The share of suicide in injury deaths in the South African context: sociodemographic distribution

Suicide Ideation in Adolescent South Africans: The Role of Gender and Coping Strategies

With an increasing number of studies showing a rise in adolescent suicidal behaviour and a wealth of literature concerning adolescent coping strategies, this study examined both these issues within a South African context. The interplay between social, political, and economic factors in South Africa, with its history of apartheid, must impact upon the lives of adolescents living in this country and play a role in stress, depression, and feelings of hopelessness, helplessness, and possible suicidal ideation. The objectives of the study were to determine the coping strategies exhibited by a South African sample of adolescents, the relationship between these coping strategies and suicidal ideation, and to investigate whether gender had any influence on this relationship. This study therefore aimed to get a better understanding of the relationship between the variables: suicidal ideation, coping strategy, and gender. Such research is important in learning to understand how adolescents cope, in order for caregivers and professionals in the field to be able to identify potential suicide ideators through their behaviours and coping strategies. A sample of 161 adolescents in grade eleven completed a demographic questionnaire, the Positive and Negative Suicidal Ideation Scale (PANSI), and The Coping Across Situations Questionnaire (CASQ). The findings indicated the majority of the sample (51 %) had a positive outlook on life, feeling optimistic about the future most or a good part of the time. Further results showed that males and females followed the same pattern of coping by scoring highest on the functional coping strategies and lowest on the dysfunctional one. There was a significant difference between males and females on each coping strategy, with females scoring higher than males in each case. Correlation studies indicated a positive significant relationship between active coping (functional coping strategy) and positive suicidal ideation scores (positive outlook on life) and between withdrawal (dysfunctional coping strategy) and negative suicidal ideation scores (negative outlook on life). Results for each gender differed, with the female sub-sample revealing significant correlations between functional coping strategies and positive suicidal ideation scores, while the only significant correlation found within the male sub-sample was between the dysfunctional coping strategy and negative suicidal ideation scores.

Mortuary based injury surveillance for low-mid income countries: process evaluation of pilot studies

OBJECTIVE

Globally, injury is the fourth major cause of death and the third leading contributor to Disability Adjusted Life Years lost due to health conditions, with the greatest burden borne by low-middle income countries (LMICs) where injury data is scarce. In the absence of effective vital registration systems, mortuaries have been shown to provide an alternative source of cause of death information for practitioners and policy makers to establish strategic injury prevention policies and programs. This evaluation sought to assess the feasibility of implementing a standardised fatal injury data collection process to systematically collect relevant fatal injury data from mortuaries. The process evaluation is described.

METHODS

A manual including a one page data collection form, coding guide, data dictionary, data entry and analysis program was developed through World Health Organization and Monash University Australia collaboration, with technical advice from an International Advisory Group. The data collection component was piloted in multiple mortuaries, in five LMICs (Egypt, India, Sri-Lanka, Tanzania and Zambia). Process evaluation was based on a questionnaire completed by each country's Principal Investigator.

RESULTS

Questionnaires were completed for data collections in urban and rural mortuaries between September 2010 and February 2011. Of the 1795 reported fatal injury cases registered in the participating mortuaries, road traffic injury accounted for the highest proportion of cases, ranging from 22% to 87%. Other causes included burns, poisoning, drowning and falls. Positive system attributes were feasibility, acceptability, usefulness, timeliness, and simplicity and data field completeness. Some limitations included short duration of the pilot studies, limited injury data collector training and apparent underreporting of cases to the medico-legal system or mortuaries.

CONCLUSION

The mortuary has been shown to be a potential data source for identifying injury deaths and their circumstances and monitoring injury trends and risk factors in LMICs. However, further piloting is needed, including in rural areas and training of forensic pathologists and data-recorders to overcome some of the difficulties experienced in the pilot countries. The key to attracting ongoing funding and support from governments and donors in LMICs for fatal injury surveillance lies in further demonstrating the usefulness of collected data.

Suicidal behaviour across the African continent: a review of the literature

BACKGROUND

Suicide is a major cause of premature mortality worldwide, but data on its epidemiology in Africa, the world's second most populous continent, are limited.

METHODS

We systematically reviewed published literature on suicidal behaviour in African countries. We searched PubMed, Web of Knowledge, PsycINFO, African Index Medicus, Eastern Mediterranean Index Medicus and African Journals OnLine and carried out citation searches of key articles. We crudely estimated the incidence of suicide and suicide attempts in Africa based on country-specific data and compared these with published estimates. We also describe common features of suicide and suicide attempts across the studies, including information related to age, sex, methods used and risk factors.

RESULTS

Regional or national suicide incidence data were available for less than one third (16/53) of African countries containing approximately 60% of Africa's population; suicide attempt data were available for <20% of countries (7/53). Crude estimates suggest there are over 34,000 (inter-quartile range 13,141 to 63,757) suicides per year in Africa, with an overall incidence rate of 3.2 per 100,000 population. The recent Global Burden of Disease (GBD) estimate of 49,558 deaths is somewhat higher, but falls within the inter-quartile range of our estimate. Suicide rates in men are typically at least three times higher than in women. The most frequently used methods of suicide are hanging and pesticide poisoning. Reported risk factors are similar for suicide and suicide attempts and include interpersonal difficulties, mental and physical health problems, socioeconomic problems and drug and alcohol use/abuse. Qualitative studies are needed to identify additional culturally relevant risk factors and to understand how risk factors may be connected to suicidal behaviour in different socio-cultural contexts.

CONCLUSIONS

Our estimate is somewhat lower than GBD, but still clearly indicates suicidal behaviour is an important public health problem in Africa. More regional studies, in both urban and rural areas, are needed to more accurately estimate the burden of suicidal behaviour across the continent. Qualitative studies are required in addition to quantitative studies.

Sociodemographic characteristics of persons committing suicide in Durban, South Africa: 2006-2007

Background

Suicidal behaviour is a leading contributor to the burden of disease worldwide and varies widely between countries. South African figures are amongst the highest in the world, with recent trends indicating a disturbing rise, especially amongst the younger age groups, across all races.

Aim

This study analysed sociodemographic characteristics and trends relating to suicides committed in Durban, South Africa during the period of 2006–2007.

Method

A retrospective analysis of suicidal deaths (during 2006–2007), extracted from autopsy registers at all three government-run mortuaries in Durban, was conducted.

Results

The total number of suicides in Durban increased by 6.68% from 2006 to 2007. Suicide accounted for an average of 8.8% of all non-natural deaths per year of the study. The overall suicide rates of 14.53 (2006) and 15.53 (2007) per 100 000 population are comparable with national and global figures. The majority of suicides occurred in single unemployed persons, men and younger age groups. The largest number of suicides per year was recorded in black people, followed by Indian, white and mixed-race people. Hanging was the preferred method in the majority of victims, followed by self-poisoning, shooting and jumping.

Conclusions

The findings indicate a disturbingly high suicide rate amongst the various population and age groups in Durban. The dominant methods used may be influenced by ease of access. The reported trends may worsen unless there is a swift and decisive public health response and cohesive community-based programmes which include a supportive multidisciplinary network.

Epidemiology of suicide in South Africa: Setting an agenda for future research

This article offers a synthesis and critical overview of published studies on the prevalence and correlates of completed suicide in South Africa. It examines the evidence that suicide is a serious public health problem and highlights what remains unknown about suicide in South Africa. Reflections are offered on the implications of these studies for subsequent research. Focus areas are suggested for future research in order to provide the information needed to inform public health efforts to reduce the morbidity and mortality associated with suicidal behaviour. This article is of interest to scholars who seek to plan suicide research in South Africa, public health officials who wish to design suicide prevention programmes, and others who wish to gain an overview of the prevalence and correlates of completed suicide in the country.

Recall of early non-fatal suicidality in a nationally representative sample of South Africans

OBJECTIVES

Little is known about socio-demographic patterns of non-fatal suicidality in early life in South Africa. We investigated the prevalence of self-reported early suicidality (suicidal ideation, planning and attempts) in a nationally representative sample of South Africans.

DESIGN

As part of a larger mental health survey, 3158 individuals aged over 25 years were asked to recall whether they engaged in non-fatal suicidal behaviour in early life (measured from childhood to 25 years). Race-based discrimination institutionalised under Apartheid profoundly influenced delivery and outcomes in health and other social services. Racial categories entrenched during Apartheid were therefore used to analyse data collected from individuals born before 1946, 1947-1956, 1957-1966 and 1967-1976.

RESULTS

3.4% (95% CI=2.6-4.1) of participants recalled early suicidal behaviour. The youngest group (born 1967-1976) recalled higher rates of early suicidality than older groups in all races. In unadjusted analysis, white people were 2.84 (95% CI=1.62-4.97) and coloured people 1.84 (95% CI=1.15-2.93) times more likely than black people to recall early suicidality. Individuals growing up in urban and higher socio-economic settings were approximately twice (OR=2.2; 95% CI=1.14-4.28 and OR=1.92; 95% CI=1.27-2.90) as likely to recall early suicidality as those growing up in rural and lower socio-economic settings. Those with post-primary education were 2.79 (CI=1.71-4.53) times as likely to recall early suicidality as those with no or only primary education. Racial differences ceased to be significant after adjustment for rural/urban location and other socio-economic measures estimated for early life.

CONCLUSION

The study provides novel evidence of increasing levels of early non-fatal suicidality recalled by younger South Africans. Levels appeared significantly higher in Whites than in Blacks. Socio-economic contexts in early life were interpreted as mediators rather than confounders of the association between race and recalled early suicidality. The findings for decreased levels of suicidality among participants growing up in lower socio-economic strata and rural settings in South Africa require further investigation. The need for widespread suicide prevention programmes targeting young people at a population level is emphasised.

Risk factors for injury mortality in rural Tanzania: a secondary data analysis

BACKGROUND

Injuries rank high among the leading causes of death and disability annually, injuring over 50 million and killing over 5 million people globally. Approximately 90% of these deaths occur in developing countries.

OBJECTIVES

To estimate and identify the risk factors for injury mortality in the Rufiji Health and Demographic Surveillance System (RHDSS) in Tanzania.

METHODS

Secondary data from the RHDSS covering the period 2002 and 2007 was examined. Verbal autopsy data was used to determine the causes of death based on the 10th revision of the International Classification of Diseases (ICD-10). Trend and Poisson regression tests were used to investigate the associations between risk factors and injury mortality.

RESULTS

The overall crude injury death rate was 33.4/100 000 population. Injuries accounted for 4% of total deaths. Men were three times more likely to die from injuries compared with women (adjusted IRR (incidence risk ratios)=3.04, p=0.001, 95% CI (2.22 to 4.17)). The elderly (defined as 65+) were 2.8 times more likely to die from injuries compared with children under 15 years of age (adjusted IRR=2.83, p=0.048, 95% CI (1.01 to 7.93)). The highest frequency of deaths resulted from road traffic crashes.

CONCLUSIONS

Injury is becoming an important cause of mortality in the Rufiji district. Injury mortality varied by age and gender in this area. Most injuries are preventable, policy makers need to institute measures to address the issue.

An Emic Perspective on the Dynamics of Non-Fatal Suicidal Behaviour in a Sample of South African Indian Women

We aimed to obtain an emic perspective on the dynamics of non-fatal suicidal behaviour in a high risk population group in South African, viz. adolescent females of Indian origin. Interviews were conducted with 10 respondents admitted to a state hospital in the greater Durban area, following their intentional overdose of prescription medication. Interviews were tape recorded, transcribed, and thematically analysed in an attempt to identify influences on suicidal behaviour. Intrapersonal influences on suicidal behaviour included poor communication and problem-solving skills. Interpersonal influences included family conflict, rigid and inflexible parental attitudes, a family history of attempted or completed suicide and high parental expectations. Socio-cultural influences related largely to conflicting social roles and values in the context of contemporary acculturation pressures. The study findings are discussed in terms of their implications for prevention and future research.

Non-fatal suicidal behavior among South Africans : results from the South Africa Stress and Health Study

BACKGROUND

Suicide represents 1.8% of the global burden of disease, yet the prevalence and correlates of suicidal behavior in low income countries are unclear. This study examines the prevalence, age of onset and sociodemographic correlates of suicide ideation, planning, and attempts among South Africans.

METHOD

Nationally representative data are from the South Africa Stress and Health Study (SASH), a national household probability sample of 4,351 South African respondents aged 18 years and older conducted between 2002 and 2003, using the World Health Organization version of the composite international diagnostic interview (CIDI). Bivariate and survival analyses were employed to delineate patterns and correlates of nonfatal suicidal behavior. Transitions are estimated using life table analysis. Risk factors are examined using survival analysis.

RESULTS

The risk for attempted suicide is highest in the age group 18-34 and Coloureds had highest lifetime prevalence for attempts. Cumulative probabilities are 43% for the transition from ideation to a plan, 65% from a plan to an attempt, and 12% from ideation to an unplanned attempt. About 7.5% of unplanned and 50% of planned first attempts occur within 1 year of the onset of ideation. South Africans at higher risk for suicide attempts were younger, female, and less educated.

CONCLUSIONS

The burden of nonfatal suicidality in South Africa underscores the need for suicide prevention to be a national priority. Suicide prevention efforts should focus on planned attempts due to the rapid onset and unpredictability of unplanned attempts.

Pattern analysis of suicide mortality surveillance data in urban South Africa

The typical circumstances of suicide occurrence in post-apartheid urban South Africa are described. Data comprise suicide cases from all geographical locations (urban municipalities) where an injury surveillance system has full coverage. Typical patterns were identified by means of a classification technique applied to eight variables descriptive of the events, their victims, and the suicide level of the cities. Six suicide mortality patterns were identified, most being race-specific and each associated with particular suicide methods. Preventive strategies should target local communities and specific population subgroups, and be appropriate and responsive to their sociocultural needs.

Prevalence and correlates of non-fatal suicidal behaviour among South Africans

We examined nationally representative data from the 2002-2004 South Africa Stress and Health Study, a national household probability sample of 4351 persons aged 18 years and older: 9.1% of respondents reported lifetime suicide ideation, 3.8% a plan and 2.9% an attempt. Among four ethnic groups, the Coloureda group had the highest lifetime prevalence for attempts (7.1%). Those at higher risk of suicide attempts had one or more DSM-IV disorders.

Assessment of accuracy of suicide mortality surveillance data in South Africa: investigation in an urban setting

Although it is not a legal requirement in South Africa, medical practitioners determine the manner of injury death for a surveillance system that is currently the only source of epidemiological data on suicide. This study assessed the accuracy of suicide data as recorded in the system using the docket produced from standard medico-legal investigation procedures as the gold standard. It was conducted in one of three cities where the surveillance system had full coverage for the year 2000. In the medico-legal system, one-third of cases could not be tracked, had not been finalized, or had unclear outcomes. For the remaining cases, the sensitivity, specificity, and positive and negative predictive values were generally high, varying somewhat across sex and race groups. Poisoning, jumping, and railway suicides were more likely than other methods to be misclassified, and were more common among females and Whites. The study provides encouraging results regarding the use of medical practitioner expertise for the accurate determination of suicide deaths. However, suicides may still be underestimated in this process given the challenge of tracing disguised suicides and without the careful examination of potential misclassifications of true suicides as unintentional deaths.

Analysis of a national toll free suicide crisis line in South Africa

The first national toll free suicide crisis line for South Africa was launched in October 2003 with the aim of providing a service dedicated to the prevention of suicide in this country. The intervention was motivated by South Africa's suicide rate which had risen higher than the global suicide rate, with the majority of attempted suicides occurring among people younger than 35 years of age (WHO, 2002). Demographic characteristics of callers were identified to evaluate the perceived helpfulness of this crisis line, so as to inform planning and implementation of future suicide prevention programs. Results showed that the majority of callers were female; between the ages of 16 and 18 years; and lived in the provinces of Gauteng, North West, or KwaZulu Natal. Callers were more likely to be from urban than rural areas; were still at school, unemployed, or studying at a tertiary institution; and had not previously attempted suicide. The majority of participants did perceive the crisis line as helpful. The continued collection of demographic data from the crisis line is recommended so that South Africa can create an updated database of areas and sectors of the population that require suicide intervention, and for planning and implementing suicide prevention programs in this country.

Two Cases of Very Late Stent Thrombosis After Implantation of a Sirolimus-Eluting Stent Presenting as AMI

Stent thrombosis after sirolimus-eluting stent (SES) implantation has been reported to occur at 6 hours to 26 months after the procedure and usually within 2 weeks after discontinuation of antiplatelet medication. However, there are very few reports of stent thrombosis after 2 years. We report 2 cases of very late stent thrombosis after implantation of a sirolimus-eluting stent presenting as acute myocardial infarction (AMI). These late thromboses occurred about 2 years after SES implantation and over 1.5 years after discontinuation of ticlopidine.

Determination of suicide in South Africa: medical practitioner perspectives

Decisional processes underlying the determination of a suicide in the largest injury surveillance system currently available in South Africa are assessed through face-to-face semi-structured interviews with 32 medical practitioners involved in the system. Focus is placed on their current work circumstances and practices, and views of operational and empirical criteria proposed by US experts. Common themes and discrepancies in opinions emerged regarding the quality of the data currently available for suicide determinations, and regarding the importance and difficulty in assessing the US-developed criteria in South Africa. A truly standard approach is unlikely without considerable changes to the medico-legal system.

Suicide mortality in South Africa: a city-level comparison across socio-demographic groups

BACKGROUND

South Africa offers a valuable study environment to assess the impact of political and social changes on health. Increasing urbanisation has led to a focus on city development and its effect on its residents. The study assesses whether sex- and race-specific suicide rates differ across six of South Africa's major cities. Regional differences may reflect varying contextual and individual underlying mechanisms. Those need to be understood for appropriately targeted prevention efforts.

METHODS

Suicide mortality data (n=4,946) for the six cities between 2001 and 2003 were used to assess whether there are differences in rates for age-standardised race and sex groups across cities and whether these differences are constant across cities. The overall age-standardised rates for the six cities was 25.3/100,000 for men and 5.6/100,000 for women.

RESULTS

Suicide rates are most often highest among whites and men, but both the magnitude and distribution of suicide vary considerably for different race and sex groups within and across cities. There is a strong association between the method of suicide used and the city.

CONCLUSIONS

Despite some common trends in the suicide profile across South African cities, city does matter for the magnitude and distribution of suicide mortality across race and sex groups and for the method of suicide used. The need for locally based suicide research investigating possible reasons for these differences is highlighted.

Suicide in Blantyre, Malawi (2000-2003)

In an attempt to identify at risk individuals, we analysed available information for individuals who committed suicide in Blantyre, Malawi. A retrospective audit of suicides autopsied at the Queen Elizabeth Central Hospital and the University of Malawi College of Medicine mortuaries between January 2000 and December 2003 was analysed by age, sex, residential location, and mode of suicide. Eighty-four suicide cases (65 males, 19 females) represented 17% of all autopsies. The major mode of suicide in Blantyre was chemical poisoning using an agricultural pesticide, accounting for 66 cases (79%)-49 males (76%), 17 females (89%). There were no cases of poisoning by therapeutic medicines, self-immolation or incised wounds. The majority of cases were from one major urban area, Limbe, and one peri-urban area, Chileka. The demographics of suicide in Malawi differ from those reported for other African countries (e.g., lower proportion of females, no use of therapeutic medicine in poisoning, few gunshots). This audit highlights a need for investigations into the sale and use of agricultural pesticides. A prospective study of social and demographic factors around suicide should be undertaken to target groups at highest risk.

Living circumstances of suicide mortality in a South African city: an ecological study of differences across race groups and sexes

In this study the importance of living area circumstances for suicide mortality was explored. Suicide mortality was assessed across race and sex groups in a South African city and the influence of area-based compositional and sociophysical characteristics on suicide risk was considered. Suicide mortality rates are highest among Whites, in particular White males. Main--and independent--dimensions of the living circumstances of residential areas (i.e., socioeconomic circumstances, economic need, and matrimony) influence age-adjusted suicide rates for both sexes but minimally so for race groups. Less favorable clusters of circumstances have a protective effect.