Girl Child Marriage and Its Association With National Rates of HIV,Maternal Health,and Infant Mortality Across 97 Countries

Abstract

This study was designed to assess associations between national rates of girl child marriage and national rates of HIV and maternal and child health (MCH) concerns, using national indicator data from 2009 United Nations reports. Current analyses were limited to the N = 97 nations (of 188 nations) for which girl child marriage data were available. Regression analyses adjusted for development and world region demonstrate that nations with higher rates of girl child marriage are significantly more likely to contend with higher rates of maternal and infant mortality and nonutilization of maternal health services, but not HIV.

Keywords

girl child marriage health and human rights HIV maternal and child health

Introduction

The marriage of minor-aged girls (i.e., less than 18 years), commonly referred to as girl child marriage, is a gender-based health and human rights violation affecting women and girls globally (United Nations Children’s Fund [UNICEF], 2000, 2005). Although there has been a substantial decline in the practice over the past 20 years, it continues to affect very large proportions of girls (up to 50%-75%) in regions such as South Asia and sub-Saharan Africa, where up to 50% to 70% of females in some countries continue to be married prior to age 18 years (UNICEF, 2009). Even in regions where the practice is less common, such as Latin America (e.g., South America, Central America) and Eastern Europe, some nations report that 10% to 20% of females are marrying prior to age 18 years of age (UNICEF, 2009), and high development nations, too, such as the United States and the United Kingdom, see cases of child marriage on occasion (Warner, 2004). Currently, above 60 million women and girls worldwide are affected by the practice of girl child marriage (UNICEF, 2000, 2005).

The Context of Girl Child Marriage

Although girl child marriage occurs in diverse world regions, certain social contexts are at increased risk for this phenomenon. Studies consistently show that marriage of minor-aged girls is more likely to occur in rural and impoverished areas with low access to health care and girl education (Gokce, Ozsahin, & Zencir, 2007; Jain & Kurtz, 2007; Mehra & Agrawal, 2004; Mensch, 2003; Nour 2006, 2009; Otoo-Oyortey & Pob, 2003; Raj, Saggurti, Balaiah, & Silverman, 2009; Santhya & Jejeebhoy, 2003, 2004; United Nations Population Fund [UNFPA], 2005; UNICEF, 2001, 2007, 2009). Regional conflict and instability further exacerbate these vulnerabilities (Kottekoda, Samuel, & Emmanuel, 2008; Raj, Gomez, & Silverman, 2011). As marriage of a girl is viewed as a means of protection, from both economic instability and rape due to perceptions of sexual availability of unmarried girls and women, poverty and conflict can exacerbate parents’ desire to have their girl married at a younger age (Raj, 2010; Raj et al., 2011). However, these social vulnerabilities as justification for early marriage of girls occur in the context of gender inequities and devaluing of women and girls (Raj, 2010); consequently, girl child marriage is more common in regions and families where there is lower access to education and employment opportunities for females relative to males, and higher rates of violence against women (Jain & Kurtz, 2007; Raj et al., 2011; UNICEF, 2007; Warner, 2004). Coinciding with these findings, extensive research documents that women and girls who marry as minors are more likely to have experienced gender-based abuse (e.g., forced marriage, restricted mobility, economic control) and violence, from their families of origin, their husbands and their in-laws (Bruce, 2003; Ertem & Kocturk, 2008; Gokce et al., 2007; Jain & Kurtz, 2007; Kishor & Johnson, 2004; Mehra & Agrawal, 2004; Mensch, 2003; Mikhail, 2002; Nour, 2006, 2009; Otoo-Oyortey, & Pob, 2003; Rahman & Kabir, 2005; Raj, 2010; Raj et al., 2009; Raj, Gomez, & Silverman, 2008; Raj, Lawrence, Saggurti, Donta, & Silverman, 2010; Santhya, 2004; Santhya & Jejeebhoy, 2003; UNFPA, 2005; UNICEF, 2007, 2009; World Health Organization [WHO], 2005; WHO & UNFPA, 2006). Across national contexts, it is consistently the poorest and least educated girls who are most vulnerable to early marriage and gender-based violence (see Jain & Kurtz, 2007; Raj, 2010; UNICEF, 2007, 2009 for reviews), and even among girls receiving an education, early marriage appears to impede continuation of that education (Lloyd & Mensch, 2008).

The Maternal and Child Health Consequences of Girl Child Marriage

Girl child marriage not only occurs among the most vulnerable girls, but it also compromises the health of this vulnerable population (Raj, 2010). Studies document that girls marrying as minors are more likely to bear children as minors and are thus at increased risk for maternal and child morbidities (e.g., delivery complications, fistula, low infant birth weight, malnutrition) and maternal and infant mortality (Raj, 2010). Early and inadequately spaced pregnancies among rural adolescent wives are critical drivers of poor maternal and child health (Gupta & Jain, 2008; IIPS, 2007; Jain & Kurtz, 2007; Mahavarkar, Madhu, & Mule, 2008; Mayor, 2004; Mehra & Agrawal, 2004; Raj et al., 2009; Santhya, 2004; Santhya & Jejeebhoy, 2007; Santhya, Jejeebhoy, & Ghosh, 2007; Smith & Pell, 2001; Stewart et al., 2007; UNFPA, 2005), and contraceptive use is least likely among adolescent wives (Raj, 2010). With such a norm, early and low spacing between pregnancies remains an issue for adolescent wives (IIPS, 2007; Raj, 2010) and compromises the health of these mothers and their offspring (Gupta & Jain, 2008; IIPS, 2007; Jain & Kurtz, 2007; Mahavarkar et al., 2008; Mayor, 2004; Mehra & Agrawal, 2004; Raj et al., 2009; Raj, Saggurti et al., 2010; Santhya, 2004; Santhya & Jejeebhoy, 2007; Santhya et al., 2007; Smith & Pell, 2001; Stewart et al., 2007; UNFPA, 2005). Research assessing direct associations between child marriage and HIV/STI are less available, but those that exist, limited to sub-Saharan Africa, do indicate significant associations between child marriage and HIV (Clark, 2004; Islugo-Abanihe, 2006; Nour, 2006, 2009).

Framework on Girl Child Marriage and Study Purpose

Based on the above overview, a framework was developed to guide our understanding of the social and gendered causes of girl child marriage and the health consequences of the practice, as highlighted in Figure 1 (figure previously published in Raj, 2010). Growing individual-level research confirms this framework and highlights that early marriage remains a risk factor for poor MCH even after controlling for sociodemographic vulnerabilities (Raj et al., 2009; Raj, Saggurti et al., 2010). However, cross-national analysis of this issue remains lacking. Review of those nations with high rates of child marriage reveal consistency with these findings at the national level; low-development and low-stability nations, particularly in South Asia and sub-Saharan Africa, report some of the highest rates of child marriage and poorest indicators of maternal and child health (MCH) in the world (United Nations Development Programme [UNDP], 2009; UNFPA, 2009; UNICEF, 2009). However, given that poor MCH indicators are more likely in low development and high conflict regions, it is possible that the associations between child marriage and poor MCH are simply an artifact of the low development and insecure context in which child marriage occurs. The purpose of this study is to assess whether nations with higher rates of girl child marriage are at increased risk for poorer MCH indicators and HIV. Such findings would offer support regarding whether reduction of child marriage should be more heavily targeted as a means of improving MCH across nations.

Figure 1.

Model of social vulnerabilities to girl child marriage and its health impact.

Method

Data from UNDP (2009), UNFPA (2009), and UNICEF (2009) were used to provide national-level data on rates of child marriage, development indicators, and MCH concerns including HIV. Data on child marriage were only available for 97 of 188 nations; 96 nations with child marriage data also had data on MCH outcomes allowing for a final sample size of n = 96 for MCH analyses. HIV data were only available for 79 of these 96 nations. Country representation was greatest in the regions known for child marriage concerns, including sub-Saharan Africa (n/n = 20/24 eastern and southern African nations and 20/26 middle and Western African nations were included) and South Asia (n/n = 6/9 South Asian nations). The following world regions were excluded due to lack of child marriage data: Oceania, North America, Northern Europe, and Western Europe; these regions are assumed to have very low rates of child marriage. (See Appendix A for details on countries included in the study, as indicated by *.)

UNICEF data (2009) were used for rates of girl child marriage. This was based on proportions of women aged 20 to 24 years who were married prior to age 18 years; data were collected at a national level at some point over the period of 1998 to 2007. UNFPA data (2009) were used for MCH outcome variables, which consisted of infant mortality (defined as total number of deaths to infants prior to their first birthday per 1,000 live births), maternal mortality (defined as total number of maternal deaths per 100,000 births), total fertility rate (defined as average number of children that would be born to a woman if reached life expectancy and experienced exact current age-specific fertility rates through her lifetime), percentage of births with a skilled birth attendant, and prevalence of modern contraceptive use. These data were collected or configured at a national level in 2009. UNFPA data (2009) were also used to identify national HIV prevalence rate (defined as percent of total population aged 15 to 49 years who are HIV infected). We dichotomized HIV prevalence into high or low HIV prevalence using a standard of 1% or greater high HIV prevalence, based on the WHO definition of this prevalence rate as indicative of a generalized epidemic (WHO, 2011).

As confounders we considered development indicators, a measure of conflict within a country, and world region. From UNDP data (2009), we derived the level of national development in the country (i.e., the human development index [HDI], categorized into very high development, high development, medium development, and low development), as well as gender differences in national development (i.e., gender-related development index [GDI], as indicated by life expectancies, adult literacy rates, education rates, and per capita income). HDI is a comparative measure of life expectancy, literacy, education, and standards of living for nations. GDI is designed to document the inequalities between men and women in the following areas: long and healthy life, knowledge, and a decent standard of living. (See the UNDP Human Development Reports for more details on HDI and GDI measurement.) GDI rankings are not categorized by UNDP; thus, for the purpose of this article we categorized these rankings based on quartiles in terms of their ranking within the world (not the subsample).

UNDP data (2009) were also used to obtain information on the number of internally displaced persons (IDPs) within a country; this indicator was used as a proxy for national or regional conflict (as defined by UNDP [2009]). Nations with any IDPs were identified as having conflict concerns. UNDP definitions of world region, also used by UNFPA (2009) and UNICEF (2009), were also used in analyses. To reduce the number of regions included in analyses, regions were categorized as (a) east and southern Africa (sub-Saharan Africa), (b) middle and west Africa, (c) north Africa, west Asia, and central Asia, (d) east and southeast Asia, (e) south Asia, (f) the Caribbean, Central America, and South America, (g) Oceania, (h) Europe, and (i) North America. (See Appendix A for more details on which countries are within which region.) Oceania and North America had no nations able to be included in analyses; no highest development nations (based on the HDI variable) were available for analyses either.

Data Analyses

Due to nonnormal distribution of the MCH outcome variables and our main independent variable, girl child marriage, we performed log transformations on these variables for use in regression analyses (Vittinghoff, Glidden, Shiboski, & McCulloch, 2005). We used univariate and chi square statistics to determine the distribution of our dependent and independent variables in the sample. We performed bivariate analyses of the independent and dependent variables prior to model building. Regression analyses adjusted for covariates were then used to assess associations between child marriage and each of our outcome variables. Linear regression analyses were conducted for all MCH outcomes and service utilization variables; logistic regression was used to assess the association between girl child marriage and the dichotomous HIV outcome variable.

To reduce risk for collinearity in multiple regression analyses, collinearity diagnostics were conducted prior to model building; covariates were required to maintain variance inflation factors (VIF) < 10 or tolerances > .2 across models (O’Brien, 2007). Collinearity was observed between HDI and GDI, as indicated by a tolerance <.2 as well as based on a correlation > .8. Because we had more complete data on HDI than GDI, HDI was retained for analyses. Categorical covariates (HDI and world region) were included in regression models as dummy variables. Given the large number of covariates and small sample size of this study, all regression analyses were conducted as a stepwise analysis, after first forcing in our independent variable, child marriage, to create more parsimonious models. Covariates were retained in final models if they had a p value < .1. Of note, the conflict variable was not significantly associated with any outcomes in this study in adjusted regression models, and thus, it was not retained in any final models.

Results

Girl child marriage as reported retrospectively by 20 to 24-year-old females ranged from 1% to 75% among the 97 nations assessed, with a mean of almost 27% (see Table 1). The most developed countries were not included in this sample, but almost 60% of the included countries were ranked as medium developed countries according to the HDI. In comparison, when focusing on the GDI, almost 40% of the included countries were ranked within the lowest quartile of Gender Development. The represented countries were mostly in various regions of Africa. Sixty-three percent of the countries of this sample are affected by conflict, as indicated by the presence of IDPs.

Table 1.

Level of Development, World Region, Conflict Characteristics and Rates of Girl Child Marriage in Nations Included in Sample (N = 94 nations).

Characteristic	Sample n(%) or Mean (SD)/Median [IQ]
Human development categorization
Very high human development	0
High human development	15 (15.5)
Medium human development	57 (58.8)
Low human development	22 (22.7)
Missing (Unranked)^a	3 (3.1)
Gender development categorization
1st (highest) quartile of gender development	0
2nd quartile of gender development	16 (16.5)
3rd quartile of gender development	31 (36.9)
4th (lowest) quartile of gender development	37 (38.1)
Missing (Unranked)^b	13 (13.4)
World region
East and Southern Africa*	20 (20.6)
Middle and West Africa*	20 (20.6)
North Africa and West Asia (middle east) and Central Asia	20 (20.6)
East and Southeast Asia	6 (6.2)
South Asia	6 (6.2)
Latin America, Caribbean, Central & South America	17 (17.5)
Europe	8 (8.2)
Conflict indication
No conflict	61 (62.9)
Conflict	36 (37.1)
Rate of girl child marriage	Mean (SD) = 26.7% (17.7)Median (IQR) = 24% (10-39)Range 1%-75%

Note. ^aIraq, Somalia and Zimbabwe were unranked on human development categorization due to poor data availability in these conflict-ridden areas.

Iraq, Somalia, Zimbabwe, Bosnia and Herzegovina, Serbia, Montengro, Egypt, Georgia, Haiti, Occupied Palestinian Territories, Turkmenistan, Ecuador, and Togo were unranked on gender development due to poor data availability on gendered indicators.

Regions constituting sub-Saharan Africa

Adjusted regression analyses documented that girl child marriage has significant positive associations with higher national rates of infant mortality, maternal mortality, and fertility (see Table 2). Adjusted analyses documented that higher infant mortality rates were also more likely in low rather than medium or high HDI countries (B ± SE = 25.55 ± 5.57), and less likely in the Caribbean, Central America, and South America (B ± SE = −35.40 ± 5.59), Europe (B ± SE = −41.92 ± 7.81), North and West Africa and Central Asia (B ± SE = −22.46 ± 5.76), and East and Southeast Asia (B ± –SE = −28.23 ± 8.20), relative to other assessed regions (e.g., sub-Saharan Africa, Middle and West Africa, and South Asia). Nations with higher maternal mortality rates were similarly more likely in low rather than medium or high HDI countries ( B ± SE = 189.52 ± 95.09) and in sub-Saharan African (B ± SE = 337.39 ± 82.37), Middle and West Africa (B ± SE = 500.72 ± 104.41), and South Asia (B ± SE = 298.60 ± 130.96). Higher fertility rates were additionally in low relative to medium and high HDI countries (B ± SE = .77 ±. 25) and in sub-Saharan African (B ± SE = 1.38 ± .33), Middle and West Africa (B ± SE = 1.17 ± .27), and North and West Africa (B ± SE = .49 ± .24) relative to other assessed regions.

Table 2.

Regression Analyses to Assess Associations Between Prevalence of Girl Child Marriage and Rates of Maternal and Child Health Concerns and Service Utilization (n = 96 nations).

	Infant mortality B ± SE	Maternal mortality^a B ± SE	Fertility rate B ± SE	Use Skilled birth attendantB ± SE	Modern contracep. useB ± SE	HIV rate^cOR (95% CI)
CRUDE
Child marriage	1.13 ± .15***	16.72 ± 2.01***	.06 ± .01***	−1.10 ± .11***	−.50 ± .11***	1.04 (1.01-1.07)***
ADJUSTED ^b
Child marriage	.29 ± .14**	6.93 ± 2.22**	.03 ± .01***	−1.01 ± .10***	−.15 ± .11	.99 (.94-1.03)
Adj R² (df)	.71(6,90)***	.62(5,88)***	.74(6,90)***	.54(3,93)***	.47(4,92)***	.Nagelkerke R² =.56***

Note. ^aDue to missing data, maternal mortality analyses included 93 nations.

Analyses adjusted for human development and world region dummy variables significantly associated with the outcome; findings noted in detail in results section of paper.

Logistic regression used for analyses. Due to missing data, HIV analyses included 79 nations.

p < .05. **p < .01. ***p < .001

Child marriage was associated with reduced rates of skilled birth attendant utilization, but it was not significantly associated with modern contraception in adjusted models (see Table 2). Skilled birth attendant utilization was also less likely in sub-Saharan African (B ± SE = −12.02 ± 4.44) and in South Asia (B ± SE = −19.74 ± 7.61) relative to other assessed regions. Contraceptive use was negatively associated with being a low relative to medium and high HDI nation (B ± SE = −10.73 ± 9.09) and with being located in Middle or West Africa (B ± SE = −16.64 ± 4.95) relative to other world regions; contraceptive use is significantly more likely in the Caribbean, Central America, and South America (B ± SE = 17.67 ± .4.34) than other assessed regions of this study.

These findings suggest that a 10% increase in child marriages in a country is associated with a 3% increase in a country’s infant mortality rate, a .3% increase in national fertility rate, and a 70% increase in their maternal mortality rate, as well as a 10% reduced likelihood of skilled birth attendant utilization (see Table 2). Further, the simultaneous assessment of the relationship of child marriage and the confounders with these maternal and child health outcomes, excluding use of contraception, explains between 54% and 74% of the variation in each maternal and child health outcome.

Also seen in Table 2, adjusted crude logistic regression analysis documents a significant association between girl child marriage and national HIV prevalence rate, but this association was lost in the adjusted analysis. Location in sub-Saharan Africa (AOR = 46.07, 95% CI = 7.33, 298.58) and Middle and West Africa (AOR = 41.36, 95% CI = 5.98, 285.86) rather than other assessed areas was significantly associated with higher national HIV rates.

Conclusion

Current findings document that nations with higher rates of girl child marriage are at increased risk for poor MCH concerns, including higher rates of infant and maternal mortality, higher fertility rates, and lower use of skilled birth attendants. These findings support previous global analyses documenting associations with girl child marriage and poor national MCH (Raj, 2010; UNICEF, 2005, 2007, 2009), but build upon these findings by documenting that such associations persist even after accounting for level of national development and world region. Findings are also consistent with other studies that demonstrate at the individual level that child marriage confers greater risk for women’s and children’s health, even after accounting for social and demographic vulnerabilities of women (Raj et al., 2011; Raj, Saggurti et al., 2010). Such findings support the likely utility of programs and policies eliminating, or at least strongly reducing, child marriage and adolescent childbirth as a means of improving national MCH (Raj, 2010). Such work would be particularly important in regions of Africa and South Asia disproportionately affected by both girl child marriage and poor MCH.

These study findings do not, however, document higher prevalence of HIV among nations more affected by girl child marriage, once accounting for world region and national development. Studies from sub-Saharan Africa have documented increased risk for HIV among married relative to unmarried minor adolescent females in Kenya, Zambia, and Nigeria (Clark, 2004; Islugo-Abanihe, 2006), while nationally representative data from India indicate no such association (Raj, 2010). Notably, data from sub-Saharan Africa and India do suggest similar sexual risks for adolescent wives across the two regions, including greater unprotected sex, less access to sexual health education, and greater difficulty in engaging in condom negotiation and sexual refusal among girls marrying at young age relative to unmarried adolescents or women who marry as adults (Clark, 2004; Clark, Bruce, & Dude, 2006; Moore, Singh, Ram, Remez, & Audam, 2009; Raj, 2010; Raj et al., 2011). These findings suggest that in the context of high HIV prevalence areas, girl child marriage is a salient risk factor warranting integration with existing HIV prevention efforts, though it may be less relevant to HIV in low prevalence areas. Clearly further research is needed to better understand the association between girl child marriage and HIV and how this association varies across nations. Those nations not currently maintaining HIV surveillance and affected by child marriage will be particularly important for future research on this issue.

While this study offers important insight into the associations between girl child marriage and poor health outcomes, there are several limitations that should be considered. This is an ecological study that epidemiologically describes the relationship between girl child marriage and MCH concerns, including HIV. All inferences are at the aggregate level, and not at the level of the individual, and these analyses do not demonstrate causation. Because ecological studies are more vulnerable to confounding, we have taken account of human development and world region. However, other confounders, in particular the GDI, could not be considered simultaneously due its collinearity with our human development variable. In addition, there is incomplete representation of nations and regions across the world; while this largely is restricted to areas known to have low rates of child marriage, lack of inclusion of these nations inhibits complete global understanding of the issue.

Other limitations are also of concern. Means of collecting data for the rates included by UNICEF and UNFPA are inconsistent across nations, and this may result in more accurate estimates for some nations relative to others. There are some concerns that investment in accurate assessment and reporting of health concerns, particularly for highly stigmatized issues such as HIV, does not consistently occur across countries. For example, a notable number of countries included in this study (n = 17/97) did not provide HIV data for analysis. Also, girl child marriage data are based solely on 20 to 24-year-old females, but no other variables were available that were consistent with this restricted age range, and the HIV prevalence data were not specific to females only. Consequently, indicators really are for the nation and not specific to gender or an age-range category. Finally, data were highly skewed across these diverse countries; child marriage and maternal and infant health outcomes were log transformed to help address this concern. Further study with a more complete, comprehensive and systematic data set is needed. Monitoring child marriage rates and consistent high quality data collection of our key health outcomes across nations would facilitate such future research.

Despite these limitations and the need for more research in this area, current findings do support previous research indicating that girl child marriage may confer increased risk for maternal and infant health concerns at a national level, and as such warrants greater attention as a public health and women’s health issue, as well as a human rights concern. These study findings suggest that a 10% reduction in girl child marriage could be associated with at 70% reduction in maternal mortality rates for a country. Currently, many nations (e.g., Yemen and Saudi Arabia) are contending with whether or not to alter policies allowing marriage of minor-aged girls, and enforcement of policies remains a concern in other countries (e.g., India, Nepal), where policies exist but are ignored. Policy and programmatic work to restrict and eliminate the practice may be effective means of improving national levels of maternal and child health.

Footnotes

Appendix

Appendix A

Regions of the World and Their Nations [Nations with “*” were included in the current analyses

SUB-SAHARAN AFRICA
EastERN and Southern Africa	MIDDLE AND WESTERN AFRICA
Eastern Africa	Middle Africa
Burundi*	Angola
Comoros	Cameroon*
Djibouti*	Central African Republic*
Eritrea*	Chad*
Ethiopia*	Congo*
Kenya*	Democratic Republic of the Congo
Madagascar*	Equatorial Guinea
Malawi*	Gabon*
Mauritius	Sao Tome and Principe
Mayotte	Western Africa
Mozambique*	Benin*
Réunion	Burkina Faso*
Rwanda*	Cape Verde
Seychelles	Cote d’Ivoire*
Somalia*	Gambia*
Uganda*	Ghana*
United Republic of Tanzania*	Guinea*
Zambia*	Guinea-Bissau*
Zimbabwe*	Liberia*
Southern Africa	Mali*
Botswana*	Mauritania*
Lesotho*	Niger*
Namibia*	Nigeria*
South Africa*	Saint Helena
Swaziland*	Senegal*
	Sierra Leone*
	Togo*

NORTHERN AFRICA AND CENTRAL AND WESTERN ASIA
Northern Africa	Western Asia
Algeria*	Armenia*
Egypt*	Azerbaijan*
Libyan Arab Jamahiriya	Bahrain
Morocco*	Cyprus
Sudan*	Georgia*
Tunisia*	Iraq*
Western Sahara	Israel
Central Asia	Jordan*
Kazakhstan*	Kuwait
Kyrgyzstan*	Lebanon*
Tajikistan*	Occupied Palestinian Territory*
Turkmenistan*	Oman
	Qatar

NORTHERN AFRICA AND CENTRAL AND WESTERN ASIA
Uzbekistan*	Saudi Arabia
	Syrian Arab Republic*
	Turkey*
	United Arab Emirates
	Yemen*

SOUTH ASIA
Afghanistan*	Iran (Islamic Republic of)
Bangladesh*	Maldives
Bhutan	Nepal*
India*	Pakistan*
	Sri Lanka*

EASTERN AND SOUTH-EASTERN ASIA
Eastern Asia	South-Eastern Asia
China	Brunei Darussalam
Hong Kong Special Administrative Region of China	Cambodia*
	Indonesia*
Macao Special Administrative Region of China	Lao People’s Democratic Republic
	Malaysia
Democratic People’s Republic of Korea	Myanmar
Japan	Philippines*
Mongolia*	Singapore
Republic of Korea	Thailand*
	Timor-Leste
	Viet Nam*

LATIN AMERICA AND THE CARIBBEAN
Caribbean	Central America
Anguilla	Belize
Antigua and Barbuda	Costa Rica
Aruba	El Salvador*
Bahamas	Guatemala*
Barbados	Honduras*
British Virgin Islands	Mexico*
Cayman Islands	Nicaragua*
Cuba	Panama
Dominica	\South America
Dominican Republic*	Argentina
Grenada	Bolivia (Plurinational State of)*
Guadeloupe	Brazil*
Haiti*	Chile
Jamaica*	Colombia*
Martinique	Ecuador*
Montserrat	Falkland Islands (Malvinas)
Netherlands Antilles	French Guiana
Puerto Rico	Guyana*
Saint-Barthélemy	Paraguay*
Saint Kitts and Nevis	Peru*

LATIN AMERICA AND THE CARIBBEAN
Saint Lucia	Suriname*
Saint Martin (French part)	Uruguay
Saint Vincent and the Grenadines	Venezuela (Bolivarian Republic of)
Trinidad and Tobago*
Turks and Caicos Islands
United States Virgin Islands

EUROPE
Northern Europe	Southern Europe	Eastern Europe
Åland Islands	Albania*	Belarus*
Channel Islands	Andorra	Bulgaria
Denmark	Bosnia and Herzegovina*	Czech Republic
Estonia	Croatia	Hungary
Faeroe Islands	Gibraltar	Poland
Finland	Greece	Republic of Moldova*
Guernsey	Holy See	Romania
Iceland	Italy	Russian Federation
Ireland	Malta	Slovakia
Isle of Man	Montenegro*	Ukraine*
Jersey	Portugal	Western Europe
Latvia	San Marino	Austria
Lithuania	Serbia*	Belgium
Norway	Slovenia	France
Svalbard and Jan Mayen Islands	Spain	Germany
Sweden	Macedonia (Yugoslav Rep)*	Liechtenstein
United Kingdom of Great Britain and Northern Ireland		Luxembourg
		Monaco
		Netherlands
		Switzerland

NORTH AMERICA
Bermuda	Saint Pierre and Miquelon
Canada	United States of America
Greenland

OCEANIA
Melanesia	Polynesia
Fiji	American Samoa
New Caledonia	Cook Islands
Papua New Guinea	French Polynesia
Solomon Islands	Niue
Vanuatu	Pitcairn
Micronesia	Samoa
Guam	Tokelau
Kiribati	Tonga
Marshall Islands	Tuvalu
Micronesia (Federated States of)	Wallis and Futuna Islands
Nauru	Oceania
Northern Mariana Islands	Australia and New Zealand
Palau	Australia
	New Zealand
	Norfolk Island

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Anita Raj, PhD, is a professor of medicine and global health at the University of California, San Diego, Department of Medicine, Division of Global Public Health. She has over 20 years of experience conducting research on sexual and reproductive health, HIV/STI, gender-based violence, and substance use. She is conducting research in North America, India, and Russia. Her research expertise focuses on the areas of qualitative and quantitative research to support development and testing of behavioral risk reduction interventions.

Ulrike Boehmer, PhD, is an associate professor of social and behavioral sciences at Boston University School of Public Health. Her research focuses on understanding the social and cultural aspects of health and illness. Most recently, she has examined the differences in quality of life and health-related decision-making within the context of gender, race, ethnicity, and sexuality.

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