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Socioeconomic inequality in the risk of intentional injuries among adolescents: a cross-sectional analysis of 89 countries
  1. Charlotte Probst1,2,
  2. Carolin Kilian3,
  3. Jürgen Rehm2,3,4,5,6,7,8,
  4. Andre F Carvalho2,8,
  5. Ai Koyanagi9,10,
  6. Shannon Lange2
  1. 1Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
  2. 2Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
  3. 3Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
  4. 4Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  5. 5Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontaio, Canada
  6. 6Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
  7. 7Department of International Health Projects, Institute for Leadership and Health Management, Toronto, Ontario, Canada
  8. 8Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
  9. 9Research and Development Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain
  10. 10Instituciò Catalana de Recerca i Estudis Avancats, Barcelona, Spain
  1. Correspondence to Dr Charlotte Probst, Heidelberg Institute of Global Health, Heidelberg University, Heidelberg 69117, Germany; mariecharlotte.probst{at}


Introduction In 2015, the elimination of hunger worldwide by 2030 was declared by the United Nations as a Sustainable Development Goal. However, food insecurity remains pervasive, contributing to socioeconomic health inequalities. The overall objective was to investigate the relationship between food insecurity and intentional injuries among adolescents.

Methods Individual-level data from the Global School-based Student Health Survey from 89 countries were used (370 719 adolescents, aged 12–17 years). Multilevel logistic regressions were used to examine the sex-specific association between the level of food insecurity (none, medium and high) and intentional injuries (interpersonal violence and suicide attempts), accounting for the clustering of observations within surveys. Random-effects meta-analyses were used to analyse dose–response relationships.

Results Medium and high food insecurity were associated with increased odds of reporting an injury from interpersonal violence among both sexes. A positive dose–response relationship was found, where each level increase in food insecurity was associated with a 30% increase in the odds of an injury due to interpersonal violence among boys (1.30; 95% CI 1.26 to 1.34) and a 50% increase among girls (1.53; 95% CI 1.46–1.62). The odds for suicide attempts increased by 30% for both sexes with each level increase in food insecurity (boys: 1.29; 95% CI 1.25–1.32; girls: 1.29; 95% CI 1.25–1.32).

Discussion The findings indicate that socioeconomic inequalities exist in the risk of intentional injuries among adolescents. Although additional studies are needed to establish causality, the present study suggests that the amelioration of food insecurity could have implications beyond the prevention of its direct consequences.

  • violence
  • suicide/self?harm
  • adolescent
  • global
  • health disparities
  • hierarchical models

Statistics from


  • Contributors CP had full access to all of the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. CP, CK, JR and SL conceptualised and designed the study. AK generated the GSHS dataset and CK prepared the covariable dataset. CP, SL and JR determined appropriate statistical procedures. CK and CP performed the data analyses and statistical modelling. CP, SL, AK, AFC and JR contributed to data interpretation. CP, CK and SL wrote the first draft of the manuscript. All authors contributed to the writing and revision of the manuscript and approved of the final version to be published.

  • Funding This study was funded by Centre for Addiction and Mental Health.

  • Disclaimer The study sponsor had no impact on study design, data collection, data analysis, interpretation of data, writing of the report, or in the decision to submit the paper for publication. The corresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. All data included in the current study are available in public, open access repositories. GSHS data can be obtained from Sources for covariate data used in the statistical modeling are indicated in the manuscript.

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