Articles
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

https://doi.org/10.1016/S2352-4642(19)30195-6Get rights and content

Summary

Background

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

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