Background
Injuries during childhood and adolescence constitute an important global public health problem. They represent a leading cause of morbidity and mortality among adolescents and youth, particularly, in developing countries [
1,
2]. Unintentional injuries have been shown to result in poor physical and psychological consequences for children and their families [
3]. School-going adolescents who sustain injuries are likely to absent themselves from school resulting in adverse educational outcomes [
4]. In addition to deaths, the literature also reports that a relatively large proportion of children who survive their injuries remain with temporary or permanent disabilities [
5]. It is now well documented that the costs of hospitalisation, rehabilitation, loss of schooling, and loss of income to parents result from absence from work in order to care for an injured child [
6,
7]. These associated adverse adolescent health and socio-economic outcomes require evidence-based intervention and prevention strategies that are targeted at specific risk and protective factors, particularly, in low resource settings, including countries in sub-Saharan Africa.
Evidence from previous studies in some countries in sub-Saharan Africa suggests that the 12-month prevalence estimate of serious injuries among school-going adolescents ranges from 38.6% in Swaziland [
8], 55.7% in Mozambique [
9], to 71.5% in Zambia [
8]. In a recent study, the prevalence of serious injuries among 95,811 students who participated in the Global School-based Student Health Surveys (GSHS) in 47 low-income and middle-income countries was found to be about 40% during the previous 12 months [
10]. Another cross-national study involving six African countries reported a relatively higher 12-month prevalence estimate of 68% among school going adolescents [
8].
Some studies have reported significant associations between sociodemographic factors such as male gender [
11,
12], and low socioeconomic status [
2] with injuries. It has also been reported that several psychological and behavioural risk factors have been linked with injuries among adolescents. For example, adolescents who experience sleep difficulties and depressive problems are more likely to report injuries, compared to those without these problems [
2,
12,
13]. Evidence also suggests that other factors such as substance use (including cigarette smoking and alcohol use) as well as factors within the school environment, such as bullying victimisation, truancy, physical fighting, and engagement in physical activity have been significantly associated with increased odds of sustaining serious injuries among adolescents [
2,
8,
14,
15].
However, there is a paucity of research regarding the prevalence estimates and key psychosocial correlates of serious injuries among school-going adolescents in Western sub-Saharan Africa. So far in Africa, most studies conducted have focused on Eastern and Southern sub-Saharan African countries [
8,
9]. Our systematic search of the literature did not show any published studies from countries in Western Africa on the prevalence of injuries and psychosocial correlates among nationally representative non-clinical samples of school-going adolescents.
Even so, clinical evidence (analysis of post-mortem records) from Ghana, for instance, revealed that 30% of adolescent injury related mortality were due to electrocution, poisoning, burns, stab/gunshot, hanging and other miscellaneous causes such as blast injury, traumatic injury from falling debris, and fall from height [
16,
17]. In Liberia, alcohol consumption is associated with increased risk of several chronic medical conditions, including unintentional injuries and psychiatric co-morbidities in secondary school students [
18]. Notably, however, no published data exists about the prevalence of serious injuries and correlates among in-school adolescents in Liberia.
Given the high burden of disability and related financial losses associated with injuries among young people [
19], it is relevant that urgent measures are instituted to improve injury prevention. The identification of the specific behaviours and risk factors associated with injuries associated with school-going adolescents in various populations is an essential foundational step to the development and implementation of effective injury prevention education programmes [
20,
21]. Accordingly, the goals of this study were to estimate the proportion of adolescents in three Western African countries (Benin, Ghana, and Liberia) who sustained serious injuries in the past 12 months, and to identify key factors associated with unintentional injuries in this population
. Ultimately, it is hoped that the findings of this study will inform programmes and efforts at the creation of safe environments for young people (at least in the participating countries), thereby contributing broadly to the attainment of Goal 3 (good health and wellbeing) of the United Nations Sustainable Development Goals.
Conceptual framework of adolescent injury
Adolescent (un)intentional injuries are multifactorial; injuries in young people could be due to the complex interplay of multilayered factors – individual, relationship, socio-cultural, and environmental factors [
22]. Introduced in the 1970s [
23], the ecological systems model has been applied to understand various public health issues among young people. Recently, the National Center for Injury Prevention and Control of the Centres for Disease Control and Prevention (CDC) has developed and applied the socio-ecological model as a framework for the understanding and prevention of injuries and violence among young people [
24]. The socio-ecological model is derived from the broader ecological systems model. This study applies the socio-ecological model to understand school-going adolescents’ injuries. The socio-ecological model suggests that injuries in young people could be complex and result from a combination of multiple factors at the individual-level, relationship-level (including family and peers), community-level (including school), and societal-level [
24]. The model underscores how an individual relates to others and the broader environment within which they live as a critical determinant of health outcomes. This means that in order to understand and develop evidence-informed prevention strategies and programmes related to (un)intentional injuries among adolescents, we need to consider the different layers of influence not only at an individual-level, but also at the immediate and the broader community and societal levels. The socio-ecological model has proven to be a useful theoretical framework for addressing several youth development and health outcomes, including injury. Among school-going adolescents, several factors may be associated with the susceptibility to injury. With the aid of a socio-ecological model, risk factors associated with adolescent injury can be grouped into four factors: 1) sociodemographic factors (male gender, older age and low socioeconomic status); 2) personal factors (psychological distress, tobacco use, alcohol use, truancy, and low peer support); 3) parental factors (parental supervision or low parental or guardian support); and 4) stressors from the school environment (bullying victimisation, physical fighting, and engagement in physical activity) [
11]. On the basis of this framework, we expect school environmental factors (i.e. physical fighting, bullying victimisation, and engagement in physical activity), and personal factors (truancy, and substance use) to heighten the risk of serious injuries, whilst parental supportive behaviours may ameliorate the occurrence of serious injuries among school-going adolescents.
Correlates of serious injuries
The predictors of serious injuries are presented in Table
3. After controlling for other covariates, the only protective factor for serious injuries among adolescents in Benin was older age (OR = 0.66; 95% CI = 0.50 – 0.88;
p = 0.004). Risk factors associated with serious injuries in Benin included having been attacked physically (OR = 2.02; 95% CI = 1.48 – 2.75;
p < 0.001), having been bullied (OR = 2.00; 95% CI = 1.38 – 2.91;
p < 0.001), anxiety (OR = 1.52; 95% CI = 1.11 – 2.07;
p = 0.008), and alcohol use (OR = 1.46; 95% CI = 1.13– 1.89;
p = 0.004).
Table 3
Predictors of Serious Injuries among school-going adolescents in three West African countries
Demographics |
Age (in years) |
11-17 years (Reference) | 1.00 | | 1.00 | | 1.00 | |
18 years and above | 0.66 (0.50, 0.88) | 0.004 | 0.88 (0.72, 1.08) | 0.227 | 1.08 (0.82, 1.42) | 0.583 |
Gender |
Female (Reference) | 1.00 | | 1.00 | | 1.00 | |
Male | 1.24 (0.95, 1.61) | 0.110 | 0.93 (0.77, 1.12) | 0.459 | 1.01 (0.79, 1.30) | 0.921 |
School/environmental factors |
Truancy | 1.26 (0.93, 1.71) | 0.131 | 1.14 (0.93, 1.40) | 0.216 | 1.05 (0.81, 1.37) | 0.709 |
Physical attack | 2.02 (1.48, 2.75) | < 0.001 | 2.04 (1.68, 2.49) | < 0.001 | 1.53 (1.17, 1.99) | 0.002 |
Physical fight | 1.05 (0.77, 1.43) | 0.771 | 2.13 (1.73, 2.62) | < 0.001 | 1.67 (1.28, 2.19) | < 0.001 |
Bullying | 2.00 (1.38, 2.91) | < 0.001 | 1.68 (1.23, 2.30) | 0.001 | 1.90 (1.22, 2.94) | 0.004 |
Peer support | 0.75 (0.55, 1.01) | 0.061 | 0.96 (0.78, 1.18) | 0.701 | 1.12 (0.86, 1.46) | 0.398 |
Family factors |
Parental monitoring | 1.21 (0.91, 1.60) | 0.188 | 1.08 (0.87, 1.34) | 0.464 | 1.17 (0.88, 1.56) | 0.271 |
Parent-adolescent bonding | 0.90 (0.67, 1.21) | 0.484 | 0.94 (0.76, 1.17) | 0.578 | 0.83 (0.62, 1.11) | 0.208 |
Parental understanding | 0.92 (0.68, 1.24) | 0.574 | 0.96 (0.78, 1.18) | 0.688 | 0.96 (0.72, 1.28) | 0.802 |
Parental intrusion of privacy | 0.98 (0.59, 1.65) | 0.948 | 0.86 (0.66, 1.13) | 0.271 | 0.78 (0.56, 1.09) | 0.143 |
Hunger | 1.07 (0.77, 1.49) | 0.691 | 1.25 (0.94, 1.67) | 0.121 | 1.24 (0.83, 1.84) | 0.296 |
Psychological factors |
Loneliness | 1.10 (0.76, 1.60) | 0.618 | 1.66 (1.28, 2.16) | < 0.001 | 1.43 (0.74, 2.19) | 0.097 |
Anxiety | 1.52 (1.11, 2.07) | 0.008 | 1.32 (0.99, 1.76) | 0.058 | 1.35 (0.96, 1.91) | 0.087 |
Personal and lifestyle factors |
Physical activity | 1.08 (0.73, 1.61) | 0.701 | 1.21 (0.98, 1.49) | 0.071 | 1.54 (1.17, 2.02) | 0.002 |
Sexual behavior | 1.23 (0.93, 1.64) | 0.144 | 1.19 (0.94, 1.50) | 0.152 | 0.76 (0.57, 1.01) | 0.055 |
Methamphetamine use | 1.09 (0.42, 2.78) | 0.862 | 1.83 (1.07, 3.13) | 0.027 | 0.41 (0.16, 1.03) | 0.057 |
Cannabis use | 2.20 (0.76, 6.36) | 0.146 | 1.71 (0.88, 3.33) | 0.111 | 3.23 (1.32, 7.87) | 0.010 |
Alcohol use | 1.46 (1.13, 1.89) | 0.004 | 1.24 (0.89, 1.71) | 0.198 | 1.39 (1.01, 1.93) | 0.048 |
Cigarette smoking | 0.98 (0.53, 1.81) | 0.949 | 0.57 (0.31, 1.06) | 0.074 | 1.13 (0.56, 2.27) | 0.733 |
Having a close friend | 1.17 (0.79, 1.71) | 0.433 | 1.42 (1.06, 1.89) | 0.017 | 1.30 (0.87, 1.93) | 0.201 |
Hosmer–Lemeshow GOF test (sig) | 9.24 (0.322) | | 7.69(0.464) | | 12.85 (0.117) | |
McFadden’s pseudo R2 | 0.064 | | 0.098 | | 0.065 | |
In Ghana, school or environmental factors such as physical fighting (OR = 2.13; 95% CI = 1.73 – 2.62;
p < 0.001), having been physically attacked (OR = 2.04; 95% CI = 1.68 – 2.49;
p < 0.001), personal and lifestyle factors such as methamphetamine use (OR = 1.83; 95% CI = 1.07 – 3.13;
p = 0.027) and bullying victimisation (OR = 1.68; 95% CI = 1.23 – 2.30;
p = 0.001), psychological factors such as loneliness (OR = 1.66; 95% CI = 1.28 – 2.16;
p < 0.001, and having a close friend (OR = 1.42; 95% CI = 1.06 – 1.89;
p = 0.017) were the significant predictors of reporting serious injuries in the past 12 months (Table
3).
The results further showed that for students in Liberia, significant risk factors for injuries include school or environmental factors such as cannabis use (OR = 3.23; 95% CI = 1.32–7.87; p = 0.01), bullying victimisation (OR = 1.90; 95% CI = 1.22 – 2.14; p = 0.004), physical fighting (OR = 1.67; 95% CI = 1.28 – 2.19; p < 0.001), personal/lifestyle factors such as having engaged in physical activity (OR = 1.54; 95% CI = 1.17–2.02; p = 0.002), physical attacks (OR = 1.53; 95% CI = 1.17 – 1.99; p = 0.002), and alcohol use (OR = 1.39; 95% CI = 1.01–1.93; p = 0.048).
Conclusion
This study investigated adolescent serious injury and its associated factors among school-going adolescents in three West African countries – Benin, Ghana, and Liberia. The analysis found that a relatively higher prevalence of adolescent injuries in the three West African countries. The findings of this study support existing evidence that injuries are a common health outcome of interpersonal violent behaviours among school-going adolescents worldwide and that there are many exposures and risk behaviours linked to injuries that can be effectively addressed through health education and other low-cost, effective intervention and prevention programmes. Since there are different risk factors that influence school-going adolescent injury in each of the three West African countries studied, development of appropriate intervention should take into consideration a more differentiated approach.
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