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Abstract
Background Drowning is a major cause of death in Uganda, especially among young adults with water-based occupations and livelihoods. Information about drowning and other water-related deaths and injuries is limited. To address this gap in knowledge, study partners assessed knowledge, attitudes and beliefs about drowning and drowning prevention interventions in the Mayuge district of eastern Uganda.
Methods This study consisted of a mixed-methods, cross-sectional community health assessment. Research was conducted in 10 landing sites of 6 subcounties within Mayuge district bordering Lake Victoria and focused on 505 head-of-household interviews, 15 key informant interviews, 10 landing site observations and 3 focus group discussions with 10 young adults each.
Results While landing site observations revealed high lake use, households reported limited community drowning prevention knowledge and revealed risky behaviours and attitudes towards water safety. Less than one-third (30.9%) of participants reported that at least one family member can swim. 64.2% of all respondents reported no existing safety measures (eg, signage, fences) around the lake and 95.8% reported no aquatic emergency response system in their community. The majority of households (85.7%) had experienced a drowning incident in their area. Key informants and focus group participants were eager for community-based interventions and offered solutions that reflected international drowning prevention recommendations.
Conclusions The results reveal gaps in services, access and knowledge and highlight a need for water safety services and interventions in lakeside communities in Uganda and throughout the Lake Victoria Basin.
- Public Health
- Community Research
- Low-Middle Income Country
- Behavior Change
- Occupational injury
- Drowning
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Drowning is a leading cause of death from unintentional injury worldwide yet has been largely neglected in global health research and practice.
WHAT THIS STUDY ADDS
This study contributes to existing drowning research, which has primarily focused on assessing incidence rates, by investigating knowledge, attitudes and beliefs related to drowning and drowning prevention among heavily burdened Ugandan communities living on Lake Victoria to strengthen water safety practice/policy instruments in Uganda.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study highlights several obstacles to drowning prevention programming at the community level along the shores of Lake Victoria and points to the specific need for implementation of science research focused on overcoming barriers to evidence-based community drowning prevention interventions, such as learn-to-swim programmes, life jacket adoption campaigns and emergency response systems, needed to reduce the burden of preventable drowning.
Introduction
On 29 May 2023, the 76th World Health Assembly adopted its first-ever resolution on drowning prevention, which requested governments and their partners accelerate action on drowning prevention.1 Drowning is the third-leading cause of death from unintentional injury worldwide.2 3 Globally, there are approximately 322 000 drowning deaths each year, and about 90% of these occur in low-income and middle-income countries (LMICs).3 4 Age-standardised drowning death rates in the WHO African region are estimated to be some of the highest in the world, with 8 per 100 000 people dying from a drowning-related incident each year.3 Lake Victoria, the world’s second-largest body of fresh water with a shoreline stretching across Kenya, Tanzania and Uganda, represents the most dangerous stretch of water in the world in terms of fatalities per square kilometre.5
Uganda faces a disproportionate burden of water-related injuries and loss of life due to drowning.6–9 This is in part due to its location on Lake Victoria’s northern shore and presence of other bodies of water including Lake Kyoga, Lake Albert, Lake Edward, and the Nile River, and is exacerbated by poorly maintained vessels, unguarded beaches, pools, and landing sites, and the lack of infrastructure and regulations around dangerous water and high-risk flood areas.6–8 10 In 2001, a general injury survey conducted around Lake Victoria found that rural, Ugandan fishing communities suffered one of the world’s highest drowning-related death rates at 502 per 100 000 persons,9 which is over 62 times higher than the WHO-African regional rate.3 This is most likely an underestimate as a 2022 study conducted in 60 districts in Uganda found many water-related deaths remain unreported.6 The study recorded a total of 2066 drowning cases identified by community health workers and confirmed through interviews over a period of 2.5 years, more than three times the number of drowning deaths when compared with official government records.
The lack of data on the risks and behaviours driving the exceptionally high rate of drowning in Uganda and the African Great Lakes region is a considerable limitation to the prediction, mitigation, response and management of drowning incidences. To help address this gap and respond to growing demands to reduce preventable drowning, Swim Safe Uganda, a registered non-governmental organisation (NGO) founded in 2011 to prevent drownings through education, prevention and rescue initiatives, partnered with Energy in Action (EIA), a youth-centred NGO with nearly a decade of experience working in Uganda, and the University of Southern California Global Research, Implementation and Training Lab (USC GRIT), to carry out a research study assessing community knowledge, attitudes and beliefs related to drowning in the Mayuge District of eastern Uganda. Mayuge, which lies on the northeastern shore of Lake Victoria, has the highest rate of drowning incidence of any district in Uganda, with an estimated 24.3 drownings per 100 000 population per year between 2016 and 2018.8 This paper presents the results of the study and discusses implications of the findings to inform future policy and infrastructure development related to drowning prevention in the Lake Victoria basin. The data is critical to fulfilling the calls for action outlined in the 2023 WHO resolution.
Methods
This study, carried out in June and July of 2022, consisted of a mixed-methods, cross-sectional community health assessment. The embedded study design, including landing site observations, household surveys, key informant interviews (KII) and focus group discussions, was selected to better explain relationships between individual and community knowledge/beliefs and recorded behaviours/outcomes. The data were collected by research assistants, comprised of EIA staff and local young adults between 18 and 25 years of age who were permanent residents of Mayuge district and spoke Lusoga and either Luganda or English as a second language. The local young adults, identified by local council leaders and trained in the study methods by EIA staff, were used as research assistants throughout the study to enhance local engagement in the study and local ownership and utilisation of the study results.
Study setting and sites
The study was conducted in and around 10 landing sites (Bugoto, Bumba, Busuyi, Bwondha, Kaaza, Lwanika, Masolya, Nakalanga, Nakirimira and Walumbe) selected in 6 subcounties (Bukabooli, Buktaube, Jagusi, Kityerera, Malongo and Wairasa) within the Mayuge district bordering Lake Victoria (figure 1). Mayuge district is primarily rural, located about 120 km east of Kampala, Uganda’s capital city and 38 km east of Jinja, Uganda’s sixth largest city. It is estimated that more than 75% of Mayuge district is covered by water, with another 10% being protected forest reserve.11 The district’s population, roughly 570 000 people, is concentrated along the district’s long shoreline and on its six islands and is growing rapidly. The district’s literacy rate is 63%. Agriculture and fishing are the major economic activities in the district, with fishing contributing approximately 63% of the district’s revenue.12 Lake Victoria, in general, has the largest freshwater fisheries in Africa, providing livelihood for millions around its shoreline, hence environmental and occupational hazards associated with drowning are ever present in the Mayuge district.13–15
. Map of Mayuge District, Uganda
The specific landing sites included in the study were selected to represent different lakeside communities and landing site environments in the region. Kaaza, Bumba and Masolya, for example, are small landing sites located on islands that are accessible only by motorboat or canoe. The islands are mainly inhabited by permanent and migrating fishing families. There are a handful of fishing canoes using the landing sites and no formal transportation canoes serving the population.16 Alternatively, Nakirimira and Lwanika are centrally located on the mainland in Kityerera, the most populous subcounty in the district, with several fishing canoes anchoring at the sites and transportation canoes serving the local population which is engaged in a wider array of occupations.
Study methods, participants and sample size
Quantitative observational and household data collection
Descriptive statistics were collected through landing site observations and household surveys. Research assistants carried out observations at the 10 landing sites using a structured form recording the presence of signage, barriers and rescue resources around the water, uses of water by community members and sanitary conditions. To optimise the quality and comprehensiveness of data collection, two 30 min visits were made to the observation sites, once in the morning and once in the afternoon, to record data. Research assistants then went door to door to households within a 3 km radius of each of the 10 landing sites to request participation in the study’s household survey with the goal of recruiting approximately 50 households (5 homes per landing site). The household sample size was determined by convenience, feasibility and resources. Eligibility was determined based on the presence of a consenting adult who could speak English (while local staff were able to translate and interpret most local languages spoken at the landing sites, due to the plethora of languages present we chose to collect data in English to ensure consistency) and a permanent resident under 10 years of age (to collect data related to parental/guardian knowledge, attitudes, beliefs and behaviours about water safety related to children in the households). The survey was completed by a consenting adult who was present at the time of the interview. Each participating household was compensated with incentives such as mosquito nets, shirts, soap and food items.
Qualitative data collection
To add to the qualitative data collected through the observations and surveys, qualitative data were collected through 3 separate focus group sessions with 10 young adults each representing different occupations, including fishermen, boat coxswains, health workers, youth groups, local traders, teachers, and law enforcement officers and 15 additional key informants identified as community leaders by local council leaders. The focus group participants, also identified by local council leaders, were required to be between 18 and 35 years, speak English and be permanent residents of the district. Key informants were recruited from a larger group of traditional and religious leaders, district-level leaders, subject matter specialists and beach management leaders based in Mayuge. The EIA country director facilitated and recorded the focus groups and KIIs. Discussion guides were standardised to be the same for all focus groups and interviews and were used to promote participation. Focus group discussion topics included access to basic preventive services, lake-based activities and proposed community suggestions for drowning prevention. Similarly, KIIs prompted insight from key community leaders on existing water safety policies and interventions, community awareness levels and available water safety infrastructure.
Data management and analysis
Observation and survey data were collected using paper questionnaires with EIA staff oversight. Data were later entered into Qualtrics17 by EIA and USC GRIT staff, where it was then uploaded to a cloud database managed by a central data manager at USC GRIT lab. Student researchers at USC GRIT lab downloaded, cleaned and analysed the data using Microsoft Excel (2021) and IBM SPSS Statistics for Windows V.27.18 Frequencies and percentages were calculated for key variables of interest including all landing site observations, general participant demographics, water safety knowledge and experience, including ability to swim and recognise a drowning victim, and access to preventive services such as emergency response systems and drowning prevention education.
Focus group and KII discussions were recorded, transcribed and translated into English by EIA staff. Transcribed transcripts were then analysed separately by two USC GRIT lab researchers using Nvivo software. Each researcher first independently reviewed the text to identify main themes and subthemes. They then met to compare, confirm and code final key themes.19 This method was used to ensure coding reliability across analysts.
Results
Final data consisted of 10 landing site observations, 505 head-of-household interviews, 15 KIIs and 3 focus group discussions with 10 participants each.
Quantitative observational and household results
Landing site observations
More than 150 people were observed in and around 8 of the landing sites engaged in activities such as swimming, fishing and recreation (figure 2). There were no lifeguards, water safety personnel or protective features (such as fences or water safety signage) observed at any landing site. 90% of people observed on the water, doing various activities, were not wearing life jackets. Data collectors noted environmental risks close to the water’s edge (<30 m), including latrines and rubbish pits. Additional observational notes recorded children swimming and bathing unsupervised, community members cleaning and bathing in polluted water, the use of poorly maintained boats, the presence of crocodiles and the absence of safety equipment.
Landing sites observations.
Head of household surveys
Among the 505 heads of households surveyed, the majority of respondents were between 20 and 50 years, had lived in the area for more than 5 years (83.2%) and were female (54.1%) (table 1). 19.6% of respondents reported having never attended school and less than 3% completed A-level secondary, the equivalent of honors-level high school. 67.9% of those surveyed derive a living from Lake Victoria, with the most common lake-based occupations being food vendors (28.5%), fishing (20.2%) and fishmongers (11.5%). Most respondents use the lake for travel (81.4%), 56.4% indicate that they access community services such as medical care, housing and police services on the lake, and 50% use the lake for recreational purposes. Nearly all those surveyed collect water for their homes from the lake (93.5%), and many (43.0%) also bathe directly in the lake.
Head of household survey demographics
Household drowning-related knowledge and behaviours
Of the heads of households surveyed, nearly 30% indicated that they are not able to supervise their children around water, and less than one-third (30.9%) reported that at least one member of their household can swim (table 2). 64.2% of all respondents were unaware of any existing safety measures (eg, signage, fences) around the lake and 95.8% were unaware of aquatic emergency response systems. More than 60% of respondents reported having no access to youth drowning prevention education, and about one-third of those surveyed reported knowing community members with injury response and prehospital care abilities. The majority of households, 63.6%, believe that a child should learn to swim after the age of 12 years, which is twice as old as WHOs current recommendations, and 65.7% of participants felt confident in their ability to recognise a drowning victim.
Households reporting drowning-related knowledge or experience and access to drowning prevention services
Qualitative focus group and KIIs
Qualitative data to assess drowning and drowning prevention priorities at the individual, household, community, regional and national levels were generated from the focus groups consisting of 10 young adults each and 15 KIIs including traditional and religious leaders, district level leaders, subject matter specialists and beach management leaders. Qualitative findings were separated into three major themes: drowning risks factors, challenges to drowning prevention, and drowning prevention priorities and solutions, with subthemes applied under each (table 3).
Focus group and KII themes, theme descriptions,and example quotes
Drowning risk factors and challenges to drowning prevention
Focus group participants and key informants emphasised the lack of basic water safety knowledge, including the inability to swim and the inability to identify drowning hazards or drowning victims among the local population (table 3, quotes 1,2). Focus group participants suggested that religious beliefs and fatalism influenced individual’s attitudes about drowning and need to be addressed within drowning prevention programming (table 3, quotes 6,7). There was varied discussion around life jacket use and misuse, including lack of access and reluctance to wear jackets, and the inadequate quality and improper use of jackets, and misperception of benefits while boating (table 3, quote 8).
Focus group participants identified dangerous boat traffic and poor conditions of fishing boats on the lake as drowning risks throughout the district (table 3, quote 9). It was widely agreed that adult males aged 18–35 experience the greatest risk of drowning within their communities, largely attributed to lake-based occupations (eg, fishing, water transport) and risky behaviours such as alcohol and substance use near the lake. At the community level, key informants did not believe cultural beliefs were a major barrier to drowning prevention interventions, but that the barrier was a severe lack of safety infrastructure and resources (table 3, quotes 12,13). Both focus group members and key informants expressed concerns about environmental risk factors, including effects of climate change, polluted fishing beds, unsustainable fishing practices, dangerous aquatic wildlife close to shore and unexpected weather on the lake attributed to drowning (table 3, quotes 3, 4, 5, 10, 11).
Drowning prevention priorities and solutions
Drowning prevention education was a main priority among focus group participants and key informants.Learn-to-swim programmes were a top priority, along with programmes increasing water safety awareness among children and adolescents. From a policy perspective, key informants stressed the need for safety signage and enforced water safety guidelines around Lake Victoria. Focus group participants were critical of some current policy approaches, believing the policies increase drowning risk. Police presence on Lake Victoria, for example, can cause people to flee their boats and swim away to avoid fines and other punishments for illegal fishing (table 3, quotes 14, 15). Additional community-level solutions included weather warning systems, fences, functional life jackets and emergency response protocols for drowning victims within their communities. At the regional and national levels, key informants suggested the need for infrastructure development and environmental hazards management (table 3, quotes 16, 17, 18, 19).
Discussion
Landing site observations and head-of-household surveys revealed a general lack of knowledge and access to drowning prevention resources within lakeside communities in Mayuge, while KIIs and focus group discussions highlighted key areas of concern and priorities for preventing drownings.
The elevated risk of drowning among the communities we studied can be in part attributed to their frequent interaction with water. Several past studies have found that a population’s dependence on water for economic livelihoods, transportation, habitation and tourism raises their drowning risk.6–9 Nearly every one of our study participants accessed Lake Victoria daily for activities including bathing, drinking, travel, recreation and employment, with nearly two-thirds deriving a living from the lake, including occupations such as fishing or fishmongering. Given this reliance on the lake, drowning prevention should be a top public health priority throughout the region and, given the presence of water bodies throughout Uganda, there is strong justification for including drowning prevention education in the national school curricula.
Previous research has repeatedly identified poverty and other socioeconomic determinants as central risk factors in drowning.3 20–22 For example, low-income individuals are more likely to use unsafe boats to access essential services and are less likely to be informed about potential risks. Young, low-income men have been found more likely to engage in dangerous fishing practices, while low-income and overburdened mothers are more likely to leave their children unsupervised around water which is associated with higher drowning rates.2 21 23–25 Low-income communities are also more likely to be neglected by political leaders and lack the political influence needed to secure investments in infrastructure and emergency response resources.2 22 26 27 Reflective of these past findings, the households surveyed near landing sites in Mayuge were low income, lacked higher education and were dependent on lake-based occupations. Focus group participants consistently reported socioeconomic risk factors for past drowning events, including travelling on poorly maintained boats, engaging in risky occupational behaviours to earn money and lacking community resources and functional emergency response systems. Consequently, socioeconomic development is critical to improving the conditions in Mayuge and elsewhere around Lake Victoria to decrease drowning rates.
Our qualitative study results also underscore the heightened drowning risks for specific vulnerable groups, particularly young, male fishermen and children. Previous research has shown that males employed around bodies of water have up to 50% higher rates of drowning compared with females, with males exhibiting riskier behaviours than females exposing them to more dangerous situations around water.22 Focus group participants repeatedly mentioned risky behaviours among young men, such as drinking alcohol while fishing. Alcohol use has been consistently found to be a major cause of boating-related injury globally, though existing research on alcohol abuse in Ugandan fishing communities has addressed other risks, such as higher HIV infection among fishermen and not increased drowning risk.28–30 This is a key area for future research.
The lack of water safety skills and awareness among mothers also heightens risks across the community, especially for children under their care. Leaving children unsupervised around water significantly increases their risk of drownings, with some studies citing up to 76% of recorded drownings in LMICs being unsupervised.22 Parental supervisory behaviour is a substantial protective factor in preventing drowning.21 22 Our study found children were often left unsupervised around the water at landing sites and identified several inaccurate beliefs held by household respondents regarding water safety, including that they can easily identify a drowning in progress (most drownings are silent and lack visible signs like splashing) and that children should not be taught how to swim until late adolescence as opposed to WHO’s recommendation that children be introduced to swimming around 5 years.31 These findings call for greater sensitisation and education among young fishermen and mothers about drowning and actions they can take to avoid preventable water injuries and drownings.
Despite the presence of substantial risk factors and high burden of drowning in the region, our study results exposed the near complete absence of drowning prevention infrastructure or warning and emergency response systems around the lake (64.2% of all survey respondents were unaware of any existing safety measures, while 95.8% reported the lack of an aquatic emergency response system). Due to underdeveloped (or missing) flood warning systems and community-protection systems, recent storms have caused major flooding and landslides in eastern Uganda resulting in food insecurity, contaminated water and unsafe conditions for travel and fishing.32 33 This damage could further increase risky behaviours around dangerous water conditions and exacerbate mortality in the event of further flooding.26 Investing in climate-resistant infrastructure, including severe weather early warning systems (SWEWS), could prevent further injury and illness due to hazardous weather and unsafe water conditions. SWEWS can be fit to accommodate basic cell phone functionalities and cell service can be strengthened over Lake Victoria so that warnings may be received on the water.34 There is also a need for investment in basic water safety infrastructure including walls, fences and signs that keep children and other vulnerable individuals away from dangerous areas. Where people congregate around the water, lifeguards are needed to supervise activity and perform rescues. The distribution of quality life jackets to those community members accessing the lake, with sensitisation campaigns promoting their correct use, and strengthened monitoring and enforcement of boat quality and occupational safety standards are also needed. However, enforcement of water and vessel safety rules must be done in partnership with community members to avoid tragedies resulting from water police presence reported by our study informants.
There were a number of limitations to the study, including having only English-speaking participants and the potential self-report bias for key study variables in the household survey such as lake usage, access to drowning prevention services, swimming ability, and knowledge, behaviours, and attitudes related to drowning. The inclusion of English speakers in the study may have resulted in collecting data from more educated members of the population, potentially meaning that inadequate and/or incorrect knowledge about drowning risk within these landing sites may be greater than what has been recorded in this study. Other key variables collected through KIIs may also be subject to recall bias. Study households were selected by convenience sampling and may not be representative of all households or adolescents in the region. The collection and comparison of quantitative and qualitative data, the range of settings studied, and the diverse set of stakeholders included in the study in the region help to offset these limitations.
Conclusion
The passage of Resolution 75/273 at the 76th World Health Assembly provides a push for urgently needed action, including community-based action, effective policy and evidence-based legislation, and further research, to address the burden of drowning. Our study provides useful insight into the gaps in community drowning prevention services, access and knowledge in the Lake Victoria basin where preventable drownings are among the highest in the world and reveals strong community support for evidence-based drowning prevention actions recommended by WHO. Additional research into the burden, risks and solutions to preventable drowning in the region is needed, along with investment in water safety infrastructure, improved emergency response capacity and community education. Such investments will be most effective if they directly engage the impacted communities in their development and implementation.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by University of Southern California Ethics Review Board, Gulu University Ethics Review Board. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors wish to acknowledge EIA staff members and Makerere University students for their contribution to the data collection process in Mayuge, including Cecilia Alonyo, Abdul Wagwa, Yesigomwe Kennedy, Amperize Mathias, Muvunyi Joseph, and Edward Mukuye. The authors would also like to thank Ray Wipfli for his contributions to the data analysis process as well as the SSU staff, especially Mathius Kabuubi, for their contributions to data collection. Finally, the authors would like to thank the public health students from the University of Southern California for their contributions to data analysis and research dissemination, including Samyu Padisetti, Hera Ballard, Samantha Gillis and Abigail Kim.
Footnotes
X @KhobanNLudin
Contributors KG assisted in data cleaning, data analysis and findings dissemination, and was a major contributor in writing the final manuscript. AR assisted in data analysis and drafting the final manuscript. PT and EB served as data collection managers and oversaw the design of the survey instrument, participant recruitment, participant training and data collection. MK led participant recruitment and managed data collection. KN assisted in data analysis and drafting the final manuscript. HW served as the guarantor and oversaw the development of the survey instrument, data collection, data analysis and the final manuscript.
Funding The study received funding from the University of Southern California and was coordinated by Swim Safe Uganda and Energy in Action, formerly known as Ray United FC. There is no award/grant number.
Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.
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.