Youth health and wellbeing: Understanding the elements of a good life
June 5, 2024 Jive Media Africa
Understanding what young people believe they need to live a “good life” can help researchers and policymakers better understand the impact of interventions on individuals’ wellbeing and can help in the design of more effective and equitable interventions, especially in resource-constrained settings.
This was the central theme of “Understanding capabilities among young people in global settings”, the second of four webinars in the Siyaphambili Youth Webinars series on “Exploring and resisting the impact of marginalisation on young people’s health and wellbeing”, held on 5 June.
The capability approach, developed in the 1980s by Amartya Sen and Martha Nussbaum as an alternative approach to welfare economics, focuses on the ability of individuals to achieve the lives they value. The focus is on improving access to the tools and resources people need to experience wellbeing and live a “good life”.
Facilitated by Neha Batura, Associate Professor in Health Economics at University College London (UCL), the webinar featured presentations from Gerard About Jaoude, a Research Associate at UCL Institute for Global Health, and Nonny Bhengu from the Gender and Health Research Unit of the South African Medical Research Council, both of whom have worked on projects trying to understand what young people in South Africa value as important in their lives.
Reflections on the webinar presentations were provided by Dr Guilia Greco, an Associate Professor of Health and Economics at the London School of Hygiene and Tropical Medicine (LSHTM).
Without words: Registering the voices of children
In his presentation on the "Enabling Schools" project conducted in rural South Africa, Jaoude described the use of the photovoice methodology to understand how children (aged six to 10 years) and adults in a rural setting in Mahikeng in South Africa’s North West Province conceived of a “good life”.
Photovoice is a qualitative approach that involves allowing participants to take photos of things they deem relevant to a specific topic. Photovoice is particularly effective in helping people describe sensitive and complex issues because it allows people to dispense with words, but still enables them to share individual perspectives on a topic. It is especially effective among children, who may not yet have the words to describe their lives in detail.
The aim of this study was to identify enablers and barriers to adult’s and children’s wellbeing. “A lot of measures of wellbeing have been developed in high income countries, but not all of which are relevant to the local lived experience of children and adults in Mahikeng – hence the study,” Jaoude explained.
“We did work with both adults and children to conceptualise what was important in their lives, to define wellbeing with them, and then we tried to come up with a set of measures within that,” said Jaoude.
Jaoude’s study had two groups of participants – parents and teachers, who were young (the mean was 27.3 years), mostly female (69%), largely unmarried (92%), mostly unemployed (75%) and a third (33%) had incomes under R2,500 per month. He also worked with children directly to understand their lives and views.
In the study, separate groups of children and adults were given a camera for the purpose of taking pictures of what was important in their lives – both the enablers and the barriers to a good life.
Pictures were selected by the collective and ranked according to their perceived importance. Focus group discussions followed, producing rich data about how people understood what was important for a good life. This data was organised thematically.
As expected, among the adults, important themes were basic needs such as access to water, food and energy as well as safe housing. Others identified the ownership of land and livestock as well as employment and job opportunities. Among the less tangible qualities identified were physical and mental health, education, positive personal and social relationships, dignity, independence and freedom from violence.
When it came to children, the photovoice exercise identified play, safety, the feeling of being cared for, and having people to care for, as being valued. “But some of it was around community and some spoke, for example, about loving their dogs,” said Jaoude.
Some children also identified possessions such as shoes and a school bag as being important, while others stressed the joy of reading and writing, receiving treats, and access to outdoor sports. The issue of violence at school and home was also raised by children as impacting on their wellbeing.
The study found that – broadly speaking – qualities such as education, access to food, physical and mental health, safety, dignity and respect and employment/business prospects were valued by both adults and children. These results were translated into potential policies which may have a positive impact on adults’ and children’s wellbeing, and these were presented to the Department of Basic Education.
HIV acquisition risk
Understanding how young people conceptualise wellbeing and translating this into capabilities was also at the heart of the second presentation on research conducted as part of the Siyaphambili Youth Project. The study aimed at developing a capabilities-based measure for young people at high risk of HIV acquisition who were living in marginalised communities in South Africa.
Despite expanding HIV treatment, HIV-acquisition is still a major challenge especially for out-of-school young people aged 18-24 living in KwaZulu-Natal, South Africa. The study, “Developing a capabilities based measure for young people at high risk of HIV acquisition in SA,” was conducted in an informal settlement in Durban and in another community on the South African border with Mozambique.
Explaining the basis of the capability approach Bhengu said an individual’s capabilities refer to them having access to resources to improve their wellbeing, and to their ability to make and act on choices that matter to them.
“People may not have the same ability to convert resources into equal states of wellbeing. So if policies do not take these differences into account they may not equalise resources among people,” she told the webinar. She said the capability approach had the benefit of capturing “personal, environmental and institutional variations”, thereby providing a more complete picture of individual wellbeing across populations.
According to Bhengu, capabilities are frequently subjective and not easy to measure. However, one measure that has been developed is the ICECAP-A (ICEpop CAPability measure for Adults) which is for use for adults in the UK and has been adapted and used in other high income settings. An important question is the extent to which a similar scale would be relevant for young people living in marginalised communities.
Bhengu described how the study collected data via focus group discussions with young men and women, with questions being structured around: “What is important in a young person's life to have a good life?”
Data were analysed thematically, using inductive and deductive methods. Subsequent workshops with young people were conducted to validate the initial findings. Using this data as a way to measure capabilities was developed based on the ICECAP-A survey. This was then reviewed via cognitive interviews with 16 young men and women in rural and urban areas which provided insights into how participants interpreted and understood the questions.
Context-specific observations
Bhengu identified a number of themes which emerged from young people’s views on what was important in their lives. The first five mapped directly onto the ICECAP measure, while two additional themes also arose.
That meant that in addition to qualities such as independence (financial, decision-making, freedom of movement), achievement and progress (education, employment, opportunity and experiences), enjoyment and happiness (socialising, having nice things and living in a good environment), stability and security (having a home, stable family and emotional stability), love and friendship (close ties with family and friends, support), participants also identified the need to feel physically safe (this was particularly highlighted by women participants) and the need for respect from others as important elements of wellbeing.
Reflecting on the presentations, Giulia Greco noted how they complemented each other.
She described Jaoude’s study incorporating photovoice as a “bottom-up” approach in the sense that participants were able to express in their own terms their understanding of a good life. She said the fact that there was a sort of “public debate or group reasoning” over the selection of the most relevant photos coincided with Sen’s framework around capabilities.
Sen recognised that capabilities are individual but they also need approval from the group, attained through “public debate and public reasoning”, she said.
Referring to Bhengu’s study, Greco said as a ready-made measure the ICECAP offered a neat framework, but in this case required a degree of “cognitive debriefing” to establish whether the measure applied in different settings and contexts around the world.
Greco said while a lot of ready-made measures insist that no adaptations are made to the original frameworks in the interests of comparability and standardisation, there were indications that some more recent measures were moving away from a highly restrictive approach.
Relational value
Greco noted that in her own experience of working with women of reproductive age in rural Malawi, they came up with “very similar lists” to the adolescents in South Africa regarding being respected and the importance of appearance as important for wellbeing.
“What struck me, for example, was the importance of having shoes that Gerard mentioned. It’s important to people not only because you need shoes … but the fact that you have shoes means no-one is going to bully you.”
Greco said having a “clothes line” was important for a good life in Malawi – not because of the clothes themselves, but because having a line indicated there were spare clothes and people who visited you could see that the family was well off.
“This very much fits in with Sen’s theory: it’s not the commodity you possess, it's what you can do with it. Shoes can facilitate walking, but they also mean people are not going to tease you. You are going to be respected … and all of that is a very tangible and direct measure that the capability approach is able to capture.
In the same way, the “treats” listed by children in Jaoude’s study, which were given out during quality time with parents and caregivers, signified something deeper.
“Treats are [part of] a good life for kids. Who wouldn't agree with that? But what is it about the treats that bring you joy? … Moving beyond the actual treats, they mean you are spending time with family and that's a recurring aspect.”
Greco said while some measures conceive of the individual as living in isolation, the capability approach puts the individual in a relational context, highlighting the “beautiful aspect” of relational wellbeing.