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Abstract
Introduction A high burden of unintentional fatal drowning has been reported in low- and middle-income countries. However, little is known about unintentional drowning in Indonesia.
Methods This population-based retrospective cohort study analysed unintentional drowning data for Indonesia sourced from The Global Burden of Disease Study 2019. Estimates of trends, mortality rates, incidence rates, years lived with disability (YLDs) and disability adjusted life years were generated.
Results A decline in unintentional drowning mortality rates was observed, with an average annual mortality rate of 2.58/100 000. Males were 1.81 (95% CI 1.79 to 1.84) times more likely than females to unintentionally drown. Average annual mortality rates were highest among the under-5 age group (9.67/100 000) and 70 and over (5.71/100 000 for males; 5.14/100 000 for females). Distributions of drowning deaths vary depending on region, with mortality rates higher in Papua, Kalimantan, Sulawesi, Maluku, Sumatra and Nusa Tenggara regions.
Discussion While a decline in drowning mortality rates in Indonesia was identified between 2005 and 2019, mortality rates for unintentional drowning remained high among children under 5 years, the elderly population and those residing in Papua, Kalimantan, Sulawesi, Maluku, Sumatra and Nusa Tenggara, warranting further focused attention.
Conclusion A downward trend in the rate of unintentional drowning deaths in Indonesia is observed from 2005 onwards, with risk variation based on age, gender and region. The findings highlight the importance of addressing drowning as a cause of premature mortality and health system burden in Indonesia, including through enhancing drowning data collection systems and identifying drowning risk factors.
- Mortality
- Drowning
- Public Health
- Health Education
- Child
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Most drowning deaths worldwide occurred in low- and middle-income countries (91%), particularly in Southeast Asia (35%).
No publication on the national level of drowning rates in Indonesia has been identified.
WHAT THIS STUDY ADDS
Between 2005 and 2019, a decline in unintentional drowning mortality rates was observed, with an average annual mortality rate of 2.58/100 000.
The unintentional drowning risk varies based on age, sex and region in Indonesia. Being male, aged under 5, aged 70 years and above and residing in provinces in Papua, Kalimantan, Sulawesi, Maluku, Sumatra and Nusa Tenggara, were recognised as risk factors.
HOW MIGHT THIS STUDY AFFECT RESEARCH, PRACTICE, OR POLICY
The findings highlight the importance of continuing to enhance drowning data collection systems, as well as identifying drowning risk factors and developing contextualised drowning preventive strategies in Indonesia.
Introduction
Drowning represents a major challenge for global public health.1 2 In 2017, an estimated 295 210 deaths occurred globally due to unintentional drowning, with a global mortality rate of 4/100 000.3 Most drowning deaths worldwide occurred in low- and middle-income countries (LMICs) (91%), particularly in Southeast Asia (35%).1 However, less is known about unintentional drowning deaths in Indonesia, the world’s largest archipelagic state and the fourth most populated nation.4
Located in the Southeast Asia region, Indonesia consists of 16 056 islands, with a population of over 270 200 000 and a density of 141 people/km2.4 Indonesia’s vast area comprises 1 919 440 km2 of land area, including 93 000 km2 of inland seas and 6 159 032 km2 of water area, exposing Indonesians to a high risk of drowning and submersion5 6 (figure 1). Despite this, according to the 2021 Regional Status Report on Drowning in Southeast Asia by the WHO, Indonesia does not have a national coordination mechanism for drowning prevention and water safety, and no coordinated national death registry from which national and subnational drowning data can be collected.7
Map of Indonesia.
To further understand the magnitude of drowning as a public health problem in Indonesia, this research aims to examine mortality rates, incidence rates, years of life lost (YLLs) and risk factors of fatal unintentional drowning in Indonesia and investigate the overall drowning burden via years lived with disability (YLDs) and disability adjusted life years (DALYs), between 2005 and 2019 using the 2019 Global Burden of Disease (GBD) Study estimates.
Methods
This study was undertaken as a population-based retrospective cohort study. This study is part of a larger explanatory sequential mixed-methods study investigating unintentional drowning in Indonesia, which comprised three phases: (1) a scoping review8; (2) a retrospective cohort study reported here and (3) a qualitative study aimed to expand the quantitative findings. The scoping review8 revealed the limited availability of drowning data in Indonesia, informing our decision to use the GBD Study 2019 data as the primary source for this investigation.
An analysis of quantitative, national data sourced from the GBD Study 20199 by the Institute for Health Metrics and Evaluation (IHME) database was performed to generate estimates of mortality rates, incidence rates, YLDs, YLL’s and DALYs for unintentional drowning at a national and subnational level in Indonesia, including all its 34 provinces. The data collected, spanned the period of 2005–2019 and, in coordination with the Indonesian Ministry of Health, was collected using verbal autopsy survey instruments and modelling.9 This current study focuses on unintentional drowning, as defined by the International Classification of Disease (ICD) ninth revision (ICD-9) and ICD-10 codes. The GBD Study 2019 used the ICD-9 code, E910 and ICD-10 codes (W65–W74) for unintentional drowning.3 10–12 These codes do not include unintentional drowning due to water transport and disaster, nor drowning of intentional or undetermined intent and are considered an underestimation of drowning.13
In this study, ‘incidence’ pertains specifically to the frequency of non-fatal drowning incidents within the Indonesian population throughout the study duration. This definition excludes drowning-related fatalities, which were treated distinctly as mortality events. Information on DALYs, YLDs and YLLs due to drowning were also inferred to assess the overall burden of drowning in Indonesia.14 One DALY represents the loss of an equivalence of one year of life with full health. DALYs for drowning are the sum of YLLs due to premature mortality caused by drowning and YLDs due to drowning and/or submersion.14
Data were downloaded using the IHME GBD results tool between March 2021 until March 2022 for collecting drowning data for the period of 2005–2019 for Indonesia and the subnational provinces.9 The year 2005 is chosen as the starting year of investigation, as a consensus on the establishment for a definition of drowning was issued by the WHO in 2005, which included both fatal and non-fatal drowning cases.15
This study complies with the Guidelines for Accurate and Transparent Health Estimates Reporting recommendations.16
Data abstraction
The following data were extracted on unintentional drowning deaths and non-fatal submersion in Indonesia: mortality rates, incidence rates, YLDs, YLLs and DALYs,14 based on year, gender, age group (under 5, 5–14 years, 15–49 years, 50–69 years and 70+ years) and province of Indonesia.
Analysis
Data were extracted from the GBD Study 2019 and entered into Microsoft Excel and analysed using IBM SPSS Statistics V.27. Trend analysis between the period of 2005 and 2019 was inferred with linear regression. Relative risk (RR), with a 95% CI (Confidence Interval), was calculated to measure the association between exposures of interest (sex, age group, jurisdiction or province) and unintentional drowning deaths. Where RR was calculated, the predictor group with the lowest annual mortality rate was used as the reference point (except for provinces, where the rate for Jakarta as the capital province of Indonesia was used as the reference point).
Ethics approval
Ethics approval was granted by the University of Mataram of Indonesia (Ethics Approval number 128/UN18.F8/ETIK/2023).
Funding
GBD is supported by the Bill and Melinda Gates Foundation. The funders of the study had no role in the study design, data collection, data analysis, data interpretation, writing of the report or the decision to submit the article for publication. All authors had full access to the data in the study and had final responsibility for the decision to submit for publication.
Results
In total, there were 94 035 (95% UI (Uncertainty Interval): 77 135.3 to 108 737.1) unintentional drowning deaths in Indonesia between 2005 and 2019, of which 69% were males.
Incidence and mortality rates
The average annual mortality rate in Indonesia between 2005 and 2019 was 2.58/100 000. Notably, there was a consistent decrease observed in the drowning mortality rate over this period, from 3.35/100 000 in 2005 to 1.93/100 000 in 2019 (table 1). This trend is supported by a high R2 of 0.99 obtained from the regression model. The regression equation (y=−0.10x+209.53) reinforces this pattern, with a negative coefficient indicating a declining trend. These results collectively suggest a significant decrease in drowning mortality rates throughout the years under analysis. While there is evidence suggesting a negative trend in non-fatal drowning incidence rates over the study period, the linear regression model fails to sufficiently explain the overall relationship between the variables (y=−0.11x+243.86, R2=0.06).
Drowning incidence, mortality, YLLs, YLDs and DALYs in Indonesia 2005–2019
Mortality rates by age group and gender
Between 2005 and 2019, drowning mortality rates for both males and females of all ages decreased in Indonesia (figure 2 and online supplemental table S2). The highest drowning mortality rate across the 15-year period was identified among under-5 males, with an average annual mortality rate of 9.67/100 000 between 2005 and 2019, contributing the largest proportion of deaths by unintentional drowning in Indonesia (34.74%) (figure 2, online supplemental table S1). Between 2005 and 2019, unintentional drowning mortality rates were higher for males than females across all age groups (figure 2, table 2, online supplemental table S2).
Supplemental material
Unintentional drowning mortality rates by age group and gender in Indonesia 2005–2019
Risk factors of fatal unintentional drowning in Indonesia
Mortality rates by province
Distributions of drowning deaths by sex vary depending on region. Of 34 provinces in Indonesia, the highest drowning death rates for all age groups in the year 2019 were observed in male populations in the provinces of North Kalimantan (10.95/100 000), Central Kalimantan (10.06/100 000), Papua (5.51/100 000 populations) and Gorontalo (5.21/100 000), which are located in the central and eastern part of Indonesia, in comparison with mortality rates from unintentional drowning in other provinces in the western part of Indonesia (figure 3, online supplemental table S1).
The 2019 mortality rates of unintentional drowning of all ages by sex and province in Indonesia.
In 2019, the highest male under-5 drowning mortality rates were observed in North Kalimantan (26.50/100 000), Papua (24.46/100 000) and West Sulawesi (18.38/100 000) (figure 4 and online supplemental table S1). For female populations, the highest drowning death rates for the under-5 age group in the year 2019 were observed in the province of Papua (32.58/100 000), which was higher than in other provinces (figure 4 and online supplemental table S1). Between 2005 and 2019, several provinces experienced the highest reductions in child drowning cases, including Maluku (y=−1.44x+30.51, R²=0.97), West Nusa Tenggara (y=−0.99x+23.35, R²=0.98), Papua (y=−0.92x+42.45, R²=0.92), West Sulawesi (y=−0.97 x+27.19, R²=0.98), North Maluku (y=−0.86x+25.07, R²=0.98), South Sulawesi (y=−0.85x+18.42, R²=0.98), East Nusa Tenggara (y=−0.83x+21.37, R²=0.96), South Sumatra (y=−0.81x+22.90, R²=0.98), North Kalimantan (y=−0.72x+27.42, R²=0.94) and Riau (y=−0.61x+15.34, R²=0.96).
The 2019 under-5 unintentional drowning mortality rates by sex and province in Indonesia.
YLDs and DALYs
Unintentional drowning DALYs showed a decrease between 2005 and 2019 (y=−8.26x+243.95, R2=0.99), with rate of DALYs of 239.46 (95% UI: 182.48 o 281.34) in 2005 and 125.13 (95% UI: 99.76 to 148.05) in 2019 (table 1).
Risk factors
In Indonesia, males were 1.81 times (95% CI 1.79 to 1.84) more likely than females to unintentionally drown (table 2). Indonesian children aged less than 5 years old were 3.67 times (95% CI 3.63 to 3.72) more likely to become victims of fatal drowning in comparison to individuals aged between 15 and 49 years (table 2). Elderly populations were also an important contributor, with individuals aged 70 years and above 2.5 times (95% CI 2.45 to 2.56) more likely to fatally drown in comparison to individuals aged 15–49 years (table 2).
The top three highest average annual mortality rates for unintentional drowning were registered in the provinces of North Kalimantan (7.23/100 000), Papua (6.92/100 000) and Central Kalimantan (6.78/100 000), and individuals in Papua had the highest likelihood of dying from unintentional drowning (RR=3.98), compared with the reference group of the metropolitan capital of Indonesia, Jakarta (table 2)
Discussion
Unintentional drowning is a little studied public health issue in Indonesia. Overall, this study identifies a decline in drowning mortality rates in Indonesia between 2005 and 2019 (R2=0.99, y=−0.10x+209.53). During the 15-year study period, mortality rates for unintentional drowning were higher in males than females and also higher among children aged under 5 years, elderly populations aged 70 years and above, and populations residing in the Papua, Kalimantan, Sulawesi, Maluku, Sumatra and Nusa Tenggara regions. These findings underscore the need for further focused attention and interventions in these demographic groups and geographical areas.
The rates and trends of unintentional drowning in Indonesia
Overall, there was a decrease in drowning mortality rates, with an average annual mortality rate between 2005 and 2019 of 2.58/100 000. However, it is acknowledged that the GBD Study 2019 data for Indonesia was mostly sourced from verbal autopsy data, and only reported unintentional drowning, while excluding cases caused by water-transport related and disaster-related drowning incidents, thus potentially underrepresenting the actual magnitude of drowning in Indonesia. A previous study in Australia has reported how different ICD-10 coding combinations affected the capture of drowning deaths in the national register.13 When specific ICD codes of W65–W74 for accidental drowning and submersion were used, as in the GBD Study 2019, only 61% of unintentional drowning deaths were captured. However, inclusion of additional drowning-related codes for accidental drowning related to watercrafts, floodings and undetermined intent increased the capture rate to 78%, and when the drowning codes used were expanded to include intentional drowning events, with multiple causes of death considered, the capture rate rose to 92%.13
DALYs attributed to unintentional drowning in Indonesia declined between 2005 and 2019 (table 1 and online supplemental table S1). The observed decrease in incidents of drowning among children under the age of 5 in Indonesia during the study period (y=−0.36x+740.01, R2=0.98) likely contributes to the overall reduction in DALYs. In this study, the low YLDs correspond with findings from a previous study, which reported lower YLDs for children aged under 5 in LMICs, compared with high-income nations. This is attributed to the higher proportion of fatal drownings in LMICs.17
The risk of drowning among males in Indonesia: informing preventive measures
This study found that in Indonesia, males were 1.81 times (95% CI 1.79 to 1.84) more likely than females to unintentionally drown. Among high-income nations, a common observation is the higher likelihood of males experiencing unintentional drowning, which has been linked to risky behaviours. This includes males tending to underestimate the risk of experiencing unintentional drowning and overestimate their knowledge and skill in water-related activities.18 Therefore, further research on the contributing factors and protective factors related to the risk of drowning is crucial. These factors may encompass behavioural and sociocultural aspects of drowning and are important in understanding drowning prevention suitable for the Indonesian context.
Unintentional drowning as a leading cause of injury death for Indonesian children
Indonesian children aged under 5 years were 3.67 times (95% CI 3.63 to 3.72) more likely to die from unintentional drowning compared with populations aged 15–49 years. Under-5 drowning mortality rates in Indonesia vary across regions. For instance, in Papua, the under-5 mortality rate in 2019 was 32.6/100 000 for females and 25.4/100 000 for males, surpassing those of other provinces in the country. This finding corresponds to the 2014 WHO Global Report on Drowning which showed children aged under 5 years being disproportionately at risk for drowning.1 This underscores the urgent need for tailoring drowning prevention strategies in Indonesia to effectively address the heightened risk of drowning among children under the age of 5, particularly across rural populations of eastern Indonesia.
There is limited understanding on contributing factors to the observed decline in child drowning rates in Indonesia.8 However, the advancement of socioeconomic determinants of health, particularly the rise in gross domestic product (GDP) per capita, educational attainments and healthcare expenditure, has been identified as an instrumental driver to the reduction of drowning prevalence, including in under-5 populations, worldwide.12 This highlights the critical need for further investigation into how socioeconomic advancements and implemented interventions can effectively mitigate the burden of child drowning fatalities across Indonesia.
Fatal unintentional drowning among elderly Indonesians
Individuals aged 70 years and above were 2.5 times more likely to fatally drown compared with individuals aged 15–49 years (table 2). This finding corresponds to reported higher mortality rates among older populations in other countries, including Japan, China, Australia, Canada and New Zealand.19 20 From 1950 to 2021, the average global life expectancy at birth has risen by 22.7 years,21 and this prolonged lifespan may contribute to the concurrent increase in drowning-related fatalities among older age groups. However, efforts to reduce drowning among older populations have lagged behind that of young children.20 The findings of the current study should be a call to action to invest in drowning prevention among older people in Indonesia.
Jurisdiction as a determinant for unintentional drowning in Indonesia
The distribution of drowning deaths across Indonesia exhibits regional disparities, with the highest mortality rates recorded in the provinces of North Kalimantan (7.23/100 000), Papua (6.92/100 000) and Central Kalimantan (6.78/100 000). This discrepancy underscores the crucial need to investigate how socioeconomic determinants, infrastructure investments and social and environmental changes influence drowning fatalities. Particularly notable are provinces in Kalimantan, Papua, Sulawesi, Maluku and Nusa Tenggara regions, which present some of the nation’s lowest GDP per capita, alongside the highest rates of drowning mortality and the highest reductions of child drowning mortalities throughout the 15-year study period.22 Therefore, it is imperative to evaluate the availability and effectiveness of water safety promotion strategies and drowning prevention interventions at both national and provincial levels in Indonesia and their impact on the varying mortality rates across provinces, particularly in provinces that have experienced the highest reductions in Maluku, Nusa Tenggara, Papua, Sulawesi and Kalimantan.
Recommendations
Future research
While this study has provided insight into the issue of unintentional drowning in Indonesia, several key areas for future research are noted: (1) comprehensive examination of mortality and burden associated with all ICD codes for drowning, encompassing unintentional drowning, water transport-related drowning, disaster-related drowning, drowning of undetermined intent and intentional drowning; (2) investigation of drowning risk factors specific to Indonesia and its individual provinces; (3) exploration of the interconnectedness between drowning prevention efforts and initiatives aimed at improving social determinants of health and (4) evaluation of the availability and effectiveness of water safety promotion and drowning prevention interventions.
Policy development
The study underscores the urgent need to advance drowning prevention efforts through robust data collection to inform burden and risk factor identification, as well as agenda setting.23 Immediate measures are required to strengthen the capabilities of the Indonesian public health system, establish standardised national reporting structures for health and mortality data, foster collaboration across multiple sectors and secure political and financial investment to construct an integrated drowning data collection system in Indonesia. In addition, the study emphasises the urgent need to tailor drowning prevention strategies in Indonesia to effectively address the heightened risk of drowning among children under 5 years of age, particularly in rural populations across eastern Indonesia.
Practice
The increased risk of drowning among children under 5 years of age emphasises the importance of adopting WHO-recommended prevention strategies aimed at reducing drowning fatalities in younger children, including enhancing supervision, establishing community-based childcare centres and installing barriers to limit children’s access to water bodies.23 24 However, effective implementation of these interventions requires tailoring to local contexts to ensure the effectiveness and sustainability of drowning prevention efforts in reducing child drowning fatalities in Indonesia.25–27
Strengths and limitations
This is the first study to explore the epidemiology of drowning in Indonesia. A key strength of this study is the mutually exclusive and exhaustively collected data available via the GBD Study, for both ICD-9 and ICD-10 coded cases for different time periods.3 11 12
However, as in many cases of less optimal injury surveillance systems in developing nations, including in Indonesia, the data on drowning as a cause of death has been collected from verbal autopsy survey instruments, which may result in the underestimation of the actual number of unintentional drowning cases in Indonesia.10 11 Moreover, the GBD Study 2019 only reported accidental drowning and submersion events (coded by ICD-10 as W65–W74), excluding disaster-related and water transport-related incidents, which may further limit understanding of the magnitude of drowning in Indonesia, where hydrometeorological disasters and water transport-related injuries frequently take place.13
Conclusions
Between 2005 and 2019, there was a downward trend in the rate of drowning deaths in Indonesia. Being male, aged under 5 years, aged 70 years and above and residing in provinces of Kalimantan, Papua, Sulawesi, Maluku, Sumatra and Nusa Tenggara regions, were recognised as risk factors. The findings highlight the importance of continuing to enhance data collection systems, identifying risk factors and developing contextualised preventive strategies for drowning in Indonesia.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the University of Mataram of Indonesia (ethics approval number: 128/UN18.F8/ETIK/2023). The participants were deceased.
Acknowledgments
R Franklin reports grants or contracts with Heatwaves in Queensland Queensland Government, Arc Flash - Human Factors Queensland Government, and with Mobile Plant Safety Agrifutures; honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events with the World Safety Conference as Conference Convener; support for attending meetings and/or travel for the ACTM Tropical Medicine and Travel Medicine Conference 2022, and the ISTM Travel Medicine Conference, Basel 2023; leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid, as Director of Kidsafe, Director of Farmsafe, Director of Auschem, Convenor of PHAA Injury Prevention SIG, and member of the Governance Committee of ISASH; all outside the submitted work. N E Ismail reports an unpaid leadership or fiduciary role as the bursar of the Malaysian Academy of Pharmacy, Malaysia, outside the submitted work. S Martini reports an unpaid leadership or fiduciary role as a member of the Indonesian Public Health Expert Association, outside the submitted work. A E Peden reports support for the present manuscript from Australian] National Health and Medical Research Council (NHMRC) Emerging Leadership Fellowship (APPID: APP2009306) through her employment at the time of writing. Y L Samodra reports grants or contracts from Taipei Medical University, Taipei, Republic of China through a doctoral scholarship, and from the Faculty of Medicine, Universitas Katolik Parahyangan, Bandung, Indonesia through a commitment fee as a contract based academic staff; mentoring fees from Benang Merah Research Center; other financial interests in idebeasiswa.com through a scholarship mentoring fee; all outside the submitted work. J H V Ticoalu reports other financial or non-financial interests in Benang Merah Research Center as it’s co-founder, outside the submitted work.
Supplementary materials
Supplementary Data
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Footnotes
X @amyepeden, @Franklin_R_C
Collaborators GBD 2019 Indonesia Drowning Collaborators: Muthia Cenderadewi (College of Public Health, Medical, and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia; Faculty of Medicine, University of Mataram, Mataram, West Nusa Tenggara, Indonesia), Susan G Devine (College of Public Health, Medical, and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia), Amy E Peden (College of Public Health, Medical, and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; Royal Live Saving Society - Australia, Broadway, New South Wales, Australia), Qorinah Estiningtyas Sakilah Adnani (Faculty of Medicine, Padjadjaran University, Bandung, Indonesia), Ali Ahmed (School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia; Department of Pharmacy, Quaid-i-Azam University Islamabad, Islamabad, Pakistan), Ernoiz Antriyandarti (Agribusiness Study Program, Sebelas Maret University, Surakarta, Indonesia), Sumadi Lukman Anwar (Department of Surgery, Gadjah Mada University, Yogyakarta, Indonesia), Kurnia Dwi Artanti (Department of Epidemiology, Airlangga University, Surabaya, Indonesia), Ni Ketut Aryastami (National Research and Innovation Agency, Jakarta, Indonesia), Vijayalakshmi S Bhojaraja (Department of Anatomy, Royal College of Surgeons in Ireland Medical University of Bahrain, Busaiteen, Bahrain), Dinh-Toi Chu (Center for Biomedicine and Community Health, Vietnam National University-International School, Hanoi, Viet Nam), Samath Dhamminda Dharmaratne (Department of Community Medicine, University of Peradeniya, Peradeniya, Sri Lanka; Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA), Ferry Efendi (Department of Community Health Nursing, Airlangga University, Surabaya, Indonesia; School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia), Nelsensius Klau Fauk (Torrens University Australia, Adelaide, South Australia, Australia; Institute of Resource Governance and Social Change, Kupang, Indonesia), Ghozali Ghozali (Department of Public Health, University of Muhammadiyah Kalimantan Timur, Samarinda, Indonesia), Arief Hargono (Department of Epidemiology, Airlangga University, Surabaya, Indonesia), Lalu Muhammad Irham (Faculty of Pharmacy, University of Ahmad Dahlan, Yogyakarta, Indonesia), Nahlah Elkudssiah Ismail (Department of Clinical Pharmacy and Pharmacy Practice, Asian Institute of Medicine, Science and Technology, Kedah, Malaysia; Malaysian Academy of Pharmacy, Puchong, Malaysia), Umesh Jayarajah (Postgraduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka; Department of Surgery, National Hospital, Colombo, Sri Lanka), Soewarta Kosen (Independent Consultant, Jakarta, Indonesia), Dian Kusuma (Department of Health Services Research and Management, City University of London, London, UK; Faculty of Public Health, University of Indonesia, Depok, Indonesia), Trias Mahmudiono (Institute of Resource Governance and Social Change, Kupang, Indonesia), Santi Martini (Faculty of Public Health, Airlangga University, Surabaya, Indonesia; Indonesian Public Health Association, Surabaya, Indonesia), Madeline E Moberg (Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA), Dina Nur Anggraini Ningrum (Public Health Department, State University of Semarang, Semarang, Indonesia; Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan), Helena Ullyartha Pangaribuan (National Research and Innovation Agency, Jakarta, Indonesia), Agung Purnomo (Entrepreneurship Department, Bina Nusantara University, Jakarta, Indonesia; Department of Management, Airlangga University, Surabaya, Indonesia), Setyaningrum Rahmawaty (Department of Nutrition Science, Muhammadiyah University of Surakarta, Surakarta, Indonesia), Yohanes Andy Rias (College of Nursing, Bhakti Wiyata Kediri Institute of Health Sciences, Kediri, Indonesia; College of Nursing, Taipei Medical University, Taipei, Taiwan), Elsa Rosyidah (Environmental Engineering Department, Nahdlatul Ulama Sidoarjo University, Sidoarjo, Indonesia), Leo Rulino (Department of Academic Affairs, Husada Karya Jaya Academy of Nursing, Jakarta Utara, Indonesia), Yoseph Leonardo Samodra (School of Public Health, Taipei Medical University, Taipei, Taiwan), Jeevan K Shetty (Department of Biochemistry, Royal College of Surgeons in Ireland Medical University of Bahrain, Busaiteen, Bahrain), Agus Sudaryanto (Department of Nursing, Muhammadiyah University of Surakarta, Surakarta, Indonesia), Henry Surendra (Public Health Department, Monash University Indonesia, Tangerang, Indonesia; Oxford University Clinical Research Unit Indonesia, Jakarta, Indonesia), Ingan Ukur Tarigan (National Research and Innovation Agency, Jakarta, Indonesia), Jansje Henny Vera Ticoalu (Faculty of Public Health, Sam Ratulangi University, Manado, Indonesia), Nuwan Darshana Wickramasinghe (Department of Community Medicine, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka), Richard Charles Franklin (College of Public Health, Medical, and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia; Royal Live Saving Society - Australia, Broadway, New South Wales, Australia).
Contributors MC is the first author. RCF is the senior author. MC, RCF and SD designed the study and drafted the initial manuscript. AEP provided critical feedback to the first draft. MC and RCF analysed the data. All other authors contributed data, interpreted the data or revised the manuscript. All authors read and approved the final manuscript. RCF is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding The GBD study is funded by The Bill & Melinda Gates Foundation. The funders of the study had no role in study design; collection, analysis, and interpretation of data; or writing of the report. The corresponding authors had full access to the data and had responsibility for final submission of the manuscript.
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Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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