Local study finds several risk factors of self-harm in young people

• Finds increased risks among females, under-18 school leavers, and those in households that are poorer or see problematic alcohol use 

By Ruwan Laknath Jayakody

Being female, having left school at any stage prior to attaining the age of 18 years, living in a household with fewer assets and problematic alcohol use in households or specifically, sharing a household with an individual with problematic alcohol consumption, were associated with an elevated risk of deliberate self-harm in young people.

This finding was made in an original article on the “Risk factors for deliberate self-harm in young people in rural Sri Lanka: A prospective cohort study of 22,000 individuals”, which was authored by K. Fernando (attached to England’s Kings College Hospital, London), S. Jayamanna (attached to the Peradeniya University’s Medical Faculty’s South Asian Clinical Toxicology Research Collaboration [SACTRC] and the Kelaniya University’s Medical Faculty), M. Weerasinghe (attached to the SACTRC), C. Priyadarshana (attached to the SACTRC), R. Ratnayake (attached to the Health Ministry’s Mental Health Directorate), M. Pearson (attached to the SACTRC and Scotland’s Edinburgh University’s Pesticide Suicide Prevention Centre), D. Gunnell (attached to the SACTRC and England’s Bristol University’s Bristol Medical School’s Population Health Sciences), A. Dawson (attached to the SACTRC and Australia’s Sydney University’s Sydney Medical School), K. Hawton (attached to England’s Oxford University’s Psychiatry Department’s Suicide Research Centre), F. Konradsen (attached to the SACTRC and Denmark’s Copenhagen University’s Health and Medical Sciences Faculty’s Public Health Department), M. Eddleston (attached to the SACTRC and Scotland’s Edinburgh University’s Pesticide Suicide Prevention Centre), C. Metcalfe (attached to the Bristol Medical School’s Population Health Sciences), and D. Knipe (attached to the SACTRC), and was published in the Ceylon Medical Journal’s 66th Volume’s Second Issue in December 2021.

Suicide is the second and third leading cause of deaths globally among young (between the ages of 10 and 24 years) females and males, respectively (per the World Health Organisation’s [WHO] “Adolescent suicidal behaviours in 32 low and middle-income countries”). Most adolescents who die by suicide (90%) are from low and middle-income countries (the WHO’s “Suicide in the world: Global health estimates”). 

Sri Lanka has historically had one of the highest suicide rates in the world, with particularly high rates in young people (D.W. Knipe, C. Metcalfe, R. Fernando, M. Pearson, F. Konradsen, M. Eddleston, and D. Gunnell’s “Suicide in Sri Lanka 1975-2012: Age, period, and cohort analysis of police and hospital data” and V. De Silva, R. Hanwella, and M. Senanayake’s “Age and sex specific suicide rates in Sri Lanka from 1995-2011”). The high rates of deliberate self-harm among adolescents in Sri Lanka may be attributed to a combination of social issues including family problems, financial hardships, interpersonal difficulties, and a widespread view that self-harm is a socially acceptable means of dealing with difficulty (the latter two aspects have been identified by De Silva et al.).

With the introduction of national pesticide regulations, the pattern of deliberate self-harm in Sri Lanka has changed, with a significant reduction in both overall and youth deliberate self-harm; however, while fatal cases of pesticide-based self-poisoning has reduced, there has been a concurrent rise in the number of adolescents and young people engaging in deliberate self-harm (R. Hanwella, S. Senanayake, and V. de Silva’s “Geographical variation in admissions due to poisoning in Sri Lanka: A time series analysis” and C. Senadheera and J. Maracek’s “Deliberate self-harm in adolescents in Southern Sri Lanka; A hospital-based study”).

Therefore, Fernando et al., using a cohort study design, aimed to investigate the association between different socioeconomic and household factors with deliberate self-harm in young people (12-18-year-olds) in rural Sri Lanka, whether any associations observed differed by sex, and whether there was any evidence that deliberate self-harm was higher in young people around school exam periods. 

Individuals aged 12-18 years at the initial baseline survey were included in this prospective cohort study; young people reporting a history of attempted suicide in the baseline survey were excluded (223 – 1%) to allow incidence rates to be estimated. This age range represents high school-aged young people in Sri Lanka and captures the ages at which national exams are taken, the pubertal developmental phase – a time of social, emotional, and physical transition, and includes mid adolescence – a period of vulnerability and higher prevalence of suicidal behaviour and self-harm (G.C. Patton, S.A. Hemphill, J.M. Beyers, L. Bond, J.W. Toumbourou, B.J. McMorris, and R.F. Catalano’s “Pubertal stage and deliberate self-harm in adolescents” and S. Aggarwal, G. Patton, N. Reavley, S.A. Sreenivasan, and M. Berk’s “Youth self-harm in low and middle-income countries: Systematic review of the risk and protective factors”). Fernando et al. linked the records of patients who presented at the peripheral hospital and were transferred to a referral hospital. For this analysis, the outcome was intentional self-poisoning or self-injury, regardless of suicidal intent. Only deliberate self-harm cases from residents within the study boundary of the cluster randomised trial were included in this analysis. Fernando et al. only included deliberate self-harm that could be matched back to an individual in the baseline dataset (82% of all cases identified in the hospital were linked). Information on sex, student status, household asset score, household access to pesticides, problematic alcohol use in the household, and a history of attempted suicide for baseline study participants was obtained at the study enrolment. Data were collected on household characteristics and members. Problematic alcohol use in the household was elicited in the baseline survey by asking participants if a household occupant consumed alcohol and if the consumption was “problematic”. If the respondents reported yes to both questions, households were considered to have “problematic” alcohol use (per D. Knipe’s “Life course influences on suicidal behaviour in low and middle-income countries: A study based on 45,000 plus households in Sri Lanka”). The composite household asset score is a measure of the socioeconomic position and was derived by combining data on household construction and the household ownership of a motorised vehicle. Factors were combined to obtain three levels: high, middle, and low. Household access to pesticides was defined as either storing pesticides within the home, home compound, or using pesticides, a factor found in other studies to increase the likelihood of deliberate self-harm (M. Gamburd’s “The kitchen spoon’s handle” and R. Abeyasinghe’s “Illicit alcohol”). Exam stress has been indicated as a potential trigger for deliberate self-harm in young people in Sri Lanka (per C. Rodrigo, S. Welgama, J. Gurusinghe, T. Wijeratne, G. Jayananda, and S. Rajapakse’s “Symptoms of anxiety and depression in adolescent students: A perspective from Sri Lanka”). Given the local concern, Fernando et al. explored the monthly variation in deliberate self-harm for students in different school years. For each student incident of deliberate self-harm, Fernando et al. determined the school year from their date of birth. Fernando et al. presented the number of student deliberate self-harm incidents by the 12 months corresponding to each academic year in Sri Lanka (years 10-13) and additionally the interim six-month period when students are either sitting for the exams or awaiting results. Fernando et al. have attempted to highlight when the examinations are taken, the time awaiting results, and when schools restart for the academic year.

The study population consisted of 22,689 individuals aged 12 to 18 years at enrolment, while a further 65 individuals (0.29%) were excluded due to missing data on at least one of the variables analysed. Of the remaining, 752 young people engaged in deliberate self-harm over an average follow-up period of four years, with a rate of 9.2 per 1,000 person years. The deliberate self-harm rate was higher in females (12.4 per 1,000 person years) than males (6.2 per 1,000 person years). The rate of deliberate self-harm increased with age at enrolment in males, whereas female rates were highest in those aged 14 years at the baseline.

In this cohort of 12 to 18-year-olds, females and those who had left school at any stage prior to the study enrolment were at increased risk of deliberate self-harm. Of the household characteristics, a lower asset score and living in a household with problematic alcohol use were associated with increased risk. There was no statistical evidence of an association between household pesticide access and the risk of deliberate self-harm.

While increased risk of deliberate self-harm was found for both males and females no longer at school, this association was stronger for males than females. No convincing evidence was found of a difference between males and females in the associations between the rate of deliberate self-harm and the household asset score, and access to pesticides. There was evidence that living in a household with problematic alcohol use was a risk factor for deliberate self-harm in females but not males.

There was no clear evidence that the General Certificate of Education (GCE) Ordinary and Advanced Level (A/L) examinations timetable was associated with deliberate self-harm in young people.

In this age group, factors associated with a higher rate of deliberate self-harm were being female, no longer being in education, living in a household with fewer assets, and sharing a household with an individual with problematic alcohol consumption. There was evidence that the association between no longer being in school and a higher risk of deliberate self-harm was stronger in males, whilst there was a stronger association between living in a household where at least one resident was perceived as having problematic alcohol use and a higher risk of deliberate self-harm in females. Fernando et al. found no clear correlation between deliberate self-harm and exam-related stress in Sri Lankan students, though a study that focuses on school pupils with a history of mental illness may have different findings.

1. Marecek’s “Culture, gender, and suicidal behaviour in Sri Lanka. Suicide and life-threatening behaviour” describes specific crises involving interpersonal relationships, school failures, and family conflicts as propagating self-harming behaviour in young girls. Parental control, restrictions and surveillance-concerning privacy, self-determination, and the freedom of movement affect young girls in Sri Lanka (J. Marecek and C. Senadheera’s “‘I drank it to put an end to me’: Narrating girls suicide and self-harm in Sri Lanka”). Often, these struggles were linked to parents’ standards of female sexual propriety, and cultural standards for women (per Marecek). With stereotypical gender roles, younger females have fewer socially acceptable ways of expressing their emotions of unhappiness or anger, in a largely hierarchical culture where overt confrontation is disapproved of and stigmatised (T. Rajapakse and S. Tennakoon’s “Gender differences in suicide in Sri Lanka – What does it tell us?”). Higher rates amongst young females may be explained by Marecek and Senadheera finding young women using self-harm (regardless of suicidal intent) to communicate what they find difficult to verbalise. Termed “dialogue suicides”, these acts were expressive, directed, and intended as communication, Fernando et al. observed. Marecek and Senadheera found that the nature of attempted suicide as “dialogue” and communication, acts often with limited association with mental illness.

The strength of association between the level of education and the risk of deliberate self-harm was stronger for males than females. Lower education levels associated with the higher risk of attempted suicide was identified in D. Knipe, D. Gunnell, R. Pieris, C. Priyadarshana, M. Weerasinghe, M. Pearson, S. Jayamanne, K. Hawton, F. Konradsen, M. Eddleston, and C. Metcalfe’s “Socioeconomic position and suicidal behaviour in rural Sri Lanka: A prospective cohort study of 168,000 plus people”. Non-student participants, especially males, were at higher risk of attempted suicide than current students. In Sri Lanka, it may be that the intergenerational cycling of poverty and limited household assets limits the incentive and capacity to invest in education (per A. Naveed and P. Sutoris’s “Poverty and education in South Asia”). Young people neither attending school nor work, have a higher risk of suicide due to poor structure and instability (per J. Bilsen’s “Suicide and youth: Risk factors”).

The lack of association between household pesticide access and deliberate self-harm may be an artefact of, Fernando et al. added, most participants (80%) living in households with access to pesticides, and because there were inadequate numbers of unexposed individuals to find a difference.

Problematic alcohol use in the household was associated with the increased risk of deliberate self-harm in this study, with this relationship being more pronounced in females. The father or husband engaging in alcohol misuse is a predisposing factor for attempted suicide in co-habiting women in Sri Lanka (D. Knipe, D. Gunnell, M. Pearson, S. Jayamanne, R. Pieris, C. Priyadarshana, M. Weerasinghe, K. Hawton, F. Konradsen, M. Eddleston, and C. Metcalfe’s “Attempted suicide in Sri Lanka – an epidemiological study of household and community factors” and F. Konradsen, W. Hoek, and P. Peiris’s “Reaching for the bottle of pesticide – a cry for help. Self-inflicted poisonings in Sri Lanka”), and is often associated with intimate partner violence (IPV – Abeyasinghe). More than one-third of female deaths, including suicides, were attributed to IPV (the United Nations Population Fund and Kelaniya University’s “Policy brief seven: Reportage of unnatural deaths of women and girls in Sri Lanka”).

Discussing the study’s limitations, Fernando et al. point out that it is noteworthy that some instances of deliberate self-harm may not result in hospital presentation; however, very few cases of self-poisoning (the most common method of self-harm) not requiring presentation to hospital were reported by participants (D. Knipe, C. Metcalfe, K. Hawton, M. Pearson, A. Dawson, S. Jayamanne, F. Konradsen, M. Eddleston, and D. Gunnell’s “Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: A cohort study”). As this survey did not contain information on factors such as mental illness and IPV, Fernando et al. were unable to explore whether these factors were associated with the risk of deliberate self-harm in young people. Fernando et al. were unable to assess the prevalence of psychiatric morbidity in presenting cases, and whether the demographic measures differed by suicidal intent. Also, problematic alcohol use was assessed using a single question and not a validated questionnaire and was also recorded at the household level and relied on the household respondent to both recognise and report problematic alcohol use.

Key prevention strategies can be population based (e.g. media coverage and limiting access to means of suicide), while targeting high risk subgroups through specific programmes to keep children in school (e.g. a grant for those studying for A/L) or apprenticeship programmes for those keen to start earning, and providing crisis hotlines and online help (Y. Kong and J. Zhang’s “Access to farming pesticides and risk for suicide in Chinese rural young people”). Problematic alcohol use (J. Sørensen, T. Agampodi, B. Sørensen, S. Siribaddana, F. Konradsen, and T. Rheinländer’s “‘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”), being more prevalent in male household members, affects both males and females and needs to be addressed by national suicide and violence prevention policies.

If you’re affected by the above content or if you/someone you know may be dealing with a similar situation, the following institutions would assist you:

National Institute of Mental Health: 1926

Sumithrayo: 0112696666

Shanthi Maargam: 0717639898

CCC: 1333