Drowning--a major but neglected child health problem in rural Bangladesh: implications for low income countries

Change in global burden of unintentional drowning from 1990 to 2019 and its association with social determinants of health: findings from the Global Burden of Disease Study 2019

OBJECTIVE

To systematically analyse global, regional and national burden change of unintentional drowning from 1990 to 2019, and to further quantify the contribution of social determinants of health (SDH) on the change.

DESIGN

Data from the Global Burden of Disease Study 2019 were used in this study.

SETTING AND PARTICIPANTS

Individuals of all ages and genders from 204 countries and territories.

MAIN OUTCOME MEASURES

The main outcomes were the age-standardised rates (ASRs) of mortality and disability-adjusted life-years (DALYs) of unintentional drowning. The percentage change in the ASRs were used to estimate the joint effect of SDH on trends in global burden of drowning.

RESULTS

We observed that the global burden of unintentional drowning declined markedly from 1990 to 2019, with age-standardised mortality rate and DALYs rate decreasing by 61.5% and 68.2%, respectively. Women, children, middle Socio-Demographic Index (SDI) countries, South-East Asia and Western Pacific region had higher reduction. At national level, greater reductions were observed in Armenia and Republic of Korea, but significant increases in Cabo Verde and Vanuatu. We found that every one percentile increase in six SDHs (Gross Domestic Product (GDP) per person, SDI, educational attainment, health spending, health workers and urbanisation) was associated with a decrease of 0.15% and 0.16% in drowning age-standardised mortality rate and DALYs rate globally, respectively. Health spending and GDP per capita were the main contributors to the reduction of drowning globally.

CONCLUSIONS

The global burden of unintentional drowning significantly declined in the past three decades, and the improvement of SDHs such as GDP per capita and health spending mainly contributed to the decrease. Our findings indicate that improvement of SDHs is critical for drowning prevention and control.

Medical care-seeking behaviours among drowning casualties: Results from a national survey conducted in Bangladesh

Objective

Despite the high magnitude of drowning, medical care-seeking behaviours among drowning casualties remain unexplored in Bangladesh. This study aimed to explore this behaviour among drowning casualties in Bangladesh.

Methods

A population-based cross-sectional study was conducted using a multi-stage cluster sampling method. Data were collected using a structured questionnaire from 299,216 rural and urban residents.

Results

From the survey, we found 191 drowning cases: 40.84% (n = 78) were fatal and 59.16% (n = 113) were non-fatal. Among the drowning cases, 71.2% (n = 136) were referred to healthcare providers, while 62.8% (n = 120) received medical care from different health service providers. Further analysis showed that 66.6% (n = 116) of children and 26.6% (n = 4) of adults sought healthcare. As many as 78.9% (n = 120/152) of rural residents sought healthcare, as compared to 61.5% (n = 24/39) of urban residents. Among all drowning casualties, 31.7% (n = 38) received healthcare from a qualified healthcare provider, whereas 68.3% (n = 82) received it from non-qual]ified healthcare providers. About 59 (49%) casualties received care from a pharmacy and 34 (28%) from a recognised hospital. The hospital admission rate for drowning was 11.7%. About 14 (11.7%) drowning casualties were brought to hospitals in motorised or non-motorised vehicles. As many as 97 (80.8%) patients sought healthcare attention and managed to survive.

Conclusion

A significant number of drowning casualties sought medical care from qualified and non-qualified healthcare providers. In Bangladesh, it is necessary to develop guidelines for providing medical care for drowning casualties.

Childhood vulnerability to drowning in the Western Cape, South Africa: Risk differences across age and sex

INTRODUCTION

Drowning is amongst the leading causes of death of children and young people worldwide, with high concentrations in Southeast Asia and Sub-Saharan Africa. In the Western Cape province in South Africa, drowning mortality rates for children were reported at 3.8 per 100,000 population. Internationally, evidence suggests that unimpeded access to water bodies and containers and lapses in supervision together with the child's limited developmental capacities, place children at greater risk of drowning. This study examined the risk for fatal drowning by age cohort and sex in child and adolescent (0-19 years old) in the Western Cape.

METHOD

Demographic and descriptive data for child drowning fatalities from 2010 to 2016 were obtained from the Western Cape Forensic Pathology Service. Descriptive variables included location of drowning incident by body of water, time of day, day of week and season. Data were analysed by age cohorts aligned to child psychosocial developmental stages. Descriptive statistics reported fatality frequencies by age cohort and sex, and logistic regression was conducted to detect differences in drowning risk across these categories.

RESULTS

A total of 538 childhood drowning fatalities were analysed, with the highest proportion occurring in children aged 13-19 years (29.6%) and the majority occurring in males (75.8%). Sex, location of drowning incident and season were significant predictors of drowning across the age cohorts. Relative to females, males between ages 0-1 and 2-3 years were less likely to drown when compared with older children.

CONCLUSION

This study confirms existing evidence that children younger than five are most at risk of drowning. In contrast to international and local research findings that have indicated a similar or higher risk for drowning amongst boys compared with girls aged 3 years and younger, this study identified that males were less likely to drown between the ages of 0 and 3 years compared with girls.

Keeping afloat: a case study tracing the emergence of drowning prevention as a health issue in Bangladesh 1999-2017

BACKGROUND

Drowning is a leading cause of child death in Bangladesh. The present study investigated the emergence of drowning reduction as a priority within Bangladesh and the position it currently holds on the national policy agenda.

METHODS

This case study documents the evolution of policy responses to drowning, reporting on data from semistructured interviews and a document analysis. To identify key factors that have facilitated the prioritisation of drowning prevention, data were synthesised using Shiffman and Smith's 2007 Policy Prioritisation Framework. Furthermore, an inductive approach was used to identify key themes unique to drowning prevention that were not embedded in the framework.

RESULTS

Four key phases of policy development for drowning prevention were distinguishable: (1) identification of issue and the emergence of actor support; (2) enhanced leadership and the accumulation of issue characteristics; (3) the formation of an internal frame and its impact on global support; and (4) enhanced national recognition and supportive global normative factors. Four additional themes unique to the case of drowning were also identified: competing health priorities, limited issue awareness, shift of disease burden to non-communicable diseases and the multisectoral nature of drowning.

CONCLUSION

This study demonstrates that the level of political prioritisation given to drowning prevention has evolved over the last decade and a half. A comprehensive understanding of factors that have elevated the issue onto the policy agenda will ensure future stakeholder engagement activities can be designed to foster deeper and more sustained commitment by key actors and organisations.

The burden of unintentional drowning: global, regional and national estimates of mortality from the Global Burden of Disease 2017 Study

Background

Drowning is a leading cause of injury-related mortality globally. Unintentional drowning (International Classification of Diseases (ICD) 10 codes W65-74 and ICD9 E910) is one of the 30 mutually exclusive and collectively exhaustive causes of injury-related mortality in the Global Burden of Disease (GBD) study. This study’s objective is to describe unintentional drowning using GBD estimates from 1990 to 2017.

Methods

Unintentional drowning from GBD 2017 was estimated for cause-specific mortality and years of life lost (YLLs), age, sex, country, region, Socio-demographic Index (SDI) quintile, and trends from 1990 to 2017. GBD 2017 used standard GBD methods for estimating mortality from drowning.

Results

Globally, unintentional drowning mortality decreased by 44.5% between 1990 and 2017, from 531 956 (uncertainty interval (UI): 484 107 to 572 854) to 295 210 (284 493 to 306 187) deaths. Global age-standardised mortality rates decreased 57.4%, from 9.3 (8.5 to 10.0) in 1990 to 4.0 (3.8 to 4.1) per 100 000 per annum in 2017. Unintentional drowning-associated mortality was generally higher in children, males and in low-SDI to middle-SDI countries. China, India, Pakistan and Bangladesh accounted for 51.2% of all drowning deaths in 2017. Oceania was the region with the highest rate of age-standardised YLLs in 2017, with 45 434 (40 850 to 50 539) YLLs per 100 000 across both sexes.

Conclusions

There has been a decline in global drowning rates. This study shows that the decline was not consistent across countries. The results reinforce the need for continued and improved policy, prevention and research efforts, with a focus on low- and middle-income countries.

Exploring the burden of fatal drowning and data characteristics in three high income countries: Australia, Canada and New Zealand

BACKGROUND

Drowning is a leading and preventable cause of death that has suffered an attention deficit. Improving drowning data in countries would assist the understanding of the full extent and circumstances of drowning, to target interventions and evaluate their effectiveness. The World Health Organization identifies data collection as a key strategy underpinning effective interventions. This study compares unintentional fatal drowning data collection, management and comparison using the databases of Australia, Canada and New Zealand.

METHODS

Cases of fatal unintentional drowning between 1-January-2005 and 31-December-2014 were extracted. Cases were combined into a single dataset and univariate and chi square analysis (p < 0.01) were undertaken. Location and activity variables were mapped and combined. Variables consistently collected across the three countries were compared to the ILCOR Drowning Data Guideline. The authors also recommend variables for a minimum core dataset.

RESULTS

Of 55 total variables, 19 were consistent and 13 could be compared across the three databases. When mapped against the ILCOR Drowning Data Guideline, six variables were consistently collected by all countries, with five compared within this study. The authors recommend a minimum core dataset of 11 variables including age, sex, location, activity, date of incident, and alcohol and drug involvement). There were 8176 drowning deaths (Australia 34.1%, Canada 55.9%, New Zealand 9.9%). All countries achieved reductions in crude drowning rates (Australia - 10.2%, Canada - 20.4%, New Zealand - 24.7%). Location and activity prior to drowning differed significantly across the three countries. Beaches (X² = 1151.0;p < 0.001) and ocean/harbour locations (X² = 300.5;p < 0.001) were common in Australia and New Zealand, while lakes/ponds (X² = 826.5;p < 0.001) and bathtubs (X² = 27.7;p < 0.001) were common drowning locations in Canada. Boating prior to drowning was common in Canada (X² = 66.3;p < 0.001).

CONCLUSIONS

The comparison of data across the three countries was complex. Work was required to merge categories within the 20% of variables collected that were comparable, thus reducing the fidelity of data available. Data sources, collection and coding varied by country, with the widest diversity seen in location and activity variables. This study highlights the need for universally agreed and consistently applied categories and definitions to allow for global comparisons and proposes a core minimum dataset.

Trends of drowning mortality in Vietnam: evidence from the national injury mortality surveillance system

Objective

To describe the trends of drowning mortality in Vietnam over time and to identify socioeconomic characteristics associated with higher drowning mortality at the provincial level.

Methods

We analysed data from the Ministry of Health injury mortality surveillance system from 1 January 2009 to 31 December 2013. The surveillance covers more than 11 000 commune health centres in all provinces of Vietnam. For provincial population and socioeconomic characteristics, we extracted data from the National census 2009, the Population change and family planning surveys in 2011 and 2013. Multilevel linear models were used to identify provincial characteristics associated with higher mortality rates.

Results

Over the 5-year period between 2009 and 2013, 31 232 drowning deaths were reported, equivalent to a 5-year average of 6246 drowning deaths. During this period, drowning mortality rate decreased 7.2/100 000 to 6.9/100 000 (p=0.035). Of six major geographical regions, Northern midland, Central highland and Mekong delta were those with highest mortality rates. In all regions, children aged 1–4 years had the highest mortality rates, followed by those aged 5–9 and 10–14 years. At provincial level, having a coastline was not associated with higher mortality rate. Provinces with larger population size and greater proportion of poor households were statistically significantly associated with higher mortality rates (p=0.042 and 0.006, respectively).

Conclusion

While some gains have been made in reducing drowning mortality, child deaths due to drowning in Vietnam remain alarmingly high. Targeted scale-up of known effective interventions such as child supervision and basic survival skills are needed for reducing child mortality due to drowning, particularly in socioeconomically disadvantaged provinces.

Drowning Prevention: Assessment of a Classroom-Based Water Safety Education Program in Vietnam

Youth drowning continues to be a primary public health issue globally with Eurasian countries experiencing some of the highest recorded rates of injury and death in aquatic settings. The country of Vietnam is currently working toward reducing the number of youth drowning fatalities. Part of these efforts is the introduction of an in-school water safety educational program. For this study, pilot pre/post data were acquired and used to assess overall knowledge acquisition and changes in knowledge of youth in grades 1 to 5 in central Vietnam. A total of 229 schools participated, resulting in 40 198 usable surveys. The results indicated that overall there was a significant change in scores with an acceptable effect size between measures. Mean scores for each of the water safety messages were rated as acceptable (above 90%), satisfactory (between 70% and 90%), and areas of concern (under 70%). Recommendations were made to program leaders about identified areas of concern.

Fatal and non-fatal injury outcomes: results from a purposively sampled census of seven rural subdistricts in Bangladesh

BACKGROUND

90% of the global burden of injuries is borne by low-income and middle-income countries (LMICs). However, details of the injury burden in LMICs are less clear because of the scarcity of data and population-based studies. The Saving of Lives from Drowning project, implemented in rural Bangladesh, did a census on 1·2 million people to fill this gap. This Article describes the epidemiology of fatal and non-fatal injuries from the study.

METHODS

In this study, we used data from the baseline census conducted as part of the Saving of Lives from Drowning (SoLiD) project. The census was implemented in 51 unions from seven purposively sampled rural subdistricts of Bangladesh between June and November, 2013. Sociodemographic, injury mortality, and morbidity information were collected for the whole population in the study area. We analysed the data for descriptive measures of fatal and non-fatal injury outcomes. Age and gender distribution, socioeconomic characteristics, and injury characteristics such as external cause, intent, location, and body part affected were reported for all injury outcomes.

FINDINGS

The census covered a population of 1 169 593 from 270 387 households and 451 villages. The overall injury mortality rate was 38 deaths per 100 000 population per year, and 104 703 people sustained major non-fatal injuries over a 6-month recall period. Drowning was the leading external cause of injury death for all ages, and falls caused the most number of non-fatal injuries. Fatal injury rates were highest in children aged 1-4 years. Non-fatal injury rates were also highest in children aged 1-4 years and those aged 65 years and older. Males had more fatal and non-fatal injuries than females across all external causes except for burns. Suicide was the leading cause of injury deaths in individuals aged 15-24 years, and more than 50% of the suicides occurred in females. The home environment was the most common location for most injuries.

INTERPRETATION

The burden of fatal and non-fatal injuries in rural Bangladesh is substantial, accounting for 44 050 deaths and 21 million people suffering major events annually. Targeted approaches addressing drowning in children (especially those aged 1-4 years), falls among the elderly, and suicide among young female adults are urgently needed to reduce injury deaths and morbidity in Bangladesh.

FUNDING

Bloomberg Philanthropies.

The epidemiology of drowning in low- and middle-income countries: a systematic review

Background

According to the World Health Organization, drowning is the 3rd leading cause of unintentional injury-related deaths worldwide, accounting for 370,000 annual deaths and 7% of all injury-related deaths. Low- and middle-income countries are the most affected, accounting for 91% of unintentional drowning deaths.

Methods

The authors performed a systematic review of literature indexed in EMBASE, PubMed, Web of Science, Cochrane Library, and Traumatology journals formerly indexed in PubMed in January 2014 and again in September 2016. Abstracts were limited to human studies in English, conducted in low- and middle-income countries, and containing quantitative data on drowning epidemiology.

Results

A total of 62 articles met inclusion criteria. The majority of articles originate from Asia (56%) and Africa (26%). Risk factors for drowning included young age (<17–20 years old), male gender (75% vs. 25% female), rural environment (84% vs. 16% urban), occurring in the daytime (95% vs. 5% night time), lack of adult supervision (76% vs. 18% supervised), and limited swimming ability (86% vs. 10% with swimming ability). There was almost equal risk of drowning in a small body of water versus a large body of water (42% ponds, ditches, streams, wells; 46% lakes, rivers, sea, ocean).

Conclusion

Drowning is a significant cause of injury-related deaths, especially in LMICs. Young males who are unsupervised in rural areas and have limited formal swimming instruction are at greatest risk of drowning in small bodies of water around their homes. Preventative strategies include covering wells and cisterns, fencing off ditches and small ponds, establishing community daycares, providing formal swimming lessons, and increasing awareness of the risks of drowning.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4239-2) contains supplementary material, which is available to authorized users.

Epidemiology of Drowning in Bangladesh: An Update

Over one-quarter of deaths among 1-4 year-olds in Bangladesh were due to drowning in 2003, and the proportion increased to 42% in 2011. This study describes the current burden and risk factors for drowning across all demographics in rural Bangladesh. A household survey was carried out in 51 union parishads of rural Bangladesh between June and November 2013, covering 1.17 million individuals. Information on fatal and nonfatal drowning events was collected by face-to-face interviews using a structured questionnaire. Fatal and non-fatal drowning rates were 15.8/100,000/year and 318.4/100,000/6 months, respectively, for all age groups. The highest rates of fatal (121.5/100,000/year) and non-fatal (3057.7/100,000/6 months) drowning were observed among children 1 to 4 years of age. These children had higher rates of fatal (13 times) and non-fatal drowning (16 times) compared with infants. Males had slightly higher rates of both fatal and non-fatal drowning. Individuals with no education had 3 times higher rates of non-fatal drowning compared with those with high school or higher education. Non-fatal drowning rates increased significantly with decrease in socio-economic status (SES) quintiles, from the highest to the lowest. Drowning is a major public health issue in Bangladesh, and is now a major threat to child survival.

Epidemiology of adulthood drowning deaths in Bangladesh: Findings from a nationwide health and injury survey

Background: Annual global death due to drowning accounts for 372,000 lives, 90% of which occur in low and middle income countries. Life in Bangladesh exposes adults and children to may water bodies for daily household needs, and as a result drowning is common. In Bangladesh, due to lack of systemic data collection, drowning among adults is unknown; most research is focused on childhood drowning. The aim of the present study was to explore the epidemiology of adulthood drowning deaths in Bangladesh.

Methodology: A nationwide cross-sectional survey was conducted from January to December in 2003 among 171,366 rural and urban households, with a sample of 819,429 individuals to determine the epidemiology of adulthood drowning in Bangladesh.  

Results:  Annual fatal drowning incidence among adults was 5.85/100,000 individuals. Of these, 71.4% were male and 28.6% were female (RR 2.39). In total, 90% of the fatalities were from rural areas. Rural populations were also found to have a 8.58 times higher risk of drowning than those in urban areas. About 95% of drowning occurred in natural water bodies. About 61.6% of the deaths occurred at the scene followed by 33.5% at the home. Of the drowning fatalities, 67% took place in water bodies within 100 meters of the household. Among the drowning fatalities 78.4% occurred in daylight between 7.00 and 18.00. Over 97% of the victims were from poor socio economic conditions with a monthly income tk. 6,000 ($94) or less. Only 25.5% of incidences were reported to the police station.

Conclusions: Every year a significant number of adults die due to drowning in Bangladesh.  Populations living in rural areas, especially men, were the main victims of drowning. This survey finding might help policy makers and scientists to understand the drowning scenario among adults in Bangladesh.

The Hidden Tragedy of Rivers: A Decade of Unintentional Fatal Drowning in Australia

OBJECTIVE(S)

Describe unintentional drowning deaths in rivers, creeks and streams (rivers) in Australia and identify risk factors to inform prevention.

DESIGN & SETTING

This study is a cross-sectional, total population audit of all unintentional fatal drownings in Australian rivers between 1-July-2002 and 30-June-2012 using Australian coronial data. A modified Bonferroni test has been applied, deeming statistical significance p<0.03 and p<0.04 respectively.

RESULTS

Rivers (n = 770; 26.6%) were the leading location among the 2,892 people who died from unintentional fatal drowning. This is a rate of 0.37/100,000 people / annum. Within river drowning deaths common groups include; males (80.4%), adults (85.3%), adults who have consumed alcohol (25.5%), people who fell in (21.3%), people involved in non-aquatic transport incidents (18.2%) and locals (74.0%). Children were 1.75 times more likely than adults (p<0.04) to drown in rivers as a result of a fall and adults 1.50 times more likely to drown in rivers as a result of watercraft incidents when compared to children. When compared to males, females were 2.27 and 4.45 times respectively more likely to drown in rivers as a result of incidents involving non-aquatic transport (p<0.04) and being swept away by floodwaters (p<0.04). Males were 2.66 and 4.27 times respectively more likely to drown in rivers as a result of watercraft incidents (p<0.04) and as a result of jumping in (p<0.04) when compared to females.

CONCLUSION(S)

While rivers are the leading location for drowning in Australia, little is understood about the risks. This study has identified key groups (males, adults, locals) and activities. While males were more likely to drown, the risk profile for females differed.

Socio-demographic, environmental and caring risk factors for childhood drowning deaths in Bangladesh

BACKGROUND

Drowning contributes to incapacity and early death in many countries. In low- and middle-income countries, children are the most susceptible to fatalities. Over 50 % of the global drowning deaths occur among children aged under 15 years old with children aged between 1 and 4 years of age being most at risk. In Bangladesh, drowning rates are 10 to 20 times more than those in other developing countries. The object of this study is to determine the socio-demographic, environmental and caring hazard issues for child drowning in Bangladesh.

METHODS

A case-control study was conducted, with data collected from the Bangladesh Health and Injury Survey (BHIS) to identify the social-demographic and environmental factors associated with childhood drowning. The participants represented 171,366 households from seven divisions of Bangladesh-Dhaka, Rajshahi, Chittagong, Barisal, Sylhet, Khulna and Rangpur. The survey was conducted between January and December of 2003. A total of 141 children drowning were identified in the year preceding the survey. Data were analysed using descriptive statistics and logistic regression analysis. The odds ratios with 95% CI intervals were estimated for various associated factors for child drowning deaths.

RESULTS

In Bangladesh, in 2003, the incidence of drowning deaths was 104.8 per 100,000 among those aged less than 5 years; 168.7 per 100,000 in rural areas; male 32.4 per 100,000; 112.7 per 100,000 between 10:00 a.m. and 2:00 p.m.; and cannot swim 134.9 per 100,000. The socio-demographic danger factors for child drowning deaths were: being male (OR = 1.45, 95% CI = 1.34-1.78), aged less than 5 years (OR = 2.89, 95% CI = 1.89-3.11), urban areas (OR = 0.67, 95% CI = 0.67-1.87), and mother being illiterate (OR = 1.69, 95% CI = 1.01-2.81). Significant environmental and caring factors included mother/caregiver not being the accompanying person (OR = 25.4, 95% CI = 14.4-45.3) and children cannot swim (OR = 4.5, 95% CI = 1.25-19.4).

CONCLUSION

Drowning is the single largest reason for the mortality of children aged less than five years. There is a need to educate Bangladeshi parents and encourage behavioural change concerning supervision. The Government should use mass media to raise awareness about drowning among the community with a focus on rural areas. Policies should focus on increasing supervision by mothers/care persons, swimming skills, and should target illiterate mothers. Therefore, there is an immediate need for the Bangladeshi Government to address the problem of drowning.

Randomized controlled trial on drowning prevention for parents with children aged below five years in Bangladesh: a study protocol

BACKGROUND

Drowning is the third leading cause of death for children aged 0-4 years in many Asian countries, and is a serious but neglected health problem in low and middle-income countries like Bangladesh. The aim of the study is to outline the study protocol of a trial to test the efficacy of a mobile coach based intervention for the prevention of childhood drowning.

METHOD/DESIGN

A two-arm cluster randomized community trial will be conducted to test the efficacy of the mobile coach intervention for childhood drowning on parents with children below five years of age and compared to an assessment only control group. A total of 1680 parents in the villages with children aged below five years of age will participate. The village will be used as a randomized unit, randomly assigned to an intervention group (N = 840) receiving the mobile coach based intervention or an assessment only control group (N = 840). An individualized mobile coach intervention based on the demographic data and the individual will be developed, and SMSs, audio messages, videos and images about childhood drowning will be sent to the participants of the intervention group over a period of six months. The participants will receive per week one text message (SMS) and image and one video and audio text per month. The primary outcome measure will be increased knowledge and safety awareness, and behaviour practice about childhood drowning assessed at the six-month follow-up, and the secondary outcome measure will be the reduced incidence of childhood drowning in Bangladesh. The study assistants conducting the baseline and the follow-up assessments will be blinded regarding the group assignment.

DISCUSSION

This is the first study testing a fully mobile coach intervention for childhood drowning prevention in Bangladesh. It is hoped that the programme will offer an effective and inexpensive way to prevent childhood drowning among children aged below five years and also increase the awareness of parents concerning the risks to their children from drowning.

TRIAL REGISTRATION

ISRCTN13774693, 08/03/2015.

The characteristics of, and risk factors for, child injuries in Andhra Pradesh, India: the Young Lives project

BACKGROUND

Injuries are an emerging public health issue among children worldwide, and one of the leading causes of disability-adjusted life years lost for children aged 0-14 years. Few studies, particularly in low- and middle-income countries, have analysed characteristics and risk factors for these injuries.

METHODS

This study examined the occurrence and risk factors of serious non-fatal injuries in children aged 7-9 years (n=1820) from Andhra Pradesh, India. Logistic regression models were used to explore potential risk factors for these injuries.

RESULTS

Based on a 3-year recall period, 336 (18.5%) children reported serious non-fatal injuries. Incidence was higher among males (209/971; 21.5%) compared to females (127/849; 15.0%). Of the most serious non-fatal injuries reported, falls (n=186, 55.4%) were the major cause of injuries, followed by road traffic injuries (50, 14.9%), and assaults/blows/hits (26, 7.7%). Twenty children (6.0%) did not fully recover from their injuries, and 14 (4.2%) had long-term health problems as a result of their injuries. The logistic regression analyses indicated that being male (AOR 1.59; 95% CI: 1.25-2.05), in poor health (AOR 2.50; 95% CI: 1.88-3.31), and having a caregiver with low education (AOR 1.53; 95% CI: 1.15-2.05) were associated with an increased risk of non-fatal injury.

CONCLUSIONS

Urgent attention is needed to reduce child injuries and address risk factors according to local context.

Drowning risk perceptions among rural guardians of Thailand: A community-based household survey

Drowning is one of the most common causes of death among young children in Thailand. Children in primary school in rural settings have a high rate of fatal drowning. Guardians' perceptions are important since children are normally in their care. This study aims to describe drowning risk perceptions of guardians and to identify barriers to developing a child's swimming skills. A cross-sectional household survey was conducted among guardians of children who attended 12 schools serving 48 villages in a rural community. The results revealed that less than one-fifth (18%) of children in the household could swim. Guardians reported that children should learn to swim at the age of seven years. About one-quarter (23%) of guardians did not perceive drowning as the leading cause of death among children. More than a quarter (25.4%) perceived that their child was not at the risk of drowning. No statistical differences were reported on drowning perception among guardians with different swimming skills as well as child's swimming skill. Significantly more parents of children who could not swim perceived lack of swimming instructors, clean water and school swimming lessons as barriers to a child's acquisition of swimming skill. The results highlight the need to consider improving the infrastructure in rural areas to facilitate swimming skills for school children to reduce drowning risk.

The prevalence of naturally acquired swimming ability among children in Bangladesh: a cross sectional survey

BACKGROUND

Most rural homes in Bangladesh have ponds nearby to serve as household water sources. As a result children of all ages are exposed to water bodies on a daily basis. Children learn to swim early in childhood from peers and relatives in a natural process that involves play and structured learning. In a large, national injury survey in Bangladesh, the ability to swim was associated with reduced risk of drowning. This study determines the prevalence of swimming ability in children in Bangladesh as a step in assessing whether this is a potential component of a national drowning prevention program.

METHODS

A descriptive study design using a subset of a national sample survey determined the prevalence of naturally acquired swimming ability (NASA) reported by children of rural and urban communities in Bangladesh. A total of 2,598 households (1,999 rural and 599 urban) housing 4,336 children (2,263 male and 2,073 female) aged 5-17 years were chosen from 4 randomly selected districts using multistage random sampling. NASA was defined as the ability to cross 25 meters of water deeper than the child's height using any body movement for self-propulsion.

RESULTS

Reported NASA was greater in males (55.6%) than females (47.9%) and among rural children (57.8%) than urban children (25.5%) for children 5-17 years. The proportion reporting NASA increased with increasing age. At age 5, 5.8% of males and 6.3% of females reported NASA, rising to 84.3% of males and 70.7% of females by age 17. By age 17, 83.1% of rural children and 57.5% of urban children reported NASA.

CONCLUSION

Most children in Bangladesh report being able to swim 25 meters and learning it by middle childhood. Reported NASA is higher for males than females and for rural children than urban children. High rates of swimming appear to be achievable in the absence of pools and a swim-teaching industry. This may facilitate development of a low cost, national drowning prevention program with swimming an integral part.

Study on unnatural childhood deaths presented to North Colombo Teaching Hospital, Sri Lanka

INTRODUCTION

Unnatural childhood deaths are not only associated with intense trauma and separation distress, but also relate to a sense of neglect to protect children from harm. Accurate information on causes and circumstances of such deaths through a process of medico-legal investigations is essential in creating an awareness among the policy makers and educators/caregivers, to prevent these tragic deaths.

OBJECTIVE

The aim of the study was to determine the causes and the circumstances of unnatural deaths of children among the medico-legal autopsy population presented to North Colombo Teaching Hospital, Sri Lanka.

STUDY DESIGN

A retrospective descriptive study was carried out based on Reports of Postmortem Examination performed in a Tertiary Care Hospital, on children who died of unnatural causes during the period from 2009 to 2011.

RESULTS

Out of 48 unnatural childhood deaths, 24 (50%) children were older than 10 years of age. The most frequent circumstance of death was accidental 39 (81%), while the most frequent cause of death was drowning 16 (33%). Fifteen died due to accidental drowning while one was a homicidal drowning. Suicidal deaths were found only among the children older than 16 years of age. Fifty-four percent of the accidental deaths had taken place at or around the home.

CONCLUSION

Accidents accounted for the majority (or greatest number) of tragic childhood deaths. The presence of drowning as the most common cause of death indicates that an immense responsibility lies with the parents and caregivers to prevent such deaths.

Epidemiology of unintentional child injuries in the South-East Asia Region: a systematic review

All the 11 members of the South-East Asia Region (SEAR) of the World Health Organization are categorised as low- and middle-income countries. This region has over a quarter of the world's total population but comprises about one-third of the world's unintentional injury-related deaths. There is a paucity of good-quality mortality and morbidity data from most of these countries. This is the first systematic review of community-based surveys on child injuries that summarises evidence from child injury studies from the SEAR countries. The included papers reported varying estimates of overall non-fatal unintentional injury rates across the countries, from 15/1000 children in Thailand to as high as 342/1000 children in India. The fatal injury rates were also found to be varying. This review revealed a need for strengthening child injury research using standard methodologies across the region and for promoting the dissemination of the results.

Drowning and the influence of hot weather

BACKGROUND

Drowning deaths are devastating and preventable. Public perception does not regard hot weather as a common scenario for drowning deaths. The objective of our study was to test the association between hot weather and drowning risk.

MATERIALS AND METHODS

We conducted a retrospective case-crossover analysis of all unintentional drowning deaths in Ontario, Canada from 1999 to 2009. Demographic data were obtained from the Office of the Chief Coroner. Weather data were obtained from Environment Canada. We used the pair-matched analytic approach for the case-crossover design to contrast the weather on the date of the drowning with the weather at the same location one week prior (control period).

RESULTS

We identified 1243 drowning deaths. The mean age was 40 years, 82% were male, and most events (71%) occurred in open water. The pair-matched analytic approach indicated that temperatures exceeding 30°C were associated with a 69% increase in the risk of outdoor drowning (OR = 1.69, 95% CI 1.23-2.25, p = 0.001). For indoor drowning, however, temperatures exceeding 30°C were not associated with a statistically significant increase in the risk of drowning (OR = 1.50, 95% CI 0.53-4.21, p = 0.442). Adult men were specifically prone to drown in hot weather (OR 1.67, 95% CI 1.19-2.34, p = 0.003) yet an apparent increase in risk extended to both genders and all age groups.

CONCLUSION

Contrary to popular belief, hot weather rather than cold stormy weather increases the risk of drowning. An awareness of this risk might encourage greater use of drowning prevention strategies known to save lives.

Modeling Unintentional Drowning Mortality Rates in Thailand, 2000-2009

The objectives of this study were to investigate the pattern of unintentional drowning deaths and to identify the factors associated with drowning deaths in Thailand from 2000 to 2009. Reported death data were obtained from the Bureau of Health Policy and Strategy, Ministry of Public Health. During the period from 2000 to 2009, 41 620 deaths were reported and 1016 deaths were excluded from this study because of unknown place of death. The overall drowning death rate per 100 000 population was 6.3 (9.6 in males and 3.0 in females). The highest death rate was in males aged 0 to 4 years and in year 2006. Males in all age-groups (except in those aged 15-29 years) and females aged 0 to 4 years had higher drowning death rates than the average rate. Death rates in some public health areas in the central, the northeast, and the northern regions and in year 2005 and 2006 were higher than the average rate.

The gap in injury mortality rates between urban and rural residents of Hubei Province, China

BACKGROUND

Injury is a growing public health concern in China. Injury death rates are often higher in rural areas than in urban areas in general. The objective of this study is to compare the injury mortality rates in urban and rural residents in Hubei Province in central China by age, sex and mechanism of injury.

METHODS

Using data from the Disease Surveillance Points (DSP) system maintained by the Hubei Province Centers for Disease Control and Prevention (CDC) from 2006 to 2008, injury deaths were classified according to the International Classification of Disease-10th Revision (ICD-10). Crude and age-adjusted annual mortality rates were calculated for rural and urban residents of Hubei Province.

RESULTS

The crude and age-adjusted injury death rates were significantly higher for rural residents than for urban residents (crude rate ratio 1.9, 95% confidence interval 1.8-2.0; adjusted rate ratio 2.4, 95% confidence interval 2.3-2.4). The age-adjusted injury death rate for males was 81.6/100,000 in rural areas compared with 37.0/100,000 in urban areas; for females, the respective rates were 57.9/100,000 and 22.4/100,000. Death rates for suicide (32.4 per 100,000 vs 3.9 per 100,000), traffic-related injuries (15.8 per 100,000 vs 9.5 per 100,000), drowning (6.9 per 100,000 vs 2.3 per 100,000) and crushing injuries (2.0 per 100,000 vs 0.7 per 100,000) were significantly higher in rural areas. Overall injury death rates were much higher in persons over 65 years, with significantly higher rates in rural residents compared with urban residents for suicide (279.8 per 100,000 vs 10.7 per 100,000), traffic-related injuries, and drownings in this age group. Death rates for falls, poisoning, and suffocation were similar in the two geographic groups.

CONCLUSIONS

Rates of suicide, traffic-related injury deaths and drownings are demonstrably higher in rural compared with urban locations and should be targeted for injury prevention activity. There is a need for injury prevention policies targeted at elderly residents, especially with regard to suicide prevention in rural areas in Central China.

Potential Risk Estimation Drowning Index for Children (PREDIC): a pilot study from Matlab, Bangladesh

Childhood drowning is a major public health problem that has been neglected in many low- and middle-income countries. In Matlab, rural Bangladesh, more than 40% of child deaths aged 1-4 years are due to drowning.

AIM

The main objective of this paper was to develop and evaluate a childhood drowning risk prediction index.

METHODOLOGY

A literature review was carried out to document risk factors identified for childhood drowning in Bangladesh. The Newacheck model for special health care needs for children was adapted and applied to construct a childhood drowning risk index called "Potential Risk Estimation Drowning Index for Children" (PREDIC). Finally, the proposed PREDIC Index was applied to childhood drowning deaths and compared with the comparison group from children living in Matlab, Bangladesh. This pilot study used t-tests and Receiver Operating Characteristic (ROC) curve to analyze the results.

RESULTS

The PREDIC index was applied to 302 drowning deaths and 624 children 0-4 years old living in Matlab. The results of t-test indicate that the drowned children had a statistically (t=-8.58, p=0.0001) significant higher mean PREDIC score (6.01) than those in comparison group (5.26). Drowning cases had a PREDIC score of 6 or more for 68% of the children however, the comparison group had 43% of the children with score of 6 or more which was statistically significant (t=-7.36, p<0.001). The area under the curve for the Receiver Operating Characteristic curve was 0.662.

CONCLUSION

Index score construction was scientifically plausible; and the index is relatively complete, fairly accurate, and practical. The risk index can help identify and target high risk children with drowning prevention programs. PREDIC index needs to be further tested for its accuracy, feasibility and effectiveness in drowning risk reduction in Bangladesh and other countries.

Quality of cause-of-death reporting using ICD-10 drowning codes: a descriptive study of 69 countries

BACKGROUND

The systematic collection of high-quality mortality data is a prerequisite in designing relevant drowning prevention programmes. This descriptive study aimed to assess the quality (i.e., level of specificity) of cause-of-death reporting using ICD-10 drowning codes across 69 countries.

METHODS

World Health Organization (WHO) mortality data were extracted for analysis. The proportion of unintentional drowning deaths coded as unspecified at the 3-character level (ICD-10 code W74) and for which the place of occurrence was unspecified at the 4th character (.9) were calculated for each country as indicators of the quality of cause-of-death reporting.

RESULTS

In 32 of the 69 countries studied, the percentage of cases of unintentional drowning coded as unspecified at the 3-character level exceeded 50%, and in 19 countries, this percentage exceeded 80%; in contrast, the percentage was lower than 10% in only 10 countries. In 21 of the 56 countries that report 4-character codes, the percentage of unintentional drowning deaths for which the place of occurrence was unspecified at the 4th character exceeded 50%, and in 15 countries, exceeded 90%; in only 14 countries was this percentage lower than 10%.

CONCLUSION

Despite the introduction of more specific subcategories for drowning in the ICD-10, many countries were found to be failing to report sufficiently specific codes in drowning mortality data submitted to the WHO.

Unintentional drowning in northern Iran: a population-based study

The Iranian Ministry of Health documented that about 1500 people died from drowning annually in Iran between years 2000 and 2001. This study is a descriptive, retrospective, population-based analysis of 342 unintentional drowning deaths occurring to residents and tourists in Guilan and Mazandran Provinces in Iran over a 1-year period (2005-2006), using multiple data sources. The findings from this study demonstrate that the drowning rate for residents of the study population, 4.24 per 100,000, is much higher than drowning rates for populations in developed economies in Europe. Risk factors for drowning in the study populations include male gender, young age, and swimming in unsupervised areas. Drownings occurred most frequently in rivers, followed by canals and lakes. While much more remains to be done to investigate the problems associated with drowning deaths and injuries in Iran, the information obtained from this study can help point the way to targeted interventions.

Community perception of childhood drowning and its prevention measures in rural Bangladesh: a qualitative study

OBJECTIVES

To gain an in-depth understanding of people's perception of causes and their concepts of prevention of childhood drowning in rural Bangladesh.

DESIGN

A qualitative study and focus group discussion (FGD) was adopted.

SETTING

A rural community in Bangladesh.

PARTICIPANTS

FGDs were conducted with mothers of children aged under 5 years, adolescent male and female students, fathers and local leaders. One FGD was conducted for each group. Out of 53 participants 25 were women.

RESULTS

The respondents considered that children of 5-10 years are at risk of drowning. Ponds, ditches and canals were frequently mentioned locations of drowning. Most of the drownings were reported to occur around noon. For prevention of childhood drowning the participants suggested that the children should be constantly supervised, unwanted ditches should be filled in, ponds should be fenced and drowning prevention awareness in the community be increased by community leaders. They suggested that government should organise campaigns for preventing childhood drowning, promoting swimming instruction activities for children and motivating communities to fence ponds.

CONCLUSIONS

People interviewed in general know the causes of childhood drowning and its preventive measures, but they do not put their knowledge into preventative actions as they fail to recognise this as a major child survival issue and they are never reached with definite actions points to change the behaviours.

Childhood drowning in low- and middle-income countries: Urgent need for intervention trials

Data available for low- and middle-income countries (LMICs) indicate that the burden of drowning in children is significant and becoming a leading public health problem. At the same time, interventions for drowning are not well documented in LMICs. The overall purpose of this paper is to make the case for research investments in conducting intervention trials to prevent child drowning in LMICs. In high-income countries (HICs), existing drowning prevention interventions include among others: pool fencing, supervision, lifeguards and water safety training at a young age. However, these measures may not be the most relevant in curtailing the number of drowning deaths in LMICs. There are differences with regard to geographical, social, cultural and behavioural factors associated with drowning between HICs and LMICs, often making it inappropriate to apply existing interventions directly in LMIC settings. This paper focuses on drowning from LMICs and reveals a dearth of data on incidence rates and risk factors; absence of public health interventions; lack of research on intervention effectiveness and cost-effectiveness; and paucity of national drowning prevention programs. Based on this evidence, this paper calls for immediate attention to drowning prevention by increasing research investments. This paper specifically discusses Bangladesh as a case study and proposes a drowning intervention study focusing on children less than 5 years in LMICs as an example of appropriate research investment.

Child drowning deaths in Xiamen city and suburbs, People's Republic of China, 2001 5

BACKGROUND

Risk-factor research and prevention programs targeting drowning deaths in children have been well developed in industrialized countries, but little research has been undertaken in developing countries where the majority of drowning deaths occur. We conducted an epidemiological study to describe the sociodemographic characteristics, drowning circumstances, and medical service in drowning deaths of children in Xiamen city and suburbs, People's Republic of China.

MATERIAL AND METHODS

Drowning deaths in 1-14-year-old children between 2001 and 2005 were identified using death certificates. Parents of each case were interviewed face to face about the sociodemographics of the family and child, the drowning event, and medical care received. Mortalities were calculated using census data for urban and rural areas, and Poisson regression was used to evaluate confounding effects and interactions of several major risk factors for drowning death.

RESULTS

Of 67 drowning deaths identified, 52 (77.6%) were males. A higher proportion of deaths were in children aged 5-9 years (40.3%) and 10-14 years (40.3%). The drowning mortality per 100 000 population was 5.84 in rural areas and 0.75 in urban areas. Drowning events occurred most commonly during the summer months (56.7% from June to August), during the hours of 13:00-17:59 (62.7%), and in natural or man-made bodies of water (eg, ponds, ditches, construction sites, and wells). None of the children were proficient swimmers, the majority of drowning events (88.1%) occurred in the absence of adult supervision, and 86.6% children died at the scene without any medical care. Results from muiltivariable Poisson regression analysis indicated that 10-14-year-old boys were at the highest risk of drowning deaths in this area.

DISCUSSION AND CONCLUSIONS

Drowning deaths in children in Xiamen city and suburbs follow trends that are markedly different from patterns observed in other countries. Different prevention strategies may be required for preventing child drowning deaths in Xiamen and other developing regions.