**4. Discussion**

Drowning is a leading, ye<sup>t</sup> preventable, cause of child death [2,5,7,19]. While risk factors for child drowning are well understood [8–10], greater consideration of the impact of determinants of health on drowning risk are needed, as well as greater investment in upstream strategies that will contribute to reducing this risk. This study explored child drowning in the Philippines, through epidemiological analysis of country-level data and an assessment of the multisector action plan on drowning prevention's relevance to children within the context of determinants of health. These two areas of focus of this study reflect two of the key elements of the WHO Implementation Guide for drowning prevention—namely, quality data on drowning and a national water safety plan [22].

### *4.1. The Importance of Data on Drowning*

Drowning is a key concern in the Philippines, with an age-standardized, cause-specific mortality rate of 5.30 per 100,000 people, 17% higher than the average for middle-income countries globally (4.30 per 100,000) [2]. Although the drowning rate in the Philippines has been decreasing, there is a need for increased action to speed the reduction in drowning deaths and there are a number of strategies that have been shown to be e ffective [29–33]. The reduction in drowning deaths was more pronounced with the 0–4 year olds, indicating further work is required in finding age-appropriate strategies to prevent drowning among 5–14 year olds.

While reductions in drowning among children are pleasing, it must be noted that the Global Burden of Disease estimates for drowning exclude incidents as a result of disasters and transportation [3]. This is likely to significantly underreport drowning in the Philippines given the impact of disasters such as typhoons and flooding [34], as well as the significant amount of inter-island travel that is conducted on boats and ferries [35].

### *4.2. Multisectoral Collaboration on Drowning Prevention (Objective 1)*

Addressing the determinants of health that impact drowning require a multisectoral approach [1,21]. The development of the multisector action plan on drowning prevention in the Philippines was guided by principles from policy documents both international (Health in All Policies (HiAP), Whole-of-Government, and Whole-of-Society approaches) and local policy guidelines. HiAP is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. It improves accountability of policymakers for health impacts at all levels of policy-making. It includes an emphasis

on the consequences of public policies on health systems, determinants of health, and well-being. The Whole-of-Government Approach invokes a participative endeavor among the different national governmen<sup>t</sup> agencies for health, education, sports, environment, urban planning, transportation and communication, labor and employment, industry and trade, finance, energy, agriculture, and social development, among many possible others.

Another strength noted is the participation of various public agencies and non-governmen<sup>t</sup> organizations in developing the Multisector Action Plan on Drowning Prevention in the Philippines. The participants of the collaborative effort to develop the action plan on drowning prevention have incorporated some recommendations made by the WHO-Regional Office for the Western Pacific (WPRO) when it comes to organizations that must be involved in such an undertaking [26]. However, there is always a need to exert effort and to collaborate more with other agencies that can provide data, share their interventions on drowning prevention (such as disaster response and transport), and provide the needed support in order to implement interventions aimed at reducing child drowning deaths (such as planning and development, and finance sectors). This sensible and needed approach recognizes and allows all agencies to be involved in drowning prevention, although this is not without challenges due to shifting priorities and staff movement. However, it is worth mentioning that the "coming together" of various organizations, with their own agency mandates and activities, has willingly contributed in meaningful discussions on how to address the drowning problem in the Philippines.

As of 2020, several agencies have already agreed to carry their specific agency commitments, with only a few remaining agencies having not ye<sup>t</sup> agreed to implement commitments due to reasons such as changes in agency leadership resulting in a change in agency representative. One good thing is that, even though there have been changes in the composition of the multisector group, attendance and discussions on how to move forward has been maintained.

The Whole-of-Society Approach invokes the participation of governmen<sup>t</sup> agencies, non-governmen<sup>t</sup> agencies, private sector, business sector, and academia. The Philippine Health Agenda (PHA), seeking to fulfill the global call for Universal Health Coverage, adopting "All for Health towards Health for All" as the rallying point to realize the vision of a Healthy Philippines by 2022 [36], identifies that drowning prevention is required to achieve this goal. As identified in the multisector action plan on drowning prevention plan, there is also an opportunity to ensure that drowning prevention as an issue is embedded within plans and strategies of other sectors, such as ensuring drowning is identified in future iterations of the National Plan of Action for Children, the Philippines Youth Development Plan, and the Philippines Development Plan.

Education is a key determinant of health and, therefore, collaboration with Departments of Education will be required. Studies have shown school attendance to be protective for drowning, with higher rates of drowning seen during periods where children do not attend school (i.e., school holidays) [37]. Similarly, in Bangladesh, poorer education levels are linked to increased risk of drowning [31]. Education is also linked to socio-economic status, another determinant of health. Studies show children of low socio-economic backgrounds are at higher risk of drowning [37–41]. Ensuring all children have access to education will contribute to better health and well-being [42], as well as reduced drowning risk.

Other countries have instigated compulsory swimming lessons for school-aged children [41,43–45] to help address increasing the number of people with swimming skills and knowledge. This strategy is not without its own challenges as access to places to undertake learning to swim, school attendance, number of swim teachers, logistics of moving children from school and back again, and cost all place barriers to the delivery of school-based learn-to-swim programs [46,47].

Proximity to water is a key risk factor [7,19] and designing public works to help remove water hazards, such as open drains, building walkways over water for children going to school, and putting barriers in

place so children cannot access water will all contribute to reducing drowning risk, thus engaging with the water, sanitation, and hygiene (WASH) community will also be required.

### *4.3. Interventions on Drowning Prevention Especially in High-Risk Groups (Objective 2)*

The Philippines is a multicultural nation with many ethnic minorities. Such groups are shown to be at higher risk of drowning and have unique needs when it comes to reducing this risk [48,49]. Understanding the unique needs of these groups will be vital to ensuring the e ffective implementation of drowning prevention strategies. Identifying high-risk groups ensures the greatest impact of the plan and this objective proposes four strategies while also building on objective 1. Of these four strategies within objective 2, three directly target children (adult supervision, barriers, and learn to swim). However, for these activities to be successful the impact of the determinants of health will need to be considered.

Constant adult supervision is not a simple task, with the adult required to be within arm's reach, focused with all their attention, all of the time [8,50]; it also requires the adult to be prepared to supervise, which includes having necessary items with them so they do not need to leave the location (e.g., towels), an understanding of the child's skill level in the water, and reduction in distractions from other sources. Education, family size, culture, and financial circumstance all influence supervision and need to be part of the communication strategy.

Physical barriers separate a child from a water hazard to reduce drowning risk [51]. In the Philippines, barriers such as house/door barriers, porch barriers, barriers preventing children from going to creeks, and reconstructing or placing covers on open, dug wells as a form of barrier have been used in order to prevent younger children from exposure to hazards from their sources of water [19,52]. WASH reduces drowning risk. Having a piped water system can also solve concerns associated with getting water from open, dug wells, thereby eliminating exposure to drowning-prone areas. Installing barriers controlling access to water has also been recommended by the World Health Organization to reduce drowning risk [22].

In terms of capability-building strategy, it is envisioned that the younger population will be able to learn the basic swimming skills. However, this will require careful planning since children will be exposed to bodies of water, which is also a drowning risk. The recommended age for children to be exposed to swimming must also be carefully studied. Agencies involved in training di fferent walks of life in swimming include the Philippine Coast Guard (PCG) and non-governmen<sup>t</sup> organizations such as the Philippine Red Cross (PRC), Philippine Lifesaving Society (PLS), and Bert Lozada Foundation, Inc. to name a few. However, learn-to-swim programs for children have been implemented in other countries and have been noted to be worthwhile endeavors that low- and middle-income countries (LMICs) like the Philippines can learn from [43,53]. On another note, teaching school-age children (aged over 6 years) swimming and water safety skills is one of the recommended interventions to reduce drowning [22].

Other strategies such as learning CPR, which is not specifically targeted at children, has been recognized as a tertiary prevention strategy for saving children/people who have drowned [54]. Globally increasing CPR skills is a challenge and requires a wide range of strategies to ensure capture of the widest possible proportion of the population and will require an understanding of the determinants to ensure these strategies are e ffective [53]. Linking the requirement for CPR to another life event, such as leaving school, gaining a driver's license, etc., have been proposed as strategies to increase CPR uptake [55,56] and these should be considered in the Philippines.

### *4.4. Strengthening Implementation and Enforcement of Policies and Regulations on Drowning Prevention (Objective 3)*

There were no activities that were directed at children in this objective. However, we note that floatation devices have been used elsewhere [57,58] to protect children when recreating in water. Lifesaving

and rescue services can also help increase the safety of children by ensuring that the location where they recreate in the water is safe and they are able to be rescued if they ge<sup>t</sup> into trouble. Unfortunately, anecdotally, lifesaving services are more likely to be at resorts and tourist areas used by non-locals.

Rescue services for boating-related incidents have been found elsewhere [59] to help reduce drowning and these services are often used during times of disaster [60]. Agencies, such as the Philippine Coast Guard (PCG), Maritime Industry Authority (MARINA), and the Philippine National Police (PNP), have a very big role in providing rescue services, thereby contributing to the reduction of drowning incidents. Policies and regulations to improve occupational fishers have wider effects than just reducing drowning. Families of fishers will be protected if the fisher is protected, i.e., if the breadwinner of the family drowns, there are major economic and societal impacts on the family and broader community as a study from Tanzania showed [61].

### *4.5. Public Awareness on Drowning Prevention (Objective 4)*

Strategies, and their associated activities, within this objective targeting child drowning prevention are information dissemination activities using various platforms (creation of instructional support materials for teachers or reference materials to be utilized in the classroom; development of advocacy materials on child safety including drowning, promotion of drowning prevention in the Regional Youth Advisory Council, and distribution of the 'Drowning Safety Tips' to all beneficiary schools). This should be undertaken using a health promotion approach that engages with the community and ensures messages are delivered in a manner and at a time that has the most impact.

Several agencies committed to contribute specific actions in order to increase public awareness on drowning prevention. To name a few, the Department of Health (DOH) together with the Department of Health Promotion of Education of the College of Public Health, University of the Philippines Manila (DHPE, CPH, UPM) will develop the health promotion, advocacy, and communication plans on drowning; the Philippine Information Agency (PIA) will assist in the dissemination of information, education, and communication (IEC) materials; the Department of Education (DepEd) will intensify the integration of drowning prevention in the K to 12 curriculum; the Council for the Welfare of Children will develop advocacy materials on child safety including drowning prevention; the National Youth Commission (NYC) will promote drowning prevention in the Regional Youth Advisory Council and in their social media campaigns. Other partner agencies will also contribute by promoting drowning prevention messages through social media (Philippine Red Cross), doing advocacy on drowning prevention in celebration of the National Disability Prevention and Rehabilitation (National Council for Disability Affairs); distributing IEC materials and conducting seminars to residents of coastal areas about safety tips regarding drowning prevention (Philippine National Police); distributing the "Drowning Safety Tips" to all beneficiary schools and conducting social media campaigns on drowning prevention (Safe Kids Worldwide Philippines). The school is one of the best places to advocate drowning prevention. With the support of the educational sector, the officials, administrators, and the student body, it is hoped that a policy for the institutionalization on the celebration of Drowning Consciousness Week can be crafted and implemented.

Increasing public awareness through the conduct of seminars in educational institutions is also a very important activity that is directed to the younger population groups. The WHO has also recommended to strengthen public awareness of drowning through strategic communications to support drowning prevention interventions. Drowning prevention messages and materials can be disseminated through various platforms [22].

### *4.6. Evidence and Data on Drowning (Objective 5)*

A challenge facing those working to prevent child drowning globally, including in the Philippines, is a lack of timely, quality data [4,22]. GBD data, as were used in this study, are modeled data and may be inaccessible to researchers and drowning prevention advocates. GBD data also lack information about risk factors such as activity and location as well as the presence or absence of prevention strategies (for example, the wearing of life jackets) to help inform stratagems to redress the drowning burden. Further work needs to be undertaken to ensure quality data capture on fatal and non-fatal drowning at the country level, with data made available to those who need it, which is comprehensive and helps inform drowning prevention. The first steps toward better data have been undertaken with the development of Online National Electronic Injury Surveillance System (ONEISS), a national injury (including drowning) surveillance system in the Philippines. ONEISS data can be used as the source of information in determining primary cause and risk factors of drowning [62]. However, there are limitations for using the ONEISS data as (1) the data are collected by selected hospitals, (2) the system is web based and hospitals with no or poor access to the internet will have problems in using the system, (3) drowning events captured by local health clinics are not usually reported, (4) cataclysmic events and water transport accidents are not included, and (5), like other countries in Asia, misclassification of cases could be a problem. The role of the Philippine Statistics Authority (PSA) in collecting timely and complete data cannot be overemphasized. In addition, there may be a need for governmen<sup>t</sup> agencies such as the Philippine Coast Guard (PCG), Department of Health (DOH), and Philippine Statistics Authority (PSA) to sit down and further discuss how data, especially in maritime events and disasters, can be captured in order to have a more complete picture of drowning situations in the Philippines.

Similarly, investment in research on child drowning and its prevention in the Philippines is needed, including the role of determinants of health. A quality surveillance system for drowning incidents, such as ONEISS, will allow for detailed epidemiological studies to be undertaken, tracking trends over time, evaluating the impact of any prevention strategies that are enacted, and identifying emerging issues. Monitoring and evaluation of the implementation of, and progress against, the activities within the multisector action plan on drowning are also key. This will allow the relevance and e ffectiveness of the activities within the plan to be assessed, as well as guide the development of future iterations of the plan. Ensuring that the actions from these activities are specific, measurable, achievable, realistic, and timely (SMART) [63] will also help with ensure success.

### *4.7. Strengths and Limitations of this Study*

This study represents the first of its kind, exploring child drowning in the Philippines and the development of the multisector action plan on drowning prevention. This study makes an important contribution to the literature regarding the role and consideration of determinants of health in preventing drowning and provides guidance to other nations on the development of a national water safety plan (referred to as a drowning prevention plan in this paper) as recommended by the WHO.

However, this study is not without limitation. The data on child drowning used in this study are modeled data sourced from the GBD Data Viz Hub. Limited variables are available for analysis using this data, which limits understanding of causal factors implicated in child drowning in the Philippines. This limitation represents a call to action for investment in and interrogation of national-level data on drowning (both fatal and non-fatal) in the Philippines, including the role of determinants of health, to better inform future prevention e fforts. Secondly, analysis of the activities of the multisector action plan on drowning prevention with respect to relevance to child drowning and the importance of inclusion of determinants of health was conducted by consensus among the authors. Others performing these analyses may have a di fferent interpretation.
