general) are subject to some important criticisms. Most notably, by summarising the findings
of individual qualitative research, the ‘rich and deep’ data that is the hallmark of qualitative
research is thinned and as such, important aspects describing the individuals experiences of
the topic of analysis are lost (Sandelowski et al. 1997, Campbell et al. 2003).

Limitations

There are a number of limitations to the review proposed in this protocol. The use of meta
synthesis to identify themes across papers has its own limitations. Principally, and in
common with all analysis based on identification of themes, the themes identified will be
influenced by the researcher’s reflexivity. Therefore, the themes that emerge will be those
that are identified by the primary researcher and may be overly idiosyncratic to their
experiences, attitudes and beliefs. Commonly, this is avoided by using corroboration to
ensure that the themes identified are also ones with other researchers agree are emerge from
the data analysis. However, due to resource limitations regarding the production of a thesis,
this will not be possible. Similarly, it is also usual for two researchers to undertake the
literature search and study identification, to ensure that the systematic approach to data
collection is valid and reliable. However, again due to resource limitations, these aspects of
the review will be undertaken by the lead researcher only.
Furthermore, although Uganda is a former British colony, the two official languages of the
state are English and Swahili. Given that one of the inclusion criteria for identified studies is
that they are published in English, it is plausible that some research will be missed.
However, since there are two official languages, it is also likely that the scope for this will be
minimal as governmental and charity funded research are likely to be published in both
languages.

Finally, and as is the case with all systematic reviews, it is possible that the search strategy
outlined will fail to find all research relevant to the topic of child marriage in Uganda.
However, care has been taken to ensure that the search strategy is transparent, systematic and
as comprehensive as possible.

Dissemination

Dissemination of research findings is defined as the targeted distribution of research findings

to a specific health or academic audience and is distinct from more general communication,
or action focussed implementation strategies (Lomas 1993). Correspondingly, the primary
method by which the findings of this review will be disseminated will be via the production
of a research thesis. This dissertation will include the background, methodology, included
studies and meta synthesis of findings regarding the causes and consequences of child
marriage in Uganda. In addition, and in consultation with the academic supervisor, the
potential for further opportunities for dissemination will be investigated, (e.g. conference
poster presentations).

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Appendix 1 Schedule of Work

Jan Feb March April May

Undertake literature searching
Review for included and excluded studies
Undertake quality and ethics review
Undertake meta synthesis
Complete manuscript and biding
Appendix 2 Example Data Extraction Tool

Bibliography Schlecht 2013

Early relationships and marriage in conflict and post-conflict settings:
vulnerability of youth in Uganda.

Method Interviews with two distinct populations in Uganda: internally displaced

persons in Mucwini transit camp in northern Uganda and Congolese
refugees in the Nakivale refugee settlement in southwestern Uganda
Methodology General qualitative with interpretivist assessment of emergent themes
Interventions Group interviews and one to one interviews of refugees. Interviews
focussed on how conflict and the immediate post-conflict period
contributed to early marriage and the development of early sexual
relationships
Setting Two refugee camps, with interviews taking place in discrete locations
away from other family members or other members of the community.
Geographical Specifically focussed in Ugandan refugees

Cultural Consideration given to the local cultural custom of early marriage.

Researchers sought to assess how conflict supported early marriage.

Participants Female refugees under the age of 20 who were married before 18.

Data analysis Thematic analysis of emergent themes

Author’s conclusions Shifts in economies, family relationships, and communication combined
with structural changes encountered in settlements resulted in changed
relationships and marriage patterns. Conflict contributed to poverty,
splintering of family, and lack of education which profoundly affected the
views, perceptions and behaviours of youth around relationships and
marriage
Reviewer’s conclusions The findings appear to be supported by the interview data, and the authors
included examples from the refugee’s stories that also support their
conclusions. However, it is not clear from the data if there was any
quality control. There is no discussion of saturation, or corroboration by
other researchers. Similarly, given the situation, there is no discussion
reflexivity or of the power inequality between the refugees and the
interviewers.
Appendix 3 Quality Appraisal Tool