The role of alcohol use in pesticide suicide and self-harm: a scoping review

PURPOSE

Suicide and self-harm by pesticide self-poisoning is common in low- and middle-income countries (LMICs). Alcohol is an important risk factor for self-harm; however, little is known about its role in pesticide self-poisoning. This scoping review explores the role that alcohol plays in pesticide self-harm and suicide.

METHODS

The review followed the Joanna Briggs Institute scoping review guidance. Searches were undertaken in 14 databases, Google Scholar, and relevant websites. Articles were included if they focussed on pesticide self-harm and/or suicide and involvement of alcohol.

RESULTS

Following screening of 1281 articles, 52 were included. Almost half were case reports (n = 24) and 16 focussed on Sri Lanka. Just over half described the acute impact of alcohol (n = 286), followed by acute and chronic alcohol use (n = 9), chronic use, (n = 4,) and only two articles addressed harm to others. One systematic review/meta-analysis showed increased risk of intubation and death in patients with co-ingested alcohol and pesticides. Most individuals who consumed alcohol before self-harming with pesticides were men, but alcohol use among this group also led to pesticide self-harm among family members. Individual interventions were recognised as reducing or moderating alcohol use, but no study discussed population-level alcohol interventions as a strategy for pesticide suicide and self-harm prevention.

CONCLUSION

Research on alcohol's role in pesticide self-harm and suicide is limited. Future studies are needed to: further assess the toxicological effects of combined alcohol and pesticide ingestion, explore harm to others from alcohol including pesticide self-harm, and to integrate efforts to prevent harmful alcohol use and self-harm.

Ethical dilemmas in conducting qualitative, public health research on social media: using a study on Facebook as a case

AIM

Platforms on social media are increasingly used for public health research. While social media provides an exceptional opportunity to explore communication about public health topics, this practice is not without ethical dilemmas. Our aim was to identify and unfold some of these dilemmas and to suggest possible solutions and ways forward for future research.

METHODS

Using our own research within a closed forum for people experiencing suicidal thoughts as a case, we explored certain dilemmas and possible answers relating to whether what is to be researched falls under a public or private social media domain; we investigated avenues for obtaining access to participants in an evolving online environment; how to secure informed consent from participants; and ways of ensuring anonymity.

RESULTS

We provide recommendations and reflections that we hope will offer inspiration for researchers embarking on similar social media public health research within and beyond suicide research.

CONCLUSIONS

The ethical framework commonly referred to in health research, based on confidentiality, anonymity, informed consent and doing no harm must be adjusted to be relevant for a social media context where technologies and regulations are constantly being altered.

Evaluating the programme and behavior change theories of a community alcohol education intervention in rural Sri Lanka: a study protocol

Risky alcohol use is a major public health problem globally and in Sri Lanka. While a reduction in alcohol consumption can result in physical, mental, and social benefits, behaviour change is difficult to achieve. Effective, context-adapted interventions are required to minimise alcohol-related harm at a community level. THEATRE is a complex, community-based intervention evaluating whether a promising Sri Lankan pilot study that utilised arts-based research to moderate alcohol use can be scaled up. While the scaled-up pilot study protocol is presented elsewhere, the aim of this protocol paper is to describe the intervention programme theory and evaluation design, and modifications made to the study resulting from COVID-19 and the financial crisis. Drawing on the Behaviour Change Wheel (BCW) and Theoretical Domains Framework, behaviour change theories are presented with potential pathways to guide implementation and evaluation. Alcohol consumption patterns and context of drinking is detailed. The multifaceted intervention targets individuals and communities using arts-based interventions. Four of nine BCW functions are employed in the design of the intervention: education, persuasion, modelling and enablement, and training. Modifications made to the study due to COVID-19 and the financial crisis are described. Ethical approval was obtained from the Ethics Review Committee, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka (ERC/2018/21-July 2018 and Feb 2022) and the University of Sydney (2019/006). Findings will be disseminated locally to community members and key stakeholders and via international peer-reviewed publications.

Differences in the characteristics of people who purchase pesticides from shops for self-harm versus those who use pesticides available in the domestic environment in Sri Lanka

OBJECTIVE

Data from South Asia indicate that for 15%-20% of suicide attempts, pesticides are purchased from shops; otherwise, pesticides are obtained from an individual's house or nearby environment. We aimed to investigate the difference between individuals who directly purchase pesticides from shops for suicide attempts and suicide deaths versus those related to accessing the pesticides from an individual's house or nearby environment.

METHODS

We conducted two comparative studies in rural Sri Lanka: (1) non-fatal shop cases (n = 50) were survivors of self-poisoning with pesticides who ingested the pesticides after purchasing them from a shop; non-fatal domestic cases (n = 192) were survivors who accessed pesticides from their house or nearby environment. (2) fatal shop cases (n = 50) were individuals who died after ingesting pesticides they purchased for the act; fatal domestic cases (n = 102) were patients who died after ingesting pesticides they accessed at house or nearby environment. Logistic regression analysis was used to assess the characteristics which distinguished between the shop and domestic cases.

RESULTS

Data indicate that 20.7% and 32.9% of individuals who used pesticides for suicide attempts and suicide deaths had purchased them from shops, respectively. Being a non-farmer was the main distinguishing characteristic of shop cases: adjusted odds ratios (AOR) 8.9, 95% confidence intervals (CI) 3.2-24.4 for non-fatal shop cases, and AOR 4.0, 95% CI 1.5-10.6 for fatal shop cases. Non-fatal shop cases also had higher suicide intent (AOR 3.0, CI 1.0-8.9), and ingesting an insecticide (AOR 4.8, CI 1.8-1.0-8.9) than non-fatal domestic cases.

CONCLUSION

A high suicide intent of individuals who purchase pesticides for the event explains the high proportion of such fatal cases. Such high suicide intent makes the prevention implications difficult to spell out for those individuals who purchase pesticides for self-poisoning. However, our findings are valuable for clinicians to assess pesticide poisoning cases in hospitals.

A protocol for evaluating the entomological impact of larval source reduction on mosquito vectors at hotel compounds in Zanzibar

There is an increasing awareness of the association between tourism activity and risks of emerging mosquito-borne diseases (MBDs) worldwide. In previous studies we showed that hotels in Zanzibar may play an important role in maintaining residual foci of mosquito vectors populations of public health concern. These findings indicated larval sources removal (LSR) interventions may have a significant negative impact on vector communities. However, a thorough analysis of the response vector species to potential LSM strategies must be evaluated prior to implementation of a large-scale area-wide control campaign. Here we propose a protocol for evaluation of the impact of LSR against mosquito vectors at hotel settings in Zanzibar. This protocol is set to determine the efficacy of LSR in a randomized control partial cross-over experimental design with four hotel compounds representing the unit of randomization for allocation of interventions. However, the protocol can be applied to evaluate the impact of LRS in more than four sites. Proposed interventions are active removal of disposed containers, and installation of water dispenser to replace single use discarded plastic water bottles, which were identified as the most important source of mosquitoes studied hotels. The ideal time for allocating intervention to the intervention arms the dry season, when the mosquito abundance is predictably lower. The possible impact of interventions on mosquito occurrence and abundance risks is then evaluated throughout subsequent rainy and dry seasons. If an appreciable reduction in mosquito abundance and occurrence risks is observed during the trial period, intervention could be extended to the control arm to determine whether any potential reduction of mosquito density is reproducible. A rigorous evaluation of the proposed LRS interventions will inspire large scale trials and provide support for evidence-based mosquito management at hotel facilities in Zanzibar and similar settings.

The case for precision medicine in the prevention, diagnosis, and treatment of cardiometabolic diseases in low-income and middle-income countries

Cardiometabolic diseases are the leading preventable causes of death in most geographies. The causes, clinical presentations, and pathogenesis of cardiometabolic diseases vary greatly worldwide, as do the resources and strategies needed to prevent and treat them. Therefore, there is no single solution and health care should be optimised, if not to the individual (ie, personalised health care), then at least to population subgroups (ie, precision medicine). This optimisation should involve tailoring health care to individual disease characteristics according to ethnicity, biology, behaviour, environment, and subjective person-level characteristics. The capacity and availability of local resources and infrastructures should also be considered. Evidence needed for equitable precision medicine cannot be generated without adequate data from all target populations, and the idea that research done in high-income countries will transfer adequately to low-income and middle-income countries (LMICs) is problematic, as many migration studies and transethnic comparisons have shown. However, most data for precision medicine research are derived from people of European ancestry living in high-income countries. In this Series paper, we discuss the case for precision medicine for cardiometabolic diseases in LMICs, the barriers and enablers, and key considerations for implementation. We focus on three propositions: first, failure to explore and implement precision medicine for cardiometabolic disease in LMICs will enhance global health disparities. Second, some LMICs might already be placed to implement cardiometabolic precision medicine under appropriate circumstances, owing to progress made in treating infectious diseases. Third, improvements in population health from precision medicine are most probably asymptotic; the greatest gains are more likely to be obtained in countries where health-care systems are less developed. We outline key recommendations for implementation of precision medicine approaches in LMICs.

Digital education for health professionals in India: a scoping review of the research

BACKGROUND

The World Health Organization (WHO) predicts a global shortfall of 18 million health workers by 2030, particularly in low- and middle-income countries like India. The country faces challenges such as inadequate numbers of health professionals, poor quality of personnel, and outdated teaching styles. Digital education may address some of these issues, but there is limited research on what approaches work best in the Indian context. This paper conducts a scoping review of published empirical research related to digital health professions education in India to understand strengths, weaknesses, gaps, and future research opportunities.

METHODS

We searched four databases using a three-element search string with terms related to digital education, health professions, and India. Data was extracted from 36 included studies that reported on empirical research into digital educational innovations in the formal health professions education system of India. Data were analysed thematically.

RESULTS

Most study rationales related to challenges facing the Indian health care system, rather than a wish to better understand phenomena related to teaching and learning. Similarly, most studies can be described as general evaluations of digital educational innovations, rather than educational research per se. They mostly explored questions related to student perception and intervention effectiveness, typically in the form of quantitative analysis of survey data or pre- and post-test results.

CONCLUSIONS

The analysis revealed valuable insights into India-specific needs and challenges. The Indian health professions education system's size and unique challenges present opportunities for more nuanced, context-specific investigations and contributions to the wider digital education field. This, however, would require a broadening of methodological approaches, in particular rigorous qualitative designs, and a focus on addressing research-worthy educational phenomena.

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.

Community-based alcohol education intervention (THEATRE) study to reduce harmful effects of alcohol in rural Sri Lanka: design and adaptation of a mixed-methods stepped wedge cluster randomised control trial

INTRODUCTION

Alcohol consumption is a leading cause of mortality, morbidity and adverse social sequelae in Sri Lanka. Effective community-based, culturally adapted or context-specific interventions are required to minimise these harms. We designed a mixed-methods stepped wedge cluster randomised control trial of a complex alcohol intervention. This paper describes the initial trial protocol and subsequent modifications following COVID-19.

METHODS AND ANALYSIS

We aimed to recruit 20 villages (approximately n=4000) in rural Sri Lanka. The proposed intervention consisted of health screening clinics, alcohol brief intervention, participatory drama, film, and public health promotion materials to be delivered over 12 weeks.Following disruptions to the trial resulting from the Easter bombings in 2019, COVID-19 and a national financial crisis, we adapted the study in two main ways. First, the interventions were reconfigured for hybrid delivery. Second, a rolling pre-post study evaluating changes in alcohol use, mental health, social capital and financial stress as the primary outcome and implementation and ex-ante economic analysis as secondary outcomes.

ETHICS AND DISSEMINATION

The original study and amendments have been reviewed and granted ethical approval by Rajarata University of Sri Lanka (ERC/2018/21-July 2018 and February 2022) and the University of Sydney (2019/006). Findings will be disseminated locally in collaboration with the community and stakeholders.The new hybrid approach may be more adaptable, scalable and generalisable than the planned intervention. The changes will allow a closer assessment of individual interventions while enabling the evaluation of this discontinuous event through a naturalistic trial design. This may assist other researchers facing similar disruptions to community-based studies.

TRIAL REGISTRATION

The trial is registered with the Sri Lanka Clinical Trials Registry; https://slctr.lk/trials/slctr-2018-037.

Conceptualising the commercial determinants of suicide: broadening the lens on suicide and self-harm prevention

Suicide is preventable, yet, in many settings, robust suicide prevention strategies have not been implemented. Although a commercial determinants of health lens is increasingly being applied to industries important to the field of suicide prevention, the interplay between the vested interests of commercial actors and suicide has received little attention. There is a need to shift attention to the causes of the causes, directing more focus to the ways that commercial determinants influence suicide and shape suicide prevention strategies. Such a shift in perspective, with an evidence base and precedents to draw upon, has transformative potential for research and policy agendas dedicated to understanding and addressing upstream modifiable determinants of suicide and self-harm. We propose a framework intended to help guide efforts to conceptualise, research, and address the commercial determinants of suicide and their inequitable distribution. We hope these ideas and lines of inquiry help to catalyse connections between disciplines and open further debate and discussion as to how to take such an agenda forward.

Making Sense or Non-Sense? Communicating COVID-19 Guidelines to Young Adults at Danish Folk High Schools

Little is known about young people's behaviors and responses under outbreaks of infectious diseases such as the COVID-19 pandemic, especially in institutional settings. This research investigated the reactions of young adults residing at Danish folk high schools (FHSs) towards COVID-19 guidelines and the communicative styles used to enforce COVID-19 guidelines. The qualitative data consists of focus group discussions (FGDs) with students, interviews with staff, and participant observations, as well as survey data from 1800 students. This study showed that young adults reacted negatively when first faced with the new reality of COVID-19 restrictions. They expressed distress over the loss of meaning (non-sense), loss of sense of community, as well as uncertainty. Hygiene guidelines, however, made immediate sense and were socially well accepted. Most FHSs actively involved students in risk communication and creative examples of community-building communication were identified. This study demonstrates that successful risk communication at educational institutions must take into consideration how young adults make sense of and cope with the uncertainties of life during crisis situations including epidemics.

Scaling up Locally Adapted Clinical Practice Guidelines for Improving Childbirth Care in Tanzania: A Protocol for Programme Theory and Qualitative Methods of the PartoMa Scale-up Study

Effective, low-cost clinical interventions to improve facility-based care during childbirth are critical to reduce maternal and perinatal mortality and morbidity in low-resource settings. While health interventions for low- and lower-middle-income countries are often developed and implemented top-down, needs and circumstances vary greatly across locations. Our pilot study in Zanzibar improved care through locally co-created intrapartum clinical practice guidelines (CPGs) and associated training (the PartoMa intervention). This intervention was context-tailored with health-care providers in Zanzibar and now scaled up within five maternity units in Dar es Salaam, Tanzania. This PartoMa Scale-up Study thereby provides an opportunity to explore the co-creation process and modification of the intervention in another context and how scale-up might be successfully achieved. The overall protocol is presented in a separate paper. The aim of the present paper is to account for the Scale-up Study’s programme theory and qualitative methodology. We introduce social practice theory and argue for its value within the programme theory and towards qualitative explorations of shifts in clinical practice. The theory recognizes that the practice we aim to strengthen – safe and respectful clinical childbirth care – is not practiced in a vacuum but embedded within a socio-material context and intertwined with other practices. Methodologically, the project draws on ethnographic and participatory methodologies to explore current childbirth care practices. In line with our programme theory, explorations will focus on meanings of childbirth care, material tools and competencies that are being drawn upon, birth attendants’ motivations and relational contexts, as well as other everyday practices of childbirth care. Insights generated from this study will not only elucidate active ingredients that make the PartoMa intervention feasible (or not) but develop the knowledge foundation for scaling-up and replicability of future interventions based on the principles of co-creation and contextualisation.

Scaling up context-tailored clinical guidelines and training to improve childbirth care in urban, low-resource maternity units in Tanzania: A protocol for a stepped-wedged cluster randomized trial with embedded qualitative and economic analyses (The PartoMa Scale-Up Study)

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births annually). This PartoMa Scale-up Study will include four main steps: I. Mixed-methods situational analysis exploring factors affecting care; II. Co-created contextual modifications to the pilot CPGs and training, based on step I; III. Implementation and evaluation of the modified intervention; IV. Development of a framework for co-creation of context-specific CPGs and training, of relevance in comparable fields. The implementation and evaluation design is a theory-based, stepped-wedged cluster-randomised trial with embedded qualitative and economic assessments. Women in active labour and their offspring will be followed until discharge to assess provided and experienced care, intra-hospital perinatal deaths, Apgar scores, and caesarean sections that could potentially be avoided. Birth attendants' perceptions, intervention use and possible associated learning will be analysed. Moreover, as further detailed in the accompanying article, a qualitative in-depth investigation will explore behavioural, biomedical, and structural elements that might interact with non-linear and multiplying effects to shape health providers' clinical practices. Finally, the incremental cost-effectiveness of co-creating and implementing the PartoMa intervention is calculated. Such real-world scale-up of context-tailored CPGs and training within an existing health system may enable a comprehensive understanding of how impact is achieved or not, and how it may be translated between contexts and sustained.Trial registration number: NCT04685668.

Current pesticide suicide surveillance methods used across the African continent: a scoping review protocol

INTRODUCTION

Every year, more than 800 000 people die from suicides of which an estimated 20% are from pesticide ingestion. Multiple studies have estimated that around 77%-80% of these pesticide suicides occur in low/middle-income countries. The full burden of pesticide suicides in African countries remains poorly documented, one reason being the lack of systematic data collection. It is essential to know the number of pesticide suicide cases to guide prevention of further cases occurring. This can be done by informing policy and legislation, and the implementation of targeted bans, as well as raising community awareness around the use of these pesticides, training of healthcare personnel, and influencing the type and level of clinical facility investments into this area of healthcare. The scoping review aims to investigate how pesticide suicide deaths in Africa are recorded by exploring the various surveillance systems in place, as well as highlighting key limitations and data collection barriers.

METHODS AND ANALYSIS

A scoping review will be carried out with the five-stage methodological frameworks set out by Arksey and O'Malley and the Joanna Briggs Institute. Studies in English that looked at pesticide suicide in African countries will be extracted and screened independently by two reviewers against the inclusion and exclusion criteria of this review. Studies' data will be extracted, and a descriptive synthesis developed of their main findings, as guided by the approach of Levac and colleagues.

ETHICS AND DISSEMINATION

Ethics approval is not required for this review as no human participants will be involved. The study findings will be distributed in a peer-reviewed publication.

REGISTRATION DETAILS

This protocol has been submitted for publication to BMJ Open.

High DDT resistance without apparent association to kdr and Glutathione-S-transferase (GST) gene mutations in Aedes aegypti population at hotel compounds in Zanzibar

Global efforts to control Aedes mosquito-transmitted pathogens still rely heavily on insecticides. However, available information on vector resistance is mainly restricted to mosquito populations located in residential and public areas, whereas commercial settings, such as hotels are overlooked. This may obscure the real magnitude of the insecticide resistance problem and lead to ineffective vector control and resistance management. We investigated the profile of insecticide susceptibility of Aedes aegypti mosquitoes occurring at selected hotel compounds on Zanzibar Island. At least 100 adults Ae. aegypti females from larvae collected at four hotel compounds were exposed to papers impregnated with discriminant concentrations of DDT (4%), permethrin (0.75%), 0.05 deltamethrin (0.05%), propoxur (0.1%) and bendiocarb (0.1%) to determine their susceptibility profile. Allele-specific qPCR and sequencing analysis were applied to determine the possible association between observed resistance and presence of single nucleotide polymorphisms (SNPs) in the voltage-gated sodium channel gene (VGSC) linked to DDT/pyrethroid cross-resistance. Additionally, we explored the possible involvement of Glutathione-S-Transferase gene (GSTe2) mutations for the observed resistance profile. In vivo resistance bioassay indicated that Ae. aegypti at studied sites were highly resistant to DDT, mortality rate ranged from 26.3% to 55.3% and, moderately resistant to deltamethrin with a mortality rate between 79% to and 100%. However, genotyping of kdr mutations affecting the voltage-gated sodium channel only showed a low frequency of the V1016G mutation (n = 5; 0.97%). Moreover, for GSTe2, seven non-synonymous SNPs were detected (L111S, C115F, P117S, E132A, I150V, E178A and A198E) across two distinct haplotypes, but none of these were significantly associated with the observed resistance to DDT. Our findings suggest that cross-resistance to DDT/deltamethrin at hotel compounds in Zanzibar is not primarily mediated by mutations in VGSC. Moreover, the role of identified GSTe2 mutations in the resistance against DDT remains inconclusive. We encourage further studies to investigate the role of other potential insecticide resistance markers.

Available information on mosquito resistance to insecticides is mainly restricted to residential and public areas, whereas commercial settings, such as hotels are overlooked. This may hide the real size of an insecticide resistance problem and lead to ineffective mosquito control. We investigated insecticide susceptibility of Aedes aegypti mosquitoes occurring at selected hotel compounds on Zanzibar Island. We also looked at whether resistance occurred in mosquitoes with gene mutations for two proteins (voltage-gated sodium channels and glutathione-S-transferase) that are known to cause resistance to insecticides in other parts of the world. The Ae. aegypti mosquitoes collected from hotels were highly resistant to DDT, and moderately and possibly resistant to deltamethrin and propoxur, respectively. However, resistance to these insecticides was not linked to mutations in either of the studied genes. The presence of insecticide resistance in Ae. aegypti in hotel compounds on Zanzibar is concerning and shows that these areas can act as sources of resistant mosquitoes. More needs to be done to establish the underlying causes for insecticide resistance in hotel Ae. aegypti populations, and this information can then be used to design measures that prevent resistance from becoming more widespread on Zanzibar.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

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

Targeted elimination of species-rich larval habitats can rapidly collapse arbovirus vector mosquito populations at hotel compounds in Zanzibar

Understanding the dynamics of larval habitat utilization by mosquito communities is crucial for the design of efficient environmental control strategies. The authors investigated the structure of mosquito communities found at hotel compounds in Zanzibar, networks of mosquito interactions with larval habitats and robustness of mosquito communities to elimination of larval habitats. A total of 23 698 mosquitoes comprising 26 species in six genera were found. Aedes aegypti (n = 16 207), Aedes bromeliae/Aedes lillie (n = 1340), Culex quinquefasciatus (n = 1300) and Eretmapodites quinquevitattus (n = 659) were the most dominant species. Ecological network analyses revealed the presence of dominant, larval habitat generalist species (e.g., A. aegypti), exploiting virtually all types of water holding containers and few larval habitat specialist species (e.g., Aedes natalensis, Orthopodomyia spp). Simulations of mosquito community robustness to systematic elimination of larval habitats indicate that mosquito populations are highly sensitive to elimination of larval habitats sustaining higher mosquito species diversity. This study provides insights on potential foci of future mosquito-borne arboviral disease outbreaks in Zanzibar and underscores the need for detailed knowledge on the ecological function of larval habitats for effective mosquito control by larval sources management.

Risk factors for occurrence and abundance of Aedes aegypti and Aedes bromeliae at hotel compounds in Zanzibar

Background

A field survey was performed to investigate local environmental factors promoting occurrence and abundance of Aedes aegypti and Ae. bromeliae mosquitoes at hotel compounds in the south-east coastal region of Zanzibar Island.

Methods

The potential risk factors were determined using generalized linear mixed models. Aedes (Stegomyia) spp. indices such as container index (CI) and pupae per container (PPC) index were also estimated.

Results

Aedes aegypti and Ae. bromeliae were the most abundant vector species, accounting for 70.8% of all Aedes mosquitoes collected. The highest CI was observed for plastic containers irrespective of the season, whereas the highest PPC was observed for coconut shells and aluminium containers in the rainy and dry seasons, respectively. The risk of Aedes mosquito occurrence and abundance were significantly associated with presence of plastic containers, coconut shells, used tyres and steel containers. These were discarded in shaded places, in the open and gardens, or found in plant nurseries.

Conclusion

This study shows that Aedes species of global health significance occur at hotel compounds on this part of Zanzibar Island. The occurrence and abundance are sustained by the presence of abundant and poorly managed solid wastes and containers used for gardening tasks. This highlights an urgent need for the adoption of area-wide environmentally sustainable Aedes mosquito management interventions that also integrate solid waste management and ornamental plant production practices for reducing the risk of arboviral disease epidemics.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-05005-9.

Emerging epidemics: is the Zanzibar healthcare system ready to detect and respond to mosquito-borne viral diseases?

Background

Effective control of emerging mosquito-borne viral diseases such as dengue, chikungunya, and Zika requires, amongst other things, a functional healthcare system, ready and capable of timely detection and prompt response to incipient epidemics. We assessed the readiness of Zanzibar health facilities and districts for early detection and management of mosquito-borne viral disease outbreaks.

Methods

A cross-sectional study involving all 10 District Health Management Teams and 45 randomly selected public and private health facilities in Zanzibar was conducted using a mixed-methods approach including observations, document review, and structured interviews with health facility in-charges and District Health Management Team members.

Results

The readiness of the Zanzibar healthcare system for timely detection, management, and control of dengue and other mosquito-borne viral disease outbreaks was critically low. The majority of health facilities and districts lacked the necessary requirements including standard guidelines, trained staff, real-time data capture, analysis and reporting systems, as well as laboratory diagnostic capacity. In addition, health education programmes for creating public awareness and Aedes mosquito surveillance and control activities were non-existent.

Conclusions

The Zanzibar healthcare system has limited readiness for management, and control of mosquito-borne viral diseases. In light of impending epidemics, the critical shortage of skilled human resource, lack of guidelines, lack of effective disease and vector surveillance and control measures as well as lack of laboratory capacity at all levels of health facilities require urgent attention across the Zanzibar archipelago.

Assessment of the core and support functions of the integrated disease surveillance and response system in Zanzibar, Tanzania

Background

Disease surveillance is a cornerstone of outbreak detection and control. Evaluation of a disease surveillance system is important to ensure its performance over time. The aim of this study was to assess the performance of the core and support functions of the Zanzibar integrated disease surveillance and response (IDSR) system to determine its capacity for early detection of and response to infectious disease outbreaks.

Methods

This cross-sectional descriptive study involved 10 districts of Zanzibar and 45 public and private health facilities. A mixed-methods approach was used to collect data. This included document review, observations and interviews with surveillance personnel using a modified World Health Organization generic questionnaire for assessing national disease surveillance systems.

Results

The performance of the IDSR system in Zanzibar was suboptimal particularly with respect to early detection of epidemics. Weak laboratory capacity at all levels greatly hampered detection and confirmation of cases and outbreaks. None of the health facilities or laboratories could confirm all priority infectious diseases outlined in the Zanzibar IDSR guidelines. Data reporting was weakest at facility level, while data analysis was inadequate at all levels (facility, district and national). The performance of epidemic preparedness and response was generally unsatisfactory despite availability of rapid response teams and budget lines for epidemics in each district. The support functions (supervision, training, laboratory, communication and coordination, human resources, logistic support) were inadequate particularly at the facility level.

Conclusions

The IDSR system in Zanzibar is weak and inadequate for early detection and response to infectious disease epidemics. The performance of both core and support functions are hampered by several factors including inadequate human and material resources as well as lack of motivation for IDSR implementation within the healthcare delivery system. In the face of emerging epidemics, strengthening of the IDSR system, including allocation of adequate resources, should be a priority in order to safeguard human health and economic stability across the archipelago of Zanzibar.

The cost-effectiveness of banning highly hazardous pesticides to prevent suicides due to pesticide self-ingestion across 14 countries: an economic modelling study

BACKGROUND

Reducing suicides is a key Sustainable Development Goal target for improving global health. Highly hazardous pesticides are among the leading causes of death by suicide in low-income and middle-income countries. National bans of acutely toxic highly hazardous pesticides have led to substantial reductions in pesticide-attributable suicides across several countries. This study evaluated the cost-effectiveness of implementing national bans of highly hazardous pesticides to reduce the burden of pesticide suicides.

METHODS

A Markov model was developed to examine the costs and health effects of implementing a national ban of highly hazardous pesticides to prevent suicides due to pesticide self-poisoning, compared with a null comparator. We used WHO cost-effectiveness and strategic planning (WHO-CHOICE) methods to estimate pesticide-attributable suicide rates for 100 years from 2017. Country-specific costs were obtained from the WHO-CHOICE database and denominated in 2017 international dollars (I$), discounted at a 3% annual rate, and health effects were measured in healthy life-years gained (HLYGs). We used a demographic projection model beginning with the country population in the baseline year (2017), split by 1-year age group and sex. Country-specific data on overall suicide rates were obtained for 2017 by age and sex from the Global Burden of Disease Study 2017 Data Resources. The analysis involved 14 countries spanning low-income to high-income settings, and cost-effectiveness ratios were analysed at the country-specific level and aggregated according to country income group and the proportion of suicides due to pesticides.

FINDINGS

Banning highly hazardous pesticides across the 14 countries studied could result in about 28 000 (95% uncertainty interval [UI] 24 000-32 000) fewer suicide deaths each year at an annual cost of I$0·007 per capita (95% UI 0·006-0·008). In the population-standardised results for the base case analysis, national bans produced cost-effectiveness ratios of $94 per HLYG (95% UI 73-123) across low-income and lower-middle-income countries and $237 per HLYG (95% UI 191-303) across upper-middle-income and high-income countries. Bans were more cost-effective in countries where a high proportion of suicides are attributable to pesticide self-poisoning, reaching a cost-effectiveness ratio of $75 per HLYG (95% UI 58-99) in two countries with proportions of more than 30%.

INTERPRETATION

National bans of highly hazardous pesticides are a potentially cost-effective and affordable intervention for reducing suicide deaths in countries with a high burden of suicides attributable to pesticides. However, our study findings are limited by imperfect data and assumptions that could be improved upon by future studies.

FUNDING

WHO.

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.

Risk of faecal pollution among waste handlers in a resource-deprived coastal peri-urban settlement in Southern Ghana

Resource-deprived coastal peri-urban settlements in Southern Ghana are characterized by indiscriminate solid waste disposal and open defecation practices. Persons engaged in waste handling in such communities perform their activities with little or no personal protective equipment. They are thus confronted with the risk of faecal pollution of the hands and other bodily parts. A mixed method approach was used to investigate 280 waste handlers performing different activities to estimate recent faecal pollution of their hands and to observe the utilization of personal protective equipment and sanitation/hygiene facilities during work. The log concentration of E. coli on hands of waste handlers after work (8.60 ± 4.20 CFU/hand, mean ± standard deviation) was significantly higher compared with the E. coli log concentration before work (2.95 ± 1.89 CFU/hand, mean ± standard deviation) (p<0.001). The odds of faecal pollution was significantly higher (aOR 4.2; 95% CI: 1.9-9.1) for workers aged 35 years and above compared with those less than 35 years; and for workers at public toilet facilities (aOR 3.0; 95% CI: 1.0-8.4) compared with those who worked for private waste handling companies. Female workers were, however, 60% less likely (aOR 0.4; 95% CI: 0.2-0.8) to experience faecal pollution of their hands compared with males. The workers had limited access to water and sanitation and hygiene facilities, and about one-fifth (n = 59; 21.1%) did not use personal protective equipment during work. Waste handlers should be provided and instructed in proper use of personal protective equipment, have access to sanitation facilities and adopt improved hygiene behaviour to avoid the risk of faecal pollution and associated disease risk.

Using ex-ante economic evaluation to inform research priorities in pesticide self-poisoning prevention: the case of a shop-based gatekeeper training programme in rural Sri Lanka

OBJECTIVES

Suicide by pesticide self-poisoning is a major public health challenge in low- and middle-income countries. While effectiveness studies are required to test alternative prevention approaches, economic evidence is lacking to inform decision-making in research priority setting. Therefore, this study aimed to estimate the costs of a shop-based gatekeeper training programme for pesticide vendors seeking to prevent pesticide self-poisoning in rural Sri Lanka and assess its potential for cost-effectiveness.

METHODS

Ex-ante cost and cost-effectiveness threshold (CET) analyses were performed from a governmental perspective based on a three-year analytic horizon, using 'no programme' as a comparator. A programme model targeting all 535 pesticide shops in the North Central Province and border areas was applied. Total programme costs (TPC) were estimated in 2019 USD using an ingredients approach and 3% annual discounting. The Sri Lankan gross domestic product per capita and life years saved were used as CET and effectiveness measure, respectively. Sensitivity analyses were performed.

RESULTS

TPC were estimated at 31 603.03 USD. TPC were sensitive to cost changes of training material and equipment and the programme lifetime. The programme needs to prevent an estimated 0.23 fatal pesticide self-poisoning cases over three years to be considered cost-effective. In the sensitivity analyses, the highest number of fatal cases needed to be prevented to obtain cost-effectiveness was 4.55 over three years.

CONCLUSIONS

From an economic perspective, the programme has a very high potential to be cost-effective. Research assessing its effectiveness should therefore be completed, and research analysing its transferability to other settings prioritised.

Searching Online for Methods of Suicide

Background: Information on methods of suicide is available online, and access to information on methods of suicide appears to contribute to a small but significant proportion of suicides. There is limited documentation of how methods of suicide are being profiled, as well as what content exists in other languages than English. Aim: We aimed to analyze and compare how methods of suicide are profiled on Danish and English-language websites. Method: We applied a categorization and content analysis of websites describing methods of suicide. Sites were retrieved by applying widely used Danish and English-language search terms. Results: A total of 136 English-language websites and 106 Danish-language websites were included for analysis. Websites were more often categorized as prevention or support sites, academic or policy sites, and against suicide sites than dedicated suicide sites (i.e., pro-suicide sites), or information sites. However, information on methods of suicide was available, and 20.1% and 8.9% of the English and Danish-language sites, respectively, suggested that a particular method of suicide was quick, easy, painless, or certain to result in death. Limitations: Only one author coded and analyzed all websites. A further operationalization of the content analysis checklist is warranted to increase reliability. Conclusion: The websites primarily had a prevention or anti-suicide focus, but information on methods of suicide was available, requiring an increased focus on how to diminish the negative effects of harmful online content.

Emerging pesticides responsible for suicide in rural Sri Lanka following the 2008-2014 pesticide bans

Background

Sri Lanka has reduced its overall suicide rate by 70% over the last two decades through means restriction, through a series of government regulations and bans removing highly hazardous pesticides from agriculture. We aimed to identify the key pesticide(s) now responsible for suicides in rural Sri Lanka to provide data for further pesticide regulation.

Methods

We performed a secondary analysis of data collected prospectively during a cluster randomized controlled trial in the Anuradhapura district of Sri Lanka from 2011 to 16. The identity of pesticides responsible for suicides were sought from medical or judicial medical notes, coroners’ records, and the person’s family. Trend analysis was done using a regression analysis with curve estimation to identify relative importance of key pesticides.

Results

We identified 337 suicidal deaths. Among them, the majority 193 (57.3%) were due to ingestion of pesticides while 82 (24.3%) were due to hanging. A specific pesticide was identified in 105 (54.4%) of the pesticide suicides. Ingestion of carbosulfan or profenofos was responsible for 59 (56.2%) of the suicides with a known pesticide and 17.5% of all suicides. The increasing trend of suicides due to carbosulfan and profenofos over time was statistically significant (R square 0.846, F 16.541, p 0.027).

Conclusion

Ingestion of pesticides remains the most important means of suicides in rural Sri Lanka. The pesticides that were once responsible for most pesticide suicides have now been replaced by carbosulfan and profenofos. Their regulation and replacement in agriculture with less hazardous pesticides will further reduce the incidence of both pesticide and overall suicides in rural Sri Lanka.

A Qualitative Analysis of Self-Harm and Suicide in Sri Lankan Printed Newspapers

Background: Media reporting may influence suicidal behavior. In-depth exploration of how self-harm and suicide are portrayed in newspaper articles in a middle-income country such as Sri Lanka is lacking. Aims: We aimed to explore how self-harm and suicide are portrayed in Sri Lankan printed newspapers. Method: Seven English- and Sinhala-language Sri Lankan newspapers were screened for articles reporting on self-harm and suicide (December 1, 2014 to January 31, 2015). A thematic analysis was conducted. Results: In the 78 articles identified for analysis, certain aspects were overemphasized (inappropriate behavior) and others underemphasized (alcohol and complexities of self-harm). Explanations of self-harm were one-sided and a suicide prevention narrative was lacking. Limitations: Another time-frame and inclusion of Tamil newspapers as well as social media and online publications would provide additional understanding. Conclusion: The study found an indication of simplistic reporting. Greater focus on prevention and a nuanced portrayal of self-harm could reduce stigma and imitative behavior.

A qualitative exploration of rural and semi-urban Sri Lankan men's alcohol consumption

Harmful alcohol drinking can have health and socio-economic consequences. However, consumption is also associated with pleasure and symbolic meanings. Alcohol intake is increasing in Sri Lanka. In-depth explorations of alcohol patterns are needed to inform interventions and policies. Qualitative data were collected over 11 months in 2014 and 2015 in the North Central Province of Sri Lanka. Ten focus group discussions were conducted in gender, age and geographically (rural and semi-urban) segregated groups. Observations were conducted at alcohol selling establishments and social gatherings. Bourdieu’s concepts practice, habitus, symbolic capital and distinction were used for the analysis. Three groups of consumers emerged: moderate consumers, abstainers and heavy drinkers. They each exercised distinctions through social codes of conduct within and towards other groups of consumers. Symbolic capital was expressed through choice of alcohol. Norms of ‘acceptable consumption’ were defined as ‘moderate drinking’ in covert, social and contained settings. Public, uncontrolled and solitary consumption violated norms of appropriate consumption. Young consumers communicated a ‘modern lifestyle’ through their consumption. This study found that alcohol practices mirrored social norms in this Sri Lankan setting. Alcohol and drug prevention and intervention efforts should take this into account.

Temporal Pattern of Mutations in the Knockdown Resistance (kdr) Gene of Aedes aegypti Mosquitoes Sampled from Southern Taiwan

Aedes mosquitoes are the principal dengue vector in Taiwan, where the use of insecticides is a key element in the national control strategy. However, control efforts are constrained by the development of resistance to most insecticides, including pyrethroids. In this study, mutations in the voltage-gated sodium channel (VGSC) gene resulting in knockdown resistance (kdr) were examined in Aedes aegypti. Fragments of the VGSC gene were polymerase chain reaction (PCR)-amplified followed by restriction fragment length polymorphism analysis in samples from various settings in Southern Taiwan covering dry and wet seasons from 2013 to 2015. Three kdr mutations were identified: V1023G, D1794Y, and F1534C, with observed frequencies of 0.36, 0.55, and 0.33, respectively, in the dry season of 2013-2014. Exploring for temporal changes, the most important observation was the 1534C allele frequency increment in the following season to 0.60 (P < 0.05). This study suggests that continued insecticide pressure is driving the mutational changes, although the selection is ambiguous in the mosquito population.

Location, seasonal and functional characteristics of water-holding containers with juvenile Aedes albopictus in urban southern Taiwan: a cross-sectional study

BACKGROUND

Urban Kaohsiung City (KC), in southern Taiwan, has experienced annual dengue epidemics for decades despite considerable vector control efforts. Substantial research has been undertaken to characterize Aedes aegypti breeding habitats, but no systematic assessment has been completed for Aedes albopictus present in KC.

METHODS

A cross-sectional survey was conducted from 2013 to 2015 in a predefined area of KC. Each identified container was characterised by season, location, ownership, function and number of juvenile A. aegypti. Negative binomial hurdle analyses were applied to evaluate the association between the number of juvenile A. albopictus and the characteristics of each identified container.

RESULTS

For all containers, high numbers of A. albopictus were significantly predicted by containers identified during the wet season (vs dry), located on government (vs private) property and classified as a discarded item (vs water storage). For outdoor containers, more A. albopictus were significantly predicted by wet season (vs dry) and discarded item (vs container in use).

CONCLUSIONS

In order to improve dengue prevention in KC, we propose that vector control efforts be expanded to include A. albopictus through an increased focus during the wet season on discarded containers that are located outdoors and on government property.

How many premature deaths from pesticide suicide have occurred since the agricultural Green Revolution?

Introduction: The agricultural Green Revolution in the 1950s and 60s is thought to have averted many deaths from famine. However, it also introduced highly hazardous pesticides such as parathion and endrin into poor rural communities that were totally unequipped to store or use them safely. Pesticide self-poisoning rapidly became one of the two most common global means of suicide. Thus far, no attempt has been made to enumerate the total number of deaths that have occurred subsequent to the Green Revolution.Objective: To calculate plausible estimates for the total global number of pesticide suicides that have occurred since 1960.Methods: We performed a literature review on Medline and Embase databases to July 2019 to find papers that reported national or global numbers of pesticide suicides. We restricted our search to papers published in English. We used the search terms: pesticide) OR insecticide) OR paraquat) OR organophosphate) OR organophosphorus) OR agrochemical) AND suicide) OR "") OR deliberate) AND poison in all fields. These searches identified 2,144 papers; a further 8 citations were added through the searching of reference lists and our own paper collections. 2,136 papers were excluded as they contained no data on pesticide suicide, or were case reports, case series, or related to specific socio-demographic groups, or were non-human studies. This left 16 papers giving country specific or global pesticide suicide data.Long-term national trend in pesticide suicides: We found studies from one low- and middle-income country (Sri Lanka) that recorded long-term trends in suicide throughout the Green Revolution. These data showed a steady increase in suicides from 1960 to the early 1970s, with a more rapid increase from 1979 to 1984. The number of suicides plateaued until 1995, when they started a steady almost linear decrease that has continued at least until 2015. We used the Sri Lankan epidemiology as a model of the incidence of pesticide suicides in other low- and middle-income countries. Data from Bangladesh suggested that the decrease might have started in 2002.Estimating global numbers since 1960: Starting from a conservative estimate of zero deaths in 1960, the best estimate of the total global burden of pesticide suicides from 1960 to 2018 is 14,272,105 or 14,936,000 (depending on whether a fall in incidence began in 1995 or 2002), with a plausible range of 9,859,667 to 17,303,333 deaths. These are likely underestimates because suicide is illegal in many countries, and most pesticide suicides occur in poor rural areas without effective death registration systems.Conclusions: Pesticide self-poisoning has been a major clinical and public health problem in rural Asia for decades, while being long ignored. Most pesticide suicides are relatively impulsive with little planning: in the absence of highly hazardous pesticides, many people would have survived their suicidal impulse, gone on to find support amongst family, community, and health services, and lived a full life. Pesticide suicides must therefore be considered a category 4 occupation condition following Schilling's classification - if they had not been brought into rural communities for agricultural use, pesticide suicides would not have occurred. Preventing these deaths should be a global public health priority.

Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study

BACKGROUND

Evidence from high income countries (HICs) suggests that individuals who present to hospital after self-harm are an important target for suicide prevention, but evidence from low and middle-income countries (LMICs) is lacking. We aimed to investigate the risk of repeat self-harm and suicide, and factors associated with these outcomes, in a large cohort of patients presenting to hospital with self-harm in rural Sri Lanka.

METHODS

In this cohort study, hospital presentations for self-harm at 13 hospitals in a rural area of North Central Province (population 224 000), Sri Lanka, were followed up with a self-harm surveillance system, established as part of a community randomised trial, and based on data from all hospitals, coroners, and police stations in the study area. We estimated the risk of repeat non-fatal and fatal self-harm and risk factors for repetition with Kaplan-Meier methods and Cox proportional hazard models. Sociodemographic (age, sex, and socioeconomic position) and clinical (past self-harm and method of self-harm) characteristics investigated were drawn from a household survey in the study area and data recorded at the time of index hospital presentation. We included all individuals who had complete data for all variables in the study in our primary analysis.

OUTCOMES

Between July 29, 2011, and May 12, 2016, we detected 3073 episodes of self-harm (fatal and non-fatal) in our surveillance system, of which 2532 (82·3%) were linked back to an individual in the baseline survey. After exclusion of 145 ineligible episodes, we analysed 2259 index episodes of self-harm. By use of survival models, the estimated risk of repeat self-harm (12 months: 3· 1%, 95% CI 2·4-3·9; 24 months: 5·2%, 4·3-6·4) and suicide (12 months: 0·6%, 0·4-1·1; 24 months: 0·8%, 0·5-1·3) in our study was considerably lower than that in HICs. A higher risk of repeat self-harm was observed in men than in women (fatal and non-fatal; hazard ratio 2·0, 95% CI 1·3-3·2; p=0·0021), in individuals aged 56 years and older compared with those aged 10-25 years (fatal; 16·1, 4·3-59·9; p=0·0027), and those who used methods other than poisoning in their index presentation (fatal and non-fatal; 3·9, 2·0-7·6; p=0·00027). We found no evidence of increased risk of repeat self-harm or suicide in those with a history of self-harm before the index episode.

INTERPRETATION

Although people who self-harm are an important high-risk group, focusing suicide prevention efforts on those who self-harm might be somewhat less important in LMICs compared with HICs given the low risk of repeat self-harm and subsequent suicide death. Strategies that focus on other risk factors for suicide might be more effective in reducing suicide deaths in LMICs in south Asia. A better understanding of the low incidence of repeat self-harm is also needed, as this could contribute to prevention strategies in nations with a higher incidence of repetition and subsequent suicide death.

FUNDING

Wellcome Trust.

Socioeconomic position and suicidal behaviour in rural Sri Lanka: a prospective cohort study of 168,000+ people

PURPOSE

Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high income countries, but this association is not established in low- and middle-income countries (LMIC).

METHODS

We investigated the association of SEP with suicidal behaviour in a prospective cohort study of 168,771 Sri Lankans followed up for episodes of attempted suicide and suicide. SEP data were collected at baseline at the household and individual level at the start of the follow-up period. We used multilevel Poisson regression models to investigate the association of SEP at community, household and individual levels with attempted suicide/suicide.

RESULTS

Lower levels of asset ownership [IRR (95% CI) suicide 1.74 (0.92, 3.28); attempted suicide 1.67 (1.40, 2.00)] and education [suicide 3.16 (1.06, 9.45); attempted suicide 2.51 (1.70, 3.72)] were associated with an increased risk of suicidal behaviour. The association of these measures of SEP and attempted suicide was stronger in men than women. Individuals living in deprived areas [1.42 (1.16, 1.73)] and in households with a young female head of household [1.41 (1.04, 1.93)] or a temporary foreign migrant [1.47 (1.28, 1.68)] had an elevated risk of attempted suicide. Farmers and daily wage labourers had nearly a doubling in risk of attempted suicide compared to other occupations.

CONCLUSIONS

Improved employment opportunities, welfare and mental health support services, as well as problem-solving skills development, may help support individuals with poorer education, farmers, daily wage labourers, individuals in young female-headed households and temporary foreign migrant households.

Are left-behind families of migrant workers at increased risk of attempted suicide? - a cohort study of 178,000+ individuals in Sri Lanka

BACKGROUND

There are an estimated 258 million international migrants worldwide. In Asia low-skilled workers often emigrate on a temporary basis (2-3 years) without their families. There is significant concern over the mental health and wellbeing of left-behind families in this region. No previous study has examined whether the risk of suicidal behaviour is elevated in left-behind family members.

METHODS

Cohort study using baseline data from a large randomised controlled trial in Sri Lanka (n = 178,730 participants; 8% households had a current temporary foreign migrant) and prospective hospital presentations of suicide attempts. Using multilevel Poisson regression models, we compared the risk of attempted suicide in households with left-behind and non-left-behind family members. We also investigated whether the sex of the migrant or the age/sex of the household member left behind altered any associations.

RESULTS

The risk of an attempted suicide was elevated in female migrant households (IRR 1.60 95% CI 1.38, 1.85), but not male migrant households (IRR 1.01 95% CI 0.76,1.36)) with strong evidence that risk differed for female vs. male migrant households (p-value = 0.005). We found no evidence that the age or sex of the left-behind household member altered the association observed.

CONCLUSIONS

This analysis suggests that members of households with a temporary female foreign migrant are at an increased risk of attempted suicide, but these findings must be interpreted with caution. The increased risk of suicidal behaviour in these households may be due to factors that were present before the migration and persist post-migration (e.g. household violence, poverty).

Estimating the government health-care costs of treating pesticide poisoned and pesticide self-poisoned patients in Sri Lanka

Background: Pesticide self-poisoning as a method of suicide is a major global health problem.Objectives: To estimate the cost and per patient cost of treating pesticide self-poisoning at different hospital levels in a Sri Lankan district, and to examine the distribution of cost components. Another objective was to investigate changes in total cost of treatment of pesticide poisoning for all causes at different administrative levels in Sri Lanka in 2005 and 2015.Methods: The economic framework was a costing analysis, adopting a government perspective. Cost data were collected prospectively over a 4-month period in 2016 for patients admitted for pesticide self-poisoning to six hospitals in the Anuradhapura District. Assumption-based scenario analyses were run to determine changes in total pesticide poisoning treatment costs.Results: We included 67 self-poisoned patients in the study. The total cost of treatment was US$ 5,714 at an average treatment cost of US$ 85.3 (9.7-286.6) per patient (across all hospital levels). Hospital costs constituted 67% of the total cost for treating self-poisoning cases and patient-specific costs accounted for 29%. Direct cost of patient hospital transfer constituted the smallest share of costs (4%) but accounted for almost half of the total costs at primary level. The estimated total cost of treating all causes of pesticide poisoning in Sri Lanka was US$ 2.5 million or 0.19% of the total government health expenditure (GHE) in 2015.Conclusion: Our findings indicate that the average per patient cost of pesticide self-poisoning treatment has increased while the total cost of pesticide poisoning treatment as a percentage of the total GHE in Sri Lanka has declined over the past decade. A continuous focus on banning the most hazardous pesticides available would likely further drive down the cost of pesticide self-poisoning and pesticide poisoning to the government.

Location, seasonal, and functional characteristics of water holding containers with juvenile and pupal Aedes aegypti in Southern Taiwan: A cross-sectional study using hurdle model analyses

Background

Aedes aegypti carries several viruses of public health importance, including the dengue virus. Dengue is the most rapidly spreading mosquito-borne viral disease in the world. Prevention and control of dengue mainly rely on mosquito control as there is no antiviral treatment or a WHO-approved vaccine. To reduce the Ae. aegypti population, studying the characteristics of their habitats is necessary. Aedes aegypti prefer breeding in artificial water holding containers in peridomestic or domestic settings. Their juveniles (1^st - 4^th instar larvae and pupae) have a tendency to cluster in certain types of containers. To inform control strategies, it is important to assess whether the pupae subgroup has a distinct distribution by container type as compared to the overall group of juveniles. The objective of this study was to assess for distinct predictors (location, season, and function) of Ae. aegypti juveniles and pupae numbers in water holding containers by applying hurdle model analyses.

Methodology

The field component of this study was carried out from November 2013 to July 2015 in Southern Taiwan where annual autochthonous dengue has been reported for decades. Water holding containers with stagnant water were identified in a predefined urban area in Kaohsiung City (KH) and a rural area in Pingtung County. Given that mosquito survey data often include many containers with zero Ae. aegypti, a negative binomial hurdle model was applied to model the association between location, seasonal and functional characteristics of the water holding containers and the number of Ae. aegypti in each container.

Results

The results showed that Ae. aegypti were almost exclusively present in the urban area. In this area, the negative binomial hurdle model predicted significantly more juveniles as well as pupae Ae. aegypti in water holding containers during the wet season when compared to the dry season. Notably, the model predicted more juveniles in containers located on private property compared to those on government property, irrespective of season. As for pupae, the model predicted higher amounts in indoor containers used for water storage compared to outdoor water storage containers, irrespective of season. However, for the specific category ‘other water receptacle’, higher amounts of pupae were predicted in outdoor compared to indoor in water receptacles, such as flower pot saucers and water catchment buckets.

Conclusions

The difference in predictors for juveniles and the pupae subgroup was identified and it may be of importance to the control strategies of the authorities in KH. At present the authorities focus control activities on all water holding containers found on government property. To improve the ongoing control efforts in KH, the focus of control activities maintained by the KH authorities should be expanded to indoor water storage containers and outdoor water receptacles on both private and government properties to adequately address habitats harboring greater numbers of pupae. In addition, it is proposed to increase community engagement in managing water in all types of water holding containers located on privately owned properties (indoor and outdoor), especially during wet season.

Dengue is considered the most significant mosquito-borne disease, globally. It is transmitted by the mosquito Aedes aegypti throughout most affected countries. In order to prevent dengue, most control efforts focus on removing Ae. aegypti from the environment, as currently there are no anti-viral treatment or WHO approved vaccine. Removing or destroying the breeding sites of Ae. aegypti is generally recommended. However, this may be difficult as the mosquito breeds in a wide variety of water holding containers readily available in the human environment. The urban areas of Southern Taiwan have experienced annual dengue epidemics for decades in spite of substantial efforts to control Ae. aegypti. In this study we investigated whether containers harboring the highest number of Ae. aegypti differ between all active aquatic stages (larvae and pupae) and the final aquatic stage (pupae only). In Kaohsiung City in Southern Taiwan, we found that more Ae. aegypti were predicted to be in containers on private property, compared with government property, when assessing all aquatic stages. However, for pupae only, more were found in indoor containers used for water storage when compared with outdoor water storage containers. For the specific category ‘other water receptacle’ such as flower pot saucers and water catchment buckets, the model predicted more pupae in outdoor containers compared with indoor containers. We recommend that future control efforts target these types of containers to reduce the risk of dengue transmission in Southern Taiwan.

Habitat Characteristics For Immature Stages of Aedes aegypti In Zanzibar City, Tanzania

Aedesaegypti is the main vector for dengue, chikungunya, yellow fever, Zika, and other arboviruses of public health importance. The presence of Ae. aegypti has never been systematically assessed in Zanzibar, including its preferred larval habitats. In 2016 we conducted a cross-sectional entomological survey to describe the preferred larval habitats of Ae. aegypti in Zanzibar City, the main urban area of the Zanzibar archipelago. The surveys for container habitats were conducted for a 17-wk period beginning in January 2016. Immature stages (larvae and pupae) were collected, reared to adulthood, and identified to species. The positive and potential habitats were categorized on the basis of physical, biological, and chemical parameters. A total of 200 samples were collected, of which 124 (62.0%) were positive for immature stages of mosquitoes and 114 (92%) for Ae. aegypti larvae and pupae. Presence of vegetation (odds ratio [OR] = 2.11, 95% confidence interval [CI] = 1.19-3.74), organic matter (OR = 2.37, 95% CI = 1.21-4.60), inorganic matter (OR = 1.78, 95% CI = 1.01-3.13), and sun exposure (OR = 2.34, 95% CI = 1.24-4.36) were all significantly associated with the presence of immature stages of Ae. aegypti, suggesting that these conditions promote colonization of containers. Plastic containers supported 64% of the immature stages and produced approximately 50% of the pupae. Although immature counts were the highest in discarded artifacts, higher pupal counts were found in domestic water storage containers. Our observations suggest that effective control of Ae. aegypti in Zanzibar City must include improved solid waste management (collection and proper disposal of potential container habitats) and reliable supply of domestic water to minimize water-storing practices that provide larval habitats for Ae. aegypti.

Self-Harm and Suicide Coverage in Sri Lankan Newspapers

BACKGROUND

Irresponsible media reporting may influence suicidal behavior. Adherence to guidelines for responsible reporting of suicide has not been examined in Sri Lanka in recent times.

AIMS

To examine the quality of reporting on self-harm and suicide in Sri Lankan newspapers and compare the quality between Sinhala and English newspapers.

METHOD

From December 1, 2014 to January 31, 2015, 407 editions of newspapers were screened. Reporting quality was measured using the PRINTQUAL tool.

RESULTS

We identified 68 articles covering an episode of self-harm or suicide (42 Sinhala and 26 English). The majority of articles were noncompliant with guidelines for sensitive reporting. Indicators of noncompliance included that newspaper articles frequently reported method in the headline (53%), included detailed characteristics of the individual (100%), used insensitive language (58% of English articles), and attributed a single-factor cause to the self-harm (52%). No information about help-seeking was included.

LIMITATIONS

The study involved a relatively short period of data collection. Including social media, Tamil language newspapers, and online publications would have provided additional understanding of reporting practices.

CONCLUSION

The majority of Sri Lankan newspapers did not follow the principles of good reporting, indicating a need for further training of journalists.

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

BACKGROUND

In South Asia, up to one in five individuals who use pesticides for self-harm purchase them immediately prior to the event.

AIMS

From reviewing the literature we proposed four interventions: (a) farmer identification cards (ID); (b) prescriptions; (c) cooling-off periods; and (d) training pesticide vendors. We aimed to identify the most promising intervention.

METHOD

The study was conducted in Sri Lanka. We mapped stakeholders' interest and power in relation to each intervention, and followed this by a ranking exercise. Seven focus group discussions (FGDs) were conducted to assess facilitators and barriers to implementation.

RESULTS

Vendor training was the most supported intervention, being ranked first by the stakeholders. The participants in the FGDs strongly supported training of vendors as it was seen to be easy to implement and was considered more convenient. Farmer IDs, prescriptions, and cooling-off periods were thought to have more barriers than facilitators and they were strongly opposed by end users (farmers and vendors), who would potentially block their implementation.

LIMITATIONS

Cost considerations for implementing the proposed intervention were not considered.

CONCLUSION

Training vendors might be the most appropriate intervention to restrict sales of pesticides to people at risk of suicidal behavior. This requires field testing.

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.

Secrets, shame and discipline: School girls' experiences of sanitation and menstrual hygiene management in a peri-urban community in Ghana

Women and girls need proper sanitation and hygiene facilities to maintain health and dignity. In this study we show how schoolgirls from a peri-urban community of Ghana, experience severe multidimensional 'hygiene poverty' when attending schools. Hygiene poverty was characterized by poor water and sanitation infrastructures and serious social and emotional challenges, including shaming and disciplining of their sanitation and menstrual practices, which forces girls to apply secretive coping strategies. We discuss the importance of changing the negative MHM discourses at schools and fostering supportive teaching methods in adolescent female health.

Quality Assessment of Economic Evaluations of Suicide and Self-Harm Interventions

Abstract. Background: Death following self-harm constitutes a major global public health challenge and there is an urgent need for governments to implement cost-effective, national suicide prevention strategies. Aim: To conduct a systematic review and quality appraisal of the economic evaluations of interventions aimed at preventing suicidal behavior. Method: A systematic literature search was performed in several literature databases to identify relevant articles published from 2003 to 2016. Drummond's 10-item appraisal tool was used to assess the methodological quality of the included studies. Results: In total, 25 documents encompassing 30 economic evaluations were included in the review. Of the identified evaluations, 10 studies were found to be of poor quality, 14 were of average quality, and six studies were considered of good quality. The majority of evaluations found the interventions to be cost-effective. Limitations: Several limitations were identified and discussed in the article. Conclusion: A notable few economic evaluations were identified. The studies were diverse, primarily set in high-income countries, and often based on modeling, emphasizing the need for more primary research into the topic. The discussion of suicide and self-harm prevention should be as nuanced as possible, including health economics along with cultural, social, and political aspects.

Vendor-based restrictions on pesticide sales to prevent pesticide self-poisoning - a pilot study

Background

In South Asia, up to 20% of people ingesting pesticides for self-poisoning purchase the pesticide from a shop with the sole intention of self-harm. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such high-risk individuals. We aimed to test the feasibility and acceptability of vendor-based restrictions on pesticide sales for such high-risk individuals.

Methods

We conducted a pilot study in 14 (rural = 7, urban = 7) pesticide shops in Anuradhapura District of Sri Lanka. A two-hour training program was delivered to 28 pesticide vendors; the aim of the training was to help vendors recognize and respond to customers at high risk of pesticide self-poisoning. Knowledge and attitudes of vendors towards preventing access to pesticides for self-poisoning at baseline and in a three month follow-up was evaluated by questionnaire. Vendors were interviewed to explore the practice skills taught in the training and their assessment of the program.

Results

The scores of knowledge and attitudes of the vendors significantly increased by 23% (95% CI 15%–32%, p < 0.001) and by 16% (95% CI 9%–23%, p < 0.001) respectively in the follow-up. Fifteen (60%) vendors reported refusing sell pesticides to a high-risk person (non-farmer or intoxicated person) in the follow-up compared to three (12%) at baseline. Vendors reported that they were aware from community feedback that they had prevented at least seven suicide attempts. On four identified occasions, vendors in urban shops had been unable to recognize the self-harming intention of customers who then ingested the pesticide. Only 2 (8%) vendors were dissatisfied with the training and 23 (92%) said they would recommend it to other vendors.

Conclusions

Our study suggests that vendor-based sales restriction in regions with high rates of self-poisoning has the potential to reduce access to pesticides for self-poisoning. A large-scale study of the effectiveness and sustainability of this approach is needed.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5178-2) contains supplementary material, which is available to authorized users.

'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.

Treatment of self-poisoning at a tertiary-level hospital in Bangladesh: cost to patients and government

OBJECTIVES

Approximately 10 000 people die from suicide annually in Bangladesh, many from pesticide poisoning. We aimed to estimate financial costs to patients and health services of treating patients with self-poisoning.

METHODS

Data on direct costs to families, sources of funds for treatment and family wealth were collected prospectively over a one-month period in 2016 at the tertiary Chittagong Medical College Hospital, Bangladesh. Aggregate operational costs to the government were calculated using annual budget, bed occupancy and length-of-stay data.

RESULTS

Agrochemicals were the most common substances ingested (58.8%). Median duration of stay and of illness was 2 and 5 days, respectively. Median total cost to patients was conservatively estimated at US$ 98.40, highest in agrochemical poisoning (US$ 179.50), with the greatest cost due to medicines and equipment. Misdiagnosis as organophosphorus poisoning in 17.0% of agrochemical cases resulted in increased cost to patients. Only 51.9% of patients had indicators of wealth; 78.1% borrowed money to cover costs. Conservatively estimated median healthcare costs (US$ 21.30 per patient) were markedly lower than costs to patients.

CONCLUSIONS

Cost to patients of treating a case of agrochemical poisoning was approximately three times the cost of one month's essential items basket. Incorrect diagnosis at admission costs families substantial sums of money and increased length of stay; it costs the national government an estimated US$ 80 428.80 annually. Widespread access to a list of pesticides used in self-poisoning plus greater focus on training doctors to better manage different forms of agrochemical poisoning should reduce the financial burden to patients and healthcare systems.

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.