Being Poor Is Not the Same Everywhere

Of five cities studied, researchers find worse health outcomes in Johannesburg and Baltimore, better ones in Nigerian city of Ibadan

Young people growing up in impoverished neighborhoods who perceive their poor communities in a positive light report better health and well-being than those with worse perceptions of where they live, new research led by the Johns Hopkins Bloomberg School of Public Health suggests.

As part of the Well-Being of Adolescents in Vulnerable Environments (WAVE) study, researchers surveyed nearly 2,400 adolescents ages 15 to 19 in poor sections of five cities across the world: Baltimore; New Delhi, India; Ibadan, Nigeria; Johannesburg, South Africa; and Shanghai, China. The survey was conducted in 2013.

In each neighborhood, the researchers found that teens are vulnerable to health challenges from dirty and crowded physical environments, few education or job opportunities, frequent encounters with violence, crime and drugs, and limited health services. But the researchers discovered stark differences in how the adolescents perceived their surroundings, finding – for the most part – that those with more positive perceptions had better health outcomes.

The findings are described in five reports that make up a special supplement to the December issue of Journal of Adolescent Health. The work was done in conjunction with researchers from the Population Council in New Delhi, the Shanghai Institute of Planned Parenthood Research, the University of Ibadan/University College Hospital and the Witwatersrand Reproductive and HIV Institute in Johannesburg.

“Being poor is not the same everywhere, and a lot of it has to do with how adolescents perceive their communities,” says one of the study leaders, Kristin Mmari, DrPH, an assistant professor in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health. “For young people living in poverty, residing in a high-income country seems to matter far less than the immediate surroundings in which they develop and grow.”

Mmari says that teens in each city were told to photograph their surroundings. Teens in Ibadan took photographs of heaps of garbage on the streets of their neighborhoods and rated their communities very high, while Baltimore teens took similar pictures and rated their communities very low.

The differences were striking in many ways. Despite residing in one of the world’s richest nations per capita, the researchers found that teens in Baltimore face high rates of mental health problems, substance use, early age of first sexual experience and pregnancy, and sexual violence. Contrast that with adolescents in New Delhi, India, a city in a significantly less prosperous nation, where the teens report little depression, cigarette smoking, pregnancy or sexual violence.

Among the five sites, the worst health outcomes were found in Baltimore and Johannesburg, where teens gave their communities very poor scores in terms of physical environment and violence. In these two sites, young people spoke of the lack of a support system and absentee parents. A significant number of young people also told researchers there was nowhere they felt safe, whether in their homes or outside.

While Baltimore and Johannesburg appeared to be the most toxic, adolescents in the other cities also had elevated levels of mental health problems and substance use relative to the general population.

The concern is that toxic environments – no matter where they are found – compromise adolescent health and well-being in the short-term, and can predispose young people to conditions that predict long-term health troubles and shortened life spans.

“Young people who grow up in economically impoverished communities live with persistent fear, an increased sense of vulnerability and more environmental distress,” says Robert Blum, MD, chair of the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, who wrote an editorial accompanying the studies and is co-principal investigator of the WAVE study. “These, in turn, set the stage for lifelong chronic health problems. Our research shows us that place and health are inexorably intertwined.”

Across the sites, boys reported tobacco, drug and alcohol use to be their primary health concern, while girls identified sexual vulnerability.

Pregnancy did not appear to be an issue in Ibadan, New Delhi and Shanghai, where sexual encounters were reported to be relatively rare. But among girls who were sexually experienced, in Baltimore more than 50 percent had been pregnant as had 29 percent of the girls in Johannesburg.

Also, more than 25 percent of the adolescent girls in Baltimore, Ibadan and Johannesburg who had ever had partners reported experiencing intimate partner violence in the previous year and more than 10 percent of the adolescent girls in Baltimore and Johannesburg reported sexual violence committed by someone other than a partner in the previous year.

These findings are important, Blum says, because no longer are infectious diseases the major killers of young people. Today, six of the top 10 causes of death among young people aged 10 to 24 are road traffic accidents, self-inflicted injury, interpersonal violence, drowning, fire and war, with the seventh, HIV, highly influenced by behavior and social contexts. Also, half of adult disease has its precursors in childhood and adolescence: smoking and other substance use, obesity, lack of exercise, stress and social adversity.

The research in the supplement was supported by Young Health Programme, a partnership between AstraZeneca, the Johns Hopkins Bloomberg School of Public Health and Plan International, a global children’s charity. In Ibadan, the study was funded by the Bill and Melinda Gates Institute for Population and Reproductive Health at the Bloomberg School through its funding to the Centre for Population and Reproductive Health, University of Ibadan.

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Media contacts for the Johns Hopkins Bloomberg School of Public Health: Stephanie Desmon at 410-955-7619 or sdesmon1@jhu.edu and Barbara Benham at 410-614-6029 or bbenham1@jhu.edu.