An investigation into the role of alcohol in self-harm in rural Sri Lanka: a protocol for a multimethod, qualitative study

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.

Factors associated with purchasing pesticide from shops for intentional self-poisoning in Sri Lanka

OBJECTIVE

In South Asia, up to one in five individuals who ingest pesticides for self-poisoning and survive purchased them from a shop immediately prior to the event. Thus far, no research has taken place to determine whether interventions implemented through the pesticide sellers might be acceptable or effective, despite the hundreds of thousands of such risk purchases each year. We aimed to investigate factors associated with purchasing pesticides for self-poisoning in Sri Lanka.

METHODS

We used a case-control study. Cases (n = 50) were individuals who ingested pesticides after purchasing them for the act, and controls (n = 200) were customers who bought pesticides but did not use them for self-harm. Logistic regression analysis was used to assess socio-demographic and purchase-specific risk factors.

RESULTS

Alcohol intoxication (adjusted odds ratios [AOR] 36.5, 95% confidence intervals [CI] 1.7-783.4) and being a non-farmer AOR 13.3, 95% CI 1.8-99.6 were the main distinguishing factors when purchasing pesticides for self-poisoning. The positive predictive values were 93.3% (95% CI 68.0-99.8%) and 88.2% (95% CI 72.5-96.7%), respectively. One and/or other of these factors characterised 72.0% of cases but only 2.5% controls.

CONCLUSION

While results need to be interpreted cautiously, sales restrictions to prevent alcohol-intoxicated persons and non-farmers purchasing pesticides for self-poisoning may be effective.

Attempted suicide in Sri Lanka - An epidemiological study of household and community factors

BACKGROUND

An individual's suicide risk is determined by personal characteristics, but is also influenced by their environment. Previous studies indicate a role of contextual effects on suicidal behaviour, but there is a dearth of quantitative evidence from Asia.

METHODS

Individual and community level data were collected on 165,233 people from 47,919 households in 171 communities in rural Sri Lanka. Data were collected on individual (age, sex, past suicide attempts and individual socioeconomic position (SEP)) and household (household SEP, pesticide access, alcohol use and multigenerational households) level factors. We used 3-level logit models to investigate compositional (individual) and contextual (household/community) effects.

RESULTS

We found significant variation between households 21% (95% CI 18%, 24%) and communities 4% (95% CI 3%, 5%) in the risk of a suicide attempt. Contextual factors as measured by low household SEP (OR 2.37 95% CI 2.10, 2.67), low community SEP (OR 1.45 95% CI 1.21, 1.74), and community 'problem' alcohol use (OR 1.44 95% CI 1.19, 1.75) were associated with an increased risk of suicide attempt. Women living in households with alcohol misuse were at higher risk of attempted suicide. We observed a protective effect of living in multigenerational households (OR 0.53 95% CI 0.42, 0.65).

LIMITATIONS

The outcome was respondent-reported and refers to lifetime reports of attempted suicide, therefore this study might be affected by socially desirable responding.

CONCLUSIONS

Our study finds that contextual factors are associated with an individual's risk of attempted suicide in Sri Lanka, independent of an individual's personal characteristics.

'We lost because of his drunkenness': the social processes linking alcohol use to self-harm in the context of daily life stress in marriages and intimate relationships in rural Sri Lanka

Introduction

Harmful alcohol use has been found to cause detriment to the consumers and those around them. Research carried out in Sri Lanka has described the socioeconomic consequences to families owing to alcohol consumption. However, the social processes around alcohol use and how it could result in behaviour such as self-harm was unclear. With an outset in daily life stressors in marriages and intimate relationships we explored alcohol use in families with a recent case of self-harm.

Methods

Qualitative data were collected for 11 months in 2014 and 2015 in the North Central and North Western provinces of Sri Lanka. Narrative life story interviews with 19 individuals who had self-harmed where alcohol was involved and 25 of their relatives were conducted. Ten focus group discussions were carried out in gender and age segregated groups. An inductive content analysis was carried out.

Results

Participants experienced two types of daily life stressors: non-alcohol-related stressors, such as violence and financial difficulties, and alcohol-related stressors. The alcohol-related stressors aggravated the non-alcohol-related daily life stressors within marriages and intimate relationships, which resulted in conflict between partners and subsequent self-harm. Women were disproportionately influenced by daily life stressors and were challenged in their ability to live up to gendered norms of marriage. Further, women were left responsible for their own and their husband’s inappropriate behaviour. Self-harm appeared to be a possible avenue of expressing distress. Gendered alcohol and marriage norms provided men with acceptable excuses for their behaviour, whether it was alcohol consumption, conflicts or self-harm.

Conclusions

This study found that participants experienced both alcohol-related and non-alcohol-related daily life stressors. These two categories of daily life stressors, gender inequalities and alcohol norms should be considered when planning alcohol and self-harm prevention in this setting. Life situations also reflected larger community and structural issues.