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Cross-national Study of Fighting and Weapon Carrying as Determinants of Adolescent Injury

William Pickett, PhD^*,, Wendy Craig, PhD, Yossi Harel, PhD^||, John Cunningham, BSc^*,, Kelly Simpson, MSc^*,, Michal Molcho, PhD^||, Joanna Mazur, PhD^¶, Suzanne Dostaler, MSc^*,, Mary D. Overpeck, DrPH^#, Candace E. Currie, PhD^** on behalf of the HBSC Violence and Injuries Writing Group

^* Community Health and Epidemiology
Emergency Medicine
Psychology, Queen’s University, Kingston, Ontario, Canada
^|| Department of Sociology and Anthropology, Bar-Illan University, Ramat Gam, Israel
^¶ Mother and Child National Research Institute, Warsaw, Poland
^# Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland
^** Child and Adolescent Health Research Unit, University of Edinburgh, Edinburgh, Scotland

	ABSTRACT

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Objectives. We sought to (1) compare estimates of the prevalence of fighting and weapon carrying among adolescent boys and girls in North American and European countries and (2) assess in adolescents from a subgroup of these countries comparative rates of weapon carrying and characteristics of fighting and injury outcomes, with a determination of the association between these indicators of violence and the occurrence of medically treated injury.

Design and Setting. Cross-sectional self-report surveys using 120 questions were obtained from nationally representative samples of 161082 students in 35 countries. In addition, optional factors were assessed within individual countries: characteristics of fighting (9 countries); characteristics of weapon carrying (7 countries); and medically treated injury (8 countries).

Participants. Participants included all consenting students in sampled classrooms (average age: 11–15 years).

Measures. The primary measures assessed included involvement in physical fights and the types of people involved; frequency and types of weapon carrying; and frequency and types of medically treated injury.

Results. Involvement in fighting varied across countries, ranging from 37% to 69% of the boys and 13% to 32% of the girls. Adolescents most often reported fighting with friends or relatives. Among adolescents reporting fights, fighting with total strangers varied from 16% to 53% of the boys and 5% to 16% of the girls. Involvement in weapon carrying ranged from 10% to 21% of the boys and 2% to 5% of the girls. Among youth reporting weapon carrying, those carrying handguns or other firearms ranged from 7% to 22% of the boys and 3% to 11% of the girls. In nearly all reporting countries, both physical fighting and weapon carrying were significantly associated with elevated risks for medically treated, multiple, and hospitalized injury events.

Conclusions. Fighting and weapon carrying are 2 common indicators of physical violence that are experienced by young people. Associations of fighting and weapon carrying with injury-related health outcomes are remarkably similar across countries. Violence is an important issue affecting the health of adolescents internationally.

Key Words: adolescent • etiology • fighting • injury • trauma • violence • weapon carrying

Abbreviations: HBSC, Health Behaviour in School-Aged Children • OR, odds ratio

Countries throughout the world have identified violence as a leading adolescent health concern.^1–3 Recent studies of adolescent populations in Canada,^4,5 Europe,^4,6 the Middle East,^4,7 and the United States^1,4,8 have described the prevalence of bullying, physical fighting, and weapon carrying within individual countries. Several studies have also examined correlates of violent behaviors, including their associations with psychosocial health,⁹ substance use,¹⁰ and fighting-related injury.¹¹ Results from these studies have broadened our knowledge of the global impact that adolescent violence has on public health. Existing international comparisons of youth violence have focused on the frequency of adolescent violence-related behaviors in a small number of countries,¹² comparisons of episodes of school violence and its determinants in Israeli and Arabic student populations,¹³ studies of "child soldiers" in countries engaged in civil and international warfare,^14,15 international comparisons of firearm-related mortality,³ and, as part of more general international comparisons, examinations of firearm regulations and rates of homicide,^3,16,17 robberies and sexual assaults,^17,18 and suicide.¹⁶ Beyond studies of firearms, international comparisons of rates of youth violence are still lacking, and the magnitude and nature of the adolescent violence problem remains unknown for many countries. Cross-national comparisons of violent behaviors in youth have been problematic, because of the use of nonrepresentative samples in many countries and a lack of uniformity in study designs.

Physical fighting and engagement in weapon carrying are common manifestations of interpersonal violence observed in adolescent populations.^1,19 Measures for both behaviors have been well developed and standardized for studies involving children.^19,20 Using such indicators, analyses of the US National Longitudinal Study of Adolescent Health have shown that group fighting, fighting with strangers, and weapon use all lead directly to elevated risks for fighting-related injury.¹¹ Furthermore, these measures might also be considered as markers for a more complex behavioral syndrome of "multiple-problem"²¹ or "multiple-risk"²² behavior. This syndrome may lead to a variety of adverse health problems (eg, depression, somatic health complaints, trauma) that go beyond injuries experienced as a result of physical fights.

The Health Behaviour in School-Aged Children (HBSC) survey, a World Health Organization collaborative cross-national study, provides a unique opportunity to compare adolescent experiences with violence and their consequences across countries. The HBSC survey was initiated by researchers in 3 European countries in 1982. Since 1985, surveys have been conducted at 4-year intervals in a growing number of countries under the auspices of the World Health Organization Regional Office for Europe. Membership is by application to a multicountry committee, and new teams are accepted based on their perceived abilities to adhere to an accepted survey protocol. In 2002 the survey was expanded to 35 countries, mainly from continental Europe, the Middle East, and North America.^23,24

The HBSC survey contains a set of measures that provide a valid representation of the health and lifestyle of adolescents in industrialized countries.²⁴ Measures, sampling, and data collection were designed to be common across countries.⁴ The current analysis uses the HBSC survey to compare recent estimates of the prevalence of physical fighting and weapon carrying among adolescents across countries and uses standard measures and methods. Separate analyses are presented for boys and girls. The consistency of relationships cross-nationally between physical fighting and weapon carrying with the occurrence of 3 standard indicators of medically treated injury are also explored. The ability to generate meaningful international comparisons is a major strength of the HBSC survey, and this cross-national analysis provides a useful first look at the problem of adolescent violence in a select number of countries.

	METHODS

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Study Population and Procedures
School-based anonymous surveys were conducted during the 2001/2002 academic year according to the common HBSC research protocol.²⁴ National research teams were initially asked to survey schools to produce national or regional estimates for 11-, 13-, and 15-year-old children. Classes within schools were then selected by using a weighted probability technique to ensure that students were equally likely to be included. In some countries, regional geography and other salient demographic factors (eg, religion, language of instruction) were taken into consideration via stratification or restriction. Statistical criteria specify that samples submitted for international comparisons were sufficient to provide confidence intervals of ±3% for representative estimates with sample design effects no more than 1.4 times greater than would be obtained from a simple random sample.

A limitation of the HBSC survey is that information necessary to calculate meaningful response rates at administrative-participant (eg, school board, school) then student-participant levels were not documented consistently in all countries. At the student-participant level, known response rates among countries varied from 64.5% to 91.2%.²⁵

Each participating country obtained approval to conduct the survey from the ethics review board or equivalent regulatory body associated with the institution conducting each respective national survey.

Primary Measures
The survey contained 120 mandatory questions about health behaviors, lifestyle factors, and demographic characteristics that were asked of all survey participants (n = 161082). Additional optional injury and violence items were assessed in a more limited number of countries. Injury and violence items used in the present analysis are described below. (Note that results in Israel are based on approximately one half of the pool of respondents. Israel used a split-sample approach in which half of the participants were asked mandatory items plus optional questions about violence and injuries, and the other half of the participants were asked mandatory items plus optional questions about different health topics.)

Injury
Participants were asked to report the frequency of injury events during the past 12 months that required medical attention from a doctor or a nurse (mandatory item). An optional injury item assessed in 8 countries (n = 29183) described the source of medical care for the 1 most serious injury reported. Wording of these questions and the response categories were based on surveillance efforts in the United States^26,27 and responses obtained during previous surveys.^23,28

Physical Fighting
Participants were asked to report how frequently they had been involved in a physical fight during the past 12 months (mandatory item) and with whom they fought the last time they were involved (9 countries, n = 37571). Frequency of fighting is a validated construct with extensive use in American and other youth risk-behavior surveys.²⁰

Weapon Carrying
Weapon carrying is also a well-developed measure of violent behavior.^3,19 In 2 optional items assessed in 7 countries, participants (n = 24750) were asked to report (1) on how many of the past 30 days they had carried a weapon such as a gun, knife, or club and (2) the type of weapon carried the last time they recalled carrying a weapon.

Statistical Analysis
Data analyses were initially conducted with SPSS 12 (SPSS Inc, Chicago, IL). A conservative design effect of 1.2 was used in the inflation of SE estimates to account for the cluster-based sampling.⁴ Descriptive analyses were conducted for each country to obtain the prevalence of physical fighting and weapon carrying by gender, and these factors were ranked and described cross-nationally. Among countries reporting fighting and weapon carrying, estimates were developed to describe with whom adolescents were fighting and the types of weapons carried within individual countries. An etiologic analysis then addressed risks for injury associated with a lifestyle that included engagement in physical violence. Multiple logistic-regression analyses were used to assess differences in risk for 3 general injury outcomes (medically treated, repeat [>1], and hospitalized injury) among groups defined by levels of fighting and weapon carrying. To examine consistency of associations, these analyses were performed within countries but were restricted to the countries that assessed the requisite optional survey items. Variables that had been identified as potential confounders of violence-injury associations (age,^25,29 gender,^29,30 poverty,^29,30 time spent out with friends,³¹ and average weekly physical activity^30,32) were included as covariates in the statistical models. Because the focus of these etiologic analyses was on the consistency of associations between measures of violence and injury, inferences were based on observed patterns of odds ratios (ORs) (eg, presence of an apparent gradient in risk) and not solely on the statistical significance of the etiologic findings.

	RESULTS

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Children (161082) in 35 countries participated in the 2001/2002 HBSC survey and answered the mandatory survey items; of these, 39953 children in 9 countries responded to the optional questions about physical fighting, 24750 children in 7 countries responded to the optional weapon-carrying items, and 29183 children in 8 countries responded to optional questions about medically treated injury.

Involvement of the boys in physical fighting during the previous year ranged from 37% in Finland to 69% in the Czech Republic (Fig 1A), with an overall average of 58%. Among girls, the prevalence of physical fighting ranged from 13% in Finland to 32% in Hungary (Fig 1B), with an overall average of 24%. The majority of countries reporting the highest rates of fighting by boys were from Eastern or Central Europe. In terms of their country ranking, reported rates of fighting by girls in some of these same countries (eg, Poland, Ukraine, Latvia) were quite low. Differences in the prevalence of physical fighting between countries were mainly attributable to the proportions of youth reporting fighting on multiple (>1) occasions. Across the 9 countries collecting optional data about physical fighting, youth most often reported fighting with friends or relatives, although there were strong cross-national differences in the participants involved in these physical fights (Table 1). Involvement in physical fights with total strangers varied from 16% (Canada) to 53% (Macedonia) of the boys and 5% (Estonia) to 16% (Macedonia) of the girls.

View larger version (63K): [in this window] [in a new window]   Fig 1. A, Boys’ self-reported prevalence of physical fighting in 35 countries during the 12 months before the 2001/2002 HBSC survey. B, Girls’ self-reported prevalence of physical fighting in 35 countries during the 12 months before the 2001/2002 HBSC survey. Error bars represent 95% confidence intervals.

View this table: [in this window] [in a new window]   TABLE 1. Specified Person With Whom Respondents Fought During Their Most Recent Physical Fight (Among Adolescents Reporting 1 Fights During Past 12 Months) According to Gender and Country

	DISCUSSION

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Physical fighting is the most common manifestation of interpersonal violence in adolescence.¹ Although researchers have documented fighting as an obvious and direct cause of adolescent injury,¹¹ our results support the idea that fighting is a marker for a lifestyle that has inherent injury risks for both boys and girls. In the past, a lifestyle that includes fighting has been described as a behavioral syndrome that can include substance use, truancy, and other problem behaviors during adolescence.^21,22 Because it is highly visible and often results in contact with health professionals, researchers have proposed fighting behavior as one of the earliest and most reliable markers of this multiple-risk-behavior syndrome.³³

Differences in rates of fighting between countries likely reflect underlying cultural differences in the acceptance of violence within different societies.³⁴ To illustrate, in a war-torn country, fighting may be viewed as a normative behavior that is observed on a daily basis as an inherent part of basic survival.³ Despite the variation observed cross-nationally, males in all countries were much more likely to fight than girls, which is consistent with the findings of others.^1–3 This finding may also indicate cultural acceptance of more overt forms of aggression as normative male behavior. Existing research suggests that boys are much more likely to become involved in physical fights, whereas girls are much more likely to engage in covert or relational forms of emotional aggression.^35,36

Differences observed in the context of physical fights by gender suggest that girls are most likely to fight within intimate relationships. Although boys also fight in such contexts, they were much more likely to fight with total strangers. This finding may reflect boys’ extrinsic tendencies to engage in group and community activities including organized sports, as well as (more speculatively) one of many possible intrinsic effects of hormonal (androgenic) differences associated with early male maturation.³⁷

In all countries studied, the vast majority of children did not report any weapon carrying in the last 30 days. Observed differences in weapon carrying by gender may reflect the number and type of aggressive encounters that boys and girls experience. Knives seem to be the common weapon of choice. Although one cannot infer the intentions of individual children from the weapon-carrying reports, boys more often carry weapons associated with proactive aggression (eg, guns, sticks or clubs, brass knuckles), whereas girls more often carry weapons for defensive purposes (eg, mace, pepper spray, tear gas). International differences in the types of weapons carried may reflect accessibility to and/or cultural acceptance of different types of weapons. For example, the relatively high rate of handgun carrying by boys in some countries reflects the relative ease of access to firearms in these countries.³⁸

Consistent with others,³⁹ our findings show that both physical fighting and weapon carrying are indicative of a violent lifestyle that has individual and family-related health consequences. We examined 3 common forms of injury, and similar etiologic findings emerged. Risks for the first 2 forms of injury examined (medically treated and repeat injuries) indicated that "ever" engaging in fighting was the most salient risk factor, whereas a stronger risk gradient was observed between the frequency of fighting and hospitalized injury occurrence. Similarly, we did not observe a gradient in risk for injury by frequency of weapon carrying, and "ever" versus "never" engaging in weapon carrying seems to have more etiologic significance.

Limitations of this analysis include our use of self-reported data and the cross-sectional nature of the survey. The HBSC questionnaire items have been subjected to extensive piloting and validation efforts,²⁴ yet the possibility of biased reporting of health risk behaviors motivated by a desire to provide socially desirable responses must also be recognized. Similarly, because these findings are based on classroom samples in selected countries, they will not be representative of adolescents in special or nonclassroom settings. Although the obvious link between physical fighting and fighting injury is established,¹¹ because of sample-size limitations we were unable to study this association, and the etiologic analyses were limited to more common injury outcomes. Finally, although the rates and trends in the occurrence of violence are thought to be representative of the countries under study, they are less likely to depict the experiences of adolescents in other (eg, war-torn^14,15) countries. Our study findings are not purported to be representative of the experiences of children globally.

Strengths of this analysis also warrant recognition. These strengths include the size and cross-national nature of our analysis, our use of standard measures and survey procedures, and the anonymous nature of reporting. The latter should promote accuracy in responses. Indeed, our study was one of the largest epidemiologic analyses of its kind, and we believe that the breadth of our cross-national comparisons is unique to the biomedical literature.

Study results inform the research agenda for these important topics in adolescent health. One leading topic to be addressed is the determinants of physical fighting and weapon carrying and how they vary across countries and adolescent cultures. Our findings also provide objective data to inform preventive research initiatives. Fighting may be an early risk factor or a marker for engaging in other forms of violent behavior.³⁷ In addition, the results suggest that prevention programs should begin early to prevent the potential escalation from fighting to weapon carrying and injury. There are several examples of effective early interventions to reduce aggression involving the family (eg, parent training).⁴⁰ Similarly, minimization of violent imagery in the media combined with parent and child review of this imagery promote understanding of the consequences of violence.⁴¹ Integration of media-awareness strategies into school curriculums has proven to be efficacious, and the school environment is an optimal setting for the early detection of aggressive behavior.^42,43 Existing trials demonstrate that programs that emphasize the development of social skills,^44–46 anger management,^44–46 and conflict resolution⁴⁷ have also led to decreases in aggression, increases in prosocial behavior,⁴⁴ reductions in injuries,⁴⁵ and improved adjustment, which are reflected by increases in assertiveness among girls and decreases in physical fighting among boys.^46,47 The latter provide a basis for future interventional work.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Physical fighting and weapon carrying are 2 indicators of adolescent violence that are commonly reported by youth across countries. Patterns of fighting and weapon carrying observed by gender and cross-nationally are indicative of cultural trends and norms in the occurrence and perhaps acceptance of violence. Associations of fighting and weapon carrying with injury-related health outcomes are remarkably similar across these same countries. Violence is clearly an important issue affecting the immediate health of adolescents internationally, and this topic continues to deserve focused interventional research and intentional programming.

	ACKNOWLEDGMENTS

 
This study was funded in part by Health Canada, which funds the Canadian version of the Health Behavior in School-Aged Children Survey, a World Health Organization/European Region collaborative study. The international coordinator of the 2001/2002 study is Dr Currie, and the data bank manager is Oddrun Samdal (University of Bergen, Bergen, Norway). This analysis was supported by grants from the Canadian Institute of Health Information, through a grant from the Canadian Population Health Initiative, and the Ontario Neurotrauma Foundation. The HBSC Violence and Injuries Writing Group includes all the authors of this article and Dora Vernai (National Institute of Child Health, Budapest, Hungary), Efrat Tillinger (Bar-Ilan University, Ramat Gan, Israel), and Anita Villerusa (Riga Stradins University, Riga, Latvia).

This publication of the 2001/2002 HBSC Violence and Injuries Writing Group reports on data from the following countries (principal investigators at that time are given in parentheses): Austria (Wolfgang Dür), Belgium-Flemish (Lea Maes), Belgium-French (Danielle Piette), Canada (William Boyce), Croatia (Marina Kuzman), Czech Republic (Ladislav Csémy), Denmark (Pernille Due), England (Antony Morgan), Estonia (Mai Maser and Kaili Kepler), Finland (Jorma Tynjälä), France (Emmanuelle Godeau), Germany (Klaus Hurrelmann), Greece (Anna Kokkevi), Greenland (J. Michael Pedersen), Hungary (Anna Aszmann), Ireland (Saoirse Nic Gabhainn), Israel (Yossi Harel), Italy (Franco Cavallo), Latvia (Ieva Ranka), Macedonia (Lina Kostorova Unkovska), Malta (Marianne Massa), Netherlands (Wilma Vollebergh), Norway (Oddrun Samdal), Poland (Barbara Woynarowska), Portugal (Margarida Gaspar De Matos), Russia (Alexander Komkov), Scotland (Candace Currie), Slovenia (Eva Stergar), Spain (Carmen Moreno Rodriguez), Sweden (Ulla Marklund), Switzerland (Holger Schmid), Ukraine (Olga Balakireva), United States (Mary Overpeck and Peter Scheidt), and Wales (Chris Roberts).

	FOOTNOTES

 
Accepted Jun 23, 2005.

Address correspondence to William Pickett, PhD, Department of Community Health and Epidemiology, Queen’s University, Angada 3, 76 Stuart St, Kingston General Hospital, Kingston, Ontario, Canada K7L 3N6. E-mail: pickettw{at}post.queensu.ca

No conflict of interest declared.

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