Gradients in risk for youth injury associated with multiple-risk behaviours: a study of 11,329 Canadian adolescents
Introduction
While there is considerable evidence that childhood injury is a leading public health problem internationally, the social etiology surrounding these injuries is not well understood. Gradients in risk for childhood injury have been demonstrated for a variety of social indicators, including those describing levels of household income (Baker, O’Neil, Ginsburg, & Li, 1992; Health Canada, 1997; Nolan & Penny, 1992; Dougherty, Pless, & Wilkins, 1990; Durkin, Davidson, Kuhn, O’Connor, & Barlow, 1994), education (Health Canada, 1997; Nolan & Penny, 1992; Jolly, Moller, & Volkmer, 1993), unemployment (Nersesian, Petit, Shaper, Lemieux, & Naor, 1985; Scholer, Mitchel, & Ray, 1997) and social status (Roberts, Marshall, Norton, & Borman, 1992; Harris & Kotch, 1994). Explanations for these differences have generally focused on material deprivation and differential exposures to environmental hazards in lower socio-economic groups (Black, Morris, Smith, & Townsend, 1982; Mare, 1982; Roberts, 1997; Wise, Kotelchuck, Wilson, & Mills, 1985). Some investigators have challenged the existence of injury gradients among populations of adolescents (youth; young people) (West, 1997; Anderson et al., 1994; Williams, Currie, Wright, Elton, & Beattie, 1997) suggesting that explanations for the observed differences in adolescents are speculative since data are often derived from observations of younger children, or are not present at all for specific forms of injury (e.g. Lyons et al., 2000)
The emphasis in the literature on socio-economic explanations for injury gradients ignores the potential for behavioural explanations. Adolescence is a period of change and transition (Feldman & Elliott, 1990), and developmental models may be useful in understanding injury risk during adolescence. Several such models have been identified in the past: cumulative events or simultaneous change, accentuation, and trajectory models.
Cumulative events or simultaneous change models of development are based upon the idea that psychological, social and biological changes in adolescence are often happening at the same time. In combination, these factors affect the ability of adolescents to adjust and cope during adolescence (Simmons & Blyth, 1987). Due to changes in the school and peer environments, renegotiations in family roles and physical changes associated with puberty, the ability of young people to cope may be overtaxed. This in turn has been linked to depressed affect, lowered self-esteem, and a drop-off in school performance (Petersen, Sarigiani, & Kennedy, 1991; Simmons, Carlton-Ford, & Blyth, 1987). It is not known whether risk-taking that results in injury is influenced by these simultaneous and rapid changes in adolescents’ lives.
According to the accentuation model of development, puberty and other times of transition act to accentuate existing difficulties or reinforce pre-existing behavioural tendencies (Block, 1982; Caspi & Moffitt, 1991). This model differs from personality theory which suggests that youth adapt to transitional events by re-organizing their behaviours and even their personalities. In contrast, the accentuation model suggests that existing individual behaviours are reinforced or magnified by challenging situations. Thus, young people may cope with stresses by assimilating new risk-taking situations into existing patterns and cognitive structures, mainly as a way of minimizing change. For example, early patterns of rough play among boys may lead to increased risk for injury in adolescent males.
Both Rutter (1989) and Elder (1985) have also discussed the use of trajectories, or long term influences, to explain patterns of development during adolescence. The social environment in which transition takes place is thought to be an important influence on how a young person develops. For example, the trajectory model suggests that the amount of time that a youth associates with older peers at an early age will influence later risk-taking. This long-term influence affects the age and extent to which youth experiment with drinking and sexual behaviours (Stattin & Magnusson, 1990), and perhaps also affects the degree to which youth put themselves at risk for injury.
The identification of behaviours that place an adolescent or groups of adolescents at risk for poor health has potential significance for the prevention of injuries. Hazardous adolescent lifestyles may include engagement in multiple risk behaviours (Irwin & Millstein, 1986) including unsafe sex, substance use and abuse, risk-taking leading to accidents and injury, and disengagement from school (Graber & Brooks-Gunn, 1995). When these behaviours occur simultaneously they place the youth at a very high risk for illness and injury. If these multiple risk behaviours occur early in adolescence (trajectory model) or cluster together temporally (simultaneous change model), the likelihood of morbidity is even greater (Jessor, 1992; Millstein, Petersen, & Nightingale, 1993.)
The ability to predict the occurrence of adverse health events associated with multiple risk behaviours may be tempered somewhat by the existence of protective factors in the life of an adolescent. For example, a young person may have high rates of risk behaviours but also have high rates of protective factors such as family, school or material supports. Health outcomes experienced by that young person may be better than those experienced by another adolescent with fewer risk behaviours, but also fewer protective factors. In addition, some risk behaviours pose both risks and benefits. Excessive drinking is clearly a risk behaviour but it may also be a potential source of social support, since experimentation represents normal activity during teenage years. This experimentation reflects a willingness to engage in behaviours that may be normative among friends and acquaintances, as the youth moves towards a peer orientation and independence as a replacement for the orientation provided by the family.
Recent analyses of the 1996 National Population Health Survey (Canada) showed that the majority of young Canadians engage in at least one high-risk behaviour such as smoking, binge drinking, and/or sex with multiple partners (Galambos & Tilton-Weaver, 1998). Large percentages (33% of females, 43% of males) engage in two or more of these same behaviours, and youth from lower socio-economic backgrounds tend to report more health risk behaviours. This pattern is analogous to the observations of Connop, King, & Boyce (1999) whose work with young Canadians identified several distinct peer groups of youth. The prevalence of high-risk behaviours including smoking tended to be clustered among groups of youth who were socially alienated from mainstream society.
Immediate and long-term health consequences of multiple risk behaviours are still undefined, although it is reasonable to assume that risk behaviours translate into elevated risks for morbidity. Whether or not injuries occur may also depend on the co-occurrence of protective factors, the intensity of engagement in risk behaviours, and the age of initiation of these behaviours (Irwin & Millstein, 1986; Jessor, 1992).
We had the opportunity to explore relationships between multiple risk behaviours and the occurrence of injury using Canadian records from the 1997–1998 World Health Organization Health Behaviour in School-Aged Children Survey (WHO-HBSC). The WHO-HBSC is a collaborative research project involving countries in Central and Eastern Europe, the Middle East, and North America (Currie, 1998). Large and representative samples of youth are drawn from school-based settings in each of the countries. Canada has participated in the WHO-HBSC on three occasions. During the latest iteration (1997–1998), a series of questions about medically attended injuries was asked, in addition to core questions about health behaviours, risk-taking, demographics, and socio-economic status (King, Boyce, & King, 1999).
The objective of the present study was to analyze medically attended injuries and their association with multiple risk behaviours among young Canadians. The factors examined included a new index that describes the occurrence of multiple-risk behaviours indicators, socio-economic status, and demographic factors. In performing this analysis, we hoped to determine: (1) whether a socio-behavioural gradient in risk for adolescent injury could be demonstrated in Canada; (2) if such a gradient between multiple risk behaviours and injury was observed, whether it could be explained by the reported socio-economic status or other related factors.
Section snippets
The WHO-HBSC
The 1997–1998 WHO-HBSC involved study of a sample of Canadian students from elementary and high schools. A cluster sample design was used with the school class being the basic cluster. The sample was designed according to the international WHO-HBSC protocol (Currie, 1998), in that the distribution of the students reflected the distribution of Canadians in the selected grades (6–10, representing youth with average ages of 11–15 years), and the sample was considered self-weighting. Within each
Results
11,416 Canadian young people participated in the 1997/1998 WHO-HBSC and of these, 11,329 answered the initial question about medically treated injuries. These constituted the sample available for study, with 36.7% reporting at least one injury event.
Table 1 provides a description of the study population according to the confounders selected a priori, as well as the three socio-economic indicators. (Note: not all respondents answered every question; hence the apparent discrepancies when summing
Discussion
There were two major findings from this national, population-based analysis. First, strong gradients in the occurrence of injury were found among Canadian youth in association with the reporting of multiple-risk behaviours. These gradients were observed consistently within subgroups defined by grade, gender, socio-economic status, injury type, severity and number of medically treated injuries. They also remained after adjustment for all available factors that were considered as potential
Acknowledgements
Health Canada funds the Canadian version of the World Health Organization-Health Behaviour in School-Aged Children Survey, under the co-ordination of Mary Johnston. The WHO-HBSC is a WHO/EURO collaborative study. International Coordinator of the 1997/98 study: Candace Curry, University of Edinburgh, Scotland; Data Bank Manager: Bente Wold, University of Bergen. This publication reports on data solely from Canada. This analysis was funded, in part, by the Queen's University Department of
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