Potential Interventions for Preventing Pesticide Self-Poisoning by Restricting Access Through Vendors in Sri Lanka

Exploring fidelity of enactment in a cluster randomised controlled trial testing the effectiveness of 'gatekeeper' training for pesticide vendors in reducing self-poisoning in rural Sri Lanka: protocol for a multimethod qualitative study

INTRODUCTION

Pesticide self-poisoning causes severe health and socioeconomic hardship in low- and middle-income countries, including Sri Lanka. A stepped-wedge cluster randomised controlled trial (cRCT) has been designed to test whether 'gatekeeper' training for pesticide vendors reduces pesticide self-poisoning in rural Sri Lanka (Vendor cRCT). Ensuring intervention fidelity in RCTs is essential for consistently replicating interventions, accurately assessing their impact and improving outcomes. Thus, the overarching goal of this proposed study is to explore to what extent the pesticide vendors use the 'gatekeeper' strategies.

METHODS AND ANALYSIS

A multimethod qualitative research design is being used to explore the pesticide-selling behaviours of vendors after the 'gatekeeper' training. A subsample of the Vendor cRCT Study population is being recruited using a stratified purposive sampling method in all six intervention districts in Sri Lanka to ensure that the sample is representative of the pesticide vendors in the study area. Participant diaries, observations and focus group discussions are being adopted to collect data. Data triangulation will be performed and data will be analysed thematically.

ETHICS AND DISSEMINATION

The study was approved by the Ethics and Research Committee, Faculty of Medicine and Allied Sciences, at the Rajarata University of Sri Lanka (ERC/2023/09). All participants will provide informed consent. Findings will be disseminated in scientific peer-reviewed journals and conference presentations.

Alcohol use, self-harm and suicide: a scoping review of its portrayal in the Sri Lankan literature

Background

Suicide is a global public health problem. Compared to other middle-income countries, much literature has been generated on the topic of self-harm and suicide in Sri Lanka. Harmful use of alcohol is a well-known risk factor to self-harm and suicide, however the connection needed further exploration.

Aim

The aim was to investigate alcohol's role in self-harm and suicide in Sri Lanka to inform policy and prevention programs and future research priorities.

Methods

We performed a scoping review exploring how the association between alcohol use, self-harm and suicide in Sri Lanka is presented in scientific literature from August 1, 2008 to December 31, 2022. Thematic analysis was used to explore emerging themes.

Results

Altogether 116 peer-reviewed articles were included. Three themes emerged: (i) gendered, inter-relational explanations of alcohol's role in self-harm, (ii) hospital management of patients who co-ingested alcohol and pesticides, and (iii) proposed research and interventions targeting alcohol, self-harm and suicide. The articles' recommendations for policy, prevention and research priorities included: Family- and community-based alcohol, self-harm and suicide reduction interventions; viewing self-harm as a window of opportunity for health personnel to intervene in families affected by harmful alcohol consumption; and introduction of and increased access to treatment of alcohol use disorder at the individual level.

Conclusion

Suggestions for alcohol, self-harm, and suicide prevention interventions were primarily targeted at the community, though this might also reflect the limited treatment, mental health, and alcohol support available in the country. Future research should explore and test context-appropriate interventions integrating alcohol and self-harm prevention and treatment.

Gatekeeper training for vendors to reduce pesticide self-poisoning in rural South Asia: a study protocol for a stepped-wedge cluster randomised controlled trial

INTRODUCTION

Pesticide self-poisoning kills an estimated 110 000-168 000 people worldwide annually. Data from South Asia indicate that in 15%-20% of attempted suicides and 30%-50% of completed suicides involving pesticides these are purchased shortly beforehand for this purpose. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such customers. We have developed a 'gatekeeper' training programme for vendors to enable them to identify individuals at high risk of self-poisoning (gatekeeper function) and prevent such individuals from accessing pesticides (means restriction). The primary aim of the study is to evaluate the effectiveness of the gatekeeper intervention in preventing pesticide self-poisoning in Sri Lanka. Other aims are to identify method substitution and to assess the cost and cost-effectiveness of the intervention.

METHODS AND ANALYSIS

A stepped-wedge cluster randomised trial of a gatekeeper intervention is being conducted in rural Sri Lanka with a population of approximately 2.7 million. The gatekeeper intervention is being introduced into 70 administrative divisions in random order at each of 30 steps over a 40-month period. The primary outcome is the number of pesticide self-poisoning cases identified from surveillance of hospitals and police stations. Secondary outcomes include: number of self-poisoning cases using pesticides purchased within the previous 24 hours, total number of all forms of self-harm and suicides. Intervention effectiveness will be estimated by comparing outcome measures between the pretraining and post-training periods across the divisions in the study area. The original study protocol has been adapted as necessary in light of the impact of the COVID-19.

ETHICS AND DISSEMINATION

The Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University, Sri Lanka (ERC/2018/30), and the ACCORD Medical Research Ethics Committee, Edinburgh University (18-HV-053) approved the study. Results will be disseminated in scientific peer-reviewed journals.

TRIAL REGISTRATION NUMBER

SLCTR/2019/006, U1111-1220-8046.

Relationship of the high proportion of suicidal acts involving ingestion of pesticides to the low male-to-female ratio of suicide rates in China

AIMS

The 2014 World Health Organization report on global suicide identified large differences in the male-to-female ratio of suicide rates between countries: most high-income countries (HICs) report ratios of 3:1 or higher while many low- and middle-income countries (LMICs) - including China and India - report ratios of less than 1.5:1. Most authors suggest that gender-based social-cultural factors lead to higher rates of suicidal behaviour among women in LMICs and, thus, to relatively high female suicide rates. We aim to test an alternative hypothesis: differences in the method and case-fatality of suicidal behaviour - not differences in the rates of suicidal behaviour - are the main determinants of higher female suicide rates in LMICs.

METHODS

A prospective registry of suicide attempts treated in all 14 general hospitals in a rural county in China was established and data from the registry were integrated with population and mortality data from the same county from 2009 to 2014.

RESULTS

There were 160 suicides and 1010 medically-treated suicidal attempts in the county; 84% of female suicides and 58% of male suicides ingested pesticides while 73% of female attempted suicides and 72% of male attempted suicides ingested pesticides. The suicide rate (per 100 000 person-years of exposure) was 8.4 in females and 9.1 in males (M:F ratio = 1.08:1) while the incidence of 'serious suicidal acts' (i.e. those that result in death or received treatment in a hospital) was 81.5 in females and 47.7 in males (M:F ratio = 0.59:1). The case-fatality of serious suicidal acts was higher in males than in females (19 v. 10%), increased with age, was highest for violent methods (92%), intermediate for pesticide ingestion (13%) and lowest for other methods (5%).

CONCLUSIONS

The incidence of medically serious suicidal behaviour among females in rural China was similar to that reported in HICs, but the case-fatality was much higher, primarily because most suicidal acts involved the ingestion of pesticides, which had a higher case-fatality than methods commonly used by women in HICs. These findings do not support sociological explanations for the relatively high female suicide rate in China but, rather, suggest that gender-specific method choice and the case-fatality of different methods are more important determinants of the demographic profile of suicide rates. Further research that involves ongoing monitoring of the changing incidence, demographic profile and case-fatality of different suicidal methods in urban and rural parts of both LMICs and HICs is needed to confirm this hypothesis.

Suicide Prevention in the Southeast Asia Region

This chapter provides an update on suicide and suicide prevention in the Southeast Asia Region, which covers 11 low- and middle-income countries, accounting for 26% of the world's population. More than one third (39%) of all suicides globally, occur in this region, with the highest suicide rate of 17.7 per 100,000, which is likely to be an underestimate due to differences in study populations, research methodology, and uncomprehensive data registration systems. The risk profile of people who die by suicide and the characteristics of suicides in Southeast Asia are distinctly different from other regions in many ways. In this region the male-female ratio for suicide is closer to 1, compared with 3:5 in higher-income countries, and the overall reported prevalence of mental disorders, such as depression or other psychiatric conditions, is lower. Both older people and adolescents show the highest rates of suicide. Suicide involving pesticide poisoning is the most common method used in both rural and urban areas in countries in this region. Updates are provided on national and regional suicide prevention activities in Bangladesh, Bhutan, Nepal, India, Sri Lanka, and Thailand.