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Childhood disadvantage andhealth inequalities: a
systematic review of thequalitative evidence
Pamela AttreeInstitute for Health Research
Bowland Tower EastLancaster UniversityLancaster LA1 4YTTel: 01524 594103
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Childhood disadvantage and health inequalities: a systematic review of thequalitative evidence
Executive Summary
1. Aims
a) To provide policy makers, practitioners and researchers with a synthesis of the
qualitative evidence regarding children’s accounts of living in disadvantage.
b) To contribute to methodological debates concerning systematic reviews of qualitative
evidence.
Objectives
To identify, critically appraise and synthesise qualitative studies of children’s accounts of
living in disadvantage.
2. Methods
A systematic review of the literature was conducted, drawing upon electronic databases in
the social sciences and health, ‘grey’ literature, selected journals and subject experts. Nine
studies were identified which met relevance and quality criteria; these were synthesised
using meta-ethnographic methods.
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Main Findings
3. Coping with disadvantage: young people’s accounts
The main sources of support described by disadvantaged children and young people were
their families, friendships, and social networks in neighbourhoods. However, these may
also be conflictual and a source of psychosocial stress.
Family relationships
The majority of children turn to their immediate family, especially their mothers, if they
need help. Family relationships, particularly the emotional aspects of parental care-giving,
contribute to children’s feelings of personal security, thus helping to protect psychosocial
health and wellbeing.
Friendships
Friends are as significant to the majority of young people as their families. Important
aspects of friendship that children described were trust, support, sharing confidences,
‘being there’ for each other, and, particularly for boys, protection against bullying.
Neighbourhood social environment
Research evidence indicates that the local neighbourhood can act as a valuable resource
for children and young people, providing a network of social support. However, young
people’s accounts suggest that their experiences of neighbourhood social environments are
often contradictory.
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4. Psychosocial consequences of living with disadvantage
Exploring the contradictions
The social resources that children and young people draw upon can be compromised by
their circumstances; thus undermining any protective effect for their psychosocial
wellbeing. Stressful aspects include:
Family relationships Friendships Neighbourhood socialenvironment
Family conflict Problems in ‘keeping upappearances’, which can lead tosocial isolation or bullying
Contested space, resulting froma social life conducted largelyin public
Lack of space in the home as asource of friction betweenfamily members
Cost of organised socialactivities and transport canprove prohibitive to socialising
Conflict with neighbours andadult authority figures
Restrictions (by cost) on sharedfamily activities
Conditions in the homerestricting friends’ visits
Fears for personal safety(particularly for girls)
Parental depression and stress Peer group membership canincrease health-damagingbehaviour
Racial harassment for childrenfrom ethnic minorities
Expectations and aspirations
Living with disadvantage for some young people may mean becoming accustomed to
economic and social restrictions, thus:
Reducing immediate expectations of life
Limiting aspirations for the future
Perceptions of poverty – living with ‘difference’
Children may cope with disadvantaged circumstances in several ways; strategies include:
Social comparisons with others seen as worse off
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Shared experience of hardship in disadvantaged areas – reduces stigma
Displays of indifference
5. Conclusions
For some children and young people, family relationships, friendships, and neighbourhood
social networks can help to reduce the impact of disadvantage on their lives. However,
these factors can also be conflictual and result in stress. As a means of protecting young
people against the negative effects of disadvantage on health and wellbeing, therefore,
informal sources of support alone are likely to prove inadequate.
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Acknowledgements
This research was funded by the Department of Health Directorate of Health and Social
Care North, post-doctoral training fellowship number RDO/35/21. I would like to thank
my supervisor, Professor Hilary Graham, of Lancaster University, for her invaluable
guidance and detailed comments on earlier drafts of this report; Professor Margaret
Whitehead of Liverpool University for her contributions to supervising the fellowship; and
my co-research fellow Beth Milton of Liverpool University for lengthy debates about
methodology and critical appraisal of the studies included in this report. I would also like
to thank members of my research advisory group at Lancaster University for their help in
discussing methodological and conceptual issues associated with this review.
Thanks for technical assistance, and for searching the HMIC and Sigle databases, are due
to Val Hamilton, of the MRC Social and Public Health Sciences Unit, University of
Glasgow. From the same unit I would like to thank Mark Petticrew, Hilary Thomson and
Matt Egan, for providing guidance on systematic review procedures, and comments on the
review protocol.
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Contents
Page
Executive summary i
Acknowledgements v
1. Introduction 1
1.1.Background 1
1.2 Social pathways between disadvantage and health 2
1.3 Importance of children’s perspectives 4
1.4 Aims and objectives 5
1.5 Research questions 6
2. Research design 6
2.1 Systematic review protocol 6
2.2 Locating studies 6
2.3 Relevance to the review 7
2.4 Quality assessment 7
2.5 Synthesising evidence 10
3. Coping with disadvantage: young people’s accounts 13
3.1 Family relationships 13
3.1.1 Financial strategies 14
3.2 Friendship and social lives 16
3.2.1 Keeping up appearances 18
3.3 The neighbourhood social environment 19
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4. Psychosocial consequences of living with disadvantage 24
4.1 Exploring the contradictions 24
4.2 Limited horizons: expectations and aspirations 27
4.3 Perceptions of poverty – living with ‘difference’ 28
5. Discussion 31
5.1 Gender 33
5.2 Ethnicity 33
5.3 Age 34
6. Limitations of the study 35
7. Conclusions 37
References 38
Appendices 47
Appendix 1: Search strategy 47
Appendix 2: Inclusion and exclusion criteria 50
Appendix 3: Sample of excluded studies: Stage 3 51
Appendix 4: Quality appraisal checklist 53
Appendix 5: Data extraction form 55
Appendix 6: Main themes and concepts 56
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Tables and Figures
Figure 1: Systematic review process 6
Table 1: Studies included in the systematic review 9
Table 2: Matrix of concepts 12
Figure 2: Psychosocial pathways to health associated
with material disadvantage 31
1
Childhood disadvantage and health inequalities: a systematic review of the qualitative
evidence
1. Introduction
1.1 Background
In response to a growing body of evidence concerning the negative effects of disadvantage on child health and
wellbeing, the UK government agenda has placed both the eradication of childhood poverty and the reduction of
health inequalities as central to its objectives (DOH, 2002). While the concept of disadvantage encompasses both
economic and social factors (for example, poor living conditions, overcrowding and lack of material resources),
a common definition identifies material poverty, such as living in a household on below average income, as its
central feature (cf. DWP, 2003). Although UK statistics show a recent fall in child poverty indicators, following
a peak in the 1990s, the risks of being in a low-income group are unevenly distributed. For example, in
2001/20021 30% of all children lived in low-income households. This compares with 54% of children in lone
parent families, 69% of children living in Pakistani or Bangladeshi households, 43% of children in households
with one or more disabled adults, and 79% of children in workless households (DWP, 2003). Wide geographical
variations in disadvantage also exist, such as regional and ward differences in child poverty levels, with clusters
of deprivation in certain areas (Bradshaw, 2002).
Disadvantage in childhood has lasting effects on the health and wellbeing of individuals in terms of life
expectancy, physical and emotional health (Blaxter, 1990; Jack, 2000). There is evidence of the cumulative
effect of early disadvantage, posing a threat to healthy child development (Power & Mathews, 1997; Power &
Mathews, 1998; Power et al. 1999; Buchanan & Hudson, 2000; Blackwell et al. 2001; Mielck et al. 2002;
Harper et al. 2003). Poor children experience worse health, have a shorter life expectancy, and are more likely to
1 Using a threshold of 60% of median household income after housing costs.
2
die in infancy or childhood (Lundberg, 1993; Duncan et al. 1994; Roberts, 1997; van de Mheen et al. 1997;
Wadsworth, 1997; McLoyd, 1998; Brooks-Gunn et al. 1999; Bradshaw, 2000, 2002). Childhood poverty is also
associated with higher rates of neglect and physical abuse, homelessness, smoking and low self esteem
(Bradshaw, 2000).
A socio-economic gradient in morbidity and mortality also exists for the most common causes of ill health
among children in the UK (and Europe) (Spencer, 2000; Mielck et al. 2002). Although there have been overall
improvements in child health in recent years, this gradient has steepened and the gap between poor and non-poor
children has widened for certain conditions (Bradshaw, 2002).
Children’s emotional and psychological wellbeing is a major public health issue (Buchanan & Hudson, 2000).
However it is a complex subject on which definitions shift and evidence is fragmented. As Bradshaw (2002)
points out, there is no good time series data on mental illness in childhood; nor is there a systematic procedure in
the UK for monitoring children’s subjective wellbeing. While some studies indicate a link between low income,
low status and poorer psychological health in childhood, adolescence, and later life (McLeod & Shanahan, 1993,
1996; Buchanan & Ten Brinke, 1997; Melzer & Gatwood, 2000), others suggest that the situation is more
complex (Clarke et al. 1999; Ermisch et al. 2001). There is evidence that the negative effects of poverty on
children’s emotional wellbeing increase with the length of time spent in poverty (Duncan et al.1994; Aber et al.
1997; McLoyd, 1998). Explanations for the link between poverty and poor health outcomes are far from
straightforward, however.
1.2 Social pathways between disadvantage and health
Social pathways between disadvantage in childhood and adult health contain numerous layers of influence,
including individual and lifestyle factors, living and working conditions, social and community influences, and
the wider social structure (Whitehead & Dahlgren, 1991).
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The evidence points to multiple chains of risk, running from the broader social structure through living
and working conditions to health related habits like cigarette smoking and exercise. (Graham, 2000, p14)
‘Chains of risk’ influencing health are broadly categorised as material, behavioural and psychosocial (Graham,
2000). Access to basic material resources, such as housing, fuel, food and clothing affects the health and well
being of children and young people (Blackburn, 1991). Lifestyle also plays a part. For example, behavioural
patterns acquired in childhood and adolescence, including diet and nutrition, exercise, smoking, drinking, drug
use, and sexual behaviours, contribute towards adult health outcomes (Wadsworth, 1997; Lynch, 2002; Mielck et
al. 2002). However, such lifestyle factors cannot sensibly be viewed in isolation, as ‘risky’ behaviours do not
take place in a social vacuum; indeed they are socially patterned, embedded in a social and economic context
(Kuh et al. 1997). As Evans points out, using smoking as an example:
Unhealthy behaviours are generally highly concentrated at the lower end of the socio-economic
spectrum. One has to ask: What is it about the social experience at different bands in that spectrum,
particularly in childhood, that predisposes or protects against smoking? (Evans, 2002, p11)
In addition to material and lifestyle factors, psychosocial processes play a role in determining health outcomes,
mediating the effects of social structure (Martikainen et al. 2002). Evidence suggests that children’s positive
relationships with parents and siblings, and parental involvement in education are important for healthy
emotional development (Jack, 2000; Schoon & Parsons, 2002), for example. Survey research in the UK also
indicates that the quality of family relationships is critical for adolescent mental health (Clarke et al. 1999).
However, family relationships in the context of material disadvantage may have contradictory effects, directly
increasing vulnerability to stress (and thus disease), or indirectly leading to health-damaging behaviour (Elstad,
1998; Bartley et al. 2000). Evidence from the National Longitudinal Survey of Youth (US), for example,
suggests that children’s experiences of poverty reinforce negative family interactions. This can place some
children at risk of developing mental health problems, such as depression (McLeod & Shanahan, 1996).
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Psychosocial stress (for example in the form of parental conflict) may therefore co-exist with risks to health
associated with economic hardship (Kuh et al. 1997).
Social networks outside the family can play a protective role in child health, or contribute to psychosocial and
behavioural risk factors (Jack, 2000; Schoon & Parsons, 2002). The peer group is important to adolescent
wellbeing, for example, particularly in determining self esteem (Clarke et al.1999) and influencing behaviour,
while friendship and social integration are key factors in developing emotional health (Blaxter, 1990; Wilkinson,
1999). Paradoxically, however, adolescent friendships can also provide the context for experimentation with
cigarettes, alcohol, drugs, and early sexual experiences (Noeller & Callan, 1991; Glendinning et al. 1994; Unger
et al. 2001)).
Neighbourhood environmental and social conditions also impact on children’s health, wellbeing and life chances
(although the effect is smaller than that of individual socio-economic status) (Bartley et al. 1998; McLoyd, 1998;
Shaw et al. 1999; DOH, 2002). Poor quality housing, residential overcrowding, noise and environmental
pollution in neighborhoods, and lack of adequate play space pose a threat to child health (Blythe &
Roelkepartian, 1993; Roberts, 1999; Evans & Kantrovitz, 2002). However there are less obvious risks for
children and young people associated with area social and economic conditions. Ecological approaches to health
and wellbeing stress the role of neighbourhoods in providing supportive contexts for social and emotional
development (Jack, 2000; Cattell, 2001). When areas appear unsafe or threatening to young people, however,
this can result in elevated levels of anxiety, depression, and stress (Aneshensel & Sucoff, 1996; McLoyd, 1998;
Farver et al. 2000). The psychosocial dimensions of neighbourhoods therefore provide an important backdrop to
understanding children’s experiences of disadvantage (Wilkinson, 1996; Airey, 2003).
1.3 Importance of children’s perspectives
Recent governmental initiatives have been influenced by debates concerning the consequences of early
disadvantage for children. Hence the introduction of interventions such as Sure Start, aimed at reducing early
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adverse influences on child development (Glass, 1999). Much of the evidence underpinning such initiatives is
based on survey research, in the main undertaken in the United States. What is largely absent from the analysis
are the voices of those most affected - disadvantaged children and young people.
While the impact of disadvantage on child health has been widely documented from an adult perspective, few
studies have explored children’s understanding of their experiences (Roberts, 2000; Daly & Leonard, 2002;
Percy, 2003). Daly and Leonard (2002) argue, for example, that ‘we know little or nothing about the experiences
of children in poor circumstances’ (p5). Therefore our understanding of poverty and its effects on young people
is likely to require recasting from a child’s perspective. The absence of children’s viewpoints in the research
literature in part reflects the greater ethical problems of conducting research with children, and the tendency in
the recent past to see children as the passive ‘objects’ of research, rather than active subjects in their own right.
Although a number of innovative research projects have been carried out (notably the ESRC’s Children 5-16
programme), which illustrate the range of methods that can be used to explore children’s attitudes and behaviour,
qualitative evidence concerning children’s experiences of disadvantage remains sparse. It is important, however,
to pay heed to children’s narratives as only by listening to children can we achieve a greater understanding of
how they deflect the impact of disadvantage on their lives.
1.4 Aims and objectives
This systematic review of qualitative evidence aimed to:
a) provide policy makers, practitioners and researchers with a synthesis of the qualitative evidence
regarding children’s accounts of living in disadvantage.
b) contribute to methodological debates concerning systematic reviews of qualitative literature.
The main objective of the systematic review was to identify, critically appraise and synthesise qualitative studies
of children’s accounts of living in disadvantage.
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1.5 Research questions
The review aimed to address the following questions:
In what ways do children and young people talk about the impact of living in disadvantage?
What resources and strategies are available to disadvantaged children and young people?
2 Research design
2. 1 Systematic review protocol
A protocol was drawn up to guide the conduct of the systematic review; this was refined in the light of feedback
from experts in review methodology and information retrieval. A pilot search was also carried out in ASSIA, to
test the sensitivity and specificity of the search strategy, before the principal review began. The process of
identification and appraisal of the research literature is outlined in Figure 1 below.
Figure 1: Systematic review process
2.2 Locating studies
In Stage 1 of the revi
carrying out a system
out in a number of ele
N=11,224Stage 1
Stage 2
Stage 3
Stage 4
Identify relevant studies -Search databases etc.
ew, literature was located using a variety of methods, following recognised guidelines for
atic review (cf. NHS Centre for Reviews and Dissemination, 2001). Searches were carried
ctronic databases, including IBSS, Ingenta, PsychINFO, ASSIA, and the Social Science
Sift references for relevanceto topic/study design andobtain primary papers
Critically appraise studies
Apply inclusion/exclusioncriteria
N=61
N=11
N=9
7
Citation Index (see Appendix 1 for the search strategy and full list of databases). Search terms were adjusted in
line with individual database requirements. Unpublished ‘grey’ literature was sought in databases such as
Dissertation Abstracts International (US), Index to theses (UK), Sigle, HMIC and Zetoc. In addition, selected
journals were hand searched, websites (such as Google; BUBL, SOSIG) were searched using key terms, and the
reference lists of identified studies were scanned. A number of key informants in poverty and health inequalities
research were consulted, in order to identify unpublished and on-going studies. Research networks were also
contacted electronically, resulting in a number of useful leads.
2.3 Relevance to the review
The located references (n=11,224) were then checked for relevance and appropriate study design, and appraised
for quality. Stage 2 of the review involved sifting lists of studies for relevance, applying pre-set inclusion and
exclusion criteria (Appendix 2). A second reviewer checked 5% of the sample, with a high level of inter-rater
reliability.2 Primary papers were then obtained for those studies that appeared (from an initial reading of titles
and abstracts) to fulfil the relevance and design criteria (n=61). Examination of these papers and further
application of the inclusion and exclusion criteria defined in the protocol (Stage 3) resulted in a set of 11 studies
remaining. (A sample of studies excluded at Stage 3 is provided in Appendix 3 for illustration.)
2.4 Quality assessment
A critical appraisal checklist was then constructed, drawing on earlier models of appraising qualitative research
(Appendix 4) (Popay et al. 1998; Mays & Pope, 2000, NHS Critical Appraisal Skills Programme, Seale, 1999;
Baldwin et al. 2002; Boaz & Ashby, 2003). At Stage 4 of the review, therefore, two researchers carried out
independent quality appraisal of the sample studies, grading for quality on a scale from A to D. Reviewers
reached broad agreement on the quality categorisation of studies, with areas of divergence resolved by dialogue
2 2nd reviewer found 2 studies (0.3%) not identified by 1st reviewer. These were subsequently checked and excluded as irrelevant.
8
and further reference to study authors where appropriate.3 The majority of the discussion centred on studies
which were felt to be borderline cases (n=4), with sampling and data analysis methods proving the most difficult
to assess consistently. Studies graded A to C were included in the synthesis (n=9); those graded D were
excluded (n=2). Table 1 below details the studies included in the review.4
3 Reviewers were in agreement on 7 studies (63.6%) (including 2 graded D); 2 studies were borderline B/C – both were ultimatelygraded B; 2 studies were borderline A/B – 1 was finally graded A, 1 graded B.4 Note that the majority of studies draw upon predominantly white samples, while those that include ethnic minority children (with theexception of Morrow) do not explore differences in their accounts of disadvantage.
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Table 1: Studies included in the systematic review
Backett-Milburn et al,2003
Daly &Leonard, 2002
Davis &Ridge, 1997
Middleton etal, 1994
Morrow, 2001 Percy, 2003 Ridge, 2002 Roker, 1998 Willow, 2002
Aim ofstudy
To investigatechildren’severydayexperiences ofhealthvariations fromtheir ownperspectives.
To explore theeveryday livesand concerns ofchildren (andparents) livingin low-incomehouseholds.
To explore theinterlockingeffects ofrurality andlow income,and children’saccounts ofexclusion andmarginalisation
To explorewhat childrenneed to ensurethat they arenot excludedfrommainstreamsociety.
To explore anddevelop theconcept ofsocial capital asit relates toyoung people,using a casestudy approach.
To gaininsights intothe experiencesof minoritypoor childrenthroughdescription ofwhat is specialto them.
To explore thelives andexperiences ofa group ofchildren andyoung peoplefrom low-incomefamilies.
To focus onyoung people’sviews andexperiences, todescribe theexperience ofgrowing up infamily poverty.
To explore howpoverty affectsthe lives ofchildren andyoung people.
Sampleno.
35 28 95 (42 on lowincome)
130 101 20 40 60 106
Sampletype
Socio-economicstatusdifferentiatedby area
Low-income,two-parent andlone parentfamilies.
Families inreceipt ofIncomeSupport & freeschool meals
Socio-economicstatusdifferentiatedby area
Comprehensiveschool areas oflow socio-economicstatus.
Childrenattending anafter-schoolprogramme
Families inreceipt ofincome supportover 6 months.
Familiesdependent onwelfarebenefits
Children inreceipt of freeschool meals
Age 9-12 12-16 8-19, (majority11-15)
8, 11, 13 & 16(year groups)
12-13, 14-15 6-12 10-17 (majority10-15)
13-18 5-16
Data In-depthinterviewsObservation.Communityprofiling.
Interviews Semi-structuredinterview
Interviews,focus groups,diaries,questionnaires
Writtenaccounts,photographs,groupdiscussions.
Small groupinterviews,photographs
In-depthinterviews
Interviews Discussiongroups,storybooks
Context ScotlandMore/lessaffluent areas
Ireland –urban/rural
West Somerset(rural)
Midlands &North ofEnglandMore/lessaffluent areas
New town inSouth East (intop third ofdeprived localauthority areasin England)
Urban low-incomehousing project(US)
Rural & urbanareas (UK)
South Coast,West ofEngland,Scotland(rural, urban &seaside)
Midlands,North & Southof England.areas with highlevels ofpoverty
Grade A C B A A B B C C
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2.5 Synthesising evidence
Synthesis of qualitative research can be envisaged as the bringing together of findings on a
chosen theme, the results of which should, in conceptual terms, be greater than the sum of
parts. (Campbell et al. 2003, p672)
Meta-ethnographic methods were used to synthesise the studies. Meta-ethnography provides an
alternative to aggregative methods of synthesising qualitative research (Noblit & Hare, 1988).
Authors’ interpretations and explanations of primary data, described as the ‘building blocks’ of the
synthesis (Britten et al. 2002), are treated as data and are translated across several studies (Campbell
et al. 2003). Although the process is described as a linear one, in practice it consists of a series of
overlapping stages of reading and re-reading, comparing, interpreting and recording.
The first task of the synthesis therefore was to identify the main concepts from individual primary
studies, using the original author’s terms as an organising structure, but paying particular attention
to children’s narratives. Data was then extracted in a pro-forma (Appendix 5) and the key concepts
organised in tabular form (Appendix 6), to enable synthesis and the reciprocal translation of
findings. Reciprocal translation entails ‘examining the key concepts in relation to others in the
original study, and across studies, and is analagous to the method of constant comparison used in
qualitative data analysis’ (Campbell et al. 2003, p673).
In order to test the utility of the meta-ethnographic method a synthesis was initially carried out on
five studies (four graded A or B, and one graded C). The remaining four studies were then
integrated into the synthesis, following the same procedures. Table 2 (below) illustrates the
distribution of the main themes across the studies.
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To address the problem of the varying quality of research included in the synthesis, and increase
confidence in its findings, only data from those studies graded A and B were used to identify the
main themes and concepts. Evidence from studies that were graded C was introduced to further
substantiate the key points. Therefore the evidence presented in this report is based only on that
research where there is a reasonable level of confidence attached to the findings.
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Table 2: Matrix of concepts
Backett-Milburn etal. 2003
Daly &Leonard,2002
Davis &Ridge,1997
Middletonet al. 1994
Morrow,2001
Percy, 2003 Ridge, 2002 Roker,1998
Willow,2002
Familyrelationships
X X X X X X X
Financialstrategies
X X X X X
Friendships andsocial lives
X X X X X X X X X
Keeping upappearances
X X X X X X X
Neighbourhoodsocialenvironment
X X X X X X
Expectations andaspirations
X X X X X X X
Perceptions ofpoverty
X X X X X X
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FINDINGS
3. Coping with disadvantage: young people’s accounts
How disadvantaged young people perceive and cope with their circumstances is influenced by
interactions with their social networks, beginning with their immediate families (Wilkinson, 1996,
1999). It was not surprising, therefore, that children and young people described important
relationships with family members and friends as resources that they could draw upon. Social and
material environments in neighbourhoods, however, were frequently described in ways suggesting
stress or conflict.
3.1 Family relationships
Supportive family relationships are important to the majority of young people (Gillies et al.1999;
Langford et al. 2001); however evidence from this systematic review suggests that they may be
particularly vital for those living in disadvantaged circumstances. Children of all ages described
practical aspects of parental care, turning to family members, especially mothers, for their everyday
needs (Daly & Leonard, 2002). One child said, for example:
She [mother] gives me anything I need. She takes care of me, feeds me, and gives me
shelter… (Percy, 2003, p61)
The significance of close and confiding relationships with parents as a source of emotional support
was clear, particularly for those in single-parent families.
14
The most important person in my life is my mum, she has brought me up the way I am. My
dad hasn’t brought me up because my mum and dad are divorced, my dad left when I was
two years of age, I don’t see him much. (Brenda, age 14) (Morrow, 2001, p15)
Because there is only me and my ma and I have only got my ma to talk to…I tell my ma
everything. (female, age 13, Scotland) (Roker, 1998, p27)
Familiar relationships can contribute to young people’s feelings of personal security (Morrow,
2001; Willow, 2002; Backett-Milburn et al. 2003), and ideally can help to protect psychological
health and wellbeing. Children’s accounts in Morrow’s (2001) study also emphasised that for
children from ethnic minorities, particularly those belonging to the Islamic faith, family life is of
central importance.
3.1.1 Financial strategies
A theme linked to both family relationships and to children’s friendships and social lives is that of
financial strategies; that is the ways in which children cope with a lack of material resources.
Middleton et al. (1994) argue that there is a common ‘culture of acquisition’ amongst children,
which those with few resources must learn to negotiate if they are not to feel excluded. This theme
was reflected in other studies. One child said, for example:
15
If your friends have got something and you can’t have that you feel like you are left out
because everyone else has got it and they pick on you because you are the odd one out.
(Willow, 2002, p53)
Not wishing to be the ‘odd one out’ amongst friends meant bargaining with parents over pocket
money, and those items seen as ‘essential’ to full involvement in the social group. Children
described a range of persuasion strategies they used on parents, such as begging, repetition of
requests, bribery, bargaining (offering help) and direct action (such as tantrums) (Middleton et al.
1994; Daly & Leonard, 2002; Ridge, 2002). Such negotiations appear to be characterised both by
persistence on the part of young people, and resignation, when the futility of asking parents for
items beyond their means was acknowledged. For example:
I wouldn’t bother [asking], I don’t see the point because if we haven’t got very much money
then we can’t get it so I don’t mind. (Martin, age 11) (Ridge, 2002, p98)
Resigned (or realistic) attitudes were more frequently found amongst older children, who were more
aware of the financial implications of their demands on parents (Middleton et al. 1994; Ridge,
2002). They also displayed sensitivity to the fluctuating monetary pressures on parents, moderating
their expectations accordingly. For example:
When they ain’t got much money and that. But when they’ve got the money it’ll be
alright…It’s just what kind of week it is – if they have to pay bills out and that. (Less
affluent male, age 15, Middleton et al. 1994, p99)
16
Limitations on resources within the immediate family were alleviated for some children, however,
by contributions in cash or kind from other family members, such as grandparents (Middleton et al.
1994; Daly & Leonard, 2002; Backett-Milburn et al. 2003). Daly and Leonard (2002) point out
however, that this additional financial support is dependent on contact with wider kinship networks,
which not all disadvantaged children enjoy.
One strategy to relieve the financial strain on families described by older children in this review was
to take part-time employment. Young people in work used their wages to contribute directly to
family income, to buy desired items, or subsidise the costs of leisure activities (Middleton et al.
1994; Roker, 1998; Daly & Leonard, 2002; Ridge, 2002). Paid work was therefore a useful means
to enable children to take part in peer groups on equal terms, economically and socially (Ridge,
2002), as well as a way of increasing independence (Morrow, 2001). There were accompanying
costs for some young people, however. For example, Shropshire and Middleton (1999) in their
survey Small expectations – learning to be poor found that children from lone parent families, or
those on Income Support, worked longer hours than their peers and received lower rates of pay.
3.2 Friendship and social lives
Alongside family relationships, the topic of friendship and social lives was central to young
people’s accounts of living in disadvantage. Children in Backett-Milburn et al’s (2003) study talked
about the experience of disadvantage, for example, in terms of social relationships, as much, or
more than, access to material resources. Research has demonstrated that as children move into
adolescence family-based influences diminish and peer groups assume increased importance
17
(Glendinning et al. 1994; West, 1997; Sacker et al. 2002; Percy, 2003). (The one exception to this
was found in Daly and Leonard’s (2002) study, in which children attached greater importance to
family relationships than to friendships.) As one young woman explained:
They [friends] are as important as your family especially when you are this age, because
your family can help you to a certain extent but for the things you don’t want to tell your
family, friends are so important to have. (Amy, age 15) (Ridge, 2002, p61)
Similarly, another child said:
It’s good to count on people…’cause I have friends to hang around with and I can always
count on ‘em when I have problems…and they make you laugh when you are sad. (Percy,
2003, p63)
Children talked about friendship in different ways. For girls, important aspects of friendship were
trust, support, sharing confidences and ‘being there’ for each other, while boys stressed joint
activities and having fun, but also listening, loyalty, and trust (Morrow, 2001; Ridge, 2002). For
boys in particular, friends also offered protection against bullying (Ridge, 2002). The problem of
bullying (sometimes associated with a ‘poor’ appearance), particularly in school settings, was a
recurring aspect of children’s accounts in this systematic review (cf. Middleton et al. 1994; Daly &
Leonard, 2002; Ridge, 2002; Willow, 2002). Maintaining social position as part of a group was
important to young people (Morrow, 2001). Economic constraints on families could make fitting in
with friends difficult, however.
18
3.2.1 Keeping up appearances
The problem of ‘keeping up appearances’ for disadvantaged young people (Middleton et al. 1994),
that is being seen in the ‘right’ kind of fashionable clothes, was an important aspect of their
accounts of living in disadvantage. Presenting an acceptable appearance is part of ‘fitting in’ to
social groups and avoiding being marked out as visibly ‘different’, for example:
Amy: It’s blending in with rest of the group, if the rest of the group are wearing Nike
trainers, you feel like you’ve gotta have Nike trainers, if the rest of the group are smoking,
you feel like you’ve gotta smoke.
Gizmo: Even with Nike trainers, as well, it’s like oh they’re the old model, this is the new
model, you must have this, you haven’t got any free choice to wear what you want.
(Morrow, 2001, p20-21)5
However, young people from low-income families described the struggle to keep up with rapidly
changing fashion trends. In consequence they worried about being teased or bullied by
contemporaries. For example:
They hassle you. They just say nasty things like, ‘you get your shoes from the tip’, and stuff
like that. (Less affluent female, age 13) (Middleton et al. 1994, p53)
5 This quotation is also illustrative of the contradictory effects of friendship for young people, in that ‘risky’ behaviouras well as styles of clothing is influenced by the group.
19
The older people [teenagers] laugh at you ‘cos of the way you are, ‘cos if you’re wearing
something they don’t like or think that is wrong they laugh at you. (Sharon, age 11) (Davis
& Ridge, 1997, p64)
In school settings the necessity to wear uniform did not alleviate pressures to conform, as one child
explained:
Every class has one that stands out. Every class has its bullies and the one that was being
bullied in my class was me. You have to wear designer stuff. All the kids have designer
names and we haven’t. We stick out and we’re picked on…Look at these crap runners
[trainers] I’m wearing. My ma can’t afford to get me the right ones and it’s terrible when
you can’t afford the right ones. You have no choice but we couldn’t afford it so I was the
one that got picked on. (Susan) (Daly & Leonard, 2002, p137)
Ridge (2002) and Daly and Leonard (2002) found that appearances formed the basis of distinctions
amongst children. According to young people with the most negative experiences, the type of
clothes that they could afford affected their ability to form friendships, setting them apart from peer
groups.
3.3 The neighbourhood social environment
Research has highlighted the spatial elements of inequality (Shaw et al. 1999; Gatrell et al. 2000;
Joshi et al. 2000), such as the physical environment in deprived areas, as a potential threat to
children’s health and wellbeing. The combination of proximity to traffic with lack of play space
20
contributes to higher accident rates for children in lower socio-economic groups (Reading et al.
1999; Social Exclusion Unit, 2002). For the younger children in Morrow’s study (aged 12-13) the
dangers of traffic, and the accompanying problems of accidents, pollution, noise, and joyriding,
were constant factors in their lives. In ostensibly safer rural areas there were also hidden dangers for
children, such as farm machinery or chemical storage facilities (Davis & Ridge, 1997).
However, for the majority of children in these studies the concept of neighbourhood was associated
with its social characteristics, suggesting a strong psychosocial dimension to the experience of place
(Airey, 2003). The context of disadvantage, therefore, is important to understanding the experience
of poverty (Roker, 1998). Evidence suggests that neighbourhood characteristics, in particular social
support networks and resources (or social capital), are important for young people’s wellbeing
(Jack, 2000).
…place and neighbourhood are strong influences on how or whether young people can
access the relationships that are so important to their sense of belonging. (Morrow, 2001,
p19)
While social relationships within communities are generally seen as protective in their effects on
psychological and emotional wellbeing, young people may experience them in contradictory ways
(O’Brien Caughy et al. 2003). Children and young people described aspects of their communities
that they found stressful, for example. Lacking access to organised leisure activities, children from
poorer backgrounds are more likely to play in public areas or simply hang around the streets
(Sweeting & West, 2000). Children in this systematic review came into conflict with adults through
21
conducting their social lives in public. However, access to formal social venues was often restricted
by cost, leaving little choice but to congregate in the open. One girl explained the problem:
The thing that always annoys me is that the police always moan that we’re on the streets, so
they build places like the new clubs and stuff, but we have to pay to get into that. (Morrow,
2001, p33)
Young people in several studies perceived adults policing their movements as contributing to an
area’s perceived friendliness or unfriendliness (Davis & Ridge, 1997; Ridge, 2002; Backett-Milburn
et al. 2003). For example:
Pete: sometimes when we play in the park, the parkie comes and tells us off. All they say is,
‘If you play a game, we will just’, because they can’t do anything, they just take you home
quite a lot of times, just for playing near, there’s a, you know, what was the work site?
JD: aye
Pete: well, you know down from it how there’s a forest kind of down there that goes right
past the back of the (exhibition place) and I was playing there one day, and there was
already smashed windows and we got into trouble. They said we smashed the windows and
all we were doing was walking past. (less affluent area) (Backett-Milburn et al. 2003, p618)
It was not only authority figures, such as police or park keepers, who monitored young people,
however. Adult disapproval of adolescents, particularly those congregating in groups, was more
22
general. For example, Morrow (2001) found little evidence of trust between different generations
living in close proximity. One young man said of his neighbourhood:
Fred: It’s OK, apart from the neighbours, they’re moany, say if you’re playing in the front
garden, yeah, and you make a bit of noise, they moan. They moan…so you can’t do
anything when they’re there. (Morrow, 2001, p29)
In prosperous rural areas disadvantaged young people also described feeling exposed to adult
scrutiny and potential criticism, partly because of the lack of available social space, and their
consequent heightened ‘visibility’ on the street.
Well, I feel more safe in the house usually than when I am outside, ‘cos when you’re
basically like on the other side of town and sometimes you feel like you’re a bit unsafe, ‘cos
like the people might be watching you or something. Some people round here who like to
watch in case you’re doin’ any trouble, you know sort of like neighbourhood watch sommat
like that so you don’t do sommat wrong. An’ [even] if you do it right or something they
might come out and say you’re doing it wrong and call the police or something. (Stewart,
age 16) (Ridge, 2002, p91)
Neighbourhood safety, particularly in poor urban districts, was also worrying to children. Some
participants in Morrow’s (2001) study felt apprehensive in local parks and on the streets, for
example, explaining that gangs hanging around shops at night and drunks in the streets could be
23
intimidating. Similarly, young people from Dublin pointed out aspects of estate life that they found
hostile.
The joy riders and the junkies are in this estate. I wouldn’t point them out to you but I know
some of them. (Daly & Leonard, 2002, p122)
Fears for personal safety were particularly evident for girls in Morrow’s (2001) study.
Amy: Like somebody was assaulted down [in the local park], I mean that makes you scared
to go down there, and that was in broad daylight, so god knows what it’s gonna be like at 10
o’clock at night…. (Morrow, 2001, p21)
Children from ethnic minorities also described racial harassment, such as verbal abuse and attacks
on their homes, which affected their perceptions of neighbourhood safety (Morrow, 2001). In
Roker’s (1998) study, young people in Scotland reported gang activities and rivalries that
influenced their perception of their neighbourhoods as ‘unsafe’. In some areas law breaking was
seen as the ‘norm’ by young people. However, although some adolescents were the perpetrators of
crime they were equally likely to be the victims (Roker, 1998; Morrow, 2001). Living in close
proximity to gangs was also a problem for participants in Percy’s (2003) study (set in a deprived
urban area of the US), particularly for older boys. As one participant explained:
You almost have to belong to a gang here: it’s really hard not to belong to any of them.
(Percy, 2003, p59)
24
Paradoxically, although children were fearful of gang-related fights and violence in their
neighbourhood, being part of a gang was also seen as a source of friendship and protection.
4 Psychosocial consequences of living with disadvantage
4.1 Exploring the contradictions
Aspects of their lives that children describe as supportive, family relationships, friendships, and (to
a lesser extent) the neighbourhood social environment, while central to reducing the impact of
disadvantage, may themselves be undermined by the constraints of poverty. There are contradictory
elements to family life for young people in disadvantaged circumstances. Previous research has
demonstrated that socio-economic disadvantage is associated not only with poorer material
environments, but higher levels of marital conflict, parental mental health problems, and stress
(Taylor et al. 2000). Young people’s accounts in this systematic review also suggest that there are
stressful aspects of family life linked with lack of material resources, stemming from lack of space
in the home, overcrowding, and restrictions on shared family activities (Middleton et al. 1994;
Roker 1998). Pressure on parents to meet children’s needs and wants, when their ability to do so is
severely circumscribed, can result in conflict and frustration (cf. Willow, 2002), and soured family
relationships. Although family life is important to young people’s emotional wellbeing, low income
brings stresses to bear on parents, and may, at worst, affect their ability to care for their children
effectively. For example, young people in Willow’s study (2002) vividly described their parents’
sadness and distress about living in poverty. Evidence suggests that, over time, parental depression
can negatively affect children’s own psychological wellbeing (Kessler & Magee, 1993; DOH,
1999). Moreover, Ridge (2002) argues that some children try to protect parents from knowledge of
25
the impact of poverty on their lives. The consequences for young people’s psychosocial wellbeing
are unclear, but seem unlikely to be positive. Risky behaviour, such as smoking, may also be
influenced by parental example (Glendinning et al. 1994; Plano Clark et al. 2002). In the context of
disadvantage, therefore, the value of family relationships as a protective resource may be diluted.
Friendships can provide social support and protection for young people’s emotional health and
wellbeing (Morrow, 2001; Backett-Milburn et al. 2003). Acceptance into social groups, as Ridge
(2002) argues, is a source of reassurance for children and young people, and therefore important to
psychosocial wellbeing. Difficulties in making and sustaining friendships may have long-term
repercussions, for example in presenting ‘challenges to social well-being, self esteem, social
identity, and social integration, coupled with a reduced capacity to make and sustain adequate social
relationships’ (Ridge, 2002, p144). However, the protective elements of friendship may be
undermined by the constraints associated with poverty. For example, children and young people
described lack of space in the family home for friends to play or stay over-night, and financial
limitations on parents’ ability to provide hospitality (Davis & Ridge, 1997; Ridge, 2002). For
children living in rural areas, especially those living with single parents, cost and availability of
transport was a further barrier to meeting friends outside school hours (Davis & Ridge, 1997;
Roker, 1998; Ridge, 2002). Material restrictions associated with economic hardship could therefore
affect children’s ability to participate socially on an equal footing with their peers. The problem of
‘keeping up appearances’ also emphasises the fragility of friendship as a resource for children in
poor circumstances. Social exclusion has potential behavioural consequences, especially for
adolescents, as Percy argues:
26
Adolescents who do not find a compatible peer group throughout their school years
frequently align with fringe groups who are involved in delinquent behaviour. (Percy, 2003,
p65)
Paradoxically, therefore, although social exclusion carries behavioural and psychosocial
consequences for young people, association with particular social groups may also have
contradictory outcomes (see Morrow, 2001). Although belonging to a peer group provides a means
of social integration (Portes & Landolt, 1996), the ‘cost’ of inclusion may involve joining in ‘risky’
behaviour, such as smoking, drinking and drug-taking (Noeller & Callan, 1991). Young people are
more likely to smoke if their friends are frequent smokers, for example (Glendinning et al. 1994),
suggesting an ‘unspoken pressure’ amongst certain peer groups to take up smoking (Plano et al.
2002).
At neighbourhood level, aspects of the social environment diminish the potential protective effect of
supportive relationships on psychosocial wellbeing. Roker (1998) suggests, for example, that those
young people living on run down estates in urban areas, which experience multiple problems, such
as crime, gang violence, unemployment and drug use, experience higher levels of deprivation and
enjoy fewer protective factors or ‘buffers’ (also see Morrow, 2001). Research has also highlighted
restrictions on social space for children in the countryside, leading to resentment between young
people and adults (Mathews et al, 2000; Smith & Barker, 2001; Tucker & Mathews, 2001). Such
problems loom large for those disadvantaged young people with few affordable alternatives.
27
Both urban and rural areas present problems for disadvantaged young people in terms of physical
safety, perceived safeness, contested space, and adult surveillance, factors which could be described
as area ‘incivilities’. A study of neighbourhood safety and social relations suggested that
‘psychosocial pathways…mediate between the experience of incivilities within the social
environment and poor wellbeing’ (Airey, 2003, p133). Conflictual social relationships in
communities, therefore, may have a negative effect on young people’s psychosocial wellbeing.
4.2 Limited horizons: expectations and aspirations
Looking to the future with confidence may also be difficult for some disadvantaged young people.
The experience of disadvantage can be one of becoming accustomed to economic and social
limitations, and moderating expectations of life (Roker, 1998; Middleton et al. 1994; Ridge, 2002).
It is argued that, in time, children become used to living a restricted lifestyle (Roker, 1998); in other
words they learn how to go without (Middleton et al. 1994). The following quotations illustrate this
point:
I don’t usually go on trips ‘cos they are expensive and that…At our school they do loads of
activities and they go to loads of different places…I don’t bother asking. (male, age 11)
(Ridge, 2002, p77)
I just put up with the things I can do and accept the things I can’t do. (male, age 15) (Roker,
1998, p23)
28
Findings from these qualitative studies are borne out by survey research. The Small expectations -
learning to be poor study (1999) found, for example, that children who believe that their family
does not have enough money or only just enough money, and children who are frequently denied
items, are more likely to restrict demands on parents. Furthermore, children in lone parent families
are significantly more likely not to ask for items because they believe their parents cannot afford
them (Shropshire & Middleton, 1999). The authors suggest that early learning of this type may
reduce both children’s immediate expectations of life and their future aspirations. This survey
found, for example, that children from lone-parent or Income Support families express lower career
ambitions than children from two-parent and non Income support families. Young people’s
accounts also suggest limitations on their expectations of the future. Only half those taking part in
Roker’s (1998) study, for example, felt that they would be successful in obtaining jobs in their
chosen careers. Similarly:
I don’t know sort of like the future what’s going to happen and that. I might not get a good
enough job and that. (Cally, age 14) (Ridge, 2002, p106)
Young people in Willow’s (2002) study acknowledged the benefits of education, but a number were
unconvinced that they would be in a position to take advantage of the opportunities on offer.
4.3 Perceptions of poverty – living with ‘difference’
How children and young people talk about the impact of living in poverty differs according to
individual, social, and spatial characteristics. (Study authors also place emphasis on different
aspects of children’s experiences.) Children in Backett-Milburn et al’s (2003) study talked about the
29
experience of disadvantage, for example, in terms of social relationships, as much, or more than,
access to material resources. (As the analysis thus far has suggested however, such relationships
may be contradictory in their effects on young people’s wellbeing.) Roker (1998) found that the
majority of young people in her sample described their lives as ‘all right’ or ‘not bad’, and said that
they enjoyed their lives as much as other people (although a few children felt that their enjoyment
of life was marred by poverty). A number of young people in Ridge’s (2002) study also said that
living on a low income made little difference to their lives. (However, these were mainly younger
children (aged under 12) and predominantly male.) The majority of her sample said that poverty did
affect their lives, particularly in relation to changes experienced living on welfare benefits, pursuing
friendships and social activities, and the social costs associated with poverty. Those children whose
families had been reliant on benefits over a long period of time, and who perceived little possibility
of change, described the greatest impact of poverty.
I don’t know what it’s like not to be on benefits, so it’s not as if like I haven’t ever not been
on benefits. (Laura, age 15) (Ridge, 2002, p101)
Similarly, half of the young people questioned in Daly and Leonard’s study felt that their
circumstances were similar to their contemporaries, and one third said they were worse off.
However, those living in families on social welfare were most likely to feel badly off in comparison
to others.
The discourse that ‘poverty makes no difference’ is not reflected in children’s accounts, therefore,
nor is it universal. Some children felt embarrassed about their circumstances (Roker, 1998)),
30
particularly if they were excluded from social activities, while for others concern over keeping up
appearances was linked with fears of social rejection (Middleton et al. 1994; Daly & Leonard,
2002). The majority of Daly and Leonard’s (2002) respondents, for example, expressed concerns
about ‘fitting in’ with their contemporaries. Fears of being singled out as ‘different’ were associated
with low income, access to fashionable clothing, and bullying.
Being poor: that’s what I would change. All the kids have brand names…we haven’t. We
stick out and we’re picked on. Look at what I’m wearing, these crap runners [trainers]. You
get picked on for wearing these. (Daly & Leonard, p123)
So is it possible to reconcile this perceived inconsistency between the discourse and young people’s
lived experiences? Firstly, experiences of poverty for young people tend to be limited to their own
social circle (Backett-Milburn et al. 2003). When young people discuss ‘poverty’, therefore, they
may not relate the concept to their own lives. The dominant image of ‘the poor’ reflected in many
young people’s accounts is of homeless people, drug addicts and beggars, and people living in
neighbourhoods perceived as ‘unsafe’ (Roker, 1998; Willow, 2002; Backett-Milburn et al. 2003).
Studies with adults have suggested that comparing oneself favourably with other people may be
protective for psychological wellbeing (Sherrard, 1994; Airey, 2003). Perceiving poverty as an
abstract concept, of little relevance to their personal experiences, may be one way for young people
to preserve their self esteem.
Secondly, the context of poverty, the shared experience of hardship, can reduce the level of stigma
attached. If ‘everyone is in the same boat’ then disadvantage may be easier to tolerate (Roker,
31
1998). However, not all poor children live in deprived areas. There are ‘pockets of disadvantage’ in
otherwise prosperous neighbourhoods (Backett-Milburn et al. 2003). In these circumstances the
protective elements of neighbourhoods may be reduced, and vulnerability to teasing and bullying
correspondingly greater (Daly & Leonard, 2002; Ridge, 2002).
Finally, a further explanation of the disparity between what some young people say about poverty in
the abstract, and accounts of their lives, relates to theories of normalisation and illness behaviour.
One strategy which has been well described in the literature on illness behaviour is that
known as ‘normalisation’: rather than bear the threat to self esteem inherent in the admission
of a problem, many will find skillful ways to deny it. (Bartley et al. 1998, p570)
In order to protect their self esteem and psychosocial wellbeing, therefore, young people living in
poverty may underplay its impact, or display a superficial show of indifference (Ridge, 2002).
5. Discussion
This synthesis of qualitative studies has explored the ways in which children talk about the impact
of living in disadvantaged circumstances, and the protective resources and strategies open to them.
However, their accounts also highlight the contradictory and often fragile nature of the resources
open to poor children. What serves as a protective resource for some young people, may, in certain
circumstances, increase vulnerability to psychosocial stress for others. (Alternatively what is
protective at one stage of development may become less so as children grow older.) Figure 2
(below) clarifies these relationships.
32
Figure 2: Psychosocial pathways to health associate
Family NFriendship andsocial networks
Rural –youth,
Bullying -exclusion
Appearance -visible ‘difference’
Limited sharedactivities/space/resources
Emotional/practical support
Sense ofbelonging/personalsecurity
Appearance –‘right’ clothes
Friendship –support/protection
Selfaffirmation/reassurance
Potential stress/conflict
VULNERABILITY FACTORS
Material constraints– home/transport
d with m
eighbourh
‘visibility’scapegoatin
Codef
PROTECFACTOR
aterial disadvantage
ood
Urban – physical safety,conflictual social relations
ofg
ntested spaceended by adults
Shared inequality reduces‘difference’ and stigma
TIVES
Favourable socialcomparisons
33
Disadvantaged young people are not a homogeneous group, however. There are certain differences
between children living in poverty that require further exploration. Both protective and vulnerability
factors, and their effects on children’s wellbeing, are mediated by gender, ethnicity and age.
5.1 Gender
The majority of studies in this systematic review do not explore gender differences in the
experience of disadvantage, while the minority that do report few areas of difference. Roker (1998),
for example, found that twice as many young males in her study were currently (or had been)
involved in crime, compared to females. Fears for personal safety were more evident amongst girls
than boys in Morrow’s (2001) study (see also Beinart et al.2002).
Two studies indicate that boys and girls might experience friendships differently. Girls in Ridge’s
(2002) study, for example, were more articulate about friendships, which were valued primarily for
offering moral support and a source of confidants. Boys were more likely to stress the protective
role of friendship against bullying. Morrow (2001) also found that girls tended to give more detail
about their friendships, which were categorised according to importance, and looked for uncritical
support and trust from friends. Although boys talked about having fun with friends they also wanted
someone to listen to them, whom they could trust. It is uncertain, therefore, whether the difference
lies in the readiness of boys and girls to discuss friendships openly, or whether the meaning of
friendship, and its role in promoting emotional wellbeing, is indeed gendered (Ridge, 2002).
5.2 Ethnicity
Few of the studies in this review explore the experiences of disadvantage from the perspectives of
ethnic minority children. Four do not include any children from these groups (Middleton et al.
1994; Daly & Leonard, 2002; Ridge, 2002; Backett-Milburn et al. 2003), while David and Ridge’s
34
(1998) study of rural children in poverty describes one incident of racist abuse. Two studies include
children from ethnic minorities (Willow, 2002; Percy, 2003) but do not explore how ethnicity
mediates the experience of poverty.
Roker’s (1998) study includes seven children from African-Caribbean, Asian and Middle Eastern
families. Conclusions about the experiences of different ethnic groups are not made however,
because of the comparatively small numbers. The author explains that the researchers encountered
difficulties in recruiting children from Asian families.
The exception is Morrow’s (2001) research, in which cultural differences are explored as a factor
affecting young people’s friendships, leisure activities, social connections and resources. For
example, she explains how for Muslim children, parental expectations and religious commitments
affect friendships and social activities, and may require careful negotiation. Fear of racial
harassment is also highlighted as a factor with implications for children’s social participation and
emotional wellbeing.
5.3 Age
While gender or ethnic differences in children’s experience of disadvantage remain largely
unexplored, there is more evidence concerning age differences. The extent to which ‘keeping up
appearances’ in terms of appearances matters to young people, for example, differs by age. Ridge
(2002) suggests that older children (age 12 and over), and those living in urban areas, may be more
influenced by changing fashions, as the social demands on them may be greater.
If you don’t wear trendy stuff…not so many people will be your friend ‘cos of what you
wear. (Charlene, age 12) (Ridge, 2002, p68)
35
In contrast, in Backett-Milburn et al’s (2003) study, other markers of status, such as personality or
popularity, mediated the perceived importance of appearance for children. The participants in this
research were younger than the majority included in this review, however, and had not yet begun to
attend secondary school, a crucial time of transition for young people. For older children, therefore,
apparent lack of concern about ‘fitting in’ becomes more difficult to sustain, as the perceived gap
between their circumstances and those of their more affluent contemporaries grows more apparent
(Ridge, 2002).
Young people’s experiences are also affected by context; that is both the physical characteristics of
the home area and the qualities of the social environment, particularly in opportunities for social
interaction. In Davis and Ridge’s (1997) study, for example, the proportion of children content with
rural life diminished amongst older participants. Moreover the needs of 12 year olds (for example a
safe place to play), differ significantly from the needs of 15 year olds (space and resources to
conduct their social lives) (Morrow, 2001). The evidence suggests a differential impact of
disadvantage on older children therefore, linked with an increased awareness of economic and
social restrictions and a desire for greater involvement in social and leisure activities (Davis &
Ridge, 1997; Ridge, 2002). Vulnerability to the effects of disadvantage may therefore be greater for
adolescents, as issues of identity, competence and self esteem increase in importance (Ridge, 2002).
The contradictory nature of protective resources in disadvantage may also become more evident, for
example in conflict with parents, the role of peer groups in encouraging ‘risky’ behaviour, and the
greater ‘visibility’ of teenagers on neighbourhood streets.
6. Limitations of the study
Certain difficulties were encountered in carrying out this systematic review, which limit the extent
to which the evidence is ‘fit for purpose’; that is useful in providing insights into children’s
experiences (Boaz & Ashby, 2003). Simply finding the relevant studies was difficult; the non-
36
standardised language used, and inconsistencies in abstracting qualitative studies in databases were
particular problems (Sandelowski et al. 1997). Delays in obtaining primary papers, particularly US
theses, compounded the difficulties. However, the most important limitation was simply the lack of
qualitative studies carried out with disadvantaged children and the consequent paucity of the
evidence base. When quality appraisal criteria were applied the pool of relevant studies shrank still
further. Specific problems encountered were gaps in the reporting of methodology, lack of detail in
description of study context (and therefore potential transferability to other settings), and sampling
deficiencies (cf. Hawker et al, 2002).
There are study-specific sampling issues, however, which affect comparability in the synthesis. The
main question is whether we are comparing like with like. Ridge (2002), for example, includes lone
parent families, and two-parent families with a disabled parent or child in her sample. This sampling
strategy was intended to capture the experiences of those children living in families in receipt of
welfare benefits over a long period of time. However it does raise the question of the extent to
which the effects of living with a disability (a potential confounder) affected the findings.
Another difficulty arises with studies that use geographical areas as a basis for sampling (for
example, Backett-Milburn et al. 2003), because although area characteristics may indicate overall
disadvantage there are variations within areas that undermine such categorisation. The experiences
of children within ‘disadvantaged’ districts are likely to be more heterogeneous than samples
drawn, for example, from families living on welfare benefits.6 Such sampling strategies, while
providing useful comparisons between areas, may therefore mask the experiences of those children
most vulnerable to the effects of poverty.
6 The authors acknowledge this point.
37
Other differences between young people are not fully explored in the synthesised studies. Few UK
studies, for example, include children from ethnic minority backgrounds, who are at increased risk
of living in poverty (DWP, 2003). Gender differences in the experiences of disadvantage are not
described in-depth in the majority of studies, although the topics of friendship and perceptions of
safety suggest interesting avenues for further research.
7. Conclusions
The aim of this systematic review review was to synthesise research that takes as its focus
children’s subjective experiences of disadvantage. The evidence presented suggests that, while for
some young people, family, friendships and (to a lesser extent) neighbourhood factors mitigate
restrictions associated with economic hardship, contradictory elements associated with disadvantage
may undermine their potential protective effects for psychosocial health.
It has been argued that more research is needed to explore the dynamics of protective factors in the
lives of children and young people in poverty (Ridge, 2002). The evidence in this review also
suggests scope for further exploration of age-specific experiences of disadvantage, and of the views
of children from ethnic minority backgrounds. Attention to the ways in which young people
experience hardship in the context of different neighbourhoods would also contribute to an
understanding of the social resources available to disadvantaged children and young people, and the
ways in which these could be strengthened.
38
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Appendix 1: Search strategySearch terms
Population Mediating factors1 Child* or adolescen* or teenag* 36 Mediat*2 Youth or young 37 Protect*3 #1 or #2 38 Buffer*
Conditions of interest4 (explode) Economic conditions/ all subheadings Responses (behavioural)5 Disadvantage* 39 Behavi*r (risk* or harm* or damag*)6 Poor 40 Substance (use or abuse or misuse)7 Depriv* 41 Alcohol or drink*8 Low*income 42 Drug*9 #4 - #8 (or) 43 Addict*10 Housing or home*and #9 44 Smoking or tobacco11 Neighbo*r* and #912 Inequal*13 Resource* (economic or material or social) Responses (psycho-social)14 Circumstance* (economic or material or social) 45 Coping or cope15 Socio*economic status or SES 46 Resilien*16 Homeless* 47 Surviv*17 Social (status or context or capital) 48 Adjust*18 Social (exclusion or inclusion) 49 Adapt*19 Or/ #9 - #18 50 Hardiness20 #3 and #19 51 Coherence
52 AutonomyType of study 53 Control
21 Qualitative 54 Depress*22 Ethnograph* 55 Vulnerab*23 Interview 56 Psych* (health or wellbeing)24 Phenomenolog* 57 Psycho-social25 Grounded theory 58 Competen*26 Case study 59 Self (esteem or reliance or efficacy)27 Focus group 60 Or/ #36- #5928 Theoretical sample 61 #60 and #20 (display all)29 Analysis (content or narrative or discourse) 62 #61 and #3430 Participant observ*31 Participat*32 Observational33 Experience* (lived or life)34 Or/ #21-#3335 #20 and #34 (display all)
Electronic databases searched
IBSS Sociological research onlineIngenta Research Findings Electronic RegisterPsycINFO Health Abstracts Online (Science Direct)ASSIA CaredataSocial Science Citation Index HDA Evidence BaseRegard (ESRC) Medline (OCLC First Search)Cochrane Controlled Trials Register Copac (inc. British Library catalogue)National Research Register WorldcatSociological Collection & Academic Search
48
Key journals searched online or hand searched
British Medical Journal
Children and Society
Journal of Adolescence
Health and Place
Poverty
Qualitative Health Research
Key experts contacted
Jonathan Bradshaw
Ann Oakley
Tess Ridge
Madeleine Leonard
Mary Daly
Kathryn Backett-Milburn
Jan Pahl
Rebecca Rees
Mike Jones
Jorun Rugkasa
Auke Wiegersma
Virginia Morrow
Kate Healey
Alan Deacon
Tim Marsh
Marion Lacey
Bryony Beresford
49
Helen Roberts
Elizabeth Such
Paula Robeson
50
Appendix 2: Inclusion and exclusion criteria
Inclusion criteria Exclusion criteriaEnglish language only Non English languageGeographical coverageDeveloped, industrialised countries. Non-industrialised countries.Timing of studiesPublished from 1987 onwards Published prior to 1987Study methodsQualitative methods of data collectionand analysis.
Non qualitative methods and analysis
Population of interestStudies relating to children aged <18 Studies relating to people aged >18
Retrospective studiesConditions of interestStudies concerned with children living insocial and economic disadvantage(including homeless families)Studies relating to health inequalities inchildren – specifically the developmentof coping strategies/resilience.
Studies with an exclusively psychologicalfocus (i.e. no social context)Studies with an exclusivelycriminological focus (e.g. delinquency,anti-social behaviour)Studies with an exclusively educationalfocusChildren coping with disabilityYouth homelessnessStudies relating primarily to interventionoutcomes
Study typeStudies that include empirical evidence –primary research.
Book reviews, opinion pieces, literaturereviews.
Quality appraisalStudies which meet pre-determinedappraisal criteria
Studies which fail to meet qualityappraisal criteria.
51
Appendix 3: Sample of excluded studies: Stage 3
Name of study Source Reasons forexclusion
Bolger, K.E. Patterson, C.J. Thompson, W.W.Kupersmidt, J. B. (1995) Psychosocial adjustmentamong children experiencing persistent andintermittent family economic hardship. ChildDevelopment, 66(4): 1107-29.
ASSIA Notqualitativeanalysis
Buchanan, A. & Hudson, B.C. (eds.) (2000)Promoting children’s emotional wellbeing –messages from research. Oxford: OxfordUniversityPress. 0-19-263174-8
www.apsoc.ox.ac.uk/Publications_PublishedPapers.html Accessed 11/11/02
Review
Burton, G., Blair, M. & Crown, N. (1998) A newlook at the health and homeless experience of acohort of five year olds. Children & Society,12(5):349-58.
ASSIA Not children’sperspective
Comtois, K.A.1990 A qualitative study of perceivedcontrol in low socio-economic status urban youthThesis (M.A.)--University of Maryland OCLC:22638237
WorldCat Psychologicalfocus
Dennehy, A., Smith, L. & Harker, P. (1997) Not to beignored: young people, poverty and health. London:CPAG. ISBN 0946744904
Worldcat Review
Garis_D (1998) Poverty, single-parent households,and youth at-risk behavior: an empiricalstudy.Journal of economic issues, Dec 1998,Vol.XXXII, No.4, pp.1079-1106
IBSS Survey data
Ginsburg, K.R. Alexander, P.M., Hunt, J. Sullivan,M. Cnaan, A. (2002) Enhancing their likelihood for apositive future. Focus groups reveal the voice ofinner-city youth. Pediatrics, 109(6):art no -e95
SSCI Notqualitativeanalysis
Hood, S. (2001) The state of London’s childrenreport. London: Office of the Children’s RightsCommissioner for London. 0954132505
Personal Communication(NCB)
Review
Masten, A. S. (2002) Ordinary Magic: resilienceprocesses in development. American Psychologist,56(3):227-238.
Science Direct Psychologicalfocus
Nettleton, S. & Burrows, R. (2000) When a capitalinvestment becomes an emotional loss: the healthconsequences of the experience of mortgagepossession in England. Housing Studies 15(3):463-79.
ASSIA Reportedelsewhere
Polivka, B. J., Lovell, M. & Smith, B.A. (1998) Aqualitative assessment of inner-city elementaryschool children’s perceptions of their neighbourhood.Public Health Nursing, 15(3):171-79.
Bibliography Notqualitativeanalysis
Shropshire, J. & Middleton, S. (1999) Smallexpectations: learning to be poor. York Publishing
Caredata Survey data
52
Services, York.Tuinstra, J. (1998) Health in adolescence: anempirical study of social inequality in health, healthrisk behaviour and decision-making styles. Thesis(Dr.) Gronigen Univ. (NL)
Sigle Quantitativeanalysis
Weinger, S. (2000) Children’s perceptions of classdifferences: worries and self perceptions. Journal ofPoverty, 4(3):99-117.
CareData Reportedelsewhere
53
Appendix 4: Quality Appraisal Checklist
Main reviewerID No.Brief reference Authors and datePurpose What are the aims of the study?Study type What kind of research design was used?Methods used Brief description of methods
StudyOverview
Evaluativesummary
Study’s main findings.Strengths and weaknesses of the research.
Background ofresearch
Source of funding (relationship to findings?)Name of study, if applicable.Is the connection of the research to an existing bodyof knowledge or theory clear?
Aims andobjectives
Is there a clear statement of the aims of the research?Are the research questions clear?
Context Is the context or setting adequately described?Appropriatenessof design
Are qualitative methods appropriate?Is the research design appropriate to address the aimsof the research? Is it ‘fit for purpose’?
Sampling Is the sampling strategy appropriate to address theresearch aims?Which criteria were used to select the sample?Does the sample include an adequate range ofpossible cases or settings?Is the sample size justified? (Data saturation.)Did any participants choose not to take part in thestudy? Why?
StudyAppraisal
Data collection Is it clear how data were collected?Is the form of data clear (eg. tape recordings,fieldnotes, etc)?Were any methods modified during the researchprocess? Why?Does data collection involve triangulation (ofmultiple methods or data sources)?Is there evidence that data collection was systematic(eg. an ‘audit trail’)?
54
Data analysis How was the analysis carried out?Are sufficient data presented to support the findings?How were data selected for inclusion in the report?Do the findings directly address the researchquestion?Does the research privilege subjective meaning?What steps were taken to demonstrate thetrustworthiness of the findings (eg. negative cases,respondent validation)?Have the limitations of the study and their impact onthe findings been taken into account?
Reflexivity Has the relationship between researchers andparticipants been adequately considered?Do the researchers reflect on their personalviewpoints and experience that they bring to theresearch setting?
How valuableor useful is theresearch?
Does the research add to knowledge, or increase theconfidence with which existing knowledge isregarded?What are the implications for policy and practice –how is it ‘fit for purpose’?
Ethics Have ethical issues been taken into consideration(eg. consent, confidentiality, anonymity, distress toparticipants)?
QUALITYSTATUS
A, B, C, D A – No or few flawsB – Some flawsC – Considerable flaws, study still of some valueD – Significant flaws that threaten the validity of thewhole study
55
Appendix 5: Data Extraction Form
ID NumberSource of Reference
Names of authorsContact details ofprincipal authorDate of publicationTitle of paperTitle ofjournal/book;volume;page numbers
Bibliographic Details
Language of paperQuality status A,B,CResearch setting Description of contextPopulation studied Description of participantsAims of studyMain findingsOther commentsReviewer name and date
56
Appendix 6 :Main themes and conceptsBackett-Milburn et al,2003
Daly &Leonard,2002
Davis &Ridge, 1997
Middleton etal, 1994
Morrow, 2001 Percy, 2003 Ridge, 2002 Roker, 1998 Willow, 2002
Familyrelationships
Importance ofgood parents -positivemental health.Emotionalresources andsupport.Effects ofpovertymitigated byparents.
Reliance onimmediatefamily. Halfchildren citedfamily as bestpart of theirlives.
- Interpersonalrelationshipscrucial tosense ofbelonging andwellbeing.Parents sourceof emotionalsupport – byjust ‘beingthere’.
Contacts withwider kinimportant.
Relationshipswith familymembers(usuallymother)‘special’.Feeling loveddemonstratedby mothers’caretakingactivities.
Responsibilityfor youngersiblings.
Attempts toprotect parents–mindful offamilysituation.Relationshipwith parentsimportant.Poverty assharedexperience.
.Supportiveaspects ofparenthood‘always therefor them’ –emotional andpractical (esp.singleparents).But conflict –disputes overspace, privacy,restrictionfamilyactivities.
Role ofparents andfamily –loving careand emotionalsupport.Closeness inadversity.
Pressures onparents tomeet needsand wants –can lead toconflict andfrustration.
Financialstrategies
Appeals towider kin(gifts &transactions).
Pocket moneymain source ofincome(amounts tendto be low).Baby-sitting,part-time work(only 1 in 7),odd jobs.Contributionto familyincome –direct orindirect.
- Childrencontribute todesired items(pocket moneyor earnings).Range ofpersuasionstrategies -parents. OlderLA childrenaware offinancialimplications(e.g. obtainingclothes).Saving as astrategy (olderchildren).Targetingwider kin.
- - Two-thirdsreceived littleor no pocketmoney. Paidwork olderchildren:money forsocial life &possessions.Contributionto familybudgets (inkind).
Contributionsto familyincome (onethird sample);contributionsin kind – e.g.agreement tohave less (orno) pocketmoney. Olderchildren part-time work (butpocket moneydiminishes).Save forfuture. Avoiddebt.Distinctionbetween needsand wants.
-
57
Backett-Milburn et al,2003
Daly &Leonard,2002
Davis &Ridge, 1997
Middleton etal, 1994
Morrow, 2001 Percy, 2003 Ridge, 2002 Roker, 1998 Willow, 2002
Friendshipsand sociallives
Importance ofrelationshipswith peers –acceptance bypeer group.Notions offairness, notbeing bullied.
Few childrenmentionedfriends – moreemphasis onrelationshipswith familymembers.Activities –mainly free –‘hangingaround’ withfriends,watching TV,listening tomusic.
School: fewchildren wenton overnighttrips or longerholidays.
Lack ofopportunity forplay andassociation(crampedhousing, coststransport, fewactivities)(rural)Children ‘feelleft out ofthings’
School: Afterschool andholidayactivities –exclusion fromparticipationbycost/transport.
More affluentchildren –greater variety,morestructuredactivities. Lessaffluent –more TVwatching.Fewerholidaysabroad, shorterduration.
School: Costof school trips– pressure onparents. (Lessaffluentchildren morereliant onschool trips.).
Friendship –theme ofuncriticalsupport, trustand ‘beingthere’ for oneanother,keepingsecrets (girls).Sharedactivities,loyalty,listening, trust– a ‘shoulderto cry on’(boys). Being‘part of thegroup’ crucial.
Activitiesaffected bycost oftransport andfacilities,parentalnorms.
School –important forsocialinteraction.
Importance of‘having friendsto count on’ –emotional andsocial support.Keepingsecrets.
Paradox: forolder boysfriendshipcontingent ongangmembership.
Maintenanceof friendshipsaffected by:space in home,cost (limitedresources),cost/accessibility of transport(rural).Problem ofreciprocity.Missing out onparticipation,meeting associal group.School trips –importantsocial events.
Seeing friendsa problem(esp. rural).Leisureactivitiesrestricted bycost/transport/lack telephone.
School: Costschool trips &equipment –restrictsparticipation.
Leisureactivities andfriends –important toconfidence andmotivation.Left out ofactivities(eating out,holidays,leisure).
School:excluded fromschool trips,disco.
58
Backett-Milburn et al,2003
Daly &Leonard,2002
Davis &Ridge, 1997
Middleton etal, 1994
Morrow, 2001 Percy, 2003 Ridge, 2002 Roker, 1998 Willow, 2002
Keeping upappearances
Access tofashionableclothes -evaluated interms of peerresponses.Other markersof statusimportant (e.g.popularity)
Clothes – basisof distinctionamongstchildren.Appearing‘different’ canlead tophysical andverbal abuse.
Fear of beingseen as‘different’ –lackfashionableclothes
Pressure towear‘acceptable’clothes. Verbalabuse andexclusion.Dislike 2nd
hand clothes.
School: costuniform
Appearanceimportant aspart of‘blending inwith the rest ofthe group’.
- Under pressureto ‘fit in’ andpresent the‘right’appearance (12critical age forselfawareness).(May be moreimportant inurban areas).
School:uniform codes
- Childrenbullied forwearingshabby or outof dateclothing.Marginalisation and ridicule.
School: costuniform.
Limitedhorizons:expectationsandaspirations
Childrenmoderatedemands byperception ofavailableresources.
Perceivedabsence ofopportunitiesin local area.Committed tovalue ofeducation;high jobaspirations.Childrencurtaileddemands inresponse toparents’financialcircumstances.
Awareness ofcosts andconstraints(transport &schoolactivities).
LA childrenlimitedaspirations andhorizons(participationin activities).Learn not toask and how togo without.
- - Self-exclusion– school trips.Participationleisureactivities –self- limiting.Perception ofneedsatisfaction –awarenessfutility ofasking parents.Resignation –acceptance ofrestrictions.
Littleanticipation ofparticipation inleisureactivities –used to livinga ‘restrictedlifestyle’Agreement tohave less (orno) pocketmoney & ‘notask parents forstuff’.
Children failto pass oninformationabout schooltrips toparents.
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Backett-Milburn et al,2003
Daly &Leonard,2002
Davis &Ridge, 1997
Middleton etal, 1994
Morrow, 2001 Percy, 2003 Ridge, 2002 Roker, 1998 Willow, 2002
Neighbourhood socialenvironment
Experience ofunfairness –adultsexercisingpower – e.g.street play,movingchildren on.Very poorareas seen as‘unsafe’
Areadifferences –urban areaperceived as‘unsafe’. Joyriding anddrug misuse
Rural spacedefended byadults –‘nowhere to goand nothing todo’.‘Visibility’ ofchildren –adult scrutinyanddisapproval.
- Experiences ofneighbourhooddiffer bygender (girlsfeel unsafe),ethnicbackground(racialharassment)and age.Problems –traffic,‘trampyplaces’, fear ofcrime.Mistrust fromadults – lackof respect,‘dirty looks’.‘Moany’neighbours.
Neighbourhood violence andgang activity –sense ofdanger.
Localneighbourhoodunsafe,potentialviolence,danger (urbanareas).Overlooked byhostile adults,harassment.Traffic &safety.
Gangactivities/rivalries (Scotland).Law breakingseen as the‘norm’ insome areas.Young peopleas perpetrators& victims ofcrime.
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Perceptions ofpoverty
Downplayingof inequality.Discourse of‘no difference’– while citingexamples ofdifference.Experience ofinequalitylimited to ownexperience &social circle(relative).
Majority hadconcerns –pressure to ‘fitin’ with peers.Fears offeelingdifferent orexcluded.
. Concern withappearance(e.g. 2nd handclothes) –associationwith poverty,fear of peerrejection.
- - Youngerchildren – said‘no difference’but accountsshowed impactof low income.Resignation -acceptance ofrestrictions.Show ofindifference –‘saving face’.
Acceptance –‘simply theway life is’.Comparativesatisfaction.Some negativeresponses –embarrassment, exclusionfrom ‘normal’social life.
Images ofpoverty –beggars andhomelesspeople.
Worry aboutmoney andfamilydifficulties(children asyoung as 7).Shame andembarrassment.
