Intentional injury reported by young people in the Federated States of Micronesia, Kingdom of Tonga and Vanuatu

Global data on the burden of injury show that in 2002 intentional injuries accounted for 1.5% of Disability Adjusted Life Years (DALYs) among 5–14 year old girls and 2% among boys in this age group [1]. Among adolescents and young adults (15–29 years) the contribution of intentional injury to total DALYs was slightly lower in females (1.2%), but dramatically higher in males (8.9%) [1]. While mortality represents a significant component of this impact, it is estimated that there are 20–40 victims of non-fatal violence for every death [2].

All forms of injury present threats to physical and psychological well-being, and for children and adolescents an important focus of research has been the nature and impact of injury arising from interpersonal violence. This encompasses violence inflicted by parents and family members, peers, dating partners, teachers and other authority figures such as police. The 1997–98 Health Behavior in School Children (HBSC) survey of 11–15 year old students in Europe and North America found that fighting caused about 4% of total injury [3]. Additional measures concerning violent behaviours used in five of the HBSC countries revealed that between 11.2% and 17.9% of students suffered at least one injury due to fighting in the past 12 mths [4]. Research among younger aged students (school years 4–6) in China found that 23% had experienced violence at a level likely to cause injury in the family context, while 14% had been exposed to this from peers and 4% from teachers [5]. Surveys among students of the same age in Korea found higher levels of exposure to violence in the family (51%) or from teachers (44%), but a similar prevalence from peers (14%) [5].

Exposure to harsh discipline from parents and authority figures has been investigated in a number of countries. In Egypt it has been reported that 37% of preparatory and high school students had been disciplined physically by parents and 26% had been physically injured as a result of such discipline [6]. In the same study, about 70% reported being physically disciplined by teachers, with just under one-quarter reporting injury as a result [7]. The WorldSafe study, a cross-national comparison of the prevalence of different methods of moderate and severe punishments by mothers, revealed that there were at least three countries (Egypt, India and Philippines) where more than 20% of mothers reported striking their child with an object or in an area other than buttocks in the past 6 months [8].

The psychological and behavioural impacts of interpersonal violence, which include depression, anxiety, substance abuse, delinquent behaviours, poor school performance and self-harm [2], mean that this continues to be a public health priority. There is a particular need for population-based data in low and middle-income countries, which account for about 95% of the global burden of injury [9]. Many of these countries are experiencing social and cultural upheavals related to poverty and urbanisation, and in some locations violence has become the number one mechanism of injury death [10].

The purpose of the present study is to examine the extent and sources of intentional injury among young people in three Pacific island societies; the state of Pohnpei in the Federated States of Micronesia (FSM), Vanuatu and the Kingdom of Tonga. Injury and violence have been recognized as a health priority across the Pacific region, but there are little country-specific data to guide action. The health and education authorities in these locations agreed to collaborate with UNICEF in the development of a Lifeskills program for adolescents, and the data presented here formed part of the baseline measures for this initiative. This investigation provides an opportunity to examine the extent of intentional injury in populations with high proportions of children and adolescents [11] which are experiencing challenges related to globalization, including economic changes and greater interaction between traditional values and western behavioural mores [12, 13]. Comparison of the behavioural and psychosocial factors associated with intentional injury across the societies assists in the identification of common issues to address in policy and programs, as well as recognizing those which are distinct to each location.

This study has found that at least one-third of boys and one-quarter of girls aged 14–17 years in these Pacific Island societies reported an intentional injury in the past 12 months, with a markedly higher prevalence among 11–12 year olds in the two populations where they were measured. The data highlight an adolescent health issue that has not been examined at the population level in the Pacific Islands region and which deserves closer attention by public health practitioners.

The limitations of the study need to be acknowledged before detailed consideration of the results. First, the findings may be subject to measurement bias as data were obtained by self-report and the validity and reliability of the questions has not been confirmed in the languages in which the study was conducted. All items were, however, translated and back-translated and efforts were made to improve confidentiality and accuracy by removing teachers from classrooms during the administration of surveys. Secondly, the data are only generalisable to in-school youth, whose characteristics may differ significantly from young people not in school. Thirdly, as a cross-sectional study the temporal sequence of the relationship between injury and other risk behaviours and psychosocial factors cannot be disentangled. The data do, however, highlight issues that are relevant to the problem of intentional injury that may assist in the design of injury control programs.

Despite its limitations, this is the first population based study of injury among school students in these Pacific Island societies. In the 14–17 years age group, for which comparable data were available from all locations, the highest period prevalence of intentionally inflicted injury was found in Pohnpei. A notable aspect of the finding in Pohnpei was that there was little difference between boys (62%) and girls (56%), whereas in both Tonga and Vanuatu girls were significantly less likely to have been intentionally injured than boys. The situation in these latter populations is consistent with literature, largely drawn from developed countries, which reports that boys are more likely to be intentionally injured, at least in the context of physical punishments at home [15, 16], physical fighting [17, 18] and bullying [19‐22].

For both boys and girls in Tonga and Vanuatu, there was a decrease in intentionally inflicted injuries with increasing age. Again, this contrasted with Pohnpei, where for girls there was no apparent pattern by age and for boys levels remained stable after a peak at age 14 years. Studies concerning intentional injury among young people have reported mixed findings in relation to age trends, depending on the type of injuries examined. For example, parental mistreatment of children has been seen to increase with age in studies in the United States [15] and New Zealand [23]. Dating violence has also been shown to increase with age [24, 25]. On the other hand, sibling abuse [15], physical fighting [17] and bullying [20‐22] have all been found to decrease with increasing age.

For boys, the primary source of injury across all societies was 'other persons'. This category was also reported as an important source of injury for girls. Given the significant association in each of the three populations between being bullied and having sustained an intentional injury, it is likely that the 'other person' category included injuries due to violence inflicted by other students. In Pohnpei students who reported bullying others were also more likely to report an intentional injury, suggesting that bullying may have resulted in violent reprisals.

In each of the three societies boyfriends/girlfriends were reported as the second primary source of injury for boys. While this was also an important source of injury for girls across the populations, boys tended to report this more frequently. Studies conducted in other countries have reported that dating violence may be inflicted in at least equal rates between genders [24‐26], indicating that it is plausible that girls in these Pacific island societies are equally as violent as boys in relationships. It is also feasible that some of the injuries sustained by boys may have been in self-defence to perceived or actual aggressive acts [26].

Parents were a frequently identified source of injury for both boys and girls across all three societies. Previous research in Pacific Island countries has found that physical punishment of children may be seen as appropriate and responsible parenting [27]. A study in the Federated States of Micronesia (FSM) found that harsh punishment for particular behaviours, including disrespect and disobedience, was acceptable provided it was restrained and did not result in serious injury [28]. In the present study it was not possible to determine whether injuries inflicted by a parent resulted from a culturally acceptable level of physical discipline, or whether they exceeded this level. Regardless of this, efforts to address this issue may be more successful if they place an emphasis on promoting adolescent social and emotional well-being, rather than directly addressing social mores regarding parenting. Framing this issue in a way that fosters dialogue among leaders and members of the wider community is a necessary step to raise awareness and develop partnerships for action.

There were inconsistent findings across the three populations about the associations between living arrangements, social relationships and intentional injury. Past studies have reported that living in an extended-family may be a protective factor for children, potentially decreasing stresses and other demands associated with child-rearing [29, 30]. In support of this, residing with parents had a protective effect in terms of intentional injury in Tonga, which may be because the extended family living arrangement is common in that society [31]. In Pohnpei, on the other hand, living with parents was found to be associated with a higher likelihood of intentional injury. This may be explained by the reports of ethnographic researchers that the extended family network in FSM is breaking down, increasing psychosocial stress upon parents and children and resulting in the loss of protective mechanisms offered by multiple parenting within extended family groups [23, 27]. A surprising finding in Vanuatu was that students reporting closer relationships with friends and family members were more likely to report an intentional injury. This may reflect the extent to which young adolescents are cared for by their older siblings, who could draw upon physical punishments as a way of controlling their younger sibling's behaviour because they are unfamiliar with other methods of discipline that could be used.

In Tonga and Vanuatu intentional injury was associated with smoking, while in Pohnpei and Vanuatu it was associated with illicit drug use. These findings support literature which reports that substance abuse may be correlated with violent behaviour among youth [32] and that health-risk behaviours can co-exist as part of a 'behaviour syndrome' [18]. A further issue for consideration is that the use of tobacco or illicit drugs may provoke disciplinary action which results in injury.

Several indicators of the school environment, including a negative perception of teachers in Tonga and Vanuatu and a poor overall rating of the physical and social environment at school in Tonga, were related to a greater risk of intentional injury. Research from the United States indicates that the school environment can have a significant effect upon injury risk [26], with students who believed that their teachers were supportive reported to be less likely to carry weapons, drink alcohol and engage in other delinquent behaviour, and more likely to practice health-preserving behaviours. This draws attention to the potentially important role that schools have to play in injury prevention, in developing life skills and assertiveness to improve interpersonal relationships and putting in place policies to control bullying.

This study has found that intentional injury is an important issue for examination and discussion by community leaders, health and educational authorities and families in these Pacific Island societies. Action should take into account the associated issues of bullying, drug use and dissatisfaction with the school environment, with relationships between peers, boyfriends and girlfriends, and parents and children being key domains for attention. The limited availability of data about the types, severity, causes and circumstances of intentional injury needs to be addressed, not only in these Pacific Island societies but in other countries where this issue has not been thoroughly examined, in order to strengthen the evidence base for injury prevention strategies.