Elsevier

Social Science & Medicine

Volume 104, March 2014, Pages 124-132
Social Science & Medicine

Adolescents' perceptions of health from disadvantaged urban communities: Findings from the WAVE study

https://doi.org/10.1016/j.socscimed.2013.12.012Get rights and content

Highlights

  • Provides a unique focus on adolescents living in poor urban communities.

  • Compares the top health concerns and perceived related factors cross-culturally.

  • Argues for a new focus on the physical and social environments to address adolescent health.

  • Describes the overall lack of health care seeking among adolescents across study sites.

Abstract

The Well-being of Adolescents in Vulnerable Environments (WAVE) is a global study of young people living in disadvantaged urban communities from Baltimore, MD, Johannesburg, South Africa, Shanghai, China, New Delhi, India and Ibadan, Nigeria. WAVE was launched in the summer of 2011 to: 1) explore adolescents' perceived health and their top health challenges; and 2) describe the factors that adolescents perceive to be related to their health and health care utilization. Researchers in each site conducted in-depth interviews among adolescents; community mapping and focus groups among adolescents; a Photovoice methodology, in which adolescents were trained in photography and took photos of the meaning of ‘health’ in their communities; and key informant interviews among adults who work with young people. A total 529 participants from across the sites were included in the analysis. Findings from the study showed that gender played a large role with regards to what adolescents considered as their top health challenges. Among females, sexual and reproductive health problems were primary health challenges, whereas among males, tobacco, drug, and alcohol consumption was of highest concern, which often resulted into acts of violence. Personal safety was also a top concern among males and females from Baltimore and Johannesburg, and among females in New Delhi and Ibadan. Factors perceived to influence health the most were the physical environment, which was characterized by inadequate sanitation and over-crowded buildings, and the social environment, which varied in influence by gender and site. Regardless of the study site, adolescents did not consider physical health as a top priority and very few felt the need to seek health care services. This study highlights the need to focus on underlying structural and social factors for promoting health and well-being among adolescents in disadvantaged urban environments.

Introduction

Adolescents between the ages of 10 and 19 account for 18% of the world's population-representing the largest population of adolescents ever in human history (UNICEF, 2011). Of those, over 86% live in low to middle income countries (United Nations, 2011). Behaviors that adolescents adopt during this life stage have critical implications for their future health, well-being, and mortality.

Transformations in the world, which include changes in the global economy, education, and technology are altering societies in every region, and in turn, are reshaping the contexts of adolescents' lives. Demographic shifts that have had and will continue to have a substantial impact include cross-national and rural to urban migration. In 1960, two thirds of the world's population lived in rural areas; by 2030, 60% will live in cities (United Nations, 2012). Not only have cities witnessed a rapid growth, but a disproportionate number of those migrating to urban areas are youth between the ages of 16 and 24 years (United Nations, 2012). Most of this growth is occurring in low to middle income countries, with the most rapid pace of growth expected to occur in Sub-Saharan Africa and Asia (Vlahov et al., 2007).

Although it was widely believed that urban residents in low and middle income countries benefited from an ‘urban health advantage’ with regards to better access to care and nutrition (Garenne, 2010), there is growing sentiment that economic stagnation has now resulted in an ‘urban penalty’, where those living in urban areas are worse off than their rural counterparts with regards to health, schooling, and access to health and related facilities (Potts, 1997). In the United States, urban poverty has been linked to a number of sexual risk behaviors among adolescents, including lower age of first sex, less contraceptive use, and more sexual partners (Brewster, 1994, Browning et al., 2005). This is supported by findings in Sub-Saharan Africa, which have found the urban poor in Nairobi, Dar-es-Salaam, Harare, and Kampala to have riskier sexual behavior compared to their non-urban counterparts with regards to earlier sexual debut, lower condom usage, and more multiple partners (Dodoo et al., 2007, Greif et al., 2011, Zulu et al., 2011). Beyond sexual behaviors, there have been other studies that document elevated levels of infant and child mortality, as well as higher levels of childhood stunting in urban areas compared to rural areas of low to middle-income countries (Dye, 2008, Mathews et al., 2010). While the majority of these studies suggest that the burden of disease is greater in cities than in nonurban areas, it is important to point out that it is not a consistent observation across all cities and diseases (Galea and Vlahov, 2005, Vlahov and Galea, 2002). Instead, what seems to be most important is an understanding of the main factors within the urban environment that contribute to residents' health and health care utilization. For example, in a review of studies conducted in the United States, Leventhal and Brooks-Gunn (2000) found that low socio-economic status and residential instability, characteristics common to those who live in distressed urban locations, were negatively associated with emotional and behavioral outcomes for adolescents and children. Surprisingly, however, in contexts outside of the United States and Europe, there is limited information about how factors within a disadvantaged urban environment contribute to the health and well-being of adolescents.

To help broaden our understanding of the health of young people living in disadvantaged urban environments, the Well-being of Adolescents in Vulnerable Environments (WAVE) was launched in the summer of 2011 to: 1) explore adolescents' perceived health and their top health challenges; 2) describe the factors within their urban communities which were perceived to be related to their health and health seeking behaviors. The study was conducted in five urban sites across the globe to gain a cross-cultural perspective about how adolescent health and health seeking behaviors may differ across cities. The WAVE study is the first of its kind to focus on very disadvantaged urban adolescents and their health globally. While there has been substantial research conducted among more accessible adolescents (e.g., those in school or stably housed), to date, there is limited data available on young people who do not necessarily go to school or live in a typical home environment – characteristics common to those living in distressed urban locations.

Section snippets

Research design

The WAVE study is implemented by a collaboration of university-based and non-government institute researchers from five cities: Baltimore, USA, Johannesburg, South Africa, Shanghai, China, New Delhi, India and Ibadan, Nigeria. The choice of these cities was largely influenced by existing research relationships between the research team but in addition they represent major urban areas with sizable economically disadvantaged populations. For each city, the local research team selected a specific

How do adolescents perceive their health and what are their health concerns?

One of the first questions asked to adolescents in each site was the perceived importance of their health. Notably, across sites and gender, physical health was not a top priority, and as a consequence, seeking health care services was rare. That said, adolescents still had concerns about health, and interestingly, these concerns varied along gender lines and in the ways they ‘manifested’ across sites. For example, sexual and reproductive health problems were perceived as the primary health

Discussion

The WAVE study was conducted to explore how adolescents in disadvantaged communities around the world perceive their health, and the factors that contribute to their health and health-seeking behaviors. While their general state of health didn't seem to be a top priority for either males or females, adolescents across sites voiced specific health concerns along gender lines: sexual and reproductive health problems for girls, and tobacco and substance use for males. Unexpectedly, the lack of

Acknowledgments

The Well-Being of Adolescents in Vulnerable Environments (WAVE) Study is part of the Young Health Programme, a partnership between AstraZeneca, Johns Hopkins Bloomberg School of Public Health and Plan International, a leading global children's charity. The two-phase study is taking place in Baltimore (USA), Shanghai (China), Johannesburg (South Africa), New Delhi (India), and Ibadan (Nigeria). The study in Ibadan is funded by the Bill and Melinda Gates Institute at Johns Hopkins Bloomberg

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