Pattern of domestic violence amongst non-fatal deliberate self-harm attempters: A study from primary care of West Bengal

Intimate partner violence, suicide and self-harm in Sri Lanka: Analysis of national data

There is increasing evidence from South Asia and internationally that intimate partner violence (IPV) is strongly associated with self-harm, however its association with suicide and self-harm has not been extensively examined, nor has this relationship been explored at a national level. Using national datasets, area-level variation in IPV, suicide and self-harm in Sri Lanka were examined. In addition, the association between individual level exposure to past-year IPV and non-fatal self-harm by any household member were explored in a series of multi-level logistic regression models, adjusting for age. Similar patterns in the distribution of suicide and IPV were found, with higher rates evident in post-conflict districts, specifically Batticaloa, Kilinochchi, and Mullaitivu. Experience of past year IPV and its various forms were strongly associated with household-level self-harm in the past year (adjusted odds ratio [AOR] = 3.83 95% CI 2.27-6.46). A similar magnitude was found for physical/sexual abuse (AOR 5.17 95% CI 2.95-9.05) and psychological abuse (AOR 4.64 95% CI 2.50-7.00). A dose-response association was also evident for frequency of abuse, with an increasing risk of household-level self-harm for women reporting abuse 'less often' (AOR 2.95 95% CI 1.46-5.92), and abuse experienced 'daily, weekly, or monthly' (AOR 4.83 95% CI 2.59-9.00), compared to no abuse. This study contributes to a growing body of evidence on the relationship between IPV and suicidal behaviour in South Asia. Addressing IPV and its various forms should be a priority for suicide prevention in Sri Lanka, alongside trauma-informed approaches in post-conflict settings.

Psychosocial distress, perceived social support, and coping in women survivors of domestic violence seeking help from a women's helpline in urban India

BACKGROUND

Domestic violence against women is a worldwide phenomenon and a major public health concern. The adverse effects on the physical and mental health of the women survivors of domestic violence are influenced by various psychosocial factors. This study aimed to understand psychological distress, perceived social support, and coping strategies among women survivors of domestic violence and its implications.

MATERIALS AND METHODS

It is a cross-sectional study conducted with 30 women survivors of domestic violence from urban Bengaluru who were registered with a women's helpline. Data were collected using a socio-demographic schedule, a self-reporting questionnaire assessing psychological distress, perceived social support scale, and ways of coping scale. Descriptive and inferential statistics were used to analyze the data.

RESULTS

Psychological distress was the highest among participants facing violence due to perpetrator using alcohol (M = 11.6, SD = 3.9) and (M = 11.73, SD = 3.5) dowry harassment. Perceived social support from family (M = 14.76, SD = 4.54) and friends (M = 11.85, SD = 4.7) was the highest among participants who reported that alcohol use was not a reason for violence.

CONCLUSION

It can be noticed that alcohol use, dowry harassment, and poor coping strategies were the main reasons for domestic violence, which has led to severe psychosocial distress among the women survivors.

Exposure to violence and the presence of suicidal and self-harm behaviour predominantly in Asian females: scoping review

Background

Exposure to violence is associated with psychological distress, mental disorders such as depression, and suicidal behaviour. Most of the studies are conducted in the West, with limited publications from Asia. Thus, we conducted a scoping review of studies investigating the association between experiences of violence and later suicidal ideation/attempts from Asia in the twenty-first century.

Results

Many studies focused on domestic violence toward women in the Southeast Asian region. Sociocultural factors such as family disputes, public shaming, dowry, lack of education opportunities, and marriage life perceptions mediated the association. Many women exposed to violence and attempted suicide suffered from mental disorders such as depression, anxiety, and post-traumatic stress. The small number of suitable studies and the possible effect of confounders on participants were limitations in the review. Future studies would have to focus on specific types of violence and ethnoreligious beliefs.

Conclusion

Women in Asia exposed to violence appear to have an increased risk of suicidal behaviour and mental disorders. The early screening of psychological distress with culturally validated tools is essential for preventing suicides in Asian victims of violence.

Intimate partner violence against women with disability and associated mental health concerns: a cross-sectional survey in Mumbai, India

OBJECTIVES

The risk of intimate partner violence (IPV) against women with disability is believed to be high. We aimed to compare the prevalence of past-year IPV against women with and without functional difficulties in urban informal settlements, to review its social determinants and to explore its association with mental health.

DESIGN

Cross-sectional survey.

SETTING

Fifty clusters within four informal settlements.

PARTICIPANTS

5122 women aged 18-49 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

We used the Washington Group Short Set of Questions to assess functional difficulties. IPV in the past year was described by binary composites of questions about physical, sexual and emotional violence. We screened for symptoms of depression using the Patient Health Questionnaire-9 and of anxiety using the Generalised Anxiety Disorder-7. Multivariable logistic regression models examined associations between functional difficulties, IPV and mental health.

RESULTS

10% of participants who screened positive for functional disability had greater odds of experiencing physical or sexual IPV (adjusted OR (AOR) 1.68, 95% CI 1.23 to 2.29) and emotional IPV (1.52, 95% CI 1.16 to 2.00) than women who screened negative. Women who screened positive for functional disability had greater odds than women who screened negative of symptoms suggesting moderate or severe anxiety (AOR 2.50, 95% CI 1.78 to 3.49), depression (2.91, 95% CI 2.13 to 3.99) and suicidal thinking (AOR 1.94, 95% CI 1.50 to 2.50).

CONCLUSIONS

The burden of IPV fell disproportionately on women with functional difficulties, who were also more likely to screen positive for common mental disorder. Public health initiatives need to respond at local and national levels to address the overlapping and mutually reinforcing determinants of violence, while existing policy needs to be better utilised to ensure protection for the most vulnerable.

Domestic violence and self-poisoning in Sri Lanka

BACKGROUND

There is increasing evidence that domestic violence (DV) is an important risk factor for suicidal behaviour. The level of risk and its contribution to the overall burden of suicidal behaviour among men and women has not been quantified in South Asia. We carried out a large case-control study to examine the association between DV and self-poisoning in Sri Lanka.

METHODS

Cases (N = 291) were patients aged ⩾18 years, admitted to a tertiary hospital in Kandy Sri Lanka for self-poisoning. Sex and age frequency matched controls were recruited from the hospital's outpatient department (N = 490) and local population (N = 450). Exposure to DV was collected through the Humiliation, Afraid, Rape, Kick questionnaire. Multivariable logistic regression models were conducted to estimate the association between DV and self-poisoning, and population attributable fractions were calculated.

RESULTS

Exposure to at least one type of DV within the previous 12 months was strongly associated with self-poisoning for women [adjusted OR (AOR) 4.08, 95% CI 1.60-4.78] and men (AOR 2.52, 95% CI 1.51-4.21), compared to those reporting no abuse. Among women, the association was strongest for physical violence (AOR 14.07, 95% CI 5.87-33.72), whereas among men, emotional abuse showed the highest risk (AOR 2.75, 95% CI 1.57-4.82). PAF% for exposure to at least one type of DV was 38% (95% CI 32-43) in women and 22% (95% CI 14-29) in men.

CONCLUSIONS

Multi-sectoral interventions to address DV including enhanced identification in health care settings, community-based strategies, and integration of DV support and psychological services may substantially reduce suicidal behaviour in Sri Lanka.

Patients with deliberate self-harm attended in emergency setting at a tertiary care hospital: A 13-month analysis of clinical-psychiatric profile

Objectives

To describe the pattern and clinical-psychiatric profile of patients presenting with deliberate self-harm attempt to an emergency setting.

Methods

The study involves the analysis of the case records of 109 consecutive patients with deliberate self-harm evaluated by the psychiatric emergency team at a premier, tertiary care hospital in India over a period of 13 months (January 2015–January 2016).

Results

Deliberate self-harm had a clinical prevalence of 16.4% (109/666) among total mental and behavioral emergencies attended in the same period. A large majority of attempters were in the age range of 18–39 years (84.4%), and females (58.7%) outnumbered males in total sample. Married females and unmarried males had significantly higher chances of attempting deliberate self-harm (χ2 = 6.57, p = 0.01). More than half (52.3%) of patients were found to have a diagnosable psychiatric illness at the time of presentation, most common being depressive disorder in 19.3% of overall sample. Past history of a psychiatric illness was evident in only 12.5% of patients. Common methods of deliberate self-harm were prescription drug/psychotropic overdose, poisoning with ingestion of phenyl cleaner or rat-killer poison. Significant gender differences were observed in the nature of precipitating events for deliberate self-harm, with interpersonal relationship problems being significantly more common in women (p = 0.03).

Conclusion

This study adds relevant and useful information on cross-cutting as well as gender-specific characteristics of patients presenting with deliberate self-harm attempt, from a developing country context. The study findings bear implications for designing interventions for primary and secondary prevention of such behavioral emergencies at a community level.

Deliberate Self-harm seen in a Government Licensed Private Psychiatric Hospital and Institute

Majority of the published studies on suicide deal with identifying the sociodemographic and psychosocial aspects of suicide attempters and those who have completed suicide or to identify the characteristic differences between the two groups. There are very few studies focusing mainly or only on deliberate self harm. Most of these are hospital based studies or in a setting of general hospital psychiatry units. The present study is from Ram Psychiatry Hospital and Institute, a government licensed private psychiatric institute at Madurai, Tamil Nadu. It is a prospective study of individuals with self harm behavior mostly without the intention to kill, attending the psychiatry outpatient department of the hospital for the period of one year (January to December 2014) a total number of 140 cases are registered. Sociodemographic, clinical profiles with Axis I or Axis II diagnosis or otherwise, and the initiating or precipitating cause or mode of self-injury or self-harm are studied. The results are presented and discussed.

Domestic violence against women in India: A systematic review of a decade of quantitative studies

Domestic violence (DV) is prevalent among women in India and has been associated with poor mental and physical health. We performed a systematic review of 137 quantitative studies published in the prior decade that directly evaluated the DV experiences of Indian women to summarise the breadth of recent work and identify gaps in the literature. Among studies surveying at least two forms of abuse, a median 41% of women reported experiencing DV during their lifetime and 30% in the past year. We noted substantial inter-study variance in DV prevalence estimates, attributable in part to different study populations and settings, but also to a lack of standardisation, validation, and cultural adaptation of DV survey instruments. There was paucity of studies evaluating the DV experiences of women over age 50, residing in live-in relationships, same-sex relationships, tribal villages, and of women from the northern regions of India. Additionally, our review highlighted a gap in research evaluating the impact of DV on physical health. We conclude with a research agenda calling for additional qualitative and longitudinal quantitative studies to explore the DV correlates proposed by this quantitative literature to inform the development of a culturally tailored DV scale and prevention strategies.

The Development and Validation of the Indian Family Violence and Control Scale

The high prevalence of domestic violence (DV) among married women in India and associated negative health repercussions highlight the need for effective prevention strategies and tools to measure the efficacy of such interventions. Literature supporting differing manifestations of DV by culture underscores the need for a culturally-tailored scale to more effectively measure DV in the Indian context. We therefore aimed to develop and validate such a tool, the Indian Family Violence and Control Scale (IFVCS), through a mixed-methods study. The psychometric development of IFVCS is herein discussed. After field pre-testing and expert review, a 63-item questionnaire was administered to a random sample of 630 married women from May-July 2013 in Pune, India. The item response theory approach for binary data to explore the IFVCS structure suggested that IFVCS is reliable, with the majority of items having high (>0.5) and significant factor loadings. Concurrent validity, assessed by comparing responses to IFVCS with the validated, abridged Conflict Tactics Scale-2, was high (r = 0.899, p<0.001) as was the construct validity, demonstrated by its significant association with several established DV correlates. Therefore, initial assessment of the IFVCS psychometric properties suggests that it is an effective tool for measuring DV among married women in India and speaks to its capacity for enhancing understanding of DV epidemiology and for evaluating the effectiveness of future DV interventions.

Ecopsychosocial Aspects of Human-Tiger Conflict: An Ethnographic Study of Tiger Widows of Sundarban Delta, India

AIMS

Human-tiger conflict (HTC) is a serious public health issue in Sundarban Reserve Forest, India. HTC is a continued concern for the significant mortality and morbidity of both human and tiger population. This is the first comprehensive report on Sundarban tiger-human conflicts and its impact on widows whose husbands were killed by tigers. The study attempts to explore the situation analysis of HTC and the aftermath of the incident including bereavement and coping, the cultural stigma related to being killed by a tiger and the consequent discrimination, deprivation, and social rejection, and the impact on the mental health of the tiger-widows.

METHODS

This is a three-phase ethnographic research with a mix of quantitative and qualitative methods. In the first phase, a door-to-door village survey (3,084 households) was carried out in two villages of Sundarban, which are adjacent to the Reserve Forest, in which the incidents of human-animal conflicts and the 65 tiger-widows identified were documented. In the second phase, the 65 tiger-widows were studied to explore the ecodemography of tiger attacks and tiger-widows alongside the stigma issue by using a stigma questionnaire (n = 49). The stigma burden was compared with normal widows (n = 21) and snake-bite widows (n = 18). In the third phase, the psychosocial and cultural dimensions related to tiger attacks were studied by using in-depth interviews (IDI) of the tiger-widows, focus-group discussions (FGD), and participatory mapping in the community. Clinical examinations of the mental health of the widows were also carried out in this phase.

RESULTS

The mean age of the 65 widows was 43.49 ± 9.58 years. Of this, 12.3% of the widows had remarried and only 4.6% of the widows were literate. In all, 67.2% of all tiger attacks occurred as a result of illegal forest entry. The main livelihood of the former husbands of the widows were 43.8% wood cutting, 28.1% fishing, 10.9% crab catching, 9.4% tiger prawn seed (juvenile prawn), and 4.7% honey collection. The maximum number of attacks took place in the months of December (24.6%) and November (13.9%). The majority of incidences happened during the morning hours (47.7%) of the day. Of the cases, 86.1% were attacked while the person was engaged in livelihood activity. In all, 57.4% widows are recorded as living "below the poverty line". Currently, 45.5% widows earn their living by laboring work followed by forest-based livelihood activities (30%) and begging (5.2%). Tiger-widows differed significantly (P < 0.001) from both normal and snake-bite widows on all stigma cluster scores and the total score. Of the tiger-widows, 44% were shown to be suffering from some designated mental illness. IDIs and FGDs helped to unfold the cultural construct of stigma related to tiger-killing. This can be seen in how the tiger-widows' quality of life has been negatively impacted in the way their economic and social security, health, remarriage opportunities, and child upbringing is restricted, along with a multitude of posttrauma psychological scars, deprivation, abuse, and exploitation.

CONCLUSIONS

The study highlights the multitude of sufferings experienced by the tiger-widows including the issues of the gender aspect of HTC and the ecopsychiatric risk factors of tiger attacks combined with the background of local sociocultural beliefs and practices. It is well known that a similar problem also exists in Bangladesh Sundarban as well, in which case it may be that a strong and practical administrative strategy for sustainable alternative income generation and a balanced conservation policy with integrated participatory forest management may go to save both human and tiger. A community ecocultural mental health program involving all the stakeholders (community, gram panchayat, and forest department) and aiming to address and even eradicate the cultural stigma of tiger attack may help to reduce the stigma burden and socicultural discrimination currently experienced by the tiger-widows.

Indicadores de risco para tentativa de suicídio por envenenamento: um estudo caso-controle

RESUMO Objetivo Considerando o envenenamento como o método mais utilizado para a tentativa de suicídio e a escassez de evidências nacionais sobre o tema, investigamos alguns possíveis indicadores de risco nesse tipo de tentativa. Métodos Estudo do tipo caso-controle em uma emergência geral de um hospital público, na cidade do Recife com 220 indivíduos, distribuídos em dois grupos de 110 pacientes cada, que estavam em tratamento, sendo o grupo casos os sobreviventes de tentativa de suicídio por envenenamento e os controles, sem história de intoxicação/envenenamento nem tentativa de suicídio, pareados por gênero e idade. Resultados O gênero feminino predominou na amostra (70,9%), com idade média de 29 anos; 73% declararam etnia branca ou morena; menos da metade vivia em convívio marital; a maioria tinha religião; ambos tinham poucos anos de estudo. Houve diferença significativa (p = 0,003) para dependência financeira entre os grupos, com chance 2,25 vezes maior para tentar suicídio entre os casos. Ter sofrido fatos traumáticos e abuso sexual na infância revelou diferença significativa. Conclusões Foram considerados indicadores de risco no grupo caso: estar em dependência financeira de terceiros, ter sofrido abuso sexual na infância, ideação suicida, histórico de transtorno mental na família, possuir algum transtorno mental e, principalmente, comorbidade(s) psiquiátrica(s). No modelo de regressão, foi possível estimar uma chance de tentativa de suicídio por envenenamento de até 94,0% na presença conjunta de quatro fatores. A pesquisa representa uma das primeiras iniciativas para ampliação das discussões sobre os fatores de risco para tentativa de suicídio em âmbito nacional.

How well does the World Health Organization definition of domestic violence work for India?

Domestic violence (DV) is reported by 40% of married women in India and associated with substantial morbidity. An operational research definition is therefore needed to enhance understanding of DV epidemiology in India and inform DV interventions and measures. To arrive at a culturally-tailored definition, we aimed to better understand how definitions provided by the World Health Organization and the 2005 India Protection of Women from Domestic Violence Act match the perceptions of behaviors constituting DV among the Indian community. Between September 2012 and January 2013, 16 key informant interviews with experts in DV and family counseling and 2 gender-concordant focus groups of lay community members were conducted in Pune, India to understand community perceptions of the definition of DV, perpetrators of DV, and examples of DV encountered by married women in Pune, India. Several key themes emerged regarding behaviors and acts constituting DV including 1) the exertion of control over a woman's reproductive decision-making, mobility, socializing with family and friends, finances, and access to food and nutrition, 2) the widespread acceptance of sexual abuse and the influences of affluence on sexual DV manifestations, 3) the shaping of physical abuse experiences by readily-available tools and the presence of witnesses, 4) psychological abuse for infertility, dowry, and girl-children, and 5) the perpetration of DV by the husband and other members of his family. Findings support the need for a culturally-tailored operational definition that expands on the WHO surveillance definition to inform the development of more effective DV intervention strategies and measures.

Sociocultural context of suicidal behaviour in the sundarban region of India

The role of mental illness in nonfatal deliberate self-harm (DSH) is controversial, especially in Asian countries. This prospective study examined the role of psychiatric disorders, underlying social and situational problems, and triggers of DSH in a sample of 89 patients hospitalised in primary care hospitals of the Sundarban Delta, India. Data were collected by using a specially designed DSH register, Explanatory Model Interview Catalogue (EMIC), and clinical interview. Psychiatric diagnosis was made following the DSM-IV guidelines. The majority of subjects were young females (74.2%) and married (65.2%). Most of them (69.7%) were uncertain about their "intention to die," and pesticide poisoning was the commonest method (95.5%). Significant male-female differences were found with respect to education level, occupation, and venue of the DSH attempt. Typical stressors were conflict with spouse, guardians, or in-laws, extramarital affairs, chronic physical illness, and failed love affairs. The major depressive disorder (14.6%) was the commonest psychiatric diagnosis followed by adjustment disorder (6.7%); however 60.7% of the cases had no psychiatric illness. Stressful life situations coupled with easy access to lethal pesticides stood as the risk factor. The sociocultural dynamics behind suicidal behaviour and community-specific social stressors merit detailed assessment and timely psychosocial intervention. These findings will be helpful to design community-based mental health clinical services and community action in the region.

Participatory Research for Preventing Pesticide-Related DSH and Suicide in Sundarban, India: A Brief Report

Deliberate self-harm (DSH) is a major public health problem in the Sundarban region, India. This study is aimed to develop a DSH-suicide prevention programme based on the principles of community-based participatory research (CBPR). Perception and opinion of community about the problem of pesticide-related DSH and suicide were elicited in a series of facilitated focus group discussions in Namkhana block of Sundarban region. Based on their suggestion, a broad preventive programme was launched involving the development of information, education, and communication (IEC) and training modules and training of the stakeholders of the block. Most of the members of each target group found that the IEC materials were culture fair (message is acceptable, understandable, and meaningful in the local context) and very useful. Analysis of Dwariknagar BPHC, DSH admission data showed a definite reduction of DSH incidents after this CBPR approach to prevention was initiated. Similar model of DSH prevention in the other blocks of Sundarban region or in agricultural community may help to reduce the enormous mortality and morbidity from pesticide-related DSH and suicide.

Indian research on suicide

The suicide rate in India is 10.3. In the last three decades, the suicide rate has increased by 43% but the male female ratio has been stable at 1.4 : 1. Majority (71%) of suicide in India are by persons below the age of 44 years which imposes a huge social, emotional and economic burden. Fifty four articles on suicides have been published in IJP. Several studies reveal that suicidal behaviours are much more prevalent than what is officially reported. Poisoning, hanging and self immolation (particularly women) were the methods to commit suicide. Physical and mental illness, disturbed interpersonal relationships and economic difficulties were the major reasons for suicide. The vulnerable population was found to be women, students, farmers etc. A social and public health response in addition to a mental health response is crucial to prevent suicidal behaviour in India.