Rivers, lakes, pools, seas and oceans provide people with their livelihoods, places of leisure, and vital resources for daily life. However, drowning is the third leading cause of unintentional injury-related death worldwide. Over 320,000 people die from drowning annually including 57,000 adolescents, two-thirds of them boys, drowned in 2015. Over 90% of deaths from drowning occur in low- and middle-income countries where open bodies of water are generally unprotected and people carry out daily activities on and in the water (World Health Organisation, 2014). Children are disproportionately affected by drowning and in many countries, drowning is the leading cause of death in children between the ages of one and four (World Health Organisation, 2020).
Guidelines
- Delivering water safety messages to children should be part of a layered approach that includes engaging and educating caregivers on drowning prevention – with a particular focus on the importance of close supervision. **
- When developing and teaching water safety messages, activities which integrate physical water competencies with the development of knowledge and attitudes, may be included. *
- The environmental, social and economic context should be considered in developing water safety messages. Messages should be culturally and contextually relevant and consider any traditional beliefs and current practices of the local population. **
- Providing regular Refresh and retrain opportunities to learn about water safety may be considered*.
Good practice points
- The development of water safety messages should be based on evidence of local risk factors for drowning and be mindful of the risk reduction measures to implement at each phase of a drowning event.
- Water safety messages should be developed and delivered using appropriate theories to change behaviours.
- Where water safety is taught in schools, refresh and retrain opportunities may be provided each term.
- Owing to the lack of evidence on the effectiveness of water safety messaging, organisations should consider developing an evaluation framework that allows them to monitor the effects of the messaging on children and caregivers’ behaviour when exposed to an aquatic environment. This framework should ensure the messaging does not increase risk-taking behaviour.
Education considerations
Context considerations
- Consider local culture, context, and risk factors for drowning when designing programmes. Additionally, ensure the messaging is age appropriate. Considering these factors is particularly useful in settings where the availability of safety equipment (lifejackets), personnel (lifeguards), signage (warning signs and flags) and adequate prehospital and hospital care is limited.
- The risks and causes of drowning vary significantly by setting and are affected by several factors including:
> Geography: prevalence and types of water bodies, seasonal weather (monsoons) and impact of climate change.
> Social context: attitudes towards risk-taking, education levels, alcohol consumption, water competency skills and recreational use of water.
> Economic context: type of use of water, availability of safe equipment (e.g., boats), availability of early warning systems and availability of response services (rescue, emergency medical services, hospital care). - Be considerate of existing common practices based on traditional or cultural beliefs. These practices may be positive; for example, using local materials to reduce the risk factors of doing activities on the water. However, they may be harmful, such as promoting practices that have proven to cause injury.
Learner considerations
- The World Health Organisation recommends several interventions, including teaching school-age children basic swimming, water safety and safe rescue skills, as well as strengthening public awareness of drowning to highlight the vulnerability of children.
- For school-aged learners, consider combining theoretical classroom-based learning with practice sessions in the water.
- Engage and educate caregivers on water safety during children’s swimming lessons.
- While caregivers are generally aware, they should supervise their children around water, they may overestimate their ability to do so. Emphasise the importance of being vigilant and provide specific suggestions on how to do so within the local context (e.g., instead of saying “supervise children”, be specific and say “supervise children and keep young children within arm’s length).
- Communities should engage in water safety programmes to generate a collective understanding of the dangers and preventative strategies for activities in, on or near water.
Facilitation tips
- Ensure water safety messages are simple and visually engaging.
- Water safety lessons delivered by educators with whom learners can culturally identify are likely to be most effective.
- Use hands-on (experiential) learning when safe to do so.
- Change caregivers’ attitudes about the value of supervision by using context-specific examples.
- When appropriate, consider providing water safety messages as part of a broader practical programme aimed at developing water competence.
- Develop programmes using behaviour change models, clearly identifying the risk factors you are trying to reduce.
- Media may be considered as part of a multi-approach to inform people of risks, safe behaviours and how to access help.
Facilitation tools
- Different organisations have developed classroom-based water safety education programmes using various methods, such as videos, lectures or games to deliver messages. See the water safety app discussed in Gamification. Check with your local organisations to see what they have available.
- Use the Water Competencies checklist to ensure you include physical, knowledge and attitudinal elements to provide a holistic approach to water safety education.
- Use the Open Water guidelines in the table below established by the International Task Force on Open Water Drowning Prevention (2011) if relevant to your context. They are based on the best available evidence and expert opinion. They aim to be generic across all settings, focused on keeping yourself safe and keeping others safe, and are set out below. Note that the only evidence-based messages were “learn to swim” and “avoid the use of alcohol”, with the other messages based on suggestive evidence or common risk factors.
| Keep yourself safe | Keep others safe |
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Learning connections
- Make connections to the topics Unresponsive and abnormal breathing (baby and child) and Unresponsive and abnormal breathing (adolescent and adult), including raising awareness of the importance of rescue breaths combined with chest compressions for people who are not breathing as a result of drowning (as opposed to chest-compression-only CPR).
- Consider any relevant practice in topics of drowning, Decompression illness, or Aquatic animal injuries.
Scientific foundation
Evidence provided for this topic was found using the search strategy used for the Education elements of these Guidelines and further embellished with insight of published work provided by water safety experts. It includes one systematic review and one structured review as well as multiple empirical studies and insight from the WHO.
Evidence available suggests that water safety messaging needs to:
a) include context-specific content targeted at learners who will be in the water and caregivers who will supervise them (Lawson et al., 2012; Ramos et al., 2018; Moran & Stanley, 2006; Sandomierski et al., 2019; Barcala-Furelos et al., 2018; Denehy et al., 2017).
b) be delivered in conjunction with activities supporting the development of water competencies (Langendorfer, 2018; Stallman et al., 2017).
However, there is an inconsistent approach to developing relevant water-safety messaging. While the International Task Force on Open water drowning prevention provides generic water safety messages, and there are several evidence-based narratives on the drowning process (Szpilman et al., 2016), this review did not identify any framework to support the development of risk-based messages.
Additionally, the programmes we reviewed included different facilitation methods (lectures, videos, posters, practical engagement, etc.). It was not possible to compare the effectiveness of each technique. Based on our review of the scientific literature we have identified the following conclusions about water safety messaging for children and caregivers.
Children
Children are disproportionately affected by incidents of drowning. Globally, the highest rates of drowning are found in “newly mobile” children ages 1–4, followed by children ages 5–9 (World Health Organisation, 2020).
Most of the studies we identified focused on the knowledge gained and retained following a lesson using pre and post questionnaires to gather data. In nearly all cases, children were better able to answer questions immediately after the learning experience and were able to retain this knowledge for a short period (Ramos et al., 2018; Azeredo & Stephens-Stidham, 2003; Barcala-Furelos et al., 2017; Greene et al., 2002; Shen et al., 2016; Wilks et al., 2017; Soloman et al., 2013; Terzidis et al., 2007; Lawson et al., 2012) . However, none of the studies measured whether this knowledge of water safety messages led to a short- or long-term behaviour change, whether they sustained this behaviour change or, ultimately, whether it reduced their risk of drowning.
Barcala-Furelos et al. (2019) and Wilkes et al. (2017) were unable to provide evidence that children retain this knowledge beyond one to two months; and Liu et al. (2019) found limited evidence that children who have water safety knowledge are at a reduced risk of drowning.
Countries with developed water safety programmes usually include messaging aimed at changing behaviours around water and teach these to children as part of basic swimming or lifesaving programmes. This is described by Stallman et al. (2017) as ‘water competencies’ – the physical, cognitive and affective competencies that help to reduce the risk of a person drowning. These competencies are set out clearly by Langendorfer et al. (2018) as a set of 15 items to be included in water safety education and are included in the Facilitation tools above.
For an example of how the competencies are used, see Royal Lifesaving Society UK or Royal National Lifeboat Institution. The messages highlight the risks of being in, on or around water and suggest practical actions to reduce these risks. In areas where resources are limited, or a training venue (e.g., a pool) is unavailable, water safety messages are often delivered to children as a stand-alone programme, often in a classroom setting and without any practical experience in the water.
There have been no comprehensive studies that evaluate the outcomes of drowning reduction nor learners’ behaviour change following a classroom-based water safety programme for children.
Supervision by caregivers
Evidence suggests that caregivers underestimate the need to carefully and continuously supervise their children; they also overestimate their ability to do so (Moran, 2009). Studies showed that caregivers’ belief in the value of supervision is influenced by their perceived judgements of their children’s swimming skills (Moran & Stanley, 2006; Sandomierski et al. 2019). In other words, caregivers place a lower value on supervision if they believe their child to be a good swimmer. As such, these evidence sources point to the need for drowning reduction programmes to be focused on educating children as a component of a broader educational strategy. This broader strategy should include components aimed at caregivers and targeted community members to educate them on preventive measures (e.g., supervision and covering outdoor pools) and rescue and resuscitation skills (Barcala-Furelos et al., 2018; Denehy et al., 2017).
While there is a gap in comprehensive studies examining how behaviour changes after receiving education on risk factors and how to reduce them, there are studies that suggest caregivers’ attitudes regarding the value of supervision may change when they learn using context-specific examples (Denehy et al., 2017; McCallin et al., 2020; Moran & Stanley, 2006; Sandomierski et al., 2019). One study supported the use of explicit messaging (e.g., using videos to depict real-life scenarios), alongside risk reduction strategies, to increase perceived susceptibility (Denehy et al., 2017). However, a separate study suggested that even families who have been affected by a submersion injury may not change their water safety practices (Hijazi et al., 2007).
References
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Barcala-Furelos, R., Carbia-Rodríguez, P., Peixoto-Pino, L., Abelairas-Gómez, C., Rodríguez-Núñez, A. (2019). Implementation of educational programs to prevent drowning. What can be done in nursery school? Implantación de programas educativos para prevenir ahogamientos. ¿Qué se puede hacer desde la escuela infantil?. Med Intensiva., 43(3), 180-182.
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Davey, M., Callinan, S., Nertney, L. (2019). Identifying Risk Factors Associated with Fatal Drowning Accidents in the Paediatric Population: A Review of International Evidence. Cureus, 11(11), e6201.
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Denehy, M., Leavy, J.E., Jancey, J., Nimmo, L., Crawford, G. (2017).This Much Water: a qualitative study using behavioural theory to develop a community service video to prevent child drowning in Western Australia. BMJ Open, 7(7), e017005.
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Greene, A., Barnett, P., Crossen, J., Sexton, G., Ruzicka, P., Neuwelt, E. (2008). Evaluation of the THINK FIRST For KIDS injury prevention curriculum for primary students. Inj Prev., 8(3), 257-258.
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