Unintentional injuries and violence among adolescents aged 12–15 years in 68 low-income and middle-income countries: a secondary analysis of data from the Global School-Based Student Health Survey
Injuries and violence account for a substantial proportion of the global burden of disease in adolescents, especially among low-income and middle-income countries (LMICs). We aimed to compare the prevalence of unintentional injuries and violence among young adolescents in LMICs.
Methods
We did a secondary analysis of data from the Global School-based Student Health Survey (GSHS) for adolescents aged 12–15 years from LMICs collected between 2009 and 2015. Survey data was collected using a standardised questionnaire. We used survey data to calculate the overall prevalence of serious injuries and violence (eg, physical attack, physical fighting) and bullying per country. We did a random-effects meta-analysis to calculate pooled overall and regional estimates. We also did subgroup analyses stratified by sex, age (12–13 years vs 14–15 years), and time period (2009–11 vs 2012–15). Logistic regression models adjusted for sex, weights, stratum, and primary sampling unit were used to analyse the differences in prevalence of serious injuries, violence, and bullying.
Findings
We included data from 68 LMICs, including 164 633 young adolescents (77 707 [47·2%] boys; 86 926 [52·8%] girls). The overall prevalence of physical attack, physical fighting, and serious injuries during the past 12 months were 35·6% (95% CI 30·7–40·5), 36·4% (29·9–42·9), and 42·9% (39·0–46·9), respectively. Prevalence varied by WHO region and was higher among boys than girls for injuries (47·8% vs 37·5%, p=0·00094), physical attack (41·0% vs 29·4%, p=0·001), and physical fighting (45·5% vs 26·9%, p<0·0001). Fractures (22·6%, 95% CI 19·1–26·1) and cuts (21·8%, 16·8–26·8) were the most common types of serious injury, and falling was the main cause of these injuries (33·1%, 30·2–35·9). The overall prevalence of bullying at least once in the past 30 days was 34·4% (27·1–41·7), irrespective of age and sex. The most common types of bullying were physical (18·3%, 13·7–23·0), verbal–sexual (13·2%, 10·2–16·2), and racial–ethnic (11·6%, 9·2–14·0).
Interpretation
The prevalence of unintentional injuries and violence remain high among young adolescents in LMICs. These countries should prioritise the development of anti-violence and anti-injury programmes to improve health in their young adolescent populations.
Funding
National Natural Science Foundation of China, National Key R&D Program of China, Natural Science Foundation of Zhejiang Province, Sanming Project of Medicine in Shenzhen, K.C. Wong Magna Fund in Ningbo University, and Ningbo Scientific Innovation Team for Environmental Hazardous Factor Control and Prevention.
Introduction
At present, the adolescent population is larger than ever before. Around 1·2 billion young people are adolescents aged 10–19 years, accounting for almost a quarter of the global population.1 Although childhood mortality has decreased by more than 80% over the past 50 years worldwide, the rate of adolescent mortality has only decreased by 50%. This discrepancy is largely due to static or increasing rates of injury-related mortality in the adolescent population.2 Traffic accidents, suicide, violence, drowning, and fire-related deaths account for nearly 40% of all youth mortality, but only 10% of deaths among people aged older than 25 years.3 The high prevalence of injury and violence among young populations constitutes a serious public health problem, especially since injuries and violence experienced during adolescence have the potential to cause lifelong disabilities or psychological and behavioural problems.4
The global burden of mortality is excessively concentrated in low-income and middle-income countries (LMICs), with more than 90% of all deaths among children.5 Among the causes of all deaths, about 91% of unintentional injury-related deaths occur in LMICs.5 Since the 1950s, the burden of some types of injuries (eg, road injuries and falls) has increased in LMICs.2 Understanding the distribution of injuries and violence among adolescents is crucial for educational campaigns, evidence-based planning, priority setting, and resource allocation for prevention and control in LMICs.
Research in context
Evidence before this study
We searched PubMed from database inception to Feb 15, 2019, for relevant articles that included the search terms “violence” or “injur*” or “physical attack” or “physical fighting” or bully* AND “youth*” or “adolescent*” or “child*” in the title, and described studies done in low-income and middle-income countries (LMICs). The majority of evidence reported findings of the Global Burden of Diseases, Injuries, and Risk Factors Study and most data was obtained from registries and other hospital-related data sources and focused on injury-related or violence-related mortality. However, a few studies used standardised methods to comprehensively assess the prevalence of injuries and violence among adolescents in LMICs. Our search identified seven articles describing primary research based on the Global School-based Student Health Survey. Most of these studies were based in a single country or region. We identified three relevant articles published after 2003 that were based on comparisons of multiple LMICs and used standardised questionnaires, focusing on specific types of injury and violence.
Added value of this study
This study is based on nationally representative data that are comparable across countries. To the best of our knowledge, this is the first study to comprehensively report country-level and overall estimates of the prevalence of injuries and violence among adolescents (aged 12–15 years) for 68 LMICs or regions. We found that adolescents in these countries or regions frequently reported physical attack, physical fighting, serious injuries, and bullying, and significant regional differences were observed. The overall prevalence of all unintentional injuries and violence, with the exception of bullying, were higher among boys than girls. The most common types of serious injury were fractures and cuts, and these were mainly attributed to falls. The most frequent types of bullying were physical, verbal–sexual, and racial–ethnic.
Implications of the available evidence
The findings of our study confirm that the prevalence of injuries and violence among adolescents remains high in LMICs. We reported sex-specific and region-specific variation in prevalence of injuries and violence, and the different types and causes of injury and bullying, which might help health systems to devise targeted interventions to meet the variable needs of adolescents in LMICs.
To date, several surveys have focused on injuries and violence affecting adolescents in LMICs, including the Demographic and Health Surveys6 and Violence Against Children Surveys.7 However, these surveys mainly focused on specific types of injury or violence—eg, the Demographic and Health Surveys assessed intimate partner violence and the Violence Against Children Surveys assessed physical, emotional, and sexual violence. By contrast, the Global School-based Student Health Survey (GSHS)8 is an ongoing multicentre, multiethnic, school-based collaborative surveillance project developed by WHO and the Centers for Disease Control and Prevention. The primary aim of the GSHS is to help countries assess the main behavioural factors associated with the leading causes of morbidity among adolescents. Since the initiation of the GSHS in 2003, three studies9, 10, 11 have reported findings for injuries or violence among adolescents using GSHS datasets; however, two of the studies9, 10 only analysed the overall prevalence of bullying and physical fighting, and the third study11 focused on serious injuries and only reported selected types and causes—eg, only reporting prevalence of injuries due to motor vehicle incidents, but not for other causes.
With the inclusion of an increasing number of countries in the GSHS dataset, the publication and analysis of more recent data is required. Thus, we used the most current GSHS datasets (published since 2009), to assess the prevalence of violence-related variables (eg, physical attack, physical fighting, and bullying) and serious injuries, and types and causes of injuries and bullying among young adolescents in LMICs.
Section snippets
Data sources
We did secondary analysis of GSHS datasets from 68 LMICs or regions collected between 2009 and 2015. We excluded surveys done before 2009 because a new version of the questionnaire that included an unintentional injuries and violence module was introduced in 2009, and thus surveys done before this time did not include this module.
All GSHS surveys use the same two-stage cluster procedure to sample a representative subset of middle-school students.8, 12 In the first stage, schools are randomly
Results
We identified 94 LMICs with GSHS datasets, of which three were incomplete and 26 used an older version (pre-2009) of the questionnaire. Thus, we included survey data from 68 LMICs or regions in our analysis (figure 1). These surveys were done across five WHO regions: 11 datasets were from the African Region, 22 from the Region of the Americas, 11 from the Eastern Mediterranean Region, five from South-East Asia Region, and 19 from the Western Pacific Region (table 2). The overall survey response
Discussion
Our analyses indicated high overall prevalence of physical attack (35·6%), physical fighting (36·4%), serious injuries (42·9%), and bullying (34·4%) in adolescents aged 12–15 years across 68 LMICs, with significant regional variation. The prevalence of physical attack, physical fighting, and serious injuries were significantly higher among boys than girls. The most common serious injuries were broken bones or dislocated joints (22·6%) and cut or stab wounds (21·8%), and falls were the main
Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
Lancet
(2017)
LF Chiang et al.
Violence Against Children Surveys (VACS): towards a global surveillance system
Inj Prev
(2016)
Global school-based student health survey (GSHS)
FJ Elgar et al.
Corporal punishment bans and physical fighting in adolescents: an ecological study of 88 countries
There is a scarcity of literature on temporal trends in physical fighting and physical attacks among the global adolescent population. Therefore, we aimed to examine these trends in a nationally representative sample of school-going adolescents aged 12–15 years from 30 countries in Africa, Asia, and the Americas, for which temporal trends of physical fighting and physical attacks are largely unknown.
Cross-sectional data from the Global School-based Student Health Survey 2003–2017 were analyzed. Self-reported data on past 12-month physical fights and physical attacks were collected. For each survey, the prevalence and 95% confidence interval of physical fights and physical attacks were calculated. Linear regression models were used to examine crude linear trends.
Data on 190,493 students aged 12–15 years were analyzed [mean (standard deviation) age 13.7 (1.0) years; 48.9% boys]. The mean prevalence of past 12-month physical fight and physical attack was 36.5% and 37.2%, respectively. Significant decreasing trends in physical fights were observed in 16/30 countries, while significant increasing trends were found in 2/30 countries. For physical attacks, significant decreasing and increasing trends were observed in 13/26 and 1/26 countries, respectively. The remaining countries showed stable trends.
It is encouraging that decreasing trends in physical fighting and physical attacks were observed across a large number of countries. However, stable trends were also common, while increasing trends also existed, suggesting that global efforts to address adolescent violence are still required.
Injuries during adolescence cause lifelong harm and death. Our study used a nationally representative sample to examine the prevalence and risk factors associated with serious injuries among in-school adolescents in Panama.
We analysed Panama’s 2018 Global School-Based Student Health Survey data using SPSS. Percentages were used to summarise the results of the prevalence of serious injuries. Binomial logistic regression analysis was performed to examine the risk factors of serious injuries. The results were presented as an adjusted odds ratio (AOR) at a 95% confidence interval (CI).
The prevalence of serious injury among in-school adolescents in Panama is 45%. Furthermore, the study found that males (AOR= 1.495, CI=1.272--1.756), truancy (AOR=1.493, CI=1.249--1.785), overweight (AOR= 1.246, 95% CI=11.057--1.469), drinking alcohol (AOR= 1.397, CI=1.151--1.695), experiencing physical attack (AOR= 2.100, CI=11.646--2.681), engaging in a physical fight (AOR=1.586, CI=1.289--1.952) and bullied outside school (AOR=1.276, CI=1.005--1.621) significantly predict serious injuries among adolescents in Panama.
Multidisciplinary approaches targeting the correlates observed will help reduce the high prevalence of serious injuries among in-school adolescents in Panama.
To verify the association between victims of bullying and weapon possession among school adolescents.
This cross-sectional study was carried out with 2,296 high school students aged 14–19 years. An instrument containing questions from the validated Youth Risk Behavior Survey questionnaire and the National School Health Survey was used. To describe the profile of interviewees, absolute and relative frequencies were calculated, and the chi-square test was applied to verify the existence of associations. To test the association of bullying with weapon possession, Poisson logistic regression (univariate and multivariate) was used. The significance level used for all analyses was 5%.
Among adolescents interviewed, 23.1% reported being victims of bullying. Among victims of bullying, 37.6% (PR = 1.68; 95% CI = 1.30 – 2.17) reported having already carried some type of weapon (knife, revolver, or truncheon) in the last 30 days, while the reported firearm possession was 38% (PR = 1.67; 95% CI = 1.16 – 2.40) and 47.5% of these adolescents carried some type of weapon (knife, revolver or truncheon) in the school environment (PR = 2.10; 95% CI = 1.50 – 2.93).
It could be observed that adolescents who are victims of bullying are twice as likely of carrying some type of weapon (knife, revolver, or truncheon) to the school environment, and are also more likely of carrying a firearm.
Adolescents are exposed to a wide range of high-risk health behaviors. This study aimed to investigate the high-risk health behaviors of adolescents in an Iranian adolescent population and gender differences.
This cross-sectional descriptive study recruited high school students in Yazd city in center of Iran. Schools were randomly selected. In each school, all selected classes were included. Sampling in each class was census. The study investigated self-reported high-risk health behaviors. Students completed the Global School-based Student Health Survey (GSHS), an anonymous, validated questionnaire.
2420 students participated in this study (52.5% male). The age range was 12–19 years. Daily consumption of ≥1 serving of fruit and vegetables per day was reported by 77.4% and 49.5% of respondents, respectively. Adequate physical activity was reported by only 18.4% of adolescents, and significantly less frequently by girls than boys (p < 0.001). 11.8% were current smokers (M/F ratio: 2.6), and 20.5% (M/F ratio: 1.5) were ever used hookah. The prevalence of ever alcohol and substance abuse was 15.5% and 8.8%, respectively. The prevalence of tobacco and substance use was significantly higher in participants' boys than in girls (p < 0.001). Males were over twice more likely to report frequent fighting in the past 12 months than girls. Overall, girls reported more parental supervision than boys (82.1% vs. 73.4%) and parental monitoring (90.6% vs. 86.8%), while boys reported higher levels of awareness over leisure activities than girls (65.8% vs. 58.4%).
High-risk health behaviors are more common in boys than girls. Health policymakers should use these results in prioritizing and designing health interventions to promote youth health. Further studies are recommended to identify the factors influencing the prevalence of these behaviors.
To examine geographical variations in involvement in physical violence and sleep disturbance among adolescents.
Cross-sectional study.
Eighty-nine low- to middle-income and high-income countries
Adolescents 13-17 years of age.
Multiple binary logistic regression analyses and meta-analyses were performed to assess the link between physical violence (number of physical fights) and sleep disturbance ("mostly" or "always" experienced worry-induced sleep loss).
Among 296,212 adolescents, 8.9% reported sleep disturbance (male: 7.5%, female: 9.6%), with the highest prevalence among adolescents from the Eastern Mediterranean region (14.1%) and high-income countries (14.1%). Overall, sleep disturbance prevalence increased gradually with the increased episodes of physical violence. Adolescents who were involved in physical violence once, 2-3 times, and 4+ times were respectively 18%, 26%, and 77% more likely than their counterparts to experience sleep disturbance (1 time: OR 1.18, 95% CI 1.13-1.24; 2-3 times: 1.26, 1.20-1.34; 4+ times: 1.77, 1.66-1.88). The association between physical violence and sleep disturbance was observed in all regions and country-income groups, with the highest odds of sleep disturbance among adolescents experiencing 4+ times of physical violence in the European region (2.34, 1.17-4.67) and upper-middle-income countries (1.91, 1.73-2.11). The association of physical violence with sleep disturbance by sex was significant in all regions and country-income groups, except the European region.
Exposure to physical violence is associated with increased odds of sleep disturbances in adolescents. School and community-level interventions, vigilance, and programs to promote violence-free environments may improve the sleep health of adolescents exposed to physical violence.
Meteorological factors are a critical component of a sustainable society, especially in the context of climate change. Although studies have linked key meteorological factors to unintentional injuries, their joint effects on the occurrence of unintentional injuries remain unclear. We conducted a case-crossover study using a sentinel-based injury database in a mega-city in China and identified the vulnerable subgroups by demographic and injury characteristics. We observed significantly increased cumulative risk associated with each interquartile range increase in temperature (excess risk [ER] range=4.78–7.05%) and precipitation (ER range=1.00–2.09%) from lag0–1 day onwards. Conversely, there was a significantly decreased risk with relative humidity (RH) from lag0–2 days onwards (ER range=-2.83 to -2.10%). The link between meteorological factors and unintentional injuries was worthy of particular attention for the working-age groups, males, and those with fall-related injuries, road-related injuries, or fractures. Climate conditions with high wind speed (WS) and temperature combined with low precipitation and RH exhibited the greatest ER. The ER of high WS and RH, combined with low precipitation and temperature, was also significant. These key factors may jointly contribute to unintentional injury, which is important for evidence-based climate mitigation and injury prevention.