A central storage facility to reduce pesticide suicides--a feasibility study from India

Suicide and suicide behavior: A qualitative study in Telangana, India

This study aimed to understand the perceptions and experiences of suicide attempters in order to suggest potential initiatives to reduce the suicide burden in rural India. The study is based on 46 in-depth interviews with suicide attempters and 4 focus group discussions with their family members. Interview content analysis revealed information related to four anticipated themes: the characteristics of a suicide attempt are complex; suicide attempters are taken to public hospitals for first aid and treatment; the consequences of suicide attempts are diverse; and quality of life improved after the suicide attempt. There were also two unanticipated themes: suicide attempters sought help from potential rescuers; and the underreporting of suicide attempts. Emergent themes from the focus group discussions were the vulnerable group for suicide; poverty, indebtedness, family conflicts and unemployment are the main reasons for suicide; non-violent methods are used to commit suicide; there were no behavioral changes before suicide; the devastating effects on the families of decedents; positive community support to suicide survivor families; and expectations of preventive measures from both the community and government. The article argues that to reduce the suicide burden, the government should adopt a two-pronged strategy of creating a secure livelihood all-year round and providing psychological counseling at both the household and community levels.

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.

Addressing State-Based Differences in Suicide Fatalities Among Children and Adolescents-Finding Another Way

This Viewpoint uses state-based data obtained from the National Center for Health Statistics’ Web-Based Injury Statistics Query and Reporting System to discuss the importance of legislatively addressing firearm-related suicide fatalities among children and adolescents in the US.

Surveillance of pesticide poisoning in an East and a West Malaysian hospital: characteristics of pesticide poisoning and the early impact of a national Paraquat ban

BACKGROUND

Previous studies have shown that pesticide bans were associated with reduced fatal pesticide self-poisoning cases in high, and low-and-middle-income countries. We aimed to investigate the characteristics of pesticide poisoning patients admitted to two Malaysian hospitals and the early impact of the national paraquat ban implemented on 1st January 2020 in a culturally heterogenous South-East-Asian upper-middle-income setting.

METHODS

Data were collected from an East (Bintulu) and a West (Ipoh) Malaysian hospital medical records in 2015-2021 and 2018-2021, respectively. Logistic regression analyses were conducted to investigate the association of aspects such as socio-demographic and clinical characteristics, paraquat ban with the types of pesticides involved (paraquat versus non-paraquat versus unknown) ,and the outcomes (fatal versus non-fatal).

RESULTS

From the study sample of 212 pesticide poisoning patients aged 15 years or above, the majority were self-poisoning cases (75.5%) with a disproportionate over-representation of Indian ethnic minority (44.8%). Most pesticide poisoning cases had socio-environmental stressors (62.30%). The commonest stressors were domestic interpersonal conflicts (61.36%). 42.15% of pesticide poisoning survivors had a psychiatric diagnosis. Paraquat poisoning accounted for 31.6% of all patients and 66.7% of fatalities. Case fatality was positively associated with male gender, current suicidal intent, and paraquat poisoning. After the paraquat ban, the proportion of pesticide poisoning cases using paraquat decreased from 35.8 to 24.0%, and the overall case-fatality dropped slightly from 21.2 to 17.3%.

CONCLUSIONS

Socio-environmental stressors in specific domestic interpersonal conflicts, seemed more prominent in pesticide poisoning compared to psychiatric diagnosis. Paraquat accounted for the majority of pesticide-associated deaths occurring in hospitals in the study areas. There was preliminary evidence that the 2020 paraquat ban led to a fall in case fatality from pesticide poisoning.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

Objective

The authors sought to identify scalable evidence-based suicide prevention strategies.

Methods

A search of PubMed and Google Scholar identi- fied 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

Results

Training primary care physicians in depression rec- ognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active out- reach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are under-studied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

Conclusions

Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physi- cian settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.Reprinted from Am J Psychiatry 2021; 178:611-624, with permission from American Psychiatric Association Publishing. Copyright © 2021.

Perspectives on reasons for suicidal behaviour and recommendations for suicide prevention in Kenya: qualitative study

BACKGROUND

Little is known about the reasons for suicidal behaviour in Africa, and communities' perception of suicide prevention. A contextualised understanding of these reasons is important in guiding the implementation of potential suicide prevention interventions in specific settings.

AIMS

To understand ideas, experiences and opinions on reasons contributing to suicidal behaviour in the Coast region of Kenya, and provide recommendations for suicide prevention.

METHOD

We conducted a qualitative study with various groups of key informants residing in the Coast region of Kenya, using in-depth interviews. Audio-recorded interviews were transcribed and translated from the local language before thematic inductive content analysis.

RESULTS

From the 25 in-depth interviews, we identified four key themes as reasons given for suicidal behaviour: interpersonal and relationship problems, financial and economic difficulties, mental health conditions and religious and cultural influences. These reasons were observed to be interrelated with each other and well-aligned to the suggested recommendations for suicide prevention. We found six key recommendations from our thematic content analysis: (a) increasing access to counselling and social support, (b) improving mental health awareness and skills training, (c) restriction of suicide means, (d) decriminalisation of suicide, (e) economic and education empowerment and (f) encouraging religion and spirituality.

CONCLUSIONS

The reasons for suicidal behaviour are comparable with high-income countries, but suggested prevention strategies are more contextualised to our setting. A multifaceted approach in preventing suicide in (coastal) Kenya is warranted based on the varied reasons suggested. Community-based interventions will likely improve and increase access to suicide prevention in this study area.

Systematic review of suicide prevention studies with data on youth and young adults living in low-income and middle-income countries

OBJECTIVES

This review aimed to provide a summary of peer-reviewed, published literature on suicide preventive interventions with data on youth and young adults in low-income and middle-income countries (LMIC).

DESIGN

A systematic review was conducted using electronic databases of PubMed/MEDLINE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center and The Campbell Collaboration databases for English-language articles published between 1 January 1990 and 15 February 2022.

ELIGIBILITY CRITERIA

Interventions of interest could include behavioural, community, clinical/medical or policy studies, or any combination of these, so long as the studies had at least one outcome of interest and at least one control group or control period. Outcomes included suicide ideation, suicide attempt and suicide. Interventions must have been conducted in an LMIC. Studies with individuals ages 0-25 in the sample were included. Articles describing data on individuals over age 25 could be included if individuals ages 0-25 were part of the sample.

RESULTS

A total of 44 eligible studies were identified, representing a broad range of universal, selective and indicated interventions. Most studies assessed interventions designed to address lethal means or mental health. Most studies were conducted in lower-middle-income or upper-middle-income countries, with the largest proportion in Asia. Assessment of outcomes across studies was heterogeneous and there were few large-scale investigations tailored specifically for youth.

CONCLUSIONS

Most of the published, peer-reviewed suicide intervention research from LMIC is concentrated in a few countries. While geographical coverage to date has been limited, strategies and samples in included studies were diverse, representing populations in clinical, educational and community settings. While current findings hold promise, this review identified a need for large-scale studies designed specifically for youth.

Pesticide Poisoning Among Children in India: The Need for an Urgent Solution

Pesticides have been increasingly recognized as a significant source of morbidity and mortality, especially in the developing world. In particular, significant attention has been given to the use of pesticides to cause deliberate self-harm in India. Approximately half of suicides in India are due to intentional poisoning of which the majority are from pesticides. Young children are commonly poisoned by accidental ingestion, unintentional dermal or inhalational exposure, whereas adolescents are more severely poisoned if attempting self-harm through intentional ingestion. It is the purpose of this paper to highlight the problem of pesticide poisoning in the pediatric population of India, and to recommend policy options to address this global problem. Reducing access to pesticides and educating farmers and the public regarding the proper storage and use of pesticides and the establishment of more poison centers in India can be part of a broader strategy to address these life-threatening poisonings in children.

The national suicide prevention strategy in India: context and considerations for urgent action

India reports the highest number of suicide deaths in the world. At this time when the Indian Government is formulating a national suicide prevention strategy, we have reviewed the current status of suicides in India, focusing on epidemiology, risk factors, and existing suicide prevention strategies to identify key challenges and priorities for suicide prevention. The suicide rate among Indian girls and women continues to be twice the global rate. Suicide accounts for most deaths in the 15-39 years age group compared with other causes of death. Hanging is the most common method of suicide, followed by pesticides poisoning, medicine overdose, and self-immolation. In addition to depression and alcohol use disorders as risk factors, several social and cultural factors appear to increase risk of suicide. The absence of a national suicide prevention strategy, inappropriate media reporting, legal conflicts in the interpretation of suicide being punishable, and inadequate multisectoral engagement are major barriers to effective suicide prevention. A scaffolding approach is useful to reduce suicide rates, as interventions provided at the right time, intensity, and duration can help navigate situations in which a person might be susceptible to and at risk of suicide. In addition to outlining research and data priorities, we provide recommendations that emphasise multilevel action priorities for suicide prevention across various sectors. We call for urgent action in India by integrating suicide prevention measures at every level of public health, with special focus on the finalisation and implementation of the national suicide prevention strategy.

Improving Suicide Prevention Through Evidence-Based Strategies: A Systematic Review

OBJECTIVE

The authors sought to identify scalable evidence-based suicide prevention strategies.

METHODS

A search of PubMed and Google Scholar identified 20,234 articles published between September 2005 and December 2019, of which 97 were randomized controlled trials with suicidal behavior or ideation as primary outcomes or epidemiological studies of limiting access to lethal means, using educational approaches, and the impact of antidepressant treatment.

RESULTS

Training primary care physicians in depression recognition and treatment prevents suicide. Educating youths on depression and suicidal behavior, as well as active outreach to psychiatric patients after discharge or a suicidal crisis, prevents suicidal behavior. Meta-analyses find that antidepressants prevent suicide attempts, but individual randomized controlled trials appear to be underpowered. Ketamine reduces suicidal ideation in hours but is untested for suicidal behavior prevention. Cognitive-behavioral therapy and dialectical behavior therapy prevent suicidal behavior. Active screening for suicidal ideation or behavior is not proven to be better than just screening for depression. Education of gatekeepers about youth suicidal behavior lacks effectiveness. No randomized trials have been reported for gatekeeper training for prevention of adult suicidal behavior. Algorithm-driven electronic health record screening, Internet-based screening, and smartphone passive monitoring to identify high-risk patients are understudied. Means restriction, including of firearms, prevents suicide but is sporadically employed in the United States, even though firearms are used in half of all U.S. suicides.

CONCLUSIONS

Training general practitioners warrants wider implementation and testing in other nonpsychiatrist physician settings. Active follow-up of patients after discharge or a suicide-related crisis should be routine, and restricting firearm access by at-risk individuals warrants wider use. Combination approaches in health care systems show promise in reducing suicide in several countries, but evaluating the benefit attributable to each component is essential. Further suicide rate reduction requires evaluating newer approaches, such as electronic health record-derived algorithms, Internet-based screening methods, ketamine's potential benefit for preventing attempts, and passive monitoring of acute suicide risk change.

Implementation of a comprehensive surveillance system for recording suicides and attempted suicides in rural India

INTRODUCTION

WHO reports that 78 of the 140 low-income and middle-income countries (LMICs) do not have a registration system for suicides and attempted suicides. Absence of data on suicide and attempted suicide in LMICs, which account for 79% of suicides worldwide, is a major impediment in understanding the magnitude of the problem and formulating prevention strategies to reduce suicide and self-harm. A comprehensive surveillance system has the potential to address this data gap. The objective of this study is to describe the development of a comprehensive surveillance system in rural India by adding a community based component and reflect on its added value in obtaining data on suicide and attempted suicide compared with relying only on hospital and police records.

METHOD

The comprehensive system consists of three components. Community surveillance involved collecting information on suicides and attempted suicides from third party key informants such as village heads, teachers, priests, shopkeepers, private physicians, private hospitals and community health workers. The second component consisted of data from public health facilities. The final component consisted of suicide data from police records. Information was collected for a period of 12 months from August 2018 to July 2019 from 116 villages (population 377 276) in Gujarat, India.

RESULTS

An average of 710 community informants were interviewed each month (mean: 6.72 informants per village). The community surveillance system identified 67 cases of suicide compared with 30 cases by hospital and police records (Cochran's Q test 67.9 p<0.01) and 70 attempted suicides compared with 51 from the hospital and police records (Cochran's Q test 66.6 p<0.01).

DISCUSSION

This is the first report of implementing a large-scale comprehensive surveillance system for suicide and attempted suicide in a LMIC. The combination of community surveillance system and official data from hospital and police records addresses the problem of under-reporting of suicide and suicide attempts in India and other LMIC.

Suicide research in India: An overview of four decades

BACKGROUND

Suicide is a global phenomenon and a major public health concern and 'it is possibly preventable if it is well understood'.

AIM

The article is an attempt to understand 'suicide in India' with the existing literature and the lacuna for the four decades.

METHODS

The information is collected from 270 articles on suicide research in India, published in various electronic data bases and different official sites as surprisingly the nation is with highest suicide mortality rate among all regional countries.

RESULTS

The review shows an increase in the number of articles on suicide in India over the period of time. Though the suicide mortality rate in India is significantly high, the number of intervention studies remains very minimal. India's understanding about 'the concept' remains questionable as the data from different sources for the same time period shows a huge disparity. Sex, age, socio-economic status, substance abuse, mental illness, medical illness, psychological and environmental stressors etc make individuals vulnerable to end their lives.

CONCLUSION

Appropriate official documentation and more qualitative studies would help in understanding the phenomena better. Intervention studies and policy level changes are the need of the hour to save the nation from the dangerous 'iceberg of suicide'.

Evaluation of the SPIRIT Integrated Suicide Prevention Programme: study protocol for a cluster-randomised controlled trial in rural Gujarat, India

BACKGROUND

Suicide is a major public health challenge globally and specifically in India where 36.6% and 24.3% of all suicides worldwide occur in women and men, respectively. The United Nations Sustainable Development Goals uses suicide rate as one of two indicators for Target 3.4, aimed at reducing these deaths by one third by 2030. India has no examples of large-scale implementation of evidence-based interventions to prevent suicide; however, there is a sizeable evidence base to draw on for suicide prevention strategies that have been piloted in India or proven to be effective regionally or internationally.

METHOD

The SPIRIT study is designed as a cluster-randomized superiority trial and uses mixed methods to evaluate the implementation, effectiveness and costs of an integrated suicide prevention programme consisting of three integrated interventions including (1) a secondary-school-based intervention to reduce suicidal ideation among adolescents, (2) a community storage facility intervention to reduce access to pesticides and (3) training for community health workers in recognition, management, and appropriate referral of people identified with high suicidal risk.

DISCUSSION

Combining three evidence-based interventions that tackle suicide among high-risk groups may generate a synergistic impact in reducing suicides at the community level in rural areas in India. Examination of implementation processes throughout the trial will also help to prepare a roadmap for policymakers and researchers looking to implement suicide prevention interventions in other countries and at scale.

TRIAL REGISTRATION

Clinical Trial Registry of Indian Council of Medical Research, India: CTRI/2017/04/008313. Registered on 7 April 2017. http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=18256&EncHid=&userName=SPIRIT Trial registry was last modified on 28 June 2019.

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.

Suicide by pesticide poisoning in India: a review of pesticide regulations and their impact on suicide trends

BACKGROUND

Pesticide self-poisoning is a common means of suicide in India. Banning highly hazardous pesticides from agricultural use has been successful in reducing total suicide numbers in several South Asian countries without affecting agricultural output. Here, we describe national and state-level regulation of highly hazardous pesticides and explore how they might relate to suicide rates across India.

METHODS

Information on pesticide regulation was collated from agriculture departments of the central government and all 29 state governments (excluding union territories). National and state-level data on suicides from 1995 to 2015 were obtained from the National Crime Records Bureau (NCRB). We used joinpoint analysis and negative binomial regression to investigate the trends in suicide rates nationally and in Kerala, in view of the robust measures Kerala has taken to restrict a number of HHPs, to identify any effect on suicides.

RESULTS

As of October 2019, 318 pesticides were registered for use in India, of which 18 were extremely (Class Ia) or highly (Class Ib) hazardous according to World Health Organization toxicity criteria. Despite many highly hazardous pesticides still being available, several bans have been implemented during the period studied. In our quantitative analyses we focused on the permanent bans in Kerala in 2005 (of endosulfan) and 2011 (of 14 other pesticides); and nationally in 2011 (of endosulfan). NCRB data indicate that pesticides were used in 441,918 reported suicides in India from 1995 to 2015, 90.3% of which occurred in 11 of the 29 states. There was statistical evidence of lower than expected rates of pesticide suicides (rate ratio [RR] 0.52, 95% CI 0.49-0.54) and total suicides nationally by 2014 (0.90, 0.87-0.93) after the 2011 endosulfan ban. In Kerala, there was a lower than expected rate of pesticide suicides (0.45, 0.42-0.49), but no change to the already decreasing trend in total suicides (1.02, 1.00-1.05) after the 2011 ban of 14 pesticides. The 2005 ban on endosulfan showed a similar effect - lower than expected pesticide suicides (0.79, 0.64-0.99), but no change to the decreasing trend of total suicides (0.97, 0.93-1.02) in 2010. There was no evidence of a decline in agricultural outputs following the bans.

CONCLUSION

Highly hazardous pesticides continue to be used in India and pesticide suicide remains a serious public health problem. However, some pesticide bans do appear to have impacted previous trends in the rates of both pesticide suicides and all suicides. Comprehensive national bans of highly hazardous pesticides could lead to a reduction in suicides across India, in addition to reduced occupational poisoning, with minimal effects on agricultural yield.

Suicide Means Used by the Older Adults in Rural China: A Comparison Between Those Using Pesticides and Other Means

BACKGROUND

The most frequently used means of committing suicide was pesticide poisoning in rural China, yet little is known about the characteristics and risk factors for suicides committed with pesticides compared to those committed via other means in older adults.

METHODS

The participants were 242 older adults (aged 60 or older) who had committed suicide in the rural areas of 3 provinces (Shandong, Hunan, and Guangxi) in China. This study was conducted using the psychological autopsy (PA) method.

RESULTS

In univariate analyses, no statistically significant differences were found between those who committed suicide with pesticide or with other means in terms of demographic and clinical variables except age, prevalence of mental disorders, suicidal intent, number of recent life events, social support, hopelessness, impulsivity, and depressive symptoms (P > .05); age, history of suicide attempts, having pesticides available at home, the total number of life events, and the number of long-term life events were significantly different (P < .05) between the 2 groups. In multivariate logistic regression model, the factors associated with committing suicide with pesticides were the availability of pesticides at home (odds ratio [OR] = 3.48, 95% confidence interval [CI]: 1.99-6.08) and the number of long-term life events (OR = 0.87, 95% CI: 0.78-0.97).

CONCLUSION

The older adults who committed suicide by pesticides and those using other means are probably the same population. The main determinant of choosing pesticides as suicide means was likely the availability of pesticides at home. Suicide risk among older adults might be reduced by placing appropriate restrictions on access to pesticides.

Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In May 2019, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved an update to the 2013 joint clinical practice guideline for assessing and managing patients who are at risk for suicide. This guideline provides health care providers with a framework by which to screen for, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients who may be at risk for suicide.

METHODS

In January 2018, the VA/DoD Evidence-Based Practice Work Group convened to develop a joint VA/DoD guideline including clinical stakeholders and conforming to the National Academy of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel drafted key questions, systematically searched and evaluated the literature through April 2018, created algorithms, and advanced 22 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

This synopsis, which includes 3 clinical practice algorithms, summarizes the key recommendations of the guideline related to screening and evaluation, risk management and treatment, and other management methods. Risk management and treatment recommendations address both pharmacologic and nonpharmacologic approaches for patients with suicidal ideation and behavior. Other management methods address lethal means safety (such as restricting access to firearms, poisons, and medications and installing barriers to prevent jumping from lethal heights) and population health strategies.

Outcomes of Community-Based Suicide Prevention Approaches That Involve Reducing Access to Pesticides: A Systematic Literature Review

OBJECTIVE

Pesticide ingestion is among the most commonly utilized means of suicide worldwide. Restricting access to pesticides at a local level is one strategy to address this major public health problem, but little is known about its effectiveness. We therefore conducted a systematic literature review to identify effective community-based suicide prevention approaches that involve restricting access to pesticides.

METHOD

We searched Embase, Scopus, PsycINFO, Cochrane Library, CINAHL, and PubMed for well-designed studies that reported on suicide-related outcomes (i.e., attempted or completed suicide).

RESULTS

We identified only five studies that met our eligibility criteria (two randomized controlled trials, two studies with quasi-experimental designs, and one study with a before-and-after design). These studies tested different interventions: the introduction of nonpesticide agricultural management, providing central storage facilities for pesticides, distributing locked storage containers to households, and local insecticide bans. The only sufficiently powered study produced no evidence of the effectiveness of providing household storage containers. Three interventions showed some promise in reducing pesticide suicides or attempts, with certain caveats.

CONCLUSIONS

Our review identified three community interventions that show some promise for reducing pesticide suicides by restricting access to means, which will require replication in large, well-designed trials before they can be recommended.

Mass media representation of suicide in a high suicide state in India: an epidemiological comparison with suicide deaths in the population

OBJECTIVES

Suicide rates in India are among the highest in the world, equating to over 200 000 suicides annually. Reports of suicides are a routine feature in major newspapers in India, and reporters may selectively present 'newsworthy' suicide stories. The aim of this paper was to systematically investigate whether mass media reports of suicides reflect the epidemiological data on suicide in a high suicide state in India.

DESIGN

We undertook a content analysis study to extract sociodemographic data on suicides reported among nine of the most highly read daily newspapers in the high suicide southern state of Tamil Nadu between June and December 2016. A total of 1258 newspaper articles were retrieved containing reports on 1631 suicides. Two-tailed binomial tests on aggregate frequencies assessed whether the sociodemographic characteristics of suicides in the newspaper articles were different to the population suicide statistics for Tamil Nadu.

RESULTS

We identified some statistically significant discrepancies between suicide characteristics in the population and the media. Suicides involving females (p<0.001), those aged under 30 years (p<0.001), separated or widowed males (p<0.001), unmarried females (p<0.001), those using methods with a higher case fatality rate (ie, hanging (p<0.001), jumping off high structures (p<0.001) and coming under vehicles (p<0.001) and those who were students (p<0.001) or working in the agricultural sector (p<0.001) were significantly over-reported relative to their occurrence in the broader population. Suicides involving men (p<0.001), those aged over 30 years and above (p<0.001), those who were married and suicides by poisoning (p<0.001) were significantly under-reported relative to their occurrence in the broader population.

CONCLUSIONS

The suicide characteristics in the print media were not entirely representative of suicides in the broader Tamil Nadu population, which may lead the general public to develop misunderstandings about suicide in their state. The discrepancies we identified will inform tailored suicide prevention education for media professionals.

[Epidemiology of suicide among adolescents and young adults in EcuadorEpidemiologia do suicídio em adolescentes e jovens no Equador]

Objective

To collect information - and provide it to decision-makers in health programs in general and mental health programs in particular - on epidemiological patterns in suicide deaths among young adults and adolescents in Ecuador.

Methods

A cross-sectional ecological study was conducted using data obtained from records of deaths by suicide among young adults and adolescents in Ecuador from 2001 to 2014. For analysis, results were disaggregated by geographic region, sex, age, ethnic group and suicide method. Rates of death by suicide (per 100,000 population) and relative risks (RR) for suicide were estimated by sex and region.

Results

Between 2001 and 2014, 4,855 suicides were recorded among adolescents and young adults. The highest estimated risk was found among males aged 15 to 24 years and adolescents living in the Amazon region, followed by those living in the Andean region. Mestizos were the ethnic group with the greatest number of suicides, although 40% of young people who commit suicide in the Amazon region are indigenous. The most frequent method was by hanging, followed by pesticide poisoning.

Conclusions

Suicide among adolescents and young adults is an important public health problem in Ecuador. Since various psychological, social, and cultural influences come into play, there is wide variation among regions, age groups, and ethnic groups. Restricting access to pesticides and other chemical products, implementing universal prevention programs and programs in education centers in the areas with the highest rates, and targeting vulnerable populations for specific interventions could help reduce the suicide rate among young people in Ecuador.

Over-the-Counter Drugs and Other Substances Used in Attempted Suicide Presented to Emergency Departments in Montreal, Canada

Background: Over-the-counter (OTC) analgesics are frequently used in suicide attempts. Accessibility, toxicity, and unsupervised acquisition of large amounts may be facilitators. Aims: To identify patient characteristics associated with OTC drug use as a suicide attempt method among adults. Method: A cross-sectional study was conducted using chart review of all individuals who presented to the emergency department (ED) of two adult general hospitals following a suicide attempt during 2009-2010 in Montreal, Canada. Results: Among the 369 suicide attempters identified, 181 used overdosing, 47% of whom used OTC drugs. In logistic regression, women and those with medical comorbidity were more likely to use overdosing, while those with substance use disorders were less likely to do so. Among those who overdosed, women were more likely to use OTC drugs, while those who were Caucasian, had children, comorbidities, diagnoses with substance use disorders, and made attempts in the Fall were less likely to do so. Substances most frequently used were: acetaminophen among OTC drugs (30%); antidepressants (37%), anxiolytics (30%), opioids (10%), and anticonvulsants (9%) among prescription drugs; and cocaine (10%) among recreational drugs. Limitations: Reasons for the suicide method choice were not available. Conclusion: OTC drugs, in particular acetaminophen, are frequently used in suicide attempts. Accessibility to these drugs may be an important contributor.

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.

Behavior Characteristics and Risk Factors for Suicide Among the Elderly in Rural China

We examine the characteristics of suicide behavior and associated risk factors in the elderly in rural China, compared with the nonelderly. Paired case-control design and psychological autopsy were used for subject recruitment and data collection. The included cases were 104 suicides of the elderly aged 60 years or older, 86 suicides of the nonelderly, and sex- and age-paired controls from the same villages. Although the characteristics of suicide behavior were similar between the two age groups of victims, the elderly who died by suicide had a greater tendency to experience negative life events and not live with a spouse. Suicide of the nonelderly was associated with family history of suicide, poor social support, and impulsivity. The influence of negative life events on the risk of suicide was greater in the elderly. Thus, efforts for suicide prevention must be tailored to the needs of specific age groups.

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.

Effectiveness of household lockable pesticide storage to reduce pesticide self-poisoning in rural Asia: a community-based, cluster-randomised controlled trial

BACKGROUND

Agricultural pesticide self-poisoning is a major public health problem in rural Asia. The use of safer household pesticide storage has been promoted to prevent deaths, but there is no evidence of effectiveness. We aimed to test the effectiveness of lockable household containers for prevention of pesticide self-poisoning.

METHODS

We did a community-based, cluster-randomised controlled trial in a rural area of North Central Province, Sri Lanka. Clusters of households were randomly assigned (1:1), with a sequence computer-generated by a minimisation process, to intervention or usual practice (control) groups. Intervention households that had farmed or had used or stored pesticide in the preceding agricultural season were given a lockable storage container. Further promotion of use of the containers was restricted to community posters and 6-monthly reminders during routine community meetings. The primary outcome was incidence of pesticide self-poisoning in people aged 14 years or older during 3 years of follow-up. Identification of outcome events was done by staff who were unaware of group allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT1146496.

FINDINGS

Between Dec 31, 2010, and Feb 2, 2013, we randomly assigned 90 rural villages to the intervention group and 90 to the control group. 27 091 households (114 168 individuals) in the intervention group and 26 291 households (109 693 individuals) in the control group consented to participate. 20 457 household pesticide storage containers were distributed. In individuals aged 14 years or older, 611 cases of pesticide self-poisoning had occurred by 3 years in the intervention group compared with 641 cases in the control group; incidence of pesticide self-poisoning did not differ between groups (293·3 per 100 000 person-years of follow-up in the intervention group vs 318·0 per 100 000 in the control group; rate ratio [RR] 0·93, 95% CI 0·80-1·08; p=0·33). We found no evidence of switching from pesticide self-poisoning to other forms of self-harm, with no significant difference in the number of fatal (82 in the intervention group vs 67 in the control group; RR 1·22, 0·88-1·68]) or non-fatal (1135 vs 1153; RR 0·97, 0·86-1·08) self-harm events involving all methods.

INTERPRETATION

We found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning. Other approaches, particularly removal of highly hazardous pesticides from agricultural practice, are likely to be more effective for suicide prevention in rural Asia.

FUNDING

Wellcome Trust, with additional support from the American Foundation for Suicide Prevention, Lister Institute of Preventive Medicine, Chief Scientist Office of Scotland, University of Copenhagen, and NHMRC Australia.

The global burden of fatal self-poisoning with pesticides 2006-15: Systematic review

BACKGROUND

Agricultural pesticide poisoning is a major contributor to the global burden of suicide. Over the last decade there has been a marked decrease in the incidence of suicide worldwide. It is unclear whether pesticide poisoning still plays a significant role in the global incidence of suicide.

METHODS

WHO method-specific suicide data were supplemented by a systematic review of the literature between 2006 and 2015, including searches of thirteen electronic databases and Google, citation searching and a review of reference lists and personal collections. Our primary outcome was the proportion of total suicides due to pesticide poisoning. Weighted estimates were calculated for seven WHO regional and income strata.

RESULTS

We identified data from 108 countries (102 from WHO data, 6 from the literature). A conservative estimate based on these data indicates that there were approximately 110,000 pesticide self-poisoning deaths each year from 2010 to 2014, comprising 13.7% of all global suicides. A sensitivity analysis accounting for under-reporting of suicides in India resulted in an increased estimate of 168,000 pesticide self-poisoning deaths annually, that is, 19.7% of global suicides. The proportion of suicides due to pesticide self-poisoning varies considerably between regions, from 0.9% in low- and middle-income countries in the European region to 48.3% in low- and middle-income countries in the Western Pacific region.

LIMITATIONS

High quality method-specific suicide data were unavailable for a number of the most populous countries, particularly in the African and Eastern Mediterranean regions. It is likely we have underestimated incidence in these regions.

CONCLUSION

There appears to have been a substantial decline in fatal pesticide self-poisoning in recent years, largely driven by a reduction in overall suicide rates in China. Nonetheless, pesticide self-poisoning remains a major public health challenge, accounting for at least one-in-seven suicides globally.

Youth self-harm in low- and middle-income countries: Systematic review of the risk and protective factors

BACKGROUND

Self-harm (defined here as an act of intentionally causing harm to own self, irrespective of the type, motive or suicidal intent) is one of the strongest antecedents of suicide in youth. While there have been a number of studies of youth self-harm in low- and middle-income countries (LMICs), there is currently no systematic review of studies of prevalence rates and risk and protective factors.

AIM

To systematically review the evidence relating to the prevalence rates and forms of self-harm in youth in LMICs and its relationship to family economic status, family functioning, relationship with the peer group, social relationships and academic performance.

METHODS

Electronic searches of three databases, MEDLINE, PsycINFO and Scopus, were performed. In total, 27 school-, community- and hospital-based studies evaluating self-harm in LMICs with youth focus (with participants between 12 and 25 years) were included.

RESULTS

The self-harm was divided into suicidal and non-suicidal depending on the nature of self-harm. The 12-month prevalence rates of non-suicidal self-harm varied from 15.5% to 31.3%, and the range of suicidal behaviour rates was from 3.2% to 4.7%. Banging and hitting were the most common in the community-based studies, followed by cutting, scratching and wound picking. Self-poisoning with pesticides was most commonly reported in hospital-based studies. Risk factors for self-harm were family conflict, peer groups with members indulging in self-harm, truancy and school absenteeism. Protective factors were having an understanding family, having friends and higher school competence. Risk factors for suicidal thoughts and attempts were lack of close friends and history of suicide by a friend.

CONCLUSION

The 12-month prevalence rates of youth self-harm in LMICs are comparable to high-income countries (HICs). The profile of risk and protective factors suggests that family-based interventions could be useful in treatment and prevention. Future studies should aim for greater consistency in assessment methods and the constructs under evaluation.

Utilization of Boxes for Pesticide Storage in Sri Lanka

Pesticide self-poisoning is now considered one of the two most common methods of suicide worldwide. Encouraging safe storage of pesticides is one particular approach aimed at reducing pesticide self-poisoning. CropLife Sri Lanka (the local association of pesticide manufacturers), with the aid of the Department of Agriculture, distributed lockable in-house pesticide storage boxes free of charge to a farming community in a rural district of Sri Lanka. Padlocks were not provided with the boxes. These storage boxes were distributed to the farmers without prior education. The authors carried out a cross-sectional follow-up survey to assess the usage of boxes at 7 months after distribution. In an inspection of a sample of 239 box recipients' households, 142 households stored pesticides in the provided box at the time of survey. Among them, only 42 (42/142, 29.65%) households had locked the box; the remaining households (100/142, 70.4%) had not locked the box. A simple hand over of in-house pesticide storage boxes without awareness/education results in poor use of boxes. Additionally, providing in-house storage boxes may encourage farmers to store pesticides in and around houses and, if they are not locked, may lead to unplanned adverse effects.

Suicide by pesticide poisoning remains a priority for suicide prevention in China: Analysis of national mortality trends 2006-2013

BACKGROUND

Despite recent declines, suicide remains a priority for China. Ease of availability of high-lethality suicide methods, such as pesticides and firearms, contributes to the overall incidence and is an important target for suicide prevention. This study investigates whether changes in the distribution of methods of suicide have contributed to the recent reduction in suicide in China.

METHOD

Suicide rates (2006-2013) were calculated using the Chinese Disease Surveillance Points system, stratified by gender, age group, and urban-rural residence, to investigate trends in suicide over the study period. Multilevel negative binomial regression models were used to investigate associations between socio-demographic factors and method-specific suicide.

RESULTS

The most common method of suicide in China for both males and females was pesticide poisoning, followed by hanging. All methods declined over the study period, with the exception of suicide by jumping in males. Suicide rates for pesticide poisoning and for hanging increased exponentially with age in those aged over ≥45 years in both sexes. Pesticide poisoning declined from 55% to 49% of all suicides, while hanging increased from 27% to 31%.

LIMITATIONS

This was an ecological study of a time series of suicide rates, with risk factor adjustment being limited to population-level point estimates derived from a single census.

CONCLUSIONS

Suicide by pesticide poisoning and hanging remain the leading methods of suicide in China. Changes to the safe use of pesticides and targeted prevention initiatives to restrict access, along with socio-economic development and urbanisation, are likely contributors to declines in suicide by pesticide poisoning.

Suicide Prevention: Beyond Mental Disorder

Suicide is a conscious act of the will with personal and societal ramifications. Its conscious and volitional nature deepens its tragic impact. India has high suicide rates compared to the other countries and also has intriguing distinctiveness due to the reports of higher rates from areas with better health indices and gender opportunities. In this article, I present a broader paradigm, in contrast to the usual 'mental disorder paradigm', which puts forward practical points for a multi-level engagement of healthcare service, community and policy makers.

Suicide prevention strategies revisited: 10-year systematic review

BACKGROUND

Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005.

METHODS

We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis.

FINDINGS

We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24-0·85; p=0·014) and suicidal ideation (0·5, 0·27-0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions.

INTERPRETATION

In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs.

FUNDING

The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.

Overview evidence on interventions for population suicide with an eye to identifying best-supported strategies for LMICs

Globally, over 800 000 people died by suicide in 2012 and there are indications that for each adult who died of suicide there were likely to be many more attempting suicide. There are many millions of people every year who are affected by suicide and suicide attempts, taking into consideration the family members, friends, work colleagues and communities, who are bereaved by suicide. In the WHO Mental Health Action Plan 2013-2020, Member States committed themselves to work towards the global target of reducing the suicide rate in countries by 10% by 2020. Hence, the first-ever WHO report on suicide prevention, Preventing suicide: a global imperative, published in September 2014, is a timely call to take action using effective evidence-based interventions. Their relevance for low- and middle-income countries is discussed in this paper, highlighting restricting access to means, responsible media reporting, introducing mental health and alcohol policies, early identification and treatment, training of health workers, and follow-up care and community support following a suicide attempt.

Suicide in India

SOURCES OF DATA

The current report reviews the data from the series Accidental Death and Suicide in India published by India's National Crime Records Bureau (NCRB) reporting official suicide rates based on police reports over the period of 10 years from 2004 to 2013. A reference to wider literature is made to present a comprehensive picture.

AREAS OF AGREEMENT

Suicide in India is more prevalent in young, is likely to involve hanging and ingestion of pesticides and is related to social and economic causes. Reducing alcohol consumption, unemployment, poverty, social inequities, domestic violence and improving social justice are essential to reduce suicide in India.

AREAS OF CONTROVERSY

NCRB data might underreport suicide. Discrepancy in farmers' suicide rate between reports suggests that this might be overrepresented in NCRB data.

GROWING POINTS

An integrated suicide prevention programme with a multidimensional approach is needed. Mental health care bill and the recent launch of first national mental health policy are welcome measures. Decriminalization of suicide is likely to positively influence mental health practice and policy in India.

AREA TIMELY FOR DEVELOPING RESEARCH

Nationally representative studies investigating fatal and non-fatal suicidal behaviours, evaluation of models of service delivery for the vulnerable population, investigating suicide following different treatment services and effects of decriminalization of suicide on suicide rates should be the focus of future research.

Completed suicide with violent and non-violent methods in rural Shandong, China: a psychological autopsy study

Background

This study aims to describe the specific characteristics of completed suicides by violent methods and non-violent methods in rural Chinese population, and to explore the related factors for corresponding methods.

Methods

Data of this study came from investigation of 199 completed suicide cases and their paired controls of rural areas in three different counties in Shandong, China, by interviewing one informant of each subject using the method of Psychological Autopsy (PA).

Results

There were 78 (39.2%) suicides with violent methods and 121 (60.8%) suicides with non-violent methods. Ingesting pesticides, as a non-violent method, appeared to be the most common suicide method (103, 51.8%). Hanging (73 cases, 36.7%) and drowning (5 cases, 2.5%) were the only violent methods observed. Storage of pesticides at home and higher suicide intent score were significantly associated with choice of violent methods while committing suicide. Risk factors related to suicide death included negative life events and hopelessness.

Conclusions

Suicide with violent methods has different factors from suicide with non-violent methods. Suicide methods should be considered in suicide prevention and intervention strategies.

A public health initiative for reducing access to pesticides as a means to committing suicide: findings from a qualitative study

Widespread use of pesticides among farmers in rural India, provides an easy means for suicide. A public health initiative involving storage of pesticides in a central storage facility could be a possible strategy for reducing mortality and morbidity related to pesticide poisoning. This qualitative study explored community perceptions towards a central pesticide storage facility in villages in rural South India. Sixteen focus group discussions held with consenting adults from intervention and control villages were followed by eight more a year after initiation of the storage facility. Analysis revealed four themes, namely, reasons for committing suicide and methods used, exposure to pesticides and first-aid practices, storage and disposal of pesticides, and perceptions towards the storage facility. The facility was appreciated as a means of preventing suicides and for providing a safe haven for pesticide storage. The participatory process that guided its design, construction and location ensured its acceptability. Use of qualitative methods helped provide deep insights into the phenomenon of pesticide suicide and aided the understanding of community perceptions towards the storage facility. The study suggests that communal storage of pesticides could be an important step towards reducing pesticide suicides in rural areas.