Alcohol and suicide in postconflict northern Uganda: a qualitative psychological autopsy study

Psychological and socio-ecological correlates of 12-month suicide behavior among junior high school students in the greater Accra region of Ghana

AIM

In Ghana, we know little about the epidemiology of suicide ideation, plan and attempts among junior high school (JHS) students in Ghana including the years preceding high school. This study explores the onset, characteristics, and recent patterns of 12-month suicide behavior among Ghanaian junior high school (JHS) students.

MATERIALS AND METHODS

Paper-based surveys were administered to a sample (n = 800) of junior high school students in the Greater Accra region of Ghana. Self-reported measures on suicide ideation, plan and attempt as well as several psychological and psychosocial factors related to mental health, substance use, poverty, sexual behavior, interpersonal relationships, and family structure were employed. Bi-variate, multivariate and logistic regression analyses were performed using Statistical Package for the Social Sciences (SPSS version 25).

RESULTS

This study found that 1 out of 5 adolescents have experienced suicide ideation in the last 12 months. Girls had significantly higher 12-month (χ2 = 3.5, p < 0.05) suicide ideation rates than boys. More importantly, the study found stress significantly increasing the odds of suicide behaviors in the last 12 months (β = 1.14; CI = 1.05-1.24, p < 0.05) and parental support significantly reducing the odds of suicide behaviors in the last 12 months (β = 0.86; CI = 0.81-0.91, p < 0.05). Additionally, we found significant associations between sexual intercourse, dating, hunger, substance use, suicide stigma and suicide behaviors.

CONCLUSION

This finding highlights a potential emerging suicide crisis among preteens which warrants attention. Additional studies are needed to observe these increasing trends and identify risk, protective and precipitating factors to help prevent suicide among these children.

Community suicide rates and related factors within a surveillance platform in Western Kenya

BACKGROUND

Suicide is an important contributor to the burden of mental health disorders, but community-based suicide data are scarce in many low- and middle-income countries (LMIC) including Kenya. Available data on suicide underestimates the true burden due to underreporting related to stigma and legal restrictions, and under-representation of those not utilizing health facilities.

METHODS

We estimated the cumulative incidence of suicide via verbal autopsies from the Health and Demographic Surveillance System (HDSS) in Kisumu County, Kenya. We then used content analysis of open history forms among deaths coded as accidents to identify those who likely died by suicide but were not coded as suicide deaths. We finally conducted a case-control study of suicides (both verbal autopsy confirmed and likely suicides) compared to accident-caused deaths to assess factors associated with suicide in this HDSS.

RESULTS

A total of 33 out of 4306 verbal autopsies confirmed suicide as the cause of death. Content analysis of a further 228 deaths originally attributed to accidents identified 39 additional likely suicides. The best estimate of suicide-specific mortality rate was 14.7 per 100,000 population per year (credibility window = 11.3 - 18.0). The most common reported method of death was self-poisoning (54%). From the case-control study interpersonal difficulties and stressful life events were associated with increased odds of suicide in both confirmed suicides and confirmed combined with suspected suicides. Other pertinent factors such as age and being male differed depending upon which outcome was used.

CONCLUSION

Suicide is common in this area, and interventions are needed to address drivers. The twofold increase in the suicide-specific mortality rate following incorporation of misattributed suicide deaths exemplify underreporting and misclassification of suicide cases at community level. Further, verbal autopsies may underreport suicide specifically among older and female populations.

Understanding the health needs of internally displaced persons: A scoping review

We seek to strengthen understanding of the health needs of internally displaced persons (IDPs) in contexts of conflict or violence. Based upon a scoping review, our paper identified limited evidence on IDP health, but nevertheless indicates that IDPs tend to experience worse health outcomes than other conflict-affected populations across a range of health issues; and this is due to the particularly vulnerable situation of IDPs relative to these other populations, including reduced access to health services. Further research is required to better understand these needs and the interventions that can most effectively address these needs.

The impact of alcohol misuse on fathering in Northern Uganda: An ethnographic study of fathers

The Acholi people of northern Uganda experienced decades of conflict. Alcohol misuse is high among northern Ugandan men. This is common in displaced or post-war communities. Because parents are often the most significant and proximal influence in a child's development, it is important to understand the relationships between parental behavioral health and parenting. The purpose of this ethnographic study was to understand the impact of alcohol misuse on fathering, from fathers' perspectives. We collected qualitative data from several sources, including in-depth interviews with 19 fathers. Informants identified three ways in which a father can "overdrink": drinking to drunkenness, spending too much money on alcohol, or spending too much time drinking alcohol. Fathers described the specific ways in which overdrinking impacted each of the three primary roles of a father, which were identified as providing, educating, and creating a stable home. Of the negative effects of overdrinking, a compromised ability to provide for basic needs was described as the most salient. The findings suggest that support for families in this region should include support for father's substance misuse, as a father's overdrinking is widely understood to be problematic for the entire family.

"[Repeat] testing and counseling is one of the key [services] that the government should continue providing": participants' perceptions on extended repeat HIV testing and enhanced counseling (ERHTEC) for primary HIV prevention in pregnant and lactating women in the PRIMAL study, Uganda

BACKGROUND

The 'Primary HIV Prevention among Pregnant and Lactating Ugandan Women' (PRIMAL) randomized controlled trial aimed to assess an enhanced counseling strategy linked to extended postpartum repeat HIV testing and enhanced counseling among 820 HIV-negative pregnant and lactating women aged 18-49 years and 410 of their male partners to address the first pillar of the WHO Global Strategy for the Prevention of Mother-to-Child HIV transmission (PMTCT). This paper presents findings of qualitative studies aimed at evaluating participants' and service providers' perceptions on the acceptability and feasibility of the intervention and at understanding the effects of the intervention on risk reduction, couple communication, and emotional support from women's partners.

METHODS

PRIMAL Study participants were enrolled from two antenatal care clinics and randomized 1:1 to an intervention or control arm. Both arms received repeat sexually transmitted infections (STI) and HIV testing at enrolment, labor and delivery, and at 3, 6, 12, 18 and 24 months postpartum. The intervention consisted of enhanced quarterly counseling on HIV risk reduction, couple communication, family planning and nutrition delivered by study counselors through up to 24 months post-partum. Control participants received repeat standard post-test counseling. Qualitative data were collected from intervention women participants, counsellors and midwives at baseline, midline and end of the study through 18 focus group discussions and 44 key informant interviews. Data analysis followed a thematic approach using framework analysis and a matrix-based system for organizing, reducing, and synthesizing data.

RESULTS

At baseline, FGD participants mentioned multiple sexual partners and lack of condom use as the main risks for pregnant and lactating women to acquire HIV. The main reasons for having multiple sexual partners were 1) the cultural practice not to have sex in the late pre-natal and early post-natal period; 2) increased sexual desire during pregnancy; 3) alcohol abuse; 4) poverty; and 5) conflict in couples. Consistent condom use at baseline was limited due to lack of knowledge and low acceptance of condom use in couples. The majority of intervention participants enrolled as couples felt enhanced counselling improved understanding, faithfulness, mutual support and appreciation within their couple. Another benefit mentioned by participants was improvement of couple communication and negotiation, as well as daily decision-making around sexual needs, family planning and condom use. Participants stressed the importance of providing counselling services to all couples.

CONCLUSION

This study shows that enhanced individual and couple counselling linked to extended repeat HIV and STI testing and focusing on HIV prevention, couple communication, family planning and nutrition is a feasible and acceptable intervention that could enhance risk reduction programs among pregnant and lactating women.

TRIAL REGISTRATION

ClinicalTrials.gov registration number NCT01882998, date of registration 21st June 2013.

A Scoping Review of the Health of Conflict-Induced Internally Displaced Women in Africa

Armed conflict and internal displacement of persons create new health challenges for women in Africa. To outline the research literature on this population, we conducted a review of studies exploring the health of internally displaced persons (IDP) women in Africa. In collaboration with a health research librarian and a review team, a search strategy was designed that identified 31 primary research studies with relevant evidence. Studies on the health of displaced women have been conducted in South- Central Africa, including Democratic Republic of Congo (DRC); and in Eastern, East central Africa, and Western Africa, including Eritrea, Uganda, and Sudan, Côte d'Ivoire, and Nigeria. We identified violence, mental health, sexual and reproductive health, and malaria and as key health areas to explore, and observed that socioeconomic power shifts play a crucial role in predisposing women to challenges in all four categories. Access to reproductive health services was influenced by knowledge, geographical proximity to health services, spousal consent, and affordability of care. As well, numerous factors affect the mental health of internally displaced women in Africa: excessive care-giving responsibilities, lack of financial and family support to help them cope, sustained experiences of violence, psychological distress, family dysfunction, and men's chronic alcoholism. National and regional governments must recommit to institutional restructuring and improved funding allocation to culturally appropriate health interventions for displaced women.

Suicide in Nepal: Qualitative Findings from a Modified Case-Series Psychological Autopsy Investigation of Suicide Deaths

South Asia accounts for the majority of the world's suicide deaths, but typical psychiatric or surveillance-based research approaches are limited due to incomplete vital surveillance. Despite rich anthropological scholarship in the region, such work has not been used to address public health gaps in surveillance and nor inform prevention programs designed based on surveillance data. Our goal was to leverage useful strategies from both public health and anthropological approaches to provide rich narrative reconstructions of suicide events, told by family members or loved ones of the deceased, to further contextualize the circumstances of suicide. Specifically, we sought to untangle socio-cultural and structural patterns in suicide cases to better inform systems-level surveillance strategies and salient community-level suicide prevention opportunities. Using a mixed-methods psychological autopsy approach for cross-cultural research (MPAC) in both urban and rural Nepal, 39 suicide deaths were examined. MPAC was used to document antecedent events, characteristics of persons completing suicide, and perceived drivers of each suicide. Patterns across suicide cases include (1) lack of education (72% of cases); (2) life stressors such as poverty (54%), violence (61.1%), migrant labor (33% of men), and family disputes often resulting in isolation or shame (56.4%); (3) family histories of suicidal behavior (62%), with the majority involving an immediate family member; (4) gender differences: female suicides were attributed to hopeless situations, such as spousal abuse, with high degrees of social stigma. In contrast, male suicides were most commonly associated with drinking and resulted from internalized stigma, such as financial failure or an inability to provide for their family; (5) justifications for suicide were attributions to 'fate' and personality characteristics such as 'stubbornness' and 'egoism'; (5) power dynamics and available agency precluded some families from disputing the death as a suicide and also had implications for the condemnation or justification of particular suicides. Importantly, only 1 out of 3 men and 1 out of 6 women had any communication to family members about suicidal ideation prior to completion. Findings illustrate the importance of MPAC methods for capturing cultural narratives evoked after completed suicides, recognizing culturally salient warning signs, and identifying potential barriers to disclosure and justice seeking by families. These findings elucidate how suicide narratives are structured by family members and reveal public health opportunities for creating or supplementing mortality surveillance, intervening in higher risk populations such as survivors of suicide, and encouraging disclosure.

Cultural responses towards the aftermath of suicide among the Acholi in Northern Uganda

BACKGROUND

Suicide is a public health problem in Uganda among indigenous societies, and different societies manage its aftermath differently.

AIM

To explore how the Acholi in Northern Uganda manage the aftermath of suicide.

METHODS

We conducted a qualitative study in Gulu district, a post-conflict area in Northern Uganda. We conducted a total of four focus group discussions (FGDs) and 12 key informant (KI) interviews. KI interviews were conducted with community leaders, while the FGDs were conducted with members of the general population. We analysed the data by means of Grounded Theory.

RESULTS

Our findings indicate that rituals form a large part in managing suicide among the Acholi. Study communities practised distancing (symbolically and physically) as a way of dealing with the threat of suicide.

CONCLUSION

Distancing was organized into two broad themes: affect regulation and securing future generations. It is recommended that public health interventions should utilize cultural institutions in the prevention of suicide.

How 'The Urge to Kill' Feels: Articulations of Emic 'Appetitive Aggression' Experiences Among Former Forcefully Recruited Children and Youth in the Acholi Region of Northern Uganda

Based on 10 months of fieldwork in the Acholi region of northern Uganda among youth and adults who were forcefully recruited into the Lord's Resistance Army (LRA) during the war, this article provides qualitative details to research on 'appetitive aggression.' Through two case-stories the article unfolds first person articulations of how 'appetitive aggression' is experienced as 'the urge to kill' and how it relates to the emic Acholi spiritual concept of 'cen'; a local Luo expression used to describe places and human beings possessed by evil spirits. The analysis illuminates what the individual and social implications of 'the urge to kill' and 'cen' entail for two Acholi men; first in a militia and then in a civil post-war context. The analysis then relates these findings to soldier experiences across cultures and time periods. While our analysis supports the findings in 'appetitive aggression' studies that appetitive aggression serves as a resilient protective factor against developing post-traumatic stress disorder (PTSD), this study documents that once the former forcefully recruited return to civilian life, 'appetitive aggression' and 'the urge to kill' precipitate individual and at times lethal social and moral complications in a fragile post-war community. Thus, the article argues that appetitive aggression and the emic perceptions and experiences of it among the local population are essential to consider in studies, processes and programs targeting demobilization, rehabilitation, reconciliation and re-integration.

Alcohol use in a rural district in Uganda: findings from community-based and facility-based cross-sectional studies

Background

Uganda has one of the highest per capita alcohol consumption rates in sub-Saharan Africa. However, the prevalence of alcohol use disorders (AUD) remains unknown in many areas, especially in rural districts. This study aimed to estimate the prevalence of alcohol consumption and of alcohol use disorder among men, and to describe the distribution of drinking intensity, among men in in Kamuli District, Uganda.

Methods

Men attending primary care clinics in Kamuli District were consecutively interviewed in a facility-based cross-sectional study, and a separate group of men were interviewed in a population-based cross-sectional study. In both studies the men were administered a structured questionnaire, which included the alcohol use disorder identification test (AUDIT) to screen for AUD, as well as sections about demographic characteristics, depression screening, internalized stigma for alcohol problems and treatment-seeking.

Results

Among the 351 men enrolled in the Community study, 21.8% consumed alcohol in the past 12 months, compared to 39.6% of 778 men in the Facility Survey. The proportion of men who screened positive for AUD was 4.1% in the community study and 5.8% in the facility study. AUDIT scores were higher among older men, men with paid/self-employment status and higher PHQ-9 score (P < 0.05). Nearly half (47.5%) of the men with AUDIT-positive scores reported that alcohol use problems had ruined their lives. A majority (55.0%) of men with AUDIT-positive scores did not seek treatment because they did not think AUD was a problem that could be treated.

Conclusions

Internalized stigma beliefs among AUDIT-positive men impede treatment-seeking. As part of any efforts to increase detection and treatment services for alcohol use problems, routine screening and brief interventions for internalized stigma must be incorporated within the normal clinical routine of primary health care.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0191-5) contains supplementary material, which is available to authorized users.

Substance Use and Self-Harm: Case Studies From Patients Admitted to an Urban Hospital Following Medically Serious Self-Harm

Few qualitative studies have explored the relationship between substance use and self-harm. We employed a multiple-case study research design to analyze data from 80 patients who were admitted to a hospital in South Africa following self-harm. Our analysis revealed, from the perspective of patients, a number of distinct ways in which substance use is implicated in self-harm. Some patients reported that substance intoxication resulted in poor decision making and impulsivity, which led to self-harm. Others said substance use facilitated their self-harm. Some participants detailed how in the past their chronic substance use had served an adaptive function helping them to cope with distress, but more recently, this coping mechanism had failed which precipitated their self-harm. Some participants reported that substance use by someone else triggered their self-harm. Findings suggest that there are multiple pathways and a host of variables which mediate the relationship between substance use and self-harm.

Suicide in Nepal: a modified psychological autopsy investigation from randomly selected police cases between 2013 and 2015

PURPOSE

Yearly, 600,000 people complete suicide in low- and middle-income countries, accounting for 75% of the world's burden of suicide mortality. The highest regional rates are in South and East Asia. Nepal has one of the highest suicide rates in the world; however, few investigations exploring patterns surrounding both male and female suicides exist. This study used psychological autopsies to identify common factors, precipitating events, and warning signs in a diverse sample.

METHODS

Randomly sampled from 302 police case reports over 24 months, psychological autopsies were conducted for 39 completed suicide cases in one urban and one rural region of Nepal.

RESULTS

In the total police sample (n = 302), 57.0% of deaths were male. Over 40% of deaths were 25 years or younger, including 65% of rural and 50.8% of female suicide deaths. We estimate the crude urban and rural suicide rates to be 16.1 and 22.8 per 100,000, respectively. Within our psychological autopsy sample, 38.5% met criteria for depression and only 23.1% informants believed that the deceased had thoughts of self-harm or suicide before death. Important warning signs include recent geographic migration, alcohol abuse, and family history of suicide.

CONCLUSIONS

Suicide prevention strategies in Nepal should account for the lack of awareness about suicide risk among family members and early age of suicide completion, especially in rural and female populations. Given the low rates of ideation disclosure to friends and family, educating the general public about other signs of suicide may help prevention efforts in Nepal.

A review of patients presenting to accident and emergency department with deliberate self-harm, KwaZulu-Natal, South Africa

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&amp;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&amp;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&amp;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.

Alcohol Consumption as a Risk Factor for Suicidal Behavior: A Systematic Review of Associations at the Individual and at the Population Level

The objective of this study was to provide an updated review of the magnitude of the relationship between alcohol use and suicidal behaviour at the individual and the population level. Systematic literature searches retrieved 14 reviews of individual level studies and 16 primary population level studies. Alcohol abuse and alcohol intoxication are often present in suicidal behaviour; risk of suicide is elevated in alcohol abusers and increasing population drinking tends to be associated with increase in suicide rates. Estimated magnitude of the relationship differs for men and women and it varies at the population level across cultures with different drinking pattern. These variations probably reflect gender differences and cultural variation in drinking behavior generally. Empirical evidence for a causal relationship is still urgently needed.

Alcohol use in South Sudan in relation to social factors, mental distress and traumatic events

BACKGROUND

Alcohol use is a major public health problem with vast implications for poor, war-torn countries. The objective of this study was to describe prevalence of alcohol use and risky drinking across socio-demographic factors in South Sudan, and to determine the association between risky drinking, traumatic events and mental distress.

METHODS

This is a randomized, population based, cross-sectional study from the north-western part of South Sudan with nearly 500 participants. We used the Alcohol Use Disorders Identification Test (AUDIT) as main outcome variable, the General Health Questionnaire (GHQ-28) for mental distress and five questions to assess traumatic events.

RESULTS

The mean AUDIT score was 2.7 (SD 0.3) with 14,2 % in the high risk problem drinking category. Being male, lack of a regular income and psychological distress were significantly associated with higher AUDIT score. Traumatic events, however, was not associated with higher score on AUDIT.

CONCLUSION

Despite decades of civil war and great poverty the alcohol use in this population was at the same level as other countries in Southern Africa. Traumatic events were not related to risk of problem drinking.

Alcohol use among adults in Uganda: findings from the countrywide non-communicable diseases risk factor cross-sectional survey

Background

There are limited data on levels of alcohol use in most sub-Saharan African countries.

Objective

We analyzed data from Uganda's non-communicable diseases risk factor survey conducted in 2014, to identify alcohol use prevalence and associated factors.

Design

The survey used the World Health Organization STEPS tool to collect data, including the history of alcohol use. Alcohol users were categorized into low-, medium-, and high-end users. Participants were also classified as having an alcohol-use-related disorder if, over the past 12 months, they were unable to stop drinking alcohol once they had started drinking, and/or failed to do what was normally expected of them because of drinking alcohol, and/or needed an alcoholic drink first in the morning to get going after a heavy drinking session the night before. Weighted logistic regression analysis was used to identify factors associated with medium- to high-end alcohol use.

Results

Of the 3,956 participants, 1,062 (26.8%) were current alcohol users, including 314 (7.9%) low-end, 246 (6.2%) medium-end, and 502 (12.7%) high-end users. A total of 386 (9.8%) were classified as having an alcohol-use-related disorder. Male participants were more likely to be medium- to high-end alcohol users compared to females; adjusted odds ratio (AOR)=2.34 [95% confidence interval (CI)=1.88–2.91]. Compared to residents in eastern Uganda, participants in central and western Uganda were more likely to be medium- to high-end users; AOR=1.47 (95% CI=1.01–2.12) and AOR=1.89 (95% CI=1.31–2.72), respectively. Participants aged 30–49 years and those aged 50–69 years were more likely to be medium- to high-end alcohol users, compared to those aged 18–29 years, AOR=1.49 (95% CI=1.16–1.91) and AOR=2.08 (95% CI=1.52–2.84), respectively.

Conclusions

The level of alcohol use among adults in Uganda is high, and 9.8% of the adult population has an alcohol-use-related disorder.

Gender and age disparities in adult undernutrition in northern Uganda: high-risk groups not targeted by food aid programmes

OBJECTIVE

To determine the prevalence of adult malnutrition and associated risk factors in a post-conflict area of northern Uganda.

METHODS

A cross-sectional community survey was performed from September 2011 to June 2013. All registered residents in Gulu Health and Demographic Surveillance System aged 15 years and older were considered eligible. Trained field assistants collected anthropometric measurements (weight and height) and administered questionnaires with information on sociodemographic characteristics, food security, smoking and alcohol. Nutritional status was classified by body mass index.

RESULTS

In total, 2062 men and 2924 women participated and were included in the analyses. The prevalence of underweight was 22.3% for men and 16.0% for women, whereas the prevalence of overweight was 1.5% for men and 7.6% for women. In men, underweight was associated with younger (15-19 years) and older age (>55 years) (P < 0.001), being divorced/separated [odds ratio (OR) = 1.91 (95% confidence interval (CI): 1.21-2.99] and smoking (OR = 2.13, 95% CI: 1.67-2.73). For women, underweight was associated with older age (P < 0.001) and hungry-gap rainy season (May-July) (OR = 1.33, 95% CI: 1.04-1.69). Widowed or divorced/separated women were not more likely to be underweight. No association was found between education, alcohol consumption or food security score and underweight.

CONCLUSIONS

Our findings are not in line with the conventional target groups in nutritional programmes and highlight the importance of continuous health and nutritional assessments of all population groups that reflect local social determinants and family structures.

Mediators of the relation between war experiences and suicidal ideation among former child soldiers in Northern Uganda: the WAYS study

BACKGROUND

Globally, suicide is a public health burden especially in the aftermath of war. Understanding the processes that define the path from previous war experiences (WE) to current suicidal ideation (SI) is crucial for defining opportunities for interventions. We assessed the extent to which different types of previous WE predict current SI and whether post-war hardships and depression mediate the relations between WE and SI among former child soldiers (FCS) in Northern Uganda.

METHODS

We performed cross-sectional analyses with a sample of 539 FCS (61% male) participating in an on-going longitudinal study. The influence of various types of previous WE on current SI and mediation by post-war hardships and depression were assessed by regression analyses.

RESULTS

The following types of war experiences: "witnessing violence", "direct personal harm", "deaths", "Involvement in hostilities", "sexual abuse" and "general war experiences" significantly predicted current SI in a univariable analyses whereas "direct personal harm", "involvement in hostilities", and "sexual abuse" independently predicted current SI in a multivariable analyses. General WE were linked to SI (β = 0.18 (95% CI 0.10 to 0.25)) through post-war hardships (accounting for 69% of the variance in their relationship) and through depression/anxiety (β = 0.17 (95% CI 0.12 to 0.22)) accounting for 65% of the variance in their relationship. The direct relationship between previous WE and current SI reduced but remained marginally significant (β = .08, CI: (.01, .17) for depression/anxiety but not for post-war hardships (β = .09, CI: (-.03, .20).

CONCLUSION

Types of WE should be examined when assessing risks for SI. Interventions to reduce SI should aim to alleviate post-war hardships and treat depression/anxiety.

Suicidal behaviour across the African continent: a review of the literature

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.

Individual and community level risk-factors for alcohol use disorder among conflict-affected persons in Georgia

BACKGROUND

The evidence on alcohol use disorder among conflict-affected civilian populations remains extremely weak, despite a number of potential risk-factors. The aim of this study is to examine patterns of alcohol use disorder among conflict-affected persons in the Republic of Georgia.

METHODS

A cross-sectional survey of 3600 randomly selected internally displaced persons (IDPs) and former IDPs. Two alcohol use disorder outcomes were measured: (i) having at least hazardous alcohol use (AUDIT score ≥ 8); (ii) episodic heavy drinking (consuming >60 grams of pure alcohol per drinking session at least once a week). Individual level demographic and socio-economic characteristics were also recorded, including mental disorders. Community level alcohol environment characteristics relating to alcohol availability, marketing and pricing were recorded in the respondents' communities and a factor analysis conducted to produce a summary alcohol environment factor score. Logistic regression analyses examined associations between individual and community level factors with the alcohol use disorder outcomes (among men only).

RESULTS

Of the total sample, 71% of men and 16% of women were current drinkers. Of the current drinkers (N = 1386), 28% of men and 1% of women were classified as having at least hazardous alcohol use; and 12% of men and 2% of women as episodic heavy drinkers. Individual characteristics significantly associated with both outcomes were age and experiencing a serious injury, while cumulative trauma events and depression were also associated with having at least hazardous alcohol use. For the community level analysis, a one unit increase in the alcohol environment factor was associated with a 1.27 fold increase in episodic heavy drinking among men (no significant association with hazardous alcohol use).

CONCLUSION

The findings suggest potential synergies for treatment responses for alcohol use disorder and depression among conflict-affected populations in Georgia, as well as the need for stronger alcohol control policies in Georgia.

Prevalence and patterns of hazardous and harmful alcohol consumption assessed using the AUDIT among Bhutanese refugees in Nepal

AIMS

This study sought to ascertain the prevalence of hazardous and harmful alcohol consumption among Bhutanese refugees in Nepal and to identify predictors of elevated risk in order to better understand intervention need.

METHODS

Hazardous and harmful alcohol consumption was assessed using the Alcohol Use Disorder Identification Test (AUDIT) administered in a face-to-face interview in a census of two camps comprising ∼8000 refugees.

RESULTS

Approximately 1/5 men and 1/14 women drank alcohol and prevalence of hazardous drinking among current drinkers was high and comparable to that seen in Western countries with longstanding alcohol cultures. Harmful drinking was particularly associated with the use of other substances including tobacco.

CONCLUSIONS

Assessment of the alcohol-related needs of Bhutanese refugees has permitted the design of interventions. This study adds to the small international literature on substance use in forced migration populations, about which there is growing concern.

An escape from agony: a qualitative psychological autopsy study of women's suicide in a post-conflict northern Uganda

We set out to investigate suicide among women in a post-conflict context in Northern Uganda using qualitative psychological autopsy interviews. Three to five relatives and friends for each of the three suicides recruited were interviewed (N=11). Through interpretative phenomenological analysis (IPA) we found that the women all had been through traumatic experiences attributable to the protracted war/conflict between the rebel groups and Ugandan Government armed forces. Nevertheless, the decision of self-inflicted death seemed to have been due to a combination of unpleasant experiences/events that prevailed within the last 3 months prior to the suicide. These experiences are summarized in two broad themes: No control in life and No care. Changes in the traditional gender roles, men's quest for their lost masculinity, and women's attempt to fight for their rights that was perceived as a cultural transgression contributed to the women's suicides.