title: A mixed methods study to examine the influence of the neighborhood social context on adolescent health service utilization.
abstract: While adolescents' access and utilization of health services is critical for ensuring their health, very few seek care, and if they do, it is primarily from family members, friends, or other non-formal sources of care. Examining the influence of the social context on adolescent health care seeking behaviors may provide us with a better understanding for how interventions can increase adolescents' utilization of formal health care services.
  
  
  
  The study is based on qualitative and quantitative data collected as part of the Well Being of Adolescents in Vulnerable Environments (WAVE) study, one of the first global studies to focus on very disadvantaged urban adolescents (aged 15-19 years) across five diverse sites, which include: Baltimore (USA), Ibadan (Nigeria), Johannesburg (South Africa), New Delhi (India), and Shanghai (China). Qualitative data was based on numerous methodologies, including key informant interviews, a Photovoice exercise, community mapping, focus groups and in-depth interviews. Quantitative data was gathered from a cross-sectional Audio Computer Assisted Self Interview (ACASI) survey that was administered to approximately 450-500 adolescents per site, yielding a total of 2,393 adolescents. Respondent-driven sampling was used to ensure the sample include out-of-school youth and unstably housed youth who are often underrepresented in school-based or household-based samples.
  
  
  
  While adolescents in Baltimore, New Delhi, and Johannesburg were more likely to seek health services if they felt illness symptoms, a fairly large proportion of adolescents indicated that even when they needed health care, they didn't seek it. In Johannesburg, more than 30 % of adolescents did not seek care even when they knew it was needed. Similarly, nearly a quarter of adolescents in Baltimore and in Shanghai indicated not seeking care when needed. Qualitative data indicated that adolescents exhibited a general lack of trust in providers and often felt embarrassed or stigmatized for seeking services. Multivariate analysis revealed that perceived fear and exposure to community violence was associated with a decreased likelihood of seeking care, while adult support from the home increased adolescents' likelihood to seek care in Baltimore and Johannesburg.
  
  
  
  Adolescent health care seeking patterns vary substantially by setting and gender. Neighborhood and family environments are important contexts in which health seeking behaviors are shaped. Efforts to connect adolescents to health care will need to target neighborhood safety as well as trust and support among adults outside of provider settings.
authors: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. kmmari1@jhu.edu.
authors: Kristin
authors: K
authors: Mmari
authors: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
authors: Beth
authors: B
authors: Marshall
authors: Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, USA.
authors: Trevor
authors: T
authors: Hsu
authors: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
authors: Ji Won
authors: JW
authors: Shon
authors: Pathfinder International, 38b Moshood Abiola Crescent, Off Toyin Street, Ikeja, Lagos State, Nigeria.
authors: Amenze
authors: A
authors: Eguavoen
mesh_terms: D000293:Adolescent; D016497:Adolescent Health Services / Q000706:statistics & numerical data*; D002681:China; D003430:Cross-Sectional Studies; D005260:Female; D017144:Focus Groups; D006798:Housing / Q000706:statistics & numerical data; D006801:Humans; D007194:India; D008297:Male; D009549:Nigeria; D010465:Perception; D011204:Poverty Areas; D012111:Residence Characteristics / Q000706:statistics & numerical data; D012494:Sampling Studies; D012574:Schools; D017678:Sex Distribution; D012931:Social Environment; D013019:South Africa; D019037:Urban Health Services / Q000706:statistics & numerical data*; D014754:Violence / Q000706:statistics & numerical data; D035862:Vulnerable Populations; D055815:Young Adult
keywords: Adolescents; Cross-cultural research; Health seeking behaviors; Social factors