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Drowning is a frequently occurring and preventable public health issue. Internationally, drowning literature has focussed on children under 5 years, however, evidence based interventions to prevent adult drowning are needed to reduce deaths on a global scale. The aim of this paper is to systematically identify and analyse the evidence for drowning interventions with an adult focus. A systematic search was undertaken for peer-reviewed articles which were published in English between 1990 and 2012, focused on adults and described a drowning intervention. After quality appraisal by expert reviewers using a purposively tailored checklist, a final total of six studies were included for review. The six studies were all conducted in high income countries. Four were drowning interventions, two were retrospective analyses. The drowning interventions duration ranged from 10 days to 5 years, the analysis studies from 6 to 21 years. Two of the studies reviewed used behaviour change theory to inform development, and two reported formative evaluation. Prevention strategies included education (n = 3), technology (n = 1) and environmental (n = 1). Positive short term effects and significant behaviour change in life jacket use was reported (n = 2). A mixed effect was observed in the six studies. The complexity of the issues surrounding drowning requires the collection of robust data and evaluation of preventative measures to support the development of targeted and tailored prevention interventions. This review reinforces the need for a genuine and sustained global approach to addressing adult drowning prevention. Drowning is a serious public health issue and should receive the same attention as other public health priorities .
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Recreational Drowning Prevention Interventions for Adults,
1990–2012: A Review
Justine E. Leavy Gemma Crawford Linda Portsmouth
Jonine Jancey Francene Leaversuch Lauren Nimmo
Kristen Hunt
ÓSpringer Science+Business Media New York 2015
Abstract Drowning is a frequently occurring and pre-
ventable public health issue. Internationally, drowning lit-
erature has focussed on children under 5 years, however,
evidence based interventions to prevent adult drowning are
needed to reduce deaths on a global scale. The aim of this
paper is to systematically identify and analyse the evidence
for drowning interventions with an adult focus. A sys-
tematic search was undertaken for peer-reviewed articles
which were published in English between 1990 and 2012,
focused on adults and described a drowning intervention.
After quality appraisal by expert reviewers using a pur-
posively tailored checklist, a final total of six studies were
included for review. The six studies were all conducted in
high income countries. Four were drowning interventions,
two were retrospective analyses. The drowning interven-
tions duration ranged from 10 days to 5 years, the analysis
studies from 6 to 21 years. Two of the studies reviewed
used behaviour change theory to inform development, and
two reported formative evaluation. Prevention strategies
included education (n =3), technology (n =1) and envi-
ronmental (n =1). Positive short term effects and signifi-
cant behaviour change in life jacket use was reported
(n =2). A mixed effect was observed in the six studies.
The complexity of the issues surrounding drowning
requires the collection of robust data and evaluation of
preventative measures to support the development of tar-
geted and tailored prevention interventions. This review
reinforces the need for a genuine and sustained global
approach to addressing adult drowning prevention.
Drowning is a serious public health issue and should
receive the same attention as other public health priorities.
Keywords Drowning Drowning prevention Adults
Review Evaluation design
Drowning is a frequently occurring and preventable public
health issue. In 2011, drowning was the third leading cause
of unintentional injury internationally, resulting in an
estimated 359,449 deaths and accounting for 7 % of all
injury associated deaths (World Health Organisation
(WHO) [16]). The focus of much of the drowning literature
is on children, particularly those aged under 5 [11]. Not-
withstanding this, two-thirds of reported drowning deaths
in 2011 were for people aged 15 and over, with almost
50 % of all drowning deaths occurring in males aged over
J. E. Leavy (&)G. Crawford L. Portsmouth J. Jancey
F. Leaversuch K. Hunt
Western Australian Centre for Health Promotion Research,
School of Public Health, Faculty of Health Sciences, Curtin
University, GPO Box U1987, Perth 6845, WA, Australia
G. Crawford
L. Portsmouth
J. Jancey
F. Leaversuch
K. Hunt
F. Leaversuch L. Nimmo
Health Promotion and Research, The Royal Life Saving Society
(Western Australia Inc.), PO Box 28, Floreat Forum, WA 6014,
J Community Health
DOI 10.1007/s10900-015-9991-6
15 [16]. Under-reporting of global drowning data may
result in significant underestimates in the number of
drowning deaths in adults [13,27].
The risk factors for adult drowning can be categorised
into behavioural and environmental factors [18]. The
higher risk for adult males in high income countries (HICs)
is reflected in their greater level of participation in recre-
ational swimming, boating and fishing [7,21]. This expo-
sure, is exacerbated by higher risk behaviours such as
swimming alone, not wearing a personal floatation device
when boating or rock fishing, and alcohol consumption [7,
8,18]. In contrast, in low and middle income countries
(LMICs), the risk of drowning stems from open access to
waterways as part of daily life [7,18]. This exposure to the
risk of drowning is compounded by a number of factors
including lack of swimming skills, illiteracy, and unsafe
watercraft [7,8]. Accordingly, any adult drowning pre-
vention effort must take into consideration multiple risks,
social and environmental factors [12,19].
Evidence-based interventions to prevent adult drowning
are needed on a global scale. The literature reinforces the
notion that public health interventions that are well
designed and delivered, underpinned by theory and sup-
ported by robust evaluation are more likely to result in
sustained, long term behavioural change [1,4,19,26]
Unfortunately, very few drowning prevention programs are
informed by behavioural theory and/or formally evaluated.
The overall aim of this review is to identify and analyse
the evidence base for adult focused, public health inter-
ventions to address drowning and non-fatal drowning. This
review describes the key characteristics of the studies
identified with the intent of making recommendations that
will ensure future interventions align with evidence based
drowning prevention, and public health practice.
Search Strategy
To identify published articles on public health interven-
tions to prevent or reduce drowning deaths or non-fatal
drowning incidents with an adult focus, a literature search
was conducted between February and August 2012 using
the following six databases: ProQuest; ScienceDirect; CI-
NAHL; Ovid, PubMed; and the Web of Knowledge (see
Fig. 1). No grey literature was searched.
The search strategy consisted of a basic ‘in topic’ or ‘in
title’ field search or a ‘keyword/abstract’ topic search using
‘boolean phrase and apply related terms’ depending on the
database chosen to search. Titles were identified using
firstly the search term (including all variations of the word)
drowning; and repeated for drowning AND prevention;
drowning AND evaluation; drowning AND best practice;
drowning AND alcohol, drowning AND program; drown-
ing AND intervention; drowning AND water safety. The
search strategy was subsequently repeated using near
drowning; submersion; then submersion AND injury;
submersion AND mortality; and water safety AND
drowning in the title field search.
Criteria for Inclusion
Articles were included that met the following criteria:
published in English between 1990 and 2012; peer
reviewed; a focus on adults; and a drowning intervention
described. To identify studies for inclusion, all titles and
abstracts were screened by two reviewers against the
inclusion criteria. The exclusion criteria are shown below
in Table 1. A list of excluded studies is available on
Selection of Articles, Screening and Quality Appraisal
Article titles and abstracts were examined for appropri-
ateness for full text review by two reviewers (GC and KH).
A hand search of relevant studies was also undertaken by
locating studies that were recommended through experts in
the field of drowning prevention and by reviewing the
reference lists and bibliographies of the final studies
selected for review. A total of six studies were included for
review (see Table 2). The six studies were then quality
appraised by expert reviewers (FL and LN). At the time of
conducting the review the expert reviewer credentials
included Chief Executive Officer of the peak body of an
international drowning prevention organisation, and a
senior public health practitioner in state-based life-saving
organisation. Their combined expertise equates to more
than 25 years of experience in design, delivery and eval-
uation of public health interventions to prevent drowning
and non-fatal drowning. Using a purposively tailored
quality appraisal checklist for interventions adapted from
the National Institute for Health and Clinical Excellence
(NICE) Quality appraisal checklist [15] and the Joanna
Briggs series of assessment and review instruments [9] The
quality appraisal checklist covered five areas which were:
study population; study methods; outcomes; analyses; and
summary (including validity and limitations).
Data Analysis and Synthesis
The data analysis consisted of de-identified, publicly
available data and therefore is IRB exempt. A meta-ana-
lysis was not conducted due to the large heterogeneity
across the small number of studies that met the inclusion
criteria. The following outcomes were sought across the six
J Community Health
drowning studies: setting and sample characteristics;
recruitment and response rate; duration, and drowning
prevention strategies, behavioural theory and formative
research, evaluation design, measures and intervention
effects (impact/outcome/results) and limitations. Of the six
studies, four of the studies were drowning prevention
interventions, while the remaining two studies represent
retrospective analysis of the effectiveness of either
drowning prevention policy or practice interventions,
which were deemed to have met the criteria for inclusion in
this review (Table 2).
Setting, Duration and Evaluation Design
All studies were delivered in high income countries; four of
the studies in the USA [2,6,22,24]. The remaining two
studies were delivered in Australia [5] and New Zealand
[14]. The drowning interventions ranged in duration from
10 days [5] to 5 years [14], with sample sizes ranging from
14 [22] to 2,991 participants [24]. In contrast, the analysis
studies ranged from 6 [2] to 21 years [6] and the number of
participants ranged from 1,008 [6] to 1,597 [2]. Of the six
studies, one was a quasi-experimental design [5], one a
matched cohort analysis [2], one a cross sectional time
series analysis [6] and one was an annual cross sectional
survey [14]. Two were observational studies [22,24] (see
Table 2).
Drowning Prevention Strategies
Three of the four drowning prevention interventions studies
described educational interventions, using print educational
materials [5,14,24] including posters, postcards, fact
sheets [5] static on-site displays [14] and celebrity sports
cards [24] all of which focussed on drowning prevention.
One study employed local media to promote safety
Inial studies idenfied
through database searching
Titles and abstracts screened
Excluded based on tle or
abstract (n=278)
Full text studies screened and
hand search completed
Final studies included
Excluded based on limitaons
and duplicaon (n=167282)
Studies excluded aer
consensus (n=3)
Studies reviewed before data
extracon (n=9)
Excluded at quality appraisal
Fig. 1 Search strategy
Table 1 Exclusion criteria
Children as the primary target group
Clinical trials
Therapy trials
Medical interventions
Studies focusing on risk factors
Studies focusing on rescuer behaviour
J Community Health
Table 2 Review of the drowning prevention interventions 1990–2012
Setting &
sample (n)
response rate
Duration; & Drowning prevention
Behavioural theory
research (FR)
design &
Intervention effects: impact/outcome/
Limitations of the
Drowning interventions (n=4)
et al.
New South
visitors were
selected at
random from the
control sites
Length: unclear. ‘‘January/February’’ stated.
Post intervention interviews took place
5–12 days after campaign launch ‘‘while
the campaign was running.’’
(BT) Cognitive theories of
up –intercept
4–6 months post
In the intervention area 28.8 % of post-
intervention & 57.2 % of follow-up
respondents had seen the campaign
Contamination between
the control and
intervention sites
Response rate: pre-
83.7 %
Strategies: poster, postcard, fact sheet and
brochure aimed at improving recognition
of rips, the danger of rips, the importance
of swimming between the flags, what to do
if caught in a rip and how to avoid panic
(FR)Structured interviews
with beachgoers
assessing knowledge,
beliefs and behaviours
relating to beach flags
and rip currents
Penetration and
recall of
Post-intervention respondents who had seen
intervention (compared to not seen) were
more likely to report correct swimming
intentions for rip (p\.0001), identify
(p\.0001) and describe a rip (p\.0001).
Pre- and post-
intervention samples
treated as independent,
although some may
have been interviewed
at both stages.
Post-intervention respondents in the
intervention area compared to the control area
were more likely (relative to baseline data
from beachgoers visiting the two selected
areas 9 months earlier) were more likely to
report correct swimming intentions for rip
(p=.019), identify (p\.0001) and describe
a rip (p=.0002) and report an intention
never to swim at unpatrolled beaches
(p=\0.001) and signal a guard (p\.0001)
Use of static vs video
footage of rips
Control n =196 There were no significant differences in either
comparison for intention to swim between the
Control 56.0 % 6 month follow-up, comparing respondents in
the intervention area with the control area,
demonstrated continued retention of reporting
correct swimming intentions for rip
(p\.0001) and identification of a rip
(p\.0001). Moderately confident in
identifying the rip
Control n =408 Post-intervention:
79.3 %
Control n =161 Control 85.3 %
Age range:
14–50 ?years
Follow-up (mail
out to those who
gave contact
57.1 %
J Community Health
Table 2 continued
Setting & sample
response rate
Duration; & Drowning prevention
Behavioural theory
research (FR)
design &
Intervention effects: impact/outcome/
Limitations of
the intervention
Sex: 47.4–59.9 %
female across the 6
sample groups
Control 54.9 %
et al.
United States Recruitment:
lifeguards and
patrons at an
outdoor public
swimming pool
Length: weather permitting, 4 days/week over
one summer with 20 observation days before
the education session and 14 observation days
(BT) Health Belief
Observational pre
and post data of
lifeguards and
pool patrons
The lifeguards were already looking at the
pool at an adequate level. After the
education session, their scanning behaviour
significantly increased (p\.01) and
distraction significantly decreased (p\.01)
Observational data
Sample: Lifeguards
n=14(8 female and
6 male)
Response rate:
Strategy: education session (1 h) aimed at
increasing lifeguards perception of
susceptibility of drowning, perceived potential
severity of drowning and introduced
techniques to overcome barriers to effective
pool surveillance. Lifeguards aware of
FR–NR Lifeguard
looking at pool,
scanning and
Three out of five risky patron behaviour
measures significantly reduced post
intervention: running (p\.01); pushing
under (pB.05); and jumping near others
Poor statistical
power for
Age range of
lifeguards16–30 years
Patron behaviours:
pushing under,
diving into
shallow water,
and aggression.
Pool patrons: included
adults (although the
primary group of
concern to the authors
was children)
reliability was
et al.
King County,
Washington, United
boaters at 12
week days and
Length: 2 years (1992–1994) BT & FR–NR Observational PFD use significantly increased in adult males
and females (14.2 % in 1992 to 24.7 % in
1994, p\.001).
Changing attitudes
about general
safety could
have played a
role in elevating
usage rates
Sample: recreational
boaters of small
vessels (16 feet or less
in length)
1992: 3 times/
week over
2 months
Strategies: education campaign with boating
safety video for use in elementary schools, a
life jacket loaner program for local beaches,
community events, fliers, brochures and
celebrity sports cards
Number of
boaters wearing
Not replicated in
other states
1992: n =1097 (89 %
adult; 73 % male)
1994: 1–3 times/
week over
2 months
Details of community events and the
development, pre-testing and distribution of
media materials not reported
Observers trained
to develop inter-
rater reliability
1994: n =2991 (85 %
adult; 64 % male)
Response rate:
J Community Health
Table 2 continued
Setting &
sample (n)
Duration; & Drowning
prevention strategies
Behavioural theory
research (FR)
Evaluation design
& measures
Intervention effects: impact/outcome/
Limitations of the
Recruitment: potential
participants approached
if fishing from 4 high-risk
sites or were in transit to
and from the sites, on
summer weekend during
daylight hours
Length: 5 years (2006–2010) BT–NR Annual on-site cross
sectional survey:
awareness, safety
knowledge, attitudes,
behaviours in
English, Mandarin
and Korean.
48 % of were aware of the project in 2010 Convenience based
sampling: participants
were recent residents,
had ESL or infrequent
visitor to the site.
Direct comparisons
cannot be estimated
Sample: Rock
Response rate: not stated Strategies: on-site static on-site
displays of fishing safety, written
material and verbal advice from
trained field officers fluent in
Chinese. Safety messages were also
communicated via television, radio,
newspapers and magazines
(FR) Initial on-site
structured survey to
enhance understanding
of fisher’s socio-
information, awareness
of fishing safety
project, safety
knowledge, attitudes,
and behaviours.
Responses integrated
into prevention
program strategies.
4-year follow-up almost 2/3rds surveyed each
year were not aware of the Fisher Safety
project (M=64.8 %).
Cross sectional—no
causality can be
2006 n =250 Fishers’ awareness of severity of risk ass’d
with drowning increased 50 % in 2006 to
66 % in 2010
2007 n =112 Self-efficacy of preventive actions: avoiding
fishing in bad weather, no change 86 %
2006 & 2010
2008 n =241 Knowledge of sea would keep safe, increased
2006, 20 % versus 2010, 33 %
2009 n =128 A comparison of 2006–2010 revealed a
significant decrease in fishers reporting they
never wear a lifejacket (2006: 72 %, 95 %
CI 0.66–0.77; 2010: 34 %, 95 % CI
0.25–0.44); and never wear gumboots or
waders (2006: 64 %, 95 % CI 0.63–0.76;
2010: 45 % (95 % CI 0.36–0.54). There
was a significant negative change in fishers
reporting never drinking alcohol when
fishing (2006: 80 %, 95 % CI 0.75–0.85;
2010: 54 %, 95 % CI 0.49–0.67)
2010 n =107 No other significant reported changes in
behaviours such as turning your back to the
sea, taking a cell phone and checking the
weather beforehand.
J Community Health
Table 2 continued
Setting &
sample (n)
response rate
Duration; & Drowning
prevention strategies
Behavioural theory
research (FR)
Evaluation design &
Intervention effects: impact/outcome/
of the
Total n =838
45–70 %
Asian over
Age range:
Sex: 83–92 %
male over
the sample
Retrospective analysis of drowning prevention policy or practice (n =2)
et al.
United States Records for 104,683
people in 46,234
vessels were
assessed. 1,597
boaters in 625 vessels
met the inclusion
Length: 6 years (2000–2006) BT & FR–NR Matched cohort Only 21 % (336/1,597) of the boaters wore a
PFD. Wearers were more often female and
less often aged 20–39 years compared with
persons who did not wear a PFD
for age and
Strategies: reviewed US Coast Guards
electronic Boating Accident Report
Database and US compressed
mortality files. Estimated risk ratios
by comparing outcomes for people in
each vessel.
Drowning deaths of boaters
from the same vessel
comparing outcomes for
those who entered the water
wearing a PFD with those
who did not wear a PFD
Unadjusted RR for drowning among those
wearing a PFD, compared with those who
did not 0.78 (95 % CI 0.68–0.91).
selection and
bias noted,
plus bias due
to missing
Age range:
82 % over
20 years of
Adjusted RR was 0.49 (95 % CI 0.31–0.78)
Sex: 90 %
et al.
United States Recruitment: N/A Length: 21 years (1970–1990) BT & FR–NR Cross sectional time series No significant association between drowning
and MLDA was found for any of the age
groups studied.
Failed to show
drowning and
changes in
public policy
J Community Health
messages [14], one used both video messages coupled with
educational sessions and community events [24], one used
face to face education sessions [22] and one new tech-
nology in the form of i-Pad presentations shown to
beachgoers [5]. The development and pre-testing of the
media materials was not described by any of the studies.
One US study implemented an environmental strategy in
the form of a loan program of life jackets for local beach
goers [24] (see Table 2).
The two analysis studies assessed the effects of legis-
lative changes in the minimum legal drinking age on
drowning [6], and the association between death by
drowning in recreational boaters and wearing a personal
floatation device (see Table 2).
Behavioural Theory and Formative Research
Two of the studies reviewed stated using a behaviour
change theory to underpin strategy development [5,22].
The Health Belief Model [20] was used to develop an
intervention to ‘‘increase the lifeguards’ perception of
susceptibility of drowning’’ [22], ‘‘educate the lifeguards
about the potential severity of drowning incidents’’, and
‘help lifeguards overcome scanning barriers by reviewing
American Red Cross recommendations about strategies for
pool surveillance and introducing alternative scanning
techniques’’ [22]. The other study was less clear about the
specific use of behaviour change theory in the intervention
and instead identified the use of cognitive theories of
behaviour as the framework to develop the education
campaign [5].
Two of the four interventions reported formative eval-
uation [5,14]. In these studies structured interviews with
beach goers and recreational fishers to assess awareness,
knowledge, beliefs and behaviours towards personal beach
safety and fishing safety were completed prior to strategy
design and implementation [5,14] (see Table 2).
Intervention Effects
Of the four drowning prevention interventions reviewed all
reported positive changes in short term effects. These
included awareness of the intervention messages for two of
the interventions, Don’t get sucked in by the rip (Australia)
[5], and Fisher Safety Project (NZ) [14]. Together with
confidence in identifying a rip, intentions to swim outside
a rip, and improved ability to identify a rip [5]. In addition,
perceptions of the severity of the risk of drowning and
vulnerability to risk were reported as ‘appearing’ to have
improved, however perceptions of the efficacy of pre-
ventive action such as avoiding fishing in bad weather did
not change over a 5 years intervention prevention period
Table 2 continued
Setting &
sample (n)
response rate
Duration; & Drowning
prevention strategies
Behavioural theory
research (FR)
Evaluation design & measures Intervention effects: impact/outcome/
of the
Response rate:
Strategy: used pooled cross sectional
time series analysis to test effects of
changes in MLDA on drowning rates.
Information derived from the US
National Health Statistics Mortality
Impact of changes in MLDA on drowning
15–23 years
Also considered: urbanicity, unemployment,
poverty, education, divorce, police per
capita, all age liquor law arrests, state beer
tax, and residence within 30 miles of a
border state with a lower drinking age.
not reported
Ass’d associated, CI confidence intervals, MLDA minimum legal drinking age, N/Anot applicable, NR not reported for one or either outcome, RR rate ratio
J Community Health
In the Fisher Safety Project (NZ) there was a significant
increase in the use of life jackets by fishers; 72 % (95 % CI
0.66–0.77) in 2010 compared to 34 % (95 % CI 0.25–0.44)
of fishers in 2006. Changes in behaviour were reported for
turning your back to the sea when fishing and checking
weather/water conditions before setting out however, these
were not significant [14]. Personal floatation device usage
increased in adults from 19.9–31.3 % (p[0.001) post
intervention in King County, Washington, US however,
there were no differences between males and females [24].
In the Lifeguard (US) observational study, there was a
change in two of the three lifeguard behaviours including
‘decreased distraction’ and ‘increased scanning’, both
changes in behaviour were significant [22]. Alcohol use
had a negative change in behaviour in the Fisher Safety
Project (NZ), with 54 % (95 % CI 0.49–0.67) of fishers
never drinking alcohol in 2010 compared to 80 % (95 %
CI 0.75–0.85) in 2006 [14].
Of the two analysis studies, one reported that wearing
a personal floatation device reduced the risk of drowning
by almost half [Adjusted RR 0.49 (95 % CI 0.31–0.78)]
[2], and no significant association between drowning and
minimum legal drinking age was found for any of the
adult age groups analysed in the second study [6](see
Table 2).
Identified Limitation of the Study Design
Four of the six studies reported less than optimal par-
ticipant recruitment and sampling [2,5,14,23]. In
addition, observational data collection and missing data
resulted in poor power calculations [2,22], and limited
Adult drowning is a multifaceted and complex public
health issue, highlighted by a paucity of published peer-
reviewed research outcomes. This review of six adult
drowning prevention studies delivered between 1990 and
2012 found mixed results for the overall design, delivery
and effectiveness of interventions. All of the interventions
reviewed were delivered in high income countries. Inter-
ventions varied by duration, strategies employed and
diversity of evaluation measures. Five different evaluation
designs were utilised across the six studies. There was little
use of conceptual theories or frameworks and formative
evaluation as part of the intervention design. The four
drowning prevention interventions varied from just several
weeks to 5 years, whilst the analysis studies ranged from
six to 21 years and provided an opportunity to measure
sustained behaviour change. Evaluation focussed on short
term effects such as awareness, intermediate effects such as
knowledge and intention, and changes in drowning pre-
vention behaviour; measurement varied however for
almost all the studies.
Behavioural Theory and Formative Research
Drowning prevention behaviour namely supervision,
attention, and concentration is inherently psychological in
nature, however behavioural theory has been used spar-
ingly in adult prevention program design [22]. Only two
interventions described the use of behavioural theory to
guide the development of their intervention, Don’t get
sucked in by the rip [5] and, the US brief lifeguard inter-
vention [22]. The brief US lifeguard intervention was
framed around three Health Belief Model constructs, and
targeted the lifeguards’ perception of susceptibility for
drowning incidents, the potential severity of drowning and
near-drowning incidents in public swimming pools, and
perceived barriers about conducting surveillance over
longer time periods [22]. Hatfield et al. [5] highlighted their
study as being one of few to thoroughly address near
drowning intervention development and evaluation meth-
odology. However, the authors did not describe in any
detail the theory or constructs used to guide the design and
development of the campaign materials, simply noting the
campaign was developed using relevant psychological
theory [5]. Of interest, only two of the interventions used
formative research to inform the design of educational
materials [5,14] and to subsequently update materials [14],
which is an important component of effective health pro-
motion practice [15].
Overall, the review shows the limited use of behavioural
and evaluation theory, and reinforces the need to employ a
theory-based approach to injury prevention programs spe-
cifically drowning, to enhance the design, implementation
and evaluation [25]. Accordingly, there is a requirement for
a multi-disciplinary team approach when designing future
drowning prevention interventions, to ensure that inter-
ventions are built on robust health promotion foundations
Previously interventions have focussed and reported on
the proximal or short term effects in the prevention of adult
drowning including: raising general awareness; education
of high risk groups; and promoting the reduction of alcohol
consumption while boating and the use of personal floa-
tation devices [19]. Over 5 years ago, the International Life
Saving Federation (ILS) developed a framework of best
practice to assist nations and organisations to reduce
drowning [8]. This framework recommended continuous
evaluation of interventions with results being well docu-
mented and shared so that results that demonstrate some
effectiveness can inform practice and prioritisation of
J Community Health
interventions [8]. In addition, the framework highlighted
that communication and behaviour change theory as an
integral part of the evidence based intervention design was
essential. To date this approach to the design and delivery
of interventions to prevent drowning events has yet to be
implemented widely, resulting in a scarcity of clear, the-
oretically based relevant information and interventions.
The six interventions reviewed used different measures
including self-report [5,14] and observation [22,24]to
assess changes in drowning prevention behaviour. These
measures have well known inherent limitations, such as
measurement bias and social desirability [3,15]. Two of
the studies retrospectively analysed data to determine
changes in annual drowning deaths [2,5]. In a recent
review of drowning prevention in children and adolescents
they also reported a lack of consistent measures of expo-
sure data [19]. The establishment of valid, reliable and
standardised measures that are comparable across drown-
ing prevention interventions are recommended for future
research. This will enhance capacity for assessing effec-
tiveness across campaigns both nationally and globally.
Drowning Prevention Effectiveness
After 5 years just over one-third of fishers reported that
they were aware of the ‘Fisher Safety Project’’ (NZ)
campaign in the previous year. However, they reported
statistically significant decreases in never wearing a life
jacket, gumboots or waders [14]. It is concerning that so
few fishers were aware of the Fisher Safety Project how-
ever, this may in part be explained by the respondents who
included infrequent visitors to the sites where they were
interviewed, recent residents and non-English speaking
fishers [14]. These factors made the measurement of impact
problematic. The Don’t get sucked in by the rip (Australia)
reported a significant impact on correct identification, and
swimming intention, in relation to a rip [5]. Lifeguard
distraction reduced and scanning behaviour significantly
increased in the shorter lifeguard intervention, however, it
was noted that the lifeguards behaviour change ‘dwindled’
over time [22]. As with other public health issues,
drowning prevention requires ‘‘booster’’ campaigns over
the course of time to maintain and sustain behaviour
change outcomes, and ideally would comprise multilevel
interventions including a combination of educational,
environmental and policy components [9,19] Overall, the
intervention effects in this review were short-term and not
replicated, and could be summarised as insufficient evi-
dence to determine intervention effectiveness.
Implications for Policy and Research Needs
Drowning prevention designs and the measurements used
to evaluate the interventions need to be more robust if the
level of observed evidence is to be influential with policy
makers [17]. There is an acute need for adult drowning
interventions to use appropriate study designs, objective,
valid and reliable measures, larger representative samples,
and quality evaluations of a sufficient time period. Fur-
thermore, it is essential that results are reviewed for rigour
and published in the peer reviewed literature [1].
Many drowning prevention interventions are conducted
by community based agencies and, these agencies may not
have the capacity or research expertise to effectively
evaluate programs. In addition, drowning prevention
campaigns may be subject to evaluation that are not doc-
umented and disseminated appropriately. On review, this
seems to be a frequent feature of drowning prevention
interventions that are funded and/or delivered by not for
profit agencies and community based organisations, per-
haps due to a lack of dedicated funding to invest in quality
evaluation, being funded to provide specific outputs or
competing priorities from funding bodies [4].
Better documentation and dissemination could be
addressed through greater collaboration between research
academics and community based organisations. Potentially
this could enhance the distribution of research findings in
both peer, and non-peer reviewed forums, build capacity
and increase knowledge transfer between stakeholders, and
accordingly is recommended as future priority between
practitioners and researchers.
Methodological Limitations
This review has a number of limitations. Although six
databases were included in the search strategy, time limits
were imposed and studies were restricted to publications in
the English language. In addition, evaluations reported
outside peer-reviewed journals were not captured and no
grey (fugitive) literature was reviewed. All final interven-
tions included in the review were delivered in high income
countries and many were from the US, limiting the gen-
eralisability of these findings to other countries or regions,
especially LMICs. It is recognised that they present a
unique and different set of priorities to high income
countries. Accordingly, there is a need for greater, ongoing
research to be undertaken.
The complexity of the issues surrounding drowning
requires the collection of robust drowning data and
J Community Health
evaluation of preventative measures to support the devel-
opment of targeted and tailored prevention interventions.
This review reinforces the need for a genuine and sustained
global approach to addressing adult drowning prevention,
with consideration of potential pitfalls to be avoided such
as, quality evaluations of a sufficient time period, and the
need for collaboration around a prioritised research agenda
[13]. Adult fatal and non-fatal drowning are a priority for
prevention and evidence informed health promotion
approaches to intervention implementation and evaluation
should be adopted for maximum gains. Accordingly,
drowning must be recognised as a serious public health
issue and receive the same attention as other public health
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J Community Health
... Intervening at the population-level using a multi-faceted strategy such as a combination of individual, environmental and populationlevel interventions within a socio-ecological framework is increasingly considered an effective approach for intervention (Golden & Earp, 2012;Leavy et al., 2016;Vlachantoni et al., 2013). Population-level interventions aim to improve the health of an entire population within and across a defined regional or national population. ...
... First, many interventions and strategies have historically focused on the individual-level or environmental modification at a microenvironment or local scale including but not limited to, lifeguard presence (Chan et al., 2018), promoting adult supervision for children (Cenderadewi et al., 2019;Mahony et al., 2017;, water familiarisation interventions (Taylor et al., 2020), placement of rescue equipment and improving early basic life support (Franklin et al., 2010). Interestingly, a recent 2023 review of interventions for drowning prevention among adults (Leavy et al., 2023) found that there had been a shift away since a previous review (Leavy et al., 2016) (in 2016) from a predominance of behavioural-only strategies which emphasise education towards population-level interventions (Leavy et al., 2023). This is important, as regulatory or environmental changes are more likely to produce population-level outcomes, which are cost-effective long term as well as translate into sustained behaviour change (Barnsley et al., 2018;Golden & Earp, 2012;Vlachantoni et al., 2013). ...
Globally, drowning is the third leading cause of unintentional injury death, accounting for 7% of all injury-related deaths. This study aimed to examine the spatial clustering in UK drowning incidents. Data were obtained from the Water Incident Database (WAID) (1/1/2012–31/12/19). We examined spatial clustering of intentional and unintentional drownings using a density-based spatial clustering of applications with the noise method (DBSCAN). Intentional and unintentional events were delineated to establish thresholds for cluster identification for moderate, high and very high priority areas respectively, all within a 500-m radius (i.e., 5–7 min walk) of the water network. We identified 2 very high priority (minPts 8), 5 high priority (minPts 6) and 21 moderate priority (minimum points [minPts] 4) areas for unintentional drowning. This study also identified 4 very high priority (minPts 16), 16 high priority (minPts 8) and 36 moderate priority (minPts 4) areas for intentional drownings. Our findings serve to identify priority spatial locations, which provide important foundations for drowning prevention interventions. Prevention efforts should now consider the wider determinants of drowning in these areas, including accounting for the evident spatial patterns in drowning events. Our study addresses key priorities of United Nations and World Health Organisation's drowning prevention guidelines.
... This is evident from the fact that the rate of drowning in LMICs in Africa and Asia is 10 to 20 times more than that in the United States [6]. Successful intervention strategies from HICs may not be applicable in LMICs since drowning occurs in day-to-day settings in LMICs, while it is associated with recreational activities such as swimming in HICs [7]. ...
... The toll is greatest in low and middle-income countries (LMICs) that suffer over 90% of the burden. 1 In high-income countries (HICs), drownings mostly occur during leisure and recreational activities. [2][3][4] Conversely, the majority of drownings in LMICs occur during occupational activities and other activities of daily living such as fishing, collecting water and travelling. [5][6][7] The World Health Organization (WHO) -African region bears the world's highest estimated drowning death rates at 8/100 000 population. 1 8 Moreover, these global estimates do not include drownings from transportation and flood disasters which are frequent in many low-income settings. ...
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Background Drowning is a major cause of unintentional injury death worldwide. The toll is greatest in low and middle-income countries. Over 95% of people who drowned while boating in Uganda were not wearing a lifejacket. We explored the determinants of lifejacket use among boaters on Lake Albert, Uganda. Methods We conducted a qualitative enquiry with a hermeneutic phenomenological undertone leaning on relativism ontology and emic subjectivism epistemology. Focus group discussions (FGDs) and in-depth interviews (IDIs) were held with boaters in 10 landing sites. We explored experiences and perspectives on lifejacket use. We used thematic analysis technique to analyse data and report results according to the Consolidated Criteria for Reporting Qualitative Research. Results We recruited 88 boaters in 10 FGDs and 11 to take part in the IDIs. We identified three themes: motivators and opportunities for lifejacket use, barriers and threats to lifejacket use, and strategies to improve lifejacket use. Many boaters attributed their lifejacket use to prior experience or witness of a drowning. Perceived high costs of lifejackets, limited knowledge, reluctance to use lifejackets because of distrust in their effectiveness, and the belief that it is women who should wear lifejackets were among the barriers and threats. Participants mentioned the need for mandatory enforcement together with community sensitisations as strategies to improve lifejacket use. Conclusion Determinants of lifejacket use among boaters include experience or witness of drowning, limited knowledge about lifejackets and distrust in the effectiveness of the available lifejackets. Mandatory lifejacket wearing alongside educational interventions might improve lifejacket use.
... Research on interventions to reduce alcohol-related drowning or burns is scarce. A study of minimum-legal drinking age laws in the USA found no impact on young-adult drowning rates [147], while programs aiming to reduce alcohol consumption while boating and fishing remain largely unevaluated [148]. Similarly, evaluation studies of workplace alcohol and drug testing are poor, with only one relatively high-quality study finding an effect of testing in the transport industry [149]. ...
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Globally, almost four and a half million people died from injury in 2019. Alcohol’s contribution to injury-related premature loss of life, disability and ill-health is pervasive, touching individuals, families and societies throughout the world. We conducted a review of research evidence for alcohol’s causal role in injury by focusing on previously published systematic reviews, meta-analyses and where indicated, key studies. The review summarises evidence for pharmacological and physiological effects that support postulated causal pathways, highlights findings and knowledge gaps relevant to specific forms of injury (i.e., violence, suicide and self-harm, road injury, falls, burns, workplace injuries) and lays out options for evidence-based prevention.
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Background Occupational drowning is a growing public health concern globally. The human cost of fishing is highest in sub-Saharan Africa. Although lifejackets prevent drowning, the majority of boaters in Uganda do not wear them. We developed and validated a peer-to-peer training manual to improve lifejacket wear among occupational boaters on Lake Albert, Uganda. Methods The intervention was developed in three stages. In stage one, we conducted baseline studies to explore and identify aspects of practices that need to change. In stage two, we held a stakeholder workshop to identify relevant interventions following the intervention functions of the behaviour change wheel (BCW). In stage three, we developed the content and identified its implementation strategies. We validated the intervention package using the Content Validity Index for each item (I-CVI) and scale (S-CVI/Ave). Results Seven interventions were identified and proposed by stakeholders. Training and sensitisation by peers were unanimously preferred. The lowest I-CVI for the content was 86%, with an S-CVI/Ave of 98%. This indicates that the intervention package was highly relevant to the target community. Conclusion The stakeholder workshop enabled a participatory approach to identify the most appropriate intervention. All the proposed interventions fell under one of the intervention functions of the BCW. The intervention should be evaluated for its effectiveness in improving lifejacket wear among occupational boaters.
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The application of the Haddon matrix in identifying drowning prevention solutions in the north of Iran is necessary. We dealt with drownings on three levels of prevention including before, during, and after the injury in northern Iran (Guilan province). This study aimed to investigate the use of Haddon's matrix in preventing three-level drowning cases before, during, and after the accident in the north of Iran. This qualitative study consisted of 9 focus groups with a sample size of 78 people including 48 nursing staff, 21 emergency medicine specialists, and 30 people from non-medical personnel (local community leaders, executive officials of relevant organizations, lifeguards, staff working in health centers, and families of victims). All group discussions were recorded and the questions were based on the focus group table. According to Haddon's table of results, the major risk group was the young and adolescent boys and more in the area of neglect in culture-building and education. In this study, the role of factors was investigated separately and the necessary solutions were presented that can be used as a scientific and practical basis to achieve the main goal of drowning prevention. These strategies require cross-sectoral collaboration, which seems to be a strong interaction with a greater focus on major risk groups to address deficiencies and prevent the recurrence of potential accidents. The study aimed to investigate the use of Haddon's matrix in the prevention of three-level drowning cases before the event, during the event, and after the event in northern Iran.
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Introduction: This retrospective observational study aims to create a comprehensive database of the circumstances of drowning (including care provided and outcomes of care) to report against the Utstein style for drowning (USFD) for patients presenting to the emergency department (ED). Four areas will be examined: a feasibility study of the USFD; a comparison of classification and prognostication systems; examination of indications and efficacy of different ventilation strategies; and differences in the circumstances, severity, treatment and outcomes of drowning by sex and gender. Methods and analysis: This protocol outlines retrospective data collection for all patients presenting to EDs of the Sunshine Coast Hospital and Health Service in Queensland, Australia with the presenting problem or discharge diagnosis of drowning or immersion between 2015 and 2022. Patients computerised health records (emergency medical service record, pathology, radiology results, medical and nursing notes for ED, inpatient units and intensive care units) will be used to extract data for entry into an USFD database. Descriptive (eg, median, IQR) and inferential statistical analyses (eg, analysis of variance) will be used to answer the separate research questions. Development of an International Drowning Registry using the USFD dataset and the Research Electronic Data Capture (REDCap) web application is discussed. Ethics and dissemination: This study has been approved by Metro North Human Research and Ethics Committee (Project No: 49754) and James Cook University Human Research Ethics Committee (H8014). It has been endorsed by national drowning prevention organisations Royal Life Saving Society Australia (RLSSA) and Surf Life Saving Australia (SLSA). Study findings will provide data to better inform clinical management of drowning patients and provide an evidence base on sex and gender differences in drowning. Results will be disseminated through peer review publications, conference presentations and media releases. Results will also be disseminated through RLSSA and SLSA membership of the Australian and New Zealand Resuscitation Council and the Australian Water Safety Council.
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Adult drowning is a complex and multifactorial public health challenge requiring community, national and global efforts to mitigate impacts. This study updates the evidence base for public health interventions that address adult fatal and non-fatal drowning. A systematic review was undertaken of the peer-reviewed literature for English-language primary studies published between 2011 and 2021describing a drowning intervention with adults. Twenty-two studies were included. Most studies (n = 16) were conducted in high-income countries. Yearly trends in drowning prevention intervention publications were analysed with 2015 (n = 6) the peak publishing year. Over half of the study designs were pre-post (n = 15). Intervention duration ranged from 4 hours to 11 years. Ten studies described either behaviour change theory or formative evaluation to inform design. Thirteen studies targeted interventions at a population level, seven at a group level and two at individual level. Studies identified a range of prevention strategies, categorised as behavioural (n = 9) (e.g., swimming lessons), socio-ecological (n = 8) (e.g., mandatory personal flotation devices) and mixed (n = 5) (e.g., awareness campaign and barriers to prevent access to water). A range of outcomes were described including changes in awareness, water safety knowledge, attitudes, water safety behaviours and skills, environmental, policy and regulation changes and drowning rates. Findings indicate a small but important increase in the evaluation and publication of effective interventions to prevent adult drowning. The complexity of the issues surrounding drowning requires multi-strategy and context -specific adult focused prevention interventions. Contemporary evidence that identifies effective interventions that contribute to prevention efforts is an essential first step in addressing the challenge.
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Drowning is the leading cause of death from unintended injury in children globally. Drowning is preventable, and mechanisms exist which can reduce its impact, however the peer-reviewed literature to guide public health interventions is lacking. This paper describes a protocol for a review of drowning prevention interventions for children. Electronic searching will identify relevant peer-reviewed literature describing interventions to prevent child drowning worldwide. Outcome measures will include: drowning rates, water safety behaviour change, knowledge and/or attitude change, water safety policy and legislation, changes to environment and water safety skills. Quality appraisal and data extraction will be independently completed by two researchers using standardised forms recording descriptive and outcome data for each included article. Data analysis and presentation of results will occur after data have been extracted. This review will map the types of interventions being implemented to prevent drowning amongst children and identify gaps within the literature.
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In 2006, a safety campaign was launched in Auckland, New Zealand to combat a spate of drowning incidents associated with fishing from rocky foreshores. This paper provides data from surveys of fishers from 2006 to 10 to determine if preventive behaviors have been adopted after five years of safety promotion. The most significant change in self-reported behavior related to the increased use of life jackets with 34% (95% CI = 0.25–0.44) of fishers in 2010 compared with 72% (95% CI = 0.66–0.77) in 2006 reporting never wearing a life jacket. Some risky behaviors (such as consuming alcohol) and at-risk attitudes (such as overconfi-dence in their local knowledge) persisted. The cultural and linguistic diversity of fishers, together with their transient participation, make them a difficult group to reach with education interventions, although changes in life jacket use were encouraging. Continuation of the safety campaign is recommended, and ways to further enhance fisher safety are discussed.
Worldwide, more than 300,000 workers are killed each year by traumatic injuries [1]. Work-related deaths have important societal impacts particularly in low- and middle-income countries where numerous people are involved in high-risk industries such as agriculture, fishing, and mining [2]. In the United States, the leading causes of work-related deaths are highway crashes, homicides, falls, and struck by object [3]. Drownings, however, occur to workers exposed to environmental hazards leading to submersion. Any maritime worker, including commercial fishers, merchant mariners, tugboat operators, and other water transportation workers, is exposed to drowning hazards. Construction workers, agricultural workers, and groundskeepers are also exposed to these hazards.
This book critically examines the potential of, and suggests ways forward in, harnessing a versatile and powerful method of research - focus groups. The book challenges some of the emerging orthodoxies and presents accessible, insightful and reflective discussions about the issues around focus group work. The contributors, an impressive group of experienced researchers from a range of disciplines and traditions, discuss different ways of designing, conducting and analyzing focus group research. They examine sampling strategies; the implications of combining focus groups with other methods; accessing views of 'minority' groups; their contribution to participatory or feminist research; use of software packages; discourse anal. © Springer-Verlag Berlin Heidelberg 2006. All rights are reserved.
The UK National Institute for Health and Clinical Excellence (NICE) provides guidance on promoting good health and preventing and treating ill health. NICE makes recommendations using the best available evidence. In 2005, the organization's remit widened from a clinical focus to include producing public health guidance on health promotion. This chapter discusses the mechanisms NICE has developed for involving the public in its work and supporting that involvement for mutual benefit.
The objective of this research was to evaluate a campaign to improve beachgoer recognition of calm-looking rip currents, known to contribute to surf drowning. Posters, postcards, and brochures conveying the message "Don't get sucked in by the rip" were distributed in an intervention area. Beachgoers were interviewed in this and a similar control area one year before and immediately after the intervention (respective response rates: 69.9% and 82.3%), Consenting respondents were sent follow-up questionnaires after approximately 6 months and 55% responded. In the intervention area, 28.8% of post-intervention, and 57.2% of follow-up respondents, had seen our campaign. At post-intervention, intervention respondents demonstrated improvement (relative to baseline) in intentions to swim away from a calm-looking rip, ability and confidence in identifying a rip, intention never to swim at unpatrolled beaches, and responses to being caught in a rip, compared to the control respondents. Similar improvements were observed post-intervention for respondents in the intervention area who had seen our campaign (relative to those who had not), and at 6 month follow-up for intervention respondents (relative to control respondents). The relatively brief print-based campaign was effective in warning beachgoers about calm-looking rips.
This study identified and reviewed grey literature relating to factors facilitating and inhibiting effective interventions in three areas: the promotion of mental health and well-being, the improvement of food and nutrition, and interventions seeking to increase engagement in physical activity. Study design: Sourcing, reviewing and analysis of relevant grey literature. Evidence was collected from a variety of non-traditional sources. Thirty-six pieces of documentary evidence across the three areas were selected for in-depth appraisal and review. A variety of approaches, often short-term, were used both as interventions and outcome measures. Interventions tended to have common outcomes, enabling the identification of themes. These included improvements in participant well-being as well as identification of barriers to, and promoters of, success. Most interventions demonstrated some positive impact, although some did not. This was particularly the case for more objective measures of change, such as physiological measurements, particularly when used to evaluate short-term interventions. Objective health measurement as part of an intervention may act as a catalyst for future behaviour change. Time is an important factor that could either promote or impede the success of interventions for both participants and facilitators. Likewise, the importance of involving all stakeholders, including participants, when planning health promoting interventions was established as an important indicator of success. Despite its limited scope, this review suggests that interventions can be more efficient and effective. For example, larger-scale, longer-term interventions could be more efficient, whilst outcomes relating to the implementation and beyond could provide a clearer picture of effectiveness. Additionally, interventions and evaluations must be flexible, evolve in partnership with local communities, and reflect local need and context.
The article presents a study on drowning as the major cause of mortality and morbidity of the children in Brisbane, Queensland. It states that the drowning death rates of young children, aging 0-4 years old, had decreased after the introduction of safety legislation. The study has shown that the drowning incidents of young children will continue to reduce with the introduction of safety legislation and enforced compliance, in combination with education for safety and ongoing advocacy.