Ending the child drowning epidemic in India and Bangladesh: Applying a framework for program development and implementation

Abstract

Globally, drowning is the second largest cause of death by injury in children aged 1-14 years old. Risk factors for child drowning include poor supervision, lower socioeconomic status, poor swimming and rescue skills, and the proximity of open water near homes. These are more prevalent in low-and middle-income countries(LMICs). The WHO has developed recommended interventions for drowning prevention in rural LMIC contexts, such as the provision of supervised childcare to prevent access to nearby water bodies. This thesis explores the process of developing and evaluating drowning prevention programs in two high-risk LMIC regions: the Sundarbans in India and the Barishal Division in Bangladesh. As no previous research on drowning burden and prevention has been conducted in India, the main aims were to: (1) Identify the burden of child drowning in the Sundarbans, and (2) identify implementation strategies for drowning prevention programs. Conversely, drowning prevention programs have been implemented in Bangladesh, but evaluation of their implementation remains. The Anchal program provides supervised childcare to younger children, while SwimSafe provides swim training to older children. The main aims in Bangladesh were to: (1) Understand implementation implications and best practices, and (2) understand the impact of gender norms on implementation. The findings from the Sundarbans mortality survey showed a significant burden of drowning, with a rate of 243.8/100 000 for 1-4-year-old children, and 38.8/100 000 for 5-9-year-old children. Common circumstances were the lack of effective adult supervision, no physical barriers against water, and proximity of open water to homes. Findings from the analysis of relevant government policy and interviews with community-based stakeholders identified three existing government programs that could be leveraged for the implementation of drowning interventions. In Bangladesh, the mixed-methods process evaluation of the Anchal program showed that while the program was acceptable in the community, geographical barriers to access, cultural beliefs and inadequate resources reduced attendance, limiting effectiveness. The gender analyses of both Anchal and SwimSafe programs revealed opportunities to ensure equitability. Fewer older girls enrolled in SwimSafe classes compared to boys due to cultural concerns. Female community-based staff found that employment in the programs improved social status, physical mobility and access to resources