Adolescents are more prone to injuries due to risk taking and sensation seeking behaviors (15). This first national survey conducted among school going adolescents after the 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 the 13-17 year age group was seriously injured at least once within the 12 months prior to the survey. The prevalence of unintentional injuries has not changed over the years. A similar prevalence (37.2%) was found in the GSHS-2008 among 13-15 year olds (16), which indicates the necessity for novel public health approaches to combat this serious menace.
Unintentional injuries are a major contributor to adolescent mortality and morbidity. Direct comparison of results between countries and even within the same 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 year old adolescents was 42.9% (3), which means that roughly one in two adolescents has 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 school going adolescents.
The current study was conducted as a community-based study, which is able to paint a more comprehensive picture of injuries when 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 represent 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 iceberg. Therefore, it is imperative to conduct community-based studies on adolescents’ unintentional injuries to identify the true magnitude of the problem.
A major limitation in comparing incidence data of unintentional injuries across studies is the lack of consistency in their assessment, recall periods, and definitions. It has been found that there is a wide variation in the 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 GSHSs have been conducted in several countries and they have all used a consistent definition and a recall period, it enables meaningful comparison across countries. Analysis of GSHS data of 13 to 15 year old school students of Indonesia, Myanmar, Sri Lanka and Thailand for the purpose of identifying the burden of serious injuries among school students has reported an overall prevalence of 42.2% for all countries, ranging from 27.0% in Myanmar to 46.8% in Thailand (21). These figures indicate 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 fact was corroborated by the current study. The 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 may 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 the GSHS results of 2008, the present study has failed to demonstrate this association.
The current study found that falls and motor vehicle accidents are the most common causes of unintentional injuries among 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 are also a leading cause of non-fatal injuries among adolescents. (33) Evidence indicates 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 the motor cycle, and most of the injured children were not wearing helmets at the time of injury (30). Riding motor cycles without a helmet is common among adolescents in Sri Lanka, which points to a serious public health problem among adolescents that needs urgent attention (35). This study has also reported that fatal road traffic accidents are more commonly seen among boys than among girls.
Though physical attacks have contributed to only 2.7% of all injuries, being in a fight was significantly associated with being injured. Globally, violence leads to 5.8% of injury related deaths among children below 17 years, 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 the provision of 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, being of the male sex, being bullied, being physically attacked and/or being in a physical fight were associated with suffering 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 school going adolescents, generalizing the findings to the entire adolescent population in Sri Lanka is not possible, as the circumstances of the various adolescents may differ significantly. Secondly, the standard questionnaire used in the study did not have the geographical location of the injury. This could have been an important piece of knowledge with which to plan the intervention. Thirdly, the study population was school-going adolescents between 13 and 17 years, and it therefore does not represent the total school-going adolescent population, as, according to the WHO, an adolescent is defined as an individual between 10 and 19 years of age. Fourthly, the 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), the authors believe that the current sample adequately represents the total school going population. Finally, recall bias is a possible limitation, as information was solicited regarding the 12 months prior to the survey, and participants may not have remembered the information accurately.