'I actually thought that I was going to die': Lessons on the rip current hazard from survivor experiences.

BACKGROUND: Rip currents are strong, narrow, fast-flowing currents of water that occur on many beaches and in Australia contributing to 26 drowning deaths and several thousand lifeguard/lifesaver rescues each year. Educating the public about the rip current hazard is a primary focus of beach safety practitioners, but there has been a lack of qualitative research exploring the firsthand experiences of being caught in a rip current to assist in this regard. The aim of this study was to analyse interviews of rip current survivors to understand more about how people react when unintentionally caught in a rip current in order to help guide future public education to mitigate rip current drowning. METHODS: Semi-structured interviews were conducted with 56 individuals (primarily Australian-born) about their experience of being caught in a rip current. Interviewees were recruited via an online survey and varied in age and self-reported swimming ability. RESULTS: Thematic analysis revealed three key temporal elements to the rip current experience: Before the Rip in which lack of awareness and knowledge, complacency, over-confidence, and attitude were prevalent themes; During the Rip which identified panic and temporary inhibition of decision-making, physical response, prior experience, and relationships with other beach users as themes; and After the Rip where post-rip effects and rip safety messaging and education were key themes. The importance of experiential immersion was a prevalent thread throughout all phases of the thematic analysis. DISCUSSION: Our research shows that being caught in a rip current can be an intense and traumatic experience and that lessons learned from survivors have significant implications for improving existing and future rip current education efforts. In this regard, we provide several recommendations based on evidence-based insights gained from our interviews including the development of immersive rip current experience using virtual reality. SO WHAT: Despite the prevalence of rip currents causing drowning deaths and rescues, there has been a lack of qualitative research on firsthand experiences to aid in public education. These interviews emphasise the intense and traumatic nature of being caught in a rip current, underscoring the need for improved rip current education to aid in prevention of this, often harrowing, experience.

Impact of a surfer rescue training program in Australia and New Zealand: a mixed methods evaluation.

BACKGROUND: Surfers play a critical role in coastal drowning prevention, conservatively estimated to make as many rescues as beach lifeguards. The Surfer Rescue 24/7 (SR24/7) program is a coastal safety intervention in Australia and New Zealand that teaches surfers safe rescue skills and promotes prevention activities. This multi-part, mixed-methods study aimed to evaluate the impact of the SR24/7 program. METHODS: The study consisted of three parts employing quantitative and qualitative methods: a retrospective survey of course participants, in-depth interviews with course participants who had conducted rescues, and an analysis of self-reported skills confidence ratings before and after the program. RESULTS: Triangulated results from the three study components indicated that after the course, participants exhibited high levels of satisfaction with their experience in the program and would encourage others to attend, were more observant and aware of safety concerns while surfing, had a better understanding of ocean conditions and hazards, learned new rescue techniques and skills, grasped important course concepts related to their own personal safety, and improved their confidence in responding to an emergency situation. Several participants had conducted rescues in real life and indicated that the course was effective in providing them with the baseline knowledge and skills to keep safe while helping others in the ocean. This study also provides new insight on the role of surfers in coastal safety, specifically that surfers are engaged in a range of prevention activities before rescue is required. CONCLUSIONS: Despite persistent challenges in combating coastal drowning rates, the SR24/7 program is an effective intervention that helps save lives. Importantly, this study provides evidence that the course successfully equips surfers with techniques to act responsibly and safely. Expanding coastal safety focus and resources towards surfers, an often-overlooked demographic in beach safety strategies, could substantially enhance community-level capacity to prevent and respond to ocean emergencies.

Burden of fatal drowning in California, 2005-2019.

OBJECTIVE: To characterise risk factors for fatal drowning in California, USA to inform priorities for prevention, policy and research. METHODS: This retrospective population-based epidemiological review of death certificate data evaluated fatal drowning events in California from 2005 to 2019. Unintentional, intentional, and undetermined drowning deaths and rates were described by person (age, sex, race) and context-based variables (region and body of water). RESULTS: California's fatal drowning rate was 1.48 per 100 000 population (n=9237). Highest total fatal drowning rates occurred in the lower population density northern regions, among older adults (75-84 years: 2.54 per 100 000 population; 85+: 3.47 per 100 000 population) and non-Hispanic American Indian or Alaska Native persons (2.84 per 100 000 population). Male drowning deaths occurred at 2.7 times the rate of females; drowning deaths occurred mainly in swimming pools (27%), rivers/canals (22.4%) and coastal waters (20.2%). The intentional fatal drowning rate increased 89% during the study period. CONCLUSIONS: California's overall fatal drowning rate was similar to the rest of the USA but differed among subpopulations. These divergences from national data, along with regional differences in drowning population and context-related characteristics, underscore the need for state and regional level analyses to inform drowning prevention policy, programmes and research.

The epidemiology, risk factors and impact of exposure on unintentional surfer and bodyboarder deaths.

Surfing and bodyboarding (SAB) are popular activities, but not without risk. Limited SAB mortality and exposure risk explorations exist, so this cross-sectional study explores epidemiology and risk factors for SAB deaths (1 July, 2004-30 June,2020) in Australia: including decedent and incident profiles, causes of death, differences between fatalities during SAB and other coastal activities; and the impact of exposure on SAB mortality risk. Fatality data were sourced from the National Coronial Information System, incident and media reports. Tide-state data, population data and participation data were sourced from relevant authorities. Analyses included chi-square testing and simple logistic regression with odds ratios. There were 155 SAB deaths (80.6% surfing; 96.1% male; 36.8% aged 55+years; 0.04/100,000 residents; 0.63/100,000 surfers). Drowning was the most common cause of death (58.1%; n = 90), but higher in bodyboarding, with bodyboarders 4.62 times more likely to drown than surfers (95%CI: 1.66-12.82; p = 0.003). Almost half (44.5%; n = 69; χ22 = 9.802; p = 0.007) were with friends/family, and the largest proportion occurred during a rising tide (41.3%; n = 64; χ23 = 180.627; p<0.001) followed by a low tide (36.8%;n = 57). Australians surf 45.7 times each year, for 1.88 hours each visit equalling 86.1 'exposed' hours. With exposure-time considered, exposure-adjusted surfer mortality rate (0.06/1 million hours) is lower than other in-water activities (0.11/1 million hours). Younger surfers (14-34 years) surfed more yet had the lowest mortality rate (114.5 hours/year; 0.02/1 million hours). Older surfers (55+ years) had a lower SAB mortality rate (0.052) than the all-cause crude mortality rate of their average population counterparts (1.36). Cardiac conditions were identified in 32.9% (n = 69) of SAB deaths. SAB are relatively safe, with lower exposure mortality rates than other activities. Prevention should target older surfers, inland residents, and identification of surfers with risk factors for cardiac events.

Mortality trends and the impact of exposure on Australian coastal drowning deaths, 2004-2021.

OBJECTIVE: The aim of this study is to characterise Australian coastal drowning trends and evaluate impact of exposure on drowning risk. METHODS: Descriptive epidemiological analysis of unintentional fatal drowning occurring July 2004-June 2021 at Australian coastal sites (beaches, rock platforms, bays, harbours, offshore locations etc.). Total population, exposed-person and exposed-person-time rates per 100,000 population were calculated by age, sex, socio-economic status, remoteness category and pre-submersion activity. Annual trends were assessed using joinpoint regression. Exposure-based rates used estimates from Surf Life Saving Australia's National Coastal Safety Survey. RESULTS: The cumulative unintentional coastal fatal drowning rate was 0.43 per 100,000 Australian residents (95%CI: 0.41-0.45) and did not change throughout the study period (p=0.289). The exposed-person rate was 0.67 per 100,000 coastal visitors (95%CI: 0.62-0.72), and there were 0.55 coastal drowning deaths per 10 million coastal visitor hours (95%CI: 0.51-0.59). Men, older people and residents of lower socio-economic and remote areas had higher drowning rates; rock fishing and scuba diving had the highest activity exposure-based rates. CONCLUSIONS: Education- and policy-based coastal safety interventions should focus on identified risk factors to reduce annual coastal drowning rates. IMPLICATIONS FOR PUBLIC HEALTH: Exposure-based risk measurements are important for developing and prioritising interventions; assessments based on counts or total population measures alone may misinform prevention efforts.

Lessons learned from co-designing a high school beach safety education program with lifeguards and students.

ISSUE ADDRESSED: School-based beach safety education programs are common, but best practice guidance and information on their design and development is limited. METHODS: Researchers, professional ocean lifeguards and students participated in a co-design process to inform a lifeguard-delivered, school-based beach safety education program for a coastal community in New South Wales, Australia. Lifeguards and researchers (experts) provided structured feedback about the program in a survey and facilitated workshop; students (n = 26) aged 11 to 13 years participated in focus group sessions intended to garner in-depth understanding of their experiences at the beach and knowledge of, and attitudes towards, beach safety. RESULTS AND DISCUSSION: The co-design process provided a novel and inclusive model for beach safety education program development, and valuable lessons for future efforts. Specifically, student focus groups identified several facets of pre-teens and younger teenagers' beach experience that prompted revision of the education program, primarily framing of program content and safety messages. Peers are a primary motivator for this age group and students' burgeoning independence emerged as an important theme. While knowledgeable about beach hazards and risks, students conveyed mixed safety attitudes and self-reported safety practices, highlighting the importance of designing programs to motivate behaviour and promote safe decision-making vs raising awareness alone. Findings illustrate the value of adopting co-design processes for all beach safety programs, school or otherwise. SO WHAT?: Beach safety programs may not be delivering information that is needed, wanted or useful. Structured consultation with the priority population must become standard practice in beach safety and drowning prevention education program development.

Drowning risk and climate change: a state-of-the-art review.

Drowning and climate change are both significant global health threats, yet little research links climate change to drowning risk. Research into the epidemiology, risk factors and preventive strategies for unintentional drowning in high-income and in low-income and middle-income countries has expanded understanding, but understanding of disaster and extreme weather-related drowning needs research focus. As nation states and researchers call for action on climate change, its impact on drowning has been largely ignored. This state-of-the-art review considers existing literature on climate change as a contributor to changes in drowning risks globally. Using selected climate change-related risks identified by the World Meteorological Organization and key risks to the Sustainable Development Goals as a framework, we consider the drowning risks associated with heat waves, hydrometeorological hazards, drought and water scarcity, damaged infrastructure, marine ecosystem collapse, displacement, and rising poverty and inequality. Although the degree of atmospheric warming remains uncertain, the impact of climate change on drowning risk is already taking place and can no longer be ignored. Greater evidence characterising the links between drowning and climate change across both high-income and low-income and middle-income contexts is required, and the implementation and evaluation of drowning interventions must reflect climate change risks at a local level, accounting for both geographical variation and the consequences of inequality. Furthermore, collaboration between the injury prevention, disaster risk reduction and climate change mitigation sectors is crucial to both prevent climate change from stalling progress on preventing drowning and further advocate for climate change mitigation as a drowning risk reduction mechanism.

Identifying risk factors and implications for beach drowning prevention amongst an Australian multicultural community.

Multicultural communities in Australia are recognised as a priority area for drowning prevention, but no evidence-based study has addressed their knowledge of beach safety. This study used an online survey tool to identify and examine risk factors relating to swimming ability, beach visitation characteristics and behaviour, and beach safety knowledge of the Australian Southern Asian community to assist in the development of future beach safety interventions. Data was obtained through 249 online and in-person surveys of people aged > 18 years. Most respondents reported poor swimming ability (80%), often swam in in the absence of lifeguards (77%), did not understand the rip current hazard (58%), but reported that they entered the water (76%) when visiting beaches. Close to one-quarter (28%) had not heard, or didn't know the purpose, of the red and yellow beach flags, which identify lifeguard supervised areas on Australian beaches. Length of time living in Australia is an important beach safety consideration for this community, with minimal differences in terms of gender and age. Those who have lived < 10 years in Australia visit beaches more frequently and are less likely to have participated in swimming lessons, be able to swim, heard of the flags or swim between them, understand rip currents, or have participated in a beach safety program. Very few (3%) respondents received beach safety information from within their own community. The importance of beach safety education and swimming lessons within the Southern Asian community should be prioritised for new and recent migrants to Australia.

Understanding a population: A methodology for a population-based coastal safety survey.

Drowning is a global public health problem, but accurately estimating drowning risk remains a challenge. Coastal drowning comprises a significant proportion of the drowning burden in Australia and is influenced by a range of behavioural factors (e.g. risk perception, knowledge, attitudes and behaviours) that are poorly understood. These factors, along with those that impact exposure (e.g. coastal visitation and activity participation) all impact on drowning risk. While excellent mortality and morbidity data exists in Australia, a lack of coastal participation data presents challenges to identifying high-risk groups or activities and prioritising prevention efforts. This methods paper describes the development and evolution of an ongoing, annual, nationally representative online survey as an effective tool used to capture valuable data about the Australian population's relationship with the coast. This paper explores how the survey is structured (12-14 sections spanning multiple topics and themes), the different question types used (including open text, 4-digit responses and categorical questions), the sample size (1400-1600 respondents), sampling strategy (using demographic quota sampling which can then be post-weighted to the population if required) and how topics and themes have changed over time to enhance the quality of data collected (i.e., wording changes to enhance participant comprehension or data usability and changing issue-specific 'feature' topics of interest such as campaign evaluation). How the survey is implemented online is described, both practically through to third-party recruitment processes and ethically to maximise anonymity of respondents and ensure data quality. Interim analyses indicate the impact of considering exposure when calculating fatal drowning rates, especially by activity (e.g., crude boating drowning rate 0.12 per 100,000 population vs 0.95 per 100,000 exposed population [relative risk = 8.01; 95% confidence interval: 4.55-14.10]). This study highlights lessons learned in the process of conducting a nationally representative coastal participation survey as well as the strengths and limitations of adopting this approach. Data collected will provide more detailed information on the skills, behaviours, knowledge and attitudes of coastal activity participants. Analyses of this unique dataset will inform research that will underpin development and evaluation of coastal drowning prevention initiatives prioritising those most at risk. It is hoped that the methods detailed within this study may be useful for other countries to develop similar approaches to understanding their own population.

Coastal drowning: A scoping review of burden, risk factors, and prevention strategies.

OBJECTIVE: Coastal drowning is a global public health problem which requires evidence to support safety initiatives. The growing multidisciplinary body of coastal drowning research and associated prevention countermeasures is diverse and has not been characterised as a whole. The objective of this scoping review was to identify key concepts, findings, evidence and research gaps in the coastal drowning literature to guide future research and inform prevention activities. METHODS: We conducted a scoping review to identify peer reviewed studies published before May 2020 reporting either (i) fatal unintentional coastal drowning statistics from non-boating, -disaster or -occupational aetiologies; (ii) risk factors for unintentional fatal coastal drowning; or (iii) coastal drowning prevention strategies. Systematic searches were conducted in six databases, two authors independently screened studies for inclusion and one author extracted data using a standardised data charting form developed by the study team. RESULTS: Of the 146 included studies, the majority (76.7%) were from high income countries, 87 (59.6%) reported coastal drowning deaths, 61 (41.8%) reported risk factors, and 88 (60.3%) reported prevention strategies. Populations, data sources and coastal water site terminology in the studies varied widely; as did reported risk factors, which most frequently related to demographics such as gender and age. Prevention strategies were commonly based on survey data or expert opinion and primarily focused on education, lifeguards and signage. Few studies (n = 10) evaluated coastal drowning prevention strategies. DISCUSSION: Coastal drowning is an expansive, multidisciplinary field that demands cross-sector collaborative research. Gaps to be addressed in coastal safety research include the lack of research from lower resourced settings, unclear and inconsistent terminology and reporting, and the lack of evaluation for prevention strategies. Advancing coastal drowning science will result in a stronger evidence base from which to design and implement effective countermeasures that ultimately save lives and keep people safe.

Studying outcome predictors of drowning at the scene: Why do we have so few answers?

BACKGROUND: Identification of predictors of outcome at the scene of drowning events could guide prevention, care and resource utilization. This review aimed to describe where, what and how scene predictive factors have been evaluated in drowning outcome studies. METHODS: We reviewed studies reporting scene drowning predictors published between 2003 and 2019. Data extraction included study populations, data sources, predictor factors (victim, incident, rescue, resuscitation and hospital-related), outcome measures and type of analyses. RESULTS: Of 49 studies, 87.6% were from high-income countries, 57.1% used data from only one source (92.9% of these from either hospital or EMS), 73.5% included cases who received medical care and 53.1% defined outcomes as survival or death. A total of 78 different factors were studied; the most commonly studied group of factors described victim demographics, included in 42 studies (85.7%), followed by resuscitation factors, included in 30 studies (61.2%). Few studies described rescue (6.1%). The most frequent statistically significant single predictors of outcome known at the scene were submersion duration (evaluated in 19, predictor in 14) and age (evaluated in 31, predictor in 16). Only 38.7% of studies employed multivariable methods. CONCLUSIONS: Gaps to be addressed in drowning outcomes research include data from low- and middle-income countries, standardized definition of factors to allow evaluation across studies, inclusive study populations that can be generalized beyond those receiving medical care, study rescue and resuscitation factors, use of more meaningful outcomes (survival with good neurologic status) and advanced analyses to identify which factors are true predictors versus confounding variables.

Need for consistent beach lifeguard data collection: results from an international survey.

BACKGROUND: Lifeguards are integral to beach safety and collect data which is used for a variety of purposes, although guidelines and best practice have yet to be established. This study served to identify and characterise existing beach lifeguard service provider (BLSP) data collection procedures in order to identify the degree of uniformity and areas for improvement. METHODS: The 'International Beach Lifeguard Data Collection and Reporting' online survey was distributed via the International Drowning Researchers' Alliance to BLSP supervisors and managers. The survey included questions on beach conditions and lifeguard activity data collection practices, and respondent's opinions on their own BLSP's methods. RESULTS: Variability in data collection practices was evident in surveys obtained from 55 lifeguard leaders in 12 countries. Discrepancies exist in definitions for 'rescue' among BLSPs, a significant amount of information related to beach conditions are recorded and beach visitation is primarily obtained by visual estimate. Respondents expressed challenges with getting frontline staff to collect information in the field and ensuring reporting consistency between recorders. They identified rescue victim demographic factors as key data they would like to collect in the future. CONCLUSIONS: Inconsistencies in lifeguard data collection present challenges to operations, safety education and prevention efforts, research and policy relying on these data. Variation in definitions, methods and collected variables generally restricts analysis to a single BLSP with limited generalisability to other beach settings. Some gaps in lifeguard data collection may soon be addressed by technology, but developing uniform, internationally acceptable standards and definitions should be prioritised.

The ocean lifeguard drowning prevention paradigm: how and where do lifeguards intervene in the drowning process?

Drowning is a global health problem that can be addressed with multiple strategies including utilisation of lifeguards in recreational swim areas. However, few studies have described lifeguard prevention activities. We conducted a retrospective analysis using lifeguard activity data collected in real time with a Computer-Aided-Dispatch (CAD) system to characterise the nature of lifeguard primary and secondary drowning prevention at a popular ocean beach in California. Preventative actions constituted the majority (232 065/423 071; 54.8%) of lifeguard activities, while rescues represented 1.9%. Most preventative actions and rescues occurred during summer months, weekends and afternoons. Statistically significant geographical clusters of preventative actions were identified all over the beach, while rescue clusters were primarily restricted to two sites. Using the most reliable and valid collection system to date, these data show spatial and temporal patterns for ocean lifeguard provision of primary prevention as well as secondary drowning prevention (rescue).

Do wave heights and water levels increase ocean lifeguard rescues?

OBJECTIVE: To investigate the association of wave height and tidal water level changes with the frequency of ocean lifeguard rescues. METHODS: All ocean lifeguard rescues recorded by Newport Beach Lifeguards in 2015 and 2016 were linked by time and location to weather and ocean variables contained in other historical databases. We performed separate multivariable analyses using mixed effects negative binomial regression to evaluate the total effects of wave height, mean water level (primarily set by tidal elevation), and rising vs. falling water level, on the frequency of ocean rescue in the study location, controlling for confounding variables. RESULTS: Newport Beach Lifeguards made 8046 rescues during the study period. In all areas of the beach, rescue frequency increased as waves got larger (IRR: 3.25; 95%CI: 2.91-3.79) but then decreased in large surf (IRR: 0.52; 95%CI: 0.37-0.73). In two sections of beach, lifeguards made more rescues during lower water levels, but in the third section of beach, made more rescues during higher water levels. Rescue frequency increased in two sections of beach with rising water levels, but did not in the other section. CONCLUSIONS: Wave height, water level, and water level direction were associated with rescue frequency, but the environmental factors included in the analysis did not fully account for most variation in rescue frequency. Other factors need to be evaluated to identify major determinants of rescue frequency.