Unintentional injury remains an important global public health issue, and efforts to address it are often hampered by a lack of visibility, leadership, funding, infrastructure, capacity and evidence of effective solutions. The growing support for a socioecological model and a systems approach to prevention—along with the acknowledgement that injury prevention can be a byproduct of salutogenic design and activities—has increased opportunities to integrate unintentional injury prevention into other health promotion and disease prevention agendas. It has also helped to integrate it into the broader human development agenda through the Sustainable Development Goals. This growing support provides new opportunities to use a human rights-based approach to address the issue. The human rights-based approach is based on the idea that all members of society have social, economic and cultural rights and that governments are responsible and accountable for upholding those rights. It incorporates a systems approach, addresses inequity and places an emphasis on the most vulnerable corners of humanity. It also leverages legal statutes and provides organisations with the opportunity to build existing international goals and benchmarks into their monitoring efforts. This paper describes the approach and highlights how it can leverage attention and investment to address current challenges for unintentional injury.
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Despite significant reductions in some countries since the issue came to light as a public health concern in the 1940s, an estimated 4.8 million people around the globe died as a result of injury or violence in 2013, and another 973 million sustained injuries requiring some type of healthcare.1 Moreover, for every individual who dies, many others are permanently disabled, seriously injured or traumatised in ways that can impact them for life.1 2 Most of the burden falls on low-income and middle-income countries (LMIC), and there are disparities in unintentional injuries and injury risks, both within and between countries.
While injuries occur to individuals, support for a systems approach to injury prevention is growing. That approach acknowledges the complex interplay between individual, relationship, community and societal factors.3 4 Socioecological models, which view injury and violence as part of complex systems requiring simultaneous action across multiple levels, are increasingly used to underpin prevention efforts.5–7 For example, comprehensively and effectively addressing child passenger safety in the USA requires action ranging from the individual to societal levels involving multiple sectors and levels of government (table 1). The systems approach is lauded as being more likely to sustain prevention efforts over time than any single intervention.5 8 9
A related development has been the acknowledgement that injury and violence prevention can be byproducts of salutogenic design and activities7 10 11 and that a prospective focus on solutions that create or enhance well-being are an important complement to traditional prevention efforts addressing injurious hazards.11–15 This insight provides more opportunities to integrate injury and violence prevention into other health promotion and disease prevention agendas, as well as the broader human development agenda. One approach commonly associated with development is the human rights-based approach.16 While this approach is not new to injury and violence prevention, unintentional injury in particular has not taken advantage of the benefits offered by a human rights-based approach.
In this paper, we describe the human rights-based approach and provide a rationale for using it to address unintentional injury prevention. Using child unintentional injury as an example, we highlight the value of the approach and cite instances where, particularly with respect to the Sustainable Development Goals (SDGs),17 it could be used as a lever to address current challenges facing the field.
The human rights-based approach
Taking a human rights-based approach is a broad idea encapsulated by organisations that look to human rights standards to guide their language, thinking, strategies and policies.16 The approach originated with the post-WWII Universal Declaration of Human Rights in 1948.18 Over time, it has evolved from examining civil and political violations to also incorporating social, economic and cultural rights. It espouses the idea that governments and other duty bearers are responsible and accountable for upholding rights and that rights holders should be directly involved in the processes that affect their access to their rights.16 In 1993, the United Nations developed the Vienna Declaration and Programme of Action, which reaffirmed the universal human rights and linked the concepts of human rights, democracy, sustainability and development.19 As a result, the human rights-based approach incorporates systems thinking and addresses inequity by placing an emphasis on the most vulnerable corners of humanity and framing issues using social justice terms. The approach leverages legal statutes and provides organisations with the opportunity to build existing international goals and benchmarks into their monitoring efforts.16 20
While commonly associated with international development, the human rights-based approach has been implemented in a variety of other fields as well. For example, in 2002, Andrew Coyle laid out a rights-based framework for prison management built on guidelines in existing human rights instruments.21 His work provides guidance for prison management professionals on a range of areas, including human dignity, torture and prison healthcare. It also outlines ideal qualities of prison staff and of treatment of female prisoners.21 Coyle’s concepts have been widely used both internationally and nationally. For example, both the WHO and the United Nations Office on Drugs and Crime have developed resources for prison professionals based on Coyle’s approach. Jordan’s correctional department’s training, widely regarded as a model of best practice, provides high-quality training to prison staff. Furthermore, they have informed the development of training models for the United Nations.22–24
Another example is the Global Initiative to End All Corporal Punishment of Children, which is based in the UN Convention on the Rights of the Child and other international and regional human rights treaties. This initiative has led to 53 states prohibiting all corporal punishment of children, including in the family home, and to 55 more states expressing a commitment to full prohibition.25
Thus, while some violence prevention organisations have incorporated human rights concepts into their thinking, actions in unintentional injury are less common. The reasoning for this certainly is not because human rights and unintentional injury have no inherent connection. Because it is considered a major global public health issue, unintentional injury can be implicitly understood as relevant to the right to good health. That right is protected in numerous declarations and treaties addressing health, as well in other declarations and treaties addressing other aspects of well-being and equity. In fact, unintentional injury has been the recipient of explicit and implicit attention in existing international and regional human rights treaties (table 2).26–33 However, to date, the unintentional injury prevention field has not taken full advantage of the potential benefits offered by these moral and legal frameworks to address some of its challenges.
What does the human rights-based approach offer?
There are a number of global trends violating human rights to safety that could be addressed by a human rights-based approach to unintentional injury prevention. This is particularly true when it comes to children.
Globalisation, urbanisation and motorisation continue to pose risks that need to be monitored and managed, particularly for LMIC. Road traffic injuries are the fourth leading cause of death among children aged 5–9 years, third among children aged 10–14 years and first among children aged 15–17 years.2 Ahead of road traffic injuries as a leading cause of death in children in some countries, drowning is among the 10 leading causes of death of children and young people in every region of the world. Children under 5 years are disproportionately at risk for drowning.34 Other notable issues in unintentional injury globally include falls, fire and burns and poisonings.2
Climate change has contributed to an increase in extreme weather events, such as floods and drought, which have both direct and indirect implications for unintentional injury.35–37 The human suffering caused by natural disasters is most profoundly felt in LMIC countries, particularly poverty-stricken nations that lack the resources to cope with the aftermath of natural disasters.38 39 In addition, beyond the immediate risks posed by natural disasters, populations displaced by climate-driven migration can face travel-related risks, particularly in new, unfamiliar environments.35
The global recession that began in 2007 is still having an impact in some countries today. The economic downturn increased poverty rates for families and children and increased inequities with respect to injury in many of the countries impacted.40 It also resulted in loss of funds directed at prevention and promotion. This has negatively impacted organisations and prevention activities in many countries, some to this day.
Today, 1 in 9 children is being raised in a war zone, such as those resulting from the civil wars in Iraq, Somalia or Syria, the Kurdish–Turkish conflict, Nigeria’s Boko Haram insurgency or one of the many other ongoing armed conflicts.35 In addition to the risks of living in war zones or being displaced, counterterrorism legislation adopted in response to extremist armed groups has increased the detention of children perceived to be security threats.41 Human Rights Watch has identified many examples of indefinite detention and torture of children in a number of countries.41 Beyond the immediate safety issues, these violent conflicts are resulting in psychological trauma, impacting access to education and increasing unacceptable practices such as child marriage.35
The global immigration crisis resulting from populations fleeing conflict, the largest since WWII, has put thousands of children and adolescents at risk.35 There are unregistered births, unsafe conditions in holding camps and precarious journeys that increase risk of injury and violence. If children are able to find a new home in another country, they then face the challenge of adjusting to new risks in new environments. For the existing unintentional injury prevention programmes in those countries accepting refugees, there are new challenges in how best to meet the needs of these new citizens.42 43
So how does a human rights-based approach help address these trends?
One of the challenges for the field is a lack of visibility for child unintentional injury. Despite the fact that they are one of the biggest threats to child survival, particularly after age 5 years, they are largely absent from child survival initiatives.2 It is unclear why this is the case. Has the field done a poor job of selling the issue? Is the wrong language used? Why have efforts to increase visibility been unsuccessful? Perhaps there are approaches and theories from other disciplines that would better inform efforts to increase visibility of the issue.
Regardless, the lack of visibility means efforts to engage world, national and even local leaders to address child injury have met with, at best, mixed success. Despite WHO-led world reports on unintentional injury and World Health Assembly Resolutions, no champions or global spokespeople have emerged, and few countries have pursued the called-for integration of child injury prevention into mainstream child and adolescent health initiatives and/or the development and implementation of a national strategy to address the issue comprehensively and ensure coordinated action.2 44 45 Nor have development agencies, already familiar with a human rights-based approach and well positioned within their countries to facilitate action on unintentional injury, been successfully engaged. Taking a human rights-based approach can add an additional weight to the issue, using violations of human rights and existing inequalities to introduce social justice arguments. Doing so could provide opportunities to align with current government commitments and could demonstrate how unintentional injury prevention can help those governments meet their commitments. For example, it is possible to frame power inequities within a system that impact exposure to hazards or access to preventive measures as ‘pathologies’ that cause health inequities.46 Injury prevention, therefore, becomes a solution to a public health issue and potentially a way to address existing inequities at a societal level. This alignment may provide previously untapped routes to increasing visibility.
The lack of visibility translates to resource commitments that may not be in line with what is required to fully address the magnitude of the problem. Furthermore, resource levels constantly fluctuate, making sustainability of prevention efforts challenging.44 The reasons are unclear. Is it an issue of prioritisation or a lack of capacity to take advantage of funds when they are presented? It is important for societies to protect individuals. Actively adopting a human rights-based approach, which speaks directly to a country’s responsibilities to its most vulnerable, may help with strategic asset allocation. This may be particularly true if the field is able to demonstrate where unintentional injury prevention intersects with other issues where a human rights-based approach is relevant. In addition to opportunities to combine resources across issues in those cases, there is specific funding for issues that align with human rights. Globally, over US$2 billion in grants were provided to projects that specifically concerned human rights issues in 2015.47
Limited data and capacity
Adequate data to understand the issue, inform programming and policies and monitor their impact are still limited, particularly in LMIC countries, where they are needed most. For example, an assessment of vital registration data found that, globally, fewer than 40% of deaths are registered and only about 65% of births for children under age 5 years are registered.48 The field also continues to struggle with data at the local level, where much of prevention takes place, and that is just outcome data; very few countries have data on exposure to hazards or preventive measures across injury areas and populations at risk. Similarly, there are capacity gaps related to both the ability to use data when available, as well as lack of professional preparation in the many sectors involved with injury prevention.
Using a human rights-based approach provides a framework for accountability. Once aligned with human rights, a strong case can be made that a country should be monitoring and reporting on progress. For example, the monitoring of progress on the Millennium Development Goals drew attention to the need for strengthening information systems and data capacity at both national and international levels. Over time, the increased availability and quality of data and improved coordination within national statistical systems helped stimulate development efforts, implement successful targeted interventions, track performance and improve accountability.49 A human rights-based approach to unintentional injury prevention should therefore increase attention to the infrastructure necessary to address injury, including data systems and capacity to use them.
Lack of evidence
There are gaps in knowledge about unintentional injury that require research, again particularly in LMIC.45 Part of this relates to capacity, some to available funding and some to the fact that injuries are complex ‘wicked’ problems and solutions are rarely straightforward.50–53 There are still a lot of important questions that need answers, and there is room for more epidemiological studies, effectiveness studies, implementation research, cost of injury and cost-effectiveness studies and policy analysis.
The fields also struggle with getting evidence into action, so that even when the need for action is recognised, state-of-the-art knowledge and good practices are not consistently applied within and between countries, and there is a lack of monitoring when action is taken.54–56 Furthermore, it may be that in the drive for evidence, the field has avoided strategies that involve integration of unintentional injury into existing services, within and without the broader health system, because of the complexity in evaluating them. A human rights framework necessitates the inclusion of societal factors such as power dynamics and intergroup relations within the system and their impact on the issue in question. In this sense, it requires an analysis of the whole system: social, economic, political and cultural aspects that impact unintentional injury and its prevention. While there is recognition within the injury prevention field of the importance of these factors, few programmes have explicitly integrated them into interventions or measured their impact on implementation. Applying these more abstract qualities to the context of injury prevention does present challenges. For one, injury prevention organisations will likely need to modify their processes and expected outcomes to attach social, economic, political and cultural contexts to their preventative efforts.57 However, there are clear benefits to overcoming these challenges: richer data, more potential entry points for intervention and a deeper understanding of the root causes of unintentional injury and why programmes are, or are not, effective.
A human rights-based approach will not directly improve the evidence base. However, as a process of moral improvement with a goal of impacting systems to equitably promote life prospects, it is inclusive of both traditional hazard-reducing and salutogenic approaches to injury prevention. The supporting legal frameworks address accountability, which again should encourage government investment and leadership to engage industry, NGOs, academia and other stakeholders. Furthermore, the broader approach also lends itself to integration of issues and solutions, which may increase the likelihood of uptake of evidence as opposed to trying to initiate separate stand-alone programmes. Finally, human rights are conceptually interpretive, experiential and grounded in history. The human rights-based approach involves a participatory approach, which uses methodologies that have typically not been incorporated in injury prevention. It also accepts additional types of evidence such as personal narratives, indigenous knowledge and ethnographic observations.58
One example from the international development sector is a WaterAid project to improve water access in Kiteto District, Tanzania, through several infrastructure installations. Through a human rights-based lens, WaterAid staff identified power imbalances, lack of land rights and exclusion of hunter-gatherer and pastoralist communities from policy-making processes as additional barriers to water access. WaterAid helped to build partnerships and foster collaboration among all relevant stakeholders, which included both duty bearers and rights holders.59 The project was able to work with communities to overcome intergroup conflict and as a result increase access to safe sources of water for all. While the main aim of this initiative was to reduce the risk of diarrhoeal disease, the solutions (piping water and capping wells with pumps) very likely also reduced the risk of drowning in rivers, lakes and uncapped wells.
Examples of the potential of the human rights-based approach to injury prevention through the SDGs
Adopted by world leaders in September 2015, the SDGs are the successor to the Millennium Development Goals and are anchored in human rights.17 While the SDGs are not legally binding, governments are expected to take ownership and establish national frameworks for the achievement of the Goals,17 and the global stage encourages meaningful action. The 17 SDGs cover a broad range of social issues, such as poverty, hunger, health, education, climate change, gender equality and social justice. They include 169 targets, some of which directly and indirectly address injury (eg, those addressing road safety) and others where injury prevention will be a potential byproduct of targeted systems.17 As such, the Goals provide an opportune point of entry for the injury prevention community to commence a human rights-based approach and explore opportunities to lever action using a human rights lens. Two examples illustrate this potential:
A practical application of connecting injury with the SDGs
The FIA Foundation works to address social issues related to interactions between automobiles and society. In 2017, the organisation spearheaded the Child Health Initiative (CHI), a global coalition focused on three child rights issues: road safety, clean air and children’s right to education. CHI uses the SDGs to measure progress on their focus areas. Their specific targets include targets 3.6 (reduce road traffic fatalities by 50% by 2020), 3.9 (substantially reduce the contribution of road transport to air pollution by 2030), 7.3 (double the global rate of improvement in energy efficiency), 11.2 (ensure safe and sustainable urban mobility by 2030) and 11.7 (universal access to safe, inclusive and accessible, green and public spaces).60 In its ‘Declaration of Every Child’s Right to Safe and Healthy Streets’, CHI recalls the SDGs and the Convention on the Rights of the Child before laying out six child rights related to safe mobility and air quality.58 By appealing to the SDGs and a human rights-based approach in their core language, the FIA Foundation and CHI have created a clear and quantified platform to build international support around major injury issues. This has created collaboration between major international players in unintentional injury prevention, environmental health and urban planning, and the coalition includes major international organisations such as UNICEF and Save the Children.61 CHI has elevated the issue’s visibility and set clear benchmarks that organisations across the globe can use to measure progress. The initiative is an example of how injury prevention can be integrated into a broader initiative where it cross cuts with other health or development issues using a human rights-based approach to leverage funding and support in LMIC.
The potential impact of SDGs on child drowning
In the 2014 Global Report on Drowning Prevention, drowning was one of the top five causes of death for children ages 1–14 years in 48 of the 85 countries whose data met inclusion criteria.34 Globally, the highest drowning rates are among children 1–4 years, followed by children 5–9 years.34 In some countries, particularly LMIC in Asia, the burden is staggering. For example, in Bangladesh drowning accounts for 43% of all deaths in children ages 1–4 years.34 The report acknowledged that drowning has been highly overlooked to date and recommends that governments develop national drowning prevention plans.
While drowning is not explicitly referenced in the SDGs, there are several goals where drowning prevention intersects with other issues. A case can be made for seeking opportunities to work with government to help them meet their targets (table 3).62 The most obvious of these is target 3.2, which addresses mortality in children under age 5 years, where introduction of strategies that specifically reduce drowning in this age group would directly contribute to the target. Three others, 1.5, 11.5 and 13.1, refer to climate-related extreme events (eg, flooding) where drowning prevention activities related to flood safety or disaster risk reduction could also provide direct benefits. Government actions to address Goal 2 – Zero Hunger, Goal 6 – Clean Water and Sanitation and Goal 9 – Industry, Innovation and Infrastructure are likely to be examples of salutogenic environmental changes, where drowning risk will be reduced as a byproduct of reducing exposure to water through irrigation and sanitation schemes or make exposure safer through safer water transport policy.
Finally, there are several goals where drowning prevention could have incidental contributions. For example, mandating water safety education and water survival skills training as part of educational curricula could contribute to Goal 4 – Quality Education. Establishing community crèches or a programme to build first-responder skills among women could provide employment opportunities for women and contribute to Goal 5 – Gender Equality.
In conclusion, the human rights-based approach offers a new angle for unintentional injury prevention. It provides both a moral and legal framework for action and accountability, which is already supported by a majority of governments around the world. As such, the approach takes a new lens to the issue and may provide new avenues to address long-time challenges for injury prevention. The focus of human rights on health, well-being and equity also supports a view of injury prevention that encourages broader systems thinking. A human rights framework requires that practitioners incorporate social, economic, political and cultural factors into the broader scope of their work to a much greater degree than has historically occurred for unintentional injury. The approach also allows the injury issue to be integrated into broader strategies that address both the more traditional route of reducing hazards, as well as injury prevention as a byproduct of salutogenic design where determinants intersect with other health and human development issues. This may also be beneficial to the injury prevention field given public health issues often compete for attention at all levels of government.
A search of PubMed and grey literature via the internet turned up no comprehensive analysis of the intersect between unintentional injury prevention and human rights, although the Danish Institute for Human Rights has mapped the SDGs to various treaties and laws and a mapping exercise has been undertaken for SDGs and violence prevention.63 64 However, given that the issues lie across many sectors, perhaps not all relevant domains were within the scope of the current review, and this is acknowledged as a limitation. Undertaking such an analysis for unintentional injury would help construct a clear blueprint for how the field could use a human rights-based approach to address continuing challenges. This could be a daunting task, as human rights exist far beyond the reaches of international treaties, emerging through tangible items such as domestic law, policy documents, spoken language as well as abstract concepts like ethical theories and social norms. The endeavour would also likely benefit from collaboration with experts from human rights organisations. However, international treaties, and commitments such as the SDGs, may be a shrewd starting point, given their creation and monitoring occurs on a world stage.
Contributors JMM conceived of the paper, drafted and revised the paper. She is guarantor. MAR drafted and revised the paper.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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