Explaining suicide: identifying common themes and diverse perspectives in an urban Mumbai slum

Unpacking the 'black box' of suicide: A latent class analysis predicting profiles of suicidal ideation in a longitudinal cohort of adolescent girls from India

INTRODUCTION

Indian women account for 37% of global suicide-related deaths. As suicide is a growing concern among adolescent girls, identifying the social determinants of suicide with this group targeted prevention. We selected social determinants that include intersectional identities and broader syndemics; we then used longitudinal data from a prospective cohort of adolescent girls from Northern India to classify them into unique profiles across multiple socioecological levels.

METHODS

Girls aged 10-19 (N = 11,864) completed self-report questionnaires measuring socio-demographic and trauma exposure variables. At three-year follow-up, they were asked to indicate current suicidal ideation (SI). We conducted latent class analysis (LCA) to classify profiles and then predicted risk of current SI at three-year follow-up.

RESULTS

LCA supported a four-class solution: a 'privileged' class (Class 1; n = 1,470), a 'modal' class (Class 2; n = 7,449), an 'intergenerational violence' class (Class 3; n = 2,113), and a 'psychological distress' class (Class 4; n = 732). Classes significantly predicted odds ratios (OR) for SI at follow up; women in Class 4 were associated with the greatest likelihood of SI (OR 1.84, 95% CI 1.38, 2.47), suggesting that psychological distress factors confer greatest risk.

CONCLUSION

Results of the distinct classes of risk and protective factors indicate targets for policy-level interventions. Disrupting cycles of psychological distress and substance use, increasing access to behavioral interventions, and intervening to mitigate intergenerational violence may be particularly impactful with this population.

Pesticides and passion: a qualitative psychological autopsy study of suicide in Guyana

Background

The suicide rate in Guyana has consistently ranked in the top ten globally, yet there is only limited literature related to the context in which these suicides occur. This study aims to better understand the psychosocial circumstances and characteristics of suicides in Guyana.

Methods

This case series study utilised a qualitative psychological autopsy method. One to three informants per deceased person (N = 31) were interviewed regarding the lives of 20 Guyanese who died by suicide (14 M, 6 F, aged 10-74 years). Interpretative Phenomenological Analysis was utilised for the data.

Findings

Four superordinate themes were identified: Interpersonal Conflict, Trauma, Health, and Unknown Reasons. Interpersonal conflict included subordinate themes of Domestic Abuse, Marital Separation, and Financial Disputes. Health included subordinate themes of Physical Health and Mental Health. Pesticide poisoning was the method used by Guyanese people whose suicide was triggered primarily by interpersonal conflict.

Interpretation

The findings illustrate the complexities of suicide in Guyana and the importance of adopting a biopsychosocial perspective to suicide prevention. Suicide prevention should include mental health and suicide literacy training of medical professionals. It is recommended that the importation of highly toxic pesticides be restricted, and that less toxic substitutes be promoted. Convenience sampling, recall bias, and limited informants are limitations of this study. Future research should focus on suicidal behaviour using larger sample sizes.

Funding

This research was supported by an Australian Government Research Training Program Scholarship through Griffith University Australia.

Spatializing stigma-power: Mental health impacts of spatial stigma in a legally-excluded settlement in Mumbai, India

In disadvantaged neighborhoods such as informal settlements (or "slums" in the Indian context), infrastructural deficits and social conditions have been associated with residents' poor mental health. Within social determinants of health framework, spatial stigma, or negative portrayal and stereotyping of particular neighborhoods, has been identified as a contributor to health deficits, but remains under-examined in public health research and may adversely impact the mental health of slum residents through pathways including disinvestment in infrastructure, internalization, weakened community relations, and discrimination. Based on analyses of individual interviews (n = 40) and focus groups (n = 6) in Kaula Bandar (KB), an informal settlement in Mumbai with a previously described high rate of probable common mental disorders (CMD), this study investigates the association between spatial stigma and mental health. The findings suggest that KB's high rate of CMDs stems, in part, from residents' internalization of spatial stigma, which negatively impacts their self-perceptions and community relations. Employing the concept of stigma-power, this study also reveals that spatial stigma in KB is produced through willful government neglect and disinvestment, including the denial of basic services (e.g., water and sanitation infrastructure, solid waste removal). These findings expand the scope of stigma-power from an individual-level to a community-level process by revealing its enactment through the actions (and inactions) of bureaucratic agencies. This study provides empirical evidence for the mental health impacts of spatial stigma and contributes to understanding a key symbolic pathway by which living in a disadvantaged neighborhood may adversely affect health.

Gender and age differences in suicide attempt: A large population study in the West of Iran

Present study was to evaluate the relationship between suicide attempt, gender and age. We used all of suicide attempt entered in Hamadan Suicide Registry Program (2016-2017). Finding revealed that suicide attempt was lower among elderly patients. Using poison and self-immolation was more common in elder patients. Suicide attempt in females against males was higher in married. In males the higher rate of suicide attempt was in autumn, while in females was in summer. Using of drug was more frequent in females, while self-harm was more common in males. Gender and age are important risk factors of suicide attempts.

Mixed-Method Investigations Uncovering Tension, PTSD Symptoms, and Trauma-Related Difficulties Among Indian Women from Slums Reporting Gender-Based Violence

Indian women exposed to gender-based violence (GBV) report experiencing cultural concepts of distress, such as tension, and trauma-related difficulties. However, tension and trauma-related sequalae have not been explicitly explored. The present study examined the symptoms, causes, and coping strategies associated with tension among slum-residing Indian women reporting GBV (N = 100). This study also explored linkages between tension and posttraumatic stress disorder (PTSD) symptom severity. Qualitative results among a subsample of women (n = 38) indicated tension was commonly reported. Tension was characterized by varied affective, behavioral, cognitive, and somatic components and was most commonly caused by interpersonal stressors. Participants described various coping strategies to manage tension, including avoiding, cognitively reframing, considering consequences, distracting themselves, seeking medical, religious and/or spiritual assistance, finding social support, and tolerating tension. Barriers to coping were stigma, hopelessness about present circumstances, and negative reactions from others. One-way analysis of covariance with Bonferroni-adjusted post hoc results (N = 100) indicated that participants with higher tension exhibited significantly higher PTSD symptom severity as compared to participants reporting no tension. Altogether, the polyvalence of tension suggested that it requires idiographic assessment. Tension appears responsive to skills consistent with evidence-based psychological treatments for Indian women from slums reporting GBV.

"A woman's life is tension": A gendered analysis of women's distress in poor urban India

The mental health of women living in poverty is a growing public health concern, particularly in India where the burden of illness is compounded by critical shortages in mental health providers and fragmented services. This was an exploratory study which sought to examine low-income women's perceptions of mental illness and its management in the context of urban poverty in India. This research was prompted by the lack of empirical studies documenting how women in marginalized sections of society understand mental illness. Data were collected through a combination of 10 focus group discussions and two individual interviews with a total of 63 women residing in low-income areas of Mumbai. Social representations theory was used to explore shared meanings of mental illness among women in this setting. Thematic analysis of the data showed that women use the expression "tension" to talk about mental illness. Tension was described both as an ordinary part of life and a condition having its origins in more profound gender-related stressors, particularly pressures surrounding motherhood, chronic poverty and domestic conflict. Approaches to managing tension were pluralistic and focused on the resumption of social roles. Findings are consistent with other studies in similar cultural contexts, suggesting a shared, transnational character to women's distress and the need for scholarship on women's mental health in low-income settings to be more attuned to gendered forms of marginalization.

The burden of injuries in Mexico: Secondary data analysis from the Global Burden of Disease Study, 1990 to 2019

IMPORTANCE

Injuries have been a major cause of premature mortality and short-term and long-term disability in Mexico.

OBJECTIVE

To report the findings from the Global Burden of Disease 2019 study on injuries in Mexico at a national and subnational scale from 1990 to 2019.

METHODS

Following the 2019 Global Burden of Disease study we examined injury mortality, premature mortality, years lived with disability and disability-adjusted life-years according to 14 subcategories. We calculated the Pearson correlation coefficient between the injury burden and the socio-demographic index.

RESULTS

While the number of deaths from injuries increased significantly, the changes in the age-standardized mortality rates trended towards declines. Interpersonal violence, road injuries, falls and self-harm accounted for 8 of every 10 deaths from injury in 2019. Injury mortality and the disability-adjusted life-years rates decreased nationally and in most states in the period as a whole, but have increased since 2007. The injury burden was higher for men in all age groups. Interpersonal violence caused the highest disability-adjusted life-years rate in males and road injuries in females. The socio-demographic index increased in all states, while the injury age-standardized disability-adjusted life-years rates between 1990 and 2019 decreased, but there was no statistical association between both indicators.

DISCUSSION AND CONCLUSIONS

This study represents a comprehensive review of injury burden of disease in Mexico. The injury burden decreased, but improved heterogeneously among states. To further reduce the injury burden of disease, it's necessary for federal, state and local governments to prioritize safety promotion and injury prevention programs, infrastructure improvements, legislation, and enforcement at a national and subnational level. Mexico's injury prevention efforts should also be tailored for specific age groups, such as males aged 20-49 years or females in the younger and older age groups, and high-burden areas.

Study of suicide burden of mortality in México 1990-2017

OBJECTIVE

The primary goal was to analyze the level and trend of the burden of suicide mortality in Mexico between 1990 and 2017 at a national and state scale.

METHODS

A secondary analysis based on the 2017 global burden of disease study. Mortality rates and years of life lost due to premature death (YLL) were reported here. A joinpoint regression analysis based on a log-linear model was used to analyze the trend of YLL.

RESULTS

The burden of disease due to suicides increased in Mexico, mainly in young males and females; though the raise that happened in the elderly is an additional challenge for the health system. The burden of disease varied substantially between states. The male mortality rates were higher than those of females during the whole period under study, nonetheless with a trend to reduce the difference between the sexes. A bimodal pattern of the burden of disease due to suicide in Mexico was also observed, with the higher rates located in those aged between 15 and 19 years, and an important increase in people older than 85 years of age.

CONCLUSION

These results show a worrisome picture, not only from a social, economic and health point of view but also from the needs of public policies. This situation represents a wake-up call about the need to implement timely identification actions, a comprehensive multisectoral prevention strategy and the detailed study of suicide associated risk factors.

Facets of clinical stigma after attempted suicide in Mumbai, India

Community stigma studies may neglect clinically relevant experience and views of stigma that are important features of mental health problems. After attempting suicide, patients in a hospital emergency ward in Mumbai, India, were assessed for stigma referring to underlying prior problems motivating their deliberate self-harm (DSH) event, the DSH event itself and serious mental illness generally based on both anticipated community views and distinctive personal views. In this cultural epidemiological study of 196 patients, assessment items and four corresponding indexes were analysed and compared on a four-point scale, 0 to 3, for prominence of indicated stigma. Narratives from patients with high, low and discordant levels of stigma for prior problems and DSH events were analysed and compared. Disclosure, critical opinions of others and problems to marry were greater concerns for DSH events than prior problems. Problem drinking, unemployment, and sexual or financial victimization were common features of prior problems. Impulsivity of the DSH event and externalizing blame were features of lower levels of stigma. Ideas about most people's views of serious mental illness were regarded as more stigmatizing than patients' prior problems and DSH event; patients' personal views of serious mental illness were least stigmatizing. Findings suggest linking suicidality and stigmatized mental illness may discourage help seeking. Suicide prevention strategies should therefore emphasize available help needed for severe stress instead of equating suicidality and mental illness. Findings also indicate the relevance of assessing clinical stigma in a cultural formulation and the value of integrated qualitative and quantitative stigma research methods.

Why Thirteen Reasons Why may elicit suicidal ideation in some viewers, but help others

When the popular Netflix series 13 Reasons Why (13RW) debuted, scholars were quick to raise concerns that the show may encourage suicide as an option, particularly for vulnerable audience members; nonetheless, others pushed back, noting that the evidence used to draw a link between exposure to media and actual suicide risk suffers from methodological weaknesses and that censoring mental health topics may do more harm than good. The problem highlighted by the debate is that researchers generally lack the kinds of studies that would truly help us understand if a show like 13RW is problematic, and if it is, which specific storylines carry risk. Indeed, this general lack of the empirical evidence is precisely why the study by Arendt and his colleagues (2019) in this issue makes such an important contribution to the literature. With this commentary, I (1) review what we know and what we don't about the media, 13RW, and suicide, (2) discuss Arendt et al.'s unique insights, and (3) outline an agenda for future research that will allow us to better answer how, when, and for whom exposure to media stories like 13RW harms - or helps - youth.

Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990-2016

Background

A systematic understanding of suicide mortality trends over time at the subnational level for India's 1·3 billion people, 18% of the global population, is not readily available. Thus, we aimed to report time trends of suicide deaths, and the heterogeneity in its distribution between the states of India from 1990 to 2016.

Methods

As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, we estimated suicide death rates (SDRs) for both sexes in each state of India from 1990 to 2016. We used various data sources for estimating cause-specific mortality in India. For suicide mortality in India before 2000, estimates were based largely on GBD covariates. For each state, we calculated the ratio of the observed SDR to the rate expected in geographies globally with similar GBD Socio-demographic Index in 2016 (ie, the observed-to-expected ratio); and assessed the age distribution of suicide deaths, and the men-to-women ratio of SDR over time. Finally, we assessed the probability for India and the states of reaching the Sustainable Development Goal (SDG) target of a one-third reduction in SDR from 2015 to 2030, using location-wise trends of the age-standardised SDR from 1990 to 2016. We calculated 95% uncertainty intervals (UIs) for the point estimates.

Findings

There were 230 314 (95% UI 194 058–250 260) suicide deaths in India in 2016. India's contribution to global suicide deaths increased from 25·3% in 1990 to 36·6% in 2016 among women, and from 18·7% to 24·3% among men. Age-standardised SDR among women in India reduced by 26·7% from 20·0 (95% UI 16·5–23·5) in 1990 to 14·7 (13·1–16·2) per 100 000 in 2016, but the age-standardised SDR among men was the same in 1990 (22·3 [95% UI 14·4–27·4] per 100 000) and 2016 (21·2 [14·6–23·6] per 100 000). SDR in women was 2·1 times higher in India than the global average in 2016, and the observed-to-expected ratio was 2·74, ranging from 0·45 to 4·54 between the states. SDR in men was 1·4 times higher in India than the global average in 2016, with an observed-to-expected ratio of 1·31, ranging from 0·40 to 2·42 between the states. There was a ten-fold variation between the states in the SDR for women and six-fold variation for men in 2016. The men-to-women ratio of SDR for India was 1·34 in 2016, ranging from 0·97 to 4·11 between the states. The highest age-specific SDRs among women in 2016 were for ages 15–29 years and 75 years or older, and among men for ages 75 years or older. Suicide was the leading cause of death in India in 2016 for those aged 15–39 years; 71·2% of the suicide deaths among women and 57·7% among men were in this age group. If the trends observed up to 2016 continue, the probability of India achieving the SDG SDR reduction target in 2030 is zero, and the majority of the states with 81·3% of India's population have less than 10% probability, three states have a probability of 10·3–15·0%, and six have a probability of 25·1–36·7%.

Interpretation

India's proportional contribution to global suicide deaths is high and increasing. SDR in India is higher than expected for its Socio-Demographic Index level, especially for women, with substantial variations in the magnitude and men-to-women ratio between the states. India must develop a suicide prevention strategy that takes into account these variations in order to address this major public health problem.

Funding

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Patient-Identified Priorities Leading to Attempted Suicide

BACKGROUND

Attempted suicide is a major public health problem.

AIM

The aim of this study was to identify patient-identified problems and triggers typically leading to attempted suicide.

METHOD

A representative sample of 66 adult patients was recruited from all clinical sites and psychiatrists who treat patients after attempted suicide in the Canton of Basel-City (Switzerland). Patients were diagnosed using the Structured Clinical Interview for DSM-IV (SCID) and interviewed with a local adaptation of the Explanatory Model Interview Catalogue (EMIC) to study underlying problems and triggers of attempted suicide.

RESULTS

Of the patients, 92.4% had at least one DSM-IV disorder, with depressive disorders being the most prevalent disorder. Although half (50.0%) of the patients identified a health problem, 71.2% identified an interpersonal conflict as underlying problem leading to the suicide attempt. Furthermore, an interpersonal conflict was identified as the trigger of the suicide attempt by more than half of the patients (54.5%).

LIMITATIONS

The study included German-speaking patients only.

CONCLUSION

According to patients, interpersonal problems often amplify underlying psychiatric problems, leading to suicide attempts. Social and interpersonal stressors should be acknowledged with integrated clinical and social interventions to prevent suicidal behavior in patients and populations.

Health Professionals' Explanations of Suicidal Behaviour: Effects of Professional Group, Theoretical Intervention Model, and Patient Suicide Experience

In a help relation with a suicidal person, the theoretical models of suicidality can be essential to guide the health professional's comprehension of the client/patient. The objectives of this study were to identify health professionals' explanations of suicidal behaviors and to study the effects of professional group, theoretical intervention models, and patient suicide experience in professionals' representations. Two hundred and forty-two health professionals filled out a self-report questionnaire. Exploratory principal components analysis was used. Five explanatory models were identified: psychological suffering, affective cognitive, sociocommunicational, adverse life events, and psychopathological. Results indicated that the psychological suffering and psychopathological models were the most valued by the professionals, while the sociocommunicational was seen as the least likely to explain suicidal behavior. Differences between professional groups were found. We concluded that training and reflection on theoretical models in general and in communicative issues in particular are needed in the education of health professionals.

Poverty and suicide research in low- and middle-income countries: systematic mapping of literature published in English and a proposed research agenda

Approximately 75% of suicides occur in low- and middle-income countries (LMICs) where rates of poverty are high. Evidence suggests a relationship between economic variables and suicidal behaviour. To plan effective suicide prevention interventions in LMICs we need to understand the relationship between poverty and suicidal behaviour and how contextual factors may mediate this relationship. We conducted a systematic mapping of the English literature on poverty and suicidal behaviour in LMICs, to provide an overview of what is known about this topic, highlight gaps in literature, and consider the implications of current knowledge for research and policy. Eleven databases were searched using a combination of key words for suicidal ideation and behaviours, poverty and LMICs to identify articles published in English between January 2004 and April 2014. Narrative analysis was performed for the 84 studies meeting inclusion criteria. Most English studies in this area come from South Asia and Middle, East and North Africa, with a relative dearth of studies from countries in Sub-Saharan Africa. Most of the available evidence comes from upper middle-income countries; only 6% of studies come from low-income countries. Most studies focused on poverty measures such as unemployment and economic status, while neglecting dimensions such as debt, relative and absolute poverty, and support from welfare systems. Most studies are conducted within a risk-factor paradigm and employ descriptive statistics thus providing little insight into the nature of the relationship. More robust evidence is needed in this area, with theory-driven studies focussing on a wider range of poverty dimensions, and employing more sophisticated statistical methods.

Understanding Suicide Attempts Among Gay Men From Their Self-perceived Causes

Gay men are at higher risk of suicidality. This paper describes the causes of suicide attempts as perceived by the men themselves and analyzes their impact on severity and recidivism. Mental health surveys conducted among gay men in Geneva, Switzerland, from two probability-based time-space samples in 2007 and 2011, were merged to yield a combined sample N = 762. Suicide ideation, plans, and attempts were assessed, and respondents who had ever attempted suicide answered open questions about perceived causes which were coded and categorized for analysis within the framework of cultural epidemiology. In all, 16.7% of the respondents reported a suicide attempt in their lifetime (59.5% of them with multiple attempts). At their latest attempt, over two thirds asserted intent to die, and half required medical assistance. There was a wide variety of perceived causes, with most individuals reporting multiple causes and many of the most common causes cited at both the first and most recent subsequent attempts. Social/inter-personal problems constitute the most prominent category. Problems with love/relationship and accepting one's homosexuality figure consistently among the top three causes. Whereas the former tend to be associated with weaker intent to die, the latter are associated with the strongest intent to die and reported at multiple attempts. Problems with family are among the most common perceived causes at first attempt but not at the most recent subsequent attempt. Nevertheless, they tend to be related to the strongest intent to die and the greatest medical severity of all the perceived causes. Ten percent of men attempting suicide cited depression as a cause. Although it tended to be associated with weaker intent to die, depression was most likely to be reported at multiple attempts. Respondent-driven assessment yielded both common and idiosyncratic causes of suicide and their distinct effects. Some of these perceived causes are not prominent in the current literature, yet they have important implications for understanding risk and preventing suicide among gay men.

How community physical, structural, and social stressors relate to mental health in the urban slums of Accra, Ghana

Urban health in developing counties is a major public health challenge. It has become increasingly evident that the dialog must expand to include mental health outcomes, and to shift focus to the facets of the urban environment that shape them. Population-based research is necessary, as empirical findings linking the urban environment and mental health have primarily derived from developed countries, and may not be generalizable to developing countries. Thus, the current study assesses the prevalence of mental health problems (i.e., depression, perceived powerlessness), as well as their community-based predictors (i.e., crime, disorder, poverty, poor sanitation, local social capital and cohesion), among a sample of 690 residents in three poor urban communities in Accra, Ghana. It uncovers that residents in poor urban communities in developing countries suffer from mental health problems as a result of local stressors, which include not only physical and structural factors but social ones. Social capital and social cohesion show complex, often unhealthy, relationships with mental health, suggesting considerable drawbacks in making social capital a key focus among policymakers.

Understanding psychological distress among mothers in rural Nepal: a qualitative grounded theory exploration

BACKGROUND

There is a large burden of psychological distress in low and middle-income countries, and culturally relevant interventions must be developed to address it. This requires an understanding of how distress is experienced. We conducted a qualitative grounded theory study to understand how mothers experience and manage distress in Dhanusha, a low-resource setting in rural Nepal. We also explored how distressed mothers interact with their families and the wider community.

METHODS

Participants were identified during a cluster-randomised controlled trial in which mothers were screened for psychological distress using the 12-item General Health Questionnaire (GHQ-12). We conducted 22 semi-structured interviews with distressed mothers (GHQ-12 score ≥ 5) and one with a traditional healer (dhami), as well as 12 focus group discussions with community members. Data were analysed using grounded theory methods and a model was developed to explain psychological distress in this setting.

RESULTS

We found that distress was termed tension by participants and mainly described in terms of physical symptoms. Key perceived causes of distress were poor health, lack of sons, and fertility problems. Tension developed in a context of limited autonomy for women and perceived duty towards the family. Distressed mothers discussed several strategies to alleviate tension, including seeking treatment for perceived physical health problems and tension from doctors or dhamis, having repeated pregnancies until a son was delivered, manipulating social circumstances in the household, and deciding to accept their fate. Their ability to implement these strategies depended on whether they were able to negotiate with their in-laws or husbands for resources.

CONCLUSIONS

Vulnerability, as a consequence of gender and social disadvantage, manifests as psychological distress among mothers in Dhanusha. Screening tools incorporating physical symptoms of tension should be envisaged, along with interventions to address gender inequity, support marital relationships, and improve access to perinatal healthcare.

A qualitative study of factors affecting mental health amongst low-income working mothers in Bangalore, India

BACKGROUND

Low-income urban working mothers face many challenges in their domestic, environmental, and working conditions that may affect their mental health. In India, a high prevalence of mental health disorders has been recorded in young women, but there has been little research to examine the factors that affect their mental health at home and work.

METHODS

Through a primarily qualitative approach, we studied the relationship between work, caring for family, spousal support, stress relief strategies and mental health amongst forty eight low-income working mothers residing in urban slums across Bangalore, India. Participants were construction workers, domestic workers, factory workers and fruit and vegetable street vendors. Qualitative data analysis themes included state of mental health, factors that affected mental health positively or negatively, manifestations and consequences of stress and depression, and stress mitigators.

RESULTS

Even in our small sample of women, we found evidence of extreme depression, including suicidal ideation and attempted suicide. Women who have an alcoholic and/or abusive husband, experience intimate partner violence, are raising children with special needs, and lack adequate support for child care appear to be more susceptible to severe and prolonged periods of depression and suicide attempts. Factors that pointed towards reduced anxiety and depression were social support from family, friends and colleagues and fulfilment from work.

CONCLUSION

This qualitative study raises concerns that low-income working mothers in urban areas in India are at high risk for depression, and identifies common factors that create and mitigate stress in this population group. We discuss implications of the findings for supporting the mental health of urban working women in the Indian context. The development of the national mental health policy in India and its subsequent implementation should draw on existing research documenting factors associated with negative mental health amongst specific population groups in order to ensure greater impact.

Suicide in rural Haiti: clinical and community perceptions of prevalence, etiology, and prevention

Suicide is a complex global public health problem, yet few studies have examined local socio-cultural explanatory models and other contextual factors surrounding suicide in low-and-middle-income countries. Such research is critical, as suicide frequency and etiology, as well as care-seeking in the case of distress, differ contextually and by sub-groups within a population. This is the first study of its kind to explore the dual perspectives of both healthcare workers and community members regarding suicide in Haiti. We conducted semi-structured, in-depth interviews between May and June 2011 with eight biomedical healthcare workers and 16 lay community members. Qualitative data analysis, drawing on interpretive phenomenological analysis, addressed themes including perceived suicide frequency, veracity of suicidal ideation claims, perceived causal factors, religious constructs related to suicide, and support resources for suicidality. Compared to community members, healthcare workers underestimated the frequency of suicide and were less likely to interpret suicide-related claims as representing true intent. Religious perspectives influenced attitudes toward suicide, albeit in different ways: Christian concern with the afterlife resulted in suicide being unacceptable and sinful, while Vodou explanatory frameworks displaced blame and stigma away from suicidal individuals. Healthcare workers' failure to recognize suicide as a serious problem suggests that the formal health system is currently ill-equipped to respond to suicide-related needs. Religious practice and community supports in rural Haiti may serve as essential resources for prevention programs.