1. Injuries among adolescents living in poverty in Ethiopia, India, Vietnam and Peru: a mixed method study Inka Barnett (IDS) Virginia Morrow UEA/IDS workshop 2 nd July

2. Global burden of injuries Leading cause of premature death and disability among adolescents 95% of fatal injuries in low income countries Number of injuries is expected to rise Most injuries are preventable & not random events! Problem: Lack of injury prevention programmes Reasons: lack of evidence and available evidence focuses on children < 5yrs, political will, competing health problems

3. Aim and design To examine patterns, causes & consequences of injuries among poor adolescents in the context of their daily lives. To address this aim we integrated quantitative and qualitative data, seeking to expand our understanding.

4. Setting: Young Lives Study Interdisciplinary cohort study of childhood poverty 20 sites in each Ethiopia, India (Andhra Pradesh), Peru & Vietnam Quantitative surveys with adolescents Qualitative interviews with a subset of adolescents

5. Sample and data 12,000 children over 15 years period.

6. Method Mixed method design that integrated:  Cross-sectional survey data from adolescents  Qualitative interviews with a ‘nested’ sub-set Complementary use of quantitative & qualitative research in which the two approaches: “ talk to each other and... [develop] a negotiated account of what they mean together” (Bryman 2007)

7. Step-by-step account Integration of quantitative & qualitative data in the analysis and interpretation phase Step 1: Parallel initial analyses of both data sets separately and identification of key themes related to injuries Step 2: Quantitative analysis finding (work, recreation, transport- injuries) as starting point for integration Step 3: Initiation of two-way process in which quantitative and qualitative data ‘talk to each other’ for deeper insights Step 4: ‘Back and forth’ between data sets to follow-up themes

8. Iterative approach Quantitative analysis Descriptive statistics Multivariate regressions Qualitative analysis Meta-theme analysis Coding framework Key types for injury Living context & risk factors

9. In reality... Data were collected as part of multi-disciplinary research study on poverty (not injury!) Only limited integration during method development  Qualitative data focussed on experience of ill health  Quantitative survey had general section on health

10. Results: Patterns Injuries emerged as major concern in both data sets Quantitative data (occurrence of injury in last 3 years): Qualitative data expanded on quantitative findings and suggested a much higher burden!  Self-treatment and delayed medical treatment frequently aggravate minor injuries

11. Results: Patterns Delay in health care seeking due to poverty can aggravate minor injuries: “An axe hit me on my leg when I was chopping wood. The wound was not bad.[...] First, my parents put chilli and alcohol on the sore.... Iwas treated in this way for one month. However, I was seriously sick and I was taken to the modern health centre. I had one medicine by injection and another medicine which was taken in the form of fluid....Then I recovered from the injury.” (15 year-old boy, Ethiopia)

12. Results: Risk factors for injury (I) Quantitative analysis:  Injuries occurred at work, during recreation and transport Qualitative follow-up found context-specific injury risks:  Dangerous work environments (e.g. stone crushing, sun- exposure, traffic)  Unsafe recreational and living environments (e.g. poor roads, no safe space)  Unsafe public transport (e.g. overcrowded busses) y

13. Results: Risk factors for injury (II) Quantitative follow-up:  Living in a poor household was significantly associated with reporting an injury Qualitative follow-up:  Necessity of poorer adolescents to work to support household  Work in often hazardous conditions and without protective gear (e.g. gloves, shoes)

14. Consequences of injuries Quantitative analysis:  Between 5% (Vietnam) and 14% (Peru) of adolescents reported long-term health problems Qualitative follow-up suggests consequences beyond these:  Drop-out of school  Loss of job  Reduced income of entire household

15. Lessons learned... Use of quantitative & qualitative data provided more comprehensive insights into realities of injuries in poverty Lack of integration in method development phases made it often challenging to integrate and follow-up emerging themes (reality of multi-disciplinary studies?) Team working (qualitative & quantitative researchers)  Different methodological languages, structures and reporting styles  Importance of lead on integration  Journal and audience identification Timeliness of data analysis (qualitative more time- consuming)

16. Future ideas... Case-by-case integration of quantitative and qualitative data for the same individual Integration of quantitative and qualitative approaches in design and method development phase to make sure the different data really ‘speak to each other’ Integration of longitudinal quantitative data with qualitative data to ‘follow-up’ consequences, the impact of improvements in living conditions, etc.

17. Publication Health Policy and Planning (2013)

18. Thank you & Questions… Email: i.barnett@ids.ac.uk