Evidence-based drowning prevention in older adults: a rapid review and Haddon’s matrix

Abstract

Background:

Drowning is the third leading cause of unintentional injury deaths worldwide. While multiple factors contribute to the risk of drowning, drowning settings, patterns, and rates vary by age. Drowning prevention efforts should be tailored based on age, however, most drowning prevention interventions focus on children and do not address the injury burden in older adults that disproportionately affects aging societies.

Methods:

A formal rapid review of drowning prevention studies of adults aged 50 years and older published between January 1, 2008, to November 30, 2025, was conducted. Results were analysed using Haddon's Matrix, a tool that organizes interventions by different phases of injury and injury components.

Results:

Eight studies were eligible for data extraction. Most interventions targeted the general population, reporting differing age ranges of older adults. Most studies used a pre-drowning behavioural intervention for both young and older populations in high income countries.

Discussion:

Drowning prevention research in older adults was limited, lacking common definitions of what age groups constitute older adults and lacking diversity in levels of prevention, target injury components, and settings unique to older adults. Recent studies indicate that drowning risk factors for older adults differ from those of other age groups and underscore the importance of focusing drowning prevention efforts on this growing high-risk group.

Conclusion:

Future drowning prevention efforts for older adults need to address older age group’s unique risk factors and a wider array of types of prevention.

BACKGROUND

Drowning is the third leading cause of unintentional injury deaths worldwide, claiming an estimated 300,000 lives [1]. Among key factors in drowning, age specifically impacts the characteristics of drownings. In the U.S., children aged 1-4 years drown most frequently in swimming pools while adults aged 65 and older, often with chronic medical conditions, drown most frequently in bathtubs [2]. Differences in physical settings, environment and host-related factors show the need to tailor drowning interventions and strategies by age [3].

Evidence-based drowning prevention efforts have focused on the children who are disproportionately burdened by drowning [1]. Research has yielded effective drowning prevention strategies for children in low- and middle-income countries (LMICs) and high-income countries (HICs) [4]. However, aging societies now experience increased drowning burdens among older adults [5]. Some countries like Australia have responded to this increase by making people aged 65+ a priority population for drowning prevention research [6].

Evidence-based prevention methods are essential to inform a comprehensive plan that addresses the unique needs of older adults; identifying these methods was the purpose of this rapid literature review. Results of the review were compiled into a Haddon’s Matrix to categorize efforts by primary (prevent the injury before it occurs), secondary (prevent or reduce the severity of the injury as it occurs), and tertiary (reduce the severity or impact of the injury after it occurs) phases of intervention [6].

METHODS

A rapid literature review of peer-reviewed and grey literature was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines [7]. Grey literature that was indexed within the databases was included. Documentation of the protocol used for this review was submitted to PROSPERO (ID #1138750). We used Covidence software to manage the review and data extraction. Two members of the study team were involved in each screening step, following a pilot screening process of the first 30 studies to review disagreements and ensure standardized application of eligibility criteria. A third team member settled disagreements. Primary evaluation of the included studies was guided by an adaptation of the MetaQAT critical appraisal tool. Ethics approval was not required for this study.

Eligibility Criteria

We included studies published in English between 1/1/2008-11/30/2025 that reported on any drowning prevention intervention outcome for older adults (Table 1). Interventions were defined as primary, secondary or tertiary prevention. Older adults were defined as those 50 and older. All papers describing a drowning prevention intervention or synthesis of data with an outcome germane to drowning prevention were included without any geographical limit. Studies were included if the average age of the target population fell within the range of our target population and if the older adult outcomes were evaluated. Studies that solely reported descriptors and risk factors for older adult drownings were excluded.

Table 1.

Inclusion, exclusion criteria; Search strategy and variables extracted for eligible papers on older adult drowning prevention

Inclusion Criteria	Exclusion Criteria
Published between January 1st, 2008, and November 30th, 2025	Exclusive focus on risk factors
Outcome/conclusion pertinent to target population	Disease/mortality surveillance without synthesis of data yielding a prevention outcome/conclusion for older adults
Primary/Secondary/Tertiary prevention
	Non-human study
Average/median age of study population within target population age
	Forensic study
English language	Systemic or scoping reviews
Peer-reviewed or grey literature
Search Strategy
("Drowning"[Mesh] OR drown*[tiab] OR submersion*[tiab])
AND
("Adult"[Mesh:noexp] OR "Middle Aged"[Mesh] OR Aged[Mesh] OR Aging[Mesh] OR Geriatrics[Mesh] OR adult*[tiab] OR elder*[tiab] OR geriatric*[tiab] OR senior*[tiab] OR older[tiab] OR quinquagenarian*[tiab] OR sexagenarian*[tiab] OR septuagenarian*[tiab] OR octogenarian*[tiab] OR nonagenarian*[tiab] OR centenarian*[tiab] OR gerontolog*[tiab] OR ageing[tiab] OR aging[tiab] OR aged[tiab])
AND
("prevention and control"[sh] OR "Accident Prevention"[Mesh] OR "Health Promotion"[Mesh] OR "Guidelines as Topic"[Mesh:NoExp] OR "Guideline" [Publication Type:NoExp] OR prevent*[tiab] OR safety[tiab] OR "health promot*"[tiab] OR program*[tiab] OR campaign*[tiab] OR intervention*[tiab] OR guidelines[tiab] OR "good practi*"[tiab] OR "best practi*"[tiab] OR polic*[tiab])
AND
(2008/1/1:2025/11/30[pdat])
Variables Extracted
Study information: author, title, year published, objective, country/income level, study type, study population/age, sample size, reported older adult age, outcomes, measures of effect, self-reported study limitations, and ethical approval.
Intervention information: name, strategy, setting, recruitment, activity, years, intervention years, duration, use of theory, and description of use of theory.
Prevention information: Type of prevention and prevention target
Equity information (included only those reported except for equity assessment): housing, income, intervention rurality, participants residence rurality, race, ethnicity, occupation, sex, religion, education, disability, sexual orientation, other vulnerable group, and equity assessment.

Search Strategy

Five databases were searched: PubMed; Embase; Cochrane; CINAHL; and Web of Science using a combination of keywords and MESH terms (Table 1).

Outcome Measures

All reported drowning prevention outcomes were considered, including those quantitatively measured, e.g. a decrease in drowning rates, and qualitatively evaluated, e.g. change in attitude.

RESULTS

Of the 7875 initial studies, 73 studies qualified for full text review after removing duplicates, screening titles and abstracts, and removing studies not retrieved (Figure 1). We retained eight studies [8-15] for data extraction following full text review.

Figure 1.

Drowning Prevention in Older Adults Rapid Review PRISMA 2020 Flow Diagram

The study populations of the eight included studies varied from recreational boaters [8] to residents and tourists of coastal areas [10], drowning patients who experienced out-of-hospital cardiac arrest (OHCA) [11], and fatal drowning victims [12]. All studies included populations of diverse ages and varying age group definitions. Most studies [8-12, 14] defined older adults as 60+ or 65+; only two studies [13, 15] reported on specific age subgroups among older adults. Of the three studies [9, 11, 14] that reported the sample size of the studied populations (Supplementary Table 1), two [9, 11] reported the older adults’ sample size. Populations of six studies [8, 9, 11-13, 15] were in HICs [16]. Studies reporting intervention years generally conducted interventions over at least 3 years between 2005-2020. All studies reported varying measures of effect, evaluating outcomes quantitatively. No interventions included an equity assessment to assess effects for vulnerable populations.

Five interventions—mandatory wear of personal floatation devices (PFDs), public awareness campaigns, environmental modifications (such as elimination of water reservoirs), development and initiation of age-specific water safety strategies, and education on rip currents and escape methods [8-10, 13, 14]—reported improved drowning prevention-related outcomes for older adults. Two interventions—different cardiopulmonary resuscitation (CPR) techniques and designating cities as WHO safe communities [11, 12]—did not improve drowning prevention-related outcomes among older adults. One intervention did not include baseline information needed to determine efficacy [15]. Organizing interventions in the Haddon matrix (Table 2) showed that primary prevention was the most studied prevention type. Interventions focused on the host in all eight studies and the environment in three studies [10-12]. Only one study targeted all three injury components [10]. Comparing effectiveness across studies was precluded by varying outcome measures.

Table 2.

Haddon’s Matrix of type of prevention and prevention targets for included studies stratified by older age groups [8-15]

		Host (drowning victim)	Agent (water)	Environment
Primary (prevent the injury before it occurs)	55 +	- Peden et al. (2021)1
		- Wilcox-Pidgeon (2025)2
	60 +	- Bugeja et al. (2014)
		- Cummings et al. (2011)
		- Zhu et al. (2023)
	65 +	- Davoudi-Kiakalayeh et al. (2013)	- Davoudi-Kiakalayeh et al. (2013)	- Davoudi-Kiakalayeh et al. (2013)
		- Kang et al. (2015)	- Kang et al. (2015)
Secondary (prevent or reduce the severity of the injury as it occurs)	60 +	- Bugeja et al. (2014)
		- Cummings et al. (2011)
Tertiary (reduce the severity or impact of the injury after it occurs)	65 +	- Fukuda et al. (2019)		- Fukuda et al. (2019)

¹Papers were bolded if the intervention yielded positive efficacy for older adult drowning prevention (refer to outcomes and measures of effect from supplementary table 1).

²Paper did not report baseline measures of effect, so no conclusion was made on its intervention efficacy for older adult drowning prevention.

DISCUSSION

This rapid review was conducted to identify evidence related to drowning prevention in older adults, defined as those aged 50 and above. In the eight included studies, interventions mostly targeted host behaviour changes in HICs [8, 9, 11-13, 15]. Effective interventions in older adults included behaviours and water safety skills, such as appropriate PFD use, or identifying and escaping rip currents. While cost-effective, teaching resuscitation skills did not provide short-term impacts for older adults [12]. Socioecological strategies that combined education and environmental protections (such as fencing) produced improvements that were sustained across different ages [10]. Classification of interventions using a Haddon’s Matrix revealed a strong need for diversifying older adult drowning prevention strategies.

This review revealed lack of focus and evidence regarding drowning prevention interventions in older adults. Compared to younger populations with few comorbid conditions, research from various countries has shown pre-existing medical conditions, most commonly heart disease, increase drowning risk for older adults, especially among individuals bathing alone [17, 18]. No intervention in this review addressed known relevant risk factors such as bathing, cardiac distress, alcohol, drugs and medications, and lack of safety devices in the bathtub [19].

Analysis and comparison of drowning prevention in older adults were complicated by varying definitions “older adults” in the included studies. Furthermore, accurately describing this high-risk group requires not only age ranges, but also other demographic, physiologic, neurologic, or functional parameters that contribute to the unique risks and mechanisms of drowning in older adults [5]. Biologic aging is affected by socioeconomic and environmental factors which contribute to discrepancies in risks and outcomes that could shape different subgroup clustering in older adults [4]. While the identifying definition for older adults may differ in context, such as HICs and LMICs, creation of more standardized definitions will facilitate more robust research on drowning prevention for older adults.

Moreover, among those greater than 50 years, physiologic changes, comorbidities, and behaviours continue to change dramatically. This is demonstrated in the increasing burden of drowning among younger subset of older adults [18]. Drowning prevention requires also parsing this heterogeneous population into subgroups who drown in different aquatic environments doing different activities as they age [5]. With increasing age, adults decrease recreational aquatic activity in natural water settings (e.g., fishing or boating in lakes, ponds, and oceans) and increase activity in man-made settings (e.g., or pools); 66% of New Zealand adults aged 65+ were significantly less likely to have engaged in aquatic activities and reported lower swim competency than younger adults [20]. One of the included studies [15] corroborated these changes, noting the sharp decline in the ability to swim 5m or 50m for those 65+ compared to those aged 55-54. Effective drowning prevention strategies for older adults need a comprehensive health promotion approach that addresses the different capabilities of the individual, their activities, and environments.

Strengths and Limitations of this Study

This review was limited by the ages studied in the included papers, although we used a broad definition of older adults to ensure a comprehensive search. We found no study whose primary focus was older adults. Although interventions were measured and reported for variously aged older adults, only one intervention [13] was age sensitive. Furthermore, varying outcome measures did not allow us to directly compare interventions. Lastly, inclusion of only papers in English may have excluded relevant studies published in other languages.

CONCLUSION

This review identified the need for drowning prevention interventions specifically targeted to the unique needs of older adults, and the need for an inclusive representation of intervention evaluations in LMIC as well as HIC. These interventions should employ a more diverse approach to prevention, including different prevention types and targets to yield evidence that can guide a layered prevention strategy. Finally, use of consistent definitions to identify older adults will facilitate more robust comparisons of the efficacy of different drowning prevention approaches. Aging populations increase the urgency of this need to better evaluate how to effectively mitigate drowning risks among older adults.

SUMMARY OF KEY MESSAGES.

What Is Already Known on This Topic

Drowning prevention interventions are age-sensitive, yet older adults are often overlooked.

What This Study Adds

The identified drowning interventions for older adults were designed for the general population rather than tailored to older adults. The few drowning prevention studies of this age group were conducted in high income counties and lacking from low- and middle-income countries. Primary prevention via behavioural change was the most targeted drowning prevention intervention type.

How This Study Might Affect Research, Practice, or Policy

A more age-specific approach and varied prevention interventions would improve drowning prevention research and policy for older adults.

Data availability statement

Data are available on reasonable request.