Comparison of Mental Health Status of Married and Unmarried Girls of Late Adolescent Age in an Urban Slum of Delhi.

INTRODUCTION: Late adolescence age (16-19 years) is organized around central task of achieving an identity. In India, age at marriage for girls has been legally declared as 18 years, but many girls are married much before this age. Early marriage for girls can have profound psychological and emotional impacts. AIMS AND
OBJECTIVES: The aim was to study the impact of marriage on mental health of married girls of late adolescent age and to compare them with unmarried girls of the same age.
MATERIALS AND METHODS: A comparison study was conducted among girls of late adolescent age in an urban slum of North East Delhi. Background information was collected through oral questionnaire method. The mental health of the study participants was assessed using validated tool "General Health Questionnaire-12" and "Symptom Checklist-90."
RESULTS: Education and economic status of participants and parents were significantly associated with early marriage. Majority of married girls were found to be associated with risk of developing mental health disorders. Copyright:

INTRODUCTION

“Adolescence” literally means “to emerge” or “to attain identity.”[1] The WHO defines adolescence as the age between 10 and 19 years marked by special attributes such as rapid physical growth, development and social and psychological maturity. It is also marked by experimentation with physical, sexual changes and transition from total socioeconomic dependence to relative independence.[23] According to the Indian census 2011 report, adolescents contribute 20.9% of total population.[4] Late adolescence between 16 and 19 years is marked by various physical, mental, and social changes.[567]

The legal age of marriage for girls in India is 18 years, but many girls are married much before this age.[8] According to NFHS-4, more than one-fourth (27%) of women aged 20–49 years were married before the age of 15 years and more than half (58%) were married before 18 years.[9] Reasons such as poverty, customs, threat of kidnapping, and old beliefs could be behind this social evil.[10]

Early marriage is associated with bad mental health and well-being, particularly for women who marry at very young ages. It can have a significant impact on women's psychological well-being, even after accounting for other factors that might affect mental health such as household wealth and experiences of intimate partner violence.[11]

Little evidence from low- and middle-income countries already suggests a negative association between early marriage and mental health outcomes. There is a need of exploration of whether and how early marriage in girls is associated with their mental health and psychological well-being. Evidence on mental well-being of married and unmarried adolescent girls from India is virtually nonexistent. Hence, this study was conducted with an objective to compare the married and unmarried girls in terms of their mental health and to study various factors associated with it.

MATERIALS AND METHODS

A comparison study was conducted in an urban slum of North East Delhi in which married and unmarried girls of late adolescent age were compared. Pregnant married girls were excluded from the study.

Taking the prevalence of depression as 16.3% among females in a large urban South Indian population – the Chennai Urban Rural Epidemiology Study-70, and taking the prevalence of depression as 24.9% among ever-married women from rural Thiruvananthapuram,[1213] using Epi Info calculator version 7, the calculated sample size was 692. However, due to limited number, all married and unmarried girls of late adolescent age group were included; thus, the total sample size of the study was taken as 320, 160 for married and 160 for unmarried girls.

Background information was collected using a predesigned, pretested anonymous questionnaire. Informed written consent form was taken from each participant. A previously validated and standardized survey instrument, “General Health Questionnaire (GHQ)-12” and “Symptom Checklist (SCL)-90,” was used to assess mental health. GHQ-12 is a quick, reliable, and sensitive questionnaire making it ideal for research studies.[131415] The presence of three or more symptoms is suggestive of the presence of a mental disorder such as anxiety or depression. The presence of four or more is highly suggestive of mental health disorders.

The SCL-90 is a psychiatric self-report inventory designed primarily to reflect the psychological symptom patterns of psychiatric and medical patients. Each item of the questionnaire is rated by the patient on a five-point scale of distress from 0 (none) to 4 (extreme).[16] SCL-90 consists of the following nine primary symptom dimensions and three global indices of distress.

The study was approved by the institutional ethical committee. All the married girls of the defined age group were included due to limited number. The unmarried girls of the same defined age group close to the married girls in the same block were included. Both the groups were age and religion matched. Statistical analysis was performed using Data was analysed using SPSS Version 23.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics, Chi-square test, and odds ratio with 95% confidence interval were calculated; P < 0.05 was considered statistically significant.

RESULTS

In this study, 320 girls in late adolescent age were participants, of which 160 were married and 160 were unmarried. Among married girls, 41.9% were between age group 18 and 19 years, whereas 41.9% of unmarried girls were 17–18 years. 63.8% of married girls had studied up to middle school, whereas 58.1% of unmarried girls had completed at least high school. The sociodemographic profile of the study participants is shown in Table 1.

Table 1

Distribution of sociodemographic variables among study participants

Characteristic	Married girls (%)	Unmarried girls (%)	P, χ2, df
Education of study participants
Illiterate	58 (36.2)	6 (3.8)	0.000*, 140.23, 2
Middle	102 (63.8)	61 (38.1)
High school and above	0 (0)	93 (58.1)
Occupation
Unemployed	160 (100)	153 (95.63)	0.028*, 7.157, 2
Employed	0 (0)	7 (4.37)
Socioeconomic status
Lower class	72 (45)	27 (16.9)	0.000*, 37.385,2 df
Upper lower	88 (55)	119 (74.4)
Lower middle	0 (0)	14 (8.8)
Father education
Illiterate	144 (90)	38 (23.8)	0.000*, 135.75, 2
Middle	10 (6.2)	96 (60)
High school and above	6 (3.8)	26 (16.2)
Mother education
Illiterate	150 (93.8)	85 (53.1)	0.000*, 20.96, 2
Middle	10 (6.2)	69 (43.1)
High school and above	0 (0)	6 (3.8)
Father occupation
Unemployed	28 (17.5)	2 (1.2)	0.000*, 85.01, 5
Unskilled	32 (20)	48 (30)
Semi-skilled	50 (31.2)	5 (3.1)
Skilled	25 (15.6)	65 (40.6)
Shop owner	25 (15.6)	38 (23.8)
Semi-professional	0 (0)	2 (1.2)
Mother occupation
Unemployed	160 (100)	137 (85.63)	0.000 *, 20.94, 1
Employed	0 (0)	23 (14.37)

As seen in Table 1, majority of married girls, i.e., about 102 (63.8%), have studied up to middle school, whereas 93 (58.1%) of unmarried girls have completed at least high school. One hundred and forty-four (90%) fathers of married girls were illiterate, whereas 122 (76.2%) fathers of unmarried girls had received education up to middle class. One hundred and fifty (93.8%) mothers of unmarried girls were illiterate, whereas 85 (53.1%) mothers of unmarried girls were illiterate. 51.2% of fathers of married girls were engaged in some unskilled or semi-skilled work, but majority of fathers of unmarried girls about 63.8% were either shop owner or doing some skilled work.

When asked about various reasons that can be lead to early their marriage, majority of married girls (58.10%) pointed out financial problem as the main reason followed by family custom, found good match, and parents being afraid that girls will have premarital sex.

The mental health status of adolescent girls was studied based on their responses to the GHQ-12. In the present study, all (100%) married girls reported 3 or more symptoms suggestive of having risk of developing mental health problems, whereas only 33.1% of unmarried girls were at risk of having common mental illness. 26.25% of unmarried girls were having GHQ-12 score more or equal to 4 which indicates most probable cases of metal disorders, but in married girls, this percentage was 85.62%.

In the present study, among the 160 married girls, the most common symptoms of mental illnesses reported were lost sleep over worry in the month preceding the interview (79.4%). 78.1% do not feel reasonably happy, 71.9% were not able to concentrate on what they were doing, 61.3% felt incapable of taking their own decisions, and 58.1% had lost confidence in themselves. Among unmarried girls, 88.10% were feeling unhappy and depressed, 81.9% felt under strain, 68.1% felt that they could not overcome their difficulties and reported not being able to concentrate on what they were doing, and 76.9% were reasonably happy, as shown in Table 2.

Table 2

General Health Questionnaire-12 comparing married and unmarried girls

General Health Questionnaire-12	Married	Unmarried
	Yes, n (%)	Yes, n (%)
1. Are you able to concentrate on what you are doing	115 (71.9)	142 (88.8)
2. Lost sleep over worry	127 (79.4)	45 (28.1)
3. Can you take decisions	62 (38.8)	103 (64.4)
4. Do you feel you are under strain	82 (51.2)	131 (81.9)
5. Can you face up to your problems	82 (51.2)	24 (15)
6. Can you overcome your difficulties	75 (46.9)	51 (31.9)
7. Do you enjoy day to day activities	79 (49.4)	131 (81.9)
8. Have you been feeling unhappy and depressed	49 (30.6)	141 (88.1)
9. Have you been losing confidence in yourself	93 (58.1)	44 (27.5)
10. Do you feel you are not playing a useful role	71 (44.4)	27 (16.9)
11. Do you feel you are worthless	66 (41.2)	12 (7.5)
12. Do you feel reasonably happy	35 (21.9)	123 (76.9)
Total	160 (100)	160 (100)

Two-tailed t-tests indicated that all scale scores in SCL-90 scale of the married girls were significantly higher than those of unmarried girls. Anxiety, phobic anxiety, depression, interpersonal sensitivity, hostility, and psychoticism were significantly higher in married girls. SCL-90 analysis revealed that there was a significant difference among cases and controls in case of depression, psychoticism, hostility, phobic anxiety, anxiety, and interpersonal sensitivity, as shown in Table 3. Global indices which included global severity, positive symptom distress, and positive symptom of the married girls were also higher than those of unmarried girls.

Table 3

Symptom Checklist-90 subscales comparing married and unmarried girls

Dimensions	Groups (n=160)	Mean (SD)	t	P
Somatization	Married girls	1.575 (0.088)	1.070	0.296
	Unmarried girls	1.385 (0.152)
Depression	Married Girls	1.611 (0.283)	1.990	0.05*
	Unmarried girls	1.440 (0.603)
Obsessive compulsive	Married girls	1.6110 (0.283)	1.054	0.306
	Unmarried girls	1.409 (0.535)
Psychoticism	Married girls	1.769 (0.295)	3.338	0.004*
	Unmarried girls	1.355 (0.257)
Hostility	Married girls	1.720 (0.137)	2.236	0.042*
	Unmarried girls	1.325 (0.392)
Paranoid ideation	Married girls	1.705 (0.343)	1.033	0.326
	Unmarried girls	1.473 (0.428)
Phobic anxiety	Married girls	1.621 (0.234)	9.962	0.000*
	Unmarried girls	0.414 (0.218)
Anxiety	Married girls	1.682 (0.221)	5.737	0.000*
	Unmarried girls	0.655 (0.521)
Interpersonal sensitivity	Married girls	1.771 (0.281)	3.267	0.005*
	Unmarried girls	0.831 (0.817)

*P≤0.05 significant. SD: Standard deviation

DISCUSSION

The study was conducted among the married and unmarried girls of late adolescent age in an urban slum of Delhi. The study showed that the mean age of marriage in married girls was 17 years, whereas the mean age of husband at marriage was 21.6 years. Similar findings have been reported in baseline survey for social and financial empowerment of adolescents by Bhatacharjee and Narayan where more than two-third of married adolescent girls got married before the age of 18 years.[17]

It was observed that among married girls, 85% were either illiterate or educated up to primary class, but among controls, 79.4% were educated up to middle school or high school with the difference in literacy being statistically significant. As per the Indian census 2011, the percentage of girls who were educated less than primary level and married below 18 years of age was 34.5%. The percentage of married women who were educated either up to primary or middle school was 30.9% and 25.4%, respectively.[4] The data indicate that the early marriage of the girls takes away the opportunity from them to pursue education.

It was seen that 93.8% of mothers of married girls were illiterate, whereas 53.1% of mothers of unmarried girls were illiterate. Similarly, 90% of cases had illiterate fathers, whereas only 23.8% of unmarried girls had illiterate fathers, the association between education of both parents and marriage being statistically significant. A similar study on married adolescent girls from Bangladesh reported that more than half (52.5%) of the fathers were illiterate and about four-fifths (77.8%) of the mothers were illiterate;[18] educated parents have a positive impact of delaying early marriage in girls.

17.5% of married girls had unemployed fathers, whereas only 1.2% of unmarried girls were unemployed. As employment can be related to the financial conditions of the families, so if parents are not financially good, a young girl may be regarded as an economic burden. This can be seen as a practice common in some Middle Eastern and South Asian societies where this is regarded as a family survival strategy.[9]

Mental health was assessed using GHQ-12 and SCL-90. On comparing the mental health profile using GHQ-12, it was observed that all married girls (100%) reported 3 or more symptoms suggestive of mental health problems, whereas only 33.1% of unmarried girls were at risk of having common mental illness. 26.25% of unmarried girls were having GHQ-12 score more or equal to 4 which indicates most probable cases of mental disorders, but in married girls, this percentage is 85.62%. On applying SCL-90 scale, two-tailed t-tests indicated that all scale scores were significantly higher in married girls than those of unmarried girls. Srinath et al. (2005) noted significantly higher depression among adolescents 12–16 years.[19] Other studies have shown that nearly 30% of adolescents show symptoms of anxiety.[20]

In the present study, among the 160 married girls, the most common symptoms of mental illnesses reported were lost sleep over worry in the month preceding the interview (79.4%). 78.1% do not feel reasonably happy, 71.9% were not able to concentrate on what they were doing, 61.3% felt incapable of taking their own decisions, and 58.1% had lost confidence in themselves. This can be compared to the findings of the Youth In India study (IIPS 2010), over 10% of young women (15–24 year old) reported losing sleep due to worry, 15.1% felt incapable of making decisions, 9% felt constantly under strain, 11.1% felt that they could not overcome their difficulties, 10.3% were unable to face up to their problems, 8.5% had been feeling unhappy and depressed, 5% had lost confidence in themselves, 4% were thinking of themselves as worthless, and 5% were not feeling reasonably happy.[21] Srinath et al. (2005) reported a high prevalence of psychiatric morbidity and depression in 10–14 years' age group.[19]

Exposure to new environment at home, stress, in-law expectations, struggle for self-identity, and role differentiation are stressful, thus precipitating mental health problems. Marriages of girls at the adolescent age make them more vulnerable to challenges which are increasingly unrecognized and nondocumented affecting their mental health.

CONCLUSION

The challenges faced by adolescents are increasingly recognized and documented. However, there has to be concerted effort on the part of the government to address the needs of young people through programs and policies directed specifically at them.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.