As children mature into adolescence, their world expands, literally, from being oriented around the relative safety of parents and the home, to a more dangerous environment beyond the home. Injuries are the leading cause of death. And a major cause of disability in adolescents and young adults. Which is the focus of this lecture. While in younger children, accidental poisoning, drowning, burns, and maltreatment by caregivers are leading causes of injuries. In adolescents and young adults, road traffic accidents, interpersonal violence, and self-inflicted injuries increasingly affect them. As the world widens and with it a wider range of injury risks. If we review the leading causes of death in 10 to 19 year old adolescents using data from the 2014 Health Organization Report Health for the world's adolescents. We can see that road traffic injuries, self-harm, interpersonal violence, and drowning constitute four of the ten leading causes of deaths, death in ten to 19 year olds. There are some interesting differences apparent by six. As you can see, when you compare the numbers of deaths in boys shown in blue, to girls shown in red. Injury related mortality disproportionately affect boys. But injury rates and patterns differ widely from country to country, even within the same region. Especially when comparing urban and rural areas. In rural areas, injuries are commonly related to patterns of land use such as access to pesticide poisoning and access to water. In urban areas, on the other hand, there's a far greater likelihood of traffic-related injuries. And there are also interesting patterns of injury deaths with age. For example, while adults are more likely to die as drivers of motor vehicles, adolescents are more likely to die as pedestrians. As the leading cause of death in adolescents, it is quite apparent that there needs to be a strong focus on health policy on injury prevention. While the need to focus on preventing road injuries is clear, it is also apparent from data like these, that there are opportunities to be gained from less obvious preventive interventions, such as swimming lessons, for example. This graphic explores the burden of disease from injuries, so includes years of life lost from premature mortality, together with years of life lived with disability. These data enable an appreciation of the dynamic pattern of injuries, with increasing age, across the adolescent and young adult years. If you focus just on the first column of 10 to 14 year olds, we can see that road traffic injuries, falls, and drowning rank in the top 10 causes of the burden of disease. With increasing age focusing now on the 15 to 19 year olds, we can see the contribution of the burden of disease by injuries changes to include self-inflicted injuries, and interpersonal violence within the top ten. Focusing now on the 20 to 24 year old age group, we see the relative increase in ranking of road traffic accidents and violence, which is even more pronounced numerically than these data suggest, due to the increase in the number of disability adjusted life years with age. We see further widening of scope. Abortion is listed distinctly, but I've highlighted it here, as it can be conceptualised as a form of self-inflicted injury. The World Health Organization estimates that around 10 million children and adolescents under 20 are injured or permanently disabled as a result of road traffic crashes each year. It's also been estimated that in Southeast Asia, for every child who dies from a road crash, 254 need hospital treatment, of whom four are left with a permanent disability. As mentioned earlier, the pattern of injury from road traffic deaths differs with age. On the left panel here, we can see that children and adolescents are most likely to be injured or killed as pedestrians. Children and adolescents under 20 account for a third of all road traffic deaths in low and middle income countries, and around a tenth in high income countries. 50 percent of all road traffic deaths in high income countries are when children and adolescents are passengers as shown in the bottom left panel, with them being more likely to die if unrestrained. In some countries in Asia, one in every three road traffic deaths in those less than 20 years are cyclists, or motorcyclists, as described in the top right panel. In teenagers in Asia, motorcycle related deaths are the leading cause of deaths in adolescents. And teenage drivers are at much greater risk of crashing than older adults, as shown in the bottom right panel, and have a disproportionate rate of death from crashes. On this last point, it is apparent that adolescent and young adult drivers are at increased risk of crashes and a greater risk of fatal crashes than older adults. A 15 to 33 fold increased risk of crashing is a very substantial increase in risk. What factors place adolescent and young adult drivers at greater risk? What can you think of to explain this difference? I'll leave this question for you to explore, but we will return to it in the later lectures on policy and programming responses. These data from the WHO 2008 Children and Road Traffic Injury Report highlight some other intriguing differences. If we look at this table that reports fatal injury rates by age, we can see that the rates are highest in 15 to 19 year old boys and in five to nine-year-old girls. Overall, boys are twice as likely to have a road traffic injury than girls. As previously described, children and adolescents are at particular risk as pedestrians, with roads being a shared space for play, transport, and work. And importantly, road traffic injuries are strongly associated with poverty. Poor adolescents are more likely to live in unsafe environments, and are therefore exposed to risks that increase their likelihood of being injured. Workplaces pose specific physical and chemical risks to adolescent workers, whose vulnerability is increased by lack of experience. The environmental factors leading to injuries, are often associated with other environmental health risks. For example, home and school construction, furnishing materials, and home cooking methods can lead to unintentional injuries and poisoning may result from exposure to chemicals that are unsafely used or unsafely stored. Urban transportation, land use patterns, and recreation areas are linked to road traffic injuries, as well as to exposure to air pollution and noise. Poor young people are particularly vulnerable, as they have less chance of overcoming these risks through reduced adult supervision and through the protective benefits of education. They also have less access to quality health services once they have experienced an injury. And while the earlier slide showed many of the more dangerous occupations for adolescent boys, we know there are numerous injury risks for girls as well. Some of these risks are also around employment, including bullying and harassment within the work place, which contributes to poor emotional well being. Let alone the risks of work itself, such as sex work, that is more common in poor adolescent girls. And as previously discussed, the context of population displacement, and the breakdown of the rule of law that occurs at times of war, famine, and other disasters places girls and women at particular risk of violence and injury. However, most gender based violence occurs within the home. Women of all social backgrounds are at risk, with those from impoverished communities being especially vulnerable, with less community supports, including health services. Intimate and non-intimate partner violence is not an isolated event. But rather as shown here in this complex schema, is increasingly appreciated as a pattern of behaviour that violates the rights of women and girls, limits their participation in society, and damages their health and well being. I would suggest you take a moment to work through this complex schema. And when we look at this slide at the prevalence of physical and or sexual intimate partner violence in women, we can say that across the world, this is a sad reality, whatever region of the world women live in. As shown in the table on the left from the WHO report on violence against women published in 2013, between one in four and one in three ever partnered women report a lifetime prevalence of intimate partner violence. And on the right, we can see that this is as much the reality for young ever partnered women as it is for more mature women in their 30s, 40s and 50s.
