4.1. Long-term trend of drowning incidents in Turkey
The data set in this study shows that an average of 562 people die due to drowning every year in Turkey (ranging between 447 and 681) — an average of two drowning deaths per day. A noticeable decreasing trend was observed in the number of UDIs and FDIs, while there was an increase in the number of SDIs throughout the study period. No evident trend was observed in the number of those who disappeared due to drowning (Fig. 1). Compared to previous years, UDIs in Turkey are down substantially; there has been a 20.9% decrease in the last years (from 2010 to 2020). Unfortunately, this decrease was not stable. The change of UDIs was erratic for years. The lowest UDIs rate in the study period was seen in 2020. FDIs were reported as 5.2 worldwide and 2.3 in high-income countries between 2010 and 2020 (WHO 2014). Despite outstanding efforts and prevention strategies, a high FDIs of 3.77 occurred in Australia in a similar period (RLS 2020). Based on the 2019 data, the average fatality rate caused by drowning was 1.35 among EU members (Eurostat 2022). With a long-term average (0.79 per 100,000 population), FDIs in Turkey are represented at much lower rates (ranging between 0.54 and 0.92 per 100,000 population) (Fig. 1) than in the world, the EU, and high-income countries.
Such low death rates are primarily attributable to increased employment of lifeguards on beaches. Barlas and Beji (2016) reported that individuals refuse to follow any safety advice and, in some cases, even go so far as to harass lifeguards in Turkey. As a result of efforts to prevent drowning in Turkey, the obligation to employ lifeguards at specific standards in all kinds of pools, water parks, beaches, and coastal enterprises was implemented for the first time in 2006 (No 26063 dated January 28, 2006, in Official Gazette). Since then, lifeguards have been trained at ILS standards in training centers under the auspices of the Turkish Underwater Sports Federation. Following the regulation, it is obligatory to have at least one lifeguard for each pool, regardless of the depth, and at least two lifeguards per 500 m2 in large pools. According to the law, beaches must have at least two lifeguards and a lifeguard tower per 200 m in the swimmable shoreline. Responsibility areas of lifeguards are defined as controlled swimming areas where a safety strip has been created at a distance they can reach within three minutes by swimming. Especially after the 2000s, the investments made in the tourism sector in Turkey and the state support showed their effects. Turkey ranks third in the world with its 486 blue flag beaches. Investments in Eco-Friendly Touristic Places and marine tourism gained momentum (Republic of Türkiye Ministry of Culture and Tourism 2022). All these investments undoubtedly contribute indirectly to preventing drowning in swimming areas and recreational activities.
4.2. Geographical location of incidents
According to the geographical location of the incidents (detailed in Fig. 2 and Online Resource 2), the highest rate of UDIs was recorded in the Black Sea region, with 2.45 per 100,000 population. In the cities on the Black Sea south coast (Bartın, Kırklareli, Sinop, Istanbul), more than 80% of UDIs occurred on beaches. Such a high drowning rate should be attributed to the Black Sea being characterized by rip currents. Beji and Barlas (2016) have suggested that hundreds of people drown due to rip currents each year on the Black Sea coasts of Istanbul. While rip currents are more typical for the coast of oceans (Gensini and Ashley 2010; Houser et al. 2011; Mucerino et al. 2021), the southern parts of the Black Sea stand as an exception. The nearshore bathymetry is responsible for forming rip currents in the Black Sea (Barlas and Beji 2016). Brander et al. (2011) described rip currents as a significant hazard to swimmers on many beaches worldwide. Safety signs and effective information strategies to warn visitors of the hazards of rip currents have yielded positive results (Beji and Barlas 2017). More efforts are needed to increase public awareness about rip currents in Turkey. We underline the lack of information, prevention, and control strategies to prevent drowning incidents related to rip currents in Turkey.
Antalya (Mediterranean) and Muğla (Aegean) were recorded as other geographic locations where drowning incidents were seen at a high rate. Contrary to the Black Sea, these regions' high drowning rates were mainly attributed to marine activities such as swimming, sailing, boating, snorkeling, and scuba diving. Antalya is one of the world's top tourism destinations and attracts 30% of foreign tourists visiting Turkey. Antalya (N = 206) and Muğla (N = 105) are the tourism centers with the highest number of Blue Flag beaches in Turkey (The Republic of Türkiye, Ministry of Culture and Tourism 2022). Although lifeguards are employed at these beaches, drowning incidents can be high during such high dense beach activities.
Şanlıurfa, which does not have a coast and is located in the Southeastern Anatolia Region of Turkey, stands out in the list of geographical locations. This region is one of the provinces with the highest maximum temperature in Turkey (up to 46.8°C). Residents and agricultural laborers living in the entire Eastern Anatolia Region, including Şanlıurfa, prefer irrigation ditches, natural and artificial lakes, and streams to cool off. Drowning incidents can frequently occur in Şanlıurfa due to uncontrolled inland waters and insufficient swimming ability.
4.3. Temporal features of incidents
RLS (2020) report has shown an increased risk of drowning during public and school holidays. Public school holidays in Turkey usually coincide with the summer period from mid-June to the beginning of September. During this period, recreating such as diving, fishing, boating, and swimming are increasing, especially in coastal areas. Similar studies confirmed a significant increase in UDIs at the beaches and swimming pools during the summer (Barlas and Beji 2016). It is known that hot weather increases the risk of drowning due to swimming and recreational activities. The significant difference between incidents on Saturday and Sunday (Fig. 4a) is that most people in the private sector in Turkey also work half a day on Saturday. The 15–19 age group accounted for an essential proportion of UDIs that occurred in summer (20.6%) and daytime (19.8%). The highest rate of UDIs (~ 75%) was recorded during daytime in both males and females. According to the dataset, temporal variables (months, seasons, weeks, and time of day) created significant differences in the incidence of UDIs (Fig. 3, Fig. 4). The awareness of the drowning risk may encourage more effective use of prevention strategies known to save lives.
4.4. Gender and age variables of incidents
Males have been determined to be a high-risk group for drowning fatality in Turkey (Fig. 5). In previous studies, most of the victims were male and more prone to drowning (WHO 2014). Riskier behavior such as swimming alone, fishing and boating, alcohol or drug use before swimming, and being more reluctant to wear life jackets are responsible for higher rates of drowning among males (RLS 2020; WHO 2014). Males may also exaggerate their swimming abilities by putting themselves in dangerous situations. According to the global report on drowning, age is a significant risk factor for drowning (WHO 2014), and half of drowning incidents worldwide occur among people under 30. UDIs varied significantly among different age groups in Turkey, and incidents were common among those younger than 30, with a high percentage (60.4%) (Fig. 5). Drowning fatalities in children is a universal concern and a preventable cause of death with simple precautions and education (Peden et al. 2008; Solomon et al. 2013; Terzidis et al. 2007; Turgut et al. 2016; White et al. 2018). Drowning in children under five years accounted for 7% of all incidents (Fig. 5), more than 90% of which were fall-related incidents. This striking statistic from the analysis (high ratio of UDIs among children under five) suggests that adult supervision was neglected. Active adult supervision is essential for preventing UDIs among children under five, and lapses in supervision contribute to fatalities (RLS 2020). There is no national initiative about swimming, lifesaving, or water safety education/training in local schools in Turkey. Attempts to help children acquire minimum swimming skills before leaving primary school will undoubtedly contribute to reducing child UDIs. More than 10% of the victims were over 65, and almost all (~ 93%) drowned during swimming and recreational activities. There are several causes of adult drowning, such as alcohol drinking, inexperience, and non-use of a personal flotation device (Peden et al. 2018). Preexisting medical conditions such as cardiac conditions can influence the drowning risk of adults (Cobbett et al. 2014). The dataset in this study does not contain information about the victim's disease history.
4.5. Location of incidents and type of activities
Beach environments, where more than half of all fatal drownings occur due to recreational and swimming activities, should be considered first in drowning prevention interventions (detailed in Table 1 and Fig. 6). Despite the existence of beaches with lifeguards in Turkey, uncontrolled and unattended beaches pose a significant risk depending on the length of the coastal structure. Swimming activities on uncontrolled beaches, especially for non-swimmers, can result in drowning. Although drownings in swimming pools have resulted in most survival, the number of UDIs is too high to be neglected. The frequency of UDIs in swimming pools can be attributed to the lack of active adult supervision, while the high SDIs rate reflects success in lifeguard interventions. It is necessary to raise awareness of non-swimmers about not entering the water outside the responsibility areas of lifeguards. Even basic water safety training will undoubtedly significantly contribute to reducing drowning incidents. We believe water safety information/training should be accessible to the public. In this way, individuals can recognize the hazards of aquatic environments and learn about crucial survival and essential rescue skills. Cardiopulmonary Resuscitation (CPR) training may increase survival rates at a more advanced stage. Most of the UDIs (~ 56%) in flood waters result in fatality (Fig. 6a). Flooding has become more frequent and severe in recent years, and this tendency is expected to continue as part of climate change (Warner et al. 2010). Flood disasters are becoming more frequent and powerful, and this trend will likely continue as part of climate change (Akay 2019; Thomas 2017). Individuals, especially adults, should avoid going alone around flood waters. All incidents recorded on the rocks and rocky foreshore resulted in a fatality.
The results highlighted the significant number of fatal drowning incidents in inland waters (Fig. 6a). Individuals who live near inland water sources, such as dams, lakes, ponds, rivers, or irrigation ditch, are especially at risk. Inner waters carry specific risks due to their geomorphological features and coastal structure (Taylor et al. 2020). Risk factors that cause drowning in inland waters are identified as lack of swimming ability (Fang et al. 2007), underestimating the risk that water conditions can pose (Willcox-Pidgeon et al. 2018), residents and farm workers (Kiakalayeh et al. 2008) and rurality of location (Peden et al. 2016). Unsupervised irrigation ditches are seen as a playground for children (Rolloque et al. 2012). Children should be taught how to call for help and respond safely in the event of an accident. This is especially important in remote, rural, and work-related settings where help may be far away. Inland waters are often beyond public control, and unlike beaches, efforts to prevent drowning are inadequate in these locations (Peden et al. 2016). The willingness to swim of migrants, refugees, and tourists unfamiliar with local water risks and features is also an essential factor related to an increased risk of drowning. Currently, the number of refugees from Syria, Afghanistan, and Pakistan is relatively high in Turkey, and this population is increasing. The drowning incidents of these people due to their swimming activities are frequently also reflected in the media and national statistics (Turkish Coast Guard Command 2022). In addition, although drowning incidents due to illegal refugee migration have an important place in the sea, this group is not included in the data set. Further efforts are needed to increase understanding of the risks of drowning and raise awareness among the communities concerned.
A relatively high rate of fall-related UDIs was recorded (Fig. 6b) and determined to be most related to non-aquatic transport, diving, and fishing activities. Incidents occur more commonly among individuals employed in water-related professions, such as fishing communities (Brooks 2005). Turkey is a maritime country, having a long coastline and a massive Exclusive Economic Zone (EEZ), and therefore offers ample opportunities for the marine sector. Although commercial fishing activities in Turkey are technologically advanced, it is thought that fishers do not have sufficient awareness in terms of sea and navigational safety (Ulukan 2016). People often refuse to wear a life jacket during fishing and aquatic sports activities in Turkey (Barlas and Beji 2016). Life jackets increase buoyancy and support the swimming ability (WHO 2014), thereby increasing the chances and duration of survival (Pitman et al. 2019; Stempski et al. 2014). It is clear that these measures also prevent drowning by boating (Cummings et al. 2011; Webber et al. 2020).
The highest number of fatal incidents were recorded during diving activities (70% of the incidents resulted in a fatality and 10% in disappearance) (Fig. 6b). Diving activities involve high risks, and the incidence of drowning fatalities is very high during commercial or sportive dives (Lippmann et al. 2017; Ramnefjell et al. 2012; Vinkel et al. 2016). More than half of the diving incidents were seen in the summer, suggesting that more recreational diving activities were carried out during this period. Although Turkey is at an advanced level for certified diving education and tourism, the number of uncertified amateur divers is relatively high. Recreational diving activities involve a drowning risk, especially for beginners, and these activities are not recommended for those who do not have fundamental diving training. Karadurmuş (2021) also reported that boat and hookah systems in Turkey pose a risk in terms of diving health and work safety. Turkish divers make risky dives due to economic concerns and a lack of safety awareness. Physical and mental fitness, equipment used, dive plan, and implementation of decompression procedures play a critical role in preventing fatal diving accidents (Karadurmuş 2021; Ramnefjell et al. 2012). Strategies to prevent drowning due to diving in Turkey should cover both sportive and commercial divers.