|Year : 2017 | Volume
| Issue : 1 | Page : 30-33
Challenges and opportunities in suicide prevention in South-East Asia
Sneha – Suicide Prevention Centre and Voluntary Health Services, Chennai, Tamil Nadu, India
|Date of Web Publication||12-May-2017|
Sneha – Suicide Prevention Centre and Voluntary Health Services, Chennai, Tamil Nadu
Suicide is a global public health problem, with over 800 000 people worldwide dying by suicide in 2012, according to the World Health Organization (WHO). The WHO South-East Asia Region is especially affected, with 39% of global suicides occurring in the 11 countries in this region. Women are a particularly vulnerable population, for a variety of social and cultural reasons. In India specifically, deaths by suicide for women peak in the age range 15–29 years. There is sufficient evidence to show that reduction of easy access to means of suicide is an effective prevention strategy. A common method of suicide in the region is by ingestion of pesticides. Strategies that have targeted limiting access to pesticides as a means of preventing suicide, such as the use of central storage and locked boxes, have shown promising results. Given the limited human and economic resources in these countries, it is essential to involve all stakeholders, including health services, voluntary and community organizations, teachers, social workers, traditional healers and other gatekeepers, in suicide prevention. A multisectoral approach, specifically targeting women and reducing easy access to pesticides, should be the way forward to reducing suicides in this region. In addition, more research is needed, to identify cost-effective and sustainable strategies.
Keywords: pesticides, South-East Asia Region, suicide, suicide prevention, women
|How to cite this article:|
Vijayakumar L. Challenges and opportunities in suicide prevention in South-East Asia. WHO South-East Asia J Public Health 2017;6:30-3
| Background|| |
The World Health Organization (WHO) 2014 report, Preventing suicide: a global imperative, states that over 800 000 persons worldwide lost their lives by suicide in 2012. The global age-standardized suicide rate per 100 000 population was estimated as 11.4, with rates of 15.0 for males and 8.0 for females. Countries from the WHO South-East Asia Region, with an estimated 314 000 suicides in 2012, accounted for 39% of all global suicides. This region consists of 11 low- and middle-income countries, which constitute 26% of the global population.
India accounted for 258 000 (82%) of the suicides in the countries of the South-East Asia Region in 2012, and so the characteristics of suicide in India shape the pattern seen across the region. The 2012 suicide rate in the region was 17.7 per 100 000 population, the male-to-female sex ratio was 1.6, and suicide accounted for 1.8% of all deaths, making it the 11th-most important cause of death in the region. In India, the age-by-sex pattern of suicide showed different rates by age. Among males, the rates rose rapidly after the age of 15 years, remained stable from 30 to 70 years, and then increased gradually, while in females there was a large peak of 36.1 per 100 000 deaths by suicide in the age range 15–29 years, lower rates in the age range 30–49 years, and then gradually increasing rates after 50 years.
From 2000 to 2012, the absolute number of suicides in the region increased by 10%; however, the regional rate per 100 000 decreased by 11% for the same period. In 2012, the national suicide rates in the region, per 100 000 population, ranged from the lowest value of 4.3 in Indonesia (3.7 in males and 4.9 in females) to the highest value of 38.5, reported from the Democratic People’s Republic of Korea (45.4 in males and 35.1 in females). Most countries of the region do not have a comprehensive vital registration system; thus, these data are best estimates and the actual figures may well be higher.
| Women as a vulnerable group|| |
Women in low- and middle-income countries are especially vulnerable to suicide; the male-to-female ratio for completed suicides is much narrower in these countries, at 1.6, compared to the value of 3.5 in high-income countries. An estimated 124 282 women died by suicide in the countries of the WHO South-East Asia Region in 2012, meaning that a little less than half of global suicides in women occurred in this region. Compared to women from low- and middle-income countries of all other WHO regions, women in countries of South-East Asia have higher suicide rates. The suicide rate (per 100 000) for women from the South-East Asia Region was 11.9, while the next highest was 5.6 from the low-and middle-income countries of the European Region. This higher rate was also maintained across all age ranges (see [Table 1]).
|Table 1: Suicide rates of women in low- and middle-income countries of the various World Health Organization regions, by age, 2012|
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In several countries of the region, notably Bangladesh, India and Indonesia, the male-to-female ratio for suicide among younger people (below 30 years of age) showed that the rates were higher for women. Maldives and Nepal also showed a very small gap with respect to the sex ratio (see [Table 2]).
|Table 2: Male-to-female suicide ratio in the World Health Organization South-East Asia Region by age, 2012|
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Several social and cultural factors make women in the WHO South-East Asia Region vulnerable to suicide. These include the practice of arranged and often forced marriages that trap women in unwanted marriages; some opt for suicide as a means of escape. Young persons who love each other, but whose families disapprove of their relationship, may take their lives, either together or alone. Unrequited love may also be the reason for some adolescent suicides.
Another sociocultural practice contributing to suicides among women in countries such as India, where the practice of dowry is still in existence, is the pressure on a young bride to bring a large dowry. Failure to do so often results in physical and emotional abuse, which can lead to suicide, especially by self-immolation. Self-immolation, which is seen almost exclusively in low- and middle-income countries, has emerged as a major cause of death and is the only method of suicide used more by women than men. In India, 64% of self-immolation is by women, while in Sri Lanka the proportion is 79%.
Pressure on women to bear children soon after marriage, failure to become pregnant, and infertility carry severe social stigma, leading some women to resort to suicide. In a 2014 systematic review and meta-analysis, the pooled prevalence of pregnancy-related deaths in the WHO South-East Asia Region attributed to suicide was 2.19%.
Domestic violence is fairly common and its practice is, to a large extent, socially and culturally condoned in these countries. In a population-based study on domestic violence, 9938 women were studied in different parts of India and across sections of society; an estimated 40% experienced domestic violence. In an international survey of women in 2001, 64% of the women surveyed in India who had experienced physical violence by an intimate partner expressed suicidal ideation. In a case-control verbal-autopsy study in Bangalore, India, domestic violence was a major risk factor for suicide. However, relatively little is known about domestic violence as a risk factor for suicide and it is an important area for further research.
| Methods of suicide|| |
The most common method of suicide in countries of the WHO South-East Asia Region is ingestion of pesticides, including herbicides and rodenticides. Self-immolation is prevalent, particularly among women. Hanging is also frequently used. A recent systematic review revealed that around 30% (27–37%) of suicides globally are due to pesticide poisoning. Pesticide suicides are a major problem in countries of the region, as the majority of the population lives in rural agrarian societies and pesticides are easily available and accessible. Pesticides are easily procured in the market, and are usually stored in close proximity to where people live, in either farms or homes. The situation is further exacerbated by the limited access to medical facilities for appropriate care in rural areas.
| Risk factors for suicide|| |
Alcohol plays a significant role in suicide in the region. Social drinking is not a way of life in the majority of these countries. Studies have shown that around 30–50% of males were under the influence of alcohol at the time of suicide., Further, many wives have been driven to suicide by their husbands’ harmful use of alcohol. It has become increasingly evident that alcohol and drugs are important preventable risk factors for suicide.
Inappropriate media reporting practices can sensationalize and glamorize suicide and increase the risk of “copycat” suicides (imitation of suicides) among vulnerable young people. Promotion of responsible reporting of suicide in the media is integral to any prevention strategy. Important aspects of responsible reporting include avoiding detailed descriptions of suicidal acts, avoiding sensationalism and glamorization, using responsible language, minimizing the prominence and duration of suicide reports, avoiding oversimplifications, educating the public about suicide and available treatments, and providing information on where to seek help. Unfortunately, these guidelines are often not followed by the countries in this region.
| Suicide legislation in the South-East Asia Region|| |
Attempted suicide remains a crime in most of the countries in the WHO South-East Asia Region, with only Sri Lanka and Thailand not considering it a criminal offence requiring police notification. Sri Lanka decriminalized suicide in 1996 and suicide rates in the country have since declined, indicating that decriminalization has not had an adverse effect. Bangladesh, Bhutan, India and Maldives have penal codes and specific laws on suicide. In India, a new mental health bill, which decriminalizes suicide, has been tabled in parliament and is currently awaiting clearance by the lower house. Some of the challenges that criminalization of suicide pose are:
- emergency treatment for those who attempt suicide is not readily accessible, as they are referred by local hospitals and doctors to tertiary centres for medico-legal reasons, resulting in delay and loss of life;
- those who attempt suicide are already distressed and subsequent police interrogation leads to increased distress, shame and guilt, which can lead to further suicide attempts;
- for a family in turmoil, dealing with police procedures adds to their distress;
- resultant gross underreporting of attempted suicides and categorizing some as accidental poisoning means that both official data and the need for mental health support and care are underestimated.
Criminalization is also a major hindrance to collecting accurate data and planning appropriate interventions. Changes in laws and associated governmental policies will pave way for better data, interventions and support for distressed and suicidal people.
| Suicide-prevention efforts in the SouthEast Asia Region|| |
Suicide has traditionally been viewed as a mental health issue that is best addressed through clinical interventions, such as treating depression. However, in low- and middle-income countries, the role of mental disorders in suicide is not as significant as it is in high-income countries. The prevailing view is now that suicide is a public health issue, and as such it is best addressed by social and public health programmes rather than solely within the mental health framework. Other factors in support of a public health approach include the fact that social reasons for suicide are more readily acceptable than mental health reasons, and countries in this region have a limited number of qualified mental health professionals. The majority of these countries have not developed a national suicide-prevention strategy, with the exception of Bhutan, Sri Lanka and Thailand.
Considering the enormity of the problem, it is imperative that these countries develop low-cost interventions that can be delivered by lay mental health professionals in the community. The dearth of mental health services has been the catalyst for the emergence of nongovernmental organizations for mental health in the region. Over 80% of countries in the South-East Asia Region have nongovernmental organizations working in the field of mental health.
| The role of nongovernmental organizations|| |
As the governments in the South-East Asia Region have limited resources to address the issue of suicide, nongovernmental organizations, in the form of suicide-prevention centres staffed mainly by volunteers, have stepped in and the majority offer their services free of charge. The primary goal of these prevention centres is to provide emotional support to those who are suicidal, through befriending and counselling, in person or by telephone. In many countries, they are the premier nongovernmental organizations in suicide prevention and offer a whole range of services, from awareness programmes to delivering interventions. These crisis centres often act as the entry point into the health system for people with psychological problems, with the volunteers being trained to identify those with mental disorders and provide appropriate referrals. Although many innovative programmes for raising awareness and increasing help-seeking behaviour have been developed to prevent suicide, the majority have not been evaluated.
| Suicide-prevention strategies: pesticide suicides|| |
Research has consistently demonstrated that restricting access to highly lethal means of suicide is an effective strategy for reducing the number of suicides. In Sri Lanka, for example, where the most common method of suicide has been ingestion of pesticides, suicide rates fell significantly after the government banned the sale of certain toxic pesticides. Another effort has been the provision of locked boxes for the storage of pesticides in farming households. Such initiatives are feasible and appreciated by the users of the storage boxes. However, Konradsen and colleagues reported that, at times, these boxes were kept unlocked at home, rather than at the farms. They cautioned that this could lead to increased risk, especially among those acting impulsively due to easy access. A major randomized trial on locked boxes is under way in Sri Lanka.
Vijayakumar and colleagues examined the feasibility and acceptability of a centralized pesticide-storage facility (supported by the Sneha Suicide Prevention Centre in India and WHO), as a possible intervention to reduce pesticide-related suicides in a district in Tamil Nadu state, in southern India. The study involved constructing a community storage facility where all farmers could store their pesticides. Two centralized storage facilities were constructed in two villages, with local involvement, and storage boxes (similar to a bank locker) were constructed. Farmers could access their pesticide-storage boxes with the key to their own locker, and a duplicate key was kept with the manager of the central storage facility. There was a significant reduction in pesticide suicides in the intervention villages compared to the control villages.
| Future directions|| |
Suicide is a global health problem and reduction of suicide should be on the agenda of all countries in the WHO SouthEast Asia Region, especially since it has been identified by the United Nations as one of the indicators of the Sustainable Development Goals. All the countries in the region should develop a comprehensive national suicide-prevention strategy and also allocate adequate resources for it.
Establishing a good monitoring and reporting system that facilitates collection of reliable and timely information on the prevalence, demographic patterns, and methods employed in both suicides and suicide attempts is essential. Reliable data are also necessary, to monitor the effectiveness of the planned intervention strategies for different target groups.
It is essential to involve and evaluate the role of gatekeepers in the community, such as teachers, social workers, crisis-line volunteers, youth leaders, family members, caregivers, police and prison staff, and religious leaders, to identify, support and provide appropriate referral to suicidal persons. Identification of specific psychological and social stressors that lead to increased risk in youth and women is essential. Community-based intervention strategies that restrict access to pesticides, decrease the availability and consumption of alcohol, strengthen interpersonal problem-solving skills, improve help-seeking behaviour, and tackle issues such as intergenerational conflicts need to be implemented and evaluated. In parallel, early identification and treatment of mental disorders is essential.
| Conclusion|| |
Suicide is a global public health problem and, as South-East Asia accounts for 39% of global suicides, the region needs to take urgent action. Women form a particularly vulnerable population in this region, for a variety of social and cultural reasons. There is sufficient evidence to show that limiting access to pesticides has the potential to reduce suicide in these countries. Using a multisectoral approach specifically targeting women and reducing easy access to pesticides will go a long way towards reducing suicides in this region. More research is needed to identify strategies that are feasible, acceptable and effective.
Acknowledgements: I thank Mr Sujit John, Assistant Director -Research and HR, Schizophrenia Research Foundation (India), Chennai, for his technical assistance.
Source of support: Nil.
Conflict of interest: None declared.
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[Table 1], [Table 2]
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