Running Head: WATER SAFETY

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A Water Safety Education Program for Primary Care Providers
Catherine Tretiakova
Arizona State University

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Abstract
Project Title: A Water Safety Education Program for Primary Care Providers
Author(s) Title(s), Name(s) and Department Affiliation:
Catherine Tretiakova, RN, BSN, Phoenix Children’s Hospital
Tiffaney Isaacson, BBM, Senior Injury Prevention Specialist, Phoenix Children’s Hospital
Diana Jacobson, PhD, RN, PPCNP-BC, PMHS, FAANP, Arizona State University College of
Nursing and Health Innovation
Diana Bowman, LLB, PHD, Arizona State University College Sandra Day O'Connor College of
Law
Purpose/Aims: We aim to increase understanding of water safety measures among primary care
providers and improve the quality and efficiency of parent water-safety education.
Background and Significance: Drownings are the leading cause of death in one to four year old
children in the United States. Arizona’s drowning rate is nearly double the national average for
this age group. Water safety is an important anticipatory guidance topic a primary care provider
should be discussing at all well visits. The Health Belief Model is an effective framework to
guide family education interventions. It is strongly encouraged that providers incorporate water
safety education into the developmental milestone discussions.
Methods: Ten providers recruited from six Arizona pediatric primary care clinics participated in
an educational one-hour session. Providers were encouraged to prioritize water safety
discussions within the one to four year old age group and deliver education in the context of
individual child development. Additionally, providers were updated on water safety
recommendations from the Center for Family Health and Safety at Phoenix Children’s Hospital.
Supplemental handouts with developmental water safety information were given to each office to
aid providers in parent education. A pre-survey was administered to the providers prior to the

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education session and a post-survey was given at an eight-week follow up. The surveys
measured provider perception and current practices of water safety education and utilized a
Likert scale to compare data sets. Current and retrospective chart reviews were conducted to
evaluate sustainability of the educational intervention.
Outcomes/Results: Sixty percent of provider participants were Medical Doctors (MD) and 40%
were Nurse Practitioners (NP) with experience ranging from one year to over 20 years.
Following the education session, providers were more likely to discuss keeping a child at armsreach at all times (p=0.046) during their well visits. There was also an increase in providers
incorporating water safety discussions into milestone education (p=0.054).
Conclusion: This educational intervention empowered providers to deliver water safety
education in the context of normal developmental milestones at each one to four year old well
visit. The anticipatory guidance emphasizes to parents that the behaviors their children exhibit
are healthy and normal, but also explains how achieving these milestones put their children at
greater risk for drownings. This quality improvement project is part of a larger initiative to
decrease the number of drownings in Arizona through education and policy.
Keywords: drowning, drowning prevention, primary care, anticipatory guidance, tailored
anticipatory guidance.

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A Water Safety Education Program for Primary Care Providers
Drowning is a devastating and complex issue impacted by both physical and social
determinants of health. Nationally, as well as in the state of Arizona, drownings are the leading
cause of death in children ages one to four years old (Centers for Disease Control and Prevention
[CDC], 2016). These deaths are considered preventable, as measures can be taken to change the
circumstances leading to drowning (Arizona Department of Health Services [ADHS], 2018).
Primary care providers (PCP) are a hub of health and safety information for most families. As
such, supporting their efforts to educate parents on drowning prevention behaviors is a critical
part in decreasing risk in toddlers.
Problem Statement
The national average unintentional drowning rates from 2001- 2016, ages zero to four
years of age per 100,000, is 2.43. Arizona’s rate is nearly double that at 4.58 per 100,000 (CDC,
2016). Both nationally and in the state of Arizona, boys are twice as likely to drown as girls
(ADHS, 2017; CDC, 2016; World Health Organization [WHO], 2018). Swimming pools,
followed by natural water ways, are the primary place for drownings to occur (ADHS, 2017;
CDC, 2016). While there is adequate evidence on the usefulness of barriers and approved
flotation devices, the only true protection against drowning is constant capable supervision
(Isaacson, 2017).
Swimming lessons for children have long been sought out by parents as a method of
protection from drowning. It has been determined that swimming lessons do not increase the
likelihood of drownings for toddlers, however, they are inadequate for decreasing drowning due
to developmental limitations associated within this age group (American Academy of Pediatrics

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[AAP], 2010). Conveying this information to parents in an effective manner still remains a
challenge.
Primary care providers are important source for parent education. Like so many others,
the topic of drowning prevention has been added to the list of anticipatory guidance (AG) topics
a provider should discuss with families at well-visits. It is well known that the list of topics
recommended to be covered in a well-visit is ever increasing, and the barrier of time is ever
present (Coker et al., 2013). Most providers are allotted an average of fifteen to twenty minutes
for a health history, physical exam, and anticipatory guidance (Gittelman et al., 2015).
Literature is exhaustive in emphasizing the need to develop programs and tools that can
provide anticipatory guidance, while decreasing the provider load (Coker et al., 2013). Amongst
health history and comprehensive physical exams, injury prevention often falls by the wayside. It
is important to support providers with evidence-based resources to ensure these critical topics do
not get left out of the conversation.
Purpose and Rational
It is the purpose of this evidence-based project to reinforce the importance of water safety
AG, evaluate effective methods of implementation, and determine reasonable solutions to lend
support to providers caring for toddlers who are at high risk for drowning.
The topic of drowning prevention was selected due to the alarmingly high rates of
drownings among children one to four years of age. This is a preventable phenomenon that
should be prioritized among primary care providers.
Background and significance
National and State wide Data

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CDC’s (2017) national action plan for drowning consists of three goals: raise awareness,
highlight prevention solutions, and mobilize action. According to the CDC, AAP, and ADHS,
prevention of drowning requires a series of behaviors to be adapted. First and foremost, constant
capable supervision by responsible adults should be emphasized as the most effective way to
keep children safe; however, lapses in supervision are an unfortunate reality and it is important to
build up layers of protection to enhance, not replace, supervision. Fencing around pools is
thought to prevent up to 50% of drownings and is strongly recommended by all major drowning
prevention advocates.
Supervising adults should know how to swim, rescue a child, perform Cardiopulmonary
Resuscitation (CPR), and call 911 (AAP, 2010; CDC, 2017). While swim lessons are a popular
focus for drowning prevention, it is noted by the AAP (2010) that lessons do not “drown-proof”
children. Therefore, proper supervision, barriers, and CPR need to be an educational priority.
The AAP (2010) includes routine anticipatory guidance as a part of their
recommendations to help identify and educate caregivers of children that are at high risk for
drownings. The primary care setting plays an important part in prevention due to its focus on
anticipatory guidance during child well-visits. Risk assessments focusing on cell phone use,
chores, socializing, and drinking alcohol while children are swimming are important and often
not covered (Isaacson, 2017). Evaluation of social health is an important part of the well-exam.
According to Healthy People 2020, social determinates of health are “conditions in the
environments in which people are born, live, learn, work, play, worship, and age that affect a
wide range of health, functioning, and quality-of-life outcomes and risks” (Office of disease
prevention and health promotion [ODPHP], 2018). Drowning is no exception to this.

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Internal Evidence
A children’s hospital in Arizona is seriously addressing the issue of social determinates
of health in regards to drowning prevention. A workshop was conducted with a pre- and postsurvey regarding prevention strategies with parents of children one to four years of age. Post
workshop survey results revealed improvements in swim skill perception of children, risk
assessment, isolation reduction, and social empowerment (Isaacson, 2017). This children’s
hospital is researching issues such as parental resilience, the role of poverty, culture, and
language barriers as they pertain to drowning risk (Isaacson, 2017). However, once these issues
are identified, the problem of information distribution and behavior change remains a barrier.
Primary care providers remain a primary source of information for parents and much of the
expectation to relay important health information falls to them.
Role of Primary care
Primary care providers need effective and time efficient strategies to address all
important points of a well-visit in the limited time frame available to them. A review of
anticipatory guidance for unintentional injury prevention, with a focus on water safety, revealed
a multitude of supplemental education strategies that showed effectiveness in adapting parent
beliefs and behavior.
A study conducted by Cheraghi and colleagues (2014) suggested that education based on
the Human Behavior model improved knowledge, attitudes and practices of mothers who had
children under five years of age. These women are located in Iran and considered to be of low
educational levels. The authors reported that visualization of injury severity using booklets and
visual teaching aids were most effective in changing the participant’s attitudes toward injuries of
children. Using booklets, visual media and other resources that may enhance knowledge outside

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of face-to-face time with a provider is desirable due to limited time during office visits. A study
evaluating web-based safety education for parents, conducted by Van Beelen and colleagues
(2014), showed significant changes in safety behaviors in regards to home hazards, including
bathing of children. Prior to Van Beelen, Christakis and colleagues (2006) found that use of an
evidenced based interactive website correlated with increased discussions on safety topics with
physicians at well visits.
Closely examining anticipatory guidance and its role in providing health information to
the public, the following PICO question is posed: For children ages one to four years of age, is
multimodal anticipatory guidance, compared to traditional one-on-one visits with a provider,
effective in increasing parent knowledge on injury prevention, specifically drowning,
consequently decreasing provider burden?
Search Strategy
Databases searched were CINAHL, PubMed, and PsycInfo (See Figure 1). Key words
used were unintentional injury, drowning, prevention, primary care, education, anticipatory
guidance, children, child, infant and pediatrics. Limits applied included literature within the past
5 years, clinical trials, and systematic reviews. Reference lists of studies deemed appropriate
were also reviewed for applicable studies. PubMed offers a similar article search, which was
utilized for acceptable articles as well. Narrowed searches were then deemed appropriate based
on potential for practice change in a pediatric office, utilization of methods that would
potentially decrease time needed with a provider, and investigation of effectiveness of
anticipatory guidance methods for practices and providers. Search strategies can be found in
Appendix B, C, and D.

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PubMed (Appendix A) search combinations included Drowning OR Water safety AND
Education OR anticipatory guidance. Limits of 5 years, clinical trial and review were added for a
final yield of 84 studies which were reviewed for appropriateness with a final yield of 4 studies.
Because drowning is often combined with other unintentional injury studies, a search for Child
OR children OR infants AND unintentional injury was made, yielding 12,812 results, the limits
of 5 years and clinical trials and reviews were added for a yield of 756 articles which were
reviewed for relevance. The studies were reviewed for appropriateness and the final yield for
critical appraisal was 18 studies.

Figure 1. Database search strategy
The search in CINAHL (Appendix C) used combinations of search terms including
Drowning OR Water safety AND Education OR anticipatory guidance. Initial yield was 262

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articles. The limit of 5 years was placed a yield of 56. Articles were then reviewed for
appropriateness and the final yield was two studies.
An additional search for Child OR children OR infants AND unintentional injury was
made yielding 232 results. Articles were then reviewed for appropriateness and the final yield
was 14 studies.
The search in PsycInfo (Appendix B) used combinations of search terms included
including Drowning OR Water safety AND Education OR anticipatory guidance. Initial yield for
this search was 606,508 articles. The limit of 5 years and academic journals yielded 145 articles,
of which 7 were deemed appropriate for critical appraisal. An additional search for Child OR
children OR infants AND unintentional injury was made yielding 4007 results. The limit of 5
years was placed resulting in a yield of 1731 articles of which 19 were appropriate for critical
appraisal.
The remaining 64 studies were then reviewed using a rapid critical appraisal tool. This
resulted in 10 high quality studies that were selected for appraisal and synthesis based on their
relevance to the PICOT question and quality of evidence. The 10 studies selected were: two
systematic reviews, five studies randomized control trials, two cohort studies, and one study was
qualitative (Appendix D).
Critical Analysis and Synthesis of Evidence
The 10 studies selected focused on anticipatory guidance pertaining to injury prevention.
According to the United States Preventative Task Force, the evidence included levels I, II, and
III studies. All studies included the target age of one to four years old. Seven of the studies were
conducted in a primary care setting. (Appendix D).

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Tailored anticipatory guidance (TAG) was a major theme found among the research
studies (Appendix E). With the constant stream of new knowledge parents must filter and the
existing environment of information overload, it is reasonable that the evidence suggests parents
respond well to information that is tailored to their present needs. Six of the 10 studies addressed
positive effects of TAG (Appendix D). Themes that emerged regarding outcomes consisted of a
combination of time needed with a healthcare provider, parent knowledge, and quality of care
(Appendix E). Most studies did not identify a framework, but the Health Belief Model
(Hochbaum, Rosenstock & Kegels, 1988) and the Stetler model (Stetler, 2001) were feasible and
applicable to guide the development of the intervention and plan the implementation of the
project.
The methods used to assess and address the specific needs of families included a
variation of technology-based interventions. Web based-platforms, including waiting room
kiosks, made up the majority of the interventions reviewed. Other platforms such as group well
visits, non-medical personal-delivered information, DVD, and a screening tool were included. In
general, there is a relationship between TAG for parents and decreased time needed for provider
visits. Utilization of alternate formats of AG showed an increase in quality overall (Appendix
E). Findings showed an increase in topics covered, utilization of new technology by parents and
practices, and positive behavior changes. In addition to technological interventions, a RCT
evaluating effectiveness of the Health Belief Model on knowledge regarding injury prevention
was included, had positive effects on parent knowledge and can potentially be used to guide
implementation of new practices (Appendix D).
Due to the nature of the inquiry, a significant amount of data was heterogeneous. There
was a variety of measurement tools used, mainly consisting of questionnaires, surveys, and data

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reviews. These tools were appropriate, but there is an increased risk of bias associated with
questionnaires and surveys limiting the quality of evidence. The majority of the studies relied on
parent feedback and self-reported behaviors which also increased the risk for bias.
Eight of the 10 studies focused on parent outcomes specifically, and the remaining
focused on practice or provider outcomes. However, in most studies, the dependent variables
were similar, with overarching themes of quality improvement, parent/provider knowledge, and
time spent with provider for AG education.
Conclusions from the evidence
While there is little evidence to suggest that there is a platform more effective than oneon-one education between a provider and family, it is reasonable to conclude that various tools
can enhance the patient experience and decrease the demand on the provider. Many practices do
not have the time or resources to adequately educate every family on injury prevention.
Therefore, it is practical to conclude that tailored anticipatory guidance has a very important
place in preventative education.
Provider buy-in is an important component to these interventions, and reviewing
evidence-based methods to increase incentives and reduce barriers would be beneficial for the
implementation of TAG projects. Creating a tool that is cost effective and saves time will only be
effective if the providers and staff believe them to be so. Likewise, TAG tools require parent
cooperation and interaction, and developing techniques to administer the information most
effectively is important to the success of any implementation.
Theoretical Framework and EBP Model to Guide Implementation
The Health Belief Model (HBM) (Appendix F) explains and predicts preventive health
behavior (Hochbaum, Rosenstock & Kegels, 1988). Concepts related to this model directly relate

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to drowning prevention. The model’s concepts focus on perception: perceived susceptibility,
perceived severity, perceived benefit, perceived barriers, cues to action and self-efficacy (Glanz,
Rimer & Viswanath, 2008). Drowning prevention behaviors such as supervision, use of barriers,
and decrease of distractions, will be more effective if parents have a greater perception of risk.
The HBM has shown to be an effective model for injury prevention (Cheraghi et al, 2014).
The evidence-based practice model (EBP) selected to guide practice is the Stetler model
(Appendix G) (Stetler, 2001). The Stetler model is a practitioner oriented approach to EBP and
was updated in 2001. It includes five phases: preparation, validation, comparative evaluation and
decision making, translation/application, and evaluation (Stetler, 2001). The criteria of this
model focuses on substantiating evidence, current practice, fit, and feasibility (Stetler, 2001).
The Stetler model is a good fit for practice implementation and delineates a clear path for
evidence based change.
Project Methods
The evidence-based project developed, based on the literature review, was a water safety
education program for PCPs. The institutional review board of Phoenix Children’s Hospital and
Arizona State University approved this project. This project includes a water safety presentation
given at six Arizona primary care offices. Providers were recruited at the presentation and
provided with a pre-survey to complete. The pre-survey was de-identified via a provider-selected
4-digit pin. By completing the survey, each provider agreed to implement new education
strategies for water safety education with parents of children ages one to four years old during a
well visit.
Four developmental handouts were created with TAG information for each separate age
(1-4 years old). The handouts emphasized normal developmental milestones for each age, and

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the risks advancing development poses around a pool. These handouts were developed to aid
providers in the water safety discussion with parents, and offered parents further educational
resources.
A PowerPoint presentation was created and printed for the education portion of the
project and contained updated information for the provider on the efficiency and effectiveness of
TAG. The information was verbally reviewed and enhanced by the educator and discussions
were encouraged. The education content encouraged water safety discussion with parents in
terms of their child’s developmental milestones, and reviewed what it means to be a capable
supervising adult at the pool (See Figure 2).
Chart audits were performed at the offices of the participating providers, assessing for
any change in the amount of water safety education being provided to parents of patients one to
four years of age, before and after the water safety education was presented to the providers. The
audits looked at three months of charts one year prior to the education session, and three months
of charts starting a month after the intervention. The chart audit form was developed by the
project leaders and included the following data: type of provider, patient age, primary language,
presence of water safety education charted before and after initiation of the project.

Figure 2. Key aspects of capable adult supervision.

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Patient charts (n=450) were reviewed utilizing randomized sampling techniques: 226
were selected for the retrospective review and 224 charts were selected 1-3 months after the
provider education was delivered. Every third well visit that fell within the 1-4 year old age
group was reviewed. This process was repeated for each office. No office or provider was
identified.
Primary care providers (n=10) agreed to participate and their agreement was confirmed
by the completion of the pre-survey before the education session. It was made clear that the
providers could decline to participate at any point during the project implementation. Eight
providers participated in the post-survey eight weeks after the education session. The post-survey
utilized Likert scale questions to evaluate for any change in provider perceptions and behavior.
Outcomes/Project Results/Impact
Data was analyzed using IMB SPSS 25. Demographic data was evaluated using
frequencies, and a Wilcoxon signed-rank test was used to compare pre- and post- survey answers
for significant change. Chart data utilized the crosstab feature to assess for clinically significant
changes in education. Sixty percent of provider participants were Medical Doctors (MD) and
40% were Nurse Practitioners (NP) with clinical experience from one year to over 20 years. No
significant difference was found between the two types of providers in regards to amount of
water safety education performed. The language the parent/patient spoke did not affect the
amount of education provided. Following the education session, providers self-reported that they
were more likely to discuss keeping a child at arms-reach at all times (M=1.88, SD=.354,
p=0.046) during their well visits. There was also an increase, but not significant increase, in
providers incorporating water safety discussions into developmental milestone education
(M=2.38, SD=.916, p=0.054). Eighty percent of providers reported time constraints as a major

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barrier to water safety education. All of the providers indicated on the pre-survey that they
thought the patient handouts would be a useful addition to their practice. The follow-up postsurvey evaluation indicated only 20% of providers reported using the handout often or always
after the educational session (See Appendix H).
Chart audits revealed an increase of water safety education among one year olds from
67% to 93%. There was significantly less education documented in the subsequent age groups
(See Figure 3). Additional chart review information can be found in Appendix I.
Discussion
Due to the high incidence of fatal drownings in the 1-4 year old age group, water safety
should be prioritized at well-child office visits. Since the start of this project, the American
Academy of Pediatrics released an updated drowning prevention policy, reinforcing the necessity
of quality supervision for this age group (AAP, 2019). The AAP (2019) also reinforces the need
for targeted interventions, such as this one, for vulnerable populations.
This project adds supports to the body of literature that addresses the need for systematic
change in regards to injury prevention education. In particular, the limited time providers are
able to spend with patients during a well visit is a barrier to delivery of anticipatory guidance.
Future projects and research should focus on strategies that address provider time constraints and
the disparities between what anticipatory guidance education is expected and what is realistic to
time limited office visits. The providers should also aim to increase pool access and safety
screening in vulnerable populations in order to target education further for these populations.
Further research is needed to determine whether discussing water safety with parents before their
child is mobile is a more effective strategy than waiting until the child is one year old. Finally,

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projects addressing the need to provide consistent, continuing education to parents of two, three,
and four year olds may help increase parent awareness and safety practices.

Figure 3. Education comparison before and after education evaluation.
Conclusion
The leading cause of death in children ages one to four years old is preventable,
unintentional drownings. Parental education on necessary behaviors to safely supervise children
around water is paramount to successful prevention. Primary care providers are expected to
provide this information in a time-limited 15-20 minute office visit. This evidence-based project
educated pediatric primary care providers on the risk and most current education strategies for
this population. Results of the project demonstrated an increase in providers educating parents to
keep their toddlers within arm’s reach at the pool at all times. In addition provider water safety
education for one year old children demonstrated a 26% increase following the brief educational
intervention.

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Appendix A
Database Search Strategy

PsycInfo

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Appendix B
Database Search Strategy

PubMed

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Appendix C
Database Search Strategy

CINAHL

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Appendix D
Evaluation table

Citation

Conceptual
Framework

Design/
Purpose

Coker et al.
(2013)

Donabedian’s
Model

Design: SR

USA
Funding:
none
Bias:
Possible
publication
biasnegative
interventio
n results
are not
included in
peer
reviewed
literature.

Purpose:
Review
intervention
s to change
WCC
delivery in
PC setting
for children
0-5 years of
age.

Sample/
Setting

Major
Variables

N=33
n= 3751

AG delivery/
Utilization

Ages: 0-5 y

Formats:
- healthy steps
- group WCC
- non-face-toface formats
- additional
providers
- home WCC
- preschool
WCC

Criteria:
- SR, RCT,
NRCT, or
OS.
- WCC
clinical
practice
redesign

Measurement/
Instrument

Data analysis

Downs and
Black
checklist

PubMed
(January 1981February 2012)

5 point Jdad
score

Three
investigators
independently
screened initial
list to exclude
irrelevant titles.

Findings &
Themes
Group WCC:
- ≥ 1:1 visits in
effectiveness and
efficiency
- WCC AG
topics covered
Web based tools:
-  Minor
clinical concerns
between well
visits.
- Time needed
with provider
Non-medical
professional
providers for
AG:
- Parent
knowledge and
experience.
-  Time spent
on AG topics
- Time needed
with Provider.

LOE/
Discussion
Level I
Limitations:
- Narrow SC
- MA not
possible due to
heterogeneity
Conclusions:
Alternative
formats to
deliver AG show
promising
results.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Conceptual
Framework

Coker et al.
(2016)

Donabedian’s
Model

Design/
Purpose
Design:
RCT

26
Sample/Setti
ng
N= 251
ages 0-3 y

USA
Funding:
none
Bias: none

Purpose:
Examine
effectiveness
of PARENT
on quality
and HC
utilization
among low
income
families.

English and
Spanish
speaking
Two
participating
pediatric
practices
Intervention
families
remained in
study for 12
month period
and received
PARENT
intervention.

Major
Variables
IV:
PARENT
program.
DV1:
ED visits
DV2: AG
given
DV3:
Psychosocial
assessment
DV4:
Family risks
assessment
DV5:
Tobacco,
Alcohol and
drug
assessment
DV6:
Family
centered care
DV7:
Helpfulness of
care

Measurement/
Instrument

Data analysis

Parent Survey

Intention to treat
analysis

Parent
Questionnaire
Qualitative
interview

T test
Pearson’s x2
Wilcoxon Rank
sum test

Findings &
Themes
 ED visits (p=
.022)
 AG (p<.001)
 Health
Information
(p=.008)
 Psychosocial
assessment
(p<.001)
 Family risks
assessment
(p<.001)
Tobacco,
Alcohol and drug
assessment
(p=.007)
 Family
centered care
(p=.008)
 Helpfulness of
care (p<.001)

Level of
Evidence/
Discussion
Level I
Limitations:
- Cost
- Unable to
report driving
element of
intervention
effect.
Conclusions:
When used in
conjunction, a
PC, web-based
WV planner and
automated AG
text messages
show positive
results in 
parent
knowledge and
 provider
burden.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Cheraghi et
al. (2014)
Iran
Bias:
Mothers
only
Funding:
Hamadan
University
of Medical
Sciences

Conceptual
Framework
HBM

Design/
Purpose
Design:
RCT
Purpose:
Assess
health belief
model on
education of
mothers for
promoting
safety and
IP among
mothers in
Iran.

27
Sample/Setti
ng

Major
Variables

N= 120

IV: HBM

ages 0-5 y

DV1:
Perceived
sensitivity
DV2:
- Perceived
severity
DV3:
- Perceived
benefits
DV4:
- Perceived
barriers
DV5:
- Cues to
action
DV6:
- Self –
efficacy

Educational
programming
based on
HBM
Exclusions:
congenital or
chronic
diseases.
Attrition rate:
0%

Measurement/
Instrument
Pre and post
Questionnaire

Data analysis

Students t test

Findings &
Themes
All differences
were statistically
significant in
favor of
intervention
group

Level of
Evidence/
Discussion
Level I
Strengths:
A pilot study
was previously
conducted

p=0.001 for all
dependent
variables

Active
participation of
subjects

 Perceived
sensitivity

0% attrition rate

 Perceived
severity

Limitations:
Participants were
mothers only

 Perceived
benefits

Data selfreported

 Perceived
barriers

Conclusions:
Educational
programming
based on health
belief model
show significant
efficacy and can
be successfully
implemented
into IP
education.

 Cues to action
 Self –efficacy

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Gittelman
et al.
(2014)
USA

Conceptual
Framework
Rosswurm
and Larabee’s
Model

Design/
Purpose
Design:
RCT

28
Sample/
Setting
N= 317

Major
Variables
IV:
Kiosk ST

ages 0-14 y
Purpose:
Determine if
kiosk in
pediatric ED
can screen
for injury
risk and
encourage
safety
changes at
follow
survey
compared
with IPS.

Pediatric ED
Kiosk ST
grouped into
tailored age
groups.

DV1:
Responses to
safety
behavior
questions.
DV2: Time to
complete

Measurement/
Instrument
- initial ED
screening
- completed
follow up
screen

Data analysis

Findings &
Themes

X2 analysis

 Kiosk less
effective in all
age groups.

Students t test

Overall p>.0001

Frequencies

 Time to
complete screen
and education in
kiosk group.
p<.0001

Level of
Evidence/
Discussion
Level I
Strengths:
Evaluates a time
limited, busy
environment.
Limitations:
Kiosk group
appeared to
practice safer
behaviors at
initial screen.
Self-reported
behavior
Conclusions
Kiosk in ED can
be appropriate
for screening
families due to
short amount of
time it takes, but
should not be
used as a standalone
intervention for
behavioral
changes.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Conceptual
Framework

Design/
Purpose

Gittelman
et al.
(2015)

Stetler Model

Design:
Cohort study

USA
Bias: none
reported.
Financial:
Supported
financially
by Ohio
Department
of Public
serviceEMS injury
prevention
research
grant.

Purpose: 
injury AG
topics
covered in
well visits
by offering
screening
tools and
focused
talking
points to
physicians.

29
Sample/Setti
ng
N=720
Children < 1
year
(2, 6, 9, & 12
months)
Pediatric
Practices
Age specific
tailored ST
(6)

Major
Variables
IV:
ST
DV1:
Percentage of
providers
using ST.
DV2:
Age
appropriate IP
AG topics
covered at
each WCV.

Measurement/
Instrument
Random
sampling of
charts (Data
review)

Data analysis

Frequencies

Findings &
Themes
 ST use in 3
months (97%)

Measures table
 IP discussion
(>88% for each
age group)
Greatest with
water safety
discussion
(10.8%-95.7%)

Level of
Evidence/
Discussion
Level II-2
Strengths:
Effective
monthly
collaborative
calls.
Limitations:
-Sample charts
used for
evaluation
-Physicians
received
incentive
-Behavior
changes not
assessed.
Conclusions:
Injury ST can be
incorporated into
PC office visits
on a consistent
basis. Tailored
information
allows the
provider more
time to address
relevant
concerns.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Brixy et al.
(2014)
USA
Financial:
none
Bias: none

Conceptual
Framework
Social
Cognitive
theory

Design/
Purpose
Design:
Cohort study

30
Sample/Setti
ng
N= 2091

Major
Variables
IV:
Kiosk

ages 0-4 y
Purpose:
Describe
pilot using
technology
to facilitate
IP risk
assessment
and
education
integration.

Downtown
Health Center
Pediatric
Clinic
Kiosk- Safe
N’ Sound
Program
English only
Tailored
safety
assessments

DV1:
Injuries risks
screening.
DV2:
-Injury
occurrence

Measurement/
Instrument

Data analysis

Findings &
Themes

Monthly data
review: Kiosks
& injury and
administrative
data.

Descriptive
statistics analysis

- 0-6 months
38% of all
screenings
- 4 years 5% of
all screenings
- 0.8% of
screened
children for
injury required
an injury related
visit.

Fisher’s exact test
Injuries identified
were compared
with injury areas
addressed in Safe
N’ Sound report.

Level of
Evidence/
Discussion
Level II-2
Strengths:
First effective
evaluation of
injury outcome
associated with
prevention
program in clinic
setting.
Limitations:
Low
participation of
children 4 years
of age.
Discussion:
No child
received an
injury that he/she
was screened for,
which may
indicate the
screening is
effective in what
it covers, or that
the screening is
not effective at
identifying risk.
Further research
is needed to
determine.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Van Beelen
et al.
(2014)

Country:
Netherland
s
Funding:
Grant from
ZonMw,
the
Netherland
s
organizatio
n for health
research
and
developme
nt.
Bias: none
listed

Conceptual
Framework
ProtectionMotivation
theory

Design/
Purpose

31
Sample/Setti
ng

Design: RCT

N=1383

Purpose:
Tailored
safety
advice (Ehealth4Uth)
compared to
generic
counseling
leaflets.

ages 0-4 y
Setting:
Youth health
care
organization
(5) and wellbaby clinical
offices (30).
Attrition:
6.6%

Major
Variables

Measurement/
Instrument

Data analysis

IV:
E-health4Uth

Pre and Post
questionnaires

DV1:
- Parent’s child
safety
behaviors
DV2
- Parent
evaluation of
E-health4Uth.
DV3
- Parent and
HCP
evaluation of
WV.

Parent
evaluation
after E-heath
modules
complete.
(intervention)

Logistic
regression
analysis and linear
regression
(evaluate Ehealth4Uth: CI95%)

Parent
evaluation of
well child visit
discussing
tailored safety
advice.

Findings &
Themes
Drowning
Specific
knowledge:
Bathing
(p=.001)
Pond (p=.82)
Swimming
pool (p=.14)
Swimming
(p=.87)

Level of
Evidence/
Discussion
Level I
Strengths:
Focuses on
tailored
intervention.
Limitations:
-Drop-out rate
highest among
low income
mothers.
-Not tested on
mobile
platforms.
-Possible recall
bias to vouchers
received.
-Safety
behaviors selfreported.
Conclusions:
E-health4Uth iseffective in
promoting some
safety behaviors.
Overall webbased tailored
advice is
supported by the
results of this
study as an
acceptable way
to deliver
unintentional
injury advice.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Conceptual
Framework

Franz et al.
(2014)

Stetler model

Design/
Purpose
Design:
RCT

32
Sample/Setti
ng
N= 84

Major
Variables
IV:
DVD

4 month WV
USA
No conflict
of interest
No funding
No bias
reported

Purpose:
determine
effectiveness
of a 5
minute DVD
as an
educational
tool used for
AG.

Community
based
pediatric
clinic
English
speaking
Exclusions:
- Non English
speaking.
- Not child’s
primary
caregiver
- Ill child

DV1:
Knowledge
scores
DV2:
Time with
provider

Measurement/
Instrument
Two page Pre
and Post
questionnaire
survey based
on bright
futures
recommendati
ons for 4
month WV.
Topics
included:
feeding, safety,
sleep and
family life.

Data analysis

Descriptive
statistics
ANOVA used to
test hypothesis
Independent t
sample conducted
on visit length.

Findings &
Themes
Knowledge
score pretest to
post test.
(p<.001)
 time spent
with provider
(p < .02)
No significant
increase in
knowledge
compared to
standard AG.

Level of
Evidence/
Discussion
Level I
Strengths:
Explores time
saving technique
for AG.
Lends support to
existing
literature that
technology can
be effective and
time saving.
Limitations:
Well educated
Participates only.
Possible
environmental
cues to
participants by
leaving TVs in
exam room.
Conclusion:
DVD AG appear
to shorten visit
time with
physician.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Tse et al.
(2014)
USA
Bias: none
reported
Funding:
intramural
research
program of
the Eunice
Kennedy
Shriver
National
institute of
child health
and human
developme
nt.

Conceptual
Framework

Design/
Purpose

Consolidated
Framework
for
Implemented
Research

Design:
Qualitative

33
Sample/
Setting
N=5
Ages: 0-4

Purpose:
Assess
implementat
ion of Safe
N’ Sound
kiosk using
interviews
and focus
groups.

Pediatric
clinics in
North
Carolina

Major
Variables

Measurement/
Instrument

Data analysis

Findings &
Themes

Facilitators
and barriers to
implementing
kiosks.

Provider focus
group

Coded scheme for
main themes of
interviews

Facilitators:
- personalization
and visual appeal
- materials
accessible to
parents
-agreement of
staff with Safe
N’ Sound
information

Office
manager
interviews
Waiting room
observations

Barriers:
- insufficient
incentive
- time and effort
required to
implement
- lack of
organizational
leadership
- competing
parent demands
- format did not
match patient
flow

Level of
Evidence/
Discussion
Level III
Strengths:
Discusses
perceived
barriers to
implementation
from staff.
Limitations:
No day to day
leadership
Providers did not
want to increase
staff demand
SNS is not a
billable service
Conclusion:
Program
implementation
can be sustained
by adapting to
organizational
needs and
desires.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION
Citation

Omaki et
al. (2015)

Conceptual
Framework

Donabedian’s
Model

Design/
Purpose

34
Sample/
Setting

Design: SR

N=44

Purpose:
Identify
technology
based
behavior
changes
evaluated in
terms of
unintentiona
l injury.

7- target
parents of
children

Only studies
reporting
results were
included

Ages 1-44 y
Inclusion:
Education
and behavior
change
evaluations
with
intervention
and/or control
was delivered
by computer
processor or
mobile
device.
Observed or
self-reported
safety
behaviors.

Major
Variables

Technology
utilization for
UI prevention.

Measurement/
Instrument

Checklist
designed for
RCT and
NRCTs
assessing:
1. external
validity
2, internal
validity
3. power of
study

Data analysis

Findings &
Themes

PubMed,
Psychoinfo,
Cochrane,
EMBASE,
SCOPUS, and
Academic Search
Complete.

Parent specific
education:
- 4/7 + kiosk
programs
- 3/7
Software/internet
programs
- 7/7 +
behavioral
impact.
- 2/7 +
knowledge
impact.

Data abstraction
form
Studies
descriptively
analyzed.
Checklist
assessing quality
of reporting,
external validity,
internal validity,
power of study.

Level of
Evidence/
Discussion
Level 1

Strengths:
Provide
information on
usefulness of
computer based
injury prevention
programs.
Limitations:
No Metaanalysis
performed

Discussion:
Injury prevention
behaviors can be
modified with
the assistance of
computer based
prevention.

Note: AG: Anticipatory Guidance; ED: emergency department; HBM: health belief model; HC: health care; HCP: Health care
provider; IP: injury prevention; IPS: Injury prevention specialist; MA: Medical assistant; NRCT: Non-randomized control trial;
OS: observational study; PARENT- Parent-focused Redesign for encounter; PC: Parent Coach; RCT: Randomize control trial; SR:
Systematic review; ST: Screening tool; TAG: tailored anticipatory guidance; WCC: Well Child Care; WV: well visit

DROWNING PREVENTION

35
Appendix E
Synthesis Table

Author

Coker

Coker

Cheraghi

Year
Design
LOE+
n=
N=
Ages
Interventions

2013
SR
I
-33
0-5 y
GWV
WBI
NMP

2016
RCT
I
251
-0-3 y
PARENT

2014
RCT
I
120
-0-5 y
HBM

TAG
GAG
Outcomes
Time*
Knowledge**
Quality***
Setting
PC
ED
M/I

X
X

Gittelman
2014
RCT
I
317
-0-14y
K

Gittelman
2015
CS
II-2
720
-<1y
ST

Brixy
2014
CS
II-2
2091
-0-4
K

Van
Beelen
2014
RCT
I
1383
-0-4
WBI

X

X

X

X

X




-
--


-

X

X

--SV
QTN

X
SC

SV
QTN
INT

Tse

Omaki

2014
RCT
I
84
-4m
DVD

2014
Q
III
-5
0-4y
K

2015
SR
I
44
1-44y
WBI

X
X





CL
JDAD
score

Franz

X

--

--

--


NC


----

-


X

X

X

X

X

DR

DR

QTN

QTN

FG
INT
OBS

--CL

Note. CL-Checklist; DR-Data Review DVD- Digital video disk; ED-Emergency Department; FG- Focus Group GAG- General
anticipatory guidance; HBM- Health belief model; INT-Interview; K- Kiosk; LOE- Level of evidence; M/IMeasurement/Instrument; NC-No change; NMP- Non-medical Professional; OBS-observation; PARENT- Parent-focused
Redesign for encounter, Newborns to toddlers; PC- Primary Care; Q-Qualitative; QTN-questionnaire; RCT- Randomized
control trial; SC-screening SR- Systematic review;; SV-Survey TAG- Tailored anticipatory guidance; WBI- Web based
intervention
*Quality = increased AG topics covered, utilization, practice change or behavioral change.
**Time= Time needed with provider
***Knowledge= parent knowledge
+LOE based on United states preventive serves task force

DROWNING PREVENTION

36
Appendix F
Health Belief Model

(Glanz et al., 2008)

DROWNING PREVENTION

37
Appendix G
Stetler Model

(Stetler, 2001)

DROWNING PREVENTION

38
Appendix H

Pre and post Survey Data
Pre and post Survey Data - Wilcoxon sign paired test Comparison
(5 Point Likert Scale)
1. How often do you offer water safety education during your well visits?
2. Do you discuss the need for constant, capable supervision around the pool?
3. Water safety topics you routinely discuss
• The presence of a supervising adult knowing how to swim
• The presence of a supervising adult trained in CPR and calling 911
• Keeping child within arm’s reach at all time
• Having no more than one alcoholic beverage while supervising children at the pool

p Value

• No cell phone use (calls, texts, or videos) while supervising children
• Rotate capable pool supervisor every 15-20 minutes to avoid fatigue
• Do not go to the pool tired
• None of the above
4. Do you incorporate water safety education into review of developmental milestones
with families?
5. What barriers are present in your practice that keep you from discussing water safety topics

= .317
= .157
= .564
= .1.000
= .054

•
•

Time constraints
Uncomfortable providing education on this topic due to limited knowledge

•

= 1.000
= .317
= .157
= .317
= .046
= 1.000

= 1.000
= 1.000

Difficulty remembering to incorporating swim safety into parent education for this age
group
• Parents are not willing to discuss
6. Does the provision of a developmentally appropriate water safety parent handout assist you
in remembering to discuss this topic by providing a visual cue

= .317

7. Do you feel that the water safety handout with information for parents about how to keep
their child safe at the pool is a valuable addition to your practice
8. Is language ever a barrier when it comes to educating your patients?

= .102

= .564
= 1.000

= 1.000

DROWNING PREVENTION

39
Appendix I
Chart Review Data