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Mboya IB, John B, Kibopile ES, Mhando L, George J, Ngocho JS. Factors associated with mental distress among undergraduate students in northern Tanzania. BMC Psychiatry 2020; 20:28. [PMID: 31996200 PMCID: PMC6988278 DOI: 10.1186/s12888-020-2448-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 01/21/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Mental distress is a major public health problem which includes anxiety, depression and somatic symptoms such as sleeping problems, fatigue and headache. University students are consistently reported to have higher levels of mental distress compared to the general population. Although university students with mental distress have significantly impaired cognitive functioning, learning disabilities and poor academic performance, the burden of this problem in Tanzania is unknown. This study aimed to determine prevalence and factors associated with mental distress among undergraduate students in northern Tanzania. METHODS A cross-sectional study was conducted among undergraduate students at Kilimanjaro Christian Medical University College from April-July 2018. Simple random sampling technique using probability proportional to size was used to sample students from their respective classes. Mental distress was screened using the self-reporting questionnaire (SRQ-20). Data was analyzed using Stata version 15.1. Frequencies and percentages were used to summarize categorical variables while mean and standard deviation for numeric variables. Multivariable logistic regression was used to determine factors associated with mental distress adjusted for potential confounders. RESULTS A total of 402 undergraduate students participated in this study, 14% screened positive for mental distress. Residing off-campus (OR = 0.44, 95%CI 0.20-0.96) and perceived availability of social support (OR = 0.22, 95%CI 0.11-0.45) reduced the odds of mental distress while students with family history of mental distress (OR = 2.60, 95%CI 1.04-6.57) and those with decreased grades than anticipated (OR = 3.61, 95%CI 1.91-6.83) had higher likelihood of mental distress. CONCLUSION One in every ten students screened was positive for mental distress. Those who reported a family history of mental illness and lower grades than anticipated had higher response of mental distress. To relieve students from stress and frustrations related to studies and their lives in general, this study recommends awareness creation, counselling to help those with mental health issues, establishment of student drop-in centers for such services and promotion of social and recreational activities at the college.
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Affiliation(s)
- Innocent B. Mboya
- Institute of Public Health, Community Health Department, Kilimanjaro Christian Medical University College (KCMUCo), P. O. Box 2240, Moshi, Tanzania
- Institute of Public Health, Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), P. O. Box 2240, Moshi, Tanzania
- Institute of Public Health, Department of Behavioral and Social Sciences, Kilimanjaro Christian Medical University College (KCMUCo), P. O. Box 2240, Moshi, Tanzania
- School of Mathematics, Statistics & Computer Science, University of KwaZulu-Natal, Pietermaritzburg, Private Bag X01, Scottsville, 3209 South Africa
| | - Beatrice John
- Institute of Public Health, Community Health Department, Kilimanjaro Christian Medical University College (KCMUCo), P. O. Box 2240, Moshi, Tanzania
| | - Eneck S. Kibopile
- Institute of Public Health, Community Health Department, Kilimanjaro Christian Medical University College (KCMUCo), P. O. Box 2240, Moshi, Tanzania
| | - Lisbeth Mhando
- Institute of Public Health, Department of Behavioral and Social Sciences, Kilimanjaro Christian Medical University College (KCMUCo), P. O. Box 2240, Moshi, Tanzania
| | - Johnston George
- Institute of Public Health, Community Health Department, Kilimanjaro Christian Medical University College (KCMUCo), P. O. Box 2240, Moshi, Tanzania
| | - James S. Ngocho
- Institute of Public Health, Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College (KCMUCo), P. O. Box 2240, Moshi, Tanzania
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Knipe D, Williams AJ, Hannam-Swain S, Upton S, Brown K, Bandara P, Chang SS, Kapur N. Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002905. [PMID: 31597983 PMCID: PMC6785653 DOI: 10.1371/journal.pmed.1002905] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 08/23/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Psychiatric disorders are reported to be present in 80% to 90% of suicide deaths in high-income countries (HIC), but this association is less clear in low- and middle-income countries (LMIC). There has been no previous systematic review of this issue in LMIC. The current study aims to estimate the prevalence of psychiatric morbidity in individuals with suicidal behaviour in LMIC. METHODS AND FINDINGS PubMed, PsycINFO, and EMBASE searches were conducted to identify quantitative research papers (any language) between 1990 and 2018 from LMIC that reported on the prevalence of psychiatric morbidity in suicidal behaviour. We used meta-analytic techniques to generate pooled estimates for any psychiatric disorder and specific diagnosis based on International classification of disease (ICD-10) criteria. A total of 112 studies (154 papers) from 26 LMIC (India: 25%, China: 15%, and other LMIC: 60%) were identified, including 18 non-English articles. They included 30,030 individuals with nonfatal suicidal behaviour and 4,996 individuals who had died by suicide. Of the 15 studies (5 LMIC) that scored highly on our quality assessment, prevalence estimates for psychiatric disorders ranged between 30% and 80% in suicide deaths and between 3% and 86% in those who engaged in nonfatal suicidal behaviour. There was substantial heterogeneity between study estimates. Fifty-eight percent (95% CI 46%-71%) of those who died by suicide and 45% (95% CI 30%-61%) of those who engaged in nonfatal suicidal behaviour had a psychiatric disorder. The most prevalent disorder in both fatal and nonfatal suicidal behaviour was mood disorder (25% and 21%, respectively). Schizophrenia and related disorders were identified in 8% (4%-12%) of those who died by suicide and 7% (3%-11%) of those who engaged in nonfatal suicidal behaviour. In nonfatal suicidal behaviour, anxiety disorders, and substance misuse were identified in 19% (1%-36%) and 11% (7%-16%) of individuals, respectively. This systematic review was limited by the low number of high-quality studies and restricting our searches to databases that mainly indexed English language journals. CONCLUSIONS Our findings suggest a possible lower prevalence of psychiatric disorders in suicidal behaviour in LMIC. We found very few high-quality studies and high levels of heterogeneity in pooled estimates of psychiatric disorder, which could reflect differing study methods or real differences. There is a clear need for more robust evidence in order for LMIC to strike the right balance between community-based and mental health focussed interventions.
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Affiliation(s)
- Duleeka Knipe
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - A. Jess Williams
- Institute for Mental Health, University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Piumee Bandara
- Translational Health Research Institute, Western Sydney University, Sydney, Australia
| | - Shu-Sen Chang
- Institute of Health Behaviors and Community Sciences and Department of Public Health, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Nav Kapur
- University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
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Abstract
Suicide is a serious worldwide health problem, particularly among youths. It is defined as the intentional act of killing oneself. Analytically, the suicidal act entails: the wish to kill, the wish to be killed and the wish to die. People who die by suicide know what they are doing and are aware of the consequences of their actions. A completed suicidal act is a complex phenomenon associated with psychological, biological and social factors. It follows severe exhaustion under a continuing assault of stressors when the suicidal individual is no longer able to cope with and to restore homeostasis. In order to categorise a case as a suicide, legal authorities demand unequivocal evidence of intent.
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Ani JO, Ross AJ, Campbell LM. A review of patients presenting to accident and emergency department with deliberate self-harm, KwaZulu-Natal, South Africa. Afr J Prim Health Care Fam Med 2017; 9:e1-e7. [PMID: 28582987 PMCID: PMC5458570 DOI: 10.4102/phcfm.v9i1.1234] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 02/10/2017] [Accepted: 12/15/2016] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND The World Health Organization has described deliberate self-harm (DSH) as a major global health challenge. Little is known about the profile of patients admitted following DSH at district and regional combo hospitals in KwaZulu-Natal, South Africa. AIM The aim of this study was to assess the profiles of patients and reasons for admission following DSH. SETTING The study was conducted on data from a busy Accident and Emergency (A&E) department in a combination district and regional hospital situated in Empangeni in northern KwaZulu-Natal. METHOD This was a retrospective descriptive study. Data were collected from charts of all patients admitted to the A&E department from April 2012 to March 2013 following DSH. Variables assessed included age, gender, race, occupation, religion, education level, coexisting medical and mental health conditions, and reasons for DSH. Data were entered into SPSS and analysed descriptively. RESULTS A total of 262 charts were identified and 215 (82%) were selected for inclusion. Most patients admitted following DSH were young, single African women with at least secondary-level education. Most (169/215;78%) admissions were for parasuicide, with relational issues contributing in more than 50% of cases and circumstance challenges contributing in just under 30%. CONCLUSION Although an underestimation, DSH is not an uncommon reason for patients to present in the A&E at this district and regional combo hospital. Findings from this study are consistent with those of other studies on DSH and highlight the need for a validated screening tool for the identification of patients at risk of DSH. There is a need to explore community-based intervention, which could address reasons for DSH and prevent future admissions.
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Affiliation(s)
- Josephat O Ani
- Department of Family Medicine, University of KwaZulu-Natal, South Africa.
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Wagenaar BH, Raunig-Berhó M, Cumbe V, Rao D, Napúa M, Sherr K. Suicide Attempts and Deaths in Sofala, Mozambique, From 2011 to 2014. CRISIS 2016; 37:445-453. [PMID: 27245814 DOI: 10.1027/0227-5910/a000383] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mozambique was recently estimated to have the highest suicide rate in Africa. AIMS To fill a knowledge gap on suicide attempts and deaths in Mozambique. METHOD We reviewed a census of 898 emergency psychiatric consultations from March 2013 to July 2014 and 1,173 violent death autopsy records from June 2011 to August 2014 at Beira Central Hospital in Sofala, Mozambique. RESULTS In all, 18.0% of emergency psychiatric consultations were suicide attempts. Females were disproportionately represented (68.3%, p < .001), and the mean age was 26.8 years. Rat poison was used in 66% of attempts, followed by unspecified methods (19.8%), and unspecified poisoning (6.8%). Of the violent death autopsies, 10% were suicides. Suicide deaths were more likely to be male (67.3%, p < .001), and the mean age was 30.8 years. Common methods were hanging (43.2%), unspecified substance (28.0%), or rat poison (26.3%). Common places of death were the hospital or hospital transit (46.4%) and the household (35.7%). Female suicide deaths more often involved toxic substances and males more often employed hanging. CONCLUSION Females more often present with suicide attempts, but deaths due to suicide are more frequent among males. Females more often use toxic substances, whereas males more often use lethal methods, such as hanging. Policies to reduce the availability or toxicity of rat poison should be considered.
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Affiliation(s)
- Bradley H Wagenaar
- 1 Department of Global Health, University of Washington, Seattle, WA, USA.,2 Health Alliance International, Seattle, WA, USA
| | | | - Vasco Cumbe
- 3 Sofala Provincial Health Directorate, Department of Mental Health, Ministry of Health, Beira, Mozambique.,4 Beira Central Hospital, Department of Medicine, Psychiatric Services, Beira, Mozambique
| | - Deepa Rao
- 1 Department of Global Health, University of Washington, Seattle, WA, USA.,5 Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Manuel Napúa
- 6 Beira Operations Research Center, Ministry of Health, Beira, Mozambique
| | - Kenneth Sherr
- 1 Department of Global Health, University of Washington, Seattle, WA, USA.,2 Health Alliance International, Seattle, WA, USA
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Abstract
BACKGROUND As part of a situational analysis for a research programme on the integration of mental health care into primary care (Programme for Improving Mental Health Care-PRIME), we conducted a baseline study aimed at determining the broad indicators of the population level of psychosocial distress in a predominantly rural community in Ethiopia. METHODS The study was a population-based cross-sectional survey of 1497 adults selected through a multi-stage random sampling process. Population level psychosocial distress was evaluated by estimating the magnitude of common mental disorder symptoms (CMD; depressive, anxiety and somatic symptoms reaching the level of probable clinical significance), harmful use of alcohol, suicidality and psychosocial stressors experienced by the population. RESULTS The one-month prevalence of CMD at the mild, moderate and severe threshold levels was 13.8%, 9.0% and 5.1% respectively. The respective one-month prevalence of any suicidal ideation, persistent suicidal ideation and suicide attempt was 13.5%, 3.8% and 1.8%. Hazardous use of alcohol was identified in 22.4%, significantly higher among men (33.4%) compared to women (11.3%). Stressful life events were widespread, with 41.4% reporting at least one threatening life event in the preceding six months. A similar proportion reported poor social support (40.8%). Stressful life events, increasing age, marital loss and hazardous use of alcohol were associated with CMD while stressful life events, marital loss and lower educational status, and CMD were associated with suicidality. CMD was the strongest factor associated with suicidality [e.g., OR (95% CI) for severe CMD = 60.91 (28.01, 132.48)] and the strength of association increased with increase in the severity of the CMD. CONCLUSION Indicators of psychosocial distress are prevalent in this rural community. Contrary to former assumptions in the literature, social support systems seem relatively weak and stressful life events common. Interventions geared towards modifying general risk factors and broader strategies to promote mental wellbeing are required.
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Mars B, Burrows S, Hjelmeland H, Gunnell D. Suicidal behaviour across the African continent: a review of the literature. BMC Public Health 2014; 14:606. [PMID: 24927746 PMCID: PMC4067111 DOI: 10.1186/1471-2458-14-606] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 05/28/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Suicide is a major cause of premature mortality worldwide, but data on its epidemiology in Africa, the world's second most populous continent, are limited. METHODS We systematically reviewed published literature on suicidal behaviour in African countries. We searched PubMed, Web of Knowledge, PsycINFO, African Index Medicus, Eastern Mediterranean Index Medicus and African Journals OnLine and carried out citation searches of key articles. We crudely estimated the incidence of suicide and suicide attempts in Africa based on country-specific data and compared these with published estimates. We also describe common features of suicide and suicide attempts across the studies, including information related to age, sex, methods used and risk factors. RESULTS Regional or national suicide incidence data were available for less than one third (16/53) of African countries containing approximately 60% of Africa's population; suicide attempt data were available for <20% of countries (7/53). Crude estimates suggest there are over 34,000 (inter-quartile range 13,141 to 63,757) suicides per year in Africa, with an overall incidence rate of 3.2 per 100,000 population. The recent Global Burden of Disease (GBD) estimate of 49,558 deaths is somewhat higher, but falls within the inter-quartile range of our estimate. Suicide rates in men are typically at least three times higher than in women. The most frequently used methods of suicide are hanging and pesticide poisoning. Reported risk factors are similar for suicide and suicide attempts and include interpersonal difficulties, mental and physical health problems, socioeconomic problems and drug and alcohol use/abuse. Qualitative studies are needed to identify additional culturally relevant risk factors and to understand how risk factors may be connected to suicidal behaviour in different socio-cultural contexts. CONCLUSIONS Our estimate is somewhat lower than GBD, but still clearly indicates suicidal behaviour is an important public health problem in Africa. More regional studies, in both urban and rural areas, are needed to more accurately estimate the burden of suicidal behaviour across the continent. Qualitative studies are required in addition to quantitative studies.
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Affiliation(s)
- Becky Mars
- School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol BS8 2BN, United Kingdom
| | - Stephanie Burrows
- Research Centre of the University of Montréal Hospital Centre, 3850 St-Urbain, H2W 1 T7 Montréal, Québec, Canada
- Department of Social and Preventive Medicine, University of Montréal, 7101 Avenue du Parc, H3N 1X7 Montréal, Québec, Canada
| | - Heidi Hjelmeland
- Department of Social Work and Health Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway
| | - David Gunnell
- School of Social and Community Medicine, University of Bristol, Oakfield House, Bristol BS8 2BN, United Kingdom
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Kinyanda E, Hjelmeland H, Musisi S. Negative life events associated with deliberate self-harm in an African population in Uganda. CRISIS 2005; 26:4-11. [PMID: 15762078 DOI: 10.1027/0227-5910.26.1.4] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Negative life events associated with deliberate self-harm (DSH) were investigated in an African context in Uganda. Patients admitted at three general hospitals in Kampala, Uganda were interviewed using a Luganda version (predominant language in the study area) of the European Parasuicide Study Interview Schedule I. The results of the life events and histories module are reported in this paper. The categories of negative life events in childhood that were significantly associated with DSH included those related to parents, significant others, personal events, and the total negative life events load in childhood. For the later-life time period, the negative life events load in the partner category and the total negative life events in this time period were associated with DSH. In the last-year time period, the negative life events load related to personal events and the total number of negative life events in this time period were associated with DSH. A statistically significant difference between the cases and controls for the total number of negative life events reported over the entire lifetime of the respondents was also observed, which suggests a dose effect of negative life events on DSH. Gender differences were also observed among the cases. In conclusion, life events appear to be an important factor in DSH in this cultural environment. The implication of these results for treatment and the future development of suicide interventions in this country are discussed.
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Affiliation(s)
- E Kinyanda
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway.
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Cherpitel CJ, Borges GLG, Wilcox HC. Acute alcohol use and suicidal behavior: a review of the literature. Alcohol Clin Exp Res 2004; 28:18S-28S. [PMID: 15166633 DOI: 10.1097/01.alc.0000127411.61634.14] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Both acute and chronic use of alcohol are associated with suicidal behavior. However, the differing relationship of each component of alcohol use and possible causal mechanisms remain unclear. METHODS This article reviews and summarizes associations between acute alcohol consumption (with and without intoxication) and suicidal behavior (both completed suicide and suicide attempts) among adults 19 years and older, as presented in literature published between 1991 and 2001. Possible mechanisms and methodologic challenges for evaluating the association are also discussed. An application of a research design (the case-crossover study) that has the potential for addressing the effects of acute alcohol use over and above usual or chronic use is presented. RESULTS The majority of articles reviewed were restricted to descriptive studies that documented the prevalence of suicide completers or attempters who tested positive for alcohol use. A wide range of alcohol-positive cases were found for both completed suicide (10-69%) and suicide attempts (10-73%). Common methodologic limitations included the lack of control groups (for evaluating risk conferred by alcohol use), selection and ascertainment bias, and small sample sizes. The results of the case-crossover pilot study indicated substantially higher risk of suicide during or shortly after use of alcohol compared with alcohol-free periods. CONCLUSIONS Although there is a substantial literature of published studies on acute alcohol use and suicidal behavior, the majority of studies focus on completed suicide and report prevalence estimates. Findings from such studies are subject to several possible sources of bias and have not advanced our knowledge of mechanisms in the association between acute alcohol use and suicidal behavior. The case-crossover design may help to overcome some limitations of these studies and facilitate evaluation of associations and possible causal mechanisms by which acute alcohol use is linked to suicidal behavior.
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Eshun S. Sociocultural determinants of suicide ideation: a comparison between American and Ghanaian college samples. Suicide Life Threat Behav 2003; 33:165-71. [PMID: 12882417 DOI: 10.1521/suli.33.2.165.22779] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study investigated the role of gender, family cohesion, religiosity, and negative suicide attitudes as potential determinants of cultural differences in suicide ideation among 375 college students from Ghana and the United States. Significant cultural differences were found for suicide ideation, family closeness, religiosity, and negative suicide attitudes. Family cohesion and negative attitudes were significant predictors for both cultural groups. Gender was a significant determinant for suicide ideation among Ghanaians, but not Americans; religiosity was not a significant determinant for either group. More extensive research on sociocultural influences on suicide, especially among countries in which suicide is underreported or not documented, is encouraged.
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Affiliation(s)
- Sussie Eshun
- Department of Psychology, East Stroudsburg University, PA 18301, USA.
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Peltzer K, Cherian VI, Cherian L. Attitudes toward suicide among South African secondary school pupils. Psychol Rep 1998; 83:1259-65. [PMID: 10079723 DOI: 10.2466/pr0.1998.83.3f.1259] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study investigated attitudes towards suicide among 622 Standard 9 (U.S. Grade 11) secondary school pupils chosen at random from schools throughout the Northern Province in South Africa. The pupils were 254 (41%) boys and 368 (59%) girls in the age range of 17 to 24 years, with a mean age of 19.3 yr. A questionnaire was administered to obtain data on attitudes and other measures. There were 31 (17%) parasuicidal boys and 34 (13%) girls. Major intentions or reasons to commit suicide mentioned were "failing to solve problems" and "mental illness." Most frequent possible suicide methods were firearms, pills, or poison. Significant associations were found with having a friend or relative who committed suicide, parasuicide (oneself), depression, stress events, ethnicity, and attitudes towards suicide.
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Affiliation(s)
- K Peltzer
- Department of Psychology, University of the North, Sovenga, South Africa
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Kilonzo GP, Simmons N. Development of mental health services in Tanzania: a reappraisal for the future. Soc Sci Med 1998; 47:419-28. [PMID: 9680226 DOI: 10.1016/s0277-9536(97)10127-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The article traces the historical development of mental health services in Tanzania from traditional practices through custodial institutions during the colonial period, efforts towards decentralization, including the development of innovative agricultural rehabilitation villages during the 60s and the introduction of primary mental health care during the 80s right up to the present. Available resources in Tanzania, including the traditional healing system, the family and ample arable land were examined as to how these might be used in the care of mental patients and the promotion of mental health in general. The article points to real opportunities and a possible course of action for the future.
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Affiliation(s)
- G P Kilonzo
- Muhimbili University College of Health Sciences of The University of Dar es Salaam, Tanzania
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