Is socioeconomic position associated with risk of attempted suicide in rural Sri Lanka? A cross-sectional study of 165 000 individuals

D W Knipe, D Gunnell, R Pieris, C Priyadarshana, M Weerasinghe, M Pearson, S Jayamanne, A H Dawson, F Mohamed, I Gawarammana, K Hawton, F Konradsen, M Eddleston, C Metcalfe, D W Knipe, D Gunnell, R Pieris, C Priyadarshana, M Weerasinghe, M Pearson, S Jayamanne, A H Dawson, F Mohamed, I Gawarammana, K Hawton, F Konradsen, M Eddleston, C Metcalfe

Abstract

Background: Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high-income countries, but this association is unclear in low-income and middle-income countries.

Methods: We investigated the association of SEP with attempted suicide in a cross-sectional survey of 165 233 Sri Lankans. SEP data were collected at the household (assets, social standing (highest occupation of a household member), foreign employment and young (≤40 years) female-headed households) and individual level (education and occupation). Respondent-reported data on suicide attempts in the past year were recorded. Random-effects logistic regression models, accounting for clustering, were used to investigate the association of SEP with attempted suicide.

Results: Households reported 398 attempted suicides in the preceding year (239 per 100 000). Fewer assets (OR 3.2, 95% CI 2.4 to 4.4) and having a daily wage labourer (ie, insecure/low-income job; OR 2.3, 95% CI 1.6 to 3.2) as the highest occupation increased the risk of an attempted suicide within households. At an individual level, daily wage labourers were at an increased risk of attempted suicide compared with farmers. The strongest associations were with low levels of education (OR 4.6, 95% CI 2.5 to 8.4), with a stronger association in men than women.

Conclusions: We found that indicators of lower SEP are associated with increased risk of attempted suicide in rural Sri Lanka. Longitudinal studies with objective measures of suicide attempts are needed to confirm this association.

Trial registration number: NCT01146496; Pre-results.

Keywords: EPIDEMIOLOGY; MENTAL HEALTH; PUBLIC HEALTH; SOCIAL MEDICINE.

Conflict of interest statement

Competing interests: None declared.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Figures

Figure 1
Figure 1
Flow chart of households/individuals included in the analysis. *Households/individuals who live in more than one place. n=households (individuals).

References

    1. WHO. Preventing suicide—a global imperative. Geneva: WHO, 2014.
    1. Knipe DW, Metcalfe C, Fernando R et al. . Suicide in Sri Lanka 1975–2012: age, period and cohort analysis of police and hospital data. BMC Public Health 2014;14:839 10.1186/1471-2458-14-839
    1. Patel V, Ramasundarahettige C, Vijayakumar L et al. . Suicide mortality in India: a nationally representative survey. Lancet 2012;379:2343–51. 10.1016/S0140-6736(12)60606-0
    1. Mak KK, Ho CS, Chua V et al. . Ethnic differences in suicide behavior in Singapore. Transcult Psychiatry 2015;52:3–17. 10.1177/1363461514543545
    1. Weissman MM, Bland RC, Canino GJ et al. . Prevalence of suicide ideation and suicide attempts in nine countries. Psychol Med 1999;29:9–17. 10.1017/S0033291798007867
    1. Eddleston M, Karunaratne A, Weerakoon M et al. . Choice of poison for intentional self-poisoning in rural Sri Lanka. Clin Toxicol (Phila) 2006;44:283–6. 10.1080/15563650600584444
    1. Gunnell D, Fernando R, Hewagama M et al. . The impact of pesticide regulations on suicide in Sri Lanka. Int J Epidemiol 2007;36:1235–42. 10.1093/ije/dym164
    1. Chen YY, Wu KC, Yousuf S et al. . Suicide in Asia: opportunities and challenges. Epidemiol Rev 2012;34:129–44. 10.1093/epirev/mxr025
    1. Gunnell D, Eddleston M. Suicide by intentional ingestion of pesticides: a continuing tragedy in developing countries. Int J Epidemiol 2003;32:902–9. 10.1093/ije/dyg307
    1. Vijayakumar L, Pirkis J, Huong TT. Socio-economic, cultural and religious factors affecting suicide prevention in Asia. In: Hendin H, Phillips M, Vijayakumar L et al., eds. Suicide and Suicide Prevention in Asia. Geneva: WHO, 2008:19–30.
    1. Li Z, Page A, Martin G et al. . Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: a systematic review. Soc Sci Med 2011;72:608–16. 10.1016/j.socscimed.2010.11.008
    1. Galobardes B, Shaw M, Lawlor DA et al. . Indicators of socioeconomic position (part 1). J Epidemiol Community Health 2006;60:7–12. 10.1136/jech.2004.023531
    1. Colucci E, Lester D, eds. Suicide and culture: understanding the context. Cambridge, MA: Hogrefe Publishing, 2012.
    1. Knipe DW, Carroll R, Thomas KH et al. . Association of socio-economic position and suicide/attempted suicide in low and middle income countries in South and South-East Asia—a systematic review. BMC Public Health 2015;15:1055 10.1186/s12889-015-2301-5
    1. Phillips MR, Yang G, Zhang Y et al. . Risk factors for suicide in China: a national case-control psychological autopsy study. Lancet 2002;360:1728–36. 10.1016/S0140-6736(02)11681-3
    1. Iemmi V, Bantjes J, Coast E et al. . Suicide and poverty in low-income and middle-income countries: a systematic review. Lancet Psychiatry 2016;3:774–83. 10.1016/S2215-0366(16)30066-9
    1. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry 2003;160:765–72. 10.1176/appi.ajp.160.4.765
    1. Gunnell D, Lofving S, Gustafsson JE et al. . School performance and risk of suicide in early adulthood: follow-up of two national cohorts of Swedish schoolchildren. J Affect Disord 2011;131:104–12. 10.1016/j.jad.2011.01.002
    1. Pearson M, Konradsen F, Gunnell D et al. . A community-based cluster randomised trial of safe storage to reduce pesticide self-poisoning in rural Sri Lanka: study protocol. BMC Public Health 2011;11:879 10.1186/1471-2458-11-879
    1. Pearson M, Zwi AB, Buckley NA et al. . Policymaking ‘under the radar’: a case study of pesticide regulation to prevent intentional poisoning in Sri Lanka. Health Policy Plan 2015;30:56–67. 10.1093/heapol/czt096
    1. Knipe DW, Pearson M, Borgstrøm R et al. . Challenges and opportunities of a paperless baseline survey in Sri Lanka. BMC Res Notes 2014;7:452 10.1186/1756-0500-7-452
    1. Herath HMA. Place of women in Sri Lankan society: measures for their impowerment for development and good governance. Vidyodaya J Manag 2015;1:1–14.
    1. Gamburd MR. The kitchen spoon's handle: transnationalism and Sri Lanka's migrant housemaids. Ithaca: Cornell University Press, 2000.
    1. Blum R, Sudhinaraset M, Emerson MR. Youth at risk: suicidal thoughts and attempts in Vietnam, China, and Taiwan. J Adolesc Health 2012;50(3 Suppl):S37–44. 10.1016/j.jadohealth.2011.12.006
    1. Khan MM, Mahmud S, Karim MS et al. . Case-control study of suicide in Karachi, Pakistan. Br J Psychiatry 2008;193:402–5. 10.1192/bjp.bp.107.042069
    1. Feroz AHM, Nurul Islam SM, Reza S et al. . A community survey on the prevalence of suicidal attempts and deaths in a selected rural area of Bangladesh. J Med 2012;13:3–9. 10.3329/jom.v13i1.10042
    1. Kumar PNS, George B. Life events, social support, coping strategies, and quality of life in attempted suicide: a case control study. Indian J Psychiatry 2013;55:46–51. 10.4103/0019-5545.105504
    1. Zhang J, Conwell Y, Zhou L et al. . Culture, risk factors and suicide in rural China: a psychological autopsy case control study. Acta Psychiatr Scand 2004;110:430–7. 10.1111/j.1600-0447.2004.00388.x
    1. Kurihara T, Kato M, Reverger R et al. . Risk factors for suicide in Bali: a psychological autopsy study. BMC Public Health 2009;9:327 10.1186/1471-2458-9-327
    1. Zhang J, Xiao SY, Zhou LA. Mental disorders and suicide among young rural Chinese: a case-control psychological autopsy study. Am J Psychiatry 2010;167:773–81. 10.1176/appi.ajp.2010.09101476
    1. Jia CX, Zhao ZT, Hu MH et al. . A paired case-control study on related factors to attempted suicide. [Chinese] Zhonghua Liu Xing Bing Xue Za Zhi 2005;26:339–43.
    1. Sauvaget C, Ramadas K, Fayette JM et al. . Completed suicide in adults of rural Kerala: rates and determinants. Natl Med J India 2009;22:228–33.
    1. Jeon HJ, Lee JY, Lee YM et al. . Lifetime prevalence and correlates of suicidal ideation, plan, and single and multiple attempts in a Korean nationwide study. J Nerv Ment Dis 2010;198:643–6. 10.1097/NMD.0b013e3181ef3ecf
    1. Dai J, Chiu HFK, Conner KR et al. . Suicidal ideation and attempts among rural Chinese aged 16-34 years—socio-demographic correlates in the context of a transforming China. J Affect Disord 2011;130:438–46. 10.1016/j.jad.2010.10.042
    1. Maselko J, Patel V. Why women attempt suicide: the role of mental illness and social disadvantage in a community cohort study in India. J Epidemiol Community Health 2008;62:817–22. 10.1136/jech.2007.069351
    1. Rebholz CM, Gu D, Yang W et al. . Mortality from suicide and other external cause injuries in China: a prospective cohort study. BMC Public Health 2011;11:56 10.1186/1471-2458-11-56
    1. Kim MD, Hong SC, Lee SY et al. . Suicide risk in relation to social class: a national register-based study of adult suicides in Korea, 1999-2001. Int J Soc Psychiatry 2006;52:138–51. 10.1177/0020764006061254
    1. Beautrais AL, Joyce PR, Mulder RT. Unemployment and serious suicide attempts. Psychol Med 1998;28:209–18. 10.1017/S0033291797005990
    1. Nock MK, Borges G, Bromet EJ et al. . Suicide and suicidal behavior. Epidemiol Rev 2008;30:133–54. 10.1093/epirev/mxn002
    1. Muntaner C, Eaton WW, Miech R et al. . Socioeconomic position and major mental disorders. Epidemiol Rev 2004;26:53–62. 10.1093/epirev/mxh001
    1. O'Connor RC. Towards an integrated motivational–volitional model of suicidal behaviour. In: O'Connor RC, Platt S, Gordon J, eds. International handbook of suicide prevention: research, policy and practice. Chichester, UK: John Wiley & Sons, Ltd, 2011:181–98.
    1. Merriott D. Factors associated with the farmer suicide crisis in India. J Epidemiol Glob Health 2016;6:217–27. 10.1016/j.jegh.2016.03.003
    1. Gamburd MR. The culture of illicit liquor in Sri Lanka: breaking the ashes. New York: Cornell University, 2008.
    1. Abeyasinghe R. Illicit alcohol. Colombo: Vijitha Yapa Publications, 2002.
    1. Rajapakse T, Griffiths KM, Christensen H et al. . A comparison of non-fatal self-poisoning among males and females, in Sri Lanka. BMC Psychiatry 2014;14:221 10.1186/s12888-014-0221-z
    1. Pearson M, Zwi AB, Rouse AK et al. . Taking stock—what is known about suicide in Sri Lanka: a systematic review of diverse literature. Crisis 2014;35:90–101 10.1027/0227-5910/a000244
    1. Gupta A, Priya B, Williams J et al. . Intra-household evaluations of alcohol abuse in men with depression and suicide in women: a cross-sectional community-based study in Chennai, India. BMC Public Health 2015;15:636 10.1186/s12889-015-1864-5
    1. Capaldi DM, Knoble NB, Shortt JW et al. . A systematic review of risk factors for intimate partner violence. Partner Abuse 2012;3:231–80. 10.1891/1946-6560.3.2.231
    1. Devries K, Watts C, Yoshihama M et al. . Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women's health and domestic violence against women. Soc Sci Med 2011;73:79–86. 10.1016/j.socscimed.2011.05.006

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi