Social and environmental risk factors for accidental drowning of children under five in China CURRENT STATUS:

Background: Accidental drowning of children under five is a serious problem in China. This study analyzed data on environmental, sociodemographic factors, and caregivers of children in order to understand factors that may contribute to this problem. Methods: This study collected information on 563 cases of drowning that appears involving children under five from October 1, 2015 to September 30, 2016 in 334 sampling districts in China. Primary caregivers were interviewed one-on-one based on the Drowning Mortality among Children under 5 Questionnaire. Results: The majority of drowned children under five years old were boys, and 71.58% lived within 100 m of a water body. The drownings occurred mainly in ponds, canals, rivers, and wells, while over 90% of these water bodies had no safety measures. There were 28.06% of primary caregivers did not provide full-time care for the children, and 83.13% of them had no knowledge of first aid skills for drowning. Conclusion: Encouraging kindergarten enrollment and providing safety education for children may reduce drowning among children under five years of age. Public water body protection measures should be strengthened to prevent children from drowning. Encouraging primary caregivers to care full-time for their childrenand learning first aid skills against drowning could also help reduce fatalities.

4 [7] . As the world's largest developing country, China has a large population and abundant water bodies in most regions, and, as a result, child drowning is a major problem in China as well. In response, China has made many efforts to reduce the accidental drowning mortality rate among children; relevant health education is actively carried out at the national level. The National Health Commission of the People's Republic of China released the "Chinese citizens' health literacy: basic knowledge and skills guidelines in 2015", which called for strengthening child supervision and education to prevent children from approaching dangerous waters [8] . Furthermore, some regional governments have issued a number of safety documents, including "Notice on the prevention of drowning in adolescents and children in 2019" and "Notice on doing a good job in preventing drowning of adolescents and children in 2019" [9][10] . The Education Bureaus of many provinces have also issued notices on the prevention of drowning, such as the "Notification of education on swimming safety for primary and middle school students" and the "Prohibition of bathing in rivers during summer vacation" [11] .
Despite these and other preventative efforts, drowning remains an important cause of unintentional deaths in Chinese children [12][13][14][15][16][17] . Given the absence of national-level data, we conducted one-toone interviews with primary caregivers of drowned children from various parts of the country (registered in the National Maternal and Child Health Surveillance System) in order to elucidate characteristics and risk factors of drowning deaths among children under five. Our results may help improve preventive measures and recommendations to reduce drowning mortality in this vulnerable age group.

Study Subjects
The survey covered all 334 districts in the National Maternal and Child Health Surveillance System (NMCHSS) covering 31 provinces, autonomous regions and municipalities of China. The NMCHSS helps the national and local provincial health management departments supervise and guide health surveillance. Further details about the NMCHSS have been described elsewhere [18] . Study subjects were children under five years of age from the 334 districts who died due to drowning between

Questionnaire
We collected information about the drowned and control children from the Drowning Mortality among Children under 5 Questionnaire, designed by the Chinese National Health Commission and UNICEF, which was filled out by the children's primary caregivers or other family members. The questionnaire contains four parts: basic information about children, caregivers and families, and the circumstances of drowning. All respondents provided informed consent for their anonymized responses to be analyzed and published.
Data collection and quality control A trained investigator of each district branch of the National Maternal and Child Health Surveillance System were responsible for the implement and conduct of the survey, as well as for quality control of the data and reporting of the results. The interviews with respondents were conducted within three months after the child's death. At the beginning the interview, the investigator needs to read the questionnaire description and corresponding notes to the respondent, and was allowed to call the  nd 2~ age group children each represented over 30%, and 3~ age group children were the next highest group at 17.58%. Although 3 years was the age required to enroll in kindergarten, 55.15% of drowned children aged 3 and over were not enrolled in kindergartens. (See Figure 1)

Safety education and risky drowning behaviors of children
The investigation also collected the safety education status of children at one year and older. The  Table 1) 2.

Sociodemographics of primary caregivers
We examined the primary caregivers for each of the 563 drowned children, and found that most of them (69.98%) were aged between 20 and 40 years old, while 20.96% were over 50 years old. A significant proportion of primary caregivers (70.69%) were the mother, and approximately a quarter (24.16%) were grandparents. Only 2% of caregivers held some form of a college degree. The vast majority (90.23%) attained a junior high school education or less. The definition of drowning first aid skills in this investigation is that the primary caregivers can notice signs of drowning, and can also complete first aid for drowning, which including removing foreign body in respiratory, helping extract fluid, and cardiopulmonary resuscitation. Drowning first aid skills were mostly lacking, with 83.13% of primary caregivers reported having received no training. *

Activities of primary caregivers at the time of drowning
Fully 28.06% of primary caregivers reported failing to provide full-time (which defined as the caregiver has no permanent job and only look after one child) care to the child, which may help explain why 43.34% of children were alone at the time of drowning (See Figure 2). Smaller proportions were accompanied by a primary caregiver (21.85%) or other children (20.25%).
Regarding those primary caregivers with the child at the time of drowning, only 12.77% of them were looking after the child, whereas 47.87% were doing house work and 20.21% were using the phone or socializing.

Locations and types of water body
Ponds, canals, rivers and wells accounted for the most drowning locations (80.82%), followed by home (12.08%) (See Table 2). The results also shows the age difference among drowning water body with the age increasing, the proportion of bathtub and water tank/bucket have decreased, while the proportion of ponds, canals, rivers and wells were significant increased.
Moreover, a higher percentage of older children drowned away from home (87.72% of 4~ age group children vs. 47.62% of 0~ age group children), while younger children were more likely to drown at home (42.86% of 0~ age group children vs. 5.26% of 4~ age group children) (See Table 2).

Environmental risk factors for drowning near children's living places
The survey indicated that 403 drowned children (71.58%) lived within 100 m of water body (See  Table 3). Of the 62 bodies of water that had warning signs, the signs were difficult to see at more than half the sites.

Environmental risk factors for drowning at home
Water containers were stored in the homes of 234 (41.56%) drowned children families (See Figure   4). Of those, 56.41% always stored water, 31.20% occasionally stored water, and fewer than 12% never stored water. No safety measures such as fences were implemented at around half (46.58%) of these water containers.

Discussion
This study suggests the following characteristics of drowning of Chinese children under 5. First, children aged 1 to 2 years old are more likely to drown, as are older children who are not enrolled in kindergarten. Second, training in drowning first aid appears to be critical for both the child and primary caregiver to prevent drowning. Third, children typically drown in water bodies within 100 m of their home, and younger children tend to drown at home, whereas older children are more likely to drown outside the home, such as ponds, rivers, and canals. This is most likely due to the mobility of older children. In most drowning cases, the children are playing next to the body of water and not in the water. Fourth, safety measures are markedly lacking in a majority of drowning cases. Finally, less educated caregivers are responsible for most drowned. Caregivers are attending to other chores and not minding the child when many drowning occur, such that nearly half of all children are alone when they drown. These findings in combination with a previous study in Hunan Province [19] , indicate that full-time caregivers, accidental injury safety training, and water safety measures are important for drowning prevention.
The study have found that g great many of drowned children lived within 100 m of water body, and most of these water body have no fences. The majority of public water body lack warning signs. For those public water body with warning signs, half of warning signs were not easy to notice. Since most of children accidental drowning occurred at ponds, canals, rivers and wells, which shows the incompletion of safety measures in living environment is an important risk factor for children accidental drowning. Therefore, in parallel with drowning prevention education, physical prevention measures are also needed. Our study underscores the urgent need for fences and visible warning signs around bodies of water. Local governments should be encouraged to enact regulations and policies requiring that warning signs and protective barriers be installed near public water bodies.
One major insight generated by this study is the role of the primary caregivers. The results suggest that primary caregivers' education level and the level of mindfulness strongly affect the risks of child drowning. In the survey, primary caregivers were paying full attention to the child in only 12.77% of drowning cases when the primary caregiver was present. This indicates neglect by a majority of caregivers.
A study in Australia showed that inadequate care and lapses in supervision, such as indoor housework, outdoor house work and talking/socializing, are a major contributor to child drowning [20] .
We also found that caregivers were occupied with housework and phone calling or socializing at the time of drowning. In addition, an Australia-based study of accidental drowning of children from 0 to 17 years old between 2002 and 2014 found that all children who drowned were unsupervised [21] .
Therefore, it is important to educate primary caregivers about the prevention of accidental drowning in children. Local communities can promote the benefits of full-time parental care within their jurisdictions, and use health education programs to help parents learn about child drowning prevention as well as first aid information for drowning. Sending injury prevention knowledge via SMS or voice messages to parents' mobile phones may effectively raise awareness and reduce the risk of drowning, as suggested by a study in Bangladesh [22] . Indeed, such strategies have proven effective in Jiangsu province in China, where parental awareness of, and behaviors to prevent, accidental suffocation and drowning of rural children changed significantly after health education programs were enacted [23] .
Raising awareness of drowning prevention may also prove beneficial when provided not only to the caregivers, but also to the child. One way to raise awareness of kindergarten-aged children would be for the local government to strengthen safety education training in the classroom and encourage kindergarten enrollment, as we found that over half of drowned children were not enrolled in kindergarten despite being of school age. Similarly, a study in Greater Athens found that school-based intervention resulted in considerable positive changes in knowledge and attitudes among very young pupils [24] .
We propose teaching children to avoid unprotected water bodies in order to help reduce drowning mortality rate. As children become older, more mobile and independent, emphasis should be shifted from safety around water containers in the home to safety around open water bodies outdoors.
Moreover, prevention programs should reinforce that a child should always seek adult supervision when playing in and around water bodies. To be most effective, such prevention programs should be age-appropriate.

Conclusions
To our knowledge, this study is the most extensive so far to survey characteristics around the drowning deaths of children under five in China. These data suggest several key risk factors, which may help guide the design and improvement of child drowning prevention programs.