Drowning prevention challenges and opportunities: An exploratory study of perspectives of delegates from ASEAN nations.

The South East Asian region has the world's second highest fatal drowning burden. This study reports analysis of survey data from representatives from nations within the Association of South East Asian Nations regarding current efforts, challenges and future opportunities for drowning prevention. Twenty-two responses were received from respondents from all ASEAN nations excepting Cambodia and Myanmar. Drowning prevention initiatives varied across ASEAN nations, with most efforts focused on public education and raising awareness, including the provision of drowning data to the media. The lack of comprehensive, national level data collection was identified as a challenge, necessitating strengthened data collection capacity. Governmental involvement spanned one to six different ministries, highlighting the multi-sectoral nature of drowning prevention. However, a lead ministry could be identified in only two countries. Despite the challenges identified, there remain many opportunities to strengthen drowning prevention across ASEAN nations, addressing a significant regional public health threat.

Conceptual definition for drowning prevention: a Delphi study.

BACKGROUND: Expanding support for drowning prevention is evidenced by interlinked Resolutions at the United Nations (2021) and World Health Assembly (2023). While progress has accelerated, a universally agreed definition for drowning prevention remains absent. Here, we aim to develop a conceptual definition of drowning prevention using the Delphi method. METHODS: First, we conducted a document review to guide our development and consensus-building process. Then, we formed an advisory group and recruited participants with diverse expertise to contribute to Delphi-method surveys. In the first round, participants selected from draft concepts to build a definition and delineate between the terms drowning prevention and water safety. In the second round, we presented a codeveloped definition, and three statements based on first-round findings. We then sought participant feedback where ≥70% support was considered consensus-based agreement. RESULTS: Participants (n=134) were drawn from community (7.46%), policy (26.87%), research (40.30%) and technical backgrounds (25.37%), and low-income and middle-income countries (38.06%). In the first- round, half (50.74%) disagreed with the proposition that drowning prevention was synonymous to water safety, while 40.30% agreed. The second- round achieved consensus-based agreement (97.27%) for the definition: Drowning prevention is defined as a multidisciplinary approach that reduces drowning risk and builds resilience by implementing evidence-informed measures that address hazards, exposures and vulnerabilities to protect an individual, community or population against fatal and non-fatal drowning. CONCLUSION: The Delphi method enabled the codevelopment of our conceptual definition for drowning prevention. Agreement on the definition forms the basis for strengthened multisectoral action, and partnerships with health and sustainable development agendas. Defining drowning prevention in terms of vulnerability and exposure might increase focus on social determinants and other upstream factors critical to prevention efforts.

Identifying strategic priorities for advancing global drowning prevention: a Delphi method.

INTRODUCTION: The burden of drowning is gaining prominence on the global agenda. Two United Nations system resolutions in 3 years reflect rising political support, but priorities remain undefined, and the issue lacks a global strategy. We aimed to identify strategic priorities for advancing global drowning prevention using a modified Delphi method. METHODS: An advisory group was formed, and participants recruited with diverse expertise and backgrounds. We used document review, and data extracted from global health partnerships to identify strategic domains and draft priorities for global drowning prevention. Participants rated the priorities in two Delphi rounds, guided by relevance, feasibility and impact on equity, and where consensus was ≥70% of participants rating the priority as critical. RESULTS: We recruited 134 participants from research (40.2%), policy (26.9%), technical (25.4%) and community (7.5%) backgrounds, with 38.1% representing low- and middle-income countries. We drafted 75 priorities. Following two Delphi rounds, 50 priorities were selected across the seven domains of research and further contextualisation, best practice guidance, capacity building, engagement with other health and sustainable development agendas, high-level political advocacy, multisectoral action and strengthening inclusive global governance. Participants scored priorities based on relevance (43.2%), feasibility (29.4%) and impact on equity (27.4%). CONCLUSION: Our study identifies global priorities for drowning prevention and provides evidence for advocacy of drowning prevention in all pertinent policies, and in all relevant agendas. The priorities can be applied by funders to guide investment, by researchers to frame study questions, by policymakers to contrast views of expert groups and by national coalitions to anchor national drowning prevention plans. We identify agendas including disaster risk reduction, sustainable development, child and adolescent health, and climate resilience, where drowning prevention might offer co-benefits. Finally, our findings offer a strategic blueprint as the field looks to accelerate action, and develop a global strategy for drowning prevention.

Lessons learned through the 20-year development of a national fatal drowning database in Australia.

BACKGROUND: Co-ordinated, evidence-based policy and programmatic efforts are needed to respond to complex drowning prevention problems. Comprehensive, current, and robust data are vital for agenda setting, burden and risk factor identification, intervention design and evaluation, as well as setting policy. We aim to record methods used in, and identify impacts of, the development of a national fatal drowning database (NFDD) in Australia, including lessons learned across research, policy, and practice. METHODS: We employ a case study method using process mapping and document review to explore the evolution, drivers and impacts of the NFDD. We analyse methodological approaches including those relating to data definitions, drowning case collection, and management, as well as tracking the various outputs of the NFDD. We describe a development timeline that presents impact of drowning prevention policy, and research agendas on database development, and research investments more specifically. RESULTS: Our study identified that the collected variables grew 20-fold from 2002 to 2022, reaching 259 variables, and 5,692 unique cases of fatal drowning. The NFDD employs data triangulation methodology, combining keyword and targeted searches of coronial files, media report monitoring, and organisational data provision. Database development is influenced by the Australia Water Safety Strategy, policymaker and practitioner-initiated research agendas, and identification of knowledge gaps. We identified numerous outputs spanning publications, media, intervention development, and legislative submissions. CONCLUSION: A comprehensive and robust NFDD informed by policymaker and practitioner input can enhance surveillance, policy, and intervention development for drowning prevention. Employing mixed data collection and validation methods can supplement weaknesses in official data sources. There is a need for the NFDD to continue to evolve in its application while maintaining rigorous case identification and data quality assurance processes. Despite significant investment, the outputs and influence on drowning prevention practice in Australia has been extremely valuable and contributed to sizeable reductions in Australia's fatal drowning rate.

Identifying opportunities for multisectoral action for drowning prevention: a scoping review.

BACKGROUND: Drowning is a complex health issue, where global agendas call for greater emphasis on multisectoral action, and engagement with sectors not yet involved in prevention efforts. Here, we explored the conceptual boundaries of drowning prevention in peer-review and grey literature, by reviewing the contexts, interventions, terminologies, concepts, planning models, and sector involvement, to identify opportunities for multisectoral action. METHODS: We applied scoping review method and have reported against Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist. We searched four electronic databases for peer-reviewed articles published on 1 January 2005 and 31 December 2020 and five databases for grey literature published on 1 January 2014 and 31 December 2020. We applied the search term "drowning," and charted data addressing our research questions. RESULTS: We included 737 peer-reviewed articles and 68 grey documents. Peer-publications reported situational assessments (n=478, 64.86%) and intervention research (n=259, 35.14%). Drowning was reported in the context of injury (n=157, 21.30%), commonly in childhood injury (n=72, 9.77%), mortality studies (n=60, 8.14%) and in grey documents addressing adolescent, child, environmental, occupational and urban health, refugee and migrant safety and disaster. Intervention research was mapped to World Health Organization recommended actions. The leading sectors in interventions were health, leisure, education and emergency services. CONCLUSION: Although drowning is often described as a major health issue, the sectors and stakeholders involved are multifarious. The interventions are more often initiated by non-health sectors, meaning multisectoral action is critical. Framing drowning prevention to reinforce cobenefits for other health and development agendas could strengthen multisectoral action. Greater investment in partnerships with non-health sectors, encouraging joint planning and implementation, and creating systems for increased accountability should be a priority in future years.

Tracing the emergence of drowning prevention on the global health and development agenda: a policy analysis.

Drowning has been a neglected health issue, largely absent from the global health and development discourse, until the UN General Assembly adopted its first resolution on global drowning prevention in 2021. This policy analysis examines the role of issue characteristics, actor power, ideas, and political contexts in the emergence of drowning prevention, and it also identifies opportunities for future actions. We identified three factors crucial to enhancing prioritisation: (1) methodological advancements in population-representative data and evidence for effective interventions; (2) reframing drowning prevention in health and sustainable development terms with an elevated focus on high burdens in low-income and middle-income contexts; and (3) political advocacy by a small coalition. Ensuring that the UN resolution on global drowning prevention is a catalyst for action requires positioning of drowning prevention within global health and sustainable development agendas; strengthening of capacity for multisectoral action; expansion of research measuring burden and identifying solutions in diverse contexts; and incorporation of inclusive global governance, commitments, and mechanisms that hold stakeholders to account.

Drowning prevention: turning the tide on a leading killer.

Drowning is a leading killer, particularly of children and young adults, yet has been greatly neglected. Despite accounting for a higher number of deaths than many other substantial public health issues, drowning has not benefitted from the targeted attention it requires, which is particularly tragic because low cost and effective drowning prevention interventions exist. Therefore, the recent UN General Assembly's adoption of a resolution on global drowning prevention is a historic first, and offers an exciting opportunity by providing a comprehensive framework and a practical roadmap that a range of actors and sectors, including governments, can follow to address the challenge of drowning prevention.

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.

Mapping Trends in Drowning Research: A Bibliometric Analysis 1995-2020.

Drowning is public health issue requiring global, national and community responses. The multisectoral nature of drowning prevention reinforces the need for multidisciplinary research, which can play a key role in identifying patterns, factors and interventions and contributes to evidence-informed prevention. This study presents a biometric analysis of drowning research published in 1995-2020 and identifies temporal trends in research themes, journals, countries and authorship to assist in the planning of future research. This study identified 935 studies, representing authors from 80 countries. Publications grew 103-fold, and 41.2% (n = 385) were published since 2014. The top 20 journals are all injury prevention, public health, or medical journals. The top 5 accounted for 24.5% (n = 229) of total publications (TP). Research from the United States (TP = 313, 25.0%) and Australia (TP = 192, 15.3%) dominates the field. Growth is highest in low-middle-income countries (LMICs) including China (TP = 54, 4.3%, 32-fold), India (TP = 30, 2.4%, 17-fold) and Bangladesh (TP = 47, 3.7%, 7-fold). The study identifies significant growth in epidemiologic studies reporting burden and risk factors. Research in LMICs is increasing but lags relative to the burden. The role of multilateral and nongovernment organisations in evidence generation is evident and needs investigation, as do gaps in evidence for interventions and partnerships to progress the drowning prevention field.

Exploring children's participation in commercial swimming lessons through the social determinants of health.

ISSUE ADDRESSED: Drowning is a public health challenge, disproportionately impacting children. Social determinants of health (SDH) such as socio-economic disadvantage and geographic isolation increase drowning risk. Swimming and water safety lessons, in part, have reduced drowning in children, while also enabling healthy aquatic participation. Research suggests that some Australian children receive insufficient swimming and water safety education and are not achieving essential skills. METHODS: A cross-sectional retrospective analysis of swimming and water safety skills achieved by a cohort of children (5-12 years) attending commercial swimming lessons in three Australian states was undertaken. Variables included participant demographics (age, gender, and the SDH of socio-economic status [SES], and geographical remoteness) and skills being taught and achieved. Skills achieved were analysed against the National Swimming & Water Safety Framework and the National Benchmark. RESULTS: Swim schools were more likely to teach freestyle (87%) and backstroke (83%); and less likely to teach water safety skills like treading water (53%), and survival backstroke (46%). Overall, 40% of 12-year-old children failed to achieve the National Benchmark of 50 metres freestyle, fewer were achieving minimum water safety skills. Children from low socio-economic areas and regional locations were less likely to be achieving 50 metres freestyle. Children in this study were commonly from major cities (94%) and of high socio-economic areas (53%). CONCLUSIONS: Swimming lessons must incorporate a broad range of swimming and water safety competencies to ensure children have the skills required to reduce drowning, especially for those deemed at increased risk. SO WHAT: Stakeholders must prioritise holistic drowning prevention education strategies, ensuring all children can access swimming and water safety programs regardless of their socio-economic status or geographical location.

Reducing inequities among adult female migrants at higher risk for drowning in Australia: The value of swimming and water safety programs.

ISSUE ADDRESSED: Drowning is a global public health challenge with a need to ensure equity to drowning prevention information and interventions. In Australia, people born overseas are identified as being at greater risk of drowning. This paper presents findings from a community-based qualitative evaluation of swimming and water safety (SWS) programs delivered to adults from migrant backgrounds in Sydney, Australia. METHODS: A qualitative study was conducted in November-December 2019 among 35 female participants of SWS programs targeted to adult migrants. While offered to all SWS program participants, no males took part in the study. Focus groups and interviews were recorded, transcribed and thematically analysed using a deductive approach. The domains of enquiry were guided by the health belief model and the theory of planned behaviour. RESULTS: Study participants were ≥25 years, first generation and most had lived in Australia for ≥10 years. Most were nonswimmers and were fearful of water prior to the program. Key themes were: direct SWS program outcomes, health and well-being; enablers and barriers to participation including: motivation, a program coordinator, fear and settlement priorities. CONCLUSION: Findings suggest that in order to increase SWS participation among migrant communities, the broader determinants of health need to be considered. Culturally appropriate strategies are required to enable both men and women equal opportunities to access SWS programs. SO WHAT: SWS programs provide multiple benefits for adult migrants; however, the impact on reducing inequities is limited, with broader multi-strategic health promotion approaches and policies required for inclusion and sustainability.

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.

Boating-related drowning in Australia: Epidemiology, risk factors and the regulatory environment.

OBJECTIVE: Recreational boating is a popular pastime in many high income countries, and is a leading activity prior to drowning. This study reports on unintentional fatal drowning associated with boating-related incidents in Australia. METHODS: A total population, retrospective, cross sectional design examined all boating-related unintentional drowning deaths between July 1, 2005 and June 30, 2015. Variables examined included age, sex, location of drowning incident, vessel type, activity, presence of alcohol/drugs, and lifejacket wear. Relative risk (with a 95% confidence interval) was calculated using fatal drowning rates per 100,000 population and rates per 100,000 registered vessels. Chi square analysis and non-parametric tests for significance were applied. Statistical significance was deemed p < .05. RESULTS: A total of 415 people drowned while boating during the study period, 91.8% male and 35.7% aged between 25 and 44 years. Men were 10 times more likely to drown when boating than females (RR = 10.64 CI:7.55-14.97). Over one-quarter (28.7%) of incidents involved alcohol, in 30.6% drugs were identified (31.3% were illegal) and 90.4% were not wearing a lifejacket. Children were more at risk of drowning on a houseboat than adults (RR = 7.13; CI:1.61-31.61). Females were more likely to drown than males when using a personal watercraft (RR = 10.53; CI:2.75-40.33). CONCLUSION: Boaters may be taking unnecessary risks by disregarding safety regulations, such as not wearing lifejackets and substance use (such as alcohol and illegal drugs). Boating in remote locations presents a high risk of drowning. While safety regulations are in place, enforcement and behavior change remain challenges. Practical application: Findings support recommendations for increased enforcement of alcohol-related regulations and introducing drug-testing for boaters. Consistency of boating safety regulations, especially around lifejacket wear, is recommended to influence behavior change. The effectiveness of current lifejacket regulations need to be critically evaluated in the context of increasing wear rates for adults and children.

Calculating the economic burden of fatal drowning in Australia.

BACKGROUND: Aquatic activities provide physical and social benefits, while the risk of drowning generates countervailing social costs. Drawing on estimates of fatal drowning gathered by Royal Life Saving Society - Australia, this paper outlines a method for estimating the economic burden attributable to fatal drowning. METHODS: This study estimated the burden of fatal drowning by combining Value of a Statistical Life Year (VSLY), hospitalization, productivity and emergency services costs. All unintentional fatal drowning cases in Australia between 1-July-2002 and 30-June-2017 were included. Foregone life years from each drowning were estimated based on Australian life expectancies for the year of death. The societal value of these Years of Life Lost was calculated using the VSLY for Australia, adjusted to reflect income elasticity. Corrections to discounting of VSLY were applied. Estimates of productivity losses not captured in VSLY were produced using net national capital growth. Time spent in hospital was found using coronial data and existing estimates of search, ambulance and coronial costs were adapted and incorporated. RESULTS: The study covers 4285 cases of unintentional fatal drowning over 15 years. Based on this sample and estimates for the VSLY ($203,000), the economic burden of fatal drowning for Australia over this 14 year period was $18.63 billion in 2017 Australian dollars, averaging $1.24 billion annually. CONCLUSIONS: Fatal drowning represents a significant source of health burden in Australia, underlining the need for further preventative measures. PRACTICAL APPLICATIONS: We provide an easily-understood estimate of the scale of Australia's fatal drowning problem, permitting comparison with other social problems. They can also be used in determining net benefits of proposed drowning prevention policies and to identify situations where burden of fatal drowning is disproportionate. Suggestions for improving the calculation of societal burden of illness can be incorporated in cost-benefit analyses in related fields of study.

Understanding the full burden of drowning: a retrospective, cross-sectional analysis of fatal and non-fatal drowning in Australia.

OBJECTIVES: The epidemiology of fatal drowning is increasingly understood. By contrast, there is relatively little population-level research on non-fatal drowning. This study compares data on fatal and non-fatal drowning in Australia, identifying differences in outcomes to guide identification of the best practice in minimising the lethality of exposure to drowning. DESIGN: A subset of data on fatal unintentional drowning from the Royal Life Saving National Fatal Drowning Database was compared on a like-for-like basis to data on hospital separations sourced from the Australian Institute of Health and Welfare's National Hospital Morbidity Database for the 13-year period 1 July 2002 to 30 June 2015. A restrictive definition was applied to the fatal drowning data to estimate the effect of the more narrow inclusion criteria for the non-fatal data (International Classification of Diseases (ICD) codes W65-74 and first reported cause only). Incidence and ratios of fatal to non-fatal drowning with univariate and Χ2 analysis are reported and used to calculate case-fatality rates. SETTING: Australia, 1 July 2002 to 30 June 2015. PARTICIPANTS: Unintentional fatal drowning cases and cases of non-fatal drowning resulting in hospital separation. RESULTS: 2272 fatalities and 6158 hospital separations occurred during the study period, a ratio of 1:2.71. Children 0-4 years (1:7.63) and swimming pools (1:4.35) recorded high fatal to non-fatal ratios, whereas drownings among people aged 65-74 years (1:0.92), 75+ years (1:0.87) and incidents in natural waterways (1:0.94) were more likely to be fatal. CONCLUSIONS: This study highlights the extent of the drowning burden when non-fatal incidents are considered, although coding limitations remain. Documenting the full burden of drowning is vital to ensuring that the issue is fully understood and its prevention adequately resourced. Further research examining the severity of non-fatal drowning cases requiring hospitalisation and tracking outcomes of those discharged will provide a more complete picture.

Using a retrospective cross-sectional study to analyse unintentional fatal drowning in Australia: ICD-10 coding-based methodologies verses actual deaths.

OBJECTIVES: Fatal drowning estimates using a single underlying cause of death (UCoD) may under-represent the number of drowning deaths. This study explores how data vary by International Classification of Diseases (ICD)-10 coding combinations and the use of multiple underlying causes of death using a national register of drowning deaths. DESIGN: An analysis of ICD-10 external cause codes of unintentional drowning deaths for the period 2007-2011 as extracted from an Australian total population unintentional drowning database developed by Royal Life Saving Society-Australia (the Database). The study analysed results against three reporting methodologies: primary drowning codes (W65-74), drowning-related codes, plus cases where drowning was identified but not the UCoD. SETTING: Australia, 2007-2011. PARTICIPANTS: Unintentional fatal drowning cases. RESULTS: The Database recorded 1428 drowning deaths. 866 (60.6%) had an UCoD of W65-74 (accidental drowning), 249 (17.2%) cases had an UCoD of either T75.1 (0.2%), V90 (5.5%), V92 (3.5%), X38 (2.4%) or Y21 (5.9%) and 53 (3.7%) lacked ICD coding. Children (aged 0-17 years) were closely aligned (73.9%); however, watercraft (29.2%) and non-aquatic transport (13.0%) were not. When the UCoD and all subsequent causes are used, 67.2% of cases include W65-74 codes. 91.6% of all cases had a drowning code (T75.1, V90, V92, W65-74, X38 and Y21) at any level. CONCLUSION: Defining drowning with the codes W65-74 and using only the UCoD captures 61% of all drowning deaths in Australia. This is unevenly distributed with adults, watercraft and non-aquatic transport-related drowning deaths under-represented. Using a wider inclusion of ICD codes, which are drowning-related and multiple causes of death minimises this under-representation. A narrow approach to counting drowning deaths will negatively impact the design of policy, advocacy and programme planning for prevention.

Willingness to administer mouth-to-mouth ventilation in a first response program in rural Bangladesh.

BACKGROUND: Timely mouth-to-mouth ventilation is critical to resuscitate drowning victims. While drowning is frequent, there are no lay persons trained in cardio-pulmonary resuscitation (CPR) in rural Bangladesh. As part of a feasibility study to create a first response system in a conservative Islamic village environment, a pilot was undertaken to examine willingness to provide mouth-to-mouth ventilation for drowning resuscitation. METHODS: A questionnaire was administered to 721 participants at the beginning of a village-based CPR training course. Trainees were asked regarding willingness to administer mouth-to-mouth ventilation on a variety of hypothetical victims. Responses were tabulated according to the age, sex and relationship of the trainee to the postulated victim. RESULTS: Willingness to deliver mouth-to-mouth ventilation was influenced by sex of a potential recipient and relationship to the trainee. Adolescent participants were significantly more willing to perform mouth-to-mouth ventilation on someone of the same sex. Willingness increased for both sexes when the postulated victim was an immediate family member. Willingness was lower with extended family members and lowest with strangers. Adult trainees were more likely to perform mouth-to-mouth ventilation than adolescent trainees in any scenario. CONCLUSION: Adults express more willingness to resuscitate a broader range of drowning victims than adolescents. However in rural Bangladesh, adolescents are more likely to be in close proximity to a drowning in progress. Further efforts are needed to increase willingness of adolescents to provide resuscitation to drowning victims. However, despite potential cultural limitations, trained responders appear to be willing to give mouth-to-mouth ventilation to various recipients. Final determination will require evidence on response outcomes which is being collected.