Adolescents are more prone to injuries due to the risk taking and sensation seeking behaviors (15). This first national survey conducted among school going adolescents after GSHS-2008 indicated that the common finding in the study group includes serious injuries necessitating medical attention and missing out daily activities. Approximately one in three children in 13-17 years age group were seriously injured at least once within the 12 months prior to the survey. The prevalence of unintentional injuries has not changed over the years. Similar prevalence (37.2%) was found in GSHS-2008 among 13-15 years age group (16), which indicates the necessity of novel public health approaches to combat this serious menace.
Unintentional injuries are a major contributor to the adolescent mortality and morbidity. Direct comparison of results between countries and even within the country, across different studies, is difficult due methodological differences (e.g. age of the study population). However, the comparison of GSHS studies provides useful information as they have used uniform definitions and study populations. Han et al (2019) conducted a secondary analysis of GSHS data from 68 LMIC countries. The overall incidence of serious injuries among 12-15 years old adolescents was 42.9% (3), which means that one in two adolescents have been seriously injured during the past 12 months. Similar to other LMIC countries, our study indicates that adolescent non-fatal injuries have the capacity to affect the daily activities of the school going adolescents.
Current study was conducted as a community-based study, which is able to paint a comprehensive picture of injuries as compared to hospital based studies (17, 18). This is best described as an injury pyramid based on the level of medical treatment of injury victims (19). The apex of the pyramid represents the injuries necessitating hospitalization, which are relatively small in number, whereas lower parts of the pyramid represents the more numerous injuries, which are of lesser severity. Since hospital-based studies can identify injuries that required hospitalization, they will only address the apex of the injury pyramid, which is the tip of the ice berg. Therefore, it is imperative to conduct community-based studies on adolescents’ unintentional injuries to identify true magnitude of the problem.
Major limitation in comparing incidence data of unintentional injuries across studies is the lack of consistency in its assessment, recall period, and definitions. It has been found that there is a wide variation in incidence of injuries with varying recall periods. The results of studies using diverse recall periods cannot be compared without bearing in mind the factors affecting such differences (20). However, since GSHS has been conducted in several countries and it has used a consistent definition and a recall period, so it enables meaningful comparison across countries. Analysis of GSHS data of 13 to 15 years old school students of Indonesia, Myanmar, Sri Lanka and Thailand for identifying the burden of serious injuries among school students has reported a prevalence of 42.2% for all countries, ranging from 27.0% in Myanmar to 46.8% in Thailand (21). It indicates that the prevalence among low and middle-income countries is uniform across countries. However, relatively low figures have been reported from developed countries (9, 22).
Boys are more prone to serious injuries that necessitate medical attention and/or lead to missing out daily activities, which was re-instated by the current study. Male gender was found to be significantly associated with the occurrence of unintentional injuries in the present study. This was in line with some other studies which had shown similar sex differences in injury rates (23-25). This might be explained by the fact that males have a higher probability of risk taking behavior, are physically more active, and have more probability of engaging in competitive sports (26, 27). Several studies have demonstrated that older adolescents are more prone to unintentional injuries (28, 29). However, similar to GSHS results in 2008, the present study has failed to demonstrate this association.
Current study found that falls and motor vehicle accidents are the most common causes of unintentional injuries among the school going adolescents, and similar studies have found these two to be the most common etiologies for the injuries (21, 30, 31). Similarly, a large-scale household survey conducted to assess the epidemiology of unintentional injuries in Nepal has reported falls as the commonest cause for unintentional injuries among adolescents (32). Likewise, vehicle accidents too are a leading cause of non-fatal injuries among adolescents (33). Evidences indicate that vehicle accidents among adolescents cause a sizeable economic burden due to loss of productivity and medical costs (34). Furthermore, it has been shown that the commonest vehicle involved in these accidents is motor cycle, and most of the injured children were not wearing helmets at the time of injury (30). Riding motor cycle without a helmet is common among adolescents in Sri Lanka, which indicates a serious public health problem among adolescents, thus it needs urgent attention (35). This study has also reported that fatal road traffic accidents are more commonly seen among boys than in girls.
Though physical attacks have contributed to only 2.7% of all injuries, being in a fight was significantly associated with being injured. Violence leads to 5.8% of injury related deaths among children below 17 years globally, and is more commonly seen among older adolescent groups (2). Therefore, more attention should be given to interpersonal violence among school children.
In addition to ill health, serious injuries also have dire effects on school performance. Thus, proper attention should be given to impose remedial measures for this problem. Knowledge about the extent and correlates of the problem is a valuable asset while designing remedial measures. According to the current study, male sex, being bullied, being physically attacked and/or being in a physical fight were associated with obtaining serious injuries. Identification of such vulnerable populations should be targeted while planning interventions for injury prevention.
This study has several limitations. Firstly, as the study was conducted among the school going adolescents, generalizing the findings to the entire adolescent population in Sri Lanka is not possible, as their circumstances may differ significantly. Secondly, the standard questionnaire used in the study did not have the location of the injury occurrence. This could have been an important piece of knowledge to plan the intervention. Thirdly, the study population was schooling adolescents between 13 to 17 years, and does not represent the total schooling adolescent population as according to WHO, an adolescent is defined as an individual between 10 to 19 years of age. Fourthly, current study only included adolescents attending government schools, excluding those who attend private schools in the country. However, since private school attendees comprise only 3% of the school going population(36), authors believe that the current sample adequately represents the total school going population. Finally, recall bias is a possible limitation, as information were inquired regarding last 12 months, and participants may not be remembering the information accurately.