child drowning prevention final report (slightly updated)

Angus Calder 09/09/2015

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Child Drowning Prevention Program Research for Save the Children

Thailand

By Angus Calder

September, 2015


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Table of Contents

Executive Summary: .................................................................................................................. 3

Introduction:.............................................................................................................................. 6

Purpose of report: .................................................................................................................... 6

Global statistics: ....................................................................................................................... 6

Introduction to the situation in Thailand ................................................................................... 6

Epidemiology: ............................................................................................................................ 7

Thai National Injury Survey (TNIS):............................................................................................ 7

Ministry of Health Data: ........................................................................................................... 7

Data Tables: ............................................................................................................................. 8

More recent data: ............................................................................................................... 18

Assessment of the main interventions ................................................................................... 19

Installing barriers controlling access to water:......................................................................... 19

Provide safe places (for example crèche) ................................................................................ 20

Teach school-aged children basic swimming, water-safety, and safe rescue skills..................... 21

Strengthen public awareness of drowning .............................................................................. 24

Local authorities, government and community partnerships ................................................... 27

The provinces in which Save the Children Thailand programs overlap with drowning rates ...... 27

Convincing policy-makers/ local authorities / donors for the need for a national program ....... 28

How to create a community led intervention: ....................................................................... 28

Merit Making program......................................................................................................... 29

Assessment of possible partner agencies: ............................................................................. 29

Ministry of Public Health: ....................................................................................................... 29

Ministry of Education: ............................................................................................................ 30

Thai Life Saving Society:.......................................................................................................... 31

UNICEF Thailand:.................................................................................................................... 32

Child Safety Promotion and Injury Prevention Research Center ............................................... 32

ASEAN Institute of Health Development, Mahidol University: ................................................. 32

College of Public Health, Chulalongkorn University ................................................................. 32

National Scout Organization of Thailand: ................................................................................ 33

Recommended Options: ......................................................................................................... 33

Other possible ideas to be developed: .................................................................................... 37

Funding Possibilities ............................................................................................................... 38

Works Cited: ............................................................................................................................ 40

Appendix:................................................................................................................................. 44

Contact List: ........................................................................................................................... 44


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Executive Summary:

Purpose of this report:

The main question of this report is “how can Save the Children help reduce child drowning deaths in

Thailand?” It was developed for the purpose of doing research into the situation of child drowning in

Thailand, interventions that have worked elsewhere and what interventions have been applied and

would be applicable to Thailand. Through the research some recommendations are outlined for a

Save the Children child drowning prevention program.

Situation analysis:

Drowning claims the lives of 372 000 people a year worldwide of which are 135,585 children

aged under 15

Two sources of information for drowning statistics are the National Injury Survey which

involved household verbal autopsies in 100,000 households and the Ministry of Publi c

Health data which involves using death certificates and medical facility reported drowning

events.

Drowning kills 2650 children in Thailand every year. The age group at the highest risk of

drowning is the 1-4 age group (according to the most reliable sources). However, less

reliable sources propose that recently the 5-9 age group has become more at risk of

drowning. Boys are twice as likely as girls to drown.

Drowning seems to occur more frequently during school holidays, weekends and after-

school.

Drowning occurs more frequently in rural areas, mostly in natural water sources. For

younger children (1-4) these natural water sources are nearby the home within 100m, and

further away for older children (5-9).

Interventions:

Installing barriers controlling access to water:

Where feasible to place a barrier around the water source, it has been shown to reduce

drowning rates by 75%.

This intervention is less applicable to the Thai setting because most drowning occurs in large

natural water sources that are not feasible to place a barrier around.

However, covering cisterns and wells would be effective and using play-pens and baby-gates

could be options to explore.

Provide safe places (for example crèche) away from the water for pre-school children, with

capable child care:

Shown to reduce drowning rates by 82% in the low and middle income setting.

While more than 84% of Thai children attend organized day care, holiday periods, after day-care,

and during weekends are times when supervision is lacking. Furthermore the 15% or more of

children not attending should be targeted.

Using the pre-school system to disseminate drowning messages would be effective in drowning

prevention.


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Teach school-aged children basic swimming, water-safety, and safe rescue skills:

This has been proven to reduce drowning rates by 88% in the low and middle income setting. It

is a sustainable and cross-generational solution to drowning as well as a factor of survival during

natural disasters.

34% of Thai children never learn to swim and therefore this intervention needs widespread

implementation. However, careful attention to risk management needs to be made for this

intervention.

There are numerous previous and current survival swim programs but the scope of these

programs is limited and not nationwide as they depend on the willingness of local authorities.

A swimming curriculum could be integrated into the school physical education system but this

needs highly motivated authorities both local and national specifically from the Ministry of

Education.

Strengthen public awareness of drowning and highlight the vulnerability of children/ focus on

behavior change:

This has been a method of drowning prevention used worldwide, but a direct link between

lower drowning rates and public awareness hasn’t been identified as this intervention is seen as

co-dependent on other interventions.

There have been numerous policies under the National Drowning Prevention Program to ensure

public awareness but their effectiveness hasn’t been studied. A study on awareness activities

needs to be developed with a particular focus on targeting behavior change for children (and not

just parents).

Local authorities, government and community partnerships

Save the Children Thailand should work off pre-existing programs, partnerships and connections

with Kanchanaburi, Bahngkok, Surat Thani, Phang Nga, Song Kla being particular provinces which

have higher drowning rates (and where Save the Children works)

Partners:

Ministry of Public Health has been motivated over the long-term to combat child drowning deaths.

They are interested in helping with monitoring and evaluation, developing the use of play-pens, and

interactive media.

Ministry of Education would be an important partner in incorporating water safety and survival

swimming curriculums into schools. Ties with the ministry through the 7% and Safe School programs

could be utilized.

UNICEF Thailand as they are working on the early stages of a drowning prevention program and

Save the Children has worked with them on DRR programs; a partnership with UNICEF is highly

recommended.

Thai Life Saving Society would be an important partner for capacity building to teach survival

swimming. It is a highly resourceful and motivated small organization.


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Child Safety Promotion and Injury Prevention Research Centre is a partnership we already have

through the 7% program, they are very willing to partner with us on this issue for implementation

and research.

The College of Public Health, Chulalongkorn University and the ASEAN Institute of Health

Development could be partners for research.

National Scout Organization of Thailand could be approached for creating a water safety ‘badge’ as

the organization is the key organization of a scouting movement in Thailand with 1,300,000

members and could easily reach many children.

Recommendations:

Monitoring and evaluation to prove that drowning is being prevented in provinces where

programs have already been implemented is an important step for advocacy, having been

requested by agencies currently working the drowning prevention it would be useful for ensuring

effectiveness of their programs.

Comprehensive drowning prevention project (pilot) this would be an important trial for developing

our expertise and capacity on drowning prevention. Given the intensive management needed for

this, the scale should be modest.

Conduct a thorough evaluation of the current drowning prevention awareness campaign and ways

in which to develop it, with a specific focus on developing awareness messages for young toddlers

this should be done to evaluate whether Save the Children should implement the previous

recommendation or implement only an awareness campaign which could be easier on a large scale.

This recommendation asks the question: do awareness campaigns really have an effect on drowning

prevention rates?

Other Possible Options:

Research into increasing the motivation of teachers to incorporate drowning prevention into

their school schedule

Survival swimming curriculum integration into Cub Scouts

After-school/ holiday camp survival swim water safety course

Development/research into the feasibility of using play-pens

Development of interactive media to incorporate drowning prevention into the ‘one-tablet-per-

child’ initiative

Ensuring water safety and survival swimming courses are mandatory in Physical Education

courses and colleges for school PE teachers or even an expansion to all teachers

A repeat of the Thai National Injury Survey, giving more recent information on drowning.

Possible Sources of funding:

Foundation Princesse Charlene de Monaco, Thai Health Promotion Foundation, Bloomberg

Foundation, Global Drowning Fund, Evian Natural Spring Water, Nanthip Bottled Water, Yum

Restaurants International , Sheraton Hotel Group, Apartment/ condominium blocks


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Introduction:

Purpose of report: The purpose of this report is to answer the question “How can Save the Children help reduce child

drowning deaths in Thailand?”

Secondary and primary data was gathered in order to carry out a situation analysis of drowning

prevention in Thailand. Through the situation analysis a draft concept of a drowning prevention

program is outlined.

As per the terms of reference of the research of report, the following deliverables are included:

Research paper on 1) keys to success for drowning prevention programs and 2) ways to

change parents and children’s behavior regarding water safety

Cataloging of current programs and agencies working on this issue, both globally and within

Thailand

Recommended program design framework

Prioritized list of businesses to approach to support this program

Global statistics: These statistics show the scope and importance of addressing the issue of drowning and in particular

child drowning:

Drowning claims the lives of 372 000 people a year worldwide of which are 135,585 children

aged under 15.

More than 90% of these deaths occur in low- and middle-income countries.

There are approximately 42 drowning deaths, every hour every day.

This death toll is almost two thirds of those deaths from malnutrition and well over half that

of malaria.

Males are twice as likely to drown as females.

Globally, over half of all drowning deaths are among those aged under 25 years.

The economic cost of lives lost is also high, and while difficult to quantify globally, national-

level estimates for Australia, Canada and the United States of America (USA) range from

US$ 85 million to US$ 4.1 billion per year (Meddings, 2014).

While the drowning death toll amounts to two thirds of that of malnutrition and over half that of

malaria the lack of resources and lack of focus on drowning largely shows it to be, in comparison, an

unrecognized and marginalized issue.

Introduction to the situation in Thailand Drowning is defined as “the process of experiencing respiratory impairment from

submersion/immersion in liquid” (Beeck, 2005).

In Thailand, which has risen from a low to middle income country, the mortality rates from

communicable diseases have decreased; however the proportion of deaths that are non-

communicable and injury related have increased significantly (trends which have also been seen in

other rapidly developing nations). The decreases in communicable disease mortality rates have


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caused drowning to become the leading killer of children under 15 (Sitthi-amorn, 2006). A national

drowning prevention program is therefore essential to reduce child mortality..

Drowning is known as a “silent killer” which owes to both it being a largely unrecognized issue

globally, as well as the quiet nature in which many of the drowning deaths occur, where youngsters

quietly slip beneath the water and drown. The majority of drowning deaths do not happen by large

scale events, such as the sinking of a ferry in South Korea in 2014; rather most drownings occur

during separate, small scale events on a one by one basis (Cox, 2013).

Epidemiology: There are two main sources for drowning statistics in Thailand:

1) Thai National Injury Survey

2) Ministry of Public Health

Thai National Injury Survey (TNIS): The Thai National Injury Survey was conducted by Chulalongkorn University, partnered with The

Alliance for Safe Children (TASC), the Ministry of Public Health and UNICEF. The survey had a

nationally representative sample of 100,000 households; the field work was conducted from

2002−2003 using the verbal autopsy method. By carrying out a household survey about child injury

incidents, researchers were able to do a verbal autopsy when there was a situation reported in

which a drowning occurred (Meddings, 2014). It must be noted this data was taken during 2002-

2003 and is perhaps outdated (depending on whether the situation has in fact changed since then).

Of 65 child drowning events identified at the community level, only 14 (21.5 per cent) were seen by

or reported to a health-care facility (fatal and non-fatal drowning combined). None of the immediate

fatal drownings were seen by or reported to a health-care facility (Linnan, 2012).

Ministry of Health Data: Ministry of Health (MoH) data was sourced primarily from the Situation Analysis of Child Drowning

Surveillance Thailand report published and complied in October 2009. For the report, a systematic

analysis was conducted utilizing three databases which had systematically compiled data on

individual reports by age as well as ongoing reports (Gerdmongkolgan, 2009).

Most of the data (death certificates, medical facility) is obtained through the ICD-10 classification

system. The ICD-10 refers to the international standard diagnostic classification of diseases and

health problems that are the causes of morbidity and mortality. Morbidity and mortality by

drowning are placed into the database as codes W65-W-74 (Gerdmongkolgan 2009). When health

care coders classify deaths under ICD-10 the categories of drowning deaths that are missed include

transport related drownings (boat/ship sinking), forces of nature such as floods and typhoons, and

intentional injury (suicide/ homicide) which affects the accuracy of Thailand’s drowning statistics

(Linnan, 2012). The three databases which are used to compile drowning statistics are :

(1) The mortality databases on death certificates


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“Death Certificate data is compiled by the Bureau of Policy and Strategy, MOPH, which elicited the

civil registration data from the Bureau of Registration Administration, Department of Provincial

Administration, Ministry of Interior, and then coded the causes of death on an individual basis based

on ICD-10. Death certificate completeness has been studied to be at 95.2% of deaths

(Gerdmongkolgan, 2009).

Limitations of this:

While completeness of death certification seems high, the portion of causes of death in Thailand

which are classified as “ill-defined and unknown causes of mortality” is as high as 20-39% which

could skew the data (“Rapid Assessment of National Civil Registration,” 2012).

(2) The database of individual inpatients

“Data retrieved from the individual inpatients database was compiled from 2005 to 2007 by the

Bureau of Policy and Strategy after it began to coordinate with the National Health Security Office,

and the Social Security office 2004” (Gerdmongkolgan, 2009). This information comes through

medical facilities.


The data did not comprehensively cover all inpatients who were admitted to hospital because it was

only inpatients who had the rights to reimbursements for medical expenses. Also, the data excludes

all the drowning deaths where the child drowned but was not admitted or registered at a medical

facility.

(3) The Injury Surveillance System. The first two databases are operated by the Bureau of

Epidemiology, Department of Disease Control (DDC), MOPH

The data was compiled periodically by the Bureau of Epidemiology and the Department of Disease

Control through 29 large hospitals in Bangkok and other provinces across the country.


This data is compiled only at 29 large hospitals and not small medical centres, which means areas

and communities would not be represented.

Data Tables: Categories of Statistics

Thai National Injury Survey (TNIS)

Ministry of Public Health Discussion

General Trends

Drowning is the leading cause of death in children aged one year and over in Thailand, causing nearly 2,650 deaths every year.

On top of these figures, some 3,000 children nearly drown every year

In Thailand, the rate of child drowning deaths is 5 to 15 times higher than those for developed countries.

Drowning is the leading cause of death in children aged under 15 years of age, notably, higher than road traffic accidents, and

While the reported average number of deaths per year is significantly more in the Thai National Injury Survey (which could be due to inaccuracies in the collection system of the Ministry of Health) both sets of data nevertheless recognize that drowning is the leading cause of death for children


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Categories of Statistics



infectious diseases In Thailand 1,243 children

under 15 years of age die each year from drowning (10 year average)

under 15.

Age Drowning caused almost half (46 per cent) of all child deaths in the 1-4 age group. These children are too young to learn to swim so prevention requires increased supervision, especially as infants develop into toddlers and outstrip a busy mother’s ability to closely supervise them (see figure 1).

On average, children in the 0-4 age group ranked first for drowning deaths between 1999 and 2008, followed by the 5-9 age group; but since 2005, the 5-9 age group has ranked first.

The proportion of drowning deaths in children under 15 years of age as high as 30.2% of drowning deaths in all age groups.

On average, the 0-4 age group has the highest drowning injury rate, two times higher than that for the 5-9 age group and 5 times higher than that for the 10-14 age group.

The age group of children who drown which has the highest incidence of drowning has been shown on average to be 1-4 for both sources of data. Although, more recent data in both the Situation Analysis of Child Drowning Surveillance (2009) and Situation of Child Drowning (2014) both show the 5-9 age group having higher incidence of child drowning (which is discussed below this table).

Figure 1. Drowning rate by age group (from TNIS)

^(Linnan, 2014)




0

10

20

30

40

50

60

0-1 1-4 5-9 10-14 15-17 1-17

Re

ate

pe

r 100,0

00


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Gender Males in the 1-4 age group are more than twice as likely to drown as females (see figure 2).

However, females aged 10 to 14 have higher rates of drowning than males their age (see figure 2).

The rate of child drowning deaths for males is approximately 2 times higher than that for females.

This is a trend seen worldwide (Child Drowning 2012). Presumed to be as a result of supervision disparities, gender roles, and higher risk-taking behaviour in boys. The females aged 10 to 14 have higher rates of drowning than males is perhaps because swimming abilities in boys of that age are higher than that of girls.

Figure 2. Drowning rate by age and sex (from TNIS)

^(Linnan, 2014)




Time of Day Drowning is essentially a daylight phenomenon. The vast majority of children (96%) are first noticed missing during daylight hours (between 6am and 6pm) (See figure 3).

47% of children who drowned were determined missing between 12:00-17:59, while 49% were determined missing between 6:00- 11:59 (see figure 3).

The time period of the day with the highest incidents of severe drowning injuries is between 12:00 noon and 17:58 hrs, accounting for 64% of all drowning fatalities (12:00-14:59 with 27% and 15:00-17:59 with 37%).

There is a difference between the two sources of data. The disparity may be to do with Public Health data being swayed by the time the drowning event is reported, rather than actually occurring (for example a child drowns in the morning, and the incident is reported in the afternoon). If the Public Health data is valid it shows when children leave school at 3pm and are

0

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30

40

50

60

70

80

1-4 5-9 10-14 1-17

Rate

pe

r 100,0

00

Male Female


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no longer supervised they are more likely to drown.

Figure 3. Known time of day drowned child is determined to be missing (from TNIS)

^(Sitthi-amorn, 2006)




Months of the year

January, April, September, and December are the four months with the most deaths (see figure 4).

April is the month with the highest number of deaths by drowning, followed by May, March, October and November.

The months that have a high drowning incidence are around school holidays. Songkran in April with a large amount of interaction with water drowning rates are high.

Figure 4. Childhood drowning by months (from TNIS)


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^(Sitthi-amorn, 2006)




Days of the week

Weekends (Saturdays and Sundays) have the highest incidents of severe drowning injuries (see figure 5).

Weekends are days when children are not supervised in day-cares or at school and are therefore more at risk.

Figure 5. Percentage of severe drowning injuries in children <15 by day of the week average 1998-

2007 (From Ministry of Public Health)

^ (Gerdmongkolgan, 2009)




National spatial trends

Overall, rural children aged 1 to 17 are almost 5 times more likely to drown than their urban counterparts (see figure 6).

The Northeastern region has the highest rate of child drowning, followed by the central, northern, and southern regions, respectively.

Nakon Ratchasima, Bangkok, Buri Ram, Ubon Ratchathani, Surin, Si Sa Ket, Ubon Thani, and Khon Kaen have the highest rates of deaths by drowning (5-year average 2004 to 2008).

Nakhon Raatchisma province had the highest number of deaths by drowning in the four-year period between 2005 and 2008.

The Northeast region is known to consistently have higher drowning rates. This coincides with the Northeast also having the highest percentage of children left in inadequate care at 2.4% (inadequate care was also highest among the poorest wealth index quintile which is linked with this, given northeast being a poorer region). However, the Northeast region was the second highest region in terms of percentage of children aged 36-59 months who are attending an organized early


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childhood education programme (“Thailand: Monitoring the Situation of Women and Children,” 2013).

Figure 6. Drowning rate by age and place of residence (from TNIS)

^(Linnan, 2014)




Location of drowning

Rivers are the leading cause in the 5-9 age group (72%) and in children 1-17 years old generally (1 to 17, 35%). No children drowned indoors (see figure 7).

76% of drownings occur in natural water sources (ponds, ditches, lakes, rivers or the sea) (see figure 7).

More than a quarter (28%) of toddlers, 1 to 4, and 15 per cent of all children aged 1 to 17 drown in wells (see figure 7).

More than half (56 per cent) of all drowning deaths occur within 100 metres of the child’s home. For toddlers, this proximity is even more striking where almost three quarters of drownings (74 per cent) occur within 100m of the home (see figure 8).

With regard to different kinds of water sources where drowning occurs, natural sources of water rank first, accounting for 49.9% of all drownings, followed by swimming pools at 5.4% and bathtubs at 2.5%.

There are two types of drowning incidents. Type I is generally in the 1-4 age group where small toddlers drown near the home which involves brief lapses of supervision and access to water, including domestic water containers and ponds around or near the house. Type II refers to the drowning incidents where children in the 5-9 age group are in neighbourhood areas further away from home and fall into ponds, canals, dams, and other natural water sources (Plitponkarnpim, 2014).

0

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80

1-4 5-9 10-14 1-17

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pe

r 100,0

00

Urban Rural


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Figure 7. Place of drowning of children (from TNIS)

^ (Sitthi-amorn, 2006)

Figure 8. Distance to water body where drowning took place (from TNIS)



Thai National Injury Survey (TNIS) Ministry of Public Health Discussion

Use of water sources where drowning occurred

Most Thai drownings occur in sources of water not connected with the household. Water sources used for “bathing/washing”, “storage”

Water sources are a large part of rural life whether for the household or part of agriculture and raising fish, the nearby access and


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and “cooking/ drinking” combined make up just 16 per cent of the drowning locations. The single largest category is “raising fish”, which accounts for 31 per cent of the sources of water. “No regular household use”, “agriculture” and “other” are the next highest categories (see figure 9).

proximity of water sources makes drowning more likely.

Figure 9. Use of water source where drowning occurred (from TNIS)





Supervision factors

At the time of drowning mothers are usually doing housework or busy with other chores

Across all age groups, only 17 per cent of drowned children were accompanied by their mother, father, or other primary caretaker at the time they drowned. Almost one

Adequate supervision is key for children particularly in the 1-4 age group when children should be watched closely.


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third (29%) of all drownings occur when the child is alone. In 1 to 4 year olds, half the time (52%) when a toddler drowns a family member other than their parents is accompanying the child, most often an older sibling acting as the supervisor for the child in absence of the mother (see figure 10).

Figure 10. Known person* accompanying child prior to drowning (from TNIS)




Swimming ability

Only about one third (34 per

cent) of Thai children ever learn to swim (see figure 11).

Only 15% of children who drown could swim (their level of swimming skill may vary.

Swimming ability has been proven to prevent drowning, the fewer children who know how to swim, the more children at a greater risk of drowning.


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Figure 11. Swimming ability by age (from TNIS)

^(Linnan, 2014)



Known activity of child when drowning occurred

Prior to drowning 52% of children were known to be playing in water and 45% were working or playing near water, with the other 3% actually swimming/ bathing in the water (see figure 12).

When playing in the water only a few further steps away from the side of the water source and the water could be too deep to stand and the child could easily drown.

Figure 12. Known activity* of children prior to drowning (from TNIS)


2.4%4.9%

7.8%11.6%

16.1%20.5%

23.4%27.8% 29.9% 31.9% 33.3% 34.3% 34.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

5 6 7 8 9 10 11 12 13 14 15 16 17

Pe

rce

nt

ca

n s

wim

Age in years


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Case-fatality rate

Mean case-fatality rate is 41.0%

While drowning kills more children than road accidents, the number of cases of road accident injuries is significantly higher though with a much lower case-fatality rate. Local and national policy makers observe that road accidents cases are more than drowning cases and believe it is a much greater problem, while failing to realize that the mortality rates are higher because of the high case-fatality rate of drowning (Dr. Adisak Interview).

More recent data:

More recent Ministry of Health data was compiled in a report in October 2014 named Situation of

Child Drowning in Thailand. The data from this report has been called into question by the child

drowning expert Dr.Michael Linnan who observes that “when one takes into account the confidence

limits that are inherent in the systems (the systems that generate the data), it is difficult to see the

differences (in recent data results) as being statistically significant” (Michael Linnan Interview).

The recent results show a reduction in the rates of child drowning deaths (per 100,000 children <15

years) in Thailand from a high of 11.5 in 2005 to 7.6 in 2013 (See figure 13, Gerdmongkolgan, 2014).

While Dr. Michel Linnan recognizes that there has been an expansion in the early childhood

development program in Thailand whereby attendance in day care centres has expanded, thus

increasing supervision of children, overall this is unlikely to have contributed such a large reduction

in drowning rates (Micheal Linnan Interview).

Figure 13. Number and rates of child drowning deaths (per, 100,000 <15 years, 2004-2013)

^(Gerdmongkolgan, 2014)


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The recent report also points to further decreases in the rates of children drowning in the 1-4 age

group, which renders the 5-9 age group firmly as the highest age group for drowning incidence.

Again, this might owe to the expansion of the early childhood development program in Thailand that

will be elaborated on later in the report. Furthermore, the Child Safety Promotion and Injury

Prevention Research Center (CSIP) noted a decrease of 400 since 2005 from their reported 600

children per year in the 1-4 age group who drown. While at the same time they saw an insignificant

decrease in the 5-9 age group in which they report 500-550 children drown every year still (CISP

Interview). Again, this data is not accurate enough to confirm these decreasing drowning trends

(Michael Linnan Interview).

Assessment of the main interventions mentioned in the WHO Global

Report on Drowning

Installing barriers controlling access to water: A peer reviewed study by Diane C Thompson and Fred Rivera concluded that fencing which

completely separates the pool from the house and the yard significantly reduces the risk of

drowning by 75% (Thompson, 1998). The study was a review of other studies all conducted in high-

income countries.

The distinct difference between high income countries and Thailand is that drowning in swimming

pools are a much larger portion of the drowning cases in comparison to the mere 5.4% of total

drowning deaths in Thailand (Gerdmongkolgan, 2009). In Thailand 50-76% of drowning cases occur

in natural water sources such as ponds, ditches, lakes, rivers or the sea, given the prevalence and

size of natural water sources placing fencing around them is unfeasible. Fencing would be unfeasible

in low and middle-income countries because it is expensive, subject to theft, requires maintenance

and creates inconvenience, given that water sources are necessary for daily activities and

community residents. They are not viewed as water hazards and therefore community residents do

not want to isolate them behind barriers (Linnan, 2014).

However, more than a quarter (28%) of toddlers 1 to 4 and 15 per cent of all children aged 1 to 17

drown in wells. Wells are the leading cause of drowning deaths in toddlers. Wells can be easily

covered using inexpensive materials and should therefore be prioritized to restrict access to them.

(Gerdmongkolgan, 2009).

Barriers around the house (baby-gates) and playpens could be a more feasible option than fences

around water sources given the significantly less amount of materials needed to build them. A study

of parents perceptions, social and behaviour norms (ASEAN Institute of Health Development noted

that this might face cultural resistance) as well as the ease and cost of obtaining or building them

(using local materials) could be done to develop this further as it has not been studied or used by

any authority working on drowning so far. It should be noted that barriers around the house and

playpens are only feasible for younger toddlers (around the age of 3) and nearly 2,000 children go to

emergency rooms each year in the USA from baby-gate related injuries which means risk

management (for example ensuring they are disassembled when children are able to start climbing

them) should be taken into account (Cheng, 2014)


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Provide safe places (for example crèche) away from the water for

pre-school children, with capable child care Lack of supervision has been consistently linked with drowning rates. “In a 10-year study of

childhood submersions in King County, Washington USA it was found that inadequate supervision

was the most common factor associated with submersions. In most cases, the adult reports leaving

the child for a short time to answer the phone or attend to household chores” (Brenner, 2003).

While this is study from a high income country it is generally applicable globally.

Programs have been implemented in Bangladesh, Cambodia and Southern India aimed towards

improving supervision in order reducing drowning rates. The day care program in Southern India was

developed following a study where the community identified the need for a larger day care program

(Isaac, 2007). The program in Bangladesh observed that drowning death rates in children aged 1-5

attending village crèches were 82% lower than among children who did not attend. The program

deemed to be cost-effective with a Cost of Creche per disability adjusted li fe year (DALY) averted of

$812, because this is less than $1486 (which is the GDP per capita of Bangladesh) it is considered

highly cost effective. The added benefits of the program included incorporating the teaching of

hygiene and sanitation to children as well as empowering mothers to work (Rahman, 2012).

Although, the implementation of the program in Bangladesh involved a high degree of risk-

management whereby there was training for injury risk reduction and first aid (mandatory provision

of first aid kits), setting class size limits as well as ensuring hygiene and sanitation at the crèches and

managing the location of the crèche away from risk areas (Meddings 2014).

“Across all age groups, only 17 per cent of drowned children were accompanied by their mother,

father, or other primary caretaker at the time they drowned. Almost one third (29%) of all drownings

occur when the child is alone. In 1 to 4 year olds, half the time (52%) when a toddler drowns a family

member other than their parents is accompanying the child, most often an older sibling acting as the

supervisor for the child in absence of the mother” (Sitthi-amorn, 2006). This shows how children

drown significantly more when not under adequate supervision.

According to latest statistics 84.7% of children aged 36-59 months are attending an organized early

childhood program. Only 21.3% of children aged 3 attend before a sharp increase in attendance to

88.8% at age 4 (“Thailand: Early Childhood Care and Education Programmes,” 2006).

Figure 12: Structure of Child Care/ Development Agencies


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^(“Thailand: Early Childhood Care and Education Programmes”, 2006).

Figure 12 shows the various ECD programs implemented in Thailand. The timing of the ECD

programs is relatively similar to primary and secondary school timings.

The gaps in supervision can be found after day-care/school, during weekends and holidays, which

can be seen in the spikes in drowning rates during these periods. A program targeting the effects of

less supervision should focus specifically on the times when children are not at school or day-care as

well as promoting ECD centres to increase enrolment to 100% for children aged above 36 months

until primary school.

Furthermore, incorporating water safety messages into ECD programs through the main agencies

responsible such as the Office of Basic Education Commission (OBEC), Department of Local

Administration as well as the Office of Private Education Commission (OPEC) could be developed.

This should involve behavioural change research targeted at children and research into the most

effective methods of disseminating information to children.

Teach school-aged children basic swimming, water-safety, and safe rescue

skills A study of 14,299 persons across age groups observed that of those who were “inundated and

completely submerged by the tsunami, mortality rates in those able to swim were half those found

in same-age respondents who were unable to swim” as seen in figure 12 (Linnan, 2012). This shows

that not only does swimming ability improve water survival but also shows how survival swimming

lessons could contribute towards disaster preparedness.

Figure 12: Mortality rates by age group and swimming ability in the 2004 tsunami, Aceh, Indonesia:

^(Kosen, 2011)

SwimSafe is a regional survival swim initiative for children aged four years and older to teach survival

swimming, safe rescue and water safety skills set up by a collaboration of The Alliance for Safe

Children (TASC), Royal Life Saving Society Association (RLSSA) and local partners in Bangladesh

(where more than 200,000 children were participants), Thailand and Vietnam (“SwimSafe History”).

A cohort study of 79,421 participant children and matched control groups showed a 93% reduction


22

in fatal drowning participants compared to those in non-attending control groups (Rahman, 2012).

Other studies such as one in various US states showed that participation in formal swimming lessons

was associated with an 88% reduction in the risk of drowning in 1- to 4-year-old children (Brenner,

2009) also add to SwimSafe’s results.

Survival swimming lessons is a cross-generational and sustainable solution because the swimming

skills, safe rescue and water safety skills can be passed to the next generation from parent to child.

The cost of SwimSafe in Bangladesh per child, per year is $13.46, and cost per DALY adverted is $85,

significantly less than the GDP per capita of $1486, entailing a high degree of cost-effectiveness

(Rahman, 2012).

A detailed risk management plan needs to be implemented, including age cut-off for entry into the

program, ensuring the skills being taught are best practice, certification of teachers and teaching

assistants (and recertification), maximum class size for children (and modification of this for disabled

children), minimum health standards at entry (e.g no previous history of seizure or epilepsy), water

quality standards, and length of training sessions. In Bangladesh supervisors for swimming training

received specific training for effective supervision. Monitoring visits were recorded and reports

reviewed periodically (Rahman, 2012).

Figure 14: Number of children needed to achieve 50 per cent coverage of children at risk of drowning

^(Linnan, 2012)

From figure 14 it can be seen that operating a program on a large scale, which involves hundreds of

thousands or millions of children, could entail a certain amount of training deaths, even if the risks

are significantly low. Therefore when developing a program careful attention should be made by

diligence in planning, recognition of the lack of capacity and experience and partnering to attain it

(Michel Linnan Interview).

Furthermore, attention needs to be paid to Thai children who are at an increased risk in a swim

learning program:

“Thailand MISC 2012 documented stunting and wasting prevalence in children under 5 years

old ranging from 10-27% nationally. Delayed development with short stature and/or wasting

places children at a significant risk when placed in water to learn how to swim.”


23

"In Thailand, the prevalence rates of seizure disorders, asthma, heart rhythm and other

conditions that increase risk approach 10-15%. These conditions may lead to loss of

consciousness, respiratory distress and seizures. These place children at very high risk of

injury, including death when placed in the water and learning to swim.”

(Linnan, 2014)

In Thailand only 34.5% of children ever learn how to swim (Sitthi-amorn, 2006) which clearly shows

the necessity for such programs. SwimSafe in Thailand focused on developing the use of portable

pools with 3 of them bought from China and set up in Samut Prakhan, Ayutthaya, and Chang Rai. The

program (which was a partnership between TASC, RLSSA, Thai Life Saving Society (TLSS) and

Chulalongkorn University College of Public Health) showed that survival-swimming courses in the

form of SwimSafe was cost-effective and suitable for Thailand. The portable pools proved useful

because of their transportability so that they reach a maximum number of students. Although

specific risk management with portable pools needs to be ensured, such as controlling access to

them outside of lessons, providing adequate shading over them, ensuring there is a site manger

properly trained in structural maintenance as well as water quality maintenance (Rubin, 2011). This

specific program run by TASC (the association for Safe Children) is no longer in operation but the

three portable swimming pools are now run and maintained by the Thai Life Saving Society (TLSS).

The Ministry of Public Health allocated 100,000 baht for each of the 220 Education Service Office

Areas (ESAO), with the intention of training 200 students per ESAO with 500baht allocated for each

student to go towards survival swimming and water safety lessons for teachers (using the curriculum

developed in cooperation with TLSS and CSIP with adaptation of SwimSafe curriculum to a shortened

version). The program involved Five Water Safety Learning Objectives, which included “the

identification of high-risk water locations, floating for 3 minutes, swimming for 15 meters, and skills

to help others, such as, shouting, and throwing and handing across a life jacket” (Plitponkarnpim,

2014). The program which coincided with the establishment of 65 out of 77 provinces having

established survival swimming training centres was said to be largely ineffective as it was

unsustainable. The money was wasted on teaching teachers and not students in some instances and

some ESAOs only taught swim skills and not water safety and rescue according to the 5 water safety

objectives. However the main issue was that the money was not continued the next year and local

authorities did not take ownership to continue the program and training centres (CISP Interview and

Ministry of Health interview).

To develop scale and integrate a survival-swimming curriculum into the school curriculum (Mackay,

2010) it would require greater willingness and cooperation from the Ministry of Education and in

particular the Office of Basic Education Council. Furthermore, it would also require support from

other agencies to develop capacity for swim training at the school level as well as the allocation of

sufficient funds for developing the numbers of swimming pools needed (as currently there is only 40

in-ground pools under the Ministry of Educations jurisdiction) (Ministry of Health Interview). At

more specific level schoolteachers also need to be motivated, encouraged and engaged in learning

and teaching survival swimming which was one of the issues highlighted in the Swim Safe program,

as well as by the MoH. In addition, behavioural change action research could be aimed at helping

and encouraging teachers to make survival swimming an addition to the teaching curriculum

including timetabling the regularity of swim classes and incorporating them into the school routine

(Rubin, 2011). The current program under Ministry of Health would also be more effective if it


24

targeted younger children, as the curriculum currently recommends only children of the age of 7 to

commence training but this is much later than children age of 4 and up targeted in Bangladesh. CISP

and TLSS note that the reason for this is because age 7 coincides with the first year of primary

school, but perhaps the program could incorporate the survival swim program through Office of

Basic Education Commission (OBEC), and Education Service Office Areas (ESAO) early childhood

development education programs (CISP and TLSS Interviews).

Currently the development of survival swimming curriculum has a more bottom-up structure

whereby the local authorities that are most willing and motivated towards implementing a survival

swim curriculum are asking for capacity building from agencies such as TLSS to teach swimming and

allocating sufficient funds to do so. For example, in a district in Surin province 40-50 portable

swimming pools were bought, with 500 trainers being trained by TLSS (Interviews with CISP and

TLSS). Organizations such as TLSS are using the early versions of the SwimSafe curriculum that need

to be updated to the third and most recent version to ensure greater risk management (Interview

with Michael Linnan).

Strengthen public awareness of drowning and highlight the vulnerability of

children/ focus on behavior change An international survey questionnaire was distributed during 2013 via e-mail and electronic social

networking to over 20,000 people from different regions and backgrounds. The survey showed five

different drowning prevention educational videos in the beginning. 62% of participants expressed

after watching the video that their attitude towards drowning had changed. The type of video that

had the greatest impact on the participant’s water safety awareness was the real testimony by a

relative of someone who drowned. The most common suggestion for how to increase people’s

awareness was to ensure the videos were as personal as possible in order to make people feel how

they too could easily be at risk of drowning (Szpillman, 2013).

While the fear-based, more personal orientated drowning prevention awareness messages should

be aimed at parents, there needs to be a different approach to children themselves. Fear-based

messages would work less effectively on children given that they are less attuned to assessing risks..

Other targeted water safety initiatives were aimed at older, child-aged children, and not pre-school

1-4 age group children. Jabari of the Water is an initiative to target young toddlers by using neutral,

recognizable characters of familiar personalities through positive stories. It is based on academic

theory of appealing most effectively to children (Robinson, 2012).

A project similar to Jabari of the Water is “the Water Giants child drowning prevention program – a

social media and web-based child drowning prevention program currently being developed by JWT

(previously J Walter Thompson World-Wide Media) in partnership with TASC. JWT Thailand has

developed an animated character that is appealing to Thai children and will be developing episodes

using this character that aim to target Thai children and communicate aspects of water safety and

how to protect themselves and their friends from drowning.” Given that this program has already

been adapted for the Thai context is might be more useful than Jabari of the Water, but they both

follow the same academic understandings (Linnan, 2014).

Another approach to behavioural change and water safety awareness was orientated around trying

to ensure that the messages were disseminated in a way that was appropriate for “rural village and


25

low-literacy environments.” The following types of media in which to disseminate the information

were found to be successful in the initiative in Bangladesh:

Home safety counselling

Courtyard meetings

Video docu-dramas

Interactive popular theatre

(Walker, 2011)

Strengthening public awareness of drowning prevention is an intervention that should not be used

alone, instead it should be used a part of broader, comprehensive drowning prevention strategy that

is adapted for different age groups. As there has been no rigorous studies observing a direct link

between strengthening public awareness and lower drowning rates this method of intervention

should be seen as a catalyst to motivate stakeholders to use additional interventions to reducing

drowning rates (Meddings, 2014).

A cross-sectional household study was conducted in Thailand in 2013 by the ASEAN institute for

Health Development observing the drowning risk perceptions among 633 rural guardians of children

who attended 12 schools serving 48 villages in a rural community. The study concluded that 23% of

guardians perceived that their child was not at risk of drowning and 40% were unable to determine

that drowning was a serious problem (Laosee, 2013).This could possibly show the shortcoming of

current drowning awareness campaigns and how much still needs to be done to increase awareness.

The 2006 National Drowning Prevention Campaign included:

Public awareness campaigns directed at the general public and senior government officials

during floods, Songkran Festival, Loy Krathong Festival, and school breaks emphasising the

preventability of drowning.

The Child Drowning Prevention Campaign Day on the first Saturday of March each year,

which is widely publicized.

Having all health-care facilities educate the parents who bring their children for

immunization and check-ups about drowning prevention and water safety

Passing a law to regulate the labelling of bath-tubs and domestic water containers about

supervision and due care.

Water safety and drowning awareness information has been incorporated into the Well

Child Book which parents receive upon the del ivery of their child.

Community Health Volunteers are being expected in the future to record drowning incidents and

conduct home visits, where parents are helped at identifying risk areas and times (Plitponkarnpim,

2014).

CSIP noted that “parental awareness regarding preventative measures for young children could be

strengthened by increasing messages with ‘case reports’ (to make them more personal). They also

noted, as did the ASEAN Institute for Health Development at Mahidol (ASEAN, CSIP Interviews) that

there was a lack of awareness regarding younger children and children in general. While the Ministry

of Public Health did note that they had created water safety awareness materials , the extent to

which they have been disseminated, the quality of the materials and the extent to which the


26

information has been adapted for young toddlers needs to be reviewed. Out of the Five Water

Safety Learning Objectives under the water safety curriculum developed by the Ministry of Health

and other agencies, the three objectives which could be incorporated into behavioural change

orientated water safety awareness campaigns are 1) the identification of high-risk water locations, 2)

skills to rescue others, such as, shouting, and throwing floatable objects (which include plastic water

containers, wood, rubber shoes, coconuts), 3) the use of life jackets.

Another possible idea for promoting water safety is the drowning of “Princess Sunandha

Kumariratana (10 November 1860- 31 May 1880) who was a daughter of King Mongkut (Rama IV).

She was one of the four queens of King Chulalongkorn (Rama V). The queen and her daughter

drowned when the royal boat capsized while on the way to Bang-Pa-In Royal Summer Palace. The

grief stricken Chulalongkorn later erected a memorial to her and his unborn child at the Bang-Pa-In

Palace. There is an opportunity to develop demonstration areas for drowning prevention that build

upon this powerful cultural meme” (Linnan, 2014).

A full evaluation of behavioural change and the current awareness campaigns needs to be

conducted in order to reach the capacity whereby there is full social mobilization toward the

prevention of drowning (Plitponkarnpim, 2014). For a behaviour change approach to awareness

programs and the evaluation of drowning prevention awareness campaigns in Thailand the ‘twin

revolutions’ circle diagrams are a useful way of understanding the different factors involved in

influencing behaviour for stakeholders such as children, teachers and parents (Eldridge). The

approach combines the general principles of behaviour in the inner circle and the context in which

these principles influence behaviour are shown in the outer circle (Interview with Christopher

Eldridge). The interactions that influence behaviour occur within the outer circle contexts, within the

inner circle principles and across both the inner and outer circles of influence. This was an approach

used for the Thai Police BI Rapid Research Project which can be emulated if a behaviour change

approach is taken towards influencing children’s behaviour around water through awareness and

influencing teacher’s behaviour to be more engaged with water safety programs (Interview with

Christopher Eldridge).

Figure 15: Twin Revolutions in the Practice and Science of Behaviour Change:


27

Local authorities, government and community partnerships

Figure 16: The provinces in which Save the Children Thailand programs overlap with

high drowning rates:

(SCI Thailand Brief, 2015 and Gerdmongkolgan, 2014)

Kanchanaburi- Not only does this province show up red on figure 16 but this province also shows up

in 2005 as having the 10th highest drowning rate. This province is under our education program,

which would be useful for the drowning prevention program as it will involve partnering with local

education authorities.

Provincial Distribution of Child Drowning Rates per 100,000,

per year


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Bangkok- Parts of provinces that make up the greater Bangkok area show up as red on figure 16. It

shows up as having the highest drowning deaths among children <15 years in 2004, and second

highest in 2005, 2006 and 2007, and third highest in 2008. It should be noted that Bangkok does not

have the highest rates of drowning (per capita) but has one of the highest total drowning deaths.

Surat Thani- This province does not feature in either the top 10 highest total numbers of drowning

deaths between 2004 and 2008 or in the top 10 highest rates of drowning deaths but does show up

as red on figure 16.

Phang Nga- This province shows up as having the fifth highest drowning rate in 2005 but does not

feature amongst the top 10 highest numbers of drowning deaths. It is shown as red on figure 16.

Song Khla- This province shows up as having the 9th highest total drowning deaths in 2004 but does

feature among the top 10 highest average drowning rates. It is also shown as red on figure 16.

Convincing policy-makers/ local authorities / donors for the need for a national program

o Emphasize that drowning is the leading cause of death for children under 15. Use the Thai

National Injury Survey Data and the Ministry of Public health Data by advocating using

ranges of data. For example, drowning deaths, per year for children under 15 are between

2,650 to 1,243.

o Discuss the economic cost of drowning, both in terms of medical facility costs for drowning

injuries and the cost to society having lost someone who could have been part of the

workforce.

o Emphasize the preventability of drowning; show evidence of the inte rventions, which can

reduce drowning effectively.

o Compare drowning death rates to road accident death rates (which are often seen to be

more important) in order to highlight that both are very important.

o Use emotive arguments, particular case studies from the specific province.

o The link between swimming ability and disaster survival might be especially useful for

obtaining funding, especially given Thailand’s susceptibility to natural disasters such as

floods and tsunamis.

o Next year (2016) will be the 10 year anniversary of the beginning of the National Drowning

Prevention Campaign and drowning prevention awareness and advocacy could be centered

around a renewed commitment following the anniversary.

How to create a community led intervention:

o Involve local authorities from the beginning; ask for advice on how to effectively implement

interventions.

o The Association for Safe Children placed specific local authority official names clearly on

water safety and drowning prevention materials for ownership to be taken of the program

(generally ensure publicity for authorities involved). The possibility of contacting politicians

to get this on their electoral platform could also be explored.

o Work through pre-existing ties for Save the Children and use Save the Children Staff that the

local authorities and government officials are familiar with (Interview with Chulalongkorn

Ministry of Public Health).

o Build local capacity to ensure the program is sustainable.


29

o A community led intervention was developed in the Phillipines where there was dialogue

with local community leaders (formation of a village drowning prevention committee), focus

group discussions, local capacity building and community walk-throughs of the drowning

prevention program. The program ensured that prevention interventions were adapted for

the specific community, in that for example materials used for covering wells, making play-

pens were locally sourced. Methods of effective intervention (covering wells) were

suggested by the community themselves (Guevarra, 2014).

o In terms of creating a local community intervention the community’s perception of specific

interventions needs to be managed. For example in Sri Lanka a local drowning prevention

program needed to adapt to promote the ability for girls to learn how to swim. For the

community to accept the program swim-suits leggings were distributed to the girls learning

to swim to preserve modesty and swimming areas were also walled/fenced in to prevent

predatory male spectators who had assembled. Such an approach, where swimming lessons

are adapted for female attendees could also be applied to certain communities in Thailand

(such as Muslim communities) (Fonfe, 2013).

Merit Making program:

o The “merit making” program is a Ministry of Public Health initiative to motivate and

promote local authorities to have a comprehensive and effective drowning prevention

program.

o The scheme is essentially a grading system to rate individual teams on their progress for

drowning prevention. The grades are ‘gold level ,’ ‘silver level’ and ‘bronze level.’ The bronze

level involves recognition for achievements at the local level, silver level involves recognition

for achievements at the provincial level and gold level involves recognition at the national

level.

o Eligibility for ‘merit making status’ involves 10 criteria towards an effective drowning

prevention program for policy (providing plans, manifest continuous performance),

administration (conducted by multiple professions obtaining resources), information

(monitoring and evaluation), risk management of water sources, kindergarten interventions,

education of the community, conducting survival swim lessons, providing a Cardiopulmonary

resuscitation workshop and publicizing activities.

o Ministry of Public Health has recommended that Save the Children either help to rate and

evaluate different ‘merit making’ teams or become a team ourselves, they think this would

be an effective way of becoming involved in drowning prevention and partnering with them.

(Gerdmongkolgan, 2014 and Interview with Ministry of Public Health)

Assessment of possible partner agencies:

Ministry of Public Health: In 2006, the Ministry of Public Health initiated the National Drowning Prevention Program. The

program was coordinated by the National Drowning Prevention Committee that consisted of 30

different agency members (mostly in government).

Under this program, the key policy directions include:


30

o Training all children aged 6 years and over to be able to swim for survival.

o Designating the first Saturday of March each year as the Child Drowning Prevention

Campaign Day.

o Having all health-care facilities educate the parents who bring their children to

immunizations and check-ups about drowning prevention.

o Train community leaders, teachers, parents, children and others on drowning

rescue, including CPR.

o Incorporating child drowning prevention in the activities of health promoting schools

o Integrating an action plan for drowning prevention and water rescue into the

national emergency medical service system.

o Teaching a course on drowning prevention in nursing colleges.

o Requiring the Ministry of Education to develop a plan for enhancing water safety

skills for school children.

o Passing a law to regulate labeling of baby bathtubs.

o Collaborating with local government organizations (LGOs) in the management of

risky water settings.

o The development of the ‘merit making’ initiative.

The extent or scope to which the key policy directions have been implemented are largel y unclear,

there are few statistics for numbers of children reached and whether these have been implemented

long-term.

The main areas in which the Ministry assesses Save the Children could help were the Merit Making

program (as mentioned previously) and monitoring and evaluation of the national program

generally. They also recommended we develop the use of play-pens and perhaps the use of

interactive media (such as phone and tablet applications) for disseminating water safety messages to

children (note: primary school children received computer tablets under a Ministry of Education

initiative named the One-Tablet-Per Child policy and water safety messages could be incorporated).

The main recommendation where I believe Save the Children could assist is ensuring the materials

developed for primary and pre-school age children are distributed widely and are quality and

effective materials adapted to promote behavior change for children of specific ages. This could be

first pre-tested in a province in which Save the Children already works.

(Gerdmongkolgan, 2014, and Ministry of Public Health interview)

Ministry of Education: The Ministry of Education are key in ensuring an effective child drowning prevention program. The

500 baht distributed for each student went through the 220 Education Service Office Areas (ESAOs),

but was primarily driven and funded by the Ministry of Public Health (Interview with CISP).

A partnership or dialogue between ESAOs (the education administration authorities), Office of the

Basic Education Commission (OBEC, who are in charge of implementing the basic education

curriculum) and the Tambon Administrative Organizations (TAO, local authorities) could be

developed. This partnership would be to ensure that the water safety curriculum (containing

information on the five objectives, both survival swimming and rescue as well as being careful

around water generally) is developed and implemented as essentially a mandatory curriculum


31

nation-wide not only at primary and secondary schools but also at pre-schools or early childhood

development centres. While this partnership has been developed to a certain extent in certain

provinces and districts it has yet to become a nation-wide and mandatory program.

The reasons for current failures on the part of the Ministry of Education to implement the water

safety curriculum as a national program are due to reluctance of teachers to take this on as it adds

to their workload, the lack of swimming pools currently under the purview of the Ministry of

Education, and OBEC arguing that the school curriculum in general is too large already. The TLSS

argues that the curriculum could simply be incorporated into the physical education program.

Another addition to a water safety curriculum could be research into changing the behaviours of

teachers to be more motivated to learn how to teach survival swim and incorporate drowning

prevention into their school schedule working with the Ministry of Education (ESAO, OBEC) and

Tambon Administrative Organizations (TAO) to reach teachers.

Save the Children Thailand should aim to ensure the dissemination of water safety messages and

materials to pre-school children particularly (if this is determined not to have been done effectively

and sufficiently) and ensure that these messages are appropriate for that age group. Partnerships

should be developed with ESAOs in a particular province to facilitate the dissemination of these

messages (could even strive to ensure this is done nationally).

Exploitation of links and partnerships developed in the “safe school” and “7% project” with local

authorities such as Bangkok Metropolitan Authority, and the ESAOs in the particular provinces

should be developed for a trial period of a survival-swimming program (as with disseminating water

safety messages) with capacity building for teaching and the curriculum being developed with the

help of the TLSS. Following the trail period, Save the Children could involve OBEC to develop the

program on a national scale. There is also the possibility of expanding the DRR and “safe school”

program with UNICEF to incorporate water safety given the significant link between disaster survival

and swimming ability.

The ministry of education should work to ensure that water safety and survival swim teaching is

mandatory/ incorporated into Physical Education Colleges for long-term capacity building.

Thai Life Saving Society: The Thai Life Saving Society is a small organization run by General Adisak Suvanprakorn who

collaborated with SwimSafe previously but has now taken over the portable pools previously used by

SwimSafe. TLSS is a non-profit organisation that aims to educate Thai people in water safety

practices. TLSS trains local community members in water safety skills and knowledge, developing the

capacity to teach young children survival swimming.

TLSS currently works with local authorities, Ministry of Public Health and the Child Safety Promotion

and Injury Prevention Research Centre at Mahidol University mainly in developing capacity to teach

swimming. The program that TLSS uses is an early version of SwimSafe with some modifications to

reduce the length of the course. Dr Michael Linnan has discussed working with General Adisak to

revise his curriculum to the third SwimSafe curriculum. Furthermore, TLSS has trouble with funding,

which it has asked for help with.

TLSS could be partnered with to build capacity and help conduct a survival swim program given their

experience and expertise in water safety. Although discussions would need to be made with them to


32

update and evaluate their swim curriculum to ensure complete risk management, this would involve

using the latest version of SwimSafe.

(TLSS Interview)

UNICEF Thailand: UNICEF is developing a drowning prevention program. In October 2014 Dr Michael Linnan

developed a program concept note. The program is in partnership with the Ministry of Education.

The program includes partnership with the Thailand ECD/ Day Care education system which would

be effective in disseminating water safety information to younger children and involve pre-school

children in survival swimming programs. Save the Children partnering with UNICEF would be helpful

to obtain funding as well as increasing capacity to reach shared goals (Linnan, 2014).

Child Safety Promotion and Injury Prevention Research Center, Ramathibodi

Hospital, Mahidol University The CISP has been working on drowning prevention since the beginning of the National Drowning

Prevention Program (2006), with Mahippathorn Chinapa, a staff member at CSIP having a seat on

the National Drowning Prevention Committee.

CISP has been integral in developing and implementing the Survival Swimming curriculum, involving

community health volunteers in drowning prevention activities, promoting the labelling of domestic

water containers and bathtubs for safety warnings (Plitponkarnpim, 2014)

CISP is working with Save the Children Thailand on the 7% project, Dr Adisak Piltponkarnpim is keen

to partner Save the Children on this issue. CISP could also be useful in developing connections with

other agencies. It was pointed out that the Minister of Public Health came from Mahidol University

and is motivated on drowning prevention; a meeting could therefore be arranged through CISP if

needed.

Working with CISP would help increase and evaluate their survival swimming and water safety

course (based on the five objectives for water safety). CSIP may also be a helpful partner in many

areas of a drowning prevention program (Interview with CISP).

ASEAN Institute of Health Development, Mahidol University: The ASEAN Institute of Health Development is part of Mahidol University. The research centre has

worked on drowning prevention, and SwimSafe Thailand. The Institute could be useful in developing

any future program mainly with assistance in monitoring, evaluation and research.

College of Public Health, Chulalongkorn University The college of Public Health at Chulalongkorn was a significant partner in SwimSafe and partnered

with TASC, TLSS, and ALSSA to establish SwimSafe Thailand. Chulalongkorn University worked with

TASC on the Safe School Project where the goal of the project was to create an injury free

environment at a school in Phang Nga Province, an area deeply affected by the 2004 Tsunami (“Safe

School Project in Thailand”).

The college conducted the Thai National Injury Survey, a report that uncovered the true extent of

child drowning as the leading cause of death for children under the age of 15. Partnering with the

college would be useful for conducting research into drowning prevention but less useful for actual


33

implementation. The college has expressed their desire to continue working on drowning prevention

and would be willing to work with Save the Children Thailand.

National Scout Organization of Thailand: There is widespread participation in scouting in Thailand, with a total number of scout members at

around 1,300,000, which is the fifth largest number of scouts per country in the world. Scouting is a

key part of the education system in Thailand, and the National Scout Organization of Thailand is the

main Thai scouting organization that partners with the Ministry of Education specifically the Office of

the Basic Education Commission (OBEC) and Office of the Permanent Secretary. Scouting is open to

both males and females, and includes different age groups such as the Cub Scouts (ages 7-9), Scouts

(ages 10-12), and Senior Scouts (13-15). “Although Scouting is part of the school program, especially

for grades 6-8, it is not actually mandatory. Options do exist for participation in other youth

programs, such as the Thai Red Cross; however, the vast majority of Thai youth participate in

Scouting. Scouts wear their Scout uniforms to school once a week, though which day of the week is

set by the local schools” (“National Scout Organization of Thailand”).

A partnership could be made with the National Scout Organization of Thailand, particularly with Cub

Scouts who number 119,134 children (59,635 female and 59,499 male) and are more at risk of

drowning (Grand Total Census). The partnership could involve setting up a Scout ‘badge’ whereby

attainment of the badge involves water safety knowledge such as survival swimming ability, safe

water rescue and CPR. There is also membership of the Girl Guides in Thailand but this is much less

widespread with only 57,731.

Recommended Options: Intervention What would it address? Who could be partnered to achieve this?

o Monitoring and evaluation to prove that drowning is being prevented in provinces where programs have already been implemented.

o While there has been quite a few drowning prevention programs being implemented, very little research has gone into analysing whether these programs are reducing drowning rates.

o Provinces such as Sukhonthai, Nakon Sawan, and Surin where control groups could be compared with those children who have been in the prevention programs.

o This study would provide motivation to other districts and provinces to replicate what these model districts/ provinces have done. It would also help these provinces to work on any weaknesses and adjust interventions for efficiency.

o This research was requested by the Ministry of Health, CSIP, and ASEAN Institute of Health Development.

o This would help with developing ties with the Ministry of Health, and building a relationship for future projects.

o For research the main partners could be the research agencies such as CSIP, Chulalongkorn College of Public Health, ASEAN institute of Health Development, as well as partnering with the Ministry of Public Health to identify the right district for this study (based on cohort size, interventions needing evaluated).

o The monitoring and evaluation should be conducted over sufficient time and size needed to observe a difference in drowning rates.


34

Intervention What would it address? Who could be partnered to achieve this? o Comprehensive

drowning prevention project

o Focus on a district within a province with Save the Children connections.

o This could be a pilot project to evaluate best practice, develop capacity and build connections with partners.

o This would involve different interventions at different stages of children’s lives.

o This pilot project would be an initial stage to increase the scale of the project.

o While this is a comprehensive plan, one or two interventions could be effective.

o *See graphic below (figure 17) for full outline of comprehensive approach to a drowning intervention plan.

o This could be an extension of the DRR project or ‘safe school’ project working with links and funded developed through those projects. The link to DRR could be easily established by showing the association between swimming ability and disaster survival.

o It could also be developed through the 7% project by working with the Bangkok Metropolitan Authority and Bangkok Education Service Office Areas which we have pre-existing ties with (Bangkok is an area recommended above for a drowning prevention program).

o TLSS could help with building capacity by teaching master trainers and supervising the performance of swim teachers. They should teach the latest version of SwimSafe.

o Former SwimSafe Thailand staff and Save the Children Vietnam could assist with ensuring risk management and best practice as well as obtaining the latest version of SwimSafe.

o The use of Community Health Volunteers which CSIP has ties with could be developed to ensure ‘home-safety-rounds’ are done.

o Chulalongkorn College of Public Health, CISP and ASEAN Institute of Health Development could help with the monitoring and evaluation side of the pilot project.


35

Intervention What would it address? Who could be partnered to achieve this?

o Conduct a thorough evaluation of the current drowning prevention awareness campaign and ways in which to develop it, with a specific focus on developing awareness messages for young toddlers.

o There has been no critical evaluation of the drowning prevention awareness campaign.

o There is a large gap in the understanding whether the awareness campaign conducted by the Ministry of Public Health and awareness campaigns in general are effective in increasing supervision specifically and reducing drowning in general.

o This would give a better understanding on whether survival swim lessons should be preferred over awareness campaigns by Save the Children.

o A focus on whether there has been sufficient and effective targeting of children and young children (instead of just parents) which has been questioned by CSIP, and the ASEAN Institute of Health Development. This also should involve whether best-practice for behaviour change of children specifically has been used.

o The campaign and targeting of children specifically should be modified and re-developed if it is found to be ineffective.

o This recommendation asks the question: do awareness campaigns really have an effect on drowning prevention rates?

o Analysing a link between awareness and supervision levels would be easier to do on a smaller scale (as supervision levels increasing implies a reduction in drowning rates).

o Next year (2016) will be the 10 year anniversary of the beginning of the National Drowning Prevention Campaign and drowning prevention awareness and advocacy could be centred around a renewed commitment following the anniversary.

o For the research into the awareness campaign, partnerships can be made with CISP, Chulalongkorn College of Public Health and the ASEAN Institute of Health Development.

o Coordination with the Ministry of Public Health to monitor the materials, and reach of their campaign.

o The Jabari in the Water initiative for drowning awareness is based on some promising and well-substantiated academic theory, but their range of materials need expanding.

o The Water Giants program (as discussed in the water awareness section) is adapted for the Thai setting and is another possible option for partnership with this program.


36

0

1

2

3

4

5

6

7

8

9

10

0-4 5-9 10-14

Rat

e o

f d

row

nin

g d

eat

hs

pe

r 1

00

,00

0

Age of child drowned

Comprehensive Drowning Intervention Plan (figure 17)

Pre-School Age (3-7)

--> Ensure the distribution of the Well Child Book through communication with Ministry of Public Health in the area.--> Community Health Volunteer visits where risk areas near and in the home are identified and dealt with appropriately (covering wells and cisterns), community health volunteers also disseminate water safety messages such as telling parents to ensure supervision of the child. --> Water Safety awareness messages focusing on supervision and recognition of risk areas spread through local media and media adapted for rural areas (such as interactive popular theatre, and puppet shows). --> Encouragement of the use of play-pens and child safety barriers through a parental targeting awarness campagin.

--> Ensure the attendence of day-care --> Child targeted water safety messages disseminated at day-care through partnership with Education Service Office Areas and Tambon Administrative Organizations (local authorities) --> Implement Survival Swim/ SwimSafe swimming lessons are implmented at day care through partnering with ESOA TAOs --> Reinforcement of messages about risk of drowning and need for constant adult supervision at home to parents through local media awareness campaigns and day-cares.

--> Coordinate with TAOs and ESAOs to allow and facilitate the attendance of a school teaching facility for basic SwimSafe/ Survival Swim program, including rescue and water safety advice --> Ensure all children who attend primary school also attend SwimSafe/ Survival Swim program

--> Training includes safe rescue, first aid and CPR.


37

^Linnan, 2014, 2015)

Other possible ideas to be developed: Research into increasing the motivation of teachers to learn how to teach survival swim and

incorporate drowning prevention into their school schedule working with the Ministry of

Education (Education Service Office Areas, Office of the Basic Education Commission) and TAO:

This issue was raised by the Ministry of Health, CISP and SwimSafe. The problem that these

agencies were facing was that teachers felt they had too busy and teaching children how to

swim, and educating about water safety was just another unnecessary addition to their

workload. Research into behaviour change and working with the Ministry of Education to

advocate for drowning and water safety curriculum aimed specifically at teachers might go far in

helping to ensure that water safety and survival swim becomes a mandatory part of the national

education curriculum in pre-school and primary school aged children aged four and above. This

would need cooperation with the Ministry of Education and local authorities with the research

agencies’ help.

Survival swimming curriculum integration into Cub Scouts

o Scouting is a large part of the school curriculum in Thailand, with many school children attending

a scout program, membership is estimated at 1,300,000 scouts. Developing a partnership with

the National Scout Organization of Thailand to develop water safety curriculum ‘badge’ for

scouts could be effective for drowning prevention. The funds for such a program could be

sustained by the Scout organization themselves (“National Scout Organization of Thailand,”

2014).

After-school/ holiday camp survival swim water safety course:

o An after-school/ holiday camp survival swimming water safety course could be incorporated into

the pilot project mentioned above as a second choice to integrating it into school curriculum.

Could have the added benefit of ensuring supervision during holiday period or after school when

drowning rates seem to be at their peak. The average time it takes to teach the survival

swimming is 15 hours; this could be spread over a few or more days to develop an intensive

camp course (Interview with TLSS and CISP). The feasibility of this may need to be assessed as

how many children are available or go away during holiday periods.

Development/research into the feasibility of using play-pens:

o Play-pens have been used in Bangladesh for aiding with supervision in the 1-4 age group. This

method of intervention hasn’t been developed and implemented in Thailand for drowning

prevention. A feasibility and community and social perception study could to be carried out

given that the ASEAN Institute for Health Development noted that parents may be afraid of

putting their child in a small confined space. There also needs to be monitoring and evaluation

to see if the intervention has an effect on drowning rates.

Development of interactive media to incorporate drowning prevention into the ‘one-tablet-per-

child’ initiative:


38

o This intervention has yet to be implemented in Thailand. Given the government’s national ‘one-

tablet-per-child’ initiative it could be feasible to incorporating a drowning prevention application

for the tablets already distributed. It could also be developed as a phone app or general

computer application. Further research is required to develop its feasibility.

Conduct another Thai National Injury Survey

o While the Thai National Injury Survey was instrumental in recognizing the issue of drowning in

Thailand and as a use of advocacy for drowning prevention it is quite outdated as the fieldwork

was conducted in 2002-2003. Conducting another survey would provide recent data on the

epidemiology of drowning and injury in Thailand that could be used to compare against Ministry

of Public Health data and would be instrumental in drowning prevention advocacy. This could be

done in coordination with the research institute which worked on the survey previously (College

of Public Health Chulalongkorn) and individuals from the ASEAN Institute of Health Development

who were previous SwimSafe staff as well as other former TASC staff.

Ensuring water safety and survival swimming courses are mandatory in Physical Education courses

and colleges for school PE teachers or even an expansion to all teachers

o Work could be done with the Ministry of Education to ensure that Physical Education colleges

and courses have to teach survival swimming. This would be more of a long-term intervention.

This intervention could be helpful for a future water safety survival swim curriculum to be

mandatory nationwide.

Funding Possibilities: Funding source: Discussion

Foundation Princesse Charlene de Monaco

Foundation Pincesse Charlne de Monaco has been funding activities by TLSS and SwimSafe Sharks (an offshoot small swim teaching program) (Stenning, 2014).

Thai Health Promotion Foundation Thai health promotion foundation works on many health issues in Thailand include road safety. This could be a possible route for funding, we have links with them through the 7% project. The foundation has a focus on water safety issues.

Bloomberg Foundation Bloomberg Philanthropies currently working on funding drowning projects in Philippines and Bangladesh where they fund large scale programs. Michael Bloomberg has an interest in funding public health programs and has set up a public health institute at John Hopkins University. The funding comes through The Johns Hopkins International Injury Research Unit (JH-IIRU). The foundation is interested in implementing and monitoring and evaluating innovative drowning prevention ideas that haven’t already been trailed and tested. For Save


39

Funding source: Discussion

the Children Thailand funding a program which observes a link between awareness programs and drowning rates could be a possibility as this hasn’t been researched thoroughly as well as developing the use of scouts for survival swim programs (Scarr, 2013).

Global Drowning fund This is an affiliated to the Australian Life Saving Society which has worked with funding programs in Vietnam and Bangladesh.

Evian Natural Spring Water The corporation funds programs that aim to manage water resources for long-term sustainability and funded a program at Bung Khong Long Lake in Thailand in 2008. Save the Children could approach the corporation with a proposal to manage water resources for drowning prevention ("Evian Natural Spring Water Expands Sustainable Development Strategy,” 2008).

Namthip Bottled Water The bottle water company is affiliated with Coca Cola and has initiated several Corporate Social Responsibility activities many related to the environment (“Namthip,” 2013).

Yum Restaurants International (Thailand) The company which is the franchise owner of KFC Thailand run sports program initiatives and also a disaster risk relief program. They could be approached to expand their disaster risk relief program with the angle of teaching children to swim ("Disaster Relief”).

Sheraton Hotel Group

This is a nationwide hotel group. Approaching them to use their swimming pools and for the opportunity of funding would be feasible considering an existing connection with them.

Apartment/condominium Blocks Apartment blocks and condominiums could be approached for the use of their swimming pools, with stipulations for managing noise levels, and during hours when the pools aren’t in significant use.


40

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Appendix:

Contact List: Agency Contact Email Phone Number Interview

Date

Bureau of Non-communicable Diseases, Ministry of Public Health

Suchada Gerdmongkolgan and Som Ekchaloemkiet

[email protected]

+(66)29510402 22/08/2015 (in person)

ASEAN Institute of Health Development, Mahidol University

Dr. Orapin Laosee [email protected]

+(66)24419040-3 ext. 43

07/08/2015 (in person)

Institute of Health Research, College of Public Health, Chulalongkorn University

Dr. Ratana Somrongthong

[email protected]

0-2218- 88226 / 0-2255-6046

25/08/2015 (in person)

Child Safety and Injury Prevention Centre (CISP), Faculty of Medicine, Ramathibodi Hospital, Mahidol University

Dr. Adisak Plitponkarnpim and Dr. Mahippathorn Chinapa

[email protected]

14/08/2015

TASC/ SwimSafe (formerly)

Dr. Michael Linnan

[email protected]

08/12/2015 (email)

Thai Life Saving General [email protected] 081 286 6864 19/08/2015

mailto:[email protected]








45

Society Adisak Suvanprakorn

(in person)

Save the Children Behaviour Change Consultant

Christopher Eldridge

[email protected]

24/08/2015 (by phone)

Jabari of the Water Initiative

Rebecca Wear Robinson

[email protected]

28/08/2015 (by email)

UNICEF Thailand Country Office

Rangsun Wiboonuppatum

[email protected]

No interview

Save the Children Vietnam

Cay Bui Thi [email protected]

+84(0)983 622 147

02/09/2015 (by email)

Sheraton Thailand (Quality Inn)

Narin Narula [email protected]

No interview

National Scout Organization of Thailand

[email protected]

02-2192731 No interview









