Dr. Robert W. Blum presentation from Youth Voices: The role of youth-adult dialogue in improving health outcomes for young people.

1. Social Contexts and NCDs among
Adolescents: lessons from The WAVE
Study

2. Background
Young Health Programme: A
collaboration among JHBSPH, Plan
International and AstraZeneca designed to
help young people in need around the world
deal with the health issues they face so they
can improve their chances of living a better
life
• Plan International is the programatic leader
• Hopkins was the thought leader
2

3. WAVE : Study Aims
• Describe the health challenges of teens in very
vulnerable communities within 5 cities:
Baltimore, Ibadan, Johannesburg, New
Delhi, Shanghai
• Examine factors across sites influencing health,
including physical and social environment,
• Link findings with the adolescent precursors of
adult NCDs
3

5. Target Population
Youth ages 15-19 in very low-income
urban neighborhoods:
–youth in and out of school
–youth in households and unstably
housed/ homeless
–Shanghai site: only included migrant
youth
5

6. Phases of the Study
Phase 1: Qualitative examination of the
perspectives of youth and
knowledgeable adults
Field Period: 2011-2012
Phase 2: Respondent Driven Sample Survey
to test results and themes emerging
from the qualitative phase
Field Period 2013
6

7. NCDs
Are they really lifestyle
conditions?

8. Phases of the Study
Phase 1: Qualitative examination of the
perspectives of youth and
knowledgeable adults.
Mmari, et al. (2014). Adolescents’ Perceptions of
Health from Disadvantaged Urban Communities:
Findings from the WAVE Study
8

9. Data Collection at each site: collecting data with
adolescents
• Photovoice to document health issues (n=10)
• Community mapping activity to document perspectives of
resources in community (8 groups)
• Focus groups to identify shared views of needs and resources
(8 groups)
• In-depth interviews to obtain their personal perspectives and
experiences (n=20)

10. The Social Environment
Matters for Health
 In Baltimore and Johannesburg, the social
environment was limited and characterized
as adolescents growing up without parents
or parental/adult guidance
 In Shanghai, it depended on the type of
migrant group status
 In Delhi and Ibadan, it depended more on
gender

11. In order to have an healthy community you have to have neighbors who
are willing to do something about it.
By: Brittany McAdams

12. What are the top health concerns among
adolescents?
Across sites, there was a general consensus:
• For adolescent girls: sexual and reproductive
health problems are prominent
• For adolescent boys: tobacco, drug and
alcohol consumption was a huge problem, which
further led to violence
– In Shanghai, smoking was the biggest
problem among boys; whereas in the other
sites, drugs and alcohol were more prevalent

13. Drugs, alcohol, and Violence a
central health issue for youth
 “You see alcohol everywhere. When you go by the corner,
there is a tavern, and when you turn, there is a tavern.
When you turn around, there is someone selling dagga
(marijuana) and you would think they are selling sweets
and samba chips.” (IDI Johannesburg male adolescent,)
 “Here, young people consume too much of intoxicants.
There is one child of 8-9 years old and he smokes cigarettes
and eats Gutkha because he stays with big youngsters, and
his parents don’t pay any attention to him.. Here, there are
many children of that kind here.” (Key informant interview,
Delhi)

14. Phases of the Study
Phase 2: Respondent Driven Sample Survey
to test results and themes emerging
from the qualitative phase
Field Period 2013
Over 500 young people participated
in Phase 2 in each of the 5 sites.
14

15. Journal of Adolescent Health, December
2014
Decker, et al. (2014). Respondent-driven sampling to reach
adolescents in vulnerable environments in five urban cities globally.
Marshall, et al. (2014). Social capital and vulnerable youth in five
global cities.
Mmari, et al. (2014). A global study on the influence of neighbourhood
contextual factors on adolescent health.
Brahmbhatt, et al. (2014). Prevalence and determinants of teenage
pregnancies in urban, disadvantaged settings across five cities.
Decker, et al. (2014). Prevalence and health impact of intimate
partner violence and non-partner sexual violence among female
adolescents aged 15-19 years
Olumide, et al. (2014). Predictors of substance use among vulnerable
adolescents in five cities: findings from the well-being of adolescents
in vulnerable environments study.
Cheng, et al. (2014). The association between social support and
mental health among vulnerable adolescents in five cities

16. A Glimpse at three outcomes
•Mental Health
•Substance Use and Abuse
•Intimate Partner violence and Sexual
Abuse

17. Mental Health concerns are significant
• In Johannesburg prevalence of depression, and PTSD,
suicidal thoughts and plans were highest:
Male (%) Female (%)
Depression 41.1 44.6
PTSD 54.5 67.0
Suicidal thoughts 32.6 39.6
Suicidal plans 19.9 25

18. Mental Health concerns are significant
• Adolescent suicide attempts in the last
12 months were highest in Ibadan
(18.3% males, 14.3% females).
• BUT… Ibadan also had the highest rates
of optimism for males and females while
Shanghai had the lowest.

19. Factors that reduced mental health risk
• Males were less buffered by protective factors than
were females
• For females a caring adult female in the home, a
caring adult male and/or connections to community
moderated depression as well as suicide attempts.
• None of the identified protective factors moderated
PTSD.
• Connection to neighborhood was most strongly
associated with positive mental health in all sites
except for females in Baltimore.

20. Location
Ever use of
at least
one
substance
(%*)
Type of Substances Ever Used
Alcohol
(%*)
Cigarette
(%*)
Chew
Tobacco
(%*)
Marijuana
(%*)
Inhalant
(%*)
Injection drugs(%*)
Baltimore 73.2 52.3 33.9 3.0 54.9 3.8 2.8
Delhi 33.0 6.7 9.1 9.2 2.0 15.2 2.2
Ibadan 53.8 25.1 5.9 10.7 6.3 7.4 --
Johannesburg 77.4 68.7 43.9 6.2 25.1 8.4 1.4
Shanghai 71.9 68.9 37.0 2.6 0.1 1.5 0.4
All Sites 62.0 44.6 26.2 6.4 17.9 7.3 1.7
Substance Use Among Adolescents in the
Five Cities

21. Substance Use begins early
•First alcohol use: 14.0 to 14.5 years
•First cigarette use: 13 to 14.9 years

22. Factors associated with Cigarette Use
• Male +
• School enrolment –
• Employment +
• Peers + (in Baltimore but not all sites).

23. Social Context and substance use is related
• Delhi
Witnessing Violence (p<.01)
• Johannesburg
Witnessing Violence (p<.01)
Perceived fear (p<.001)
• Shanghai
Perceived lack of personal safety (p<.001)

24. Health, NCDs Precursors and Intimate
Partner Violence (IPV) in Baltimore
AOR=1.8
(1.0, 3.4)
AOR=0.6
(0.2, 1.9)
AOR=3.0
(2.0, 4.6)
11%
41%
33%
39%
50%
14%
19%
10%
44%
29%
0%
10%
20%
30%
40%
50%
60%
Past-month binge
drinking
Multiple sex
partners, past year
Anal intercourse,
ever
Condom non-use
at last sex
Positive
depression screen
(CES-D)
IPV-exposed IPV-unexposed
AOR=1.3
(0.6, 2.9)
AOR=2.8
(1.4, 5.7)

25. Health, NCDs and IPV in
Johannesburg
AOR=1.7
(0.7, 4.1)
AOR=0.9
(0.5, 1.5)
AOR=1.8
(1.1, 3.0)
22%
41%
45%
43%
54%
16% 16%
25% 26%
44%
0%
10%
20%
30%
40%
50%
60%
Past-month binge
drinking
Multiple sex
partners, past
year
Ever pregnant Condom non-use
at last sex
Positive
depression screen
(CES-D)
SA-exposed SA-unexposed
AOR=4.4
(2.5, 7.5)
AOR=2.8
(1.1, 7.0)

26. Adolescent Precursors to Adult
NCDs
• Unsanitary living conditions
• Poverty
• High stress families
• High stress communities
• Interpersonal violence
• Lack of adult supervision
• Cigatette smoking/tobacco use
• Substance use
• Unprotected sexual intercourse
• Poor nutrition

27. Conclusions and Implications
Young people who grow up in impoverished communities live
with persistent fear, increased sense of vulnerability, less social
capital, more environmental distress which in turn predispose
to:
• more chronic mental health disorders,
• more cigarette smoking,
• more precocious sexual behavior with less protection
against HIV, STIs and pregnancy, hypertension
• less social capital
• less social cohesion
• less parental engagement

28. Key messages from the WAVE Study
• Behaviors that predispose to NCDs are
increased in low income, distressed
communities
• The environments in which young
people grow up influence males and
females differently
• Addressing solely the behavioral
precursors to NCDs and not the social
contexts that are the breeding ground
is unlikely to have great impact.

29. NCD Prevention: It’s not Rocket Science… it may
be tougher: Recommendations from WAVE the
YHP
• Policies matter: advertising, taxation, drinking
laws, driving laws
• School programs matter: Health promoting
schools, mental health promoting schools, Physical
activity requirements, healthy eating, life-skills training
• Clinical services and brief interventions
matter: alcohol, tobacco, contraceptive behavior
• Families matter: parent supports, clear behavioral
expectations, parental monitoring
• Media matter: normative images, advertising, video
games, social media, news reporting.

30. Collaborating Organizations
• Shanghai Institute of Planned Parenthood Research
(China)
• Wits Reproductive Health and HIV Institute (South
Africa)
• Population Council (India)
• Center for Population and Reproductive Health,
University College Hospital (Nigeria)
• Department of Population, Family and Reproductive
Health, Johns Hopkins
30

31. Special Acknowledgements
• Freya Sonenstein PhD, Professor, Study
PI
• Michele Decker PhD, Associate
Professor
• Kristin Mmari, DrPH, Assistant Professor
• Beth Marshall, DrPH, Assistant Scientist
• Henna Brahmbhatt, PhD Associate
Professor