Drowning, defined as “the process of experiencing respiratory impairment from submersion/immersion in liquid”,1 is a common cause of death and disability worldwide, with over half of all drowning deaths happening to children less than 15 years of age.2 In the US, drowning is a preventable primary unintentional cause of morbidity and mortality for children from birth to 19 years of age.34 Mortality data from 1999–2006 (US only) show an infant (<1 year) drowning fatality rate of 1.6 per 100 000. Drowning death rates among toddlers and young children (1–4 years) rises to 3.0 per 100 000, then falls for school-aged children (5–9 years and 10–14 years) to 0.8 and 0.7 per 100 000, respectively. Alarmingly, the drowning fatality rate returns to 1.6 per 100 000 for adolescents (15–19 years).5

Along with age, drowning fatalities vary demographically. Drowning deaths occur more often with African–American youth than with white youth,6 and less often with girls than boys.5 Also, low educational attainment and income have been consistently connected with higher drowning fatality rates.7

Drowning prevention measures for children typically include accountable supervision, pool safety systems and swimming instruction.8 Although there is limited research that connects increased swimming ability with a decrease in or elimination of drowning events,9 it is still considered a preventive step.467 Research on swimming competence of US children is lacking, and only one study was found that examined swimming ability in US adults. This investigation confirmed that, overall, 37% of American adults reported “limited swimming ability” (unable to swim/could not swim a pool length) and that swimming skill was lowest among African–Americans (62%) and Hispanics (44%). Conversely, only 32% of the study’s white subjects conveyed “limited swimming ability.”10 Although a key limitation for this study was self-report, the sample was large (n = 5234) and weighted to meet conditions for representativeness. Racial inequalities are apparent within US youth competitive swimming clubs. USA Swimming confirmed that 92.5% of club members were Caucasian, 4.2% Hispanic, 1.7% African–American, and 1.1% Asian/Pacific Islander, and 0.5% listed Native American as their race (J. Cruzat, personal communication, 29 August 2008).

The American Academy of Pediatrics (AAP) recommends research in order to better understand obstacles to swimming encountered by disenfranchised populations.8 Only one study clearly documents differences in swimming ability by race among adults,10 while no research exists concerning swimming ability among children. An absence of nationwide data detailing minority youth swimming ability was verified by USA Swimming. Therefore, this study fulfils two purposes: (1) to ascertain swimming ability in marginalised youth; (2) to explore demographic variables that influence swimming ability in these populations.

METHODS

A research team, assembled from a large metropolitan university in the southeastern area of the USA, developed study methodology in collaboration with USA Swimming, which included creation and validation of the study’s survey, planning and executing data collection, and data analysis.

Instrument development

An original survey, drawn from physical activity constraint studies,11^–13 was developed. The 50-question survey contained three parts: 33 affirmation statements (four-point Likert scale) concerning swimming; a yes/no segment (six questions) about facility access; 11 demographic questions. Survey completion time was 5–10 min. The survey was read aloud to subjects seeking assistance.

A panel of adolescent education, survey design and aquatic consultants reviewed survey versions for content and face validity purposes. A pilot test using targeted subjects (100 inner-city, minority youth) was conducted. Pilot participant feedback was used for the present study survey and protocol. The pilot-altered version of the instrument was designated for use with adolescent subjects (12–17 years). A slightly altered form was validated for use with parents and/or care givers of young subjects (4–11 years) who completed the survey in place of their oldest child within that age range.

Data collection

To develop a cross-sectional sample of minority youth aged 4–17 years, the survey was conducted in six metropolitan areas arbitrarily chosen by USA Swimming: Chicago, Illinois; Houston, Texas; Memphis, Tennessee; Miami, Florida; Oakland, California; Philadelphia, Pennsylvania. Research staff worked with the administration from each city’s Young Men’s Christian Association of the USA (YMCA) to identify appropriate data collection sites using branches typically found in impoverished areas. The YMCA was used because of their nationwide access to minority youth. Each selected YMCA branch used non-swimming programmes (eg, after-school care, basketball programmes) to access adolescents and consenting parents of young children. Passive consent for the adolescents was fulfilled using a note home to parents. City-site visits were scheduled for data collection and YMCA staff training to continue data collection. An established protocol was communicated including methods for gaining proper consent. Each participating YMCA organisation was offered US$500 for meeting survey objectives.

Description of participants

The sample primarily consisted of non-white children aged 4–17 years of varying swimming ability from low-income households (free/reduced lunch recipients) with moderately educated parents/care givers. The age groups (4–11 and 12–17 years) resemble those used in CDC research, specifically the National Health and Nutrition Examination Survey (NHANES). The lowest age (4 years) reflects AAP policy that designates initiating swim lessons at 4.8 Racial identities used were based on those in the Youth Risk Behavior Survey (YRBS), a national adolescent surveillance system.14 Because of a low number of cases in some categories, a collapsed race variable was used for statistical analyses and consisted of six groups: African–American, Hispanic/Latino, white, Asian, multiracial and other. The “other” category incorporated identities with less than 3% of the sample: American Indian/Alaska Native, Native Hawaiian/other Pacific Islander and original “other” category. Lunch programme status represented the variable of income. For an average US family of four during the 2007–8 school year, the annual income eligibility level was US$26 845 for free lunch and US$38 203 for reduced lunch.15 Poverty level for a family of four during this time was US$20 650.

Swimming ability was identified from one central item which instructed subjects to select a statement that best described their swimming ability: (1) unable to swim; (2) could swim a little, but not comfortable in deep water; (3) comfortable in deep water, but could not swim for very long; (4) able to swim for an extended period of time; (5) could swim competitively (or used to be able to) and for an extended period of time. Respondents citing that they were “unable to swim” or “could swim a little, but were not comfortable in deep water” were considered “at risk” swimmers. Although all swimmers can be considered “at risk” for drowning, this research used the term “at risk” to categorise subjects with regard to individual self-reported swimming competence.

Statistical analysis

Data were analysed using SPSS V15. Descriptive statistics were calculated to describe the sample and determine apparent differences by variables. Swimming ability differences between minority groups of children were analysed with one-way analysis of variance tests (p<0.05), followed by Fisher least significant difference post hoc tests when appropriate. Multiple linear regression analysis was used to explore predictability for significant variables associated with swimming for minority youth within this sample.

RESULTS

Approximately 2000 surveys were distributed in English and Spanish, yielding 1680 completed, legible surveys: 1116 adolescent and 564 parent surveys. Only 19 Spanish surveys were included, ∼1.1% of total survey number. The response rate was not accounted for in this research and is unknown. Respondents completed the instrument under supervision of at least one trained research member who assisted subjects with difficulties.

Table 1 displays sample demographic results.16 The mean age of children completing the adolescent survey was 13.5 years. Mean age of respondent data provided by a parent/care giver was 8.5 years. Approximately half of the sample identified their race as African–American, and the majority of respondents (64%) noted that they were on free or reduced lunch programming at school. About 57% of the sample indicated that the parent/care giver of the child had received either a high school diploma (22.6%) or an undergraduate college or technical school degree (34.1%).

Swimming ability analysis

Overall, 51.2% of the sample reported that they were “at risk” swimmers (table 2). Of all very young children (ages 4–11 years), 65.3% were deemed “at risk,” while 43.6% of the adolescents responded as “at risk.”

Descriptive results by gender point to variations regarding “at risk” swimming ability (table 3). Of the female respondents, 54.7% rated themselves “at risk” compared with 47.5% of the male respondents. Swimming ability differences by race were also apparent. Approximately 57.5% of African–American, 56.2% of Hispanic/Latino, 47.2% of multiracial and 45.7% of children in the “other” race category indicated that they were “at risk” swimmers. These numbers compare with only 30.9% white and 28.6% Asian children who rated their swimming ability “at risk.” Therefore, racial identities were categorised into two separate groups concerning swimming ability. The more “at risk” group consisted of the African–American, Hispanic/Latino, multiracial and other children, and the less “at risk” swimming ability group was made up of white and Asian.

Recognition of significant variables affecting minority youth swimming ability was the secondary research purpose. One-way analysis of variance tests were used to determine strength of association between the dependent variable, swimming ability, and demographic variables measured. Table 4 gives means and standard deviations for significant variables.

For significant variables with three or more categories, post hoc analysis was applied. Post hoc analysis found that subjects on free and reduced lunch programmes were not significantly different from each other, but both were significantly different from the “no lunch programme” group. Parental education was significant concerning swimming ability. Post hoc analysis revealed that all categories of educational attainment were significantly different from each other except “high school diploma/GED” and “college or technical school degree.” Also, race was significant, with post hoc analysis confirming African–American, Hispanic/Latino, multiracial and other categories assembled together to form the “at risk” swimming group, and all were significantly different from the white and Asian subject cluster who rated their swimming ability at higher levels.

Swimming ability of minority children: associated variables

Multiple linear regression was applied to uncover predictor variables for swimming ability using significant demographic factors. Categorical variables with more than two levels (race, lunch programme and parent education) were collapsed and recoded for regression analysis using post hoc results. Race categories of African–American, Hispanic/Latino, multiracial and other were coded together to form the first category, and white and Asian groups formed the second. The three categories of lunch programme were collapsed into two levels: one was the combination of “free lunch” and “reduced lunch programme,” and “no lunch programme” was coded as the second. Also using post hoc analysis, we coded the four-category parent education variable into three groups of “some high school” as the first category, “high school diploma” and “college/technical school diploma” as the second, and “advanced college degree” as the third.

Standard multiple regression results confirmed a model comprising all significant demographic variables (table 5). Age group, the most significant predictor variable, was understandable. Younger-aged children should be less skilled at swimming than older, more experienced adolescents. The other demographic factors that followed in variance-explained order were race, parental education and ability to qualify for free/reduced lunch (socioeconomic status (SES) variables). The variable of sex, which was also loaded into the model, did not affect it. All variables have been previously noted in the literature as associated with swimming for marginalised groups.61017

DISCUSSION

Results from this study reveal swimming ability deficiencies among minority youth, with a majority of African–American and Hispanic children found to be “at risk,” meaning they possess limited swimming competence. Although the AAP policy on water safety has cited a lack of data to support the relationship between swimming ability and drowning,8 this study provides a hint that marginalised children are at a disadvantage, which helps explain drowning rates for these groups. Further, the data reasonably correspond to US adult swimming ability.10 The study of Gilchrist et al,10 the lone investigation reporting US adult swimming skills, found that 62% of African–American and 32% of white adults indicated “limited swimming ability.” These results are similar to the outcomes of this study: 57.5% of African–American and 30.9% of white children reported “at risk” swimming ability. The data used in the adult study were gathered in 1994. Unfortunately, it seems little has happened since then to enhance swimming ability in these populations.

Findings from this research show female minority children accounted for the highest number of “at risk” swimmers. African–American girls reported the highest percentage of “at risk” ability followed by Hispanic/Latino girls. However, boys from these minority groups, who indicated they were highly skilled swimmers, drown at higher rates.18 This dissimilarity matches male adolescent beliefs, which typically lead to risky health behaviours and outcomes.1819 Conversely, white and Asian female respondents scored the lowest of all subgroups measured on the “at risk” swimming ranking. This sex difference also mirrors their documented health behaviours and outcomes, which are more positive than male counterparts.1420

Household income and parental education are key SES indictors21 and were strongly associated with swimming ability in this sample. Using lunch programme status and parental education variables, results from this study show that these SES determinants were formidable attributes associated with self-reported swimming ability in this sample. These results reflect other findings that significantly link SES to youth participation in physical activity.11^–13 Competitive swimming participation has also been found to be more prevalent in financially affluent households.22

Regression analysis verified with this sample that demographic characteristics account for roughly 20% of the variance regarding swimming ability. This is a sizeable proportion considering that this analysis did not include the individual child’s interest or actual swimming ability. Additional research is necessary to uncover factors that yield the remaining variance, which include both tangible and intangible obstacles that disenfranchised children may encounter regarding swimming participation.

It is important to note that highly skilled swimmers drown. Prevention specialists have even discussed a possible relationship between high exposure to swimming and an increase in drowning fatalities.9 One recent small-scale study concluded that fatal and non-fatal drowning events occur despite swimming competence.23 How swimming ability relates to drowning is unknown despite consistent recommendations for swimming instruction as a key preventable step.6^–824 Swimming is an open motor skill based on personal and situational factors. For example, skilful swimmers who are impaired, tired, sick or injured can drown despite their competence. Also, swimming in a controlled body of water, such as a swimming pool, is easier than in an open body of water with choppy waves and irregular currents (eg, rivers, oceans). However, a high percentage of drowning events for US minority children occur in pools,4 and a high level of swimming competence has been noted to be a protective agent in controlled environments such as a pool.25 Along with various levels of swimming instruction, communities must ensure that safety information is stressed in all swimming lessons.26

Limitations

Research limitations include those common to large population studies. Given the research objectives, the sample was targeted and convenient. Survey sites were geographically diverse, but not randomly chosen, and may not be representative of the USA or for the population of children who use urban YMCAs. Also, self-report data can yield imprecise findings. However, large-population self-report studies score high on validity and reliability measures because of large numbers of subjects.27^–29

The research instrument was a newly constructed survey drawn from physical activity studies. Care was taken to ensure readability levels and relevance to swimming concerns. In addition, pilot study participants gave input regarding instrument modification as well as fine-tuning research protocol. Although time restrictions affected the ability to gather data, the total number of surveys collected (n = 1680) was well above that necessary for robust statistical analyses.

The question of swimming ability was open to individual interpretation. We strived for precision with this question, seeking feedback from several aquatics specialists. Also, during YMCA staff training sessions, this key question was highlighted. Specific strategies were communicated during training, enabling YMCA staff administering the surveys to help subjects to comprehend this important item and answer correctly. Finally, the definition of “at risk” used in this research is comparable to that used in the study of Gilchrist et al10 (“limited swimming ability”), which measured adult swimming competence. Accordingly, study results are similar.

IMPLICATIONS FOR PREVENTION

Findings from this study show that certain youth populations report “at risk” swimming ability. More research is strongly recommended. One possible solution is to add swimming ability questions to other injury prevention questions on the Youth Risk Behavior Survey, the CDC national surveillance system that measures youth health indices.

SES factors should be considered for prevention purposes. Offering free/low-cost swimming lessons is suggested, especially for communities that have high drowning rates. Programme costs may be off-set by corporate sponsorship as part of corporate social responsibility (CSR) initiatives which have been shown to bolster an area’s socioeconomic potential and community appreciation for companies.30 Communities are encouraged to explore funding through grant programmes offered by USA Swimming and other agencies.

Swimming initiatives should take place at convenient locations such as apartment building pools and community facilities, as disadvantaged families face economic challenges. Typically, schools encounter financial difficulties in supporting swimming instruction. Those near year-round community pools are encouraged to collaborate with the facility management to schedule swimming classes. Alliances between schools and facilities would allow more children to receive water safety instruction, either in school or during an after-school programme. The UK mandates swimming instruction for all school-aged children and details this in their National Curriculum.31 The drowning fatality rate for the UK is 0.6 per 100 000, half that of the USA (1.3 per 100 000).32

Race differences within this sample suggest that cultural influences shape swimming participation. Within high-risk communities, water safety information should be delivered to both minority youth and parents/care givers during lessons. Research is suggested to uncover specific cultural mores that influence swimming participation and to explore successful programming for “at risk” groups. Until then, minority parent/care givers are encouraged to prioritise swimming lessons for their children.

CONCLUSIONS

Results from this study show that swimming ability in US minority children differs significantly across demographic groups, particularly socioeconomic and racial categories. Economically disadvantaged African–American and Hispanic/Latino youth were the most “at risk” populations concerning swimming ability. Improving swimming competence and water safety knowledge in these marginalised youth may help decrease fatal and non-fatal drowning events.

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