The data analyzed are from a larger cross-sectional study conducted in Malawi among pregnant and parenting adolescents in rural and urban settings of Blantyre, a district in the country’s southern region to understand their lived experiences. We collected data between March and May 2021 when the status of the COVID-19 pandemic at the time was severe and the government through Malawi’s Ministry of Health was enforcing strict preventive measures.
Sampling: We applied a two-stage cluster random sampling approach. The first stage was a random selection of 66 rural (26) and urban (40) enumeration areas (EAs) from the Primary Sampling Frame (PSF) developed by the Malawi National Statistical Office (NSO). EAs in Malawi are stratified as urban and rural. The second stage of sampling was done through a household listing exercise within the EAs to isolate all households with pregnant and parenting adolescent girls. Demographics of household members were listed, such as age, sex, relationship to the household head. This exercise produced an updated list of households for all selected EAs where the now sampled households represented the total population. Study participants were eligible if they had ever been pregnant (irrespective of the outcome of the pregnancy), were currently pregnant or ever had a biological child (irrespective of whether the child was alive or dead) regardless of their marital status. Through this process, we identified 679 pregnant and parenting adolescent girls but interviewed 669 girls because ten declined to participate in the study or had relocated when we returned to their homes for questionnaire interview. Reasons for refusual included reluctance to participate because prior surveys had not benefited them, fear of repercussions for being in child marriage and misunderstandings that our survey was a COVID-19 vaccination drive. Additionally, of the 669 interviewed, three failed to complete the mental health scale and were excluded from the analysis for this paper. This sample size is sufficient to generate 80% statistical power using the following parameters: in 2015, 29% of adolescent girls in Malawi had begun childbearing[18]; adolescent fertility in the base population is 0.136 in Malawi; a design effect of 1.5, a relative margin of error (RME) of 0.0325; average household of 5 members in Malawi, and 5% possible incomplete responses.
Procedures: Well-trained and experienced research assistants conducted the interviews in the participants’ homes. Interviews were conducted in Chichewa using a standardized questionnaire that we developed for probing girls on if they had experienced more or less of any 9 symptoms of depression during the COVID-19 pandemic. Specifically, the symptoms we probed on included worry, fear, restlessness, frustration, anxiety, stress, and boredom. The research assistants collected data electronically on Android tablet programmed using SurveyCTO. The collected data were synchronized daily to the secured APHRC server and later transferred to Stata version 15 cleaning and processing. First, we conducted a pilot study to more accurately contextualize the questionnaire. This was very useful for translating mental health symptoms into the local language which is Chichewa.
Ethical considerations: This study was approved by the University of Malawi Research Ethics Committee (UNIMAREC) in addition to APHRC’s internal review committee approval. Written informed parental/guardian consent and adolescent assent for those aged less than 18 years were obtained prior to conducting the interviews. Married adolescents are considered emancipated minors in Malawi and therefore provided their own written informed consent to participate in this study. All interviews were conducted in spaces providing auditory privacy and all data were de-identified prior to analysis.
Variables and measurements
Dependent variable: The main dependent variable, mental distress, was assessed using nine symptoms. Shigemura et.al. [2] describes mental distress as some mental health reactions that include fear, anger, and insomnia. In this study, girls were asked if during the COVID-19 pandemic they had experienced more or less of the following nine symptoms: worry, restlessness, anxiety, sadness, loneliness, frustration, fear, stress or boredom. These questions were translated to the local Malawian language, Chichewa, and tested in a pilot survey to ensure PPAs understood their meaning. This ensured that girls could uniformly respond to these questions without losing their intended meanings. Responses were given on a 5-point scale: much less, somewhat less, same, somewhat more, and much more. Those reporting somewhat more and much more were considered to have experienced mental distress during the pandemic.
Independent variables: covariate selection was informed by previous studies suggesting that factors associated with mental distress among young people operate at individual, household, and community levels. At the individual level, we included age, marital status, ever worked for pay, location (rural and urban), orphanhood, parent support, friends support, part of a social group, support from the father’s child, living with both parents and depression as predictor variables. Age was coded as 13-16, 17, 18, and 19. Marital status was categorized as single, married, and separated or divorced while employment was defined as working for pay.
We included four household-related factors: living with both parents, whether parents are alive or dead, parental support, and partner support. Parent and partner support was explained to the girls to mean both material and non-material provisioning, including child care. Participants reported whether they were living with their fathers and mothers and coded responses as living with both parents or not. Parental survival was coded as both parents alive, one parent dead, and both dead. Participants rated the support they receive from their parents, including material and financial support, as good, fair, poor or no support.
We considered two community-level factors: location (categorized as urban or rural) and neighborhood safety. The definition of neighborhood safety in this study is having relationship resources to draw from in the community like friends or adult mentors that girls could turn to if they had serious problems. Neighborhood safety was measured using seven questions related to the feeling of safety when taking a walk around the community during the day and night, feeling scared of the possibility of being raped, touched indecently, robbed, and teased in the past six months. Higher scores indicate higher community safety.
Analytical approach
We analyzed data using the statistics software Stata version 15 by running descriptive statistics, including mean, frequencies and percentages for variables of interest. Sampling weight was applied to correct for oversampling in rural areas and to ensure the findings represent Blantyre. To examine the association between nine mental distress symptoms during the COVID-19 pandemic and the sociodemographic, family and neighborhood factors, we ran two logistic regression models. The first model was an unadjusted logistic regression model to estimate the independent association between each co-variate and nine mental distress symptoms. The second model was an adjusted logistic regression to ascertain the main predictors of nine mental distress symptoms among girls during the COVID-19 pandemic. We considered a p-value of less than 0.05 statistically significant.