Adult migrants urgent need for drowning prevention in Australia

Study design

An exploratory, qualitative study design was conducted using semi-structured interviews and focus groups to gain in-depth perspectives from the chosen study population. A deductive approach was applied to inform the design of questions in this qualitative study, described as ‘a structured approach to enrich your understanding of qualitative data through the lens of established theories’ (Delve and Limpaecher 2024), guided by the TPB (Ajzen 1991).

The TBP proposes that an individual's behaviour is influenced by attitudes, subjective norms and perceived behavioural control, which in turn, informs the intention to perform a certain behaviour (Ajzen 1991). This model has been used widely to predict a range of health behaviours, including healthy eating and nutrition (Kothe et al. 2012), oral hygiene (Anderson et al. 2012), and most recently for predicting uptake of the Covid-19 vaccination (Dou et al. 2022). The TPB was used to understand people's influencing factors towards drowning risk (age, gender, cultural background, experiences, and swimming ability). In a drowning context, behavioural beliefs inform attitudes towards the behaviour, e.g. a person may believe that they do not need a lifejacket while boating, due to their past experiences, perceived skills, and confidence that nothing will go wrong. Normative beliefs inform perceived norms, e.g. in some cultures swimming is not a popular leisure activity, and learning to swim may not be seen as important. Control beliefs inform perceived behavioural control which in turn influences behavioural intentions, e.g. males overestimating their swimming ability and underestimating the risk of drowning leading them to swim, at unsupervised locations, at night or after consuming alcohol. Actual control could be influenced by swimming skills, experience around water, the environmental conditions (water and weather conditions), and if there are lifeguards present or not (Fig. 1). These domains were used to prompt the interview questions (Supplementary Table S1).

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Terms and definitions

This study uses the term ‘migrants’. For this study, this included adults ≥18 years from a migrant background (i.e. not born in Australia), who were residing in Australia at the time of the study for any purpose; people born in Australia of migrant parents; international students; and people from refugee backgrounds. Visa status was not asked for, nor a requirement to be included in this study. Country of birth and length of time were asked to gain background information and establish rapport between the leader researcher and participants. Participants could choose not to answer this question.

Participants and selection criteria

A purposive sampling approach (Creswell and Plano Clark 2018) was used to recruit migrant adults (≥18 years) between May and December 2021 who (i) had attended a learn-to-swim program in adulthood (‘new swimmers’) or (ii) could not swim (‘non-swimmers’) but had visited an aquatic environment within the last 12 months. The Australian capital cities of Sydney in New South Wales (NSW); Brisbane in Queensland; Peth in Western Australia (WA); and Melbourne in Victoria, were chosen for the study to reflect the locations with the largest migrant populations (ABS 2024), These cities are also where migrant drowning incidents most commonly occur (Willcox-Pidgeon et al. 2021).

Focus group (FG) and interview participants were recruited through adult learn-to-swim programmes or from English language programmes. The lead researcher (SW-P) initially approached swim program managers, swim teachers and English language program teachers, who then discussed the study with their participants, accounting for varying levels of English language proficiency (in some cases an interpreter assisted in providing greater clarification). Information flyers about the study were distributed to potential participants in English only. FGs were scheduled to take place during their usual program timetable, for participant convenience, in coordination with program managers and teachers. Swim program managers and teachers were not present during the focus groups.

Data collection

Interview questions were developed, then piloted for a previous qualitative study which explored migrant women learning to swim in Australia (Willcox-Pidgeon et al. 2020a^, 2020b). Questions were then adjusted for this current study to include people not engaged in swimming lessons (Supplementary File S1). The development of the questions was guided by the domains of the TPB (Fig. 1). Methodology followed the Consolidated Criteria for Reporting Qualitative Research tool (Supplementary File S2) to improve the quality and enhance the rigour of qualitative research (Tong et al. 2007).

The data collection of the study was intended to be face-to-face FGs across Australia. However, soon after the initial FGs took place in May and June 2021, the second phase of Covid-19 social and travel restrictions occurred in Australia and the rest of the study data collection had to take place via online interviews, as described below. The lead researcher (SW-P) lead in-person FGs and interviews in Brisbane, Queensland and in Perth, WA, in May and June 2021. The FGs in Brisbane were conducted in English during English language classes, as guided by the head teacher; with other participants/peers acting as interpreters when required. The researchers noted that while the use of peers as interpreters may have introduced a bias, at the same time, it was important for participants to feel comfortable to share their experiences and perspectives, and they may not have been as forthcoming to share with a stranger or an official interpreter. In Perth, FG participants did not require translation due to a high level of English language comprehension of participants. Due to Covid-19 travel restrictions across Australia from mid-June 2021, after the Perth FGs had taken place, the remainder of the study with participants based in NSW and Victoria was conducted online or phone interviews (via Zoom or Microsoft Teams). All interviews were conducted by the lead researcher (SW-P) and did not require translation.

Analysis

While the FGs were conducted face-to-face, and the interviews conducted online, all data coding and analysis were handled the same way. All FGs and interviews lasted between 30 and 60 min, were audio recorded, and transcribed verbatim using the Otter.ai translation service. The first author (S.W-P.) checked all the transcripts separately for accuracy and undertook the initial coding from each transcript using NVivo V12. Data from both the interviews and FGs were thematically analysed using Braun and Clark's six-stage approach using a deductive approach utilizing the TPB, while also allowing for inductive analysis (Braun and Clarke 2006). Researchers (R.C.F. and S.D.) also reviewed the transcripts and coded for similar themes. Final themes were reviewed and agreed upon by the entire research team (S.W-P., R.C.F., and S.D.). The lead author coordinated member checking with participants to check accuracy and correct interpretation of data via email. Several participants did not respond to the email; therefore, not all participants provided feedback which may be a limitation to the study.

Research team and positionality

The research team included a female PhD student (lead author S.W-P.) with a background in drowning prevention research, employed by a lead water safety agency in Australia, who has a migrant background from an English-speaking, HIC country, along with two senior Australian university academics. The potential for bias and power imbalances between some participants and the researchers is recognized. To address this, efforts were made from the outset to include diverse voices across a range of genders, age, cultures, religions, time in Australia, parents and non-parents, ensuring a broad range of perspectives were reflected in the study findings. Throughout the data analysis phase, the research team members were constantly checking and reflecting on their positionality, privilege and potential biases.

Ethics

All participants provided written and verbal informed consent prior to taking part in the study. Where required, information was interpreted in the FGs by other participants, or an English teacher (in the Brisbane FGs only) to ensure that all participants understood and provided informed consent to participate in the study, to be audio recorded and quotes used for research and publication purposes. All results are presented using anonymous quotes with gender, country of origin and years in Australia noted, e.g.: ‘male, India, 5 YIA’. At no stage are study participants identified. Ethics approval was granted by the James Cook University Human Research Ethics Committee (H7945).

Water safety experiences

This theme explores participants’ lifelong experiences related to water and examines how these experiences influence current water safety awareness. This is explored through four subthemes (i) Swimming experiences in early life, (ii) Cultural and family awareness and knowledge, (iii) Water safety awareness and knowledge in Australia, and (iv) Where and how people receive water safety information.

Attitudes, beliefs and behaviour towards water safety

This theme explores attitudes and behaviours, regardless of swimming ability, around the water, including the following concepts (i) risk perception, (ii) negative experiences (including a fear of water), (3) cultural/religious perspectives, and (4) stigma of being unable to swim.

Learning to swim

This theme describes influences on migrants participation in swimming and water safety programmes (swimming programmes), including barriers (fear, accessibility), experiences of learning to swim in adulthood (negative and positive), and the motivation for learning to swim.

Benefits of learning to swim

This theme highlights the benefits of learning to swim, ranging from physical and mental health benefits, social inclusion and new opportunities to participate in Australian culture, described in the following subthemes (i) finding joy in swimming, (ii) inclusion into the Australian community/culture, (iii) ongoing participation in aquatic activities, (iv) health and wellbeing.

Awareness and knowledge

This study identified that migrants from both HIC and LMIC experienced limited exposure to water for leisure and recreational purposes prior to arriving in Australia, consistent with studies of Asian migrants in Australia (Woods et al. 2022), NZ (Moran and Willcox 2013) and the US (Quan and Bennett 2006^, Koon et al. 2021). However, study participants reported some awareness of water safety and their perceived skills, based on their previous experiences. They also recognized the importance of children's safety around water, and knowing where to swim at Australian beaches.

Adults in this study mainly sourced their water safety information from within their community networks, including family and community members, places of worship, and English language classes. This contrasts with an Australian study of migrants of Indian and Nepalese backgrounds residing in NSW, who sourced beach safety information from online resources or once at the beach (Woods et al. 2022). Methods of communicating health and safety messages for diverse communities have mostly focused on disaster or health risk communication (Hanson-Easey et al. 2018), particularly during the Covid-19 pandemic (Jia et al. 2022), emphasizing the roles of settlement agencies, education providers and community leaders in delivering risk messages. Despite reliance on media channels, disseminating information through traditional community networks may still be an effective way to reach migrant populations where word of mouth remains a favoured method of receiving information. Learning from how other health promotion sectors have integrated the TPB into the design of health communication campaigns may be useful. For example, campaigns to encourage healthy eating among university students (Kothe et al. 2012), or that promote and predict the uptake of vaccinations (Dou et al. 2022).

Attitudes and behaviour

Both male and female migrants reported a shift in awareness and knowledge about water safety and swimming after migrating to Australia, often due to negative experiences in the water or related to their children (e.g. swimming lesson, supervision), consistent with other studies (Willcox-Pidgeon et al. 2020a^, 2020b). Negative experiences and a fear of water are common barriers to learning to swim (Irwin et al. 2015^, Peden and Franklin 2020), resulting in reduced exposure to water. This study found that fear and negative experiences directly informed migrants awareness and attitudes towards water safety and impacted their participation regardless of swimming ability (control beliefs) and motivation to learn (behaviour). Fear of water can be generational, with parents’ fear influencing their children's swimming participation (Irwin et al. 2011). Adults role modelling safe water behaviour, including learning to swim or wearing a lifejacket, can have an intergenerational impact on their families (Peden et al. 2018). This study suggests that overcoming a fear of water may positively impact entire family and communities’ knowledge, attitudes, and behaviour towards swimming and water safety.

Cultural nuances

An important insight from the findings was the significant role of water in some cultures. Several participants described the rituals and significance that water plays in their culture across the lifespan, ‘from birth to death, different rituals throughout the lifespan is related to water’, contributing to their respect for water. These findings support previous research suggesting that people hold onto their cultural beliefs and rituals related to water when moving to new countries (Quan et al. 2006). This perspective perhaps explains why adult migrants may be reluctant to go in the water for leisure or recreational purposes. Previous studies have also highlighted socio-cultural barriers and perceived benefits in relation to physical activity for improving broader health outcomes (Jepson et al. 2012^, Warbrick et al. 2016).

From a water safety perspective, this means that although people may be frequently exposed to water, they may not be prepared for an unexpected entry into it. It is important that water safety advocates, researchers and practitioners acknowledge and respect traditional cultural beliefs while embedding safety and prevention knowledge. Learning from the Indigenous perspective may be helpful. For example, the spiritual and cultural connection to water among Māori peoples in NZ, and for Aboriginal and Torres Strait Islander peoples in Australia, is deeply entwined with cultural, spiritual, and physical wellbeing. This connection is integral to both individual and community identity (Phillips 2020^, Moggridge and Thompson 2021). The ‘Wai Puna’ water safety model developed by Phillips (2020) from the Māori perspective, suggests that local contextual knowledge and environmental ethic may be key in addressing high drowning rates in Indigenous communities globally, acknowledging how Māori communities have ‘an intertwined knowledge and respect for water in all forms’ and interact with the water from both cultural and spiritual perspectives (Phillips 2020).

Inclusion and social cohesion

A common theme reported by adults who had learnt to swim, was discovering the joy of swimming, not only from a safety perspective, also for inclusion and equity into the Australian lifestyle. Many participants viewed swimming as a core part of Australian culture, ‘Swimming is part of the DNA’ (in Australia). This study cohort was keen to embrace the Australian ‘culture’ of swimming and aquatic participation regardless of previous experiences and skills. These results are consistent with research involving African migrants in Australia, who were willing to adopt new behaviours and practices of their new host culture to feel a ‘sense of belonging’, whilst maintaining their own cultural and moral values (Akosah-Twumasi et al. 2020). However, from a drowning prevention context and for reducing inequalities, these results suggest that some parts of the community may be unintentionally excluded from participating in the Australian culture of aquatic recreation. Some participants were willing to participate in water activities despite limited swimming ability, which may increase their risk of drowning, as it gave them a sense of inclusion.

The study also highlighted that the inability to swim impacted opportunities in other sporting activities, such as triathlons. Participants who learnt to swim in Australia reported feeling empowered to set goals to keep improving, as seen in those who started competing in triathlons. Participation in sport, recreational activities, and volunteering has been shown to reduce inequities and promote positive settlement and assimilation experiences among migrants (Nathan et al. 2013^, Life Saving Victoria 2021^, Tank 2022). This could be an effective approach to encourage migrant adults to engage with swimming and water safety programmes and other informal/social aquatic-based activities.

Implications

This study highlights that inequalities exist for some adult migrants regarding their safety around water and drowning risk, particularly when migrating to a country with a strong association of aquatic recreation and leisure like Australia. For example, people bring varied experience and knowledge of water, others may have had fewer opportunities to access swimming and water safety education prior to migrating, some people may have a fear of water, stemming from a negative experience, which all shape a person's norms, attitudes, knowledge, and behaviour (positive or negative) around water.

Encouragingly, this study suggests that adults can positively shift their behaviour when exposed to a new environment and experiences. Cultural, normative and control beliefs play a role in shaping awareness, knowledge, attitudes and behaviour among migrant adults, which should be integrated when developing drowning prevention strategies, across policy, research, and practice. Future research should explore culturally informed approaches to water safety, particularly for adults who migrate to countries with a strong culture associated with aquatic recreation and leisure.

Comprehensive drowning prevention strategies that incorporate communities’ social determinants of health are needed to address the inequities faced by migrants in accessing safe places to swim and opportunities to learn essential swimming and water safety skills. At the upstream level, whole of government multisectoral policies and partnerships across education, health and migration sectors are needed (Scarr et al. 2024a^, 2024b), to embed water safety knowledge and swimming education pre- and postmigration. One such example of multisectoral action in drowning prevention is the Thailand Drowning Prevention Strategy, focused on reducing drowning among children, and implemented across government departments (Gerdmongkolgan and Ekchaloermkiat 2018^, WHO 2024b).

Access to swimming and water safety information should be made available throughout a person's settlement journey. Research suggests that the time of residence in a new country may play a role in drowning risk, particularly for recent arrivals (Saunders et al. 2017^, Willcox-Pidgeon et al. 2021). For example, migration agencies could offer water safety modules prior to leaving their home country and once in Australia (or other countries), water safety and swimming education could be embedded into Adult English Language Programmes or through migrant settlement support agencies to improve both water safety and English language skills. Some of these types of programmes do exist in Australia, however there is no national consistency, and are often reliant on ad hoc funding (Willcox-Pidgeon et al. 2020a^, 2020b). Community-based health promotion programmes could include swimming and other water-based activities, promoting social cohesion and broader health, wellbeing, and fitness for different cohorts of migrants, e.g. parents of young children or elderly people. Several studies from other HIC have highlighted swimming as a low-impact physical activity to address obesity, diabetes, cardiovascular and other noncommunicable diseases, particularly within local community contexts in the UK (Jepson et al. 2012) and the US (Stempski et al. 2015).

Effective policies at the community level need to address equity and access to safe places to swim, and water safety and swimming education for migrant communities. Study participants from a range of different countries, cultures and religions, shared their experiences, barriers and enablers towards swimming, participation and behaviour around the water. Policies and programmes should consider lived experiences and be co-designed with community members to address equity and to ensure cultural sensitivity. Identifying and appointing (paid) community ambassadors or role models to promote the benefits of learning to swim, including social inclusion, employment and competition pathways may also reduce barriers, encourage broader participation among migrant communities and be seen as more acceptable to migrants of all ages.

These findings are applicable at the global level to ensure the health and safety of migrants worldwide. Providing water safety and swimming programmes before migrants are exposed to the water or have a negative experience is imperative and should be a core part of a national comprehensive multisectoral settlement support strategies to ensure that people can purse aquatic activities safely in their new country. While it was beyond the scope of this study, we acknowledge that some migrants may be exposed to drowning risk when they transit by sea between countries, and there is a need to improve migrants’ safety at sea (IOM 2024).

Further research and evaluation related to drowning and water safety among migrants is needed from all countries, not just HIC, to enable learning and development of comprehensive global drowning prevention strategies that address contemporary drowning issues (Scarr et al. 2024a).

Strengths and limitations

A strength of this qualitative research is that it provides deeper insights than would be gained from data collection methods such as self-reported surveys, or epidemiological studies that cannot explain the decisions that reflect the situation or provide information on the factors leading to a potentially life-threatening situation.

Study participants included migrants residing across Australia, males and females from a range of countries and cultures, of varying length of time in Australia, whose voice may have been neglected in previous drowning prevention research, to gain as many perspectives as possible to inform culturally sensitive drowning prevention initiatives. Including the voices of adult migrants allowed for rich insights that can complement quantitative data and guide practical, real-life drowning prevention policies, programmes and practice.

Applying the TPB to guide the interview questions provided deeper insights into the previous and current awareness, attitudes and knowledge of water safety among a priority population at risk for drowning. The focus on behavioural, normative and control beliefs, was reflected in the emerging themes. Grounding studies and interventions in behavioural change theory helps explain the underlying factors influencing awareness, knowledge and attitudes and has been used extensively across the health promotion field. This approach can inform the development of targeted interventions aimed at addressing these factors, promoting safer behaviours and motivating adult migrants to learn to swim.

A limitation of this study may be the sampling approach used to recruit the participants in this study, which may have introduced a selection bias and limit the representativeness of the findings for all migrants. Interpreters and translators were included in the FGs to increase inclusion; however, their interpretations could also introduce bias. Due to some of the data collection having to change from face-to-face FGs to online interviews, this may have limited the diversity and type of migrants willing to participate in the study and differences in responses between the FG and interview participants may have occurred (e.g. FG participants may have been influenced by group responses). While efforts were made to ensure diversity and inclusivity, the findings may not be generalizable beyond the study population in Australia, or other HICs. We recognize that researcher bias and power may have also influenced the findings, however the research team were conscious of checking their biases throughout the study.

Acknowledgements

We wish to sincerely thank the study participants for their valuable time and insights provided for this study to inform drowning prevention in Australia. Thank you to Justin Scarr for feedback to drafts of the manuscript and the reviewers for their feedback.

This research is supported by the Royal Life Saving Society—Australia to aid in the reduction of drowning. Research at the Royal Life Saving Society—Australia is supported by the Australian Government.