Article Text

Identifying opportunities for multisectoral action for drowning prevention: a scoping review
  1. Justin-Paul Scarr1,2,
  2. Jagnoor Jagnoor1,3
  1. 1 The George Institute for Global Health, University of New South Wales, Sydney, Newtown, New South Wales, Australia
  2. 2 Royal Life Saving Society - Australia, Broadway, New South Wales, Australia
  3. 3 Injury Division, The George Institute for Global Health, New Delhi, India
  1. Correspondence to Mr Justin-Paul Scarr, The George Institute for Global Health, Newtown, New South Wales, Australia; jscarr{at}


Background Drowning is a complex health issue, where global agendas call for greater emphasis on multisectoral action, and engagement with sectors not yet involved in prevention efforts. Here, we explored the conceptual boundaries of drowning prevention in peer-review and grey literature, by reviewing the contexts, interventions, terminologies, concepts, planning models, and sector involvement, to identify opportunities for multisectoral action.

Methods We applied scoping review method and have reported against Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist. We searched four electronic databases for peer-reviewed articles published on 1 January 2005 and 31 December 2020 and five databases for grey literature published on 1 January 2014 and 31 December 2020. We applied the search term “drowning,” and charted data addressing our research questions.

Results We included 737 peer-reviewed articles and 68 grey documents. Peer-publications reported situational assessments (n=478, 64.86%) and intervention research (n=259, 35.14%). Drowning was reported in the context of injury (n=157, 21.30%), commonly in childhood injury (n=72, 9.77%), mortality studies (n=60, 8.14%) and in grey documents addressing adolescent, child, environmental, occupational and urban health, refugee and migrant safety and disaster. Intervention research was mapped to World Health Organization recommended actions. The leading sectors in interventions were health, leisure, education and emergency services.

Conclusion Although drowning is often described as a major health issue, the sectors and stakeholders involved are multifarious. The interventions are more often initiated by non-health sectors, meaning multisectoral action is critical. Framing drowning prevention to reinforce cobenefits for other health and development agendas could strengthen multisectoral action. Greater investment in partnerships with non-health sectors, encouraging joint planning and implementation, and creating systems for increased accountability should be a priority in future years.

  • Drowning
  • Systematic Review
  • Global
  • Advocacy

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All data relevant to the study are included in the article.

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  • Drowning is a complex health issue that has disproportionate impacts on children, older adults, socially and economically disadvantaged populations and those living in low-income and middle-income countries.

  • The World Health Organization and the United Nations Resolution on Global Drowning Prevention, 2021 call for increased in multisectoral action, especially with sectors not yet engaged in prevention efforts.


  • We identify that more than two-thirds of peer-review studies are situational assessments that contribute to contextual understanding of the drowning problem, often within injury and other mortality studies.

  • We identify intersections of drowning within adolescent, child, environmental, occupational and urban health, refugee and migrant safety, and disaster risk reduction agendas.

  • The review findings build deeper understanding on the role of non-health sectors such as leisure, education, emergency services and transport in initiating drowning prevention interventions.


  • There is a need to strengthen multisectoral action by framing drowning prevention in ways that reinforce mutual benefits for other health and development agendas.

  • There is a need for implementation research to expand WHO recommended interventions for diverse risks, contexts and settings.

  • There is a need for investment in strategic frameworks for multisectoral action with non-health sectors, and to coproduce drowning prevention policies, plans and interventions.


Drowning is a complex health issue, newly visible in global health and development discourse.1 Global estimates for drowning exceed 236 000 deaths annually. The greatest burden is borne by children, older adults, socially and economically disadvantaged populations and those living in low-income countries and low-income and middle-income countries (LMICs).2 Understanding of the drowning problem is improving, with research growing 103-fold between 1995 and 2020.3 This new evidence and recognition of the need for coordinated responses for drowning prevention has increased global engagement.

In 2014, the World Health Organization (WHO) described drowning as a highly preventable public health challenge never before targeted by global strategic prevention efforts.4 WHO subsequently recommended 10 key actions to prevent drowning, published intervention guidance5 6 and status reports in western-pacific and south-east Asian regions.7 8 In 2021, the United Nations (UN) adopted a Resolution on Global Drowning Prevention (the Resolution), calling for improved data in adolescent, climate, disaster, and occupational-related settings and across communities most susceptible to drowning.9 Ensuring these global developments catalyse action by UN agencies, national governments, civil society, donors and academics requires further consensus on the scope of the problem and its solutions, and the strengthening of multisectoral action (MSA), especially with sectors not yet engaged in drowning prevention.1 2 10

MSA has gained prominence within agendas including universal health coverage and the Sustainable Development Goals and has been studied in the context of progressing health agendas in LMICs.11–13 There are few studies analysing MSA for drowning prevention.14 15 We posit that MSA for drowning prevention may be strengthened by first studying what is known about drowning prevention as a field, identifying the sectors and stakeholders currently active, and by assessing opportunities for engagement with other agendas and disciplines.

We apply scoping review method16 to map the field of drowning prevention. We explore the conceptual boundaries of drowning prevention in peer-review and grey literature. We aim to (1) review studies that provide context to the drowning problem and identify intersections for drowning within other health and development issues, (2) review studies identifying interventions for drowning prevention, (3) identify key terminologies, key concepts and planning models applied in drowning prevention and (4) document the sectors and stakeholders currently involved in drowning prevention interventions. By mapping the boundaries of drowning prevention, we seek to inform future efforts to build consensus, frame drowning in ways to inspire action, expand coalitions with other sectors and to strengthen institutions for MSA.1


We apply scoping review methodology as it supports the identification of key concepts in preparation for evidence synthesis.16 17 The review includes grey literature as it can provide information about implementation and co-ordination of complex interventions not covered by peer-review studies.18

Scoping review method was applied in five stages: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting data and (5) collating, summarising and reporting results.16 We were guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews,19 and registered at OSF registries (

Search strategy and selection criteria

We searched four databases: MEDLINE (via PubMed), the Cochrane Library, Web of Science and Embase for peer-review literature using the search terms “drowning”, “drowning MESH”, and “near drowning”, in titles, abstracts and keywords for the period 1 January 2005 to 31 December 2020.

Four databases; WHO library-Iris, UNICEF website database, Google, Relief Web were searched for grey literature, including global, regional or national level reports and planning documents. The search terms applied were “drowning” and “drowning and water safety” for literature published between 1 January 2014 and 31 December 2020. The search period for peer-review reports on research 10 years prior to the publication of the WHO Global Report on Drowning,4 and for grey literature the search covers the period following this report.

Studies were included if they were systematic reviews, randomised and non-randomised controlled trials, cohort studies, case–control studies, cross-sectional studies, retrospective analysis, observational studies and qualitative studies. Only studies published in English were included. Studies were excluded if they were forensic studies, case reports, animal studies, comments, editorial and letters, conference papers, journal news articles, studies with singular focus on either water quality or intentional drowning.

Grey literature was included if published by UN specialised agencies, multilateral organisations, governments, international or national drowning prevention organisations. For annual or repeated publications, the most recent version of publications was selected.

Study selection

Screening was conducted by J-PS and JJ in two rounds. First, duplicates were removed using Endnote V.X9. Titles and abstracts were then screened independently by J-PS and JJ using Rayyan. Full texts of all selected articles were obtained.

Data charting

Data extraction tools were piloted in Redcap.20 Three research assistants trained in evidence synthesis were recruited, oriented to the data extraction tool and supervised throughout the data extraction process. Data items were matched to study objectives including study identification, setting, interventions, sectors, stakeholders, research objectives and study outcomes. We charted data to the PROGRESS framework to analyse equity and identify reporting of underserved groups in drowning prevention peer-reviewed literature.21 PROGRESS refers to: Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital.

Collating, summarising and reporting the results

We collated, and reported results in tables, figures, descriptive formats including author derived frameworks that align to study objectives. We applied a micro-meso-macro analytical framework where: macrolevel included global, regional and national domains; mesolevel included institutional, group or programmatic domains; and microlevel applied to individual and community level research. Guided by WHO recommendations,4 5 we created a framework to explore conceptual boundaries, situational assessments and interventions research.

Textual analysis of the terms ‘drowning prevention’ and ‘water safety’ was conducted by first extracting descriptive text blocks from studies and assigning each block a code. The codes were then categorised into frames, defined as the central idea being presented in the text.22

We documented the sectors and stakeholders involved in drowning prevention interventions, after a pilot analysis for situational assessments showed limited insight as most were conducted by academic (health) and/or health sector actors (hospital). Sectors were defined as an array of actors and institutions linked by functional roles or areas of work,23 and charted according to policy areas or topics. (Online appendix 1). The health sector role was classified as lead actor—part of the core mandate of health, supporting actor—a collaboration with a non-health sector where health is not leading or minimal—where health plays little or no role.24 25 Stakeholders were defined as actors (individual or group), who influence or are affected by a concern, process or outcome, and charted into constituency groups; government, UN agency and/or multilateral, international non-government organisation (INGO), NGO, philanthropic group, academia, private sector or healthcare provider. Stakeholder roles were categorised as data analysis, policy-maker, funder or implementer, which included being a participant in an intervention being studied.

Supplemental material


The search yielded 4323 items, and 788 items were selected after duplicate removal and screening of title and abstracts. Seventeen grey documents were added from author records, resulting in 805 studies being selected for synthesis, including peer-reviewed (n=737, 91.55%) and grey literature (n=68, 8.43%) (online appendix 2).

Peer-review studies were initiated by authors from academic (n=582, 78.97%), government (n=374, 50.75%) or NGO (n=75, 10.18%) affiliations. Fifty-one per cent of authors had more than one affiliation (n=378). Peer-reviewed studies were cross-sectional (n=321, 43.55%), retrospective analysis (n=187, 25.37%), systematic reviews (n=61, 8.28%) or randomised and non-randomised controlled trials (n=41, 5.56%) (table 1).

Table 1

Characteristics, design and settings of included peer-review and grey literature

Grey documents were published by UN agencies including WHO, UNICEF, UNHCR, UN Habitat (n=30, 44.11%), NGOs (n=22, 32.35%), governments (n=15, 22.06%) or INGO (n=1, 1.47%). Documents were reports (n=45, 66.18%) or plans (n=23, 33.82%). Eighteen were subcategorised as drowning prevention plans at national (n=11, 61.11%), provincial (n=5, 27.78%) and community level (n=2, 11.11%). The drowning prevention plans were initiated by multistakeholder groups of government and NGOs (n=10, 55.56%), government only (n=6, 33.33%) or multistakeholder groups of NGOs only (n=2, 11.11%), and were from High Income Countries (HICs) (n=14, 77.78%) and LMIC (n=4, 22.22%) settings. All LMIC plans were government initiated (n=4, 100%), and majority of HIC plans were multistakeholder groups of government and NGOs (n=10, 71.43%) (Online appendix 3).

Peer-review studies were categorised as national (n=313, 42.47%), subnational (n=350, 47.75%), or global (n=65, 8.88%) settings and meso (n=307, 41.66%) or macro (n=252, 34.19%) domains (table 1).

Peer-review literature was analysed for equity lens using the PROGRESS framework. Details on gender/sex (n=560, 75.98%), personal characteristics—principally age (n=550, 74.63%) and place of residence (n=289, 39.21%) were most common. Studies were less likely to include religion (n=8, 1.09%), social capital (n=13, 1.76%), occupation (n=83, 11.26%) or education status (n=103, 13.98%) (online appendix 4).

Conceptual boundaries of drowning prevention

A framework to explore the conceptual boundaries of drowning prevention was guided by WHO recommended actions.4 5 Peer-review studies (n=737) were first classified based on their primary objective as (1) situational assessments (n=478, 64.86%), defined as studies providing data identifying contexts for drowning or (2) intervention research (n=259, 35.14%), defined as studies providing data on a prevention measure (figure 1). Then, situational assessment studies were categorised into two subcategories: (1) drowning specific (n=243, 32.97%) or (2) drowning as a subset to another health issue (n=235, 31.89%).

Figure 1

Peer-review studies (n=737); situational assessments or intervention research, and intersections in grey literature (n=68).

Situational assessments providing context to drowning prevention

The situational assessments that were drowning specific reported on drowning context in life stages, drowning risk factors, activities and locations for drowning or events that resulted in drowning (figure 1). Studies often reported on multiple topics. Where drowning appeared within a situational assessment covering another health issue, drowning was commonly reported in injury studies (n=157, 21.30%), mortality studies (n=60, 8.14%) or within a report on specific medical issue, that is, epilepsy or autism (n=18, 2.44%). Childhood injury was the most prominent subset in the injury studies (n=72, 9.77%). The health sector was identified in situational assessments (n=292, 61.09%), principally as a supporting (n=166, 34.73%) or lead actor (n=80, 16.74%), and the health sector played no role in almost half of situational assessments (n=186, 38.91%) (online appendix 5).

Intersections for drowning were identified in grey literature that reported on world health statistics,26 child mortality,27 adolescent health,28 29 alcohol impacts on health,30 environmental health,31 urban health,32 water, sanitation, hygiene and health (WASH),33 occupational health,34 refugees and migration,35 36 and disaster risk reduction.37 Reports identified drowning as an emerging issue in South East Asia Region38 and Europe region.39 40

Interventions for drowning prevention

Interventions were mapped to WHO’s recommended actions from both peer-review literature and drowning prevention plans (table 2). Interventions identified in peer-review studies included; teach school-age children (>6 years) swimming and water safety skills (n=55, 21.24%), train bystanders in safe rescue and resuscitation (n=44, 16.99%), set and enforce safe boating, shipping and ferry regulations (n=31, 11.97%), instal barriers controlling access to water (n=24, 9.27%), provide safe places away from water for preschool aged children (n=23, 8.88%), and build resilience and manage flood risks and other hazards (n=15, 5.79%). Additional interventions were identified that were not directly listed in WHO recommended actions including community education (n=111, 42.86%), lifeguard or rescue services (n=66, 25.48%), or (non-shipping or boating) regulations, that is, signage or alcohol regulations (n=33, 12.74%).

Table 2

WHO recomended actions and sectors in intervention research and drowning prevention plans

Drowning prevention plans were a useful source for identifying interventions that are actively adopted and implemented. Teach school-age children (>6 years) swimming and water safety skills (n=18, 100.00%), train bystanders in safe rescue and resuscitation (n=15, 83.33%), set and enforce safe boating, shipping and ferry regulations (n=13, 72.22%), instal barriers controlling access go water (n=13, 72.22%) were prominent. Again, we identified interventions not listed directly in the WHO recommended actions including community education (n=12, 66.67%), lifeguard or rescue services (n=10, 55.56%) and regulations (n=6, 33.33%). The top three sectors involved in each intervention were identified, noting that the results were affected by overrepresentation of health due to nature of the study (table 2).

Drowning prevention terminology, key concepts and planning models

Data were extracted from studies to identify the use of the terms ‘drowning prevention’ and/or ‘water safety’ and its context. No formal definitions were identified, and the terms were often absent from studies (n=493, 61.33%). The term ‘drowning prevention’ (n=254, 31.55%) was more commonly used than ‘water safety’ (n=191, 23.73%), although some studies used both terms (n=133, 16.52%), at times interchangeably.

Textual analysis was applied to identify how the terms were used (table 3). The term ‘drowning prevention’ was used as a collective term for drowning prevention measures (n=99, 38.98%), as an aim to prevent drowning (n=53, 20.87%) or to label an area of activity or a field (n=44, 17.32%). The term ‘water safety’ was used in association with safety knowledge, skills or behaviours (n=53, 27.75%), in the context of a programme, often with swimming (n=43, 25.51%) or general to safety in the water (n=27, 14.14%).

Table 3

The top five framings for drowning prevention (n=254) and water safety (n=191) in selected studies

The key conceptual models or frameworks used in drowning prevention were identified (Online appendix 6). Nine approaches were found, including adaptations to the public health approach, use of the Haddon Matrix41 and the Hierarchy of Control.42 Drowning prevention specific models were often focused on recreational contexts and included the drowning prevention chain,43 drowning chain of survival44 and open water guidelines developed by Delphi method.45

Government led drowning prevention plans such as those in Philippines, Sri Lanka, Thailand and Vietnam and positioned drowning relative to other health plans. Whereas those developed by multistakeholder forums that included lifesaving NGOs applied a range of approaches. Canada,46 and Western Cape in South Africa, incorporated multiple health and recreational drowning prevention models. The Australian Water Safety Strategy47 presented a codesigned framework of key challenges across life stages, activities, locations and populations. Some provincial level plans, including those identified in Australia (South Australia and Northern Territory), took their planning cues from the respective national plans. The WHO recommended actions4 5 are an influential model and were evident in most plans. Tensions exist between key concepts of drowning prevention in recreational contexts, and those concepts applied to drowning risks and impacts in everyday life, as well as in preferred terminology, drowning prevention or water safety.

Sectors and stakeholders in drowning prevention interventions

We analysed sector involvement in drowning prevention intervention research studies (figure 2). The most common sectors were health (n=175, 67.57%), leisure (n=105, 40.54%), education (n=66, 25.48%) and emergency services (n=47, 18.15%). Disaster (n=7, 2.70%), WASH (n=4, 1.54%), agriculture (n=6, 2.32%) and cities (n=6, 2.32%) sectors were less common. The most common government sector in intervention research was leisure (n=43, 16.60%), health (n=40, 11.97%), emergency services (n=32, 12.36%) and education (n=31, 11.97%).

Figure 2

Sector involvement in intervention research and drowning prevention plans.

The most common sectors in drowning prevention plans were leisure (n=16, 88.89%), emergency services (n=15, 83.33%), health (n=15, 83.33%) and transport (n=14, 77.78%). Disaster (n=3, 16.670%), WASH (n=4, 22.22%), agriculture (n=2, 11.11%) and cities (n=2, 11.11%) sectors were less common.

We analysed cross sector relationships, that is, two sectors identified together in intervention research. The most linked sectors were ‘health and leisure’ (n=46, 17.76%), ‘health and education’ (n=34, 13.13%) and ‘health and emergency services’ (n=32, 12.36%). Non-health relationships included ‘education and leisure’ (n=27, 10.42%), ‘leisure and emergency services’ (n=20, 7.72%) and ‘leisure and transport’ (n=13, 5.02%) (Online appendix 7).

Unsurprisingly, the participation of academic stakeholder constituencies in intervention research was high (n=256, 98.84%). Government (n=144, 55.60%) and NGO (n=101, 39.00%) stakeholder constituencies were also common. Government stakeholders were involved as implementers (n=101, 39.00%) or funders (n=52, 20.08%). NGOs were involved as implementors (n=69, 26.64%) or researchers (n=49, 18.92%) (table 4).

Table 4

Stakeholder constituencies and their roles in intervention research and drowning prevention plans

Government stakeholders were present in all 18 drowning prevention plans, followed by NGOs (n=15, 83.33%) and academics (n=6, 33.33%). Government was involved as policy-makers (n=16, 88.89%), implementers (n=16, 88.89%) or funders (n=13, 72.77%). NGOs were implementors (n=15, 83.33%) or policy-makers (n=11, 61.11%), or researchers (n=8, 44.44%).


This scoping review explores the conceptual boundaries for drowning prevention in peer-review and grey literature. We reviewed studies that provide context to the drowning problem and identified intersections for drowning within other health and development issues. We identified interventions, terminologies, key concepts and planning models used in drowning prevention. We documented the sectors and stakeholders involved to inform future efforts to build consensus, frame drowning in ways to inspire action, expand coalitions and strengthen institutions for MSA for drowning prevention.1

Identify drowning prevention context beyond injury studies

This review found that more than two-thirds of peer-review studies were situational assessments that contribute to context to the drowning problem. Injury studies were prominent. Drowning can be a high proportion of child injury burden in many settings.48 49 Adolescent injury studies,50 sometimes show relatively high proportions of drowning mortality but have not attracted the same focus as child drowning prevention. Few adolescent specific interventions have been identified beyond the promotion of swimming skills.51 52

Drowning is often identified in studies investigating child mortality, a disaster event or where data are gathered through community survey or verbal autopsy methods. Analysis of drowning relative to other injuries or causes of mortality provides a comparative basis for advocacy, context for existing non-drowning interventions and identifies potential for engagement with other sectors and stakeholders.

Studies with a sole focus on drowning mortality or morbidity represent more than one-third of peer-review studies. These studies frequently report life stages, risk factors including alcohol consumption and remoteness, the location of drowning incidents and activities prior to drowning, thereby deepening knowledge of issue specific characteristics. Growth in epidemiological studies is not necessarily matched by a similar increase in implementation research for known interventions, or studies seeking to develop or test novel solutions in the areas where gaps exist.

Investigate intersections with other health and development agendas

Our review of grey literature identified promising intersections for drowning prevention within global reports for adolescent, alcohol, child, environmental, occupational and urban health, refugee and migrant safety, disaster risk reduction and WASH. In one example, adolescent health literature finds that the rate of adolescent mortality due to drowning in African LMICs is almost twice that of Western Pacific LMICs.28 Further, the report notes that other disease and injury burdens have a much greater impact, meaning drowning often has a relatively low rank within countries.28 Drowning mortality is also reported in refugee and migrant transit in Africa and the Mediterranean,35 36 and in WASH sector reports where higher drowning rates were reported in LMICs, and attributed to underdeveloped recreational safety, water transport safety and flood control systems.53

Sadly, simply identifying drowning morality within other health areas may not be enough to ensure these agendas take notice and that drowning prevention efforts gain traction. Kuruvilla et al 23 reinforce the importance of framing a health problem strategically so that other sectors and agendas can see the mutual benefits of collaboration. The identification of mutual benefits requires detailed analysis of potential partner agendas or sectors. Key questions include how these agendas make decisions, prioritise, fund and target interventions, and how they partner with groups from outside of their core interests. Influencing decisions made by non-health actors including those in education, justice, transport, industry and employment sectors to impact on public health is a theme common to many global health and development initiatives. Capturing and disseminating those lessons may inform approaches to MSA for drowning prevention.

Create a more universal framework of recommended actions

Our study identified interventions that feature in peer-review and grey literature but are not directly included within the WHO recommended 10 key actions,4 5 including the provision of community education and lifeguard services. Explanations for these gaps include that: (1) the WHO recommendations are intended to serve LMIC contexts, so may underrepresent traditional HIC approaches to drowning prevention or (2) that while lifeguard and community education are often acceptable to policy makers and practitioner communities, WHO has previously pointed to gaps in evidence for each.54 Perhaps, the more pressing opportunities to strengthen guidance relate to areas outside of child drowning prevention. Creating a more universal framework of recommendations that reflects diverse contexts including drowning prevention for adolescent, occupational and disaster contexts, as well as African and small island nation settings, and links closely to the UN resolution on global drowning prevention,9 should be a priority and may assist in progressing MSA for drowning prevention. The coproduction of such a framework, and a global strategy for drowning prevention, should include diverse policy and practitioner voices, including those with implementation expertise from other sectors, and those from communities with the highest drowning burdens.

Develop framings to inspire MSA

Previous studies identified a tension between the framing of problems and solutions by drowning prevention advocates.1 3 Agreed definitions for key terms ‘drowning prevention’ and ‘water safety’ were absent, and two-thirds of studies used neither term. Instead, our study analysed the framing of both terms in peer-review and grey literature. Studies framed water safety in relation to; the safety knowledge, skills and behaviours; as information or messages communicated in safety initiatives; or as a component of a swimming and water safety programme. In contrast, studies framed drowning prevention in the context of measures or interventions aimed at reducing or preventing drowning; as a specific field; or as an overarching aim. Framing has been shown to be critical to agreement on problems and solutions and subsequent prioritisation of health issues. The variability in framing of drowning prevention and water safety reflects diverse and multidisciplinary approaches. Koon et al 55 identified inconsistent use of terminology in coastal drowning contexts, and proposed that standardisation of terms would enhance the research agenda. Agreed terminology may be as important to external audiences, as it is to insiders to drowning prevention. The development of strategic framings and agreed definitions that are designed to portray drowning prevention in ways that connect with other health and development agendas, and match to their respective terminologies and objectives should be prioritised and may strengthen advocacy outcomes.

Expand theoretical approaches to drowning prevention, matched to potential partner sectors

Our study identified several theoretical approaches to drowning prevention. Two commonly applied examples, the drowning prevention chain43 and the drowning chain of survival44 focus on tertiary and secondary prevention techniques of rescue, resuscitation and medical treatments.56 57 In these models, approaches to prevention commonly focus on influencing individual behaviours through messaging, education or instruction, and were sometimes framed as actions to be taken by lifeguard services. In contrast, the application of frameworks commonly used in injury prevention such the Haddon Matrix41 and the Hierarchy of Control42 has prompted consideration of pre-event factors in drowning prevention approaches. Analysis of conceptual approaches applied by potential partner agendas may assist in building capacity for MSA for drowning prevention. Influencing decisions taken by non-health actors, and targeting social, economic, commercial and political determinants of health are common approaches in health and development agendas. Further analysis of the upstream determinants of drowning may support the identification of cobenefits within these agendas.

Prioritise leadership and governance of MSA for drowning prevention

While drowning is a health issue, drowning prevention is multisectoral and often involves leadership by non-health sectors, including the leisure, education, emergency service and transport sectors prominent in interventions studies. The leisure sector extends to recreational locations such as swimming pools and beaches, activities such as swimming, fishing and boating, and measures including education, risk awareness and safety standards. Analysis of drowning prevention plans shows four sectors; leisure, health, emergency services and transport were prominent. Less than 40% of drowning prevention plans linked to the policies and plans of other sectors. When they did, maritime safety or public health plans were most linked. Further analysis investigating how drowning prevention can be integrated into existing national and local government agendas could lead to increased MSA. Further research on approaches to the governance and co-ordination of drowning prevention plans, and related collaborative activities may provide insights into MSA for drowning prevention.

Multisectoral leadership can be a contested space. As with other injury prevention agendas, a key strategic question remains whether the pathway for the expansion of MSA for drowning prevention is decentralised into other agendas or developed within the existing silo of drowning prevention.58 An analysis of strategic challenges in road traffic injury where WHO has been coordinating efforts with much success for decades, identified the need for designated global lead agency to increase accountability for achieving national targets and action.59 Constraints to WHO leadership in MSA, including a lack of convening power for non-health sectors, are well known in other fields.60 Determining who leads, whether health or non-health, may be less important than ensuring that relevant sectors are well resourced and at the table. Developing agile, inclusive, and equitable governance at all levels should be a key priority for any future global strategy for drowning prevention.


This scoping review is not without limitations. The search term ‘drowning’ may have missed studies not specifically mentioning drowning in title, abstracts or key words. For example, our search identified some resuscitation studies but may have missed those studies focused on technical aspects of treatment without mentioning drowning. Also, the search may have missed studies on rescue, swimming or coastal safety, if their research objectives focused on technical elements, without specific reference to drowning. Health sector prominence in selected literature may reflect the health databases chosen.

Searching grey literature proved an effective method for identifying intersections in other global health and development agendas. A more expansive search using multiple drowning related terms, particularly those focused on accepted interventions and at national and subnational levels may have identified further studies. The search method was less effective in identifying national government policies, where more systematic search methods, and using national research teams may prove more effective. Search methods applied to languages other than English may identify further relevant studies.


This scoping review aimed to map the drowning prevention field and explore the conceptual boundaries of drowning prevention in peer-review and grey literature. Situational assessments in peer-review literature provide context to drowning problems and identify potential interventions. However, more implementation research is needed. Analysis of grey literature identified intersections of drowning within other health and development agendas, including adolescent, child, environmental, occupational and urban health, migrant and refugee safety, and disaster risk reduction. Mapping intervention research to WHO recommendations identified a need to create a more universal and strategic framework to address diverse contexts and settings, and more effectively align to other health and development agendas.

MSA for drowning prevention could be strengthened by the development of agreed definitions and strategic framings designed to initiate and enhance partnerships with other health and development agendas. Reframing drowning prevention as multisectoral issue requires working with and beyond the health, leisure, education and emergency service sectors that we identified as being central to drowning prevention. Greater investment in drowning prevention partnerships with non-health sectors, encouraging joint planning and implementation, and creating systems for increased accountability should be a priority in future years.

Data availability statement

All data relevant to the study are included in the article.

Ethics statements

Patient consent for publication


We acknowledge the research assistants who helped with data extraction including Deepti Beri, Pompy Konwar, and Sucharita Panigrahi of The George Institute for Global Health, India.


Supplementary materials

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  • Twitter @JustinScarr, @jjagnoor80

  • Contributors J-PS contributed to study conception, design, analysis, interpretation and manuscript writing. JJ contributed to study conception, design, analysis, interpretation and review of manuscript. Both authors read and approved the final manuscript. JJ accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding J-PS is supported by the Australian Government Research Training Programme Scholarship. Award/Grant number not applicable. JJ is supported by a National Health and Medical Research Council (NHMRC) early career fellowship. Award/Grant number not applicable. Research at Royal Life Saving Society-Australia is supported by the Australian Government. Award/Grant number not applicable.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.