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Challenges and Opportunities in Suicide Prevention in South-East Asia

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Challenges and Opportunities in Suicide Prevention in South-East Asia Perspective Challenges and opportunities in suicide prevention in South-East Asia Lakshmi Vijayakumar Sneha – Suicide Prevention Centre and Voluntary Health Services, Chennai, Tamil Nadu, India Correspondence to: Dr Lakshmi Vijayakumar ([email protected]) Abstract 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 Background 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 World Health Organization (WHO) 2014 report, Preventing the Democratic People’s Republic of Korea (45.4 in males and suicide: a global imperative, states that over 800 000 persons 35.1 in females).2 Most countries of the region do not have a worldwide lost their lives by suicide in 2012.1 The global age- comprehensive vital registration system; thus, these data are standardized suicide rate per 100 000 population was estimated best estimates and the actual figures may well be higher. 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 Women as a vulnerable group estimated 314 000 suicides in 2012, accounted for 39% of all global suicides.1 This region consists of 11 low- and middle- Women in low- and middle-income countries are especially income countries, which constitute 26% of the global population.1 vulnerable to suicide; the male-to-female ratio for completed India accounted for 258 000 (82%) of the suicides in the suicides is much narrower in these countries, at 1.6, compared to countries of the South-East Asia Region in 2012, and so the the value of 3.5 in high-income countries.1 An estimated 124 282 characteristics of suicide in India shape the pattern seen women died by suicide in the countries of the WHO South-East across the region. The 2012 suicide rate in the region was 17.7 Asia Region in 2012, meaning that a little less than half of global per 100 000 population, the male-to-female sex ratio was 1.6, suicides in women occurred in this region. Compared to women and suicide accounted for 1.8% of all deaths, making it the from low- and middle-income countries of all other WHO regions, 11th-most important cause of death in the region.1 In India, the women in countries of South-East Asia have higher suicide rates. age-by-sex pattern of suicide showed different rates by age. The suicide rate (per 100 000) for women from the South-East Among males, the rates rose rapidly after the age of 15 years, Asia Region was 11.9, while the next highest was 5.6 from the low- remained stable from 30 to 70 years, and then increased and middle-income countries of the European Region. This higher gradually, while in females there was a large peak of 36.1 rate was also maintained across all age ranges (see Table 1).1 per 100 000 deaths by suicide in the age range 15–29 years, In several countries of the region, notably Bangladesh, India lower rates in the age range 30–49 years, and then gradually and Indonesia, the male-to-female ratio for suicide among increasing rates after 50 years.1 younger people (below 30 years of age) showed that the rates From 2000 to 2012, the absolute number of suicides in were higher for women. Maldives and Nepal also showed a the region increased by 10%; however, the regional rate per very small gap with respect to the sex ratio (see Table 2).1 100 000 decreased by 11% for the same period. In 2012, the Several social and cultural factors make women in the WHO national suicide rates in the region, per 100 000 population, South-East Asia Region vulnerable to suicide. These include 30 WHO South-East Asia Journal of Public Health | April 2017 | 6(1) Vijayakumar: Suicide prevention in South-East Asia Table 1. Suicide rates of women in low- and middle-income countries of the various World Health Organization regions, by age, 2012 World Health Total number of Average suicide rates for women (per 100 000) Organization region suicides All ages 5–14 years 15–29 years 30–49 years 50–69 years ≥70 years African 17 000 3.7 1.2 5.1 3.5 7.9 29.2 Region Region of the 7949 4.2 1.3 6.1 4.5 6.1 7.5 Americas South-East Asia 124 282 11.9 1.3 14.7 11.5 18.0 40.4 Region European 7474 5.6 0.7 4.4 5.1 7.9 12.9 Region Eastern Mediterranean 12 516 3.3 1.0 4.5 3.1 6.2 22.6 Region Western Pacific 70 344 4.2 0.5 3.8 4.0 9.3 25.5 Region Total 239 565 — — — — — — Average — 5.5 1.0 6.4 5.3 9.2 23.0 Source: World Health Organization 2014.1 Another sociocultural practice contributing to suicides among Table 2. Male-to-female suicide ratio in the World Health women in countries such as India, where the practice of dowry Organization South-East Asia Region by age, 2012 is still in existence, is the pressure on a young bride to bring Country and age (years) Male-to-female ratio a large dowry. Failure to do so often results in physical and Bangladesh emotional abuse, which can lead to suicide, especially by self- 3 <30 0.52 immolation. Self-immolation, which is seen almost exclusively >30 0.82 in low- and middle-income countries, has emerged as a major Bhutan cause of death and is the only method of suicide used more <30 1.41 by women than men. In India, 64% of self-immolation is by 4 3 >30 2.47 women, while in Sri Lanka the proportion is 79%. Pressure on women to bear children soon after marriage, India failure to become pregnant, and infertility carry severe social <30 0.94 stigma, leading some women to resort to suicide.5 In a 2014 >30 2.52 systematic review and meta-analysis, the pooled prevalence Indonesia of pregnancy-related deaths in the WHO South-East Asia <30 0.95 Region attributed to suicide was 2.19%.6 >30 0.63 Domestic violence is fairly common and its practice is, to a Maldives large extent, socially and culturally condoned in these countries. <30 1.03 In a population-based study on domestic violence, 9938 women >30 1.27 were studied in different parts of India and across sections of Myanmar society; an estimated 40% experienced domestic violence.7 In <30 1.65 an international survey of women in 2001, 64% of the women >30 1.64 surveyed in India who had experienced physical violence by an 8 Nepal intimate partner expressed suicidal ideation. In a case–control <30 1.02 verbal-autopsy study in Bangalore, India, domestic violence 9 >30 1.84 was a major risk factor for suicide. However, relatively little is known about domestic violence as a risk factor for suicide and Sri Lanka it is an important area for further research. <30 3.03 >30 2,.92 Thailand Methods of suicide <30 3.07 The most common method of suicide in countries of the WHO >30 2.12 South-East Asia Region is ingestion of pesticides, including Timor-Leste herbicides and rodenticides. Self-immolation is prevalent, <30 1.46 particularly among women. Hanging is also frequently used. A >30 1.06 recent systematic review revealed that around 30% (27–37%) Source: World Health Organization 2014.1 of suicides globally are due to pesticide poisoning.10 Pesticide suicides are a major problem in countries of the region, as the practice of arranged and often forced marriages that trap the majority of the population lives in rural agrarian societies women in unwanted marriages; some opt for suicide as a and pesticides are easily available and accessible. Pesticides means of escape. Young persons who love each other, but are easily procured in the market, and are usually stored in whose families disapprove of their relationship, may take their close proximity to where people live, in either farms or homes. lives, either together or alone. Unrequited love may also be the The situation is further exacerbated by the limited access to reason for some adolescent suicides.3 medical facilities for appropriate care in rural areas.10 WHO South-East Asia Journal of Public Health | April 2017 | 6(1) 31 Vijayakumar: Suicide prevention in South-East Asia Risk factors for suicide depression.
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