570047 research-article2015

HEBXXX10.1177/1090198115570047Health Education & BehaviorStempski et al.

Article

Everyone Swims: A Community Partnership and Policy Approach to Address Health Disparities in Drowning and Obesity

Health Education & Behavior 2015, Vol. 42(1S) 106S­–114S © 2015 Society for Public Health Education Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1090198115570047 heb.sagepub.com

Sarah Stempski, MPH, MCHES1, Lenna Liu, MD, MPH1,2,3, H. Mollie Grow, MD, MPH2,4,5, Maureen Pomietto, MN, RN1, Celeste Chung, MSW, MPH1, Amy Shumann, MSW6, and Elizabeth Bennett, MPH, MCHES1

Abstract Well-known disparities exist in rates of obesity and drowning, two public health priorities. Addressing these disparities by increasing access to safe swimming and water recreation may yield benefits for both obesity and injury prevention. Everyone Swims, a community partnership, brought community health clinics and water recreation organizations together to improve policies and systems that facilitated learning to swim and access to swimming and water recreation for low-income, diverse communities. Based in King County, Washington, Everyone Swims launched with Centers for Disease Control and Prevention grant funding from 2010 to 2012. This partnership led to multiple improvements in policies and systems: higher numbers of clinics screening for swimming ability, referrals from clinics to pools, more scholarship accessibility, and expansion of special swim programs. In building partnerships between community health/public health and community recreation organizations to develop systems that address user needs in low-income and culturally diverse communities, Everyone Swims represents a promising model of a structured partnership for systems and policy change to promote health and physical activity. Keywords community-based partnerships, disparities, drowning prevention, obesity prevention, swimming Swimming represents a lifelong form of physical activity and provides access to other water recreation opportunities, such as kayaking and rowing. Swimming is specifically recommended for people with chronic conditions and obesity (Centers for Disease Control and Prevention, 2013). Learning to swim also reduces the risk of drowning (Brenner et al., 2009). Swimming promotion therefore addresses two public health priorities, obesity prevention and injury prevention, and may have the potential to reduce related disparities. Obesity is recognized as one of the most concerning health problems of our time and is associated with disparities that have persisted across decades. Between 1971 and 2002, the prevalence of overweight among 6 to 11 year olds increased approximately threefold among White children and fivefold among Black children (Freedman, Khan, & Dietz, 2006). Among adults, obesity prevalence increased twofold, with substantial differences in obesity prevalence among Black adults compared with White adults (Flegal, Carroll, Ogden, & Curtin, 2010). According to recent data from NHANES 2009-2010, 24% of Black children and adolescents were obese compared with 14% of White children and adolescents (Ogden, Carroll, Kit, & Flegal, 2012).

Drowning is the second leading cause of unintentional injury death in children and adolescents and also disproportionately affects communities of color (Centers for Disease Control and Prevention, 2005). The highest rates of drowning are among males 0 to 4 and Black adolescent males 15 to 19 years of age (Centers for Disease Control and Prevention, 2005). In addition, Hispanic youth and American Indian/ Alaska Native (AI/AN) children have higher drowning fatality rates than White youth (Centers for Disease Control and Prevention, 2005).

1

Seattle Children’s Hospital, Seattle, WA, USA University of Washington, Seattle, WA, USA 3 Odessa Brown Children’s Clinic, Seattle, WA, USA 4 Seattle Children’s Research Institute, Seattle, WA, USA 5 Harborview Pediatric Clinic, Seattle, WA, USA 6 Environmental Health Services Division, Public Health, Seattle & King County, Seattle, WA, USA 2

Corresponding Author: Sarah Stempski, MPH, MCHES, 4800 Sand Point Way NE, RB.7.420, Seattle, WA 98105, USA. Email: [email protected]

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Individual •Ability to swim •Personal/cultural beliefs about swimming/water •Comfort with water •Familiarity with pools

Family •Ability to swim •Beliefs about swimming and water •Comfort with water •Familiarity with pools and swimming

Community/Institutions •Water program information easily available •Pool resources for scholarships •Water program Information in languages other than English •Scholarship form income verification requirements Availability of single gender or other special swim programs •Providers recommend swimming and ask about swimming ability •Clinics have information about water recreation •Health clinics and pools work together

Policy

•Pools allow diverse swim

wear •Pools use non-invasive proof of income for scholarships •Health clinic has swim ability built into electronic health record •Health clinic refers families to water recreation •Single gender swim offered as part of public programs

Figure 1.  Social ecological model: Factors that influence swimming and water recreation.

Swimming ability reflects drowning disparities. In one study, Black and Hispanic youth had almost double the rates of “at risk” swimming ability compared with White youth (57% and 56%, respectively, versus 31%; Irwin, Irwin, Ryan, & Drayer, 2009). Low socioeconomic status, low parental education, and non-White race were all significantly (p < .05) related to lower swimming ability, as was parental swimming inability (Irwin et al., 2009). Historical experiences, cultural beliefs, and religious beliefs also play a role in swim ability, comfort with water, and access to swimming and water recreation (Quan, Crispin, Bennett, & Gomez, 2006). In addition, many families with low-incomes and racial/ethnic diversity experience barriers to accessing swimming lessons and water recreation areas with lifeguards (Irwin et al., 2009). The Socio-Ecological Model, a public health framework for multisystem change, describes how strategies to change policy and systems at a community level help to improve health indicators and may ultimately reduce disparities (Sallis et al., 2012), such as factors that influence swimming and water recreation (Figure 1). Collaborative approaches are recommended as a strategy to change policies and systems, and have been demonstrated to be effective for specific health indicators such as asthma and cardiovascular disease

(Brownson et al., 1996; Clark et al., 2014). Collaborations to target obesity prevention are thought to be especially important, as they help bridge resources, reach people in multiple environments, and ultimately affect a greater number of people (National Institute for Health Care Management, 2007). We formed a community partnership between community health clinics and water recreation organizations (Everyone Swims) seeking to change policy and systems that enhanced access to safe swimming (i.e., swimming lessons and lifeguarded water recreation) in Seattle and King County, Washington. A process evaluation was conducted to identify policy and systems changes and to understand their potential impact.

Method Setting Communities Putting Prevention to Work (CPPW) was a Department of Health and Human Services national initiative to improve nutrition and physical activity and to reduce tobacco use through policy, systems, and environment change. CPPW grants were given to 44 U.S. communities, including King County, Washington (Bunnell et al., 2012).

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Seattle Children’s Hospital received CPPW funding through a grant from Public Health Seattle and King County from July 2010 to March 2012 to establish Everyone Swims.

Partnership Model Everyone Swims was designed to promote policy and systems changes related to safe swimming and water recreation access for low-income and diverse families through a collaborative partnership model (Smith et al., 2011). Fourteen organizations, representing 21 community health clinic sites, 28 pools, 9 beaches, and 2 rowing houses formed the partnership. Community health clinic and water recreation organization partners were identified and paired for 9 out of 10 geographic communities in King County with high disparities in obesity rates. We were not able to facilitate a partnership in one geographic community because of financial constraints and barriers to the in-kind staff time the project required. This community and others outside the geographic area were invited to receive information and attend meetings. Everyone Swims partnership used the concepts of collective impact to develop, implement, and evaluate the multipartner structure (Kania & Kramer, 2011). The following constructs of collective impact shaped the project: •• Common agenda and shared measurement: All partners collectively developed and committed to the vision, goals, objectives, and evaluation of Everyone Swims. •• Mutually reinforcing activities: Each partner was encouraged to pursue policy changes that built strong connections between clinics and water recreation organizations. •• Continuous communication: Each partner committed to participating in regular meetings, email dialogue, and to sharing their learning to help foster change among others. •• Backbone support: Seattle Children’s Hospital served as the backbone organization with technical assistance provided by Public Health Seattle and King County, who granted the funds. While Everyone Swims partners shared mutual goals and were closely involved from conception to final evaluation, their individual work varied, as each organization was given flexibility to determine which of the priority policy and system changes they would pursue. We chose community health clinics as partners because of their contact and trusted relationships with low-income and diverse families, as well as their focus on prevention-based health through well-child visits that incorporate health screening. Water recreation partners, including those offering swimming programs at pools and beaches, and two rowing programs, were selected for their proximity to clinic

partners, the communities they served, and for their interest in serving a more diverse community as part of their race and social justice initiatives. Each organization identified at least one site representative who participated in regular meetings, evaluations, and communications. Organizations were offered a stipend (averaging $3,000/site) to offset staff time for participation. Continuous communication and monthly meetings with and between partners, facilitated by the lead agency, allowed for collaborative decision making. Meetings were mandatory, rotating between all partners together, all water partner meetings and all clinic partner meetings.

Interventions Partners collectively identified four priority areas for policy and system change within Everyone Swims: (a) swim ability screening at the 5- or 6-year well child check by health care providers, (b) referral from community health clinics to swimming and water recreation programs, (c) swimming and water recreation scholarships, and (d) special swim programs for children, families, and adults with unique needs (e.g., cultural requirement for single gender swim or overweight). To identify specific changes needed within the four priority areas, focus groups and key informant stakeholder interviews were conducted. Five focus groups including 51 participants were conducted with Black, White, Latino, Vietnamese, and Somali families to represent the socioeconomic, ethnically and racially diverse focus communities. Focus groups were conducted by trained facilitators fluent in the primary language of each group. Focus groups questions aimed to identify the predisposing, enabling, and reinforcing factors (Green, 2005) associated with learning to swim and participating in water recreation among families in the grant’s focus communities. •• Predisposing factors focused on understanding the attitudes and beliefs related to swimming, and how doctors and clinics could be supportive of swimming. Sample question: How do you compare learning to swim with other activities you might do with your free time? •• Enabling factors focused on what made it possible for families to swim or impede families from swimming, such as how scholarships help or hinder participation in swimming lessons. Sample question: What factors do you consider when choosing a swimming pool or beach? •• Reinforcing factors were identified as strengths that were likely to keep families engaged in water recreation (or keep them from becoming engaged). Sample question: Are there other things that are essential for you and your children to go swimming? All Everyone Swims partners and several community leaders participated in stakeholder interviews (n = 22

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Stempski et al. organizations). We conducted the interviews by phone. Interview questions focused on collecting data in five areas: existing partnerships, screening and referral processes, scholarships, special programming, and perceptions of the access to their organization to low income and culturally diverse populations. Seattle Children’s Institutional Review Board reviewed and approved the focus group and stakeholder assessment. A group-consensus methodology (Duncan, 2006), informed by stakeholder interviews and focus groups with culturally and ethnically diverse families, was used to identify and rank specific model system and policy changes within each priority area. Clinic and water partners were asked to brainstorm potential policy and system changes after reviewing summary data from the stakeholder interviews and focus groups. Partners were then asked to rank their top two changes in each of the four priority areas. The list was compiled and summarized for implementation among the partners (33 relevant for clinics and 40 for water recreation facilities; see Appendix A, Tables A.1 and A.2). All partners were encouraged but not required to pursue the top priorities in each area.

Evaluation We conducted a process evaluation focused on measuring policy or system changes achieved by the partner organizations. Recognizing unique starting points, we sought to demonstrate continual and sustained progress rather than expect all partners to reach the same endpoint. Data were collected at baseline and quarterly over 18 months from all water and clinic partners (n = 14 partner organizations) to identify barriers and measure progress in the four priority areas. Each partner organization completed standardized online surveys via Survey Monkey™. Partner surveys were 10 questions, including 7 close-ended and 3 open-ended questions. Partners reported progress in the priority areas of system and policy changes within their organization, and provided open-ended responses to report on barriers, countermeasures to address barriers, successes, feedback from community members, and any additional projects that emerged. Baseline and final evaluation also assessed number of individuals served to gauge community impact. Survey results were shared between partners and discussed at bi-monthly meetings as a collaborative and iterative process of improvement, and to highlight learnings about successes and barriers. Partners were encouraged to attend in person but could also call in if transportation time to the meeting site was a barrier to attendance.

Results The survey response rate was 100%. In all of the top-ranked priority areas, there were more partners who had implemented

these strategies by the end of the project compared to the beginning. By the end of the grant, 58 out of 73 identified policy and systems changes were made by one or more partners: 26 of 33 (79%) community health clinic policy and systems changes and 32 out of 40 (80%) water recreation policy and system changes (see Appendix A, Tables A.1 and A.2). Among these changes, we highlight the progress made in the top-ranked elements in each of the four priority areas below and in Figure 2. For swim ability screening, the top-ranked priority changes were referrals and assessment of swimming ability. As shown in Figure 2, by project end all community health clinic partners had a system in place to refer to water recreation when appropriate and six out of seven had a standard tool to screen for swimming ability. Among water partners, two out of seven were working with a clinic that had a policy to screen for swimming ability and five out of seven were partnering with a clinic for referrals. For swimming referrals, higher numbers of clinic and swim partners reported implementing both priority changes (systematic dissemination of materials and availability of scholarship forms) at the final survey. All seven clinic partners systematically gave out swimming/water recreation information, and six clinics were providing scholarship forms (Figure 2). Correspondingly, six water recreation partners partnered with clinic(s) to ensure they actively distribute swimming/water recreation information (Figure 2). Community health clinics reported additional improvements to their referral process including using customized faxreferral system linking patients to pool registration, consistently providing information about swimming or water recreation directly to families within waiting rooms or exam rooms, and providing swim lesson/program registration assistance to families (see Appendix A, Table A.1). In the area of scholarships, both top-ranked priority changes for clinics and water partners were improved from baseline to final. Four clinics reported receiving program information and two had scholarship information from partner water recreation organizations by project end. Water partners reported greater implementation of both top-ranked referral strategies: five pools used enrollment in federal income-based programs such as Medicaid, Head Start, or National School Lunch Program as a more simplified way to qualify for a scholarship and four pools reported providing program information to clinics by project end (Figure 2). In addition, water partners reported multiple other improvements in their scholarships processes, including making forms available in other languages, editing their scholarship application forms for readability, providing forms online, and offering “sponsor a child” scholarship programs (see Appendix A, Table A.2). The special swim program domain saw the fewest reported changes for the top-ranked priorities from baseline to final surveys. Only water recreation partners reported a

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0

1

2

3

4

5

6

7

Screening

Clinic: refers to water recreaon when appropriate Clinic: uses standard tool to screen for swim ability WP: working with a clinic with a policy for screening WP: partners with a clinic to ensure referrals

Referrals

Clinic: acvely gives out water rec info systemacally Clinic: has water rec scholarship forms available WP: working with a clinic with referral policy

Special programs Scholarships

WP: working with a clinic to acvely give out info Clinic: receives water program info in a standard way Clinic: receives scholarship info in a standard way WP: uses automac scholarship eligibility WP: water rec program info provided to clinics Clinic: partners with WP on special programs Clinic: partners with WP on providing equipment WP: partners with clinic on special programs WP: partners with clinic on providing equipment Baseline

Final

Figure 2.  Top-ranked policy/system changes based on results from group consensus methodology in each of the four priority areas by clinic partners* (n = 7) and water recreation partners (WP*; n = 7) at start of project (July 2010) and end of project (March 2012). *Response rate among partners before and after surveys = 100%.

change in partnering with clinics to offer a special swim program (from one at baseline to three at final). Water partners reported an increase from baseline to final in working with community organizations to offer swimming for firsttime and diverse communities (from zero to five partners). In contrast, water partners reported decreases in some of the special programs offered during the time period of the grant. However, after the grant period ended, a significant policy modification within the City of Seattle allowed Seattle Parks & Recreation to offer publically available single gender swim times rather than only as private rentals. This policy change allowed male- and/or female-specific swim programs during public swim sessions at four different community pools in the city. In addition to these policy and system changes, partners reported in the open-ended response section about higher numbers of people served as a result of Everyone Swims. For example, by responding to a recommendation by parents in one of the focus groups to offer free swim lessons at beaches in the evenings in addition to the day, Seattle Parks & Recreation increased their free swim lesson attendance by 303% (starting n = 253, final n = 1,019). Pool swim lesson registration also increased with more visibility about scholarship availability: one pool’s swim lesson registration increased 28% (starting n = 3,735, final n = 4,763); another increased 216% (starting n = 2,097, final n = 4,533). The

number of publically available single gender swim sites increased from zero to eight.

Discussion Everyone Swims represents an innovative partnership approach between community health clinics and water recreation organizations to address disparities in two key health priorities, obesity and injury prevention. Use of PRECEDE PROCEED and the Socio-Ecological Model helped shape the project structure and priority areas for policy and system change. Collective Impact was used to create the infrastructure to support Everyone Swims. Evaluation results from this partnership suggest positive system and policy changes in four priority domains to address access to swimming and water recreation among low income and culturally diverse communities in King County, Washington. In all four priority areas, higher numbers of partners reported implementing system and policy strategies: using standardized screening for swim ability, referring patients from clinics to water organizations, using improved scholarship forms and processes, and developing special swim programs. Key to the success of Everyone Swims was a collaborative partnership model with the involvement of all project partners from the initial development of the project, feedback from families and stakeholders throughout, a commitment

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Stempski et al. among all partners to pursue sustainable change, and flexibility for each partner to identify policy and systems changes needed within their organization. Another important factor was each partner identifying internal staff members as project champions to ensure their organization actively engaged with change. Partnerships were supported by project facilitation, technical assistance, and tools developed by Seattle Children’s Hospital with support of the public health department. Multiple challenges had to be addressed throughout the project. One challenge was the length of time needed to develop relationships between community health clinics and water recreation partners, which had not previously worked together. Facilitated introductions between partners occurred through group and one-on-one meetings. Some elements were more difficult to change, such as scholarship requirements, which could not be standardized across all organizations because of different institutional funds available and guidelines. However, we were able to facilitate and streamline the process within pools that belonged to the same organization. Finally, for single gender swims, most partner organizations were initially unable to offer them during public swim sessions due to concerns about excluding participants based on gender. However, as noted above, the education and advocacy provided through Everyone Swims and other community advocates eventually allowed single gender swims in Seattle to be approved after the grant period. Everyone Swims is being disseminated across Washington State, has been presented at several national and international meetings (Liu, Pomietto, & Bennett, 2012), and is featured in a national play book on partnerships between public health and primary care (de Beaumont Foundation, 2014). This partnership approach may also be readily adapted for other types of physical activity (Madsen, Garber, Martin, Gonzaga, & Linchey, 2014), and is recommended as part of the chronic-care model applied to obesity (Pomietto et al., 2009). An Everyone Swims toolkit and information about accessing background materials is available online (Seattle Children’s Hospital, 2014). Future expansion and evaluation of this program and related CPPW programs could examine the ultimate effects on reducing obesity and drowning. This project had several limitations. Our article describes the process evaluation of a real-world development and implementation of a coalition linking health and community sectors. Evaluation was limited to self-reported changes in policy and systems and could not systematically evaluate changes in numbers served or impact on obesity and/or drowning rates. The evaluation of Everyone Swims was not designed as a formal research study, and we cannot assign

statistical significance to the changes assessed. We believe that sites reported as honestly as possible, and this is partly reflected in the fact that improvements were not seen in all domains. During this project, we found that many partners either did not gather or have comparable information on participation rates or on demographics such as race, ethnicity, and income, making pre–post comparisons of numbers reached difficult. Partners required structural assistance on how to collect data on race, ethnicity, and income in a culturally sensitive way, and training was offered so that this data could be collected in the future. Another limitation for the partnership was not involving representation from more sectors, such as the business sector, schools, and organizations serving specific ethnic communities. We started with those sectors most directly involved in referring to and offering programs, but engagement of additional sectors could potentially expand impact for sustainable policy and system change (Kania & Kramer, 2011).

Conclusions Partnerships between swimming pools, water recreation organizations, community health, and public health clinics represents a promising approach to policy and system changes designed to increase access and remove barriers to swimming and water recreation among low income and culturally diverse children, families, and adults. In the traditional model of health promotion, clinicians counsel patients and/or families to engage in healthy behaviors and/or injury prevention, but they do so in isolation. A family’s ability to act on a recommendation from a health care provider is increased when systems are in place that support access and remove barriers to physical activity. This new type of partnership makes a more direct relationship between the counseling and the action (e.g., signing up for swimming classes). Furthermore, this model facilitates the process by building relationships across organizations and systems and removes barriers to create sustainable changes that, as in this case, can lead to improved access to swimming and water recreation. We found that by engaging multiple sectors working together to improve policies and systems, we were able to achieve sustainable, meaningful changes. Further research is needed to assess the impact of Everyone Swims policy and system changes on the use of pools and water recreation organizations by families who are from low income and/or from culturally diverse backgrounds. The partnership and coalition model used in Everyone Swims has the potential to be replicated to promote improvements in other health care disparities.

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Appendix A Table A.1.  Clinic Partners’ Policy/System Changes by Priority Areas From Baseline to Final. n (%) Policy/system change (top 2 listed in each were considered highest priority) Priority Area 1: Screening for Swim Ability 1. Clinic makes referral to water recreation when appropriate 2. Clinic has standard tool or system in place to assess swim ability of child at 5- to 6-year well child check 3. Clinic providers recommend water recreation as a physical activity 4. Clinic has standard tool or system to assess patient interest or barriers to water recreation 5. Providers screen for patient swim ability at other age well child checks Priority Area 2: Referrals 1. Clinic actively gives out water recreation information in systematic way 2. Clinic has water recreation scholarship forms available 3. Clinic fills out a “referral” form and faxes it to the water recreation organization 4. Clinics plays water recreation informational video in waiting room 5. Clinic provides hands on assistance to help families fill out scholarship forms 6. Clinic has water recreation information in waiting room 7. Clinic provides list of referred families to pool Priority Area 3: Scholarships 1. Clinic receives program information from partner water recreation organization in standardized way 2. Clinic receives scholarship information from partner water recreation organization in standardized way 3. Clinic partners with water recreation organization to secure dedicated source of scholarship funding 4. Registration forms bookmarked and available to print on demand in clinic 5. Scholarship forms bookmarked and available to print on demand in clinic 6. Clinic staff role established to assist with finding water recreation information and registration 8. Clinic staff role established to assist with recreation registration and scholarship application in other languages 9. Clinic supported system in place to enable patients and families to attend family swim at a special rate 10. Clinic supported system in place to enable patients and families to attend swim lessons at a special rate 11. Clinic supported system in place to enable patients and families to attend special swim events at a special rate 12. Scholarship forms available in clinic Priority Area 4: Special Programs 1. Clinic partners with a water recreation organization on a special program 2. Clinic partners with a water recreation organization to provide water recreation equipment (swimsuits, etc.) 3. Targeted outreach to first time and diverse communities 4. Clinic refers patients to pools that offer child–parent beginning swim program 5. Clinic partners with pool to hold a yearly pool party for patients and families 6. Clinic refers patients and families to pools that offer single-gender swims for girls and women 7. Clinic refers patients and families to pools that offer single-gender swims for boys and men 8. Clinic refers patients and families to pools that offer children/teens/adults who are obese/ overweight 9. Clinic partners with pool to offer special programming for children/teens/adults who are obese/overweight

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Baseline (n = 7)

Final (n = 7)

3 (43) 2 (29)

  7 (100) 6 (86)

4 (57) 0 2 (29)

0

7 (100) 1 (14) 3 (43)   7 (100) 6 (86) 1 (14) 2 (29) 4 (57) 5 (71) 1 (14)   4 (57)

0

2 (29)

1 (14)

2 (29)

0 0 1 (14)

3 (43) 3 (43) 6 (86)

0

4 (57)

1 (14)

1 (14)

0

1 (14)

1 (14)

0

1 (14) 1 (14) 1 (14)

6 (86)   1 (14) 1 (14)

1 (14) 2 (29) 0 1 (14) 0 1 (14)

3 (43) 6 (86) 0 3 (43) 1 (14) 4 (57)

1 (14)

0

3 (43) 1 (14) 0 0 1 (14) 1 (14) 0

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Stempski et al. Table A.2.  Water Partners’ Policy/System Changes by Priority Areas from Baseline to Final. n (%) Policy/system change (top 2 listed in each were considered highest priority) Priority Area 1: Screening for Swim Ability 1. Water recreation organization is working with a clinic that has a policy for screening patients for swim ability 2. Water recreation organization is working with a clinic to ensure referral to water recreation when appropriate 3. Water recreation organization is working with a clinic with providers who recommend water recreation as a physical activity 4. Water recreation organization is working with a clinic who have a standard tool to assess patient interest and barriers to water recreation Priority Area 2: Referrals 1. Water recreation organization is working with a clinic with a policy defining responsibilities and systems or referring patients to water recreation 2. Water recreation organization is working with a clinic to ensure they actively give out swimming/water recreation 3. Water recreation organization is working with a clinic to ensure they have scholarship forms available 4. Water recreation organization is working with a clinic who utilizes a water recreation referral form system 5. Water recreation organization is working with a clinic to ensure they have water recreation information in their waiting room 6. Water recreation organization is working with a clinic who provides list of referred families Priority Area 3: Scholarships 1. If a child is on Medicaid, Head Start, eCap, Step Ahead, or free/reduced school lunch automatically qualify for scholarship 2. Water recreation program information is provided to partner clinics 3. Partner with other non-profits organizations to offer programming through dedicated source of scholarship funding 4. Scholarship forms available on water recreation organization website 5. Scholarships are extended to community center/other physical activities 6. Scholarship information is available in other languages 7. Swimming program information is available in other languages 8. Can apply for scholarship online 9. Family does not have to pay upfront for swim lessons and then be reimbursed 10. Scholarship offered for family swim 11. Scholarship offered for open swim 12. Scholarship offered for swim lessons 13. Have reviewed and edited scholarship application for readability and ease of use for diverse populations 14. Scholarship guidelines posted online and in print 15. Have a “Sponsor a Child” scholarship program 16. Scholarship forms available when pool is closed 17. Scholarship extended to include swimming parties (perhaps as an incentive) 18. Scholarship applications are reviewed and families are notified within 48 hours 19. Donation field for scholarship fund when signing up for programming 20. Public swim offered regularly for a reduced cost Priority Area 4: Special Programs 1. Water recreation organization partners with clinics on a special swim program 2. Water recreation organization partners with clinics to facilitate equipment for swimming (suits, etc.) 3. Water recreation organization has targeted outreach to first-time and diverse communities 4. Water recreation organization offers child–parent beginning swim program 5. Water recreation organization partners with clinics to offer an annual pool party 6. Water recreation organization partners with clinics to offer single-gender swims for girls and women 7. Water recreation organization partners with clinics to offer single-gender swims for boys and men 8. Water recreation organization partners with clinics to offer special swim programming for children/teens/ adults who are obese/overweight 9. Water recreation organization partners with clinics to offer a group swim 10. Water recreation organization partners with community organizations to offer swim opportunities to first-time and diverse communities

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Baseline (n = 7)

Final (n = 7)

0

  2 (29)

1 (14)

5 (71)

1 (14)

5 (71)

1 (14)

4 (57)

0

  2 (29)

1 (14)

6 (86)

1 (14) 0

5 (71) 2 (29)

1 (14)

6 (86)

1 (14) 3 (43)

4 (57)   5 (71)

0 1 (14)

4 (57) 5 (71)

2 (29) 3 (43) 1 (14) 1 (14) 0 3 (43) 0 0 5 (71) 0 1 (14) 0 3 (43) 0 1 (14) 0 1 (14) 1 (14) 1 (14) 6 (86) 5 (71) 0 2 (29) 1 (14) 0

2 (29) 4 (57) 4 (57) 2 (29) 2 (29) 6 (86) 1 (14) 1 (14) 7 (100) 5 (71) 3 (43) 3 (43) 5 (71) 0 5 (71) 3 (43) 3 (43)   3 (43) 1 (14) 4 (57) 4 (57) 1 (14) 2 (29) 1 (14) 1 (14)

3 (43) 0

3 (43) 5 (71)

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Acknowledgments We would like to thank Public Health Seattle and King County; Columbia Health Center; Covington Aquatic Center; Evergreen Pool; George Pocock Rowing Foundation; Harborview Pediatric Clinic; HealthPoint; International Community Health Services; Issaquah Pool; Kent Meridian Pool; Mt Rainier Pool; Neighborcare Health; Odessa Brown Children’s Clinic; Orca Swim School; Resident Champions from the WA Chapter of the American Academy of Pediatrics; Roxbury Clinic—Highline Medical Group; Sea Mar Community Health Centers; Seattle Parks and Recreation; YMCA of Greater Seattle; Cleveland High School; Cross Cultural Health Care Program; Puget Sound Off; Neighborhood House; Linda Quan, MD; Kim Arthur, MPH; Sarya Sos; and Florence Kim for their role in Everyone Swims.

Authors’ Note The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or the Centers for Disease Control and Prevention.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Supported in part by a cooperative agreement from CDC’s Communities Putting Prevention to Work program (1U58DP002423).

Supplement Issue Note This article is part of a Health Education & Behavior supplement, “The Evidence for Policy and Environmental Approaches to Promoting Health,” which was supported by a grant to the Society for Public Health Education (SOPHE) from the Robert Wood Johnson Foundation. The entire supplemental issue is open access at http://heb.sagepub.com/content/42/1_suppl.toc.

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