Preventive infrastructure and childhood health equity in Israel: socioeconomic and ethnic disparities in playground access and swimming instruction.

BACKGROUND

Despite universal health coverage and longstanding child-safety initiatives, socioeconomic and ethnic inequalities in childhood injury remain pronounced in Israel. Unintentional childhood injuries (UCI) function as a proxy for health inequity, reflecting structural gaps in preventive infrastructure and access to safe environments.

METHODS

This study examines two case studies that illustrate how differential public investment contributes to unequal injury risks: (1) public playgrounds availability, and (2) participation in school-based swimming lessons. Both are analyzed within a social-determinants-of-health framework, emphasizing the interaction of environment, education, and municipal capacity. Data on fatal childhood injuries in public spaces and drowning incidents were drawn from Beterem Safe Kids Israel's national media-based mortality database (2008-2025). Playground availability was assessed through triangulated sources, including OpenStreetMap, field validation, and Standards Institution of Israel records. Swimming-participation data were obtained from Ministry of Education responses to Freedom of Information requests for 2022-2023. Associations between infrastructure and training and child mortality were tested using Spearman's rank correlation.

RESULTS

Across 62 municipalities with child populations above 10,000, a significant positive correlation was found between children per playground and UCI (Unintentional Child Injury) mortality in public spaces (ρ = 0.290, p < 0.05). Swimming participation displayed a inverse, though non-significant, relationship with drowning mortality (ρ = - 0.357, p = 0.08). Participation inequalities were substantial: only 25% of children from low-SES clusters (1-3) and 20.5% of Arab children participated in swimming instruction, compared with 60% in affluent and Jewish municipalities. Between 2021 and 2025, Arab children were more than twice as likely to die from drowning as Jewish children (rate ratio = 2.43, χ² = 14.83, p < 0.001).

CONCLUSIONS

These findings point to a shared structural mechanism behind injury inequalities: persistent underinvestment and institutional barriers that restrict access to preventive infrastructure in low-income and minority municipalities. Although playgrounds and swimming lessons are distinct domains, both exemplify how inequitable distribution of safety-enhancing resources produces measurable health risks. Addressing these gaps requires coordinated policy reforms that integrate public health, education, and urban planning; establish equity-weighted funding for preventive infrastructure; and institutionalize monitoring of child-safety environments. Equitable investment in prevention is essential for reducing injury and advancing child health equity in Israel.