A scoping review of the literature on effectiveness of legislative and regulatory measures to prevent drowning

Abstract

Background

Drowning has been the cause of millions of deaths over the last decade. Regulation is believed to be an effective measure in drowning prevention efforts; however regulatory regimes vary substantially. This study sought to (1) map the coverage of legislation and regulation related to drowning prevention; (2) examine the effectiveness of these regulatory measures; (3) explore the lessons learnt from the development, implementation, and enforcement, and; (4) provide an overall assessment of the quality of this literature.

Methods

A systematic scoping review was undertaken of the academic and grey literature. Papers were included if they gave insight into regulatory coverage or reported findings explicitly related to drowning prevention policies, laws, or regulation. After screening 25 papers (21 academic, four grey literature) were included in this review.

Results

While the literature provides some insights into global regulatory coverage when it comes to drowning prevention, this varies substantially. Relatively few studies have directly assessed the effectiveness of regulation.

Conclusions

Global regulatory coverage varies substantially, however when done well, regulatory efforts appear to be promising intervention when it comes to drowning prevention. However, the effectiveness of regulation is dependent on a range of factors, like resourcing and enforcement. Given the limited literature in this area, there is no clear picture of what works, for whom, and why.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-27234-2.

Introduction

In any given year, hundreds of thousands of people drown, and it is estimated that over three million people have lost their lives to drowning over the past decade [1], although most of these deaths are preventable. Drowning remains a major but often neglected public health problem, with a disproportionate burden borne by low- and middle-income countries [2]. Amongst several possible interventions, regulatory action is assumed to be a particularly powerful means to address rates of drowning, whether this be legislation, guidelines, or policy. In practical terms, regulation could include mandating of barriers around bodies of water, policies related to swimming and water safety skills or regulating boating, shipping, or other watercraft. Legislation that relates to public health, can shape the conditions in which risk occurs—by setting minimum safety standards, shifting defaults, and enabling consistent implementation at population scale [3]. However, the impact of any given law is not guaranteed, with it dependent on the content of the legislation, how it is implemented, and whether it is monitored and enforced, making the synthesis and evaluation of regulatory approaches an essential part of prevention research [4].

Despite being a potentially effective tool, regulation is underutilised, at least as it relates to drowning prevention. Amongst the 126 countries that submitted data to the ‘Global Status Report on Drowning Prevention’ report [1], there were marked differences between the utilisation of regulatory or legislative mechanisms related to drowning prevention by regions and related to the issues at hand. These findings showed substantial variation: only 14% of countries had legislation regulating private or public swimming pools, 24% addressed drowning prevention in disaster risk management policies, and 50% had laws regulating alcohol use around bodies of water. Regulation was higher for lifejacket use, with at least 65% of responding countries having some type of mandate, while 81% regulated the safety and/or seaworthiness of water-transport vessels. This regulatory variation is increasingly salient given recent global commitments, with both United Nations General Assembly and the World Health Assembly resolutions calling for accelerated, multisectoral national action and stronger policy, planning and accountability for drowning prevention [5, 6]. Understanding what regulatory measures exist, how they are designed, and what evidence supports their effectiveness will be central to translating global commitments into measurable reductions in drowning risk.

While these findings paint a somewhat mixed picture, even in areas with broader regulatory coverage, the mere existence of regulation or legislation says little about its effectiveness in changing behaviour or reducing drowning deaths. Regulation itself may have its own shortcomings; compliance may be poor, or it may require enforcement, which may not occur. For example, while the Global Status Report on Drowning Prevention report [1] found that a relatively high number of countries (81%) regulated the safety and seaworthiness of water-transport vessels, a much smaller number (44%) required mandatory inspections, required lifesaving equipment onboard (38%) or emergency plans to be included on the vessel (12%). Put another way, the structure, content and coverage of legislation and other regulatory instruments can vary substantially, as can their implementation and enforcement. This distinction is well illustrated in the drowning literature: for example, evidence syntheses suggest that pool fencing—particularly isolation fencing that separates the pool from the home—reduces children’s risk of drowning, yet effectiveness depends on real-world compliance and maintenance of barriers [7].

Given the disparities and variation in regulatory practices across countries, there is a clear need for guidance on best-practice approaches to legislative and regulatory efforts for drowning prevention. This study, therefore, sought to examine both the academic and grey literature related to regulatory mechanisms that address drowning prevention, including legislation, policies or other forms of regulation, whether related to infrastructure and swimming pools, watercraft, maritime transportation, or lifejacket use, among others. Specifically, the study had four aims: (1) map the coverage of legislation and regulation related to drowning prevention; (2) examine the effectiveness of these regulatory measures, whether assessed through reductions in drowning deaths or improvements in drowning prevention outcomes; (3) explore the lessons learnt from the development, implementation, and enforcement of regulation or legislation to identify factors that influence the success or otherwise of these approaches, and; (4) provide an overall assessment of the quality of this literature.

Methods

This paper utilised an approach widely recognised in systematic and scoping reviews, largely following1 the approach laid out by JBI [8]. In the following sections, we report on the steps taken to identify, synthesise, and appraise the literature related to the regulation of drowning prevention, with reporting consistent with that outlined by JBI guidance and the preferred reporting items for systematic reviews and meta–analyses scoping review (PRISMA ScR) guidance [9].

Search strategy

Although we followed largely the same process for both the academic and grey literature searches, there were some points of divergence in the search terms used and the screening methods applied. These differences were necessary to accommodate the specific features and limitations of each database and to achieve an appropriate balance between sensitivity and specificity in the search results. Notably, for this reason, and because we were interested in a broad range of studies, we did not utilise a search framework (i.e. PICO) to structure our searches. Each search process is reported separately below. Both searches were carried out in April 2025. To search academic literature, we utilised five academic databases: PubMed, Scopus, Web of science, Embase, and Cochrane Library. To search these databases, we developed a set of search terms to capture the key concepts of interest. The first concept encompassed drowning and water safety, including terms for drowning and drownings, as well as terms such as water safety. The second concept captured regulation and legislation, terms for policy analysis, along with terms such as policy, law, legislation and legal framework. The third concept focused on effectiveness and outcomes, incorporating terms such as effectiveness, impact, evaluation, reduction, prevention, and outcomes. No language or date restrictions were applied. The terms used for each database are included as supplementary material (appendix 1).

The search of academic databases provided 1825 results. These results were imported into Rayyan [10] where duplicates were removed, leaving 939 articles. A title and abstract screen was carried out by two researchers (RE and DB). Disagreements were resolved through discussion between the two reviewers, with a third reviewer (JJ) consulted when consensus could not be reached. This process resulted in 39 papers proceeding to full-text screening which was undertaken, again by two researchers (RE and DB). After full-text screening, 21 peer-reviewed studies were included in this review. This process and the exact number of studies found at each stage are included as supplementary material (appendix 2).

The grey literature search employed a similar method, with slight variation. In total, 12 databases were searched: National Technical Reports Library, Grey Literature Report (Grey Lit Report), World Health Organization-Institutional Repository for Information Sharing (WHO-IRIS), WHO (PAHO-IRIS), International Labour Organization, Food, Agriculture and Renewable Natural Resources Legislation Database (FAOLEX), ECOLEX, EURLEX, Organisation for Economic Co-operation and Development (OECD) library, World Bank Open Knowledge Repository, Google Scholar, and WordLII. After several preliminary searches, a simplified Boolean search string was utilised for these databases. The terms used for each database are included as supplementary material (appendix 1).

The grey literature search provided 6367 results. These results were screened manually by title/abstract by two researchers (RE and DB), which left 137 reports, articles, or pieces of legislation. A full text screen was then conducted which resulted in four reports for inclusion. This process and the exact number of studies found are included as supplementary material (appendix 2). In total, and including both peer reviewed and grey literature, 25 papers are included in this review.

Eligibility criteria

In screening the above papers, both from academic and grey literature databases, we applied a consistent and explicit eligibility criteria. We included any study (of any type, inclusive of both theoretical/descriptive and empirical research), report, guideline, policy or legislative document that gave insight into regulatory coverage or reported findings explicitly related to drowning prevention policies, laws, or regulations (this, therefore, included but was not limited to studies, reports, plans, guidelines, strategies, initiatives and orders). We also did not limit the searches to any time point in the past, as laws or regulations introduced decades ago may have still been in effect. We also did not exclude studies that examined superseded or amended legislation, as we felt that even if out of date, such studies may provide valuable insights into the effectiveness or otherwise of such legislation.

The criteria set above were deliberately broad; as from previous work on this topic, we understood there to be a paucity of evidence in this area. These criteria also allowed us to apply some flexibility to include studies with a range of outcomes reported. As noted in our research question, we were primarily interested in regulatory coverage, the effectiveness of regulation and the factors that explained this effectiveness or otherwise. These criteria allowed us to include such studies. Amongst the studies that were excluded against these criteria were several studies that reported rates of drowning or the extent of other prevention efforts in the absence of a more explicit discussion about legislative and/or regulatory effectiveness.

Before moving on, a brief note on terminology is warranted. Throughout, in reference to legislative and regulatory measures, we generally mean directives that normally come from government or other authorities that mandate some type of action or compliance and that could potentially be enforced. While there is overlap, this generally distinguishes instruments like legislation and policy from other directives, like guidelines, instructions, and protocols (Fig. 1). We have included other directives in the forms of policy, protocols, instructions and guidance, where these were explicitly supported by legislation or other regulations.

Fig. 1.

Conceptual hierarchy of regulatory mechanisms

Data extraction

Data were extracted to provide an overview of the papers included in this study and to inform the mapping of legislative coverage. Data extracted more generally included details such as the author/s, location of study, study aims and objectives, research methods/design and sample information, the name of the legislation or regulation in question, and a summary of the key findings of the study. Data extraction related to legislative coverage utilised academic and grey literature sources. Where legislative coverage was identified, data were extracted and collated utilising the domains outlined in the Global Status on Drowning Report 2024, and the reports focused on South-East Asia and the Western Pacific [11, 12], each of which reported legislative coverage in slightly different ways. Both tables are included as supplementary material (appendix 3).

Synthesis

The synthesis below combines both descriptive analyses and narrative synthesis. That is, data were collated to provide details on the number of types of studies as well as regulatory coverage. A narrative synthesis was also undertaken, particularly to address questions related to the effectiveness of legislation and in exploring the lessons learnt from the development, implementation, and enforcement of regulation. This approach offered flexibility in how results were arranged and analysed from these data [13] and was best suited to answering our research questions.

Quality appraisal

Given the nature of the studies found in the above search, we used the Mixed-Methods Appraisal Tool (MMAT) [14]. The MMAT is a critical appraisal tool designed to assess the methodological quality of empirical studies. The MMAT is particularly useful in reviews that integrate diverse forms of evidence, offering a structured framework to appraise each study type using specific criteria, thereby ensuring consistency and rigor in mixed-methods syntheses. It provides criteria for five study types: qualitative research, randomised controlled trials, non-randomised studies, quantitative descriptive studies, and mixed methods studies. The Authority, Accuracy, Coverage, Objectivity, Date, and Significance (AACODS) Checklist was used to appraise the grey literature [15]. This tool utilises six criteria to evaluate sources such as reports, policy documents, theses, and other non-peer-reviewed materials. To evaluate both the academic and grey literature included here, two authors (RE and DB) independently assessed each study/report using the respective checklist. Disagreements and discrepancies were resolved with a discussion between reviewers or with a third reviewer (JJ) until consensus was reached.

Results

Amongst the 21 peer reviewed studies included in this review, eight were from Australia, six from the United States, two from Vietnam, while China, India, New Zealand, Poland and Sweden each contributed one study respectively. Amongst the four sources of grey literature, one report had a global focus, while the others focused on Europe, the Western Pacific and South-East Asia respectively. The earliest publication was in 1980, with the most recent in 2024. There has been a steady stream of publications since the 1990’s with no notable uptick in recent years. These are summarised in Fig. 2.

Fig. 2.

Summary of studies included in this review and topics covered in empirical papers. Note: The above figure identifies studies that examined the effectiveness of legislation/regulation and where they were published. The below figure links year and country of publication

Of the 25 included papers, 14 (56%) empirically examined the effectiveness of regulatory measures, while 11 (44%) focused on regulatory coverage, implementation challenges, or policy analysis without effectiveness data. Studies examining effectiveness were concentrated in high-income countries, with all 14 conducted in Australia (n = 6), the United States (n = 6), Poland (n = 1), or Sweden (n = 1). No effectiveness studies were identified from LMICs.

Results are presented below in line with the above research question, notably examining the global coverage of drowning regulation, effectiveness of regulation on drowning prevention, and the factors that explain the effectiveness (or otherwise) of these measures, discussing the more general lessons learnt in regard to regulation, followed by the results of the quality appraisal.

Regulatory coverage for drowning prevention

To map the legislative and regulatory coverage, we extracted data from four reports [1, 11, 12, 16]. We collated this into the domains reported in the respective reports. These are presented below to give an indication of countries that have some form of legislation or regulatory mechanism in each domain. The most recent report published that gives some indication of regulatory coverage was the Global Status on Drowning report [1]. This report classified regulatory measures into seven categories. The most common regulatory measures related to domestic water transport safety, with over 70% of responding countries reporting some form of national or sub-national regulation in this area. Pool fencing, both for private and public pools, was among the least regulated areas, with only 5% and 15% of countries reporting some type of regulation respectively. These results are summarised in Figs. 3 and 4.

Fig. 3.

Countries reporting national or sub-national regulatory measures in WHO Global Status report (2024)

Fig. 4.

Countries reporting national or sub-national regulatory measures in WHO Global Status report (2024)

Data were also extracted from the South-East Asia and Western Pacific Status on Drowning reports [11, 12]. While these reflected several similar domains to that of the Global Report, these reports contained more granular data, organised in different domains. These are visualised below in Fig. 5. Amongst the most regulated domains were maritime safety, with close to 90% of countries having regulations around licensing, safety inspections, and lifejackets. When it came to protecting children, close to 90% of countries had regulations that dealt with child maltreatment. However other child protection measures like swimming lessons (30%) and pool fencing (30%) were amongst the least regulated domains, alongside, requiring competencies for swimming instructors and lifeguards, with about 20% of countries reporting some type of regulation. These results are largely reflective of the more recent report, with legislation around life jacket use as the most highly regulated and pool fencing amongst the least regulated.

Fig. 5.

Domains regulated in South-East Asia and Western Pacific status reports (World Health Organization, 2021a, 2021b)

Two additional studies examined legislative coverage but are not represented in the figures above. One study was carried out in China and sought to map legislative coverage for child injury prevention more generally [17]. In 2015, this study found six regulations relating to resuscitation, three related to covering or removing water hazards, one in relation to pool fencing and none in regard to wearing personal floatation devices. A study from the United States [18] examined the presence of regulations related to open water safety across 30 US states, finding that only 12 states (40%) had all five examined regulatory components (lifeguards, rescue/safety equipment, water quality testing, signage, and infrastructure for tracking/planning/reporting).

Together these findings revealed two patterns. First, regulatory coverage varied dramatically by domain, with maritime safety (licensing, inspections, lifejackets) most comprehensively regulated globally (approximately 80–90% of countries), while pool fencing remained among the least regulated (5–30% of countries depending on region). AudioVolumeUp Second, data on regulatory coverage were absent for many countries, particularly in LMICs, limiting our understanding of the global regulatory landscape.

Importantly, as it relates to coverage, reports did not provide contextual information to interpret whether the presence or absence of regulation was appropriate for a given setting. For example, data showed that only 5–15% of countries reported pool fencing regulations, but reports did not indicate which countries were landlocked, had climates with limited pool ownership, or had housing patterns where pool fencing would be relevant. Similarly, while over 70% of countries reported maritime safety regulations, no information was provided about which countries had coastlines, ports, or significant water transport requiring such regulation. The coverage data, therefore, provide a snapshot of legislative presence but insufficient context to assess regulatory adequacy or identify priority gaps across different country contexts.

The effectiveness of regulation in relation to drowning prevention

Amongst the 20 studies included in this review, the majority (n = 14) provided some kinds of analysis related to the effectiveness of legislative or regulatory efforts, both directly on drowning mortality and drowning prevention efforts. Studies were carried out in four countries, Australia (n = 6), the US (n = 6), Poland (n = 1), and Sweden (n = 1). These studies focused on pool fencing or regulation related to pools (n = 6), lifejacket use (n = 4), open water regulations (n = 2), swimming lessons (n = 1), and boating/personal watercraft (n = 1). This, along with the key findings of these studies is summarised in Table 1 (also see Fig. 2 above).

Table 1.

A summary of the issues related to the development, implementation and enforcement of regulatory efforts

Getting legislation right	Legislative and regulatory instruments may be inadequate or ineffective in that they may not be stringent enough, have loopholes, or simply offer inadequate coverage, whether this be jurisdictional or allow exceptions. These issues also speak on how legislation is developed, in that this often involves advocacy and compromise; seemingly progressive legislation can also be rolled back.
Compliance	Regulatory efforts require compliance. For any legislation to be effective, people, businesses, government, and other entities need to comply with it, whether this be taking steps to fence the pool, or purchase and wear a lifejacket. Compliance is not always forthcoming.
Enforcement	Closely related to the issue of compliance was enforcement. That is, enforcement is one means to achieve compliance. While it was not discussed in the literature, it appeared that different forms of regulation in relation to different issues tend to be more easily enforced. Notably the question of enforcement also raises the issue of who enforces the law or regulation and what penalties may be attached for non-compliance.
Resources	Whether legislation or a regulation was enforced, it often came down to resourcing constraints. That is, while several countries had passed regulatory measures, many struggled to adequately police and enforce them. Even in higher income countries, a lack of resources was cited as a problem. Resourcing also matters in other ways. Even where a law is introduced if the public does not have the resources to comply (for example, purchasing a lifejacket), this will likely impact the effectiveness of the law/regulation in question.
Education and awareness	Education and awareness campaigns were noted as important factors that predicted the success or otherwise of a law or regulation. That is, for people to comply with a law, at a minimum, they need to be aware of the law; they need to be aware of what it requires of them. Several studies spoke about laws being introduced alongside broader education and awareness campaigns. Education and awareness also appeared to be important in other ways, for example, one study found that even after legislation was introduced, the number of drownings were attributable to lifejacket not being worn correctly. Studies also suggested that education and awareness is required over the longer term.
Social factors	There are likely several broader social factors that may influence the effectiveness of legislation. One study discussed the ‘normalisation’ of lifejacket use after legislation was introduced, while another discussed the importance of ‘modelling’.

Amongst the studies that examined pool fencing, three were undertaken in Australia. The earliest of these studies came from Queensland and compared drowning rates across two neighbouring local government areas, Mulgrave Shire and Cairns. Mulgrave Shire introduced strictly enforced pool-fencing legislation in 1960, whereas Cairns did not. Over the ten-year study period (1970–79), two drownings occurred in Mulgrave Shire compared with five in Cairns. Importantly, no drownings occurred in pools that were fenced; both deaths recorded in Mulgrave Shire occurred in pools without fencing. This finding suggests that the presence of a physical barrier was protective, while the difference in deaths between the two areas reflects the broader impact of the legislative environment and compliance with fencing requirements [19]. A further study from Brisbane Queensland also applied a comparative approach but examined drowning rates before and after the introduction of legislation that mandated the use of barriers around private pools in 1991 (in effect in 1992). A total of 55 preschool-aged children (0–4 years) drowned in Brisbane over the 20-year survey period. In the decade prior to the introduction of the legislation (1982–1991) there were 28 drowning deaths and in the decade after (1992–2001) there were 10 drowning deaths. While drowning deaths decreased in Brisbane overall throughout this time, the authors estimated that the legislation was responsible for at least 30% of the reduction in drowning deaths in private pools [20]. The final study from Australia, employed a retrospective case series design, examining the factors present amongst 80 drownings in Victoria in children aged 0–4 years between 1989 and 2007 [21]. While this study considered several factors that led to these drownings, a lack of legislatively compliant fencing (or barrier) was most common, with this lacking in 64 of the 80 drowning deaths analysed. Amongst the four deaths where a compliant barrier was present, behavioural intervention (e.g. leaving a gate open) enabled access to the pool or spa in question.

Amongst the studies from the US, two examined the impact of regulation in King County, Seattle, related to public and semi-public swimming pools. In 1981 the county began to mandate several safety measures, including the fencing of outdoor pools and signage, which were audited in regular inspections. From 1975 (prior to the legislation) to 1986, several shifts occurred that included substantial reductions in drowning deaths, near drownings and improved safety around pools, including a greater number of trained lifeguards [22]. In a follow up study using the same data, the impact of these findings seemingly reinforced by the fact that near drownings did not decrease in private pools, where this legislation was not applicable [23]. A further study from the US stands in comparison to those of the above. Notably, this study did not directly set out to assess the impact of pool fencing; it did however provide a contrasting example whereby regulation had a questionable impact. This study noted that between 1976 and 1984 amongst the 1587 drowning deaths in Los Angeles, 707 occurred in private swimming pools. The authors go on to speculate why this was the case, despite there being pool fencing regulations, something which will be considered below [24].

The next group of studies examined regulation related to lifejackets and again came from Australia and the US. Amongst the Australian studies, one examined the introduction of legislation that mandated the wearing of lifejackets for rock fishing in New South Wales. This study examined drownings related to rock-fishing in the five years prior to (2011–2016) and after (2016–2021) the introduction of this legislation, finding that amongst the areas covered by the legislation, the odds of drowning while rock fishing was over twice as high prior to this legislation coming into force [25]. A further study from Victoria examined the impact of legislation introduced in 2005 to mandate lifejackets amongst recreational boaters. This study examined 59 recreational boating drowning deaths between 1998 and 2004 prior to the introduction of this legislation and 16 deaths between 2005 and 2010 after this legislation was introduced in what was a significant reduction. Issues were still noted however, after the introduction of this legislation related to compliance with a number of victims identified as having inappropriate or incorrectly fitted lifejackets [26].

Rather than focusing on drowning rates, both studies from the US examined the effects of lifejacket mandates on lifejacket use. In Washington State, lifejacket use was only required by certain groups; people being towed by boats, such as water-skiers, people in personal watercraft, such as canoes and kayaks, and children. It was hypothesised that lifejacket use amongst these groups would be higher than the average seen throughout the state. This study found that amongst 5157 boaters, about 30% wore life jackets, whereas rates for personal water-craft users and people being towed were over 90%, while over 80% of children wore life jackets. After accounting for differences in on-water activities, boat size, and weather conditions, this study concluded that people were two to three times more likely to wear a lifejacket when required by law [27]. A further study from the US also reported similar findings, but instead employed a comparative approach to examine the effectiveness of two interventions that both sought to increase lifejacket use. An awareness campaign that took place throughout the California Delta, starting in 2007, was compared to the mandated use of lifejackets amongst US Army personnel in Mississippi. In California, lifejacket use increased from 8.5 to 12.1% in the first year of the campaign; however, it dipped to around 9–10% in subsequent years. In comparison, mandating the use of life jackets resulted in far higher compliance, with 75% of people wearing one in the first year, dropping to about 70% in subsequent years [28].

Two contrasting studies examined the impact of mandatory interventions for open water, that is, lakes, rivers, and coastal waters. The first and only study from Poland examined legislation introduced in 2011 that included a range of regulations including standards for water rescue training, signage, equipment, and the number of lifeguards required in any given location. While this study reported a modest decrease in drowning after this legislation was introduced, there was also reportedly poor compliance with these laws (something that will be discussed below) [29]. In what was perhaps the broadest study, Quan et. al. [18], examined regulation across the US related to open water. Safety regulations were categorised into one of five policy areas: lifeguards, rescue/safety equipment, water quality testing, signage, and infrastructure for tracking/planning/reporting. This study found that states with greater regulation generally had lower open water drowning death rates. Amongst states without any form of regulation, drowning rates were three and four times higher amongst young people and non-white residents respectively, compared to those who had all five types of regulation.

A further study from Australia examined a range of aspects related to watercraft/boating safety throughout Australia [30]. This included lifejacket use but also included legislation regarding alcohol and the operation (licensing and registration) of personal watercraft. This study offered a comparison between Australian states, with one particularly notable finding. In the Northern Territory, the state which had the weakest boating regulations (at the time lifejackets were not mandatory, alcohol was not regulated, and a license and registration was not required to operate a vessel/boat) also had the highest rates of risky behaviour and drowning per capita in Australia [30].

One final study that speaks to the impact of regulation, briefly discusses the impact of Sweden’s mandatory swim training, something that was introduced and mandated in the school curriculum in the 1950’s. While drowning had decreased substantially since the 1950’s from 35 children a year to 7 in 2001, care is needed in drawing a causal link, as Sweden had also introduced several other strategies over this time that have contributed to a reduction in childhood injuries [31]. This study also speaks to some of the challenges in mandating swimming training, something which will be considered below, along with several other studies.

Across the 14 studies examining regulatory effectiveness, several patterns emerged. Pool fencing regulations (n = 6 studies) showed mixed results; three Australian studies [19–21] and two US studies examining public pools [22, 23] reported reductions in drowning deaths or near-drownings following legislation, while one US study [24] found high drowning rates in private pools despite existing regulations. Lifejacket mandates (n = 4 studies) consistently showed either protective effects on drowning mortality [25, 26] or increased usage rates [27, 28]. Open water regulations (n = 2 studies) suggested protective effects, with one US study [18] finding substantially lower drowning rates in states with comprehensive regulation, while a Polish study [29] reported modest decreases in drowning deaths, but poor compliance with the regulations in question. Single studies examining boating regulations [30] and mandatory swimming lessons [31] each reported associations between stronger regulation and lower drowning or childhood injury rates.

Across all domains, 12 of the 14 effectiveness studies (86%) reported some form of positive association between regulation and either reduced drowning mortality or increased safety behaviours. However, several studies [21, 24, 26, 29] identified ongoing challenges related to compliance, enforcement, or correct use of safety equipment even after regulations were implemented. The two studies reported limited or questionable effectiveness [24, 29] both specifically noting poor compliance or enforcement as potential explanatory factors.

Why regulation is effective (or not), and lessons learnt

In considering what may be best-practice when it comes to regulation in relation to drowning prevention, perhaps equally as important as the more direct impacts of legislation or regulation are the factors that explain its success or otherwise, that is the challenges, enablers, constraints, or more generally the lessons that can be learnt in relation to the development and implementation of any given regulatory effort. On this point, it is important to note that most studies reported below offered speculative or anecdotal evidence, reflecting on the more immediate challenges faced or lessons learnt in relation to the legislation or regulation in question. The issues frequently raised in the literature related to shortcomings or inadequacies of regulation itself or the regulatory process, compliance, enforcement, resourcing, education and awareness, and to a much lesser extent, how broader social forces might also facilitate behaviour change. Each will be discussed below, with these findings summarised in Table 2.

Table 2.

Study details that examined effectiveness of drowning prevention legislation

Regulatory Domain	Country	Regulation Type	Key Findings	Reference
Pool fencing	Australia (QLD)	Mandatory pool fencing (1960)	2 drowning deaths in area with pool-fencing legislation vs. 5 in area without (1970–79). No drownings occurred in fenced pools; both deaths in the regulated area occurred in pools without fencing.	[19]
Pool fencing	Australia (QLD)	Mandatory pool barriers (1992)	28 deaths pre-legislation (1982–1991) vs. 10 deaths post-legislation (1992–2001); authors estimated legislation responsible for at least 30% of the reduction	[20]
Pool fencing	Australia (VIC)	Mandatory compliant fencing	Non-compliant fencing in 64/80 deaths (80%); compliant fencing present in 4/80 deaths (behavioural factors enabled access)	[21]
Pool fencing/safety	USA (WA)	Multiple pool safety requirements (1981)	Substantial reductions in drowning deaths and near-drownings from 1975–1986; increased trained lifeguards	[22]
Pool fencing/safety	USA (WA)	Multiple pool safety requirements	No decrease in near-drownings in private pools where legislation did not apply	[23]
Pool fencing	USA (CA)	Pool fencing regulation	707 of 1,587 total drownings (45%) occurred in private pools despite existing regulations	[24]
Lifejacket use	Australia (NSW)	Mandatory lifejackets for rock fishing (2016)	Odds of drowning while rock fishing “over twice as high” before legislation in covered areas (comparing 2011–2016 vs. 2016–2021)	[25]
Lifejacket use	Australia (VIC)	Mandatory lifejackets for recreational boating (2005)	59 deaths pre-legislation (1998–2004) vs. 16 deaths post-legislation (2005–2010); compliance issues with incorrect fitting noted	[26]
Lifejacket use	USA (WA)	Selective mandatory use requirements	~ 30% general lifejacket use; over 90% for personal watercraft users and people being towed; over 80% for children; 2–3 times more likely to wear when required by law	[27]
Lifejacket use	USA (CA/MS)	Mandatory use vs. awareness campaign	California awareness campaign: 8.5–12.1% use (year 1), 9–10% (subsequent years); Mississippi mandate: 75% (year 1), ~ 70% (subsequent years)	[28]
Open water safety	Poland	Comprehensive open water regulations (2011)	“Modest decrease in drowning”; poor compliance reported	[29]
Open water safety	USA (30 states)	Five regulatory components	States without regulation had drowning rates 3x higher (young people) and 4x higher (non-white residents) vs. states with all 5 regulations	[18]
Boating/watercraft	Australia (multiple states)	Comprehensive boating regulations	Northern Territory (weakest regulations: no mandatory lifejackets, no alcohol regulation, no licensing) had highest drowning rates per capita and risky behaviours	[30]
Swimming lessons	Sweden	Mandatory school-based swim training (1950s)	Child drownings decreased from 35/year (1950s) to 7/year (2001); authors cautioned against causal attribution due to multiple concurrent interventions	[31]

Regulatory design and adequacy (n = 7 studies): Studies from the United States [24] and Australia [21, 28] identified design inadequacies in pool fencing legislation. Los Angeles pool fencing regulations did not cover all county areas [24]. Victorian legislation did not require physical separation of pools from property, allowing direct access [21]. Scott [32] documented that Australian pool fencing legislation required decades to address identified flaws and faced opposition leading to repeals of progressive measures. Regional WHO reports [11, 12] found legislation was often outdated or difficult to interpret.

Compliance (n = 9 studies): An Australian survey [33] found pool fencing inspections were conducted infrequently and compliance information was minimal. Vietnamese stakeholders [34] reported policies existed but were rarely enforced for water transport. One study [28] quantified that ranger patrol visibility correlated with greater lifejacket use. A New Zealand study [35] documented pool compliance increasing from 43% (1997) to 71% (2007) and authority re-inspections increasing from 28% to 63%, changes occurring over two decades. An Australian study [25] reported only ten fines issued for rock fishing lifejacket violations.

Enforcement (n = 8 studies): Studies from Sweden [31], Poland [29], Vietnam [34], and Australia [25, 33] reported enforcement challenges. Swedish mandatory swim training was not offered by 30% of schools despite being mandatory [31]. Vietnamese policies for safe water transport were rarely enforced [34].

Resources (n = 9 studies): Resource constraints were identified in high-income countries [31, 32] and low- and middle-income countries [32, 34–37]. Vietnam faced challenges with data capture capacity and healthcare system instability [34, 36]. An Indian study [37] identified limited resources for staffing and monitoring as barriers. All three regional reports [11, 12, 16] identified that countries reported lacking capacity and resources for effective implementation.

Education and awareness (n = 8 studies): Studies from Australia [25, 26, 30, 32] and the United States [24, 28] discussed education accompanying regulation. Victoria’s 2005 lifejacket mandate included widespread public education with initially educational rather than punitive enforcement [26], yet drowning victims were still found wearing incorrectly fitted lifejackets. Mississippi’s lifejacket mandate was preceded by substantial publicity [28]. Studies [24, 32, 35] emphasised ongoing education needs, with one noting 40% of Queensland drownings were attributable to poor pool maintenance [32].

Social factors (n = 2 studies): Two US studies [27, 28] identified social influences on compliance. One suggested mandatory use coupled with awareness campaigns led to ‘normalization’ of lifejacket use [28]. Another found that when adults wore lifejackets, adolescents were more likely to wear them despite no mandate for either group [27].

Quality appraisal results

Peer-reviewed studies that were included were categorised as either qualitative (n = 2), quantitative (descriptive) (n = 8) or quantitative (non-randomised) (n = 9) according to MMAT criteria. One study did not neatly fit these criteria and so was excluded from the quality appraisal. Overall, and across all three categories, most studies met most or all MMAT criteria, meaning that quality of these studies was generally acceptable and that the appropriate methods were used to answer the questions being raised (Fig. 6). Issues in regard to the quantitative (descriptive) studies related to response bias and statistical analysis, while a number of the quantitative (non-randomised) studies did not have complete outcome data or did not account for confounders in their analysis. While there were only two qualitative studies, there was a lack of clarity in one of these studies in relation to whether findings were adequately substantiated and derived from the data that was collected. These results are summarised below, with full scoring included as supplementary material (appendix 4).

Fig. 6.

Quality appraisal results utilizing MMAT scales

Discussion

The above review synthesised the literature related to legislative and regulatory efforts in relation to drowning prevention. The focus of this review was on the coverage, effectiveness of regulation on drowning prevention mortality and related behaviours and the key lessons learnt form the literature, whether this be about the development, implementation or enforcement of these regulatory efforts, that is, the factors that made the legislation or regulation effective or successful (or otherwise). Regarding regulatory coverage, our findings reveal a global regulatory landscape characterised by uneven development across domains and substantial data gaps. Regulatory approaches are more comprehensively developed in areas related to transport and maritime safety, while protective regulations targeting specific high-risk populations, particularly children around residential water hazards, remain sparse. However, the presence or absence of regulation must be interpreted within local context. Landlocked countries may deprioritise maritime legislation, while colder climates with limited pool ownership may reasonably lack pool fencing mandates. Conversely, having legislation provides no guarantee of benefit; regulatory effectiveness depends fundamentally on scope, content, enforcement mechanisms, and implementation resources. Our inability to examine these elements of regulatory quality, beyond simply documenting legislative presence, represents a critical limitation in understanding whether apparent coverage gaps represent genuine policy deficiencies or context-appropriate priorities. (see below discussion on limitations).

Regarding effectiveness, the evidence base, while suggestive of regulatory promise particularly for pool safety and lifejacket mandates, is fundamentally limited by its narrow scope. Studies are geographically concentrated in two high-income countries, focus on specific regulatory domains that may not represent priority risks elsewhere, and in many cases are decades old. Most critically, effectiveness evidence is entirely absent from LMICs where drowning mortality is vastly higher [38], raising questions about generalisability to contexts with different risk profiles, resource constraints, and implementation capacity. The pattern whereby studies reporting limited regulatory impact specifically attributed this to poor compliance and enforcement suggests that regulatory design and implementation quality, rather than regulation alone, determines effectiveness.

The third aim of this study was to explore the lessons learned from the development, implementation, and enforcement of regulatory efforts, and to identify factors that may explain their effectiveness. Here, the literature was mainly speculative or anecdotal, with studies and authors often reflecting on the more immediate challenges or issues they faced in regard to the development or implementation of legislation. In short, there was no one size fits all approache, and regulation should not be seen as a panacea, despite its potential to reduce drowning deaths. Whether legislation has its desired effect will depend on a range of factors, many of which are likely still yet to be identified in this relatively small literature. There have been no studies that comprehensively consider what ‘best practice’ could be in this space. In saying this, several studies mentioned issues and challenges in this area that begin to paint a picture of what best practice in this area may require. These discussions focused on compliance with legislation, enforcement of legislation, education and awareness campaigns to complement legislative change and to a much lesser extent, how broader social forces might also facilitate behaviour change.

The final aim of this study was to examine the quality of the evidence as it relates to the regulation of drowning prevention. While the quality of the evidence in this study was generally good, and while most studies were well designed and executed, there were only a handful of larger observational studies. For this reason, we cannot draw any firm conclusions about causation and more generally, we should be cautious in interpreting the above findings regarding the effectiveness of legislation and the lessons we can draw from this literature.

In addition to answering the above research questions, this study provided insight into several more general limitations, as well as points for directions for future research. First, there is a need for further data in relation to legislative coverage as it relates to drowning prevention, and not just in relation to coverage, but the scope and content of the legislation in question. Second, there are some issues that can be clearly identified as needing further research, like maritime safety legislation (see below discussion on limitations) and drowning prevention regulation in LMICs. Third, more systematic empirical work is needed to explore what makes regulation effective or otherwise. While several studies speculated on this and offered anecdotal evidence, there seems to be particular scope for greater work on these issues. For example, why or why not people comply with a piece of legislation seems to be a particularly important question, that is, regulation itself may not address the root causes of why people may not be complying, in fact regulation may be counter-productive if people cannot comply. Future studies need to consider this point, on how best to ensure compliance and the unintended effects of regulation. There also appears to be a need to examine the broader factors that may contribute to the success or otherwise of regulatory efforts, whether this be education and awareness raising campaigns or other measures that seek to modify behaviour or prompt some type of change. Finally, throughout the above literature there was a distinct lack of normative analysis, for example, the issue of enforcement. While there appeared to be an assumption that this was a key part of any legislative effort and a means to achieve compliance, little thought was given to other interventions or means to promote compliance. This is perhaps unsurprising in some ways given the focus of this research, however, at the same time there is a vast public health ethics literature that deals with these issues that have seemingly been overlooked. Overall, we know little about the factors that contribute to successful or effective regulation in drowning prevention. While there are cases (i.e. Australia’s approach to pool fencing) we could draw from that have been relatively successful, given the multi-sectoral nature of drowning prevention and the extent to which these issues differ across time and place, caution should be exercised in thinking such cases could be applied in all circumstances.

Limitations

Several limitations related to this study are worth noting. First, our discussion should be seen in light of the other evidence discussed in this study. That is, our discussion about coverage is not only limited because of missing data; we know little about the scope and content of this legislation, so care is needed in interpreting this. A further major limitation relates to the papers we included in this study and in relation to scoping review methodology more generally. That is, we only included papers that discussed the impact or influence of legislative or regulatory mechanisms explicitly. This means that a number of studies were likely excluded that examined some type of intervention that had regulatory backing. For example, while there is a substantial literature the speaks to the effectiveness of pool fencing, and in many cases, this may have been mandated, this literature was not included as it often did not explicitly discuss the ‘effectiveness’ of regulatory efforts, but rather the effectiveness of pool fencing itself [39]. The same could be said about other forms of regulation or drowning prevention initiatives. This also applies to the potential gaps we found, notably with regards to maritime safety legislation and the potentially different terminology used across these somewhat disparate domains. Given the breadth of this paper, it was not feasible to include all possible search terms to capture this literature, nor would it have been feasible to identify studies where drowning was not directly considered. For example, a vast literature on maritime safety that was not included that may have some bearing on drowning prevention efforts [40]. Future studies could address this shortcoming with more targeted research questions and scope. Furthermore, the majority of studies that were included were from higher-income countries, with most from Australia and the US. Finally, we also cannot comment on whether the legislation referred to in these papers remains in force or is current, that is, many of the studies included, particularly those which are older, may now refer to legislation that has been amended or superseded.

Conclusions

This study examined the coverage, effectiveness, and lessons learnt in relation to drowning prevention regulation. While in some ways this appears to be a promising approach to prevent drowning, there is a dearth of evidence and no guide for best practice exists when it comes to regulation. Any regulation of drowning prevention efforts should be considered alongside other strategies, as well as local requirements and priorities. It also appears important to consider the resources required to introduce and maintain any regulatory approach. In terms of looking to the future, there is vast scope to undertake research in this area to better understand the impact of legislation on drowning and what it takes to introduce and sustain successful legislation in this space.

Authors' contributions

JJ and DB conceived the study and ran the search. RE and DB led screening and quality appraisal. RE led synthesis and write up. DB and JJ contributed to revisions of the drafts.

Funding

Funding for this work was received from the World Health Organization to inform the development of a technical policy resource for drowning prevention.

Data availability

All data used here are publicly available.

Declarations

Ethics approval and consent to participate

This was a scoping review and thus, ethical approval was not required.

Consent for publication

N/A.

Competing interests

The authors declare no competing interests.