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Abstract
To address Washington State’s high pediatric fatal drowning rates in Asian
children, especially Vietnamese, we conducted and evaluated a community water
safety campaign for Vietnamese American families. Working with community
groups, parks departments and public health, we disseminated three messages
(learn to swim, swim with a lifeguard, and wear a life jacket) in Vietnamese media
and at events, increased access to free/low cost swim lessons and availability of
lifeguarded settings and life jackets in the community. Parents completed 168 pre-
and 230 post-intervention self-administered, bilingual surveys. Significantly more
post-intervention compared to pre-intervention respondents had heard water safety
advice in the previous year, (OR 8.75 (5.07, 15.09)) and had used lifeguarded sites
at lakes and rivers (OR 2.3 (1.04,5.08)). The campaign also increased community
assets: availability of low-cost family swim lessons, free lessons at beaches, low
cost life jacket sales, life jacket loan kiosks in multiple languages, and more Asian,
including Vietnamese, lifeguards.
Keywords: drowning, drowning prevention, water safety, social marketing, health
disparities
Introduction
Fatal drowning rates vary among different races and ethnicities of United States
children less than 18 years. In 2017, African Americans had the highest adjusted
unintentional drowning rates per 100,000 persons (1.29) and Asian Americans, the
lowest (1.07) (Gilchrist & Parker, 2014). In the Western United States from 2013-
2017, Asians had the second highest drowning rate among 5-9 year olds, 10-14 year
olds and 15-19 year olds (Centers for Disease Control, 2020).
Centers for Disease Control data shows that in Washington State, drowning
is the second major cause of unintentional injury related death from birth to 19
years. From 2013-2017, Asians had the second highest fatal drowning rates among
5-9 year olds, 10-14 year olds and highest among 15-19 year olds. These rates are
greater than the overall crude fatal drowning rate for each of those age groups
(Centers for Disease Control, 2019; 2020). A Child Death Review (CDR) report
identified that in Washington state between 1999 to 2003, Asian/Pacific Island
children had the highest rates of drowning deaths of children less than 18 years (3.1
per 100,000), double that of white children (1.5) (Quan, Pilkey, Gomez & Bennett,
2011; Washington State Department of Health, 2004). In contrast, national
drowning rates during the same time period for children less than 18 were lowest
among Asian/Pacific Island children (1.2 per 100,000), compared to rates of 2.15
for African American, 1.93 for Native American and 1.31 for white children
(Centers for Disease Control, 2019). During this time period, several local, high
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profile open water swimming-related drownings in Washington involved local
Vietnamese American school-aged children.
Our goal was to develop and conduct a community based drowning
prevention campaign based on our local experience with drownings among
Vietnamese American children. At that time, the few studies addressing drowning
and its prevention among Asian immigrants were surveys of behaviors and attitudes
of Asian New Zealanders (McCool et al., 2008; Moran, 2008). The only study of
Asian Americans reported they lacked experience, safety principles and practical
competencies around water activities compared to white peers, even when
controlling for socioeconomic status (Allen et al., 2007). No studies had
specifically addressed drowning risks and prevention amongst Vietnamese
immigrants. Since the Asian American population represents multiple ethnic and
cultural groups from wide ranging locales, specific cultural and linguistic
approaches were needed for drowning prevention in this ethnic group.
First, in 2005, we conducted focus groups of local Vietnamese American
teens and parents to understand their skills, behaviors and beliefs around
swimming, life jacket use and drowning risk. We published our findings that
participants did not take part in water sports, were unaware of the risks and lacked
water safety and swimming skills (Quan, Crispin, Bennett & Gomez, 2006). Based
on these findings, we developed a drowning prevention campaign whose objectives
were to increase awareness of drowning and drowning prevention, increase safe
behaviors around water and facilitate acquisition of water safety skills. The purpose
of this study was to describe the development, components and evaluation of a
drowning prevention campaign for a previously untargeted diverse minority
community.
Method
Setting:
Vietnamese American communities of Seattle area
In the 2000 U.S. Census, Washington State had the third largest number of
Vietnamese people nationally (50,687). Of these, 74% were foreign born and 89%
spoke another language besides English at home (U.S. Census Bureau, 2010). In
the Seattle area, Vietnamese was one of the top four non-English languages spoken.
Vietnamese residents numbered 11,943 making them the third largest group of
Asians (17%) with the highest number of linguistically isolated households (49%).
Vietnamese Americans lived primarily in the Central and South Seattle districts,
which had the largest numbers of non-whites, the highest injury rates leading to
hospitalization, and the lowest socioeconomic status in the Seattle area.
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Campaign Development
To develop the campaign, PRECEDE-PROCEED was used as a framework. (Green
& Kreuter, 2005; Kotler et al., 2002; Lefebvre & Rochlin, 1997). It provides a
robust structure for assessing health needs and assets by addressing predisposing,
enabling, and reinforcing factors. Key constructs we used included the following:
Social assessment of how families recreated around water and their concerns;
epidemiological assessment using the CDR data and report; educational and
ecological assessment using the CDR data and focus group report to identify
predisposing, reinforcing and enabling factors; and community assessment and
meetings with community leaders to identify administrative issues. These findings
were then used to develop the resources, messaging and focus areas for the
campaign (Table 1).
Principles of Social Marketing, which takes traditional marketing strategies
and applies them to achieving social good, including health behavior change
(Kotler et al., 2002; Lefebvre & Rochlin, 1997), were also used and included:
Audience segmentation – we narrowed our focus to Vietnamese families in the
Seattle area; use of formative research in message development – we used findings
from our focus groups with Vietnamese parents and teens; development of specific
communication channels – we communicated using Vietnamese specific media and
events; tailored messaging – we developed culturally specific and unique education
materials, photos and posters based on focus group input; incorporation and
promotion of a tangible object or service – we promoted and facilitated use of life
guarded swim areas, free lifejackets and low cost/free swim lessons and family
swim periods at local pools; and easy access and development of an appealing
location for the product or service – we provided translated resources with
culturally tailored visuals and messages at water locations, events and venues with
large numbers of Vietnamese families.
To identify participants, community assets, culturally and linguistically
appropriate strategies and ideas for how to present the drowning problem to the
community, we met with community leaders, liaisons and other collaborators such
as public health and parks and recreation. At their recommendation, we prioritized
families at Vietnamese language schools, Head Start programs that primarily serve
Asian children (Head Start is a Federal program for low-income preschool
children), church and temples’ family groups, and the Têt festival venues.
Community representatives, including Vietnamese Professionals Society, three
Vietnamese Language Schools, Denise Louie Head Start, Seattle Parks and
Recreation, Lynnwood Parks, Washington State Parks, Injury Prevention Division
of Public Health Seattle & King County, and the Injury Free Coalition for Kids of
Seattle, also participated in the evaluation process.
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We chose three key drowning prevention messages for the campaign: learn
to swim, swim with a lifeguard and wear a lifejacket. Selection was guided by the
state’s CDR of drowning deaths, focus groups (Quan et al., 2006) and an
assessment of community assets such as lifeguarded swim areas.
Learn to Swim was chosen because teen focus group participants reported
lack of swim skills but asked to start lessons immediately. Parents in focus groups
reported swimming was not a recreational activity in Vietnam; they lacked swim
skills and did not own swimsuits. Moreover, parents believed children should not
learn to swim until nearly 8 years of age although they were aware that white
children learned earlier (Quan et al., 2006).
Swim with a Lifeguard was chosen because focus groups of parents and
teens reported they could not swim and lacked water rescue skills and knowledge
of local waters. Parents did not enter the water when supervising children and did
not supervise children who had learned to swim or were “old enough”. Both parents
and teenagers stated that peer pressure caused Vietnamese teenagers to swim with
white peers despite lacking skills (Quan et al., 2006).
Wear a Lifejacket was chosen because the community stated they recreated
around open water settings, i.e. lakes and rivers, and avoided swimming pools.
These messages were disseminated by posters and handouts (printed in
Vietnamese and English), in oral presentations at small (classes or church meetings)
and at large public functions such as the Têt festival, and via a multimedia campaign
(see Table 1).
Process Measures That Were Tracked
To increase community awareness:
• Held seven informational presentations at churches, temples, language
schools, and a Head Start Preschool program.
• Developed posters illustrating the three messages in Vietnamese, which
were disseminated to more than 200 community stores, clinics, and
organizations that catered to Vietnamese families.
• Published an Op Ed article written by a board member of the Vietnamese
Professionals Society in the three Vietnamese newspapers.
• Developed a bilingual brochure with Seattle Parks on how to access free
and low cost swim lessons and life jackets as well as the location of local
lifeguarded public pools and beaches.
• Provided information booths at four community health fairs.
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To develop, expand, and promote use of free and low-cost swimming opportunities
and lessons:
• Hosted three free Vietnamese family water safety and swim sessions at
lifeguarded public pools with Vietnamese interpreters, attended by 25, 46,
and 140 persons.
• Worked with Seattle Parks and Recreation to translate the letters sent to
Seattle school families, which promoted use of free swim lesson vouchers
for third and fourth graders.
To increase availability and use of lifeguarded sites:
• Worked with Washington State Parks to reinstate lifeguarding at two
popular local parks; Seattle Parks reinstated lifeguards at two beaches.
• Seattle Parks and Recreation worked to increase numbers of Asian
American adolescents trained to be swim aids or lifeguards.
To increase lifejacket use:
• Increased the number of lifejacket loaner boards at city swim beaches,
added visuals of Asian children and parents borrowing lifejackets; and
translated instructions on their use into Vietnamese.
• Posted a banner promoting lifejackets featuring Asian American children at
all eight Seattle indoor public pools.
Table 1
Campaign elements incorporating Predisposing, Enabling and Reinforcing factors
Predisposing factors ͣ
Enabling factors
b
Reinforcing factors ͨ
Learn to Swim
Parents see drowning as fate
Promote free and low cost
swim lessons
Participation in dominant
culture water activities
Never perceived a need to
know how to swim
Translate information about
free lessons into Vietnamese
Tailored posters with photos
of Vietnamese families at
community locations
Swim lessons needed later
Provide free family swims
Visuals/messaging/media in
Vietnamese newspapers
Interested in water safety
Recruit Vietnamese Asian
swim aids
Provide brochure/
education sessions promoting
free/low cost swim lessons
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Predisposing factors ͣ
Enabling factors
b
Reinforcing factors ͨ
Life Jacket
Life jacket is not necessary
except in a boat
Promote free life jacket loan
at all pools and beaches
Posters/handouts/media
reinforce benefits and
modeling by Vietnamese
families
Expensive
Translate life jacket loaner
board instructions and
provide visual instructions
Life jacket fashion shows for
teens
Bulky
Provide life jacket education
program and low cost sale at
Head Start schools
Free life jacket drawings at
events
Provide brochure/education
session promoting free/low
cost life jackets
LifeGuard
Parents/teens lack swim
skills
Promote life guarded
beaches/pools
Parents more assured for
child’s safety
Parents want to keep kids
safe
Recruit Vietnamese/Asian
lifeguards
Posters/handouts/media
reinforce benefits
Parents do not go in the
water to supervise
Provide brochure and
education session promoting
lifeguarded pools and
beaches
Believe that older children
need less supervision
Recognize peer pressure
among teens
ͣ Predisposing factors: Includes knowledge, attitudes, beliefs, personal preferences, existing skills and self-
efficacy towards the desired behavior
b
Enabling factors: Includes skills or physical factors such as availability and accessibility of resources or
services that help motivate desired behavior
ͨ Reinforcing factors: Includes factors that reward or reinforce the desired behavior including social support,
economic rewards, and social norms
Campaign Evaluation
We evaluated the campaign with a pre and post written survey completed by a
convenience sample of parents and addressing assessment of community assets and
process measures. This study was approved by Seattle Children’s Institutional
Review Board.
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The survey was anonymous, self-administered, available in Vietnamese or
English, and took approximately five minutes to complete. Fifteen questions were
developed based on content from the focus groups, translated into Vietnamese by a
professional translation service and checked with back translation to assure
accuracy. Questions and survey design were reviewed by Vietnamese community
members, leaders, and faculty experts from Seattle Children's Research Institute.
(See Appendix 1 for the survey.)
The survey was distributed to Vietnamese parents at Têt festivals,
Vietnamese language schools, Head Start, churches, temples, and community
centers in the Seattle area. Incentives included whistles for children of parents who
completed the surveys and a small stipend for language schools who coordinated
dissemination and collection of surveys. Pre-intervention surveys were conducted
between December 2006 and March 2007, post intervention surveys between
November 2007 and April 2008.
Demographic questions included sex and age of the parent, number and ages
of children in the household and primary language spoken at home. Three questions
addressed the key messages: “Had their child 1)... had swim lessons (ever or since
the previous June)?; 2)... swum in a lifeguarded area?; and 3)... worn a lifejacket?
To determine campaign exposure, questions included “Had they heard water safety
advice in the past 6 months? If so, where?” (Open-ended format).
We evaluated three community assets before and after the campaign and
again in 2019: number of Seattle and State Parks with lifeguards, number of parks
with translated lifejacket loaner boards (i.e. in Vietnamese as well as English), and
percent of Asian American lifeguards at Seattle Parks beaches and pools.
Data Analysis
We used descriptive statistics and calculated frequency distributions. Statistical
analysis was performed using a Pearson's chi-square test, odds ratios (OR) and 95%
Confidence Intervals (CI). STATA version 11.0 was used to generate statistics and
perform the analysis.
Results
Survey Results
Pre- and post-intervention questionnaires were answered by 168 and 230
respondents, respectively, most of whom were female, had 1-8 children, and spoke
Vietnamese at home (see Table 2).
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Table 2
Characteristics of surveyed parents
Compared to participants from the pre-intervention survey, parents
answering the post-intervention survey were significantly more likely to recall
having heard water safety advice in the prior year (84% vs 37%, OR 8.75 (95% CI
5.07,15.09), at local sites (40% vs. 0%), in the media (31% vs. 21%) or at schools
(8% vs. 2%). Additionally, they were more likely to report attending lifeguarded
sites at lakes/rivers (84% vs. 70%, OR 2.3 (95% CI 1.04,5.08). (See Table 3.)
Community assets results: Comparing 2006 to 2009, Asian Americans
comprised 10% (8/81) of lifeguards at Seattle beaches versus 7% (6/81) with one
Vietnamese; 11% (15/136) versus 17% (28/163) at Seattle Parks swimming pools,
five of whom were Vietnamese. These changes were not statistically significant.
However, in 2019, Asian Americans comprised 21.7% (74/341) of lifeguards at
Seattle parks; at one facility, 25.4% (14/55) were Vietnamese. The number of
lifeguarded Seattle Park sites has remained the same. King County Parks’
lifeguarded sites increased from zero to two but subsequently decreased to one. The
number of translated lifejacket loaner boards in Seattle has increased from one to
ten total.
Characteristics of
Surveyed Parents
PRE, Total N = 168
POST, Total N = 230
Mean (SD)
or
Percentage
Number
of
Responses
Mean (SD) or
Percentage
Number of
Responses
Mean Age in years
(SD)
41.1 (9.1)
123
42.7 (10.5)
196
Male
27%
45/166
38%
87/227
Mean Number of
Children (SD)
2.2 (1.1)
137
2.2 (1.1)
160
Language at home
Vietnamese only
57%
92
61%
137
English only
8%
13
10%
22
Vietnamese/English
35%
57
29%
67
Survey completed
in Vietnamese
46%
75/163
73%
170/230
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Table 3
Results of parents’ pre and post intervention surveys
Survey
Question
PRE, Total N = 168
POST, Total N = 230
Percentage
Number
of
Responses
Percentage
Number
of
Responses
Odds Ratio
and 95%
Confidence
Intervals
Child wore a
life jacket at
lake or river
36%
27/74
50%
69/137
1.76
(0.98,3.11)
Ever enrolled
children in
swim lessons
52%
76/147
55%
120/219
1.13
(0.74,1.72)
Ensured
lifeguard
77%
72/93
67%
96/143
0.59
(0.33,1.08)
In Pool
In
River/Lake*
70%
42/60
84%
75/89
2.3
(1.04,5.08)
Saw/heard
water safety
information**
37%
48/129
84%
140/167
8.75
(5.07,15.09)
*p=.01, **p=.001
Discussion
This is one of few community drowning prevention programs evaluated, and the
first to focus on Vietnamese Americans (Bennett et al., 1999; Wallis et al., 2015;
Moran, 2017). High drowning rates and local experience with drownings of
Vietnamese American children prompted the development of a drowning
prevention campaign in the Vietnamese American community. Guided by an
evaluation of their reported beliefs and behaviors around water, the campaign used
a social marketing approach, linguistically and culturally tailored for this
community. To increase open water safety awareness, water skills of Vietnamese
youth (swimming lessons), and safe behaviors in both parents and children (use of
life jackets and life guarded sites), three campaign messages were delivered with
educational and experiential interventions. Pre- and post-intervention evaluations
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showed the campaign increased community members’ awareness and significantly
increased their use of lifeguarded open water sites but not swimming lessons for
children or use of lifejackets. Importantly, community assets increased, including
numbers of available swim sessions, Asian lifeguards, and access to low cost swim
lessons and life jackets.
The reported increased use of lifeguarded sites at open water but not pools
may reflect that lifeguarded lake and river sites were lower cost and also preferred
over pools. The lack of swimming lessons may reflect the numerous barriers stated
by the focus groups, including cost, antipathy towards indoor pools and reluctance
for early initiation of swim lessons. (Quan et al., 2006). However, the free
swimming pool sessions for Vietnamese families generated interest amongst
families who were keen for their continuance. A focus on socially organized
sessions may be a way to encourage families from diverse communities to learn
skills.
Limitations
This study’s limitations were multiple. Different pre- and post-intervention groups
were convenience samples. However, the post-intervention group was larger, due
to our increasing access to the Vietnamese speaking community and differed only
in that respondents were more likely to complete the survey in Vietnamese. Our
written survey was biased toward literate groups. Parents’ reported behaviors were
not validated (Hatfield, et al., 2006). While observations would have been a
stronger study design, we were limited by the inability to determine specific Asian
type by observation. Parents surveyed may not have been representative of the
Vietnamese community; however, we surveyed parents at multiple community
venues based on community advisor recommendations. We attempted to survey a
control group in Portland, Oregon but could not find a community liaison in time
for the pre-intervention phase. Importantly, our methods and experience may not
be generalizable to non-Vietnamese Asian communities. Lastly, this campaign was
conducted ten years ago. However, a recent review of injury disparities research
between 2007 and 2017 showed few studies addressed prevention and very few
addressed Asian groups. It stated, “public health prevention campaigns to address
the disparity identified are urgently needed to fill the gaps.” (Moore et al., 2019).
Although higher rates of drowning amongst minority children are well
documented, they are poorly understood. (Gilchrist & Parker, 2014). Racial groups’
drowning risk varies by setting; the highest rates of nonfatal US drownings
typically occur in children of racial/ethnic minorities in natural waterways. (Felton
et al., 2015). The Vietnamese Americans’ drowning risks, absent recreational
swimming experience and water competence, have been similarly reported by
Asian New Zealand beachgoers; more Asian New Zealanders reported their
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children had poor swim ability and saw themselves as high risk in five water
scenarios presented to them than non-Asians. (Stanley & Moran, 2017; Moran &
Wilcox, 2013). Moran concluded, “Immigrants are quickly adapting to the aquatic
lifestyle of their newly-adopted country but, these same immigrants may lack the
safety skills and knowledge to minimize the risk of harm” (Moran & Wilcox, 2013,
p.144).
Fear of drowning is an identified deterrent to recreational aquatic
involvement and an explanation for low swim skills among low income African
Americans (Pharr et al., 2018). Drowning fear was also reported by Asian New
Zealand students (Moran, 2010). The drownings of several local Vietnamese youth
could have contributed to Vietnamese American families’ avoidance of swim
lessons.
Additional risk contributors in low income and diverse neighborhoods
include lack of access to swimming pools and swim lessons and social exclusivity
(Hastings et al., 2006). Thus, we promoted swim lessons primarily in pool settings.
However, the antipathy towards unfamiliar, cold and expensive indoor pool settings
and preference for free open water sites reported by parents in focus groups, along
with this campaign’s failure to increase swim lesson participation, suggest the need
for other approaches. These might include a socially supportive experience and
swim/water safety sessions in open water.
Challenges reaching the Vietnamese community included identification of
Vietnamese community liaisons. Hatfield reported success in addressing this
inhibiting factor by using community health educators (Hatfield et al, 2006).
Implementation of the current campaign was time limited. Key elements to working
with the Vietnamese community identified in this study were language, community
liaisons and nontraditional venues for outreach, tailored messaging and emphasis
on family. Bilingual skills were critical to working with the community and its
leaders.
This campaign increased community assets for Vietnamese and other
diverse groups in the area. Several agencies made substantial policy and
programmatic changes, for example Head Start continues to provide water safety
education for its immigrant and refugee preschool families. Since exclusively
Vietnamese swim sessions required external funding sources after the campaign,
Seattle Parks and Recreation started low-cost family swim lessons for all parent
and school age child pairs. They now offer scholarship applications in Vietnamese.
Seattle Parks and Recreation has standardized their dissemination of key messages:
Learn to swim, Swim in a lifeguarded area, and Wear a lifejacket. Developing and
recruiting diverse youth as lifeguards and swim aids, they have doubled the
percentage of Asian lifeguards at their facilities. They continue to provide lifeguard
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staffing at nine beach sites and have expanded free swim lessons at lifeguarded
beaches. They have also increased low cost lifejacket sales and numbers of life
jacket loan kiosks with standardized information in eight languages, including
Vietnamese. Head Start, Seattle Children's Hospital and several community groups
continue to provide water safety information and low cost lifejackets to families.
Conclusion
A unique community drowning prevention campaign for Vietnamese Americans
driven by local data and community focus groups addressed barriers and promoted
swimming lessons and water safe behaviors, including use of life guarded sites and
lifejackets. Evaluation showed the campaign increased drowning prevention
awareness and some safe behaviors, specifically use of lifeguarded sites.
Importantly, it improved community water safety assets such as access to swim
lessons, lifejackets and lifeguarded sites that continue a decade after for the entire
community.
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Appendix 1 Survey of Water Activities in the Vietnamese Community
(English version)
(Circle your answer)
1. What language do you mostly speak at home?
Vietnamese English Both
2. What is your age?
3. What is your gender?
4. Do you have children? Yes No
5. How many children?
6. What are the ages of your children?
The next questions are about one of your children between 5 and 16 years old
who played near or by the water this past summer.
7. Can he/she swim? Yes No
8. Has he/she ever taken swim lessons? Yes No
9. Since last June, has he/she ever taken swim lessons? Yes No
10. Since last June, did he/she visit a swimming pool? Yes No
11. If the answer was yes, did he/she get into the water? Yes No
12. Was a lifeguard present? Yes No
13. Since last June, did he/she visit a lake or river? Yes No
14. If the answer was yes, did he/she swim or wade? Yes No
15. If he went swimming or wading, who watched him/her when he was in the
water?
Another child An adult A lifeguard No one
16. Was a lifeguard nearby or present? Yes No
17. Did he/she use a lifejacket when in the water? Yes No
18. Do you know where you can borrow a lifejacket to wear at the beach?
Yes No
19. If yes, where would you go? (Please write in):
20. Would you attend a session about water safety at lakes and beaches?
Yes No
21. Did you hear any advice last summer about how to be safe around water?
Yes No
22. If yes, where did you hear it? (Please write)
23. If yes, what did you hear? (Please write)
24. Where would you prefer to get information on water safety? (Please write)
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