An analysis of global legislation and regulation related to drowning prevention

Drowning remains a leading but neglected cause of injury-related death worldwide. While some forms of regulation, such as pool fencing, have demonstrated clear effectiveness, less is known about the broader influence of legislation and regulatory measures on drowning mortality. This study provides the first global analysis of drowning-prevention legislative coverage, utilising secondary analysis of cross-sectional data, to explore country-level associations between legislation/regulation and drowning rates. Utilising the World Health Organization (WHO) Global and Regional Status Reports on Drowning, alongside economic, environmental, governance, and health-system indicators, we assembled a cross-section of 127 countries. We estimated several models that included the full set of national legislation indicators and nine covariates, complemented by a random-forest analysis. Across specifications, we observed no consistent association at the country level between the presence or count of legal measures and lower drowning mortality. By contrast, structural determinants were repeatedly implicated. For example, in our main models, higher per-capita alcohol use was positively associated with drowning mortality (IRR = 1.18, 95% CI [0.99, 1.40]), while better access to safe water/sanitation was protective (IRR = 0.84, 95% CI [0.71, 0.99]). Exploratory interactions examining the influence of institutional/governance capacity suggested that public-pool fencing and, more tentatively, alcohol restrictions near water, were more protective where institutional capacity was stronger. Our findings support the idea that legalisation/regulation is likely to be most effective when embedded within broader investments in infrastructure, service delivery, and enforcement capacity.