Broward County is located in the southeastern portion of the State of Florida with a 2014 population estimate of 1,869,235. DOH-Broward’s mission is “to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts”. Drowning is a significant public health issue especially impacting children under the age of 5. Drowning is a process, once someone starts to drown, survival is determined almost exclusively at the scene of the incident and dependent on two factors: how quickly the victim is removed from the water and how quickly immediate and proper resuscitation is administered. Water is the very attractive to children who do not understand its danger that leads children to tragedy.
In Florida, drowning is the number-one killer of children ages 1 – 4 years old. The Florida Department of Health (DOH) Injury Prevention Program indicates that in 2013, 448 Florida residents drowned with an additional 285 hospitalizations for non-fatal drowning incidents. Children aged 1-4 years old make up 14% of the deaths and 38% of the hospitalizations. Florida’s drowning death rate among children ages 1 - 4 is the highest in the nation with a drowning rate of 7.54 per 100,000 populations. Fatal drowning incidents for Florida resident children aged 1 - 4 years old in 2012 by location were as follows: 56% in swimming pools, 21% as an intentional act, 15% in natural/open water, and 6% in bathtubs. According to the 2012 Florida Child Abuse Death Review Report, the leading cause of verified child abuse/neglect deaths in Florida was drowning. The State Committee reviewed 32 verified child neglect cases involving drowning.
In 2014, 68% of drowning deaths and non-fatal hospitalizations combined occurred during the months of April through September. The median admission charge for non-fatal drowning hospitalizations was $16,034 in 2012; total charges exceeded $16 million. The median length of stay was two days. Medicaid was the payer source for 50% of these hospitalizations, followed by commercial insurance at 26%, self-pay/underinsured at 13%, Medicare at 10% and other at 1%.From 2010 through 2014, Broward County experienced 41 drowning fatalities for children aged 1 - 4. In the late 1990s, Broward County reported an average of ten drowning deaths per year among children ages 1 through 4 years old, and non-fatal drowning incidents left three out of four victims suffering brain damage. The CDC reports that for every child who dies from drowning, another 5 receive emergency department care for nonfatal submersion injuries. Nonfatal drowning injuries can cause severe brain damage that may result in long term disabilities and in some situations, permanent loss of basic function (e.g., vegetative state). Applying these statistics, an additional 170 children in Broward County experienced a nonfatal drowning; approximately 85 of those children have a permanent disability as a result of a drowning incident.
The overall objective of the Water Smart Broward practice is to protect children from fatal drowning and aquatic related injuries and disabilities by promoting safer water practices and providing premier, strategic community-wide education to residents of Broward County. Specific objectives are as follows;• Objective 1: Increase public awareness of risk factors that contribute to fatal and nonfatal drowning among children ages 1 to 4 years old.• Objective 2: Analyze available local drowning data to improve intervention programs.• Objective 3: Integrate drowning prevention education into community based organizations, child care providers, protective investigators, and health professionals to reach and influence vulnerable populations.• Objective 4: Educate government officials, emergency responders and other stakeholders about the importance of residential and public pool barrier ordinances to increase safer environments for children.
The practice implemented by increasing partnerships to advance capacity building for drowning prevention education and resources, improving water safety knowledge through available data sources, using train the trainer module to integrate prevention education to professionals in position to influence target audiences, enhancing community engagement in Water Smart Broward Initiative.
Results/ OutcomesAll of the objectives have been achieved, and remain as ongoing activities. At least once quarterly, the objectives are reviewed and monitored with the lead contact designated for each objective for progress, obstacles and improvement.The success of this practice has been through collaborations and shared resources of Water Smart Broward partners.
Public Health impact of practice: Child drowning fatalities leave families broken apart. Lives are forever changed. Children who survive a drowning typically face a disability that limits their ability to perform everyday activities over their lifetime and often require extensive and expensive healthcare needs. These deaths and injuries need not occur because toddler drowning is a predictable. The economic impact of care for a disabled child can be averted. The safety of a child is a human right, and simple steps to prevent drowning can alleviate the tragedy and burden of a fatal and nonfatal drowning.
The website for DOH-Broward is http://broward.floridahealth.gov/
Statement of the problem/public health issueAlarmingly, drowning is the number one cause of unintentional injury among children ages 1 through 4 in the United States, Florida, and in Broward County. Yet drowning among this population is almost always preventable. Drowning fatalities and injuries among children ages 1 to 4 almost always are a result of a non-recreational event, whereby there was no intention of the child to be in the water. Risk factors that contribute to this issue are:1. Absence of appropriate adult supervision, or an abrupt break in adult supervision 2. Lack of knowledge/awareness of the surrounding hazards3. Absence of barriers to prevent or delay access to water4. Inability or unwillingness on behalf of bystanders to respond to appropriatelyEvidence has proven that a range of interventions are effective in preventing drowning fatalities and minimizing consequences of nonfatal drowning. Drowning prevention has much in common with other public health agendas that protect and improve the health of individuals such as safe water, communicable diseases, epidemiology and immunizations. Unfortunately, drowning prevention is often overlooked as a public health issue.
What Target Population is affected by the problem: (include demographics) Children ages 1 to 4 are most at risk to drown, however, the tragic and abrupt loss of a young life impacts entire communities. Children deserve a safe environment to grow, play and learn. Sadly a fatal drowning incident can deny a child a future. A survivor of a drowning is likely to live the remainder of their life with a disability that can be as extensive as severe brain injury. Families of a child drowning are not only stricken with grief, but often with guilt realizing simple steps would have prevented the event from happening.
First responders, bystanders, law enforcement and healthcare providers are faced with a difficult emotional experience when their efforts fail to provide a favorable outcome of a needless tragedy. And of course, the victim’s social network is impacted when a school or playmate is suddenly missing in the classroom or neighborhood.
Percent of Population: According to the U. S. Census Bureau, children aged 1-4 represent 5.8% of total Broward population of 1.8 million.
Percent of Population Reached: The training and education under this project are provided through five primary outreach efforts that reach a total population exceeding 116,000.1. Event participation to the general public as well as organizations, schools, businesses and membership groups for the purpose of creating awareness of drowning risks and prevention measures. Printed materials are provided as well as activities, demonstrations and one-on-one interaction to motivate individuals to make safer choices through simple steps that prevent drowning.At least 10 events are supported annually, with an average attendance of 100 individuals (a total of 10,000)2. Educational presentations to specific groups of individuals such as community based organizations, parent groups, schools, professional associations and community/neighborhood groups. The length of the presentations range from 30 to 45 minutes, depending on group size, the age and learning abilities of the group and the timeframe allotted by the requesting organization. Typically there is a time afforded for questions; printed materials are also distributed. At least 40 presentations are facilitated annually with an average of 25 participants per presentation ( a total of 1,000)
3. Train the Trainer workshops for the staff of family strengthening providers and child protective investigators. The staff of family strengthening providers works directly with families, often making home visits to help parents to ensure their children grow and develop in a positive, healthy and safe manner. Likewise, child protective investigators make on site visits to households to investigate a report of suspected child abuse or neglect. In situations where there is a child or children under the age of 5 in the household and there is a body of water in close proximity to the home, the investigator conducts a water safety assessment with the parent/guardian and provides door alarms to install that will alert a child leaving the home and possibly accessing a canal, pool, pond, etc unsupervised.At least 75 staff members of family strengthening agencies are trained per year, and they in-turn provide water safety education to an average of 18,000 families annually. ( a total of 18,075)At least 60 child protective investigators are trained annually who provide a water safety assessment to approximately 600 families per month (7,260 total)
4. Water Smart Prescription Program is collaboration with Broward County pediatricians to discuss and distribute drowning prevention and water safety education to parents during a child’s 12-month well visit. Pediatricians are in position to influence parents to apply safer practices to minimize drowning risks and to take action: learn CPR and enroll children in swim instruction. Parents receive a Water Smart Broward Resource guide and a prescription to enroll in a CPR class for themselves as well as others that are likely to supervise the child, and also a prescription for water safety lessons for their child(ren). At least 30,000 parents receive the Water Smart Resource guide from their child’s pediatrician each year.
5. Hospital/Emergency Department discharge process includes water safety education to all parents upon the discharge of a child from an ED or inpatient admission from a major Broward Hospital. Parents during the discharge process are asked 5 screening questions to assess their knowledge about drowning risks and prevention measures. Additionally, the parents watch a brief video and are provided an informational handout that is available in English, Spanish, French and Creole.Approximately 1,000 families are reach per month with water safety education. (a total of 12,000 per year.
What has been done in the past to address the high incident of fatal and nonfatal drowning in Broward County to protect the most vulnerable population, children ages 1 to 4: In 1997, an ad hoc committee was formed to discuss the magnitude of fatal and nonfatal drowning among young children in Broward County. The committee was comprised of membership from various organizations including, Nova SEU Child Injury Prevention Institute, Broward County Fire Rescue, American Red Cross, Broward County Commission and Broward County School District. The committee met regularly for approximately a year to determine and implement a plan of action. A decision was made to develop a resource and referral program to provide parents with information about the availability and importance of swim lessons. This program, known as SWIM Central was established in 1999. Over time, with additional funding, SWIM Central expanded to fund swim instruction during the school year to elementary aged children, initially targeting schools within walking distance to a pool. By 2004, SWIM Central was able to begin reaching children in day care centers. Drowning fatalities among young children in Broward County in the 1990’s averaged about 10 per year. That drowning rate was reduced to an average of 8 per year.
In spite of the great success of the SWIM Central program, the incidence of fatal drowning has not changed since 2004. And sadly, the number of hospitalizations of non fatal drowning admissions has reached the highest rate since the late 90s, and unfortunately, Broward County consistently ranks above the state and national average for the highest number of drowning fatalities and hospitalizations of nonfatal child drowning ages 5 and under.
In 2009, Children’s Services Council of Broward County approached the Florida Department of Health in Broward County to house the Infant/Toddler Drowning Prevention Initiative to focus on county-wide education and to coordinate drowning prevention efforts throughout the County through a strategic action plan as fatal drowning among children averaged 8 per year since 2004.
By early spring of 2014, Broward had already experienced 7 drowning fatalities among children ages 1 to 4, which signaled a failure to provide the most essential prevention strategy: education. Drowning among young children is predictable and preventable. Almost every fatal drowning incident tells the same story:• A toddler leaves the home unnoticed and finds easy access to water• The drowning occurs in backyard pool. • Lack of barriers/alarms allow easy access to water• At least one adult is in the home at the time of the incident• The child was not expected to be in or near the water and was wearing clothing, not bathing attireYet another set of common circumstances occurred in the spring of 2014. Two sets of twins, two different apartment complex pools, each with broken gate locks. Both complex pools were built prior to more stringent fencing and gate codes and were not required to comply with current codes. The toddlers had easy access to water, resulting in 3 fatalities and 1 child living the remainder of his life in a nursing home – all within less than 30 days apart.
These two situations provided an alarming question, how many individuals entered those pools and never thought that a broken gate lock was more than easy entrance to their recreational swim? Rather, that the faulty latches/locks were entrance to death traps for young children leaving a home unsupervised. The circumstances of these events, as well as the high number of fatalities launched the initiative now known as Water Smart Broward, which is a countywide educational and awareness campaign to bring awareness that drowning prevention is the responsibility of everyone. The launch of the program was difficult and was slow to take-off, as promotional resources were not available. However, in December of 2014, a collaborative initiative known as #Saferby4 was created to address the high incidence of child fatalities in Broward County due to unsafe sleep as well as toddler drowning. The #Saferby4 Campaign was a collaboration with DCF, Health Mothers-Healthy Babies and the Florida Department of Health in Broward. An educational seminar was planned to recruit local municipalities and Broward Fire and Police Chiefs to make the Saferby4 pledge and bring aggressive drowning prevention and unsafe sleep education to their respective local levels. The seminar, attended by more than 100 officials and decision makers, received the traction and attention needed for Water Smart Broward.
Simultaneously, under the Water Smart Broward umbrella, the major healthcare providers adopted the Water Smart Prescription program to provide awareness of drowning risks and simple steps to prevent drowning. The Water Smart Rx Program was funded and led by the Pediatric Associates Foundation. Additionally, one of the primary Pediatric Hospitals implemented a Water Smart education component upon discharge from in-patient or Emergency Department care. This process includes a questionnaire for parents and water safety/drowning prevention education.
Why is the current/ proposed practice better?Water Smart Broward is a comprehensive community/countywide drowning prevention effort to develop a culture of water safety and responsibility that protecting children from drowning is everyone’s responsibility. Research provides evidence that community based injury prevention programs are most effective because of the use of multiple interventions implemented throughout the year and via various communication channels afford prevention measures to be repeated in different forms, languages and contexts, yet under a single branding: Water Smart Broward.
Is it new to the field of public health or
A creative use of existing tool or practice?
Drowning is often ignored as a public health issue. However, drowning is classified as a component of unintentional injuries. Unintentional injuries are preventable, provided all safety measures are effectively in place. The most significant intervention of unintentional injuries is education simply because what people have learned they do not know.
Is current practice evidence based, if yes, provide references:• Public Health Model Injury Prevention• CDC National Action Plan for child injury prevention
Is current practice innovative, if so how: Water Smart Broward is certainly innovative. Drowning prevention programs are typically housed under a single local agency. Water Smart Broward, although administered by the Florida Department of Health in Broward, distinguishes itself with a branding that comprises and coordinates all drowning prevention efforts within the county. Additionally, the Water Smart drowning prevention program has been adopted in Palm Beach County as Water Smart Palm Beach, and in Miami Dade County as Water Smart Miami Dade. Hillsborough and St. Lucie Counties will soon be on board. Currently, the Florida Department of Health at the state level is adopting the branding, Waterproof Florida.
Goals and objectives of proposed practice
The overall objective of the Water Smart Broward practice is to protect children from fatal drowning and aquatic related injuries and disabilities by promoting safer water practices and providing premier, strategic community-wide education to residents of Broward County.
Specific objectives are as follows;• Objective 1: Increase public awareness of risk factors that contribute to fatal and nonfatal drowning among children ages 1 to 4 years old.• Objective 2: Analyze available local drowning data to improve intervention programs.• Objective 3: Integrate drowning prevention education into community based organizations, child care providers, protective investigators, and health professionals to reach and influence vulnerable populations.• Objective 4: Educate government officials, emergency responders and other stakeholders about the importance of residential and public pool barrier ordinances to increase safer environments for children.
How was practice implemented / activities:Goal 1: Increase public awareness of risk factors that contribute to fatal and nonfatal drowning among children ages 1 to 4.Increase partnerships to advance capacity building for drowning prevention education and resources• Support community water safety events • Identify and engage stakeholders to access and disseminate drowning prevention education to target groups.• Provide support to relevant partners to develop effective interventions.Provide administrative oversight to Broward County Drowning Prevention Task Force• Schedule/ facilitate at least 10 meetings annually• Record and distribute meeting minutes• Provide strategic framework • Organize calendar of events• Continually recruit leadership membership of organizations, decision makers and other stakeholders to contribute knowledge, expertise and resources.Supervise a systematic Water Smart media campaign• Conduct seasonal PSA in conjunction with CSC• Utilize social media to promote messaging to raise water safety awareness• Disseminate available PSAs to community stakeholders• Use Water Smart branding • Oversee development of watersmartbroward.org Engage community organizations, membership groups and pool industry providers in Water Smart Broward campaign• Identify training opportunities for home inspectors, HOA & Condo associations, Real Estate groups to reach their respective members with drowning prevention education.• Provide available resources to pool industry merchants to distribute to their customer base.Improve parent perceptions of swim instruction as additional layer of protection to prevent drowning• Provide a component in all drowning prevention outreach presentations to address parental resistance to seek swim instruction for children.• Provide DOH PIO and Community Affairs to explain swimming lessons do not drown proof children, but are an important layer of protection.Increase community outreach drowning education through the Water Smart Broward campaign• Recruit at least 3 groups each year to participate in a 12-month Water Smart campaign for their group or municipality• Identify target groups among Water Smart partners; provide at least 3 outreach education presentations to the most vulnerable populations.Increase public awareness of knowledge and skills to respond appropriately to a submersion incident• Provide a component in all drowning prevention outreach presentations that emphasize the importance of immediate bystander response actions• Disseminate information to distinguish the difference between Hands-Only CPR and CPR with rescue breaths.• Encourage hospital and fire departments to offer CPR training and awareness.• Monitor attendance in CPR classes through Water Smart Rx program.
Goal 2: Analyze available local drowning data to improve intervention programs.Improve water safety knowledge through available data sources.• Acquire monthly drowning fatality report from Broward ME office & DCF Child Fatality website• Secure/renew MOU with DCF to collect nonfatal data • Attend Child Death Review meetings to learn causes and contributing factors related to drowning fatalities.Evaluate/analyze data• Prioritize outreach to specific target audiences and zip codes according to fatal and nonfatal drowning indicators.• Provide education to policy makers about risk factors to minimize risk factors and increase safer environments.Disseminate data• Report monthly fatal and nonfatal drowning occurrences to Task Force members• Provide data as requested to DOH-Broward PIO Community Affairs Department
Goal 3: Integrate drowning prevention education into community based organizations, child care providers, protective investigators and health professionals to reach and influence vulnerable populations.Use train the trainer module to integrate prevention education to professionals in position to influence target audiences.• Provide at least 6 Train the Trainer workshops to providers who strengthen families and build skills in supervision of children.Integrate water safety education through pediatricians and family practitioners• Facilitate Water Smart Broward Rx program with pediatricians to counsel parents about water safety strategies. • Expand Rx program to pediatric/family practitioners not currently participating in the Water Smart Rx program.Integrate outreach water safety education through healthcare systems• Distribute at least 100 PSAs to medical clinics. • Provide PSA link for healthcare partners to post on website.Coordinate community outreach and awareness of childhood drowning issues through licensed child care providers• Monitor participation of Child Care Licensing and Enforcement & Swim Central to ensure compliance of Broward Ordinance 2004-02 Section 7-8.• Develop a concise and efficient process to meet the objectives of Broward Ordinance 2004-02 Section 7-8
Goal 4: Educate government officials, emergency responders and other stakeholders about the importance of residential and public pool barrier ordinances to increase safer environments for childrenEnhance community engagement in Water Smart Broward Initiative• Follow up with pledged #Saferby4 municipalities to obtain commitment to Water Smart Broward campaign Promote environmental changes that minimize drowning injuries and fatalities• Provide drowning risk education to partners in position to review current residential pool codes to increase protective strategiesTrain fire rescue and law enforcement to identify public pool safety issues• Provide pool safety education to fire rescue and law enforcement to identify public pool safety concerns
What did you do to achieve the goals and objectives?Community partners were involved in establishing the goals and objectives. Through quarterly meetings, activities are reported and goals are monitored for progress and to address possible challenges and opportunities.
Steps taken to implement the programThe Broward County Drowning Prevention Task Force was already established prior to the launch of the Water Smart Broward project. The Task Force worked more as a network, and less as a working group. Therefore a Steering Committee has been recently formed to provide guidance and direction to the Task Force.
Any criteria for who was selected to receive the practice (if applicable)? Drowning fatalities and injuries are a result of lack of adequate supervision, although data reveals drowning rates vary by race and income. Therefore our program priority is to target zip code areas that experience higher counts of drowning as well as minority populations.
What was the timeframe for the practice The program was formed in fall of 2014, formally launched in 2015. We continue to work with community partners to integrate strategic education throughout the county.
Were other stakeholders involved? What was their role in the planning and implementation process? Stakeholders who share similar efforts/priorities or that serve as gatekeepers to target communities are sought to help and support education outreach. For example:
Broward Sheriff’s Office implemented a Training Advisory Bulletin at our request to inspect and report any apartment and condominium pools for possible safety issues as they are out and about in the community.
The City of Coral Springs provides drowning prevention during car seat installations to parents and grandparents
The City of Davie includes Water Smart Broward messages to their residents via utility bills.
Provide drowning prevention printed materials through all licensed child care providers in Broward County
What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s)
Collaboration is powerful and an effective use of talent, knowledge and resources. Membership of the Water Smart Broward Steering Committee was selected using the CDC Strategic Framework model related to child injury prevention:
? A coordinated, multi-sector approach? A roadmap to align priorities and capitalize on strengths and fill gaps? A process to build commitment and buy-in? Membership comprised of interest in protecting children? An approach to provide clear priority areas to make life safer for our children Any start up or in-kind costs and funding services associated with this practice? Please provideactual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown. The Children’s Services Council of Broward County, since 2009 has funded the Infant/Toddler Drowning Prevention Program which has transitioned to Water Smart Broward. The funding amount is $112,000 annually, which supports a dedicated FTE and a PTE (20 hours per week), some marketing efforts, educational materials and printing expenses. Water Smart Resource Guides provided to pediatrician practices were developed and printed by the Pediatric Associates Foundation and Joe DiMaggio Hospital/Memorial Healthcare System.
Upon completion of the Train the Trainer seminar participants are provided an evaluation to assess learning and competency to share education. Our surveys report an average of 93% satisfaction in those areas.
Water Smart Broward demonstrates an increase of awareness of the high incidence of fatal and nonfatal drowning; additional initiatives are implemented as a result of this awareness.
The fact that four other counties are on board with the Water Smart initiative as well as the Florida Department of Health in Broward adopting the branding demonstrates the effectiveness of the message. Measuring the impact on behavior is a difficult task, and is currently being addressed by the Water Smart Broward Steering Committee.
What did you find out? To what extent were your objectives achieved?
· Parents who do not know how to swim, do not value swim lessons and therefore do not seek swim instruction for their children.
· Parents believe that teaching the fear of water to their children protects the child from drowning.
· Parents often overestimate the swimming ability of their child.
· The ability of a child to swim can relax supervision by the parent.
· Parents do not regard CPR training as a necessary skill, as they believe their child will never drown or have a breathing emergency.
· Concern that stressing swimming ability in messages reinforces a fear of water among parents.
· Relevant and diverse messages are essential to influence safer behaviors.
Did you evaluate your practice? We are in the process of developing evaluation tools. Determining the impact of education as it relates to injury prevention is a tremendous challenge. We do have an evaluation survey that is provided after all Train the Trainer workshops.
Lessons learned in relation to practice
· Nonfatal drowning surveillance data, currently not available, will be helpful in forming more effective strategies. We are currently working on an MOA with Broward Sheriff’s office to obtain this confidential information for surveillance purposes[BCT1] that would provide insight on the circumstances of a nonfatal drowning.
· Current residential and community pool codes do not apply to almost 85% of the pools in Broward County.
Lessons learned in relation to partner collaboration (if applicable)
· Partnerships are critical
Did you do a cost/benefit analysis? If so, describe.
· We are provided a budget from the funder, Children’s Services Council of Broward County
Is there sufficient stakeholder commitment to sustain the practice?
· Describe sustainability plans
· Sustainability is sufficient through continued priorities of the funder, Children’s Services Council of Broward and support of community partners who include Children’s Services Council of Broward, YMCA, Broward County Commission, Broward Sheriff’s Office, Memorial Healthcare System, Broward Health, SWIMS Foundation, Pediatric Associates Foundation, Center for Autistic and Related Disabilities, Department of Children and Families, Broward Rules of Appeals and Codes, Florida Swimming Pool Association and Pediatric Emergency Medicine.