Intersections between polyvictimisation and mental health among adolescents in five urban disadvantaged settings: the role of gender

Polyvictimisation (PV), or exposure to violence across multiple contexts, causes significant short- and long-term morbidity and even mortality among adolescents [1‐3]. Research interest has grown in understanding the impact of multiple exposures to violence across a range of contexts including within the family and community, and from intimate partners and peers [4, 5]. Globally, rates of exposure to PV in adolescents vary considerably. In high-income countries, for example, estimates of PV range from 10 to 93% [5‐10]. Rates of PV are generally higher in low- and middle-income countries (LMICs) [11], reaching almost 95% in one community-based sample in Cape Town, South Africa, for example [12].

A constellation of social vulnerabilities means that adolescents living in disadvantaged urban settings are at a particularly high risk for PV [12‐15], and there are often very few social and health resources to counter these vulnerabilities [15, 16]. Victims of PV are at a considerably higher risk for poor mental health, as well as emotional, behavioural and developmental problems compared with those exposed to violence in a single context [17‐19]. It has, however, not been clearly established whether the impact of PV on mental health varies by gender in these settings. The burden of PV and the associated mental health outcomes might be more profound for girls than boys, given high levels of sexual violence against females [4, 20]. Previously, we showed that adolescent women living in disadvantaged environments experienced a significant burden of gender-based violence and associated health consequences [15]. Equally however, boys may be impacted more by male-on-male physical violence. Studies that have explored differences in prevalence of PV by gender have inconsistent findings [4, 20], suggesting that variations in forms or combinations of violence may create different risk profiles, and that these may be further moderated by age, place of residence and a host of other factors. Multi-site studies, applying standardized survey and analytical methodology, can explore gender differences in detail, and overcome the present problems with generalising findings from studies of single populations. Conclusions that are generalizable are needed to guide broad recommendations for victimisation prevention and care initiatives in disadvantaged urban settings. These, in turn, can then be adapted for implementation in similar settings.

Against this backdrop, we have a unique opportunity to extend the literature by examining gender differences in the association between PV and mental health among adolescents in five economically-distressed urban settings, across three continents. Also, the prevalence of PV, each type of violence and mental health problems in the whole study population are described. This provides useful insights into how adolescents’ lived experiences vary in disadvantaged, urban settings across the world.

We primarily aimed to explore whether there are gender differences in the association between PV and mental health outcomes among urban disadvantaged adolescents in five cities. In this regard, we demonstrate that whilst past-year PV is remarkably common in adolescents in all five cities, affecting around three quarters of adolescents in four of the five cities, its effects on mental and physical health vary, and differ by gender. PV was strongly associated with negative perceptions of overall health for both boys and girls, but the effect sizes tended to be higher for boys than girls. By contrast, girls that experienced PV had an increased likelihood of suicidal thoughts, posttraumatic stress and depression, while for boys these associations were not significant in adjusted analyses. The point estimates of associations between PV and the mental health outcomes were lower among the boys and not significant aside from depression. We also illustrated clearly that city of residence is an important determinant of all associations studied, even independent of whether boys or girls experienced victimisation.

Most previous studies involved data from one site only and report on single types of victimisation, making it difficult to compare our results to those of others. Where differences are observed between studies, these may also be accounted for by variations in the definition of exposure and outcomes. Nevertheless, our findings are broadly consistent with that of an Italian study among university students, which concluded that PV was associated with a high risk of depression, panic attacks, heavy alcohol use, eating problems, suicidal ideation and attempts, and a negative perception of overall health [4]. Other studies in high-income countries [20] and LMICs [17] have also found that adolescent girls who experienced violence were at a higher risk for depression than their male counterparts.

Somewhat unexpectedly, in quite a few instances, boys carried an equal burden of violence and mental illness as girls. This reinforces the importance of overcoming the challenges of reaching men with health services, starting with adolescent boys. Notably, rates of some outcomes among boys escalate rapidly with age.

Addressing the burden of mental illness in adolescents would require site-specific, innovative interventions that are able to take account of the diverse forms of gendered behaviours in different settings. This seems unlikely to occur in the near future, as access to mental health services is dismal for each of the conditions measured and in all sites. With a few exceptions, none of the affected adolescents, whether male or female, are currently receiving treatment. Even if services were available, stigma, especially prevalent among boys, would remain a major obstacle to treatment [31]. Stigma leads to secrecy and avoidance of treatment, and initiatives to counter stigma have met with little success to date [32]. Moreover, as noted in a systematic review, adolescents across the world commonly hold uninformed, negative views of mental health services and professionals, and may believe that accessing such services is a ‘sign of weakness’ [33]. However, adolescents, especially adolescent boys are proficient in the use of mobile technologies and this has the potential to improve uptake and accessibility of mental health interventions [34].

Regarding city of residence, boys and girls in Johannesburg had higher ORs than Baltimore for almost all indices assessed. In other words, something about living in Johannesburg – other than PV, gender and being disadvantaged – is responsible for the poor mental and physical health in this city. The high levels of PV in Johannesburg is perhaps not surprising given that South Africa is one of the most violent countries in the world [35]. Living in Delhi, by contrast, appears to be protective against PV and mental illness, though girls in Delhi reported alarming levels of physical violence in the home and from peers. Equally, physical violence from intimate partners affected a quarter to a third of girls in Baltimore, Ibadan and Johannesburg. Variations in violence by gender might partly be explained by differences in gender inequality across sites. Based on the UNDP Gender Inequality Index [36], inequality is highest in Delhi of the cities included in the study, potentially explaining the high levels of family violence among girls in the city. Gender inequalities are also high in Johannesburg, again correlating with high rates of violence among girls and boys in that area. By contrast, in Shanghai, which has the lowest levels of victimisation in the study, inequalities are lowest of the five cities according to the UNDP Index.

Several limitations and strengths of this study should be noted. The cross-sectional design limits the ability to draw causal inferences about the associations detected. We also lack data on the intensity of the individual elements of violence assessed, which implies that severe repeated family violence, for example, would still be counted only as one form of violence. The relatively large samples drawn from five cities across three continents are a strength of the study and increase the validity of the study’s assertions. Longitudinal studies could more fully unravel the immediate, underlying and environmental factors that account for PV and its impacts, and identify different patterns of PV and its effects over the life course. Additionally, qualitative analyses could deepen our understanding of how victimisation is experienced by adolescents in different settings [37], and how they develop coping strategies in response.

In conclusion, this study sheds some light on the role of gender in the intersections between PV and mental health among adolescents in five urban disadvantaged settings. The results show that PV is associated with the mental health outcomes for girls, and poor self-rated health and depression for the boys. Girls who have experienced PV require specific targeting with services that address posttraumatic stress and depression. Overall, the findings highlight the dire need for interventions that reduce violence exposure and improve safety in these settings. For instance, there is evidence from Uganda, which shows the potential to reduce violence by focussing on social mobilisation [38]. It is also possible to modify violence outcomes within programmatic time frames when interventions are delivered at a structural level [39]. mHealth interventions for adolescents show much promise, such as the rapidly expanding Circle of Six smartphone application which addresses gender-based violence [27]. Historically, intervention systems address specific forms of violence in general - for example, IPV support, family violence support etc., but rarely consider the overlap between these [16].

This study highlights the need to shift this approach to one which understands and addresses the interacting compounding impacts of violence exposure across multiple contexts. Moreover, high levels of PV indicate that current preventive efforts are poorly, if at all, effective, and the effects of this are magnified by the absence of treatment for the mental health consequences thereof. This highlights the critical importance of identifying new funding for interventions to prevent victimisation across multiple contexts and to mitigate its short- and long-term consequences among adolescents of both sexes in these settings.