Improving lifejacket wear among occupational boaters on Lake Albert, Uganda: A cluster-randomized controlled trial

Abstract

For nearly two decades of documentation, drowning has plateaued as the third leading cause of unintentional injury deaths globally. Despite being one of the oldest occupations in human history, water-related boating activities like fishing and water transport remain among the most affected by drowning. The toll is greatest in Africa, with lakeside boat using communities, especially in Uganda, experiencing the highest death rate recorded globally. Wearing lifejackets can prevent over 80% of drownings. However, a staggering 95% of individuals who drown in boat-related incidents in Uganda do not wear lifejackets. Unfortunately, interventions addressing occupational drowning prevention in low-income countries remain limited in their scope. This thesis focuses on developing and evaluating an intervention aimed at promoting lifejacket wear among occupational boaters on Lake Albert, Uganda. Methods This study was conducted in three phases. Phase one was a baseline in which a mixed methods sequential exploratory design was used. I began by conducting in-depth interviews and focus group discussions to explore the perceived determinants of lifejacket wear through lived experiences and perspectives. This then informed the refining of the tool for the cross-sectional survey to estimate the prevalence of lifejacket wear and its determinants. In phase two, the baseline findings and results were used in a stakeholder insight workshop to identify and develop an intervention. The intervention package was validated using content and face validity index for each item (I-CVI) and scale (S-CVI/Ave). In phase three, I conducted a two-arm cluster randomized controlled trial in which fourteen landing sites were randomized to the intervention and non-intervention arm using a 1:1 allocation ratio. In the intervention arm, a six-month peer-to-peer training program on lifejacket wear was implemented while the non-intervention arm continued to receive the routine Marine Police sensitizations on drowning prevention through its community policing program. The effect of the intervention was assessed on self-reported and observed lifejacket wear using a test of differences in proportions of lifejacket wear following intention to treat (ITT) analysis principle. The effect of contamination was assessed using a mixed effects modified Poisson regression following As Treated (AT) analysis principle. The results are reported at 95% confidence interval. Results The baseline studies showed that lifejacket wear was low, and was largely influenced by insufficient knowledge about the benefits of lifejackets, experiencing or witnessing a drowning incident, and related widespread myths. Peer-led training was most preferred intervention identified and developed. Validation showed that the lowest I-CVI for the content was 86%, with an S-CVI/Ave of 98%, and the S-CVI/Ave for face validity was at least 86%; indicating that the intervention package was highly relevant to the target community. After a six-month implementation of the peer-led training, self-reported lifejacket wear increased markedly from 30.8% to 65.1% in the intervention arm than in the non-intervention arm which rose from 29.9% to 43.2%. Observed wear increased from 1.0% to 26.8% in the intervention arm and from 0.6% to 8.8% in the non-intervention arm. The test of differences in proportions of self-reported lifejacket wear (65.1% – 43.2% = 21.9%, p-value <0.001) and observed wear (26.8% – 8.8% = 18%, p-value <0.001) showed statistically significant differences between the intervention and non-intervention arm. Self-reported lifejacket wear was higher among boaters who received peer training than those who did not (Adj. PR 1.78, 95% CI 1.38 – 2.30). Conclusion Peer-led training on lifejacket wear was the most preferred and feasible intervention. This study demonstrated that the peer-led training significantly improved lifejacket wear among occupational boaters. The Ministry of Works and Transport, Ministry of Agriculture, Animal Industry and Fisheries together with the Landing Site Management Committees should embrace and scale up peer-to-peer training on lifejacket wear.