Need of global student safety and insurance day observance: a suggestion

INTRODUCTION

Child injuries are a growing global public health problem that requires urgent attention. They are a significant area of concern from the age of one year, and progressively contribute more to overall rates of death until the children reach adulthood. Globally, millions of children die each year from injuries or violence, and millions of others suffer the consequences of non-fatal injuries. For each area of child injury, there are proven ways to reduce both the likelihood and severity of injury.¹

At this juncture the authors suggested ‘global student safety and insurance day observance’ in order to create awareness against unintentional injury prevention among the students and their family members/care givers/ other stakeholders and providing student safety insurance to overcome the financial hardship of the families as a consequence of unintentional injury.

Injuries are categorized into unintentional (accidental) and intentional (deliberate). Here our main concern is to discuss about unintentional child injuries such as road traffic injuries (RTIs), drowning, burns, falls, accidental poisoning, animal bites, machine injury, electric shocks etc. These all affect children and as a resulting sometimes death or disability.¹

A student is one who is enrolled or attends classes at a school, college, or university. Student safety insurance policies are offered to students and can be availed by educational institutions such as schools, colleges, etc. for the benefit of their students. The students are being paid a yearly premium towards the insurance policy. If any student disabled or died due to unintentional injuries, the claim is paid out to the guardian or parent of an affected student. This policy is issued under the name of the educational institution. Once the institution purchases a student safety insurance, all the students in the institution will be covered.

Every day around the world the lives of more than 2,000 families are affected by the loss of a child to an unintentional injury that could have been prevented. The grief that these families go through is immeasurable and often impacts entire communities. Such tragedy can change lives irrevocably.¹

The landmark convention on the rights of the child, ratified by almost all national and state governments that children around the world have a right to a safe environment and to protect from injury and violence. Safeguarding these rights everywhere is not easy, but it can be achieved by concerted action. Children are exposed to hazards and risks as they go about their daily lives and are vulnerable everywhere to the same types of injury. However, the physical, social, cultural, political and economic environments in which they live differ greatly. Their particular environments are thus very important.¹

Objectives

To estimate the burden of unintentional injuries among students at global and country level. To evaluate various causes of unintentional injuries among the students. To determine the association of unintentional injuries among the students with various socioeconomic factors. To identify the student safety days/weeks and student safety insurance policies available at global and country levels and recommend accordingly.

METHODS

The study involved a descriptive analysis of the articles published in various journals regarding unintentional injuries among the students, student safety days/weeks and student safety insurance policies in 2019. A thorough internet search was carried out to collect information on the public domains regarding unintentional injuries across the globe. A systematic, predetermined strategy was undertaken for collecting and collating the gathered information. The search was conducted using search engines like Google, Google scholar, Pub MED, The Lancet etc. A set of keywords was used for the search which included: unintentional injuries, death and disabilities among children due to unintentional injuries, consequences of injury, injury prevention, student safety insurance, student safety day/week etc. Data were compiled and assimilated in a systematic manner. The unrelated articles were not considered.

DISCUSSION

The discussion is categorized into unintentional injuries and injury-wise also.

Unintentional injuries globally

The WHO in a report (global burden of disease: 2004 update in 2008) mentioned that injury and violence were major killers of children throughout the world, responsible for about 9,50,000 deaths in children and young people < 18 years each year. Unintentional injuries accounted for almost 90% of these cases. They were leading cause of death for children aged 10-19 years. RTIs alone were the leading cause of death among 15-19 and the second leading cause among 10-14 years old. In addition, millions of children required hospital care for non-fatal injuries. Many were left with some form of disability, often with lifelong consequences. The leading causes of disability-adjusted life years (DALYs) lost for children aged 0-14 years, with RTIs and falls ranking in the top 15 causes.²

Child injury must be a central part of all initiatives to prevent the situation of child mortality and morbidity and to improve the general well-being of children. In a study conducted in the USA found that more than 9,000 children die each year from injuries. For every one child that died from injury, there were 25 hospitalizations, 925 treated in emergency rooms and many treated in Doctor’s office. The individual, family, community and our society also feel the cost burden of child injuries, as does the state and the nation.³

In a study conducted in the USA (1980-81) the authors had often represented the Injuries graphically as a pyramid, with the small group, that of death, at the top, hospitalized injury in the middle and the largest group, non-hospitalized injury at the base. The sizes of these groups’ analysis showed that for every one child aged under 19 who was fatally injured, 45 children required hospitalization and a further 1,300 were seen in an emergency department and discharged.⁴

Unintentional injuries in India

In a research conducted in India, China, Brazil, and Mexico between 2005-16 among 5-14 years published in The Lancet on 12^th March 2019 found that the most of deaths occurred between 2005-16 in all four countries arose from preventable or treatable conditions. Despite regional differences, the common leading causes of death in all four countries include transport accidents, drowning, cancers and neurological diseases in both sexes. Boys aged 5-14 years had higher death rates than girls for all injuries in both India and China. In India, in 2016 standardized injury death rate among girls was 15.8 (total deaths: 18,890) and 20.8 (total deaths: 27,770) among boys per 1,00, 000 children (5-14 years). Of which 12,640 deaths due to drowning and 9,640 due to road traffic injuries. About 90% of the road traffic accident deaths in India throughout the study period occurred among pedestrians, pedal cyclists, or occupants of two-wheeled or three-wheeled vehicles. Substantial declines in deaths in this age group are possible in many countries with cost-effective, affordable, and feasible interventions.⁵

The authors found in a cross-sectional study (2015) conducted in Kenya that, the injuries were the third leading cause of mortality and were the fifth leading cause of morbidity among patients attending health care facilities. More than half (56.7 %) of the pupils were absent from school due to the injury. Although 95.7 % of the pupils reported being taught about road safety in school, only 24 % of the pupils demonstrated a high-level of awareness regarding road safety. Interventions such as adequate supervision by caregivers while children were playing and review of teaching strategies for road safety education in schools could aid in the reduction of injuries among the pupils.⁶

In Bangladesh, the authors opined in a study (2015) that the children in rural Bangladesh got injured and then died very frequently in different accidents. Most of the children died from drowning and the death rate of children who were injured was highest at home. The uneducated mothers were not aware of the effect of injuries of their children that caused death. In most cases the lack of adequate supervision and carelessness turned out to be causing these accidental deaths.⁷

Dr. Gururaj, the author estimated in a study (2013) that the injuries resulted in the deaths of nearly 100,000 children every year in India among 2 million children hospitalized. The RTIs, drowning, falls, burns and poisoning were leading causes of injury in India. Drowning and burns were major causes of mortality in <5 years, while RTIs, falls and poisoning were leading causes in 5-18 years. Number of males, those in rural areas, and the majority of poor income households were affected due to injuries. The child injuries were predictable, preventable and should be an integral part of child health and survival.⁸

In another cross-sectional survey (2009) conducted in Bangladesh the authors found that among under 18 years of age, injuries were major causes of child mortality and morbidity with an overall incidence rate of 1585.9 per 100, 000 children per year. The boys had a higher injury incidence rate than that of girls, while rural children had the highest incidence rate. Drowning was the leading cause of injury mortality in children over 1 year of age, and falls were the commonest type of injury morbidity in all age groups. Home and its premises were the most common place for injury while the most of children get injured at the time indoor playing. The authors felt that there is a need for educational and intervention programs to increase the awareness by involving local experts from the health, education, engineering, legal, and business sectors to determine appropriate steps, intervention techniques, and legislative activities needed to decrease the risk of death or injury from the identified causes.⁹

A study was conducted in India (2005), wherein the authors found that unintentional injuries are an important cause of death in India. There is no availability of reliable nationally representative estimates of unintentional injury deaths. Unintentional injury caused 648, 000 deaths (7% of all deaths; 58/one lakh population). Unintentional injury mortality rates were higher among males than females, and in rural versus urban areas.¹⁰

The investigators examined a total of 400 children in a descriptive hospital-based study (2011) conducted in north Kerala and identified that the mechanical injuries comprising of RTIs and accidental fall were the major cause of unintentional injuries (36%), followed by poisoning (22.3%). A higher proportion of unintentional injuries were noted to occur among children of younger mothers, overactive child, children belonging to extended or joint families, child left alone or with friends, pre-school children, male child and from urban dwellings.¹¹

RTIs

RTIs are defined as ‘fatal or non-fatal injuries incurred as a result of a road traffic crash’.¹⁸ The WHO in its Key facts published on 19^th February 2018 with regards to RTIs globally that without sustained action, road traffic crashes were predicted to become the seventh leading cause of death by 2030. The road traffic crashes costs 3% of their gross domestic product in most of the countries. More than 1.25 million people died each year as a result of road traffic crashes and between 20 to 50 million more people suffer non-fatal injuries, with many incurring a disability as a result of their injury.¹⁹

The WHO detailed (global status report-2018 on road safety) that, the number of road traffic deaths continues to climb, reaching 1.35 million in 2016. If the trend continues, the sustainable development goals (SDG) target 3.6 to halve road traffic deaths by 2020 will not be met. RTI was the eighth leading cause of death for all age groups. While too many countries still lacking in legislation that appropriately addresses risks such as speeding, drink-driving, the use of helmets, seat-belts and child restraints, since 2014 progress has been made in a number of these areas. Still drastic action is needed to save the lives from RTIs.²⁰

The Indian institute of technology, Delhi conducted a research in 2015 wherein the investigators found that the situation in India was worsening and RTIs have been increasing over the past twenty years. The number of fatalities continued to increase at about 7% a year over the past decade except over the last couple of years.²¹

NA= Not available.

Drowning

The drowning is defined as ‘the process of experiencing respiratory impairment from submersion/immersion in liquid’.²² In 2012, WHO estimated 372, 000 people died from drowning, making drowning a major public health problem worldwide. Drowning was the 3^rd leading cause of unintentional injury death, accounted for 7% of all injury related deaths. Worldwide drowning was the 6^th leading cause among 5-9 years and 3^rd leading cause among 10-14 years aged children. The distribution of global child injury deaths among 0-17 years due to drowning cause accounts 16.8%. The WHO suggested that, building the capacity to implement, manage and monitor drowning prevention programmes is essential, but focus must also be given to the issue of elevating drowning prevention into the national priorities of governments, increasing the availability of funds and devising systems and plans to prevent and reduce drowning at a national level.²³

A qualitative study was conducted (2013) in south India on community perception of child drowning, wherein the authors identified that the drowning was not perceived as a major cause of childhood death. So, the authors suggested that there is an urgent need among rural communities to create awareness of the high rate of drowning in children and to motivate and facilitate individuals, communities, organisations and government agencies to make the communities safer for children.²⁴

Electrical and flame/burn injuries

The WHO has defined a burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals. Skin injuries due to ultraviolet radiation, radioactivity, electricity or chemicals, as well as respiratory damage resulting from smoke inhalation, are also considered to be burned. The WHO in its key facts on burns (6^th March 2018) mentioned that the burns are a global public health problem, accounting for an estimated 180, 000 deaths annually. Nearly 173,000 Bangladeshi children are moderately or severely burnt every year. In Bangladesh, Colombia, Egypt, and Pakistan, 17% of children with burns had a temporary disability and 18% had a permanent disability. Burns was the second most common injury in rural Nepal, accounting for 5% of disabilities. In 2008, over 410, 000 burn injuries occurred in the United States of America, with approximately 40, 000 requiring hospitalization. In south Africa an estimated US$ 26 million is spent annually for the care of burns from kerosene cook stove incidents. Indirect costs such as lost wages, prolonged care for deformities and emotional trauma, and commitment of family resources, also contribute to the socioeconomic impact. Along with adult women, children were particularly vulnerable to burns. Burns was the fifth most common cause of non-fatal childhood injuries.²⁵

The WHO has estimated in the global burden of disease: 2004 update in 2008 that the rate of child deaths from burns was over 7 times higher in low and middle-income countries than in high-income countries. In India, over 1,000,000 people were moderately or severely burnt every year.³

Fall injuries

The WHO has defined that a fall is ‘an event which results in a person coming to rest inadvertently (accidentally) on the ground or floor or other lower level’. Fall-related injuries may be fatal or non-fatal, though the most are non-fatal.²⁶

The WHO has published some of the key facts in January 2018 regarding falls, wherein: the falls was the second leading cause of accidental or unintentional injury deaths worldwide and each year an estimated 646,000 individuals die from falls globally. Of those over 80% was in low- and middle-income countries. The children in the people's republic of China, for every death due to a fall, there were 4 cases of permanent disability, 13 cases requiring hospitalization for more than 10 days, 24 cases requiring hospitalization for 1-9 days and 690 cases seeking medical care or missing work/school. Falls, though not fatal, approximately 37.3 million fall, severe enough to require medical attention occur each year. Such falls are responsible for over 17 million DALYs lost. Children were more prone to fall injuries. So, fall prevention strategies should promote engineering to remove the potential for falls, the training of health care providers on evidence-based prevention strategies; and the education of individuals and communities to build risk awareness. Evidence from Canada suggests the implementation of effective prevention strategies with a subsequent 20% reduction in the incidence of falls among children under 10 years of age could create a net savings of over US$ 120 million each year.²⁶

The national crime and records bureau (NCRB), which was the only agency that collects national injury data in India, reported that in 2005 falls contributed 3.2% of all unintentional injury deaths in the country. In India unintentional falls accounted for 25% (2003/8023) of all unintentional injury deaths. The authors opined that falls are an emerging and major public health challenge in India.²⁷

Snake, scorpion and other animal bites

The key facts of the WHO publication (5^th February 2018) on animal bites stated that worldwide, up to five million people were bitten by snakes every year; the majority in Africa and Southeast Asia. Dog bites accounted for tens of millions of injuries annually; the highest risk was among children. Rabies was a significant health concern following dog bites, cat bites and monkey bites.²⁸

Snake bites

Worldwide, up to five million people were bitten by snakes every year. Of these, poisonous (envenoming) snakes cause considerable morbidity and mortality. There were an estimated 2.4 million envenomation (poisonings from snake bites) and 94, 000–125, 000 deaths annually, with an additional 400, 000 amputations and other severe health consequences, such as infection, tetanus, scarring, contractures, and psychological sequelae. Poor access to health care and the scarcity of antivenom increased the severity of the injuries and their outcomes.²⁸

In India, the researchers conducted a nationally representative study of 123,000 deaths from 6,671 randomly selected areas in 2001-03. A total of 562 deaths (0.47% of total deaths) was assigned to snake bites. Snakebite deaths occurred mostly in rural areas (97%) and more common in males (59%) than females (41%). The bites peaked at ages 15-29 years (25%) and during the monsoon months of June to September. This proportion represents about 45,900 annual snake bites deaths nationally (99% CI 40,900 to 50,900) or an annual age-standardised rate of 4.1/100,000 (99% CI 3.6-4.5), with higher rates in rural areas (5.4/100,000; 99% CI 4.8-6.0), and with the highest state rate in Andhra Pradesh (6.2). Annual snakebite deaths were greatest in the states of Uttar Pradesh (8,700), Andhra Pradesh (5,200), and Bihar (4,500).²⁹

Dog bites

In a fact sheet, the WHO declared (2018) that there was no global estimates of dog bite incidence, however, studies suggest that a dog bites accounted for tens of millions of injuries annually. In the USA, approximately 4.5 million people were bitten by dogs every year and estimated that, 59, 000 people die annually from rabies, and bites from rabid dogs accounted for the vast majority of these deaths. Suggested that communities - especially children - should be informed about the risks of dog bites and prevention techniques such as avoiding stray dogs and never leaving a child unattended around any dog.²⁸

Scorpion bites

A hospital-based, prospective study conducted in coastal Andhra Pradesh, India on children admitted to scorpion sting between December 2009 and November 2010. Sorpion stings accounted for 1 in every 36 admissions. Maximum cases was in 0-3- and 7-9-years age groups with a mean of 6.78 years.³⁰

Socioeconomic causes - unintentional injuries

A broad range of socioeconomic factors associated such as family income, maternal education, single parenting, maternal age, numbers occupying the household, and number of children, type of tenancy, type of housing, level of overcrowding and various factors describing the neighbourhood with injury risk was identified.³¹

Gender

Boys tend to have both more frequent and more severe injuries than girls. Sex differences in injury rates appeared within the first year of life for the most types of injury. According to WHO data, in children under 15 years, there was, on average, 24% more injury deaths among boys than there are among girls.³ The boys had higher activity levels and engage in more risk taking than girls. The boys were socialized in a different way from girls and are less likely to have their exploration restrained by parents, that they are more likely to be allowed to roam and play alone.³²

Poverty

A study in Bangalore, India and in Bangladesh found that the burden from road crashes had pushed many households into poverty. In Bangalore, 71% of households in urban areas and 53% in rural areas were not poor before the crash; in Bangladesh the comparable figures were 33% in urban areas and 49% in rural areas.³³ In Viet Nam, the cost of injury to poor households was estimated as equivalent on average to 11 months income. The risk of a poor household falling below the poverty line was 21% higher among those that had had an injury than among those that had not.³⁴ In Ghana, a study of the economic consequences of injury within the family found that in rural households, 28% of families reported a decline in food consumption following an injury.³⁵

Tenancy

The victims of unintentional injuries were a heterogeneous group, often living in remote rural areas or conflict zones or else displaced. In the Islamic republic of Iran, a community- based survey has shown that the majority of fatal unintentional injuries to children under the age of 15 years occured in remote or rural areas.³⁶ In the light of results the children/students were the most neglected group globally, especially in middle and low-income group countries. Due to unintentional injuries daily, many children were dying and got disabled, especially from the poor, illiterate and ignorant families. At this juncture there was an urgent need of review on action taken against unintentional injury prevention.

Action taken against prevention of unintentional injuries

Some of the universities and nations with different objectives under the caption viz national safety week/campaign in Canada, America's safe schools week, student safety week - slippery rock university and national school bus safety week in the USA, national student fire safety week - Lancashire, U.K., are also observing within the limited jurisdictions only (accessed through the internet).

Road safety week in India

Road safety provides every person to become secure and safe from unwanted road accidents. The Road Safety Week observance during the second week of January every year is being initiated by the Ministry of Road and Transport and Highways since 2011.³⁷ The week is being observed only the prevention of RTIs, but not all other unintentional injuries.

Promoting road safety education in school curriculum

National Institution for Transforming India (NITI) or NITI Aayog, is a government of India policy think-tank, providing both directional and policy inputs. The experts and stakeholders of NITI Aayog decided for promoting road safety education in school curriculum.³⁸

The tribal welfare department, Andhra Pradesh, India in a module designed for the head of the educational institutions in tribal areas in Telugu under the caption ‘Pradhanopadhyayula Karadeepika - 9 (training module for head of the educational institutions in tribal areas) detailed about the student safety and prevention of unintentional injuries.³⁹ Mr Pinarayi Vijayan, the chief minister of Kerala, India has said on 6^th December 2019 that the swimming will be a part of the school curriculum starting from the academic year 2019 and swimming pools would be constructed in all the 140 assembly segments.⁴⁰

With the available data it is understood that there is no concerted activity across the world against the prevention of unintentional injuries. Some of the nations/states are taking action based on their own agenda with the available resources by making safety laws and creating awareness as discussed above. Due to the unintentional injuries the poor families again pushed into the poorest. So, certain national/state governments, districts and universities with the collaboration of general insurance companies have taken up ‘student safety insurance policies’ under the various captions to meet the hospital expenses incurred due to the injury as detailed below. Unfortunately, if the insured child will be disabled due to injury, the claimed amount may fulfil the future financial needs of the disabled up to some extent.

Primarily all the data were collected through the internet and most of the detailed information pertaining to Indian institutions collected through RTI Act-2005. Features of the policies and premium payment differ from institution to institution. Basing on the available data it is understood that a little number of nations/states are implementing the student safety policies.

CONCLUSION

Children are a particularly vulnerable group, either directly through being injured themselves or indirectly through the loss of their parents. The low-income families were again pushed into irrecoverable poverty due to injuries. Healthcare costs and the loss of income were the main factors contributing to injury effect. Protection of the children is Nation's responsibility which was reinforced by many of the researchers. Meanwhile, the United Nations Convention on the Rights of the Child (CRC) draws on attention to survival, protection, development and participation. Some of the countries/states are prioritizing the protection from RTIs only, whereas the remaining unintentional injuries were neglected.

Recommendations

In light of the results a convergent and cost benefit new initiative "Global Student Safety and Insurance Day Observance" has been suggested every year on a particular day/date in order to prevent all unintentional injuries by creating awareness on both safety measures and insurance among the stakeholders across the globe with the coordination of education, health, transportation, police, fire, revenue, women and child welfare, insurance departments and NGOs. If unfortunately, any untoward incident occurs the safety insurance will support financially. The global student safety and insurance day observance enable to achieve one of the 'Sustainable Development Goal' No. 03 'Good Health and Well Being' by 2030.

Sensitization of the students (about 1/3^rd of the population) regarding the prevention of all unintentional injuries through the campaign and spreading the message to their family as well as the community will help in protecting themselves, their parents and community. The campaign should also have an inbuilt promotion of having health insurance among the students and their parents, which could help in minimizing out of pocket expenses. This indirectly favour in reducing the school absenteeism and increase in student cognitive levels.

A door is much smaller compared to the house. A lock is much smaller compared to the door. A key is the smallest of all, but a key can open entire house. Thus, a small thoughtful solution can solve major problems - said by Dr APJ Abdul Kalam, former president of India. Similarly, even though the global student safety and insurance day observance is the smallest suggestion, but its impact will be a greater in future if implemented successfully. Being international health advisors, the WHO and UNICEF have to play a major role while convincing and adapting the global student safety and insurance day observance among the member countries.

ACKNOWLEDGEMENTS

The authors of this study would like to thank Dr T. Shailaja, Associated Professor, IIPH, Hyderabad, Dr Shakir, Asst. Professor, Apollo Medical College, Chittoor, AP, Dr V. Chandra Sekhar, Asst. Professor, SVIMS, Tirupati, AP and Dr Audinarayana, Professor (Rtd) Chandragiri, Tirupati, AP., for their encouragement and support throughout completion of the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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