|Year : 2019 | Volume
| Issue : 4 | Page : 140-144
Burdened by the bag: A school-based cross-sectional survey
Grace Elizabeth Muppidi1, Ann Salome John1, MR Angel1, MJ Ronald Thomvic1, Grace Rebekah2, Sanjeev Manasseh Padankatti1
1 Occupational Therapy Unit, Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore, Tamil Nadu, India
2 Department Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||07-May-2019|
|Date of Acceptance||04-Oct-2019|
|Date of Web Publication||3-Jan-2020|
Dr. Sanjeev Manasseh Padankatti
Department of Physical Medicine and Rehabilitation, Christian Medical College, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: The demands of education in our country have led to an increase in the loads children carry on a daily basis to school. Research evidence confirms that excessive loads lead to musculoskeletal problems in children, predisposing them to chronic back pain in adulthood. This problem becomes pertinent in primary school children, owing to the development of the spine at this age. Objectives: This study aims to assess the magnitude of the issue of heavy schoolbags, by measuring schoolbag weights and the factors affecting the ≤10% of body weight recommendation, and the children's perception of discomfort and pain. Study Design: Cross-sectional survey design was chosen for the research. Methods: Two schools with different syllabi, Indian Certificate of Secondary Examination and Central Board of Secondary Examination were approached and the schoolbags of children from Grades 1 to 5, aged 6-12-year (n = 776; boys = 402 and girls = 374), were weighed, and followed up over a week. Children were asked to rate their pain on the Faces Pain Scale-Revised and teachers' responses were collected through a teacher reported questionnaire prepared by the authors, which assessed their knowledge and control regarding the issue. Results: Majority of children carried a backpack and a separate lunch bag to and from school. A large percentage, 97.8% of schoolbags, weighed more than the recommended limit of ≤ 10% of the body weight. The mean weight of schoolbags carried was 5.9 ± 1.5 kg. Boys carried on an average 5.91 ± 1.48 kg and girls 5.98 ± 1.55 kg. Forty-eight percent of the children reported that carrying the schoolbag was causing discomfort and musculoskeletal pain and 77% of them reported discomfort at the shoulder region. Faces Pain Scale-Revised score ranged from 2 to 9 with 8 as an average intensity. Eighteen children reported absenteeism from school ranging from 1 to 5 days over the last term. The perception of teachers regarding the problem of schoolbag weights was mixed. Conclusion: This study concludes that heavy schoolbags are a problem in both the schools, with different syllabi. Being forced to carry heavy bags may lead to “schoolbag syndrome” in children. Thus, stringent measures need to be undertaken to reduce the bag burden and protect the health of children.
Keywords: Discomfort, Loads, Musculoskeletal Problems in Primary School Children, Pain, SchoolBags, Weight Limit
|How to cite this article:|
Muppidi GE, John AS, Angel M R, Ronald Thomvic M J, Rebekah G, Padankatti SM. Burdened by the bag: A school-based cross-sectional survey. Indian J Occup Ther 2019;51:140-4
|How to cite this URL:|
Muppidi GE, John AS, Angel M R, Ronald Thomvic M J, Rebekah G, Padankatti SM. Burdened by the bag: A school-based cross-sectional survey. Indian J Occup Ther [serial online] 2019 [cited 2020 Sep 22];51:140-4. Available from: http://www.ijotonweb.org/text.asp?2019/51/4/140/274804
| Introduction|| |
Children are the spine of our future. However how vigilant are we about their spines? Schoolbags represent a considerable daily “occupational load” for school children., The concern revolving around the excess weights carried by children in their schoolbag is recurrent and increasing by the day.
Research has been done worldwide to chronicle the issue. Researchers from Poland, the US, Egypt, Istanbul, France, Spain, etc., have studied the detrimental effects of heavy bags on postural alignment, angles, and spinal curvature.,,,, Others have studied parameters such as back pain and musculoskeletal discomfort,,,,,, as well as gait patterns, and balance. In addition, studies have been done on the effects of carrying heavy weights on children's vital capacity, blood pressure, and lung volumes,,, which have agreed that a weight of 10% of the bodyweight has the least effect on these physiological functions.
A general guideline of 10% of body weight which was initially proposed in 1977 continues to be followed as the load limit. Multiple reviews of the literature concluded that there is still no globally recommended limit on schoolbag weights.
In India, studies have been done as well as numerous newspaper articles in reputed newspapers published to portray the detrimental effects of heavy schoolbags and suggestions for design of schoolbags.,,,,,,,,, A bill has also been passed in 2006, stating the limit to be 10%.
Hence, this study aims to assess the magnitude of this problem by measuring schoolbag weights (SBW) of two different and most followed syllabi, and the factors affecting the ≤10% of body weight recommendation, the children's perception of discomfort and pain, and the school teacher's opinion about the same.
| Methods|| |
This cross-sectional survey study was approved by the Institutional Review Board and Ethics Committee of Christian Medical College, Vellore. To compare different syllabi, i.e., Central Board of Secondary Examination (CBSE) and Indian Certificate of Secondary Examination (ICSE) and two of the best schools of Vellore, with a holistic approach to education, were approached for data collection and necessary permissions were requested and granted. Children from Class 1 to 5 (ages 5-12) from both syllabi were recruited for this study, and verbal assent from children and written informed consent from parents were collected from the children, before measuring their bag weights. With reference to Dockrell et al, the sample size required was calculated as 652 children per syllabus with a power of 80% and alpha error at 5% for this two-sided study. Data collection though originally planned for 5 days in April 2018, only 4 days of data could be included from both schools for conformity, as one of the schools happened to have a program on one of the days.
After assent was taken from the children and written informed consent was obtained from the parents, they were asked to weigh themselves at the entrance of the school on arrival (so as to reduce the Hawthorne effect, which, in this context means the alteration of the students behavior due to their awareness of being observed), with and without their schoolbag and additional bags. Demographics of the child, as well as details of the bag, like the number of bags, carried, extra contents of the bag besides books, lunch carried separately, etc., were collected and recorded by the coinvestigators along with their discomfort rating on the Faces Pain Scale-Revised. Those who felt pain were then asked to indicate specific areas of pain and discomfort experienced due to heavy schoolbags. Children's bags were tagged according to class, and they were followed up for 4 consecutive days. Children who were tagged but missed in the crowd of students were checked in their classroom, hence the absence of missing data.
A teacher reported questionnaire (written by the authors) was answered by the teachers from both the schools. This questionnaire had seven questions and was divided into two broad categories. The first section assessed the teachers' knowledge regarding the issue, and consisted of the questions, “Do you feel the schoolbags are heavy or light?” “Do you think heavy schoolbags could result in musculoskeletal problems for the child?” “In your opinion, what are the major contributing factors toward heavy schoolbags?” What steps have already been taken by the school management to manage this issue?” and “What do you think is the ideal weight a child is supposed to carry?” The second part of the questionnaire assessed the teachers control over the issue and asked them “If allowed to make changes, what would you do to address this problem?”
Data were analyzed using the IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Bangalore, Karnataka; descriptive statistics was reported using frequency and percentage for categorical variables. Continuous variables were represented using mean ± standard deviation (SD); median (interquartile range). Two independent samples t- test was used to compare the means between groups. Generalized estimating equation was used to assess the change from the baseline with respect to each day, as shown in [Graph 1]. P < 0.05 was considered statistically significant and 95% confidence interval (95% CI) values were also computed.
| Results|| |
A total of 776 children (boys = 402, girls = 374), with 414 from School A (ICSE) and 362 from School B (CBSE), Classes 1-5 were assessed. Age of the children ranged from 4 to 12 years, with being a mean age of 8.24 ± 1.62.
The mean and SD of the bodyweight of children was 28.6 ± 8.5 kg and the weight of schoolbags carried was 5.9 ± 1.5 kg. The lightest bag, 2.20 kg was seen in Class 1 and the heaviest, 11.63 kg. The number of bags carried by each child ranged from 1 to 3. Boys carried on an average 5.91 ± 1.48 kg and girls 5.98 ± 1.55 kg showing no significant difference (P = 0.108) between the two. The mean bag weight carried by School A was 5.75 ± 1.52 kg and in School B was 6.34 ± 1.84 kg, giving a sizeable difference of 0.6 kg (P = 0.000), showing that CBSE syllabus students carried heavier bags. The students of Class 1 and 2 carried heavier schoolbags in relation to their body weight when compared to other classes.
Analysis of the 4 consecutive days of data showed that there was a significant spike of mean bag weights on day 3.
Children's perception of pain and discomfort due to the heavy bags was checked using the faces pain scale-revised. Forty-eight point four of the total children reported scores ranging from 2 to 9 (mild to severe). Of these 375 children reporting pain, 288 reported pain in the shoulders (77%), 55 reported pain in the back (14.6%) with minimal reports in hand and neck. Among the children who rated severe pain, 23.2% of them were carrying bags above the recommended limit. This showed no significant correlation (P = 0.144) between pain perceived by the children and excess bag weights. There were 18 children who reported absenteeism due to school bag-related pain, ranging from 1 to 5 days.
The teacher reported questionnaire was given to the teachers at both schools. A total of 107 of them returned the filled forms. A large percentage, 81.3% (n = 87) of them had knowledge that schoolbags were heavy, whereas 99 (92.5%) of them knew that heavy bags can cause musculoskeletal problems. Forty percent of the teachers attributed heavy bags to the number of textbooks and class schedule, while 19.6% of them said it was because of the demands of the education system. There were 16 (15%) who were unaware of the steps taken by the management to alleviate this issue like having a fixed time table/class schedule and lockers in the classrooms. Only 47.7% (n = 51) of them were aware that the recommended limit for schoolbag weight limit is ≤10% of the bodyweight of the child.
The second part of the questionnaire assessed the teachers control over the issue. They suggested possible solutions, of which the most common answers were “leaving books at school” (10.3%), having an “all-in-one book for all subjects” (9.3%) and having “online assignments/use of technology” (9.3%).
As a part of this study's endeavor, backpacks were measured at shops for their dry weight (empty bag without books). Twenty-one backpacks and three trolley bags which are popular among children of these classes were weighed individually, to assess whether this significantly contributed to the overall bag weight. The mean dry bag weight of all the backpacks was 0.442 ± 0.125 kg while that of the trolleys was 1.032 ± 0.152 kg (P = 0.000). This 600 g difference was statistically significant between the two, which shows that the notion that trolley bags are better and easier for schoolchildren may, in fact, not be the best, especially in scenarios where children have to carry their bags when they climb stairs to the classroom.
As there is no universally accepted limit to a safe load that can be carried by children, the most accepted limit, i.e., ≤10% has been used in this study as well. Despite the positive measures taken by both the schools like lockers at school and having a fixed time table, the results showed otherwise. Overall, a total of 759 (97.8%) of the children assessed carried schoolbags >10% of their body weight, of which, there were 96.6% in School A and 99.2% in School B.
Out of the 776 assessed, only 17 (2.2%) carried light loads that were safe for them (<10%). Among the majority carrying heavy bags, 450 (58.8%) of them carried bags heavier than 20% of their body weight [Graph 2].
| Discussion|| |
The mean bag weight in this study was found to be consistent with other parts of the country.,, To the best of the knowledge of the author, there have been Ten studies that have been published in India in relation to the issue of heavy schoolbags and its effects on the musculoskeletal system. Of which, five have researched the extent of heavy bags carried,,,,,,,, two have suggested and designed ideal schoolbags,, two have studied detrimental effects of heavy bags on postural angles, and the overall musculoskeletal impact that it can cause and another two correlate bag weight to pain and discomfort.,
The mean bag weight measured in this study is more than that of certain cohorts like in Istanbul, where mean bag weights ranged from 3.5 to 4.1 kg, Iran where it is 2.9 kg, or Uganda with 3.8 kg. However, it is less than other cohorts studied like in Dublin where it is 6.2 kg, Poland where it is 6.3 kg, Italy where it is 9.3 kg, and Egypt with 7.5 kg.
There was no significance on comparing weights carried by boys and girls in this study, but certain studies have found differences in the weights carried by genders, except for one study, mostly girls carrying heavier bags than boys.,,,,
This study is only one among the few where such a large sample size was collected over a week.
There is a significant difference seen among the days of the school week as well as between classes, as shown in [Graph 1] and [Graph 3].
Correlating pain and specific areas of perceived pain with SBW, this study is consistent with others stating that the major parts where the pain is felt due to heavy bags are the shoulders, followed by the back.,,,, Although no statistical significance found between perceived pain and excess bag weights.
The current study on SBW is the first in India, which compares two reputed schools of different syllabi, children between the ages of 4 and 12 years (Classes 1-5), parameters like pain and discomfort, and regions of pain felt. A recent literature search on PubMed and Google Scholar shows that it is the first study of its kind to document the teacher's perception of excessive school bag weight. Authors of this study felt that it was important to study this under-researched parameter since teachers are in fact part and parcel of the school children's life as well as the major decision-makers regarding how many books the child should carry home for assignments, or to school for classes and for extracurricular activities.
In India, the Labor law (Factories Act, 1955 - Manual Labor-Maximum Weights and Transport Regulation, 1972.) states that an adult male should not carry more than 55 k. In the case of an adult female, the weight should not be more than 16 kg. The heaviest bag carried by a 4th standard student in this cohort was 11.3 kg, almost nearing the safe limit of an adult female, which is quite alarming.
In this study, the mean weight of children (n = 776) was 28.6 kg, which according to the recommended limit (≤10% of body weight), the schoolbag should ideally weigh 2.8 kg or less, but, the mean bag weight was 5.9 kg, which is more than two times of the recommended weight, which highlights the magnitude of the problem at hand.
Newspapers have been abuzz since 2012 and a web search revealed that in the past 5 years at least 22 articles have been published in just a single reputed newspaper (The New Indian Express) highlighting the urgency surrounding this issue. Many more have been published in other newspapers from different states of India, especially Maharashtra, Telangana, and Karnataka. The Government of India, as well as these individual state governments have been taking steps with regard to placing a cap on the weight a child can carry to school by the SBW Bill in 2006, manuals and statements by the National Commission for the Protection of Child Rights and the Right to Education Act.
There is still much work to be done to completely conquer this issue and to establish a universally accepted safe load limit. In this study, courtesy the large sample size, the authors have been able to derive an ideal school bag weight calculator for both the syllabi studied, using the individual weights of the children. This could be helpful for the school to calculate SBW realistically and promises to contribute and alleviate the issue at hand.
| Conclusion|| |
A sincere attempt has been made by the authors to study the true extent of the “School Bag Weight issue.” We hope that this study adds to the depth of information available worldwide, and especially in India, as the clinical data pool is quite shallow. Although the media, newsprint, parents, various groups, government agencies, and schools are aware of the problem and are brainstorming possible solutions, the problem still exists.
We would like to thank the students who cooperated with us so well, as well as the school boards of Ida Scudder School and Srishti School, Vellore. Our thanks to the Department of Occupational therapy, CMC for their support while conducting this study and our heartfelt gratitude to those who helped with the data collection and collation of the manuscript.
Financial Support and Sponsorship
This study was financially supported by Internal Fluid Research Grant.
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Dockrell S, Simms C, Blake C. Schoolbag carriage and schoolbag-related musculoskeletal discomfort among primary school children. Appl Ergon 2015;51:281-290.
Dockrell S, Simms C, Blake C. Schoolbag weight limit: Can it be defined? J Sch Health 2013;83:368-377.
Brzęk A, Dworrak T, Strauss M, Sanchis-Gomar F, Sabbah I, Dworrak B, et al
. The weight of pupils' schoolbags in early school age and its influence on body posture. BMC Musculoskelet Disord 2017;18:117.
Çolak TK, Apti A, Dereli EE, Özdinçler AR, Çolak İ. Scoliosis screening results of primary school students (11-15 years old group) in the West side of Istanbul. J Phys Ther Sci 2015;27:2797-2801.
Ali El-Nagar S, Mady MM. School bag usage, postural and behavioral habits and its effect on back pain occurrence among school children. Am J Nurs Sci 2017;6:218-231.
Schmidt J, Docherty S. Comparison of the posture of school children carrying backpacks versus pulling them on trolleys. Clin Chiropr 2010;13:253-260.
Hong Y, Fong DT, Li J ×. The effect of school bag design and load on spinal posture during stair use by children. Ergonomics 2011;54:1207-1213.
Spiteri K, Busuttil ML, Aquilina S, Gauci D, Camilleri E, Grech V. Schoolbags and back pain in children between 8 and 13 years: A national study. Br J Pain 2017;11:81-86.
Dianat I, Javadivala Z, Allahverdipour H. School bag weight and the occurrence of shoulder, hand/Wrist and low back symptoms among Iranian elementary schoolchildren. Health Promot Perspect 2011;1:76-85.
MacDonald J, Stuart E, Rodenberg R. Musculoskeletal low back pain in school-aged children: A review. JAMA Pediatr 2017;171:280-287.
Mwaka ES, Munabi IG, Buwembo W, Kukkiriza J, Ochieng J. Musculoskeletal pain and school bag use: A cross-sectional study among Ugandan pupils. BMC Res Notes 2014;7:222.
Azabagic S, Spahic R, Pranjic N, Mulic M. Epidemiology of musculoskeletal disorders in primary school children in Bosnia and Herzegovina. Mater Sociomed 2016;28:164-167.
Talbott NR, Bhattacharya A, Davis KG, Shukla R, Levin L. School backpacks: It's more than just a weight problem. Work 2009;34:481-494.
Chen YL, Mu YC. Effects of backpack load and position on body strains in male schoolchildren while walking. PLoS One 2018;13:e0193648.
Perrone M, Orr R, Hing W, Milne N, Pope R. The impact of backpack loads on school children: A critical narrative review. Int J Environ Res Public Health 2018;15. pii: E2529.
Hong Y, Li JX, Wong AS, Robinson PD. Effects of load carriage on heart rate, blood pressure and energy expenditure in children. Ergonomics 2000;43:717-727.
Lasota A. Schoolbag weight carriage by primary school pupils. Work 2014;48:21-26.
Voll HJ, Klimt F. Strain in children caused by carrying schoolbags (author's transl). Offentl Gesundheitswes 1977;39:369-378.
Devanarayanan TG, Parameshwaran M. A study of effects of heavy schoolbag on students and to develop a new bag concept for reducing difficulties. Int Res J Eng Technol 2017;4:1773-1776.
Mohan M, Singh U, Quddus N. Effect of backpack loading on cervical and shoulder posture in Indian school children. Indian J Physiother Occup Ther 2006;56:10-12.
Kulshrestha S, Rajesh D. Effect of backpack weight on cervical angle in school going children. Int J Clinical Skills 2017;11:4-7.
Ramprasad M, Alias J, Raghuveer AK. Effect of backpack weight on postural angles in preadolescent children. Indian Pediatr 2010;47:575-580.
Ananda Kesavan TM, Jose R, Nithya T. Overloaded bags of school children- a precursor to “school bag syndrome"? Natl J Med Dent Res 2016;5:6-11.
Siddalingappa H, Murthy N, Kulkarni P, Shrinivasa BM, Sunilkumar D, Renuka M. Burden of heavy schoolbag among high school students and its relation with their physical growth in Mysore and Chamarajanagar district. Int J Health Sci 2015;5:8-14.
Ashtekar SV, Powar JD, Aqsa S, Padhyegurjar SB, Padhyegurjar M, Banginwar A. Schoolbag-weights and musculo-skeletal complaints in three schools in rural Maharashtra. Natl J Community Med 2017;9:52-55.
Balamurugan J. School-bags and musculoskeletal pain among elementary schoolchildren in Chennai city. Int J Med Sci Clin Invent 2014;1:302-309.
Koley S, Kaur N. An association of backpack weight and postural habits in school going children of Amritsar, Punjab, India. Anthropologist 2010;12:107-111.
Fatima A, Srivastava S. A study on school bags of children. Asian J Home Sci 2013;8:556-559.
The Children School Bags (Limitation on Weight) Bill; 2006.
Tsze DS, von Baeyer CL, Bulloch B, Dayan PS. Validation of self-report pain scales in children. Pediatrics 2013;132:e971-e979.
Abaraogu UO, Ezenwankwo EF, Nwadilibe IB, Nwafor GC, Ugwuele BO, Uzoh PC, et al.
Immediate responses to backpack carriage on postural angles in young adults: A crossover randomized self-controlled study with repeated measures. Work 2017;57:87-93.
Negrini S, Carabalona R, Sibilla P. Backpack as a daily load for schoolchildren. Lancet 1999;354:1974.
Batista IT, de Melo-Marins D, Carvalho RG, Gomes LE. Weight and mode of carrying schoolbags at elementary school: Effect of the school grades and sex. Fisioter Pesqui 2016;23:210-215.
Arghavani F, Zamanian Z, Ghanbary A, Hassanzadeh J. Investigation of the relationship between carrying school bags (handbags and backpacks) and the prevalence of musculoskeletal pains among 12-15 year old students in shiraz. Pak J Biol Sci 2014;17:550-554.
Factories Act, 1955 -Manual Labor-Maximum Weights and Transport Regulation; 1972. p. 35.
National Commission for the Protection of Child Rights. Right to Education Act. National Commission for the Protection of Child Rights; 2009.