Social and environmental risk factors for the accidental drowning of children under five in China

Drowning is a serious contributor to mortality and disability. With nearly 372,000 deaths reportedly due to drowning each year worldwide, it is a leading cause of child mortality [1]. Drowning that does not end in death may lead to cognitive difficulties, hypoxic-ischemic brain injury, cardiac abnormalities, and adult respiratory disease syndrome later in life [2‐4]. Although the mortality rate due to drowning is decreasing [5], the associated economic burden remains significant. For example, the combined effects of fatal and nonfatal drowning in 2017–2018 cost 1.47 billion AUD (over 7.1 billion Chinese renminbi) [6].

Drowning is the main cause of accidental deaths in children worldwide under 5 years of age [7]. As the world’s largest developing country, China has a large population and abundant water bodies in most regions, and child drowning is also a major problem in China. In response, China has made many efforts to reduce the accidental drowning mortality rate in children, and relevant health education is actively performed at the national level. The National Health Commission of the People’s Republic of China released the “Chinese citizens’ health literacy: basic knowledge and skills guidelines in 2015”, which called for the strengthening of child supervision and education to prevent children from approaching dangerous waters [8]. Some regional governments issued a number of safety documents, including “Notice on the prevention of drowning in adolescents and children in 2019” and “Notice on doing a good job in preventing drowning of adolescents and children in 2019” [9, 10]. The Education Bureaus of many provinces also issued notices on the prevention of drowning, such as the “Notification of education on swimming safety for primary and middle school students” and the “Prohibition of bathing in rivers during summer vacation” [11].

Despite these and other preventative efforts, drowning remains an important cause of unintentional death in Chinese children [12‐17]. Because of the absence of national-level data, we performed individual interviews with primary caregivers of drowned children from various parts of the country (registered in the National Maternal and Child Health Surveillance System) to elucidate the characteristics and risk factors of drowning deaths in children under five. The surveillance districts were evenly distributed in 31 provinces (autonomous regions and municipalities) of China to ensure representation of the entire country and different regions. Our results may help improve preventive measures and provide recommendations to reduce drowning mortality in this vulnerable age group.

The present study suggests the following characteristics in the drowning of Chinese children under 5 years. First, children aged 1 to 2 years old and older children who are not enrolled in kindergarten were more likely to drown. Second, most children older than 1 year old had not received any accidental injury safety education (accounted for 70.9%), and most primary caregivers (accounted for 83.1%) had not received first aid training in drowning. Third, children typically drowned in bodies of water within 100 m of their home. Younger children tended to drown at home, and older children were more likely to drown outside the home in ponds, rivers, and canals. This difference is most likely due to the mobility of older children. The children in most drowning cases were playing next to the body of water and not in the water. Fourth, safety measures were markedly lacking in most drowning cases. Finally, most drowned children had caregivers who were less educated. Caregivers were attending to other chores and not minding the child when many drownings occurred, and nearly half of all children were alone when they drowned. These findings, in combination with a previous study in Hunan Province [19], indicate that full-time caregivers, accidental injury safety training, and water safety measures are important for drowning prevention.

The present study found that a great many drowned children lived within 100 m of the body of water, and most of these bodies of water had no fences. Most public bodies of water lacked warning signs. For the public bodies of water with warning signs, half of the warning signs were not easy to notice. Since most accidental drownings occurred at ponds, canals, rivers, and wells, the incompletion of safety measures in the living environment is an important risk factor for accidental drowning in children. Therefore, physical prevention measures in parallel with drowning prevention education are needed. Our study underscores the urgent need for fences and visible warning signs around bodies of water. Local governments should be encouraged to enact regulations and policies requiring that warning signs and protective barriers be installed near public bodies of water.

One major insight from the results of this study is the role of the primary caregivers. The results suggest that primary caregivers’ education level and the level of mindfulness strongly affect the risks of child drowning. Primary caregivers in our survey were paying full attention to the child in only 12.8% of drowning cases when the primary caregiver was present. This result indicates a lapse in supervision among most caregivers.

A study in Australia showed that inadequate care and lapses in supervision, such as indoor housework, outdoor housework, and talking/socializing, were major contributors to child drowning [20]. We also found that caregivers were occupied with housework, phone calls or socializing at the time of the drowning. An Australia-based study of the accidental drowning of children from 0 to 17 years old between 2002 and 2014 found that all children who drowned had a lapse in supervision, and common supervision lapses were due to indoor household duties, outdoor household duties and talking/socializing [21]. Therefore, it is important to help primary caregivers understand the consequence of supervision lapses. Local communities can promote the benefits of full-time parental care within their jurisdictions and use health education programs to help parents learn about child drowning prevention and first aid information for drowning. Sending injury prevention knowledge via SMS or voice messages to parents’ mobile phones may effectively raise awareness and reduce the risk of drowning, as suggested by a study in Bangladesh [22]. These strategies were effective in the Jiangsu province in China, where parental awareness of, and behaviors to prevent, accidental suffocation and drowning in rural children changed significantly after the enacting of health education programs [23].

Raising awareness of drowning prevention may also prove beneficial when it is provided to the caregivers and the children. One way to increase awareness of kindergarten-aged children would be for the local government to strengthen safety education training in the classroom and encourage kindergarten enrollment because we found that over half of drowned children were not enrolled in kindergarten despite being of kindergarten age.

We propose teaching children to avoid unprotected bodies of water to help reduce the drowning mortality rate. As children become older, more mobile and independent, emphasis should be shifted from safety around water containers in the home to safety around open bodies of water outdoors. Moreover, prevention programs should reinforce that a child should always seek adult supervision when playing in and around bodies of water. To be most effective, these prevention programs should be age-appropriate.

To our knowledge, the present study is the most extensive survey of the characteristics of drowning deaths of children under 5 years in China. These data suggest several key risk factors that may help guide the design and improvement of child drowning prevention programs.