Cause of Death in Women of Reproductive Age in Rural Nepal Obtained Through Community-Based Surveillance: Is Reducing Maternal Mortality the Right Priority for Women's Health Programs?

Studying Scripts of Women, Men and Suicide: Qualitative-Method Development and Findings from Nepal

Information about suicidal behavior in Nepal is limited. According to official records, suicide rates were high until the year 2000 and declined thereafter. Official records are considered unreliable and a gross undercounting of suicide cases, particularly female cases. Suicide research in Nepal has been mostly epidemiologic and hospital-based. Little is known about how suicide is understood by Nepali people in general-including dominant suicide attitudes and beliefs in Nepal. Suicide attitudes and beliefs, which are elements of a culture's suicide scripts, predict actual suicidality. Drawing on suicide-script theory, we developed and used a semi-structured survey to explore Nepali beliefs about female and male suicide. The informants were adult (Mage = 28.4) university students (59% male). Female suicide was believed to be a response to the society-sanctioned oppression and abuse that women are subjected to, in their family and community. The prevention of female suicide was viewed as requiring dismantling ideologies, institutions, and customs (e.g., child marriage, dowry) that are oppressive to women, and ensuring that women are protected from violence and have equal social and economic rights and opportunities. Male suicide was believed to be a symptom of societal problems (e.g., unemployment) and of men's psychological problems (e.g., their difficulties in managing emotions). The prevention of male suicide was viewed as requiring both societal (e.g., employment opportunities) and individual remedies (e.g., psychological counseling). This study's findings suggest that a semi-structured survey can be a fruitful method to access the suicide scripts of cultures about which there is limited research.

Perception of the criminality of attempted suicide in Nepal and its impact on suicide reporting

In 2018-2019, according to the official statistics, 5754 people died as a result of suicide in Nepal. This is a high number for a country with a population of 29 million people. Experts believe that the actual rate is considerably higher and that many suicides are not reported. This underreporting of suicide is frequently blamed on the stigma and the criminality of attempted suicide. Yet, there has never been a criminal liability for attempted suicide in Nepal. This article discusses the reasons for the perception of the criminality of attempted suicide in the country, its consequences, and the ways of addressing them. We found that the involvement of the police at the initial stages of suicide investigation confirms public perceptions that attempted suicide is a punishable offense and this may reinforce the stigma of suicide. Recent criminalization of the abetment of suicide has contributed to this perception as the public may not be clear about the distinction between abetment of suicide and attempted suicide. Criminalization of suicide not in the laws but in minds discourages reporting and help-seeking behaviour and victimizes people who need support and services. We argue that decriminalization is more than removing the outdated legal clauses from the legal statutes, but also public awareness raising about the reasons for police investigation of suspicious deaths, sensitivity training, and education of government officials, policymakers, and police about suicide and its prevention. These are needed to dispel the myth of criminalization of attempted suicide in Nepal. Our findings could be of wider interest to scholars working on reducing the stigma of suicide and decriminalization of suicide attempts.

Suicide and deliberate self-harm among women in Nepal: a scoping review

Background

Suicide is a growing public health problem globally. Suicide accounts for 70% of violent deaths among women in low and middle income countries. In Nepal suicide is the single leading cause of death among women of reproductive age. The aim of this scoping review is to explore and understand the various contexts related to vulnerability of Nepalese woman towards suicide and deliberate self-harm.

Methods

A scoping review based on Arksey and O’Malley’s methodological framework including a combination of peer-reviewed publications and grey literature was conducted. The National Library of Medicine’s PubMed and Google Scholar search engines were used during July 2019 applying a Boolean search strategy.

Results

Suicide incidence was found to be higher among younger age group and married women, with poisoning as the most common means of suicide. Psychosocial and economic factors such as abuse, interpersonal conflicts, marital disputes, relationship problems, adjustment problems, unpaid loans and financial losses; and mental health conditions such as mood disorder, adjustment disorder and substance abuse disorder were found to be contributing factors for suicide and deliberate self-harm among women in Nepal.

Conclusion

Socio-cultural and economic factors shape family and marital relationships which impacts psycho-social and mental wellbeing of women in Nepal inciting suicidal attempts and deliberate self-harm. However, very few studies were found that explore the context of poverty, social exclusion, gender inequality, education, traditional/cultural and patriarchal system in which suicide among women in Nepal occurs.

Community-based surveillance: A scoping review

Background

Involving community members in identifying and reporting health events for public health surveillance purposes, an approach commonly described as community-based surveillance (CBS), is increasingly gaining interest. We conducted a scoping review to list terms and definitions used to characterize CBS, to identify and summarize available guidance and recommendations, and to map information on past and existing in-country CBS systems.

Methods

We searched eight bibliographic databases and screened the worldwide web for any document mentioning an approach in which community members both collected and reported information on health events from their community for public health surveillance. Two independent reviewers performed double blind screening and data collection, any discrepancy was solved through discussion and consensus.

Findings

From the 134 included documents, several terms and definitions for CBS were retrieved. Guidance and recommendations for CBS were scattered through seven major guides and sixteen additional documents. Seventy-nine unique CBS systems implemented since 1958 in 42 countries were identified, mostly implemented in low and lower-middle income countries (79%). The systems appeared as fragmented (81% covering a limited geographical area and 70% solely implemented in a rural setting), vertical (67% with a single scope of interest), and of limited duration (median of 6 years for ongoing systems and 2 years for ended systems). Collection of information was mostly performed by recruited community members (80%).

Interpretation

While CBS has already been implemented in many countries, standardization is still required on the term and processes to be used. Further research is needed to ensure CBS integrates effectively into the overall public health surveillance system.

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.

An Investigation into Suicides Among Bhutanese Refugees Resettled in the United States Between 2008 and 2011

An increase of Bhutanese refugee suicides were reported in the US between 2009 and 2012. This investigation examined these reported suicides in depth to gain a better understanding of factors associated with suicide within this population. The study employed 14 psychological autopsies to elicit underlying motivations and circumstances for self-inflicted death and to identify potential future avenues for prevention and intervention among refugee communities. Disappointment with current (un)employment, lack of resettlement services and social support, and frustrations with separation from family were believed to contribute to suicidal acts. Suicide within refugee populations may be connected with experiences of family withdrawal, integration difficulties, and perceived lack of care. It is important to assess the effectiveness of improving refugee services on the mental health of migrants. More research is needed in order to better understand, and respond to, suicide in resettled populations.

Dose of antivenom for the treatment of snakebite with neurotoxic envenoming: Evidence from a randomised controlled trial in Nepal

BACKGROUND

Currently, there is inadequate evidence on which to base clinical management of neurotoxic snakebite envenoming, especially in the choice of initial antivenom dosage. This randomised controlled trial compared the effectiveness and safety of high versus low initial antivenom dosage in victims of neurotoxic envenoming.

METHODOLOGY/ PRINCIPAL FINDINGS

This was a balanced, randomised, double-blind trial that was conducted in three health care centers located in the Terai plains of Nepal. Participants received either low (two vials) or high (10 vials) initial dosage of Indian polyvalent antivenom. The primary composite outcome consisted of death, the need for assisted ventilation and worsening/recurrence of neurotoxicity. Hourly evaluations followed antivenom treatment. Between April 2011 and October 2012, 157 snakebite victims were enrolled, of which 154 were analysed (76 in the low and 78 in the high initial dose group). Sixty-seven (43·5%) participants met the primary outcome definition. The proportions were similar in the low (37 or 48.7%) vs. high (30 or 38.5%) initial dose group (difference = 10·2%, 95%CI [-6·7 to 27·1], p = 0·264). The mean number of vials used was similar between treatment groups. Overall, patients bitten by kraits did worse than those bitten by cobras. The occurrence of treatment-related adverse events did not differ among treatment groups. A total of 19 serious adverse events occurred, including seven attributed to antivenom.

CONCLUSIONS

This first robust trial investigating antivenom dosage for neurotoxic snakebite envenoming shows that the antivenom currently used in Nepal performs poorly. Although the high initial dose regimen is not more effective than the low initial dose, it offers the practical advantage of being a single dose, while not incurring higher consumption or enhanced risk of adverse reaction. The development of new and more effective antivenoms that better target the species responsible for bites in the region will help improve future patients' outcomes.

TRIAL REGISTRATION

The study was registered on clinicaltrials.gov (NCT01284855) (GJ 5/1).

Suicide surveillance and health systems in Nepal: a qualitative and social network analysis

BACKGROUND

Despite increasing recognition of the high burden of suicide deaths in low- and middle-income countries, there is wide variability in the type and quality of data collected and reported for suspected suicide deaths. Suicide data are filtered through reporting systems shaped by social, cultural, legal, and medical institutions. Lack of systematic reporting may underestimate public health needs or contribute to misallocation of resources to groups most at risk.

METHODS

The goal of this study was to explore how institutional structures, cultural perspectives on suicide, and perceived criminality of self-harm influence the type and quality of suicide statistics, using Nepal as an example because of its purported high rate of suicide in the public health literature. Official documentation and reporting networks drawn by police, policy makers, and health officials were analyzed. Thirty-six stakeholders involved in various levels of the death reporting systems in Nepal participated in in-depth interviews and an innovative drawn surveillance system elicitation task.

RESULTS

Content analysis and social network analysis revealed large variation across the participants perceived networks, where some networks were linear pathways dominated by a single institution (police or community) with few nodes involved in data transmission, while others were complex and communicative. Network analysis demonstrated that police institutions controlled the majority of suicide information collection and reporting, whereas health and community institutions were only peripherally involved. Both health workers and policy makers reported that legal codes criminalizing suicide impaired documentation, reporting, and care provision. However, legal professionals and law review revealed that attempting suicide is not a crime punishable by incarceration. Another limitation of current reporting was the lack of attention to male suicide.

CONCLUSIONS

Establishment and implementation of national suicide prevention strategies will not be possible without reliable statistics and comprehensive standardized reporting practices. The case of Nepal points to the need for collaborative reporting and accountability shared between law enforcement, administrative, and health sectors. Awareness of legal codes among health workers, in particular dispelling myths of suicide's illegality, is crucial to improve mental health services and reporting practices.

Use of Molecular Diagnostic Tools for the Identification of Species Responsible for Snakebite in Nepal: A Pilot Study

Snakebite is an important medical emergency in rural Nepal. Correct identification of the biting species is crucial for clinicians to choose appropriate treatment and anticipate complications. This is particularly important for neurotoxic envenoming which, depending on the snake species involved, may not respond to available antivenoms. Adequate species identification tools are lacking. This study used a combination of morphological and molecular approaches (PCR-aided DNA sequencing from swabs of bite sites) to determine the contribution of venomous and non-venomous species to the snakebite burden in southern Nepal. Out of 749 patients admitted with a history of snakebite to one of three study centres, the biting species could be identified in 194 (25.9%). Out of these, 87 had been bitten by a venomous snake, most commonly the Indian spectacled cobra (Naja naja; n = 42) and the common krait (Bungarus caeruleus; n = 22). When both morphological identification and PCR/sequencing results were available, a 100% agreement was noted. The probability of a positive PCR result was significantly lower among patients who had used inadequate "first aid" measures (e.g. tourniquets or local application of remedies). This study is the first to report the use of forensic genetics methods for snake species identification in a prospective clinical study. If high diagnostic accuracy is confirmed in larger cohorts, this method will be a very useful reference diagnostic tool for epidemiological investigations and clinical studies.

Maternal Deaths Account for a Small Proportion of the Total Deaths Among Reproductive Age Women

BACKGROUND

For more than 30 years, the focus for women's health in low- and middle-income countries has been on reductions in maternal mortality. This perception was reinforced by the choice of the maternal mortality ratio as the primary indicator for women's health in the Millennium Development Goals. This analysis provides a more objective view by comparing the relative magnitudes of mortality among reproductive age women during pregnancy and the 6-week postpartum period versus other periods during this age range.

MATERIALS AND METHODS

Data were aggregated from 38 countries in three regions with Demographic and Health Surveys that contained a maternal mortality module and were conducted in the prior 10 years to derive the proportion of total mortality ascribed to maternal mortality (proportion maternal [PM]) among women 15-49 years of age in 5-year age groups by country, region, and human immunodeficiency virus (HIV) prevalence. Estimates of maternal and nonmaternal deaths were based on the sisterhood method. Age-adjusted PM ranged from 5.7% in Swaziland to 41.7% in Timor-Leste. Regional averages were 14.3% in Latin America and the Caribbean, 24.2% in Asia, and 19.8% in sub-Saharan Africa (SSA). The age-specific pattern of PM showed an increasing trend into the mid-30s followed by a decline. The age-adjusted PM for each country in SSA stratified by HIV prevalence showed an inverse relationship between HIV prevalence and PM with countries with high and low HIV at the lower and upper ends of the PM distribution, respectively.

CONCLUSIONS

Maternal deaths account for only 6%-40% of all deaths occurring among reproductive age women in a selection of low- and middle-income countries. Although a continued focus and push to reduce maternal mortality is warranted, attention to other causes of death and health issues for women of reproductive age is clearly needed. Research on the causes of death among women and prevention and treatment policies that provide health, education, and nutrition services to women need to be a priority.