Preventing river drowning deaths: Lessons from coronial recommendations

Insights from coronial recommendations for preventing natural deaths in sport and recreation in Québec, Canada

Introduction

This descriptive retrospective study analyzed coronial recommendations for natural deaths in sport and recreation from January 2006 to December 2019 using data from the Bureau du coroner du Québec.

Methods

Reports with recommendations were analyzed by sex, age group, cause of death, context, and activity. The nature of recommendations was assessed using a public health-based model. Thematic analysis was conducted following a four-phase approach in which themes developed were emphasized and further connected with existing literature.

Results

Reports involving individuals aged 18-24 and reports related to ice hockey were significantly more likely to contain recommendations. Reports related to individuals ≥45 years old, or related to cycling or hunting had higher death frequencies, but relatively low recommendation rates. Most recommendations aligned with the public health-based model but specifying implementation time frames was rare (11.7%). Nearly 60% of coroner's recommendations focused on automated external defibrillator implementation, delivery and training.

Discussion

Mitigation of sudden cardiac arrest risk for individuals ≥45 years old, timely treatment of life-threatening arrhythmias especially for activity practiced in remote regions and specifying implementation time frames were identified as improvement areas. The multi-faceted approach to enhancing public access defibrillation developed by the International Liaison Committee on Resuscitation in 2022 addresses recurrent themes covered by coroners and holds the potential to inform evidence-based decision making.

Unintentional injury deaths associated with sport and recreation in Québec, Canada, 2006-2019

OBJECTIVES

This study examined trends in the frequencies and rates of deaths associated with unintentional injuries in sport and recreation in Québec, Canada, for the period January 2006-December 2019.

METHODS

In this descriptive retrospective study, data were extracted from the database of the Bureau du coroner du Québec. Incidence rates were calculated using participation data from the Étude des blessures subies au cours de la pratique d'activités récréatives et sportives au Québec (ÉBARS) and Canadian census population data. Poisson regression was used to investigate changes in death rates over the 14-year period by estimating incidence rate ratios.

RESULTS

There were 1937 unintentional injury deaths and the population-based death rate was 1.72 per 100 000 person-years. The participation-based rate was 1.40 per 100 000 participant-years, considering the 24 matching activities in both ÉBARS' editions. Using both population-based and participation-based denominators, separate analyses consistently showed declining death rates in non-motorised navigation and cycling. Deaths related to all-terrain vehicles, snowmobiles, swimming, cycling, motorised navigation and non-motorised navigation activities accounted for 80.2% of all deaths. Drowning was documented as a cause of death in 39.3% of all fatalities. Males represented 86.8% of all deaths, with males aged 18-24 years and 65 and over having the highest rates.

CONCLUSION

The death rates of unintentional injury deaths associated with non-motorised navigation and cycling declined, from January 2006 to December 2019. The characteristics and mechanisms of drowning deaths and fatalities that occurred in activities associated with higher death frequencies and rates need to be further investigated.

Analysis of fatal unintentional drowning in Australia 2008-2020: implications for the Australian Water Safety Strategy

OBJECTIVE

To examine temporal trends in drowning in Australia against targets set in the Australian Water Safety Strategy (AWSS) 2008-2020 and to inform the development of the next iteration of the Strategy.

METHODS

A national analysis of unintentional fatal drowning rates per 100,000 population over 16 years (2004/05-2019/20) was conducted. Baseline rates (three-year average 2004/05-2006/07) were compared to the current three-year average (2017/18-2019/20) by sex, age group, drowning location and jurisdiction.

RESULTS

The overall rate of unintentional fatal drowning during the period decreased by 28%. Substantial reductions were observed in children 0-4 years (-63%) and 5-14 years (-56%). Progress has been less pronounced among people aged 75 years and over (-11%) and 15-24-year-olds (-14%). All locations and jurisdictions recorded reductions, aside from rocks (+46%).

CONCLUSIONS

Although the strategy fell short of its aspirational target of a 50% reduction in drowning by the year 2020, this target was exceeded in key age groups, including children. Implications for public health: The AWSS is a powerful tool to align drowning prevention sector actions to agreed objectives. Forthcoming strategies must take into consideration demographic and social change, areas where limited progress has been made and the latest evidence to guide future priorities.

Preventing Child Drowning in the Philippines: The Need to Address the Determinants of Health

Drowning is a public health issue in the Philippines, with children at significantly increased risk. Determinants of health (DoH) such as education, socio-economic status, ethnicity, and urbanization are factors that impact drowning risk. As drowning is a multisectoral issue, a national drowning prevention plan can drive collaboration with relevant stakeholders. This study reports trends in unintentional child (0-14 years) drowning in the Philippines (incidence, rates, and trends over time for fatal and non-fatal (years lived with a disability (YLDs) and disability adjusted life years (DALYs) from 2008-2017 and conducts an analysis of the Philippines' Multisector Action Plan (MSAP) on Drowning Prevention. From 2008-2017, 27,928 (95%UI [Uncertainty Interval]: 22,794-33,828) children aged 0-14 years died from drowning (52.7% aged 5-14 years old). Rates of drowning have declined among both age groups, with greater reductions seen among 0-4 year olds (y = -0.3368x + 13.035; R² = 0.9588). The MSAP has 12 child drowning-specific activities and 20 activities were identified where DoH will need to be considered during development and implementation. The MSAP activities, and work done to prevent drowning more generally, must consider DoH such as education, urbanization, water and sanitation health, and safe water transportation. A national drowning surveillance system and investment in research in the Philippines are recommended.

"They don't think it will ever happen to them": Exploring factors affecting participation in alcohol-influenced aquatic activity among young Australian adults

ISSUE ADDRESSED

Young adults are over-represented in alcohol-related drownings in high-income countries; however, little research has investigated their behaviours and decision-making to inform prevention efforts.

METHODS

Semi-structured interviews were conducted with 23 young Australian adults (aged 18-24 years). Questions, informed by previous research, inquired about behavioural practices in aquatic contexts and influences on involvement in alcohol-influenced aquatic activity. Interviews were transcribed verbatim. Thematic and interpretative phenomenological analysis followed.

RESULTS

Two main themes: personal and contextual awareness, and the impact of other people affected perceptions and involvement in alcohol-influenced aquatic activity. Perceived control of situations and self-confidence affected how these influences impacted individuals' involvement. Participants acknowledged some young adults likely overestimate their aquatic abilities. This awareness was not discussed in relation to their own capabilities.

CONCLUSION

Drowning prevention efforts should inform young adults of the dangers of combining alcohol and aquatic activities, and make risks appear more immediate and applicable. Consideration should be given to measuring both perceived and actual aquatic abilities within various aquatic environments, to determine whether self-reported perceived competence is an accurate proxy measure for actual aquatic ability. The influence of alcohol should also be highlighted. Steps are required for a positive shift in Australian norms of alcohol use in aquatic settings and the social and cultural attitudes towards this. SO WHAT?: This study provides new insight into young adults' perceptions and involvement in alcohol-influenced aquatic activity. It enhances the evidence base for drowning prevention and health promotion practitioners and should inform more focused campaigns to prevent alcohol-related drownings among young Australian adults.

Comparing rivers to lakes: Implications for drowning prevention

OBJECTIVE

To contrast unintentional fatal drowning in rivers with lakes to determine appropriateness for application of existing river drowning prevention strategies.

DESIGN

A total population retrospective cross-sectional analysis using coronial data.

SETTING

Australia, 1 July 2013 to 30 June 2018.

PARTICIPANTS

Children and adults (n = 342) who died from unintentional drowning in a river or lake.

MAIN OUTCOME MEASURES

Incidence, crude fatality rates, relative risk (95% confidence interval) and chi-square tests of independence for risk factors for unintentional fatal drowning. Subset analysis of land management for lake drowning locations.

RESULTS

Four-fifths (82%) occurred in rivers. Lake drowning was more likely among 0- to 17-year-olds, Aboriginal and Torres Strait Islander people and when swimming or using watercraft. River drowning most commonly occurred following a fall into water and with alcohol involvement. Drowning risk in very remote areas was elevated for both lakes (relative risk = 18.34; 95% confidence interval: 1.61-209.44) and rivers (relative risk = 15.89; 95% confidence interval: 5.56-45.37) compared to major cities. Those responsible for land and water management at lakes were primarily local government (59%), water authorities (32%) and parks and wildlife authorities (7%).

CONCLUSIONS

In contrast to a focus on adults and alcohol in existing river drowning prevention strategies, lake interventions must target children, Aboriginal and Torres Strait Islander peoples and recreational lake users. Fatal drowning rates are high for remote rivers and lakes, necessitating focused effort. There are opportunities to embed drowning prevention strategies within land and water management plans. Lake drowning prevention requires broader engagement with land and water managers and Aboriginal and Torres Strait Islander peoples.

Next steps for drowning prevention in rural and remote Australia: A systematic review of the literature

OBJECTIVE

To examine unintentional drowning by remoteness in Australia.

DESIGN

A systematic review of both peer-reviewed and grey literature published between January 1990 and December 2019 (inclusive).

METHOD

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, MEDLINE (Ovid), PubMed, EMBASE, Scopus, PsycINFO (ProQuest), SPORTDiscus and Google Scholar were searched for studies exploring fatal and non-fatal unintentional drowning by remoteness. Epidemiological data, common factors and prevention strategies were extracted and mapped to Australian standard geographical classifications (major cities, inner regional, outer regional, remote and very remote). Level of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation and prevention strategies aligned to the hierarchy of control.

RESULT

Thirty-two studies satisfied inclusion criteria (66% reporting epidemiology; 59% risk factors; and 44% prevention strategies). All (100%) included studies were assessed very low against Grading of Recommendations Assessment, Development and Evaluation. Findings indicate rural populations (ie, excluding major cities) have higher rates of drowning positively correlated with increasing remoteness. Common factors included age (child), natural water bodies, undertaking boating and watercraft activities and alcohol consumption. While a range of prevention strategies has been proposed, only one study outlined a rural drowning prevention strategy which had been implemented and evaluated. Strategies were generally low on the hierarchy of control.

CONCLUSION

Rural populations are proportionately overrepresented in drowning statistics. Proposed prevention strategies have unknown efficacy. Greater research into rural drowning of Australians is needed especially exploring behavioural motivations, program delivery, cost-effectiveness and evaluation. Development and use of a standard definition for remoteness are recommended. Rural populations use water extensively; therefore, there is an urgent need to keep them safe.

Observing Patterns of River Usage

Rivers are a leading location for drowning, yet little is known about people’s usage of these waterways. This pilot study aimed to test the use of direct observations to calculate river usage. Direct observations were conducted at regular intervals within defined zones at four river drowning locations in Australia (including weekends and the Australia Day national public holiday). Data recorded were date and time of observation; total people (including males, females, children, and adults); and number of people on, in, and beside the water. Univariate analysis with mean (SD) and range was conducted. Interrater reliability for observations was determined using the intraclass correlation coefficient (ICC) (one-way random-effects, average measures model), with a 95% confidence interval (CI). Across 149 time points, 309 observations resulted in 13,326 river interactions observed by multiple observers. There was an average of 39 people (M = 39.4, SD = 29.4, range = 0–137) per observation, 44 people (M = 44.2, SD = 32.7, range = 0–37) on an average weekend, and 97 people (M = 96.8, SD = 58.1, range = 20–190) on Australia Day. More females (M = 20.6, SD = 16.0, range = 0–83) than males (M = 18.3, SD = 14.5, range = 0–68) were observed. More people were observed in the water (M = 20.6, SD = 20.4, range = 0–84) than beside or on the water. Interrater reliability was excellent, consistently above 0.900 for all variables collected (apart from the variable of beside the river). Despite males accounting for 80% of river drowning fatalities, more females were observed than males. Increased visitation on the Australia Day public holiday may be linked to increased drowning risk. This study detailed a simple approach to data collection, exploring exposure within a defined zone at river locations. River usage is dynamic, with people’s movement in and out of the water changing their risk exposure. Observational-based data collection for drowning, particularly for rivers, is an important yet highly neglected area of research.

Exploring Flood-Related Unintentional Fatal Drowning of Children and Adolescents Aged 0–19 Years in Australia

Disasters, such as flooding, are predicted to increase. Drowning is one of the leading causes of death during times of flood. This study examined the little explored topic of child drowning during floods, with the aim of identifying risk factors to inform prevention strategies. A retrospective, total population examination of cases of children and adolescents aged 0–19 years who died from unintentional flood-related drowning in Australia for the 16-year period 1 July 2002 to 30 June 2018 was undertaken. Univariate and chi-square analysis was conducted, with Fisher’s exact test used for cell counts <5. Across the study period, 44 flood-related drowning deaths occurred among children and adolescents (63.6% male; 34.1% aged 10–14 years). Almost all (84.1%) occurred in rivers, creeks, or streams in flood, with the remaining incidents occurring in storm water drains (n = 7). Leading activities immediately prior to drowning were non-aquatic transport (40.9%), swimming in floodwaters (25.0%), and falls into floodwaters (15.9%). Flood-related fatal drowning among children and adolescents is rare (0.05 per 100,000 population), however flood-drowning risk increases as remoteness increases, with children and adolescents drowning in floodwaters in very remote areas at a rate 57 times that of major cities. All drownings are preventable, and this study has identified key causal factors that must be considered in advocacy and prevention efforts. These include: the importance of adult supervision, avoiding flooded waterways when driving or for recreational purposes, and the increased risks for those residing in geographically isolated and socially disadvantaged areas. Findings must be considered when developing interventions and advocacy for the purposes of the reduction of child and adolescent drowning during times of flood.

Exploring the burden of fatal drowning and data characteristics in three high income countries: Australia, Canada and New Zealand

BACKGROUND

Drowning is a leading and preventable cause of death that has suffered an attention deficit. Improving drowning data in countries would assist the understanding of the full extent and circumstances of drowning, to target interventions and evaluate their effectiveness. The World Health Organization identifies data collection as a key strategy underpinning effective interventions. This study compares unintentional fatal drowning data collection, management and comparison using the databases of Australia, Canada and New Zealand.

METHODS

Cases of fatal unintentional drowning between 1-January-2005 and 31-December-2014 were extracted. Cases were combined into a single dataset and univariate and chi square analysis (p < 0.01) were undertaken. Location and activity variables were mapped and combined. Variables consistently collected across the three countries were compared to the ILCOR Drowning Data Guideline. The authors also recommend variables for a minimum core dataset.

RESULTS

Of 55 total variables, 19 were consistent and 13 could be compared across the three databases. When mapped against the ILCOR Drowning Data Guideline, six variables were consistently collected by all countries, with five compared within this study. The authors recommend a minimum core dataset of 11 variables including age, sex, location, activity, date of incident, and alcohol and drug involvement). There were 8176 drowning deaths (Australia 34.1%, Canada 55.9%, New Zealand 9.9%). All countries achieved reductions in crude drowning rates (Australia - 10.2%, Canada - 20.4%, New Zealand - 24.7%). Location and activity prior to drowning differed significantly across the three countries. Beaches (X² = 1151.0;p < 0.001) and ocean/harbour locations (X² = 300.5;p < 0.001) were common in Australia and New Zealand, while lakes/ponds (X² = 826.5;p < 0.001) and bathtubs (X² = 27.7;p < 0.001) were common drowning locations in Canada. Boating prior to drowning was common in Canada (X² = 66.3;p < 0.001).

CONCLUSIONS

The comparison of data across the three countries was complex. Work was required to merge categories within the 20% of variables collected that were comparable, thus reducing the fidelity of data available. Data sources, collection and coding varied by country, with the widest diversity seen in location and activity variables. This study highlights the need for universally agreed and consistently applied categories and definitions to allow for global comparisons and proposes a core minimum dataset.

Who rescues who? Understanding aquatic rescues in Australia using coronial data and a survey

OBJECTIVE

To examine fatal drowning associated with aquatic rescues and prior self-reported experience of undertaking an aquatic rescue in Australia.

METHODS

Previous aquatic rescue experience was sourced through the 2013 Queensland Computer Assisted Telephone Instrument Survey and compared to data on rescue-related fatal unintentional drowning between 1 January 2006 and 31 December 2015.

RESULTS

Twenty-three per cent (n=294/1291) of survey respondents had previously performed an aquatic rescue. Males (X² =35.2; p<0.001) were more likely to have performed a rescue; commonly at a beach/ocean/harbour location (X² =13.5; p<0.001). Females were more likely to have rescued a child (0-4 years of age) (X² =29.2; p<0.001) from a swimming pool (X² =34.3; p<0.001). Fifty-one people drowned while performing an aquatic rescue (Males=82.4%; 25-44 years of age=53.0%; beaches=54.9%).

CONCLUSIONS

Drownings are prevented by bystanders; this is not without risk to the rescuer. Most people perform only one rescue in their life, often at a younger age, on an altruistic basis, of family members or young children. Community-wide rescue skills, taught at a young age, with consideration for coastal, inland and swimming pool environments, may prevent drowning. Implications for public health: There is a need to train people early in their life on how to undertake a safe rescue and provide resuscitation, including promoting regular updates, in particular if supervising children.

Developing drowning prevention strategies for rivers through the use of a modified Delphi process

Introduction

Internationally, rivers are a leading drowning location, yet little evidence exists evaluating river drowning prevention strategies. This study aims to use expert opinion to identify strategies more likely to be effective.

Methods

Using a modified Delphi process, a virtual panel of 30 experts from 12 countries considered, grouped and prioritised strategies for river drowning prevention. Proposed strategies were assessed against known evidence and suitability in high-income countries (HICs) as well as low-income and middle-income countries (LMICs) using expert opinion. The final phase consolidated a list of strategies whose effectiveness was assessed against 10 evidence-based river drowning scenarios.

Results

An initial list of 424 prevention strategies was refined to 22. After being assessed against the 10 scenarios, a final list of 13 strategies was derived. Strategies addressed alcohol consumption around rivers, flood mitigation, improving child supervision, learning to swim, increased lifejacket wear and achieving community-wide resuscitation skills.

Discussion

While all 13 strategies were assessed as being effective in both LMICs and HICs by at least 60% of the respondents, further work is required to define river drowning at a country level and therefore allow for effective solutions to be developed, particularly in LMICs. No strategy will be effective in isolation and must be implemented alongside policy and behaviour change, public awareness and education. Evaluation should be incorporated as part of any future implementation of strategies.

Conclusion

This Delphi process identified 13 drowning prevention strategies for rivers. Further research is required to validate the efficacy of these findings through implementation and evaluation.

Characteristics of aquatic rescues undertaken by bystanders in Australia

An issue of growing importance within the field of drowning prevention is the undertaking of aquatic rescues by bystanders, who sometimes drown in the process. The main objectives of this study were to describe characteristics of bystanders making rescues in different Australian aquatic environments, identify the role of prior water safety training in conducting bystander rescues and provide insights into future public education strategies relating to bystander rescue scenarios. An online survey was disseminated via various social media platforms in 2017 and gathered a total of 243 complete responses. The majority of bystander rescues described took place in coastal waterways (76.5%; n = 186), particularly beaches (n = 67), followed by pools (17.3%; n = 42) and inland waterways (6.2%; n = 15). The majority of respondents were males (64.2%; n = 156) who rescued on average approximately twice as many people in their lifetime (6.5) than female respondents (3.6). Most rescues occurred more than 1 km from lifeguard/lifesaver services (67%; n = 163), but in the presence of others (94.2%; n = 229). The majority of bystander rescuers had water safety training (65.8%; n = 160), self-rated as strong swimmers (68.3%; n = 166), conducted the rescue without help from others (60%; n = 146), did not use a flotation device to assist (63%; n = 153), but were confident in their ability to make the rescue (76.5%; n = 186). However, most considered the situation to be very serious (58%; n = 141) and felt they had saved a life (70.1%; n = 172). With the exception of pools, most bystanders rescued strangers (76.1%; n = 185).While Australia clearly benefits from having a strong water safety culture, there is no clear consensus on the most appropriate actions bystanders should take when confronted with a potential aquatic rescue scenario. In particular, more research is needed to gather information regarding bystander rescues undertaken by those without prior water safety training.

The Influence of Alcohol and Drugs on Drowning among Victims of Senior Years

Unintentional fatal drowning among older people is an issue as lifespans lengthen and older people embrace active retirement. While pre-existing medical conditions are a known risk factor for drowning among this age group, less is known about the role of alcohol and drugs. This 15-year (1 July 2002 to 30 June 2017) Australian study used coronial data to investigate the impact on older people (aged 65 years and older) of the obtundent effects of prescribed drugs which had been ingested by those with a positive blood alcohol concentration (BAC). Of the closed coronial cases with toxicological information (N = 471), one quarter (24.6%; N = 116) had consumed alcohol prior to drowning (one in seven BAC ≥ 0.05%), of which a third also had obtundent drugs present (33.6%; N = 39). Rivers/creeks/streams and swimming pools were the locations with the highest number of drowning deaths. Bathtubs (36.8%) and rivers/creeks/streams (17.9%) recorded the highest proportion of cases with victims having a BAC ≥ 0.05%. Bathtubs (13.2%), lakes (7.0%), and rivers/creeks/streams (6.8%) recorded the highest proportion of drowning cases with obtundent drug involvement. Obtundent drug involvement was significantly more likely for activities where the person who drowned was alone (i.e., unknown activity) (X2 = 6.8; p = 0.009). Common obtundent drugs included Diazepam, Tempazepam, and Codeine. Advocacy to prevent drowning in older people is a complex challenge, due to the myriad of locations where drowning occurs, the consumption of alcohol, and polypharmacy required for treating illness and maintaining good health.

Breathalysing and surveying river users in Australia to understand alcohol consumption and attitudes toward drowning risk

BACKGROUND

Little is known about people's river usage, a leading drowning location. This study examines alcohol consumption patterns of river users and their attitudes to drowning risk.

METHODS

A convenience sample of adult (18+ years) river users were surveyed at four river locations. The survey covered eight domains: demographics; river attendance frequency; frequency of engaging in water activities; drinking patterns; alcohol and water safety knowledge; alcohol and water safety attitudes; alcohol consumption; and Blood Alcohol Concentration (BAC). For BAC, participants were asked to record time since their last alcoholic drink and were then breathalysed to record an estimate of their BAC. BAC was examined by BAC reading (negative, positive, ≥0.050%). Hazardous lifetime drinking levels were calculated and their impact on drowning risk evaluated. Univariate and chi square analysis (95% confidence interval) was conducted.

RESULTS

Six hundred eighty four people participated (51.6% female; 49.0% aged 18-34 years). Sixteen percent (15.9%) had a positive BAC (Mean + BAC = 0.068%; SD ± 0.08; Range = 0.001-0.334%), with 7.2% ≥0.050% (Mean BAC ≥0.050% =0.132%; SD ± 0.06). Those significantly more likely to record a BAC ≥0.050% at the river were: aged 18-34 years, resided in inner regional and low socio-economic areas, visited the river in the afternoon, with friends, on days with higher maximum air temperatures, frequent river users (11+ times in the last 30 days) and those who spend longer in the water (301+ minutes). River users who recorded a BAC ≥0.050% were more likely to self-report engaging in risky activities (i.e. diving into water of unknown depth and jumping into the river from height). River users on Australia day (a national public holiday) were significantly more likely to drink heavily (Mean BAC ≥0.05% = 0.175%; SD ± 0.09).

CONCLUSIONS

Despite males accounting for 85% of alcohol-related river drowning deaths, similar numbers of males and females were consuming alcohol at the river. This study has addressed a gap in knowledge by identifying river usage and alcohol consumption patterns among those at increased drowning risk. Implications for prevention include delivering alcohol-related river drowning prevention strategies to both males and females; at peak times including during hot weather, afternoons, public holidays and to river users who swim.

Cardiopulmonary resuscitation and first-aid training of river users in Australia: A strategy for reducing drowning

ISSUE ADDRESSED

Rivers are a leading location for fatal drowning worldwide, often geographically isolated from timely medical assistance. Cardiopulmonary resuscitation (CPR) benefits drowning victims and those who suffer cardiac arrests. This study explored CPR and first-aid training of river users in Australia.

METHODS

Adult river users (18+ years) were surveyed at four high-risk river drowning sites. Respondents were asked the last time they undertook CPR (responses converted into: "CPR ever undertaken"-yes/no; and "CPR training current"-yes/no (training undertaken ≤12 months ago). Responses were explored by demographics and social determinants of health.

RESULTS

Of those surveyed (N = 688), 98.4% responded regarding CPR. Seventy-five percent (74.9%) had undertaken CPR training previously. Females and 35- to 44-year-olds were more likely to have undertaken training (P < 0.05). Males and older people (65+ years) were less likely to hold a current qualification (P < 0.05). Major city residents reported a longer mean time (5.4 years) since last trained than remote and very remote locations (2.0 years). People in low socio-economic areas had a shorter time since qualification current (5.8 years) than those in areas deemed high (7.2 years).

CONCLUSION

Current CPR qualifications are important, particularly among those visiting high-risk river drowning locations. System-level, upstream strategies that should be explored include compulsory CPR training in secondary schools and linking CPR updates to motor vehicle licence renewals. SO WHAT?: Cardiopulmonary resuscitation is a vital component of multifaceted river drowning prevention. Social determinants of health, such as socio-economic disadvantage and geographical isolation, were not barriers to participation or currency of qualification.