Abstracts

INTRODUCTION

Injuries are the main cause of morbimortality among children and adolescents aged less than 18 years old - WHO estimates 875,000 deaths a years -, and they also affect the lives of about 30 million people due to wounds, inabilities and psychic disorders¹1. Organização Mundial da Saúde and United Nations Children's Fund. Child and adolescent injury prevention: a global call to action. Genebra: WHO e UNICEF; 2005.. About 98% of the unintentional injuries in childhood occur in low and mid-income countries¹1. Organização Mundial da Saúde and United Nations Children's Fund. Child and adolescent injury prevention: a global call to action. Genebra: WHO e UNICEF; 2005.^,22. Hyder AA, Puvanachandra P, Tran NH. Child and adolescent injuries: a new agenda for child health. Inj Prev 2008; 14: 67..

Studies by the Global School and Health Survey indicated an annual prevalence of 41.3% related to injuries or wounds reported by adolescents aged between 11 and 15 years old, in the past 12 months, in 11 industrialized countries. This study also pointed out to great variation between countries³3. Pickett W, Molcho M, Simpson K, Janssen I, Kuntsche E, Mazur J, et al. Cross-national study of injury and social determinants in adolescents. Inj. Prev 2005; 11: 213-18.. Most studies indicates that unintentional injuries are more common among boys³3. Pickett W, Molcho M, Simpson K, Janssen I, Kuntsche E, Mazur J, et al. Cross-national study of injury and social determinants in adolescents. Inj. Prev 2005; 11: 213-18.

4. Brasil. Secretaria de Vigilância em Saúde. Saúde Brasil, 2012: Uma análise de Situação de Saúde. Brasília (DF): Ministério da Saúde; 2013.

5. Malta DC, Mascarenhas MD, Bernal RT, Andrade SS, Neves AC, Melo EM, et al. Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência Capitais Brasileiras - 2009. Ciênc Saúde Coletiva 2012; 17(9): 2291-304.^-66. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93..

In Brazil, in 2010, deaths caused by accidents and violence among children and adolescents aged 10 to 19 years old accounted for 16,232 deaths, rate of 47.5/100,000. Besides, they constituted the major magnitude events of victimization among adolescents in the country⁴4. Brasil. Secretaria de Vigilância em Saúde. Saúde Brasil, 2012: Uma análise de Situação de Saúde. Brasília (DF): Ministério da Saúde; 2013..

Analyses about external causes in adolescents who use morbidity or mortality data are the most frequent ones in Brazil⁵5. Malta DC, Mascarenhas MD, Bernal RT, Andrade SS, Neves AC, Melo EM, et al. Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência Capitais Brasileiras - 2009. Ciênc Saúde Coletiva 2012; 17(9): 2291-304.^,77. Soares Filho AM. Vitimização por homicídios segundo características de raça no Brasil. Rev Saúde Pública 2011; 45(4): 745-55., therefore, it is important to make progress in the analysis of studies about the occurrence of injuries in the population scope.

Pickett et al.⁶6. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93. emphasize that the occurrence of aggravations in youth involves a complex interaction between several social, environmental, cultural and behavioral elements. The author also points out to the occurrence of association between several risk factors, or multiple risks, such as predictors of injuries/wounds. Literature indicates many factors associated with injuries among young people, such as: being male¹1. Organização Mundial da Saúde and United Nations Children's Fund. Child and adolescent injury prevention: a global call to action. Genebra: WHO e UNICEF; 2005.^,33. Pickett W, Molcho M, Simpson K, Janssen I, Kuntsche E, Mazur J, et al. Cross-national study of injury and social determinants in adolescents. Inj. Prev 2005; 11: 213-18.

4. Brasil. Secretaria de Vigilância em Saúde. Saúde Brasil, 2012: Uma análise de Situação de Saúde. Brasília (DF): Ministério da Saúde; 2013.^-55. Malta DC, Mascarenhas MD, Bernal RT, Andrade SS, Neves AC, Melo EM, et al. Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência Capitais Brasileiras - 2009. Ciênc Saúde Coletiva 2012; 17(9): 2291-304., black or mulatto race/color⁷7. Soares Filho AM. Vitimização por homicídios segundo características de raça no Brasil. Rev Saúde Pública 2011; 45(4): 745-55., having low socioeconomic status⁶6. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93., living in violent and insecure environments³3. Pickett W, Molcho M, Simpson K, Janssen I, Kuntsche E, Mazur J, et al. Cross-national study of injury and social determinants in adolescents. Inj. Prev 2005; 11: 213-18.^,66. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93., reporting insecurity during the route home-school, school-home and inside the school environment⁸8. Malta DC, Souza ER, Silva MM, Silva CS, Andreazzi MA, Crespo C et al. Vivência de violência entre escolares brasileiros: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE). Ciênc Saúde Coletiva 2010; 15(2): 3053-063., and being bullied⁹9. Andrade SS, Yokota RT, Sá NN, Silva MM, Araújo WN, Mascarenhas MD, et al. Relação entre violência física, consumo de álcool e outras drogas e bullying entre adolescentes escolares brasileiros. Cad Saúde Pública 2012; 28(9): 1725-36.. Individual risk behaviors are also described as the non-use of the seatbelt and helmet and the use of alcohol, cigarette and drugs⁶6. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93.^,1010. Starkuniviene S, Zaborskis A. Links between accidents and lifestyle factors among Lithuanian school children. Medicina (Kaunas) 2005; 41: 73-80..

Other risk factors are also mentioned in studies concerning the behaviors of life as a family and the way parents and children relate, especially when they use violent communication and behavioral forms; when there is little parental control over their children's school and social life; when adolescents evade from school, relegate their school tasks and have low school performance; when they stay out of the house for long periods and do not notify their parents about their whereabouts in their free time⁶6. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93.^,1111. Malta DC, Porto DL, Melo FCM, Monteiro RA, Sardinha LMV, Lessa BH. Família e proteção ao uso de tabaco, álcool e drogas em adolescentes, Pesquisa Nacional de Saúde dos Escolares. Rev Bras Epidemiol 2011; 14(1): 166-77.. A study also mentions other aspects associated with injuries, such as mental suffering, feelings of loneliness and isolation⁶6. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93.. Literature also indicates that practicing sports can be a risk factor¹²12. Williams JM, Wright P, Currie CE, Beattie TF. Sports related injuries in Scottish Adolescents Aged 11-15. Br J Sports Med 1998; 32(4): 291-96..

Knowing the factors that are associated with injuries is important to encourage actions of health prevention and promotion in different contexts. In Brazil, these studies are still lacking. With the conduction of the II National Adolescent School-based Health Survey (PeNSE), in 2012, questions referring to injuries were introduced, which made it possible to analyze this feature among students¹³13. Brasil. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Rio de Janeiro: IBGE; 2013..

The objective of this study is to estimate the prevalence of injuries among adolescents, and to examine the factors that are associated to them, such as sociodemographic characteristics, risk behaviors, family ties and other factors.

METHODS

The National Adolescent School-based Health Survey (PeNSE), conducted in 2012¹³13. Brasil. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Rio de Janeiro: IBGE; 2013., investigated some risk behavior and health protection factors in a sample of students attending the 9^th grade of elementary school, during daytime, in public or private schools located in the urban or rural zones of a set of cities placed all over the Brazilian territory. This age group is comparable with the one in the study Global School and Health Survey, performed by the World Health Organization¹⁴14. Organização Mundial de Saúde. Social determinants of health and well-being among young people. Health behaviour in school-aged children (HBSC) study: international report from the 2009/2010 survey. Copenhagen: WHO; 2012..

The register used for sampling selection was constituted of elementary schools listed in the School Census 2010, which informed having 9^th grade groups in daytime shifts. The sample estimated population parameters (prevalence) in several geographic domains: each of the 26 Brazilian State capitals and the Federal District, the set of these capitals, each one of the five major geographic regions and the country as a whole.

In the selected groups, there were 134,310 students enrolled in the 9^th grade of elementary school, in daytime shifts of schools located in urban or rural zones of the whole country. Out of these, 132,123 attended classes, 110,873 were present at the time of the study and 109,104 answered the study questionnaire (83% of those who attended classes). About 90% of the students were between 13 and 15 years old, being 52% female and 48% male participants¹³13. Brasil. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Rio de Janeiro: IBGE; 2013..

The cluster sampling process was used, and the sampling plan was formed by schools (primary units) and classrooms (secondary units). Outside the capitals, primary units were made of groups of cities; secondary units, of schools; and classrooms consisted of the tertiary sampling units.

STUDIED OUTCOME

The studied outcome, "having suffered a serious injury in the past 12 months" was extracted from the question: "in the past 12 months, how many times were you seriously injured?", being categorized into: "No, not even once", and "Yes, once or more".

In order to better explore the severity of the injury, additional questions were asked to those who were injured - About the type of wound or injury: "in the past 12 months, which was the most serious wound/injury that affected you?" The options of answers were: broken bone or dislocated joint; cut or perforation; trauma or another lesion on the head or neck; fainting; difficulty breathing; severe burning; lesion or bruise. About the cause of wound or injury: "in the past 12 months, which was the main cause of wound/injury that affected you?" The options of answers were: accident or being hit by a motorized vehicle; falls; something fell on the person; being attacked; fighting with someone; fire or something hot; inhaling something; having swallowed something that made you feel bad; and others.

EXPLANATORY VARIABLES

The association model between wounds or serious injuries in the past 12 months is expressed in Figure 1. The model was proposed by the authors and is based on evidence in literature³3. Pickett W, Molcho M, Simpson K, Janssen I, Kuntsche E, Mazur J, et al. Cross-national study of injury and social determinants in adolescents. Inj. Prev 2005; 11: 213-18.

4. Brasil. Secretaria de Vigilância em Saúde. Saúde Brasil, 2012: Uma análise de Situação de Saúde. Brasília (DF): Ministério da Saúde; 2013.

5. Malta DC, Mascarenhas MD, Bernal RT, Andrade SS, Neves AC, Melo EM, et al. Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência Capitais Brasileiras - 2009. Ciênc Saúde Coletiva 2012; 17(9): 2291-304.

6. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93.

7. Soares Filho AM. Vitimização por homicídios segundo características de raça no Brasil. Rev Saúde Pública 2011; 45(4): 745-55.

8. Malta DC, Souza ER, Silva MM, Silva CS, Andreazzi MA, Crespo C et al. Vivência de violência entre escolares brasileiros: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE). Ciênc Saúde Coletiva 2010; 15(2): 3053-063.

9. Andrade SS, Yokota RT, Sá NN, Silva MM, Araújo WN, Mascarenhas MD, et al. Relação entre violência física, consumo de álcool e outras drogas e bullying entre adolescentes escolares brasileiros. Cad Saúde Pública 2012; 28(9): 1725-36.

10. Starkuniviene S, Zaborskis A. Links between accidents and lifestyle factors among Lithuanian school children. Medicina (Kaunas) 2005; 41: 73-80.

11. Malta DC, Porto DL, Melo FCM, Monteiro RA, Sardinha LMV, Lessa BH. Família e proteção ao uso de tabaco, álcool e drogas em adolescentes, Pesquisa Nacional de Saúde dos Escolares. Rev Bras Epidemiol 2011; 14(1): 166-77.^-1212. Williams JM, Wright P, Currie CE, Beattie TF. Sports related injuries in Scottish Adolescents Aged 11-15. Br J Sports Med 1998; 32(4): 291-96. that points out to multiple determinations associated with the occurrence of wounds/injuries in children and adolescents, which include sociodemographic, environmental, cultural and behavioral elements⁵5. Malta DC, Mascarenhas MD, Bernal RT, Andrade SS, Neves AC, Melo EM, et al. Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência Capitais Brasileiras - 2009. Ciênc Saúde Coletiva 2012; 17(9): 2291-304.

6. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, et al. Multiple risk behavior and injury: an international study of youth in 12 countries. Arch Pediatr Adolesc Med 2002; 156: 786-93.

7. Soares Filho AM. Vitimização por homicídios segundo características de raça no Brasil. Rev Saúde Pública 2011; 45(4): 745-55.

8. Malta DC, Souza ER, Silva MM, Silva CS, Andreazzi MA, Crespo C et al. Vivência de violência entre escolares brasileiros: resultados da Pesquisa Nacional de Saúde do Escolar (PeNSE). Ciênc Saúde Coletiva 2010; 15(2): 3053-063.

9. Andrade SS, Yokota RT, Sá NN, Silva MM, Araújo WN, Mascarenhas MD, et al. Relação entre violência física, consumo de álcool e outras drogas e bullying entre adolescentes escolares brasileiros. Cad Saúde Pública 2012; 28(9): 1725-36.

10. Starkuniviene S, Zaborskis A. Links between accidents and lifestyle factors among Lithuanian school children. Medicina (Kaunas) 2005; 41: 73-80.

11. Malta DC, Porto DL, Melo FCM, Monteiro RA, Sardinha LMV, Lessa BH. Família e proteção ao uso de tabaco, álcool e drogas em adolescentes, Pesquisa Nacional de Saúde dos Escolares. Rev Bras Epidemiol 2011; 14(1): 166-77.^-1212. Williams JM, Wright P, Currie CE, Beattie TF. Sports related injuries in Scottish Adolescents Aged 11-15. Br J Sports Med 1998; 32(4): 291-96.. In this case, analyses including several explanatory variables were performed, and they can be grouped into:

1. Sociodemographic aspects:

2. Individual risk or protective factors:

3. Factors related to mental health:

4. Family context:

5. Contextual violence factors:

At first, there was an estimate of the outcome prevalence (injury), with 95% confidence interval (95%CI), as well as the description of the type of injury.

In order to verify factors associated with the injuries, a bivariate analysis was conducted with odds ratio (OR) estimates and the respective confidence intervals. Subsequently, all of the variables of interest were inserted in the multivariate model, and those with descriptive level equal to or lower than 5% (p < 0.05) and with epidemiological base remained; statistically significant variables remained in the final adjusted model (p < 0.05).

In order to correct the different selection probabilities of each student, weights were used to estimate proportions. The analysis was conducted with the software SPSS, version 20, using procedures from the Complex Samples Module, which is adequate to analyze data obtained by the complex sampling plan.

The study that originated this article was approved by the Research Ethics Committee of the Ministry of Health, report n. 192/2012, registration n. 16805 of CONEP/MS, on 27/03/2012.

RESULTS

Out of the adolescents who composed the sample, 10.3% reported having suffered serious injuries in the past 12 months. Out of these, 6.8% suffered only one wound, 2% had repeated events, from two to three times, and 1.5%, four or more times (Table 1).

The injuries that less serious or medium, wound or bruise and cut or perforation, were the most reported ones by adolescents. Afterwards came the more severe injuries, such as broken bone or dislocated joint. Lower frequencies, below 4%, were burns, traumas or other injuries on the head and neck, with fainting/difficulty breathing. Among the causes of injuries, the most mentioned one was falling (44%), followed by other unspecified reasons (about one third). The other causes, like being hit by an object, being attacked or participating in a fight, suffering an accident or being hit by a motorized vehicle, occurred in less than 10% of the cases.

The analysis according to sociodemographic factors showed that injuries were most common among male students, increasing with age, in black, mulatto, indigenous adolescents, children of mothers with no schooling, who attend public schools and work (Table 2).

Among individual risk behaviors, adolescents who used tobacco, illicit drugs, alcohol or those who had sexual intercourse were associated with injuries. Variables corresponding to health domain were associated with injuries: report of insomnia, loneliness, not having friends. The following situations of exposure to violent situations and accidents were also associated with injuries: feeling insecure at school, feeling insecure in the route home-school, being bullied, being conducted by an inebriated person, driving a motorized vehicle, not wearing a seatbelt and not wearing a helmet on the motorcycle (Table 3).

The family context factors associated with injuries were: assault from Family members, missing school without notifying the parents and not living with father and/or mother. Protective factors were demonstrated by adolescents who reported family supervision, or the fact that parents and people in charge knew about the adolescents' whereabouts during their free time (Table 3).

In the final model, the following variables remained independently associated with being severely injured: being male, black, mulatto and indigenous, and working, besides individual risk factors, such as the use of alcohol, cigarettes, trying drugs and having early sexual intercourse. Physical activity lost statistical significance in the final model. As to mental health, the variables having insomnia and feeling lonely remained associated; in the family context, being assaulted by family members, missing classes without notifying the parents and not living with father and mother were associated. Family supervision proved to be a protective factor. Factors associated with exposure to violent situations were: feeling insecure in school and in the route home-school, being conducted by an inebriated person, driving a motorized vehicle, not wearing a seatbelt, not wearing a helmet when riding a motorcycle and being bullied (Table 4).

DISCUSSION

The study about injuries in adolescents with data from PeNSE indicated that 1 out of tem adolescents has been seriously injured in the past 12 months, with cuts or perforations, broken bones or dislocated joints. More severe injuries, such as brain trauma, fainting or difficulty breathing were less mentioned (about 2%). The cause of injuries is mainly falls, which constituted almost half of the mentioned injuries. Attacks or fights, and being hit by a car by a motorized vehicle accounted for less than 10%. In the analysis of associated factors, the following remained independently associated with being injured: being a male adolescent, being black, mulatto or indigenous and working. Family factors were found when bonds between members were fragile: adolescents who get injured the most are the ones who are assaulted at home, miss classes without notifying the parents, do not live with parents and have low family control. The most relevant aspects of mental health are having insomnia and feeling lonely. The factors associated with the exposure to violent situations that remained in the model were: insecurity at school and in the route home-school, being conducted by an inebriated person, driving a motorized vehicle, not wearing a seatbelt, not wearing a helmet on the motorcycle and being bullied. Among the individual risk behaviors, the following stand out: using alcohol, cigarettes, trying illicit drugs and having early sexual intercourse.

In a comparative view, the prevalence of severe injuries in adolescents in the country (10%) is lower than in the study of Canadian Youth, which found an annual prevalence of 36%¹⁵15. King MA, Pickett W, King AJ. Injury in Canadian youth: a secondary analysis of the 1993-1994 Health Behaviour in School-Aged Children survey. Can J Public Health 1998; 89(6): 397-401.. In South Africa, prevalence was higher and the victimization of boys prevailed (52%) in relation to girls (33%)¹⁶16. Peltzer K. Injury and lifestyle factors among school-aged Black and White South African children in the Limpopo Province. Afri Saf Promot 2006; 4: 15-25.. Another study on the subject in six African countries, conducted by Peltzer¹⁷17. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8., found prevalence average of 62% of injuries among adolescents aged 13 to 15 years old, especially the victimization of boys. The lowest prevalence in Brazil can be explained by the different cultural contexts and also by the way the question was understood by the students. PeNSE used the reference of being severely injured, which may have led to more specificity in the question. Besides, international contexts are very different, which can limit comparisons.

However, all of the studies¹⁵15. King MA, Pickett W, King AJ. Injury in Canadian youth: a secondary analysis of the 1993-1994 Health Behaviour in School-Aged Children survey. Can J Public Health 1998; 89(6): 397-401.

16. Peltzer K. Injury and lifestyle factors among school-aged Black and White South African children in the Limpopo Province. Afri Saf Promot 2006; 4: 15-25.^-1717. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8. were unanimous to identify, as is the case of Brazil, the higher prevalence among boys in relation to girls. The male gender is pointed out as a predictor of violent behaviors, be it in intentional or unintentional violent situations¹⁷17. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8.. The higher prevalence of injuries among boys has been described since childhood, followed by adolescence, in teenagers and adults, leading to male over-mortality due to external causes¹⁹19. Souza ER. Masculinidade e violência no Brasil: contribuições para a reflexão no campo da saúde. Ciênc Saúde Coletiva 2005; 10(1): 59-70.^,2020. Malta DC, Mascarenhas MD, Silva MM, Macario EM. Perfil dos atendimentos de emergência por acidentes envolvendo crianças menores de dez anos: Brasil, 2006 a 2007. Ciênc Saúde Coletiva 2009; 14(5): 1669-679.. A possible explanation provided by the authors is based on cultural behaviors, in which boys are more encouraged to collective outdoors activities, such as playing soccer, riding a bike and entering violent games with weapons, while girls are mostly encouraged to playing with dolls indoors¹⁹19. Souza ER. Masculinidade e violência no Brasil: contribuições para a reflexão no campo da saúde. Ciênc Saúde Coletiva 2005; 10(1): 59-70.^,2020. Malta DC, Mascarenhas MD, Silva MM, Macario EM. Perfil dos atendimentos de emergência por acidentes envolvendo crianças menores de dez anos: Brasil, 2006 a 2007. Ciênc Saúde Coletiva 2009; 14(5): 1669-679.. These cultural gender differences end up exposing boys to higher risks of accidents and injuries¹⁸18. Hanson RF, Borntrager C, Self-Brown S, Kilpatrick DG, Saunders BE, Resnick HS, et al. Relations among Gender, Violence Exposure, and Mental Health: The National Survey of Adolescents I. Am J Orthopsychiatry 2008; 78(3): 313-21., which is a result of the sexist culture that encourages belligerency and bellicosity, domain and taking risks²¹21. Minayo MC. Laços perigosos entre machismo e violência. Ciênc Saúde Coletiva 2005; 10(1): 18-34.^,2222. Minayo, MC, Constantino P. Visão ecossistêmica do homicídio. Ciênc Saúde Coletiva 2012; 17(12): 3269-278..

Some authors alert that researching throughout the long reminiscent period of 12 months in this age group may lead to underestimated information, and they recommend the analysis of shorter periods (1-3 months)¹⁷17. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8.; however, the same author mentions that the 12-month recollection enables to remember more severe events and lesions. Therefore, PeNSE maintained the 12 month reference, as did the GSHS.

The higher frequency of falls as the cause of injuries in this study is in accordance with what has been described by the system of Accident and Violence Surveillance (VIVA), survey that is conducted every three years in emergency units in the country. VIVA points out that falls were prevalent, followed by other accidents and, in the third position, transport accidents⁵5. Malta DC, Mascarenhas MD, Bernal RT, Andrade SS, Neves AC, Melo EM, et al. Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência Capitais Brasileiras - 2009. Ciênc Saúde Coletiva 2012; 17(9): 2291-304..

In VIVA, burns are not as prevalent as in this study⁵5. Malta DC, Mascarenhas MD, Bernal RT, Andrade SS, Neves AC, Melo EM, et al. Causas externas em adolescentes: atendimentos em serviços sentinelas de urgência e emergência Capitais Brasileiras - 2009. Ciênc Saúde Coletiva 2012; 17(9): 2291-304.. The burns were reported in 4.9% of the studies about African countries¹⁷17. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8.. In Sub-Saharan Africa, burns are one of the main causes of prolonged hospitalization, deformation, impairment and death among adolescents²³23. Hyder AA, Kashyap KS, Fishman S, Wali SA. Review of childhood burn injuries in sub-Saharan Africa: a forgotten public health challenge. Afr Saf Promot 2004; 2(2): 43-52..

Some authors point out to the great prevalence of injuries and trauma among adolescents due to sports and recreational activities. It is the case of the studies by Peltzer¹⁷17. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8., in Africa, and analyses in Canada²⁴24. Pickett W, Dostaler S, Craig W, Janssen I, Simpson K, Shelley SD, et al. Associations between risk behavior and injury and the protective roles of social environments: an analysis of 7235 Canadian school children. Inj Prev 2006; 12(2): 87-92.^,2525. Simpson K, Janssen I, Craig W, Pickett W. Multilevel analysis of associations between socioeconomic status injury among Canadian adolescents. J Epidemiol Community Health 2005; 59(12): 1072-77., as well as the investigation Scottish School Children, in Scotland¹²12. Williams JM, Wright P, Currie CE, Beattie TF. Sports related injuries in Scottish Adolescents Aged 11-15. Br J Sports Med 1998; 32(4): 291-96.. PeNSE did not include specific questions about injuries in the practice of sports among Brazilian adolescents, therefore it is difficult to compare this aspect with the international scope. However, questions referring to the regular practice of physical exercise for one hour a day or more were analyzed. In this case, the bivariate analysis shows that such activities are protective when performed regularly, even though they did not remain in the final model. The benefits of physical activities for young people, in general, are associated with healthy habits and lower exposure to risks, besides the best muscle and joint conditioning²⁶26. Organização Mundial da Saúde. Handbook for guideline development. Genebra: WHO; 2009.^,2727. Janssen I. Physical activity guidelines for children and youth. Can J Public Health 2007; 98(2): S109-21..

As in PeNSE, other studies¹⁰10. Starkuniviene S, Zaborskis A. Links between accidents and lifestyle factors among Lithuanian school children. Medicina (Kaunas) 2005; 41: 73-80.^,1717. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8.^,2323. Hyder AA, Kashyap KS, Fishman S, Wali SA. Review of childhood burn injuries in sub-Saharan Africa: a forgotten public health challenge. Afr Saf Promot 2004; 2(2): 43-52. showed association between injuries and risk behaviors, such as tobacco, alcohol and illicit drugs. An international study¹⁷17. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8. showed that drunkenness was associated with the occurrence of injuries among young people, which was confirmed by PeNSE, both in relation to the regular alcohol consumption and in relation to drunkenness (data not shown). The use of substances (tobacco, alcohol and drugs) among adolescents is a predictor of other risk behaviors, since it increases the chances of getting involved in dangerous practices, like driving a motorized vehicle and getting involved in fights, which constitutes a risk factor for injuries and wounds¹1. Organização Mundial da Saúde and United Nations Children's Fund. Child and adolescent injury prevention: a global call to action. Genebra: WHO e UNICEF; 2005.^,1010. Starkuniviene S, Zaborskis A. Links between accidents and lifestyle factors among Lithuanian school children. Medicina (Kaunas) 2005; 41: 73-80.. Other studies indicate more distal determiners, such as poverty and social inequality, associated with injuries and wounds¹⁰10. Starkuniviene S, Zaborskis A. Links between accidents and lifestyle factors among Lithuanian school children. Medicina (Kaunas) 2005; 41: 73-80.^,1717. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8.^,2323. Hyder AA, Kashyap KS, Fishman S, Wali SA. Review of childhood burn injuries in sub-Saharan Africa: a forgotten public health challenge. Afr Saf Promot 2004; 2(2): 43-52.. In this study, the variables related to socioeconomic level in the final model were: being mulatto, black and indigenous and the act of working. These variables are potential markers of social inequalities and can expose adolescents to living in insecure places, dislocating in insecure routes, with more exposure to violence and conflicts¹¹11. Malta DC, Porto DL, Melo FCM, Monteiro RA, Sardinha LMV, Lessa BH. Família e proteção ao uso de tabaco, álcool e drogas em adolescentes, Pesquisa Nacional de Saúde dos Escolares. Rev Bras Epidemiol 2011; 14(1): 166-77.. Working in this age group exposes adolescents to risk situations, with dangerous exposure to inadequate equipment and work overload, besides physical and emotional violence²⁸28. Libório RM, Ungar M. Children's labour as a risky pathways to resilience: children's growth in contexts of poor resources. Psicol Reflex Crit 2010; 23(2): 232-42., which can result in higher risks of accidents and injuries.

In the study by Peltzer¹⁷17. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8. in six African countries, the author found variations in the strength and direction of associations, according to different types of lesion. The indicator of low economic condition and loneliness were the highest predictors of injuries caused by motorized vehicles, while school evasion associated with physical struggling and depression were strong predictors of burns. In the current study, the following variables are also associated with the higher prevalence of injuries: poorer economic status, missing classes and symptoms related to poorer health status. The highest strengths of association were found when the teenager suffered family assault, lived in a violent context, felt insecure in school, had insomnia and felt lonely. All of these situations expose adolescents to vulnerable violent situations.

In this study, family supervision was the only variable with a protective effect associated with injuries. Studies have pointed out the protective role of parental supervision. Springer et al.²⁹29. Springer AE, Sharma S, de Guardado AM, Nava FV, Kelder SH: Perceived parental monitoring and health risk behavior among public secondary school students in El Salvador. ScientificWorldJournal 2006; 6: 1810-4. reported that parental supervision plays a protective role, thus reducing violent situations and, consequently, injuries, besides risk sexual behaviors, among others.

We also emphasize the association of lesions with multiple risk behaviors6. This is the case of Peltzer's study¹⁷17. Peltzer K. Injury and social determinants among in-school adolescents in six African countries. Inj Prev 2008; 14(6): 381-8. with teenagers from African countries: this author found increasing gradient of injuries according to the increasing number of risk behaviors. The data in this study also confirm the weight of multiple associated risks: use of tobacco, alcohol, illicit drugs, the non-use of helmets, the non-use of the seatbelt, being conducted by an inebriated person, driving a vehicle, being bullied and having early sexual intercourse, which shows the complexity of policies to promote health and prevent accidents and violence in this age group.

It is also necessary to mention the limits of this study:

CONCLUSIONS

This article is originated from the analysis of data from PeNSE, and it mentions one more type of victimization of adolescents. Even though it is frequent, it is little studied: being severely injured. Instead of thinking about this phenomenon as something autonomous and casual, it is possible to observe its association with several factors. As well as in all of the studies about violence, male young people are the most vulnerable ones.

Most studies mentioned in this article agrees at some points and, in others, they are different from the findings in this study. One relevant point of agreement is the increasing number of injuries and their association with several risk behaviors. This study brings new knowledge that reinforces the importance of an integrated work with health policies for children and adolescents. Educational programs developed by the health and educational sectors, which approach behavioral causes and determiners, instead of focusing on individual risk factors, may use a more complex reflection by observing the articulation between various situations and considering them in the work that favors the health of adolescents.

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