by Duleeka Knipe
Over 800,000 people die by suicide every year – that’s one death every forty seconds. A disproportionate number (76%) of these deaths occur in the world’s poorest countries. Our knowledge of the reasons why people die by suicide in this part of the world is severely limited, but a better understanding is desperately needed given that suicide is a leading cause of death in young people.
A huge barrier to improving our understanding is that we simply did not have good data from low and middle income countries to help us better comprehend this complex behaviour – until now.
In 2011 I travelled to Sri Lanka to help on a large public health trial in a rural agricultural area. Sri Lanka is known for its beautiful beaches, tea production and produces some of the food we consume here in the UK. A less known fact is it also has a high suicide rate. My job was to manage the data collection of a large census-like survey of all households in the area. My time in this arid part of the world gave me a valuable insight into the hardships faced by people in these communities. The opportunity presented itself for me to use the data I helped collect to better understand how we could improve the lives of this population and reduce the number of people ending their lives.
My study used data collected from over 165,000 rural Sri Lankans and used statistical techniques (multi-level modelling) which allowed me to pick out whether community factors (eg areas with concentrated poverty) or individual characteristics (eg educational attainment) were independently associated with an increased risk of attempted suicide.
My analysis found that individuals who live in households or communities that are economically deprived were at increased risk of attempted suicide, regardless of whether that individual experienced economic hardship. I also found that women who live in households with men who have problematic alcohol use are nearly twice as likely to try to end their life, and individuals living in areas with a high proportion of households reporting problematic alcohol use (potentially a marker of social discord) are also at increased risk of attempted suicide. These finding are particularly striking as it suggests that strategies targeted at communities might be effective in saving lives. Community strategies are likely to be logistically easier to implement than individual level interventions.
One of my observations while in Sri Lanka was how a person’s identity was strongly influenced and defined by their family and where they lived. Before my time in Sri Lanka I was used to people asking me about what I did and where I grew up. I was less used to people forming a picture of me based on who I was married to, who my parents were and what they did, but this was really important in Sri Lanka. Therefore perhaps the importance of family and community factors might be more important in societies like Sri Lanka, than in more western societies. In our current study we certainly found evidence of this.
What next? Whilst this study highlights that the social environment at a community and household level is important in suicidal behaviour, it still isn’t clear exactly what shape community or household interventions should take. Emerging findings from an in-depth qualitative study exploring the role of alcohol in suicidal behaviour within this community shows the significant role that intimate partner violence has in increasing the likelihood of women self-harming. Therefore, potentially, household and community interventions targeted at reducing intimate partner violence are needed; community mobilisation programs, like SASA!, might address the power imbalance between men and women and change the acceptability of violence in relationships.
In 2017, I was supported by an ESRC fellowship grant to complete the analysis of this study and start working with communities who will be affected by my research. This also included working with policymakers and practitioners to interpret my findings and to identify ways policy and practice could be changed in a positive way to change the lives of people in Sri Lanka and reduce the risk of suicide. This work led to a set of recommendations which I hope will help other low and middle income countries who are facing similar challenges.
Dr Duleeka Knipe is an ESRC Global Challenges Research Fund postdoctoral fellow at the University of Bristol and is affiliated to the South Asian Clinical Toxicology Research Collaboration in Sri Lanka.
Duleeka is interested in understanding the influence of life course risk factors for suicide and self-harm, with a particular interest in the social determinants of mental ill health.
If you or anyone you know is affected by the issues covered in this blog, you can contact the Samaritans for free from any telephone on 116 123 in the UK. Alternatively you can email email@example.com for details of your nearest branch, where you can talk to one of their trained volunteers face to face. The International Association for Suicide Prevention (IASP) has details of support organisations in other countries.