Using ERIC to Assess Implementation Science in Drowning Prevention Interventions in High-Income Countries: A Systematic Review

This systematic review identifies and describes the use of the Expert Recommendation for Implementing Change (ERIC) concepts and strategies using public health approaches to drowning prevention interventions as a case study. International calls for action have identified the need to better understand the implementation of drowning prevention interventions so that intervention design and implementation is improved. In high-income countries (HICs), interventions are sophisticated but still little is known or written about their implementation. The review was registered on PROSPERO (number CRD42022347789) and followed the PRISMA guidelines. Eight databases were searched. Articles were assessed using the Public Health Ontario Meta-tool for quality appraisal of public health evidence. Forty-nine articles were included. Where ERIC strategies were reported, the focus was on evaluative and iterative strategies, developing partnerships and engaging the target group. The review identified few articles that discussed intervention development and implementation sufficiently for strategies to be replicated. Findings will inform further research into the use and measurement of implementation strategies by practitioners and researchers undertaking work in drowning prevention in HICs and supports a call to action for better documentation of implementation in public health interventions.


Introduction
The generation and use of knowledge is critical for evidence-informed public health practice.There is recognition of the need to address the challenges that hinder closing the "know-do" gap in public health implementation [1,2].Implementation science seeks to address these barriers using methods and strategies that facilitate the uptake of evidencebased practice and research into regular use by practitioners and policymakers [3].There are several considerations inherent in this sentiment.When interventions are assessed as being effective, if others do not utilise them, they will not become widely accepted [4].Intervention implementation requires active consideration to ensure that programs are deployed with and into communities more efficiently and effectively.
A range of frameworks and tools have been developed to guide implementation, for example, the Consolidated Framework for Implementation Research (CFIR) [5] and Theoretical Domains Framework [6].Common to these frameworks is the use of domains and constructs to explain and measure implementation and describe the interplay of the intervention content and context to effect behaviour change.However, there are few frameworks specific to public health [1,7], despite growing interest in the use and impact of implementation science for public health interventions [7][8][9][10].The Expert Recommendations for Implementing Change (ERIC) project identified nine concepts and 73 strategies that aid in the development [11] of implementation strategies and can serve as a tool to assess the strategies used in implementation.This tool was initially designed for a clinical setting [11,12]; it has been refined and used to reflect public health practice within a community setting [7].There are examples of implementation science being used in some health and community settings [7,11,13] across mental health [4,11,12,14,15] and substance use [16].However, in other public health areas, such as drowning prevention, which is the case study for this review, the application of implementation science is limited [7].
Drowning is a leading cause of unintentional injury [17,18], resulting in over 2.5 million deaths worldwide over the last decade [19].Drowning is a complex global public health issue with different drivers across low-, middle-and high-income contexts [20][21][22][23].In HICs, drowning events tend to occur during recreational activities [17,24] around the water and around the home [25].In low-and middle-income countries (LMICs), there is a higher prevalence of children drowning close to home due to issues of supervision, barriers to water sources and water safety skills, while older children and adults drown when undertaking work or during travel on water [21,26].While there is evidence of communityled interventions [22,23] and institutional guidance around effective strategies to reduce drowning [27], the literature also highlights gaps in the quality, consistency and reporting of programs [22,23,28].There are also differences in the number of drowning preventionrelated peer-reviewed publications published [22,23] and the types of interventions [29] relevant for LMICs compared to HICs.Of the limited published interventions from LMICs, most were delivered by agencies without the capacity to include large-scale evaluation or knowledge translation [17,23]; thus, implementation in the two settings (HIC and LMIC) is not directly applicable [29].
Consequently, there have been international calls for action to establish processes to better understand the implementation of drowning prevention interventions in community settings [19,26,30] and several resources have been developed to aid in the implementation of drowning prevention interventions [31][32][33].However, these resources have concentrated on the activities of interventions (e.g., the WHO implementation guide focusses on ten evidence-based interventions and strategies [31]) rather than the process of implementation and tend to be conducted in LMICs.In HICs, there is a growing focus on the use of evidence to strengthen the design, delivery and evaluation of interventions [23], with calls for practitioners and researchers to learn from each other [26].Recent advancements in the publication of more sophisticated approaches to the development of drowning prevention interventions [23] lend themselves to further exploration of context of intervention implementation.
This systematic review aims to identify drowning prevention studies undertaken in HICs as a public health case study of implementation science and describe and assess the use of implementation science ERIC concepts and strategies.The review asks: 1. What are the implementation strategies used in drowning prevention interventions in high-income countries and how are they described?2. What are the gaps in the use and reporting of implementation strategies in drowning prevention interventions in high-income countries?

Materials and Methods
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [34] and registered with the International Prospective Register of Systematic Reviews (PROSPERO) (ID CRD42022347789) [35].The search strategy for included articles and the PRISMA checklists for abstracts and manuscripts were completed (Supplementary Tables S1, S2 and S3, respectively).

Criteria for Inclusion
Included articles were primary studies, addressed drowning prevention interventions in HICs, were written in English and were published between 2002 and 2022 (see Table 1).HICs are defined as economies with a gross national income (GNI) of USD12,696 or more per capita [36].Exclusion criteria included articles that focus on clinical aspects of drowning events; specific target groups or locations not relevant to the wider population (i.e., those with water phobia, working on specific construction sites); simulation studies (i.e., studies of cardio-pulmonary resuscitation (CPR) or rescue delivery in specific settings) or other injury prevention (i.e., not solely drowning prevention).Articles addressing the development of recommendations and/or guidelines, where no intervention was described, were also excluded.

Search Strategy
In consultation with the university health sciences faculty librarian, the initial literature search strategy was developed using medical subject heading (MESH) and text words related to implementation and drowning prevention.Once an initial Medline search was completed, the strategy was adapted to the subject headings of seven additional databases (see Supplementary Table S1 for full search strategy): PubMed, PsycINFO, ProQuest, Scopus, Web of Science, Global health and SPORTDiscus.

Screening and Quality Appraisal
The initial database search identified 3547 articles.All citations from the initial search were imported into Endnote 20 [37] referencing management software.Using the Endnote and Rayyan software [38] "find duplicates" tool, 1539 articles were removed.Two reviewers (MDB and BR) individually screened the identified articles by title and abstract using Rayyan [38] to determine the relevance of the remaining articles (n = 1515).Articles were categorized as "possibly relevant", "maybe" (where the reviewer was unsure if the article met the criteria) and "excluded".The systematic review PRISMA 2020 flow diagram [34] is presented in Figure 1.
Articles identified as "maybe" during the title and abstract search were re-classified through discussion amongst two research team members (MDB and BR) and.where there was disagreement, with a third member of the team (JL).The full text articles identified as "possibly relevant" were retrieved and assessed by one reviewer (MDB) using a standardized exclusion list.A second researcher (BR) randomly cross-checked 10% of articles to identify any selection anomalies.Any full-text articles classified as "maybe" were resolved with a co-author (GC).To ensure coverage, the reference lists of "possible inclusion" articles (n = 104) were hand-searched for any articles not previously identified; 22 further articles were identified (see Figure 1).
All included articles (n = 49) were assessed for quality using the Public Health Ontario Meta-tool for quality appraisal of public health evidence (PHO META QAT) [39] by one reviewer (BR).Another reviewer (MDB) randomly cross-checked 10% of the appraisals to ensure accuracy.Articles were analysed and scored using four domains (relevance, reliability, validity and applicability) containing nine categories [40] and were scored as met the criteria = 2, not sure/unclear = 1 and did not meet the criteria = 0.As in previous reviews [23], articles were categorized on their summed score, where ≤9 = low quality (n = 11), 10-14 = medium quality (n = 17) and 15-18 = high quality (n = 21).All 49 articles met the criteria for inclusion based on the quality appraisal.

Outcome Measure (Implementation)
Included drowning prevention intervention articles were assessed for inclusion using the refined Expert Recommendations of Implementing Change (ERIC) project concepts and strategies for use in community settings [7,11,41].Refinement was made to the criteria by the first author (MDB).Changes are described in Supplementary Table S4.In summary, refinements included terminology changes to reflect drowning prevention "interventions" in place of "clinical innovations" [11], "target group and support networks" in place of "patient/consumers and families" [11] or "priority populations" [7], and "providers" in place of "clinicians" [11].These modifications were verified with a practitioner with over 10 years' experience in the drowning prevention sector.The final list of nine ERIC concepts and 73 strategies are described in Table 2.The nine concepts include: c1 use evaluative and iterative strategies, c2 provide iterative assistance, c3 adapt and tailor context, c4 develop partner relationships, c5 train and educate stakeholders, c6 support providers, c7 engage target group, c8 financial strategies and c9 change infrastructure.

Concepts and Strategies Definition Identifier
CONCEPT 1: Use evaluative and iterative strategies c1 Assess for readiness and identify barriers and facilitators Assess various aspects of an organization to determine its degree of readiness to implement, barriers that may impede implementation and strengths that can be used in the implementation effort.
Audit and provide feedback Collect and summarize intervention performance data over a specified time period and give it to providers and administrators to monitor, evaluate and modify provider behaviour.

Concepts and Strategies Definition Identifier
Conduct cyclical small tests of change Implement changes in a cyclical fashion using small tests of change before taking changes system-wide.Tests of change benefit from systematic measurement, and results of the tests of change are studied for insights on how to do better.This process continues serially over time, and refinement is added with each cycle.
Conduct local needs assessment Collect and analyse data related to the need for the intervention (with the target group or their support network).c1_04 Develop a formal implementation blueprint Develop a formal implementation blueprint that includes all goals and strategies.
The blueprint should include the following: (1)  Purposely re-examine the implementation Monitor progress and adjust intervention practices and implementation strategies to continuously improve the quality of the intervention.c1_09 Stage implementation scale-up Phase implementation efforts by starting with small pilots or demonstration projects and gradually move to a system-wide rollout.c1_10 CONCEPT 2: Provide interactive assistance c2 Centralise technical assistance Develop and use a centralised system to deliver technical assistance focused on implementation issues.c2_01 Facilitation A process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship.
Provide technical assistance Develop and use a system to deliver technical assistance focused on implementation issues using local personnel.c2_03

Provide supervision
Provide providers with ongoing supervision focusing on the intervention.
Provide training for provider supervisors who will supervise providers of the intervention.

c2_04 CONCEPT 3: Adapt and tailor context c3
Promote adaptability Identify the ways an intervention can be tailored to meet local needs and clarify which elements of the intervention must be maintained to preserve fidelity.c3_01 Tailor strategies Tailor the implementation strategies to address barriers and leverage facilitators that were identified through earlier data collection.c3_02 Use data experts Involve, hire and/or consult experts to inform management on the use of data generated by implementation efforts.c3_03 Use data warehouse techniques Integrate intervention records across facilities and organizations to facilitate implementation across systems.c3_04 CONCEPT 4: Develop partner relationships c4 Build a coalition Recruit and cultivate relationships with partners in the implementation effort with partners involved throughout the whole intervention.c4_01 Table 2. Cont.

Concepts and Strategies Definition Identifier
Capture and share local knowledge Capture local knowledge from implementation sites on how implementers and providers made something work in their setting and then share it with other sites. c4_02

Conduct local consensus discussions
Collect and analyse data related to the need for the innovation (carried out with stakeholders).c4_03 Develop academic partnerships Partner with a university or academic unit for the purposes of shared training and bringing research skills to an implementation project.c4_04

Develop an implementation glossary
Develop and distribute a list of terms describing the intervention, implementation and stakeholders in the organizational change.c4_05 Identify and prepare champions Identify and prepare individuals who dedicate themselves to supporting, marketing and driving through an implementation, overcoming indifference or resistance that the intervention may provoke in an organization or intended community.

c4_06
Identify early adopters Identify early adopters at the local site to learn from their experiences with the practice intervention.c4_07

Inform local opinion leaders
Inform providers identified by colleagues as opinion leaders or "educationally influential" about the intervention in the hopes that they will influence colleagues to adopt it.

Concepts and Strategies Definition Identifier
Alter fees for target group Create fee structures where the target group or their support network pay less for the intervention (e.g., community pool access).c8_03

Develop disincentives
Provide financial disincentives for failure to implement or use the intervention.c8_04 Fund and contract for the evidence-informed intervention Governments and other payers of services issue requests for proposals to deliver the intervention, use contracting processes to motivate providers to deliver the intervention and develop new funding formulas that make it more likely that providers will deliver the intervention.

c8_05
Make billing easier Make it easier to bill for the intervention.c8_06 Place interventions on a fee-for-service list/formularies Work to place the intervention on lists of actions for which providers can be reimbursed (e.g., pool fence compliance checks charged to pool owners).c8_07 Use capitated payments Pay providers a set amount per target group member for delivering the intervention.c8_08 Use other payment schemes Introduce payment approaches (in a catch-all category).c8_09 CONCEPT 9: Change infrastructure c9

Change accreditation or membership requirements
Strive to alter accreditation standards so that they require or encourage use of the intervention.Work to alter membership organization requirements so that those who want to affiliate with the organization are encouraged or required to use the intervention.c9_01

Change liability laws or enforcement
Participate in liability reform efforts that make providers more willing to deliver the intervention.c9_02 Change physical structure and equipment Evaluate current configurations and adapt, as needed, the physical structure and/or equipment (e.g., changing the layout of a room, adding equipment) to best accommodate the targeted intervention.

c9_03
Change record systems Change records systems to allow better assessment of implementation outcomes.c9_04 Change service sites Change the location of service sites to increase access.c9_05 Create or change credentialing and/or licensure standards Create an organization that certifies providers in the intervention or encourage an existing organization to do so.Change governmental professional certification or licensure requirements to include delivering the intervention.Work to alter continuing education requirements to shape professional practice toward the intervention.c9_06

Mandate change
Have leadership declare the priority of the intervention and their determination to have it implemented.c9_07

Start a dissemination organization
Identify or start a separate organization that is responsible for disseminating the intervention.It could be a for-profit or non-profit organization.c9_08 Italics indicate strategies of a technical/clinical nature, not expected to be seen in the literature.

Data Extraction and Synthesis
The following data were extracted from the drowning prevention articles: 1. Author; year; aim; location; sample (n); recruitment; response rate.

Results
A total of 49 peer-reviewed articles were included .Table 3 presents the extracted data.Abbreviations: CPR-cardiopulmonary resuscitation, LJ-life jacket, PFD-personal flotation device, N/A-not applicable, N/R-not recorded, USA-United States of America.

Implementation Key Concepts and Strategies
Table 4 summarizes the identified ERIC concepts and strategies.Throughout the tables and text, the concepts and strategies have been identified in brackets, where "cX" identifies the concept and the underscore number "_XX" identifies the strategy.All nine concepts were identified across the 49 articles, with developing partner relationships (c4) (n = 32, 65.3%), evaluative and iterative strategies (c1) (n = 29, 59.2%) and engaging with the target group (c7) (n = 22, 44.9%) the most common concepts.Four articles reported the concept change infrastructure (c9) (8.2%).One included study [76] did not identify any implementation strategies.
Concepts and strategies identified in the intervention articles are detailed below, in order of frequency.

Conduct local consensus discussions (c4_03) 5
Interaction with stakeholders about the intervention Identification of ability of stakeholders or facilities to undertake the intervention (conducted with stakeholders) [56,73,83,86,89] Use advisory boards and workgroups (c4_15) 3 Develop and implement tools for qualitymonitoring (c1_06) 7 Tools developed to evaluate the intervention Observation strategies put in place Study protocols documenting all changes and revisions to the intervention  Intervene with target group to enhance uptake and adherence (c7_02) Involve target group in intervention development or implementation Telephone interviews to assess uptake and adherence Barriers such as language and childcare resolved Ensuring participants comfort as intervention progresses Community ownership of intervention messaging Location and timing of intervention [47,53,55,65,67,68,71,75,79,80,83,85,86,91] Increase demand (c7_01) 7 Use of existing events and networks to reach the target group at a convenient time or location [57,58,67,80,81,86,90] Use mass media (c7_05) 6 Use of mass media to informe the community of intervention messages [52][53][54]60,62,83] Table 4. Cont.

Develop Academic Partnerships (c4_04)
Partnerships with university academics (n = 18) were identified as human research ethics committee (HREC) approvals and research-practitioner collaborations.More than half the examples of developing academic partnerships (55.6%) involved the use of university or research group ethics boards [46,51,53,75,77,[85][86][87][88][89], whilst almost two-thirds of articles (n = 31, 63.3%) indicated they had received ethical approval.HREC approval within the strategy develop academic partnerships were recorded if it was clear where the ethics approval was obtained, with an approval number included.For example, an intervention designed by Koon and colleagues [64] was undertaken by the Lake Macquarie City Council and the University of New South Wales Beach Safety Research Group, obtained HREC approval and aided in developing tools for the intervention.In another study, Hamilton and colleagues [61] reported the development of resources in partnership with university academics.

Promote Network Collaboration (c4_13)
Network collaborations involved identifying and expanding existing networks within and outside the lead organization to promote information sharing, collaborative problem solving and a shared vision/goal for implementing the intervention [11].The collaboration took the form of involvement of organization staff with expertise from a variety of backgrounds [48,79,84,90,92], working with not-for profit organizations [59,83], development of multi-sectorial partnerships [49,83,89], expert input into the campaign [73,94] and the development of evaluation tools [59,90].For example, Quan, Shepard and Bennett [83] worked with community groups, the parks department and public health organizations to limit barriers to uptake by the Vietnamese community by reinstating lifeguards at beach and lake sites, providing low-cost swim lessons and the development of translated material for services.In another study, Sandomierski and colleagues [85] reported that linking programs with a broader drowning prevention initiative may have created more opportunities for collaboration and consistency messaging regarding child water safety.

Engage the Target Group (c7)
Target group engagement included improving participation in an intervention by using existing networks and events [52,57,58,64,67,74,81].For example, Franklin and colleagues [57] used schools to engage children, and Giresek [58] used pre-natal classes to engage new parents.Moran and Stanley [74] provided poolside education for parents while their children undertook swimming lessons.Mass media were used to disseminate information, such as updated boating safety regulations, to the general community in the study by Bugeja and colleagues [52].
Intervene with the Target Group to Enhance Uptake and Adherence (c7_02) In the study by Petrass and colleagues [82], the community provided feedback on the timing of interventions, whilst Beattie, Shaw and Larson [50] received feedback on their intervention location, and Yusef and colleagues [93] reviewed evaluation tools used by pediatricians to educate parents.

Evaluative and Iterative Strategies (c1)
Several (n = 6) drowning prevention pilot study interventions were identified [50,67,74,84,90,92].The ongoing examination and refinement of implementation strategies by the intervention teams were also common in four studies [70,80,82,93].Koon and colleagues [64] piloted school-based intervention materials based on lifeguards' expertise in delivering an intervention and used focus groups with high school children to refine the program content and delivery [64].

Conducting Local Needs Assessment (c1_04)
Several articles (n = 11) described the use of local needs assessments to understand the target group.This included the use of focus groups (n = 6) [64,73,83,84,86,89], identification of barriers by experts (n = 2) via existing knowledge [75,92], review of the literature (n = 2) [77,81] and drowning trend data [95].Morrongiello and colleagues [77] described using a review of the literature, local drowning trends and the National Water Safety Framework to inform the content for an awareness-raising program for parents on supervision of children around the water.Intervention locations were also purposively selected by need based on the formative findings [77].In other articles, Mitchell and Haddrill [73] and Quan and colleagues [83] conducted focus groups with the local Chinese and Vietnamese-American communities, respectively.Savage and Franklin [86] conducted focus groups with culturally and linguistically diverse people regarding barriers to participating in water safety programs.

Adapting and Tailoring the Context (c3)
Examples of ways in which interventions were adapted to suit local conditions included adaption to the availability of swimming facilities [80] and the swim ability of the target group [48,80,81].The needs of the target group [79] and providers [64] and the accessibility and relevance of the interventions for specific communities [73,90] were considered.For example, Olaisen and colleagues [79] offered a variety of enrolment options for swimming lessons, providing between one and three swimming lessons.Petrass and Blitvich [81] tested perceived swim ability against actual swim ability in the first four lessons of their water-based intervention and then introduced specific skills relevant to the participants.

Train and Educate Stakeholders (c5)
Stakeholder training and education were included in initial drowning prevention sessions (conduct educational meetings (c5_01)) to ensure key community leaders [66] and staff [69,79,82,91] understood the intervention before it was delivered to the wider community, as well as ongoing implementation meetings (create a learning collaborative (c5_04)) to ensure providers were learning from each other [93].Other strategies included the development and distribution of resources for providers to support implementation [67,82,93] and the use of [45,79] and recommendations for [73,75] dynamic training delivery methods.For example, Love-Smith and colleagues [67] developed a presentation script and talking points for presenters at educational sessions, while Petrass and colleagues [82] developed lesson plans and other resources for providers to ensure the consistency of content delivery and lesson progression.The strategy to provide ongoing consultation (C5_08) was not identified in any articles.

Provide Interactive Assistance (c2) and Support Providers (c6)
Only one strategy, facilitation (c2_02), was identified [45,48,75,80,86].Examples of facilitation included interactive problem solving undertaken with the target group, their support network and/or providers.For example, Olivar [80] identified that the swim teacher's role was to identify issues in swimming skills with teaching styles focused on learner-centered problem solving with the participants.Teachers were considered active participants in the learning process and prioritized creating a supportive environment and opportunities were offered for participants to complete tasks at their own readiness and competency levels.The strategies providing supervision (c2_04), remind providers (C6_04) and revising professional roles (c6_05) were not identified in the articles.

Financial Strategies (c8) and Change Infrastructure (c9)
The concepts addressing financial strategies (c8) and change infrastructure (c9) were the least-frequently identified in the articles, with neither concept including strategies identified more than five times (key strategies).
Fund and contract for the evidence-informed intervention (c8_05) was identified in two articles.Franklin and colleagues [57] identified the Swim and Survive Program as being subsidized by the Australian Capital Territory (ACT), and the Water Safety in the Bush project was funded by community organizations [50].
Van Weerdenburg, Mitchell and Wallner's study [91] into pool fence compliance with the state's Swimming Pools Act of 1992 in Australia described financial strategies (c8) and change infrastructure (c9).Changes were made to liability laws and enforcement (c9_03) by granting authority to councils to access properties to inspect pools.Recommendations were made to correct or make explicit inconsistencies between the Act and other regulations and related Australian standards (change liability laws or enforcement (c8_02) and introduce a provision within the Act for inspection fees to assist with the cost of managing compliance, record systems and inspections (place interventions on a fee-for-service list (c8_07)).

Discussion
This review sought to identify, describe and categorize the drowning prevention implementation strategies used in HIC settings.The findings were mapped to ERIC implementation concepts and strategies [7,11,41] to capture the breadth of implementation of drowning prevention interventions in HICs published in the peer-reviewed literature.It included 49 articles about drowning prevention interventions in HICs published between 2002 and 2022.The review found that articles were mostly from Australia and the USA, varying by sample and intervention level, with most interventions delivered at the group (e.g., school classroom, expectant parents) and population levels.Interventions most frequently used behavioral [42] strategies or a combination of behavioral and socio-ecological strategies [43].Interventions covered the drowning prevention activities identified by the International Life Saving Federation [27], including environmental modifications, promoting swimming and lifesaving skills, cardiopulmonary resuscitation skills, surveillance and supervision.Evaluation designs were mostly quantitative, with several mixed-method and observational studies also included.All nine ERIC concepts and forty-two ERIC strategies were identified within the intervention studies.Fifteen strategies across six concepts were identified five times or more (key strategies).

Understanding the Use of Implementation Strategies in Drowning Prevention Interventions
Three concepts were consistently identified: developing partner relationships, engage target group and iterative and evaluative strategies.This indicates that "developing relationships, engaging with the target group and checking what works as programs progress" are at the forefront for researchers and practitioners when reporting on drowning prevention activities.These strategies are also core competencies for those working in public health, health promotion [42,96], injury prevention [97] and advocacy [98], indicating that a complementary public health and injury prevention lens is used to frame drowning prevention interventions in HICs.This aligns with the way drowning prevention is framed as a public health issue by the World Health Organization [30][31][32][33]99].The development of skills related to relationship building, target-group engagement and advocacy are a priority for the public health workforce, as central capabilities highlighted in the Global Charter for Public Health [100]  Our review highlights that the fundamental principles of planning and evaluating programs (i.e., the concepts of formative research and stakeholder and target group engagement) are clearly identifiable components of the peer-reviewed drowning prevention literature in HICs.However, while these concepts were consistently identified, there was not always sufficient detail [102] available to support those implementing future interventions to replicate or decide [103] to use similar strategies and limited examples of implementation strategies described in the context of recommendations for similar programs.For example, Stempski and colleagues [89] stated that partner organizations identified a representative (project champion) who shared survey learnings at bimonthly meeting to help foster change among others as a collaborative and iterative process of improvement highlighting success and barriers, but did not explain how project champions were identified or engaged.To build practitioner implementation capacity, understanding what was carried out may not always be enough [104].The implementation strategies used need to be compared and/or assessed against current practice to improve uptake [7].
This review highlights a need for the processes related to the transformation and adaptation of implementation strategies used in practice to be better understood [104].One way to do this may be through the use of causal loop diagrams and system modelling [103] in drowning prevention interventions to better explore the interactions influencing decision making [104] and allow for an exploration of factors, such as organizational and evaluation capacity [102], affecting implementation decision making [7].Alternatively, exploration of the gaps and factors affecting the uptake of implementation strategies [105] with practitioners and researchers would also be beneficial.
Developing partner relationships was the most frequently identified ERIC concept; developing academic partnerships was the most cited ERIC strategy.It is posited that the requirement for HREC approval when publishing in peer-reviewed journals may mean the impact of academic partnerships in the implementation of drowning prevention interventions in HICs is over-estimated in the literature.Research has found that practitioners often feel intimidated by the term "ethics", equating oversight processes to research, and feel that the process of gaining ethics approval has limited benefit to service delivery [106,107].Other identified barriers to the use of institutional ethical approval include organizational capacity, competing priorities and access [106].These perceptions have the consequent effect of limiting the integration of ethical oversight into policy and practice [108] and further, reducing the likelihood of practitioners and policy makers publishing in the peer-reviewed literature, as ethical oversight is a requirement for most journals [109].Being explicit about the ethical foundations of public health interventions are important to ensure they are informed by evidence, do what was intended, avoid iatrogenic effects and follow agreed guidelines and principles related to the ethical conduct of human research [107].
Drowning prevention interventions are designed and delivered by water safety practitioners, who have varying capacity and skills [97,110] in designing, implementing and evaluating programs.For example, practitioners in the water safety space are often lifeguards, fishers and swim instructors [110] working in complex settings and impacted by system factors that affect the intervention, provider and community [111,112], with variations in organizational capacity, staff skills and technical components [113].Thus, consistent with findings in community health promotion more broadly [106], it is likely that drowning prevention practitioners may feel ethical approval has a limited benefit to service delivery.Enhancing knowledge of ethical practice and streamlining access to ethical oversight by making research-practice partnerships more common may facilitate greater participation in formal ethical oversight processes and greater contribution to the peer-reviewed literature by a broader range of practitioners.
Community and academic partnerships have the greatest potential to improve the successful implementation of evidence-informed practice [114].Community and academic partnerships ensure that decision-making processes and subsequent interventions are feasible and sustainable [115,116] by utilizing a shared vision and impact benchmarking.To ensure that researchers consider interesting, important research questions and use effective methodology [114], practitioners develop evaluation practices and skills [117] and knowledge translation [106] within the industry occurs in a timely manner, there is a need to further develop strategies that truly enhance research-practice partnerships.
Overall, the review identified a lack of consistent language used to describe implementation of the interventions.For example, in the five articles [45,48,75,80,86] where examples of facilitation (c2_02) (a process of interactive problem solving and support that occurs in the context of a recognised need for improvement and a supportive interpersonal relationship [11]) were identified, the terms facilitation or problem solving were not used.Instead, examples described how the participants "engaged in tasks that targeted their underlying deficit" [45], described how "factors such as personal instructor qualities, program structure and support and day-to-day interactions with students were important" [48] and iterated that "time was allowed for the pool-side parents to seek advice from the instructor" [75].Similar issues of inconsistent terminology have been identified by other authors when reviewing the obesity literature [118] and implementation guidelines more broadly [119].More consistent use of implementation terminology in the drowning prevention literature would be useful to ensure that the implementation strategies are easier to identify and better understood.This could be achieved with the development and use of a framework guide for the implementation of drowning prevention interventions for use by practitioners, researchers, funding bodies and decision makers.

Gaps in the Use and Reporting of Implementation Strategies
Approximately 40% of the ERIC implementation strategies (n = 30) were not identified in included articles.This result is consistent with observational and qualitative research into the use of ERIC strategies in general practice across the USA [120].We speculate that some non-identified ERIC strategies are likely to be undertaken but are limited in detail or not formally captured and reported in the peer-reviewed literature.This is highlighted by the limited reporting of informing local opinion leaders (c4_08) (n = 2) and identifying and preparing champions (c4_06) (n = 1) and no cases of identifying early adopters (c4_07), despite community groups identified as partners and collaborators in multiple articles [48,49,73,83,84] and included in pre-delivery training to provider and community members [66].The limited detail included in the literature, whereby the definitions for the ERIC strategies have not been met (e.g., identify and prepare champions), has been noted by other studies discussing the use of implementation strategies in community settings [7] and may also be the case for other strategies such as remind providers (c6_04) and provide ongoing consultation (C5_08).
The concepts of financial strategies and change infrastructure did not include any key strategies and were largely absent from the reviewed literature.Drowning prevention interventions tend to focus on education, the physical environment or community and social context, with financial strategies (c8) mainly utilized by interventions undertaken by local councils (in the case of pool fencing requirements) [91] and involving service delivery (i.e., access to pool facilities [83] or subsidized swim lesson participation [57]).In the case of financial strategies, it may be that the use of public health [26,31,99] rather than implementation science [7] to frame drowning prevention means that the economic impacts on behaviour change [121] and financial indicators of organizational capacity [122] have been somewhat overlooked [121].

What Was Learnt?
In general, the current use and reporting of implementation strategies in the published literature highlights that various implementation strategies are likely over-reported (reported in the literature at a higher proportion than they are used), under-reported (used more often than they are reported in the literature) and in some cases, overlooked (neither likely used nor reported in the literature).The consequence of over-reporting implementation strategies is a false sense of what is occurring in the field whilst under-reporting means interventions are difficult to replicate.Those publishing drowning prevention interventions in the peer-reviewed literature could refocus efforts towards intervention implementation.Further exploration of the use and adaptation of existing resources and systems (e.g., databases, provider training) to support providers to deliver interventions could go some way to support and strengthen the implementation of drowning prevention interventions.

Strengths and Limitations
Whilst the call for methodologically sound reviews of implementation in public health interventions has been made [7,119], this review is the first to report on ERIC implementation concepts and strategies using the HIC drowning prevention literature as a case study.Strengths include searching eight databases, a purposefully broad scope (i.e., did not include "interventions" in the search terms), following procedures for previously published systematic reviews [22][23][24] and the use of a public health-specific quality-appraisal tool (Meta QAT) [39].Several limitations included the restriction to English language and the exclusion of the grey literature.The grey literature may have yielded a wider range of interventions; however, technical reports [123], annual reports [124] and websites [125] were more likely to describe interventions for funders and the general community and were deemed unlikely to describe implementation strategies.An over-representation of from Australia and the USA may reflect that drowning prevention efforts have attracted funding and resources, which has allowed for a research-practice nexus to be established and afforded peer-reviewed publications.In contrast, there were few non-English articles, suggesting drowning prevention may be a lower priority for research funding in some countries and the opportunity to publish becomes limited.As with other reviews of public health intervention implementation [118], the lack of consistent terminology to describe implementation strategies in the drowning prevention literature may mean some articles were missed.Despite these limitations, this study begins a discussion of the use of implementation science in drowning prevention interventions and adds to the small but growing evidence base on how drowning prevention interventions are implemented.

Conclusions
The findings of this systematic review serve as a starting point for further exploration of the implementation strategies used in drowning prevention interventions.The review highlights the need for more detailed, accurate reporting of the implementation of interventions to aid in the replication and refinement of evidence-informed interventions.The use and reporting of implementation strategies in published, peer-reviewed drowning prevention interventions in HICs is varied and lacks depth, making interventions difficult to replicate or making it difficult to know which implementation strategies add to the success of an intervention and why.The concepts of evaluative and iterative strategies and adapting to the context are relatively well-developed.However, there is a paucity of evidence on other concepts such as how providers and stakeholders are supported, trained and educated.
Potential improvements that may support better capture of the implementation strategies include increased articles in the peer-reviewed literature that describe the process of program planning, implementation and evaluation and the use of consistent drowning prevention implementation language.Supporting practitioners to identify and apply implementation strategies in their day-to-day work can facilitate real-world enhancements in public health action for drowning prevention in HICs.
Future endeavors include an exploration of intervention implementation with drowning prevention practitioners and researchers, which will allow for the gaps identified in this review to be further understood.We anticipate that this will go some way to better describe the use of implementation strategies, which has theoretical, methodological and practical implications, thus strengthening the implementation of evidence-informed interventions in HICs.

Figure 1 .
Figure 1.Flow diagram for review of implementation concepts and strategies identified in drowning prevention literature from 2002-2022.

7
group (c7) 22 Int.J. Environ.Res.Public Health 2024, 21, x FOR PEER REVIEW 38 of Audit and provide feedback (c1_02Use of existing events and networks to reach the target group at a convenient time or location [57,58,67,80,81,86, Use mass media (c7_05) 6 Use of mass media to informe the community of intervention messages [52-54,60,62,83 Involve the target group and support network (c7_03) 4 Prepare target group to actively participate (c7_04) 0 Adapt and tailor context (c3) 13 Assessment of suitability of an existing program

12 Use 9 Work 1 9 Work 9 Work 86 Provide 9 Work 6 Facilitation (c2_02) 5
tailored to each participant Barriers such as facility availability, language, travel time, transportation, local water ways and weather taken into account[45,48,50,64,73,85,92] Use data experts (c3_03) 0 Use data warehouse techniques (c3_04) 0 Train and educate stakeholders (c5) 12Promote adaptability (c3_01) 9 Assessment of suitability of an existing program Community involvement in adapting an existing program Adaptability in levels of involvement in activities Priority variations for different intervention locations [45,50,56,73,79-81,89,90] Tailor strategies (c3_02) 8 Swim teaching techniques tailored to each participant Barriers such as facility availability, language, travel time, transportation, local water ways and weather taken into account [45,48,50,64,73,85, 90tailored to each participant Barriers such as facility availability, language, travel time, transportation, local water ways and weather taken into account [45,48,50,64,73,85 92] Use data experts (c3_03) 0 Use data warehouse techniques (c3_04) 0 Train and educate stakeholders (c5) .Environ.Res.Public Health 2024, 21, x FOR PEER REVIEW 39 of Conduct educational meetings (c5_01) 6 Training or meeting with community leaders, providers and stakeholders to share information about the intervention prior to delivering it to the target group Training varied in length and content [66,69,73,79,81,Centralise technical assistance (c2_01) 0 Provide supervision (c2_04) 0 Support providers (c6) 6 Develop resource-sharing agreements (c6_02) 4 Create new provider teams (c6_01) 3 Facilitate relay of program data to providers with community leaders, providers and stakeholders to share information about the intervention prior to delivering it to the target group Training varied in length and content [66,69,73,79,81,91] Int.J. Environ.Res.Public Health 2024, 21, x FOR PEER REVIEW 39 o Conduct educational meetings (c5_01) 6 Training or meeting with community leaders, providers and stakeholders to share information about the intervention prior to delivering it to the target group Training varied in length and content [66,69,73,79,81,Int.J. Environ.Res.Public Health 2024, 21, x FOR PEER REVIEW 39 o Conduct educational meetings (c5_01) 6 Training or meeting with community leaders, providers and stakeholders to share information about the intervention prior to delivering it to the target group Training varied in length and content [66,69,73,79,81,undertaken with the target group, their support network and/or providers [45,48,75,80,interactive assistance (c2) 6 Int.J. Environ.Res.Public Health 2024, 21, x FOR PEER REVIEW 39 of Conduct educational meetings (c5_01) 6 Training or meeting with community leaders, providers and stakeholders to share information about the intervention prior to delivering it to the target group Training varied in length and content [66,69,73,79,81,other experts (c5_09) 0 Provide interactive assistance (c2) Interactive problem solving undertaken with the target group, their support network and/or providers [45,48,75,80,86] Provide technical assistance (c2_03) 1 Centralise technical assistance (c2_01)
and the Council of Academic Public Health Institutions Australasia (CAPHIA) Master of Public Health competencies [101].

Author
Contributions: M.D.B. conceived the study design with input from J.E.L., G.C. and J.J. Material preparation, data collection and analysis were performed by M.D.B. and B.R.; J.E.L. and G.C.

Table 1 .
Inclusion and exclusion criteria.
c4_08Involve executive boards Involve existing governing structures (e.g., boards of directors, medical staff boards of governance) in the implementation effort, including the review of data on implementation processes.c4_09ModelandsimulatechangeModelorsimulatethechangethatwillbeimplementedpriorto implementation.c4_10ObtainformalcommitmentsObtainwrittencommitmentsfromkeypartnersthatstatewhat they will do to implement the intervention.c4_11OrganiseimplementationteammeetingsDevelopandsupportteams of providers who are implementing the intervention and give them protected time to reflect on the implementation effort, share lessons learned and support one another's learning.c4_12PromotenetworkcollaborationIdentifyandbuildonexistinghigh-qualityworking relationships and networks within and outside the organization, organizational units, teams, etc. to promote information sharing, collaborative problem solving and a shared vision/goal related to implementing the intervention.Change who serves on the provider team, adding different disciplines and different skills to make it more likely that the intervention is delivered (or is more successfully delivered).c6_01Developresource-sharingagreementsDeveloppartnerships with organizations that have resources needed to implement the intervention.Includes cases whereby existing resources were used but no sharing agreement was mentioned.c6_02Facilitaterelay of program data to providersProvide as close to real-time data as possible about key measures of process/outcomes using integrated modes/channels of communication in a way that promotes use of the targeted intervention.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevent literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.

Table 4 .
Summary of implementation concepts and strategies identified in the drowning prevention literature.