Background
Methods
Research design
Survey measures
Social factors
Social factor indicator | Component items |
---|---|
Adult social support | |
Caring male adult at home | There is a male presently in your home who: |
- expects you to follow the rules. | |
- believes that you will be successful. | |
- you can turn to when you have a problem. | |
- listens to you when you have something to say. 12
| |
Caring female at home | There is a male presently in your home who: |
- expects you to follow the rules. | |
- believes that you will be successful. | |
- you can turn to when you have a problem. | |
- listens to you when you have something to say. | |
Caring adult at school | Has there been a teacher or some other adult in your school who |
- really cared about you. | |
- told you when you do a good job. | |
- noticed when you were not there. | |
- always wanted you to do your best. | |
- listened to you when you had something to say. | |
- who believed that you would be successful. | |
Responses: Never True (0) Sometimes True (1) Often True (2) Always True (3); Range: 0-12 | |
Peer social support | |
Social support | I have at least one friend: |
- that I can trust. | |
- who would lend me money if I needed it. | |
- I can talk to about family problems or real personal problems. | |
- that I find it easy to talk to about sex. | |
- I would turn to if I were in trouble. | |
- who accepts me for who I really am. | |
Response Options: Agree a lot (0) Agree a little (1) Disagree a little (2) | |
Disagree a lot (3); Range: 0-18 | |
Neighborhood social factors | |
Sense of belonging | - I feel connected to most people in this neighborhood. |
- I know most of the people in this neighborhood. | |
- I feel like I am part of a community in this neighborhood. | |
Response Options: Agree a lot (0) Agree a little (1) Disagree a little (2) Disagree a lot (3); Range: 0-18 | |
Perceived fear | How afraid are you: |
- of being attacked or robbed when you are out with other people in your neighborhood at night? | |
- of being attacked or robbed when you are out alone in your neighborhood at night? | |
- when you are on the street in your neighborhood during the day? | |
- in your neighborhood when you are on your way to school or work? | |
- when you are at school or work? | |
- when you are at home in your house or apartment? | |
Response Options: Not at all (0) A little (1) Somewhat (2) Very fearful (3); Range 0–18 | |
Witnessing community violence | In the past 12 months, how often: |
- did you hear guns being shot in your neighborhood? | |
- did you see somebody get arrested in your neighborhood? | |
- did you see drug deals in your neighborhood? | |
- did you see gangs in your neighborhood? | |
- did you see someone being beaten up in your neighborhood? | |
- was your house broken into? | |
- did you see somebody in your neighborhood pull a gun, knife, or other weapon on another person? | |
- did you see someone get killed in your neighborhood? | |
Response Options: Never (0) – Once or more (1); Range 0–8 |
Health care seeking
Demographics
Baltimore W % (U %, N) | Delhi W % (U %, N) | Ibadan W % (U %, N) | J’burg W % (U %, N) | Shanghai W % (U %, N) | |
---|---|---|---|---|---|
N
| 456 | 500 | 449 | 496 | 438 |
Sex | |||||
Male | 46.4 (57.7, 263) | 52.8 (50.0, 250) | 45.2 (49.0, 200) | 56.7 (54.8, 272) | 48.0 (50.7, 222) |
Female | 53.6 (42.3, 193) | 47.2 (50.0,250) | 54.8 (51.0, 229) | 43.3 (45.2, 224) | 52.0 (49.3, 216) |
Age group | |||||
15–16 | 43.0 (55.3,252) | 47.5 (56.8, 284) | 49.4 (59.5,267) | 50.6 (24.8,123) | 41.9 (29.0,127) |
17–19 | 57.0 (44.7, 204) | 52.5 (43.2, 216) | 50.6 (40.5,182) | 49.4 (75.2, 373) | 58.1 (71.0, 311) |
Mean Age (SE) | W 16.8 (0.2) | 16.6 (0.1) | 16.6 (0.1) | 16.6 (0.2) | 16.9 (0.2) |
U 16.3 (0.1) | 16.4 (0.1) | 16.4 (0.1) | 17.3 (0.1) | 17.3 (0.1) | |
School enrollment | |||||
Enrolled | 81.0 (85.3, 388) | 82.7 (85.6, 428) | 81.4 (81.3, 364) | 84.3 (82.2, 406) | 37.2 (28.5, 125) |
Not Enrolled | 19.0 (14.7, 67) | 17.3 (14.4, 72) | 18.6 (18.7, 84) | 15.7 (17.8, 88) | 62.8 (71.5, 313) |
Graduated of Not Enrolled | 66.6 (70, 47) | 42.5 (41.7, 30) | 68.0 (69, 58) | 42.9 (36.4, 32) | 30.1 (31.3, 98) |
Raised by | |||||
Two Parents | 48.2 (45.3, 206) | 94.7 (94.6, 473) | 72.8 (71.6, 320) | 54.7 (54.55,270) | 83.1 (82.9, 363) |
One Parent | 27.7 (23.1,105) | 1.31 (1.4, 7) | 7.4 (7.4, 33) | 9.7 (9.7, 48) | 1.8 (1.8, 8) |
Other Relative or Non-Relatives | 24.2 (31.2, 142) | 4.0 (4.0, 20) | 19.8 (18.6, 83) | 35.6 (35.6, 176) | 15.1 (15.1, 66) |
Analysis
Baltimore Female W % (U %, N) Male W % (U %, N) | New Delhi Female W % (U %, N) Male W % (U %, N) | Ibadan Female W % (U %, N) Male W % (U %, N) | Johannesburg Female W % (U %, N) Male W % (U %, N) | Shanghai Female W % (U %, N) Male W % (U %, N) | |
---|---|---|---|---|---|
Female (n) Male (n) | 188 251 | 250 250 | 222 213 | 224 272 | 215 220 |
Contact with a health care provider in the last 12 months *** | 83.0 (78.2, 147)** 64.8 (65.9, 164)** | 51.5 (51.0, 127)** 63.9 (62.7, 156)** | 36.5 (37.8, 84) 43.9 (44.6, 95) | 63.0 (64.7, 145) 61.7 (58.8, 160) | 42.5 (45.1, 87) 33.5 (36.4, 80) |
Been sick or needed a health care provider *** | 53.7 (51.1, 96)* 37.0 (39.8, 100)* | 46.5 (50.0, 125)* 61.0 (60.8, 152)* | 35.9 (38.0, 84)* 37.9 (37.1, 79)* | 59.0 (61.6, 138)* 40.9 (44.1, 120)* | 36.2 (37.4, 80)** 22.6 (22.7, 50)** |
Reasons for Seeking Care in the last 12 months (among those who report being sick or needing a health care provider) | |||||
Female (n) Male (n) | 97 96 | 124 147 | 89 82 | 138 119 | 79 49 |
Sickness (e.g. flu, fever, diarrhea, etc.) | 60.4 (51.6, 50) 63.3 (43.8, 42) | 65.6 (67.0, 83) 71.2 (68.0, 100) | 48.5 (52.8, 47) 48.4 (51.2, 42) | 74.9 (75.4, 104)*** 48.1 (53.9, 64)*** | 85.3 (91.1, 72) 78.2 (77.6, 38) |
Annual physical/sports check-up | 26.5 (25.8, 25)** 14.5 (21.9, 21)** | 12.5 (12.1, 15) 14.4 (16.3, 24) | 7.0 (6.7, 6) 13.2 (11.0, 9) | 4.7 (3.6, 5) 5.8 (8.4, 10) | 15.9 (13.9, 11) 11.9 (14.3, 7) |
Chronic disease issue (diabetes, asthma, etc.) | 10.0 (5.2, 5)*** 2.3 (5.2, 5)*** | 9.0 (8.9, 11) 4.0 (2.7, 4) | 1.7 (2.3, 2) 1.4 (1.2, 1) | 8.1 (9.4, 13) 7.4 (4.2, 5) | 1.6 (2.5, 2) 5.6 (4.1, 2) |
Reproductive health (contraceptives/condoms, pregnancy testing, etc.) | 4.7 (6.2, 6)** 0.1 (1.0, 1)** | 1.6 (0.8, 1) 2.0 (1.4, 2) | 0 (0, 0) 4.6 (2.4, 2) | 10.0 (6.5, 9)*** 1.0 (1.7, 2)*** | 1.0 (1.3, 1)*** 5.0 (2.0, 1)*** |
HIV testing or treatment | 2.9 (2.1, 2) 0 (0, 0) | 0 (0, 0) 2.0 (1.4, 2) | 0 (0, 0) 1.2 (1.2, 1) | 1.2 (2.9, 4)*** 8.2 (7.6, 9)*** | 0 (0, 0)* 5.0 (2.0, 1)* |
STI diagnosis or treatment | 4.6 (3.1, 3) 2.9 (1.0, 1) | 2.7 (2.4, 3)** 0.2 (0.7, 1)** | 3.9 (3.4, 3) 5.5 (3.7, 3) | 1.7 (2.9, 4)*** 4.7 (4.2, 5)*** | 0 (0, 0) 0 (0, 0) |
Mental health (counseling, diagnosis, treatment) *** | 5.7 (7.2, 7) 3.2 (4.2, 4) | 3.1 (3.2, 4) 2.8 (2.0, 3) | 0 (0, 0) 1.9 (1.2, 1) | 0.5 (1.5, 2) 0.5 (0.8, 1) | 1.7 (2.5, 2)** 9.3 (6.1, 3)** |
Injury, accident or violence *** | 8.0 (10.3, 10) 8.1 (8.3, 8) | 18.4 (21.0, 26) 12.9 (15.0, 22) | 3.4 (5.6, 5) 6.8 (7.3, 6) | 4.5 (4.4, 6)* 12.5 (10.1, 12)* | 10.7 (6.3, 5) 14.1 (10.2, 5) |
Alcohol or substance use *** | 0.7 (1.0, 1) 0.7 (1.0, 1) | 1.6 (1.6, 2) 1.3 (1.4, 2) | 1.1 (1.1, 1)** 0.3 (1.2, 1)** | 1.3 (1.5, 2)* 7.3 (7.6, 9)* | 4.8 (5.1, 4)* 12.2 (4.1, 2)* |
Other *** | 9.4 (19.6, 19) 15.7 (22.9, 22) | 16.9 (16.1, 20) 9.6 (9.5, 14) | 12.2 (11.2, 10) 10.5 (13.4, 11) | 6.4 (10.9, 15) 6.5 (6.7, 8) | 16.1 (13.9, 11) 20.0 (24.5, 12) |
None *** | 5.2 (7.2, 7)*** 10.3 (16.7, 16)*** | 11.4 (10.5, 13) 9.8 (8.2, 12) | 20.0 (18.0, 16) 13.5 (12.2, 10) | 1.7 (2.9, 4)*** 8.6 (6.7, 8)*** | 0 (0, 0) 2.2 (4.1, 2) |
Baltimore Female W % (U %, N) Male W % (U %, N) | New Delhi Female W % (U %, N) Male W % (U %, N) | Ibadan Female W % (U %, N) Male W % (U %, N) | Johannesburg Female W % (U %, N) Male W % (U %, N) | Shanghai Female W % (U %, N) Male W % (U %, N) | |
---|---|---|---|---|---|
Female (n) Male (n) | 188 248 | 125 148 | 219 214 | 224 271 | 79 50 |
Needed but did not seek health care in the last 12 months*** | 23.4 (23.4, 44) 23.4 (25, 62) | 17.3 (18.4, 23) 22.2 (25.0, 37) | 9.9 (11.0, 24)** 18.6 (22.0, 47)** | 31.6 (33.5, 75) 37.8 (35.8, 97) | 20.1 (22.8, 18) 23.7 (22, 11) |
Reasons for Not Seeking Care in the last 12 months (among those who needed but did not seek health care) | |||||
Female (n) Male (n) | 43 62 | 23 37 | 29 47 | 74 97 | 18 11 |
Location | 16.5 (11.6, 5)** 5.4 (11.3, 7)** | 31.0 (34.8, 8) 47.9 (35.1, 13) | 1.9 (3.5, 1) 9.4 (12.8, 6) | 12.1 (10.8, 8) 12.2 (14.4, 14) | 5.5 (11.1, 2)* 0 (0, 0)* |
Distance | 12.1 (11.6, 5) 17.1 (11.3, 7) | 27.9 (21.7, 5) 16.2 (13.5, 5) | 7.8 (6.9, 3) 0 (0, 0) | 14.6 (9.5, 7) 10.8 (9.3, 9) | 22.8 (33.3, 6) 0 (0, 0) |
Fees/payment | 11.5 (14.0, 6) 6.5 (8.1, 5) | 14.1 (30.4, 7) 13.1 (16.2, 6) | 14.6 (13.8, 4) 12.7 (14.9, 7) | 10.2 (13.5, 10) 10.3 (13.4, 13) | 37.7 (27.8, 5) 7.7 (18.2, 2) |
Service hours | 5.1 (2.3, 1) 5.3 (6.5, 4) | 13.2 (13.0, 3) 4.0 (2.7, 1) | 0 (0, 0) 11.3 (8.5, 4) | 9.6 (8.1, 6)*** 4.2 (7.2, 7)*** | 9.0 (16.7, 3) 11.1 (18.2, 2) |
Waiting time | 22.0 (16.3, 7)* 12.6 (12.9, 8)* | 25.2 (30.4, 7) 10.7 (8.1, 3) | 10.5 (6.9, 2) 19.3 (12.8, 6) | 16.3 (20.3, 15)* 11.4 (15.5, 15)* | 40.9 (27.8, 5) 35.8 (36.4, 4) |
Staff attitude | 9.5 (4.7, 2) 0.9 (1.6, 1) | 8.3 (8.7, 2) 0 (0, 0) | 0 (0, 0) 5.1 (4.3, 2) | 9.9 (13.5, 10) 5.9 (10.3, 10) | 22.0 (5.6, 1) 27.3 (18.2, 2) |
Lack of confidentiality | 0.6 (2.3, 1)* 1.9 (1.6, 1)* | 7.5 (4.4, 1) 1.0 (2.7, 1) | 1.8 (3.5, 1) 1.2 (2.13, 1) | 19.3 (13.5, 19)** 6.9 (10.3, 10)** | 3.5 (5.6, 1) 13.1 (18.2, 2) |
Health problems were connected to illegal activities | 3.0 (2.3, 1)* 1.2 (3.2, 2)* | 16.4 (21.7, 5)** 3.8 (5.4, 2)** | 5.8 (10.3, 3) 18.1 (12.8, 6) | 14.6 (5.4, 4)** 2.7 (2.1, 2)** | 0 (0, 0) 18.1 (9.1, 1) |
Other | 33.4 (44.2, 19) 46.8 (45.2, 28) | 26.4 (17.4, 4) 35.9 (37.8, 14) | 17.8 (20.7, 6) 20.4 (27.7, 13) | 9.9 (14.9, 11) 16.3 (22.7, 22) | 66.6 (50.0, 9) 45.9 (36.4, 4) |
Baltimore | Ibadan | Johannesburg | |
---|---|---|---|
aOR (aCIs) | aOR (aCIs) | aOR (aCIs) | |
n = 415 |
n = 363 |
n = 462 | |
Social Factors | |||
Adult support from female | .87 (.77, .97)* | .98 (.91, 1.06) | .96 (.94, 1.00) |
Adult support from male | .99 (.96, 1.03) | 1.00 (.91, 1.09) | .95 (.91, 1.00)* |
Peer social support | .92 (.84, 1.00) | 1.02 (.89, 1.17) | .98 (.94, 1.01) |
Perceived fear | 1.08 (1.01, 1.15)* | 1.04 (.97, 1.11) | 1.07 (1.03, 1.11)** |
Community Social belonging | 1.04 (.88, 1.23) | .90 (.72, 1.12) | 1.10 (1.01, 1.19)* |
Witnessing Community Violence | 1.06 (1.02, 1.09)** | 1.07 (1.01, 1.13)* | 1.08 (1.05, 1.12)*** |
Results
Demographics
Health seeking and reasons for seeking care
Barriers for seeking health care services
Factors that influence health care seeking: findings from qualitative phase
Lack of trust
They just told me that I have an STI but never treated me and they referred me to the general hospital
I: What happened?
I just stayed home (Laughing)! They shouted at me (IDI, female adolescent, Johannesburg)
I actually think that birth control messes us up. I think they need to stop pushing birth control so hard because it’s messing up our insides. I think it’s on purpose, though. My cousin, she’s on birth control right now and she won’t stop bleeding. She keeps going to the doctors telling them what’s going on and they say it’s normal. I think they need to stop pushing it so hard. OK, you don’t want a high rate of population, but it’s messing up our insides. It really is. (IDI female adolescent, Baltimore)
I remember one case – the girl that got raped, fortunately she got home and told her mother.... she was treated as if – oh you went out and did something and now you are lying that you got raped”. “. Her mother called me and I got involved and took her to UCH but the way she was handled, I got appalled to myself. (Key Informant, Ibadan)
Embarrassment and stigma
Unfortunately there are stigmas associated with that. To talk with a counselor or a psychologist or psychiatrist means that you are crazy. … And as such you are seen as vulnerable. Being seen as vulnerable on the street, especially if you’re someone who has to be on the streets, is not good because being seen as vulnerable could make the difference between life and death for you. (Key informant, Baltimore)
There are services provided, but for migrants, they are afraid of losing faces, so they don’t want to go into the neighborhood health committee {the local health center} for consulting. (Photovoice, male discussion, Shanghai)
I don’t like doctors touching me period. It’s uncomfortable. Because I don’t know whether I want a male doctor or a female doctor. You don’t want a female doctor because she might be gay.
Most youth feel that each time they go to a provider they will be judged or they would know the health care provider – and then they’d feel guilty that they have this health problem. Around the health care provider, they’d feel too young to have this health problem…. Actually, so many youth will not come out to tell a health care provider that they have been raped or anything as they believe they would only get trouble from the provider (Key informant, Ibadan)
And some think, that everyone who is HIV positive has it because they have been sleeping around -- but most of the children or these young people they are perinatal infected…(Key informant, Johannesburg)
Lack of support from parents
Because I’m only 15, I can’t make any of my own appointments. For my OB doctor, I can do that myself because I’m old enough, I guess…. But other doctors, no. (female adolescent, Baltimore)
One of the things about us men – is that we don’t like to go to the doctor. That’s bad because that cycle is passed down to our children, be it a boy or a girl. They may feel that they don’t want to go to the doctor, but I think it has something to do with that.
Multivariate analysis of social and neighborhood factors on health care seeking
Discussion
The father assumes a crucial role in problem solving and protection of the family by exercising a moderating influence on family interactions with the external world. He is expected to be the first person to be consulted or informed of any trouble or major change in a child’s life. (p. 4).