**5. Conclusions**

This study demonstrated the usefulness of the Washington State HYS dataset to evaluate drowning risk and protection in the context of other adolescent risk-taking behaviors. The findings provide surveillance data but also new insights into drowning injury. They sugges<sup>t</sup> the need to reframe our thinking and approach to promoting water safety to adolescents and their families. Findings align with previous studies' that youth experiencing low socioeconomic status and racial and ethnic disparities—specifically Black and African American and Hispanic and Latino or Latina—are at a significant disadvantage concerning swimming ability and water safety behaviors [20,21,33]. This study suggests identifying risk-taking adolescents as being at greater risk for drowning, identifying non-White or Caucasian and low income communities for improved access to swimming lessons, and a more

holistic approach to life jacket use in teens by addressing risk-taking behaviors, risk and protective factors and emphasizing that swim ability does not mean that a life jacket is needed less often. Further evaluation of associations between risk-taking behaviors and life jacket usage may help identify psychosocial predecessors of risk-taking behaviors.

**Author Contributions:** Conceptualization, V.S., T.L., E.B. and L.Q.; data curation, I.S., S.S., V.S. and T.L.; formal analysis, S.S.; supervision, E.B. and L.Q.; writing—original draft, I.S., S.S., V.S. and T.L.; writing—review and editing, I.S., S.S., T.L., E.B. and L.Q. All authors have read and agreed to the published version of the manuscript.

**Funding:** This study was funded by Seattle Children's Hospital Community Health and Benefit Department, with in-kind support from Harborview Injury Prevention and Research Center INSIGHT Program.

**Acknowledgments:** We would like to acknowledge the INSIGHT Program, Emma Gause, Brianna Mills, and Erin Morgan, Harborview Injury Prevention and Research Center for their input to the study; Anar Shaw and Will Hitchcock, Washington State Department of Health; Molly Adrian, Seattle Children's Hospital Research Institute; William Koon, University of New South Wales; and all the students who participated in the Healthy Youth Survey.

**Conflicts of Interest:** The authors declare no conflict of interest.

**Ethics:** The Seattle Children's Hospital Institutional Review Board (IRB) determined that review was not required for this study as the study was based on an anonymous public use data set with no identifiable information on the survey participants.
