Study On Risk Factors And Establishment Of High Risk Assessment Score Model Of Female Suicides In Rural Area Of Shandong Province

BackgroundSuicide is defined as the act of deliberately killing oneself, with full awareness and expectations of the lethal consequences. Suicide is an important public health issue around world. Every year, approximate 1,000,000 people died by suicides all over the world. In China, about 287,000 people committed suicide every year, accounting for more than a quarter of all suicides worldwide. Suicide is the fifth leading cause of death among China.There are three unique characteristics in Chinese suicides:1) rural suicide rate is about two-fold to three-fold greater than the urban suicide rate; 2) the female/male ratio is 1.25:1. Rural female suicide rate is 30.5/100,000, ranking the highest among urban male and female and rural male and female.3) about 35% of completed suicides and 60% of attempted suicides weren't diagnosed mental disorders when they committed suicides.Suicide is the first leading cause of death for rural youth female in China. Rural female are at a high risk of suicide. Rural female bear multiple responsibilities of upbringing children, supporting for the elder and doing farmer work, while they receive little education and low social support, which lead them to solve the problems they face by committing suicides. The high rural female suicide rate not only brings medical burden but also causes serious losses of labor force. The severity of rural female suicide has aroused much attention of experts. Until now, the following risk factors for suicides have been known:mental disorders, impulsivity, negative coping skills, low social support, suicide attempt history, physical diseases, family suicide history, cultural factors, negative life events and accessibility to lethal methods for suicide. Recent studies have shown great changes on characteristics of suicides, such as the decrease of suicide rates and female suicide rates not so high as before. Therefore risk factors on rural female suicides may have already changed. This study tries to establish high risk assessment score model on the basis of former studies. This study aims to explore the characteristics of rural female suicidal behaviors and risk factors on rural female suicides so as to provide scientific basis for prevention and intervention.Objectives1. To explore the characteristics of rural female suicides;2. To explore risk factors for rural female suicides associated with social-demographic factors, psychological traits, psychosocial stress and mental disorders;3. To initially establish high risk assessment score model of rural female suicides in Shandong Province.Methods1. Subjects and MethodTwenty-five towns of three counties were chosen from disease surveillance points of Shandong Province.219 suicide cases happened from September 1st,2008 to August 31st,2009 were selected from the twenty-five towns.200 cases were successfully recruited, while 19 cases withdrew because family members of cases refused to participate or no suitable controls were found. One informant of each suicide or paired control with the same age (no more than 3 years), same gender and same district as suicide was interviewed by trained interviewers. The informant was the person who knew most of cases or controls, including family members, relatives, friends or neighbors. Besides, one third of controls attended the interviews themselves. Among them, there were 30 female controls. At last,85 rural female suicides and their paired controls were acquired as our targets.Case control study with psychological autopsy method was used to collect data by face to face interviews.2. Instruments1) General information:personal information including age, educational level, marital status, personal income, status in family, physical condition, religious belief, etc; family information including family economic status, family relationship, family suicide history, pesticides stored at home, etc.2) Suicidal behavior characteristics:Suicide Intent Scale (SIS) was used to measure death intent of suicides.3) Psychological traits were measured by Self-Esteem Scale (SES),Barratt Impulsivity Scale (BIS),Simplified Coping Style Questionnaire (SCSQ),Beck Hopelessness Scale (BHS),State-Trait Anxiety Inventory (STAI),Center for Epidemiologic Studies Depression Scale (CES-D).4) Psychosocial stresses were measured by Paykel life events scale (Interview for Recent Life Events, IRLE) and Social Support Rating Scale (SSRS).5) Mental disorders:the Structured Clinical Interview for DSM-IV Axis I Disorders Patient Version (SCID-I) was used.Main Results1. Informants'basic information:compared with informants'of controls, the informants'of cases had lower education level and higher proportion of being separated, divorced or widowed and higher CES-D scores (mean score=5.0).2. The characteristics of suicidal behavior for rural female suicides:1) there were a little more suicides in Spring (31.8%) and female suicides tended to commit suicide indoor (80.0%), mainly by ingestion of poison and hanging (88.1%); 2) the first third direct reasons for female suicides were low quality of life caused by severe diseases (38.8%), interpersonal conflicts (20.0%) and mental disorders (15.3%); 3) the mean score of Suicide Intent Score (SIS) of rural female suicides was 5.71±2.42; rural female committed suicides with less preparation of pre-suicidal behavior and 71.1% suicides had no preparation before suicides.3. The demographic characteristics of rural female suicides:for suicides, mean age was 59.54years, with poorer health status than controls (χ2=12.87, P=0.002); compared with controls, suicides were more likely to be alone in marital status (χ2=5.69, P=0.017) and believe in superstition (χ2=11.05, P=0.001), with positive family suicide history (χ2=9.94, P=0.002).4. The psychological traits, psychosocial stress and mental disorders of rural female suicides:1) psychological traits:comparing to controls, suicides had relatively higher level of hopeless, trait anxiety, self esteem and impulsivity (all P<0.001) and lower level of positive coping skills (P<0.000); 2) psychosocial stress:suicides tended to have lower social support (P<0.001) and the incidence rates of the following five negative life events were significantly higher among the suicides than controls, "incurable or severe diseases", "been in hospital", "needing home care ", "bitter disputes with spouse or cohabitant" and "bitter disputes with other family members" (P values were 0.000,0.004,0.001,0.038,0.038, respectively); 3) mental disorders: 28.3% of suicides had at least one diagnosis of mental illness and suicides tended to have higher level of total prevalence of mental disorders and severe depression than controls (both P<0.001).5. Risk factors for rural female suicides and the establishment of high risk assessment score model1) At the level ofα=0.05,13 factors were found to be related to rural female suicides by univariate analysis, which were marital status, familial economic status, health status, physical diseases, superstition, family suicide history, negative life events, social support, self esteem, impulsivity, positive coping skills, hopelessness and trait anxiety. Four factors were shown to be associated with rural female suicides by multiple unconditional Logistic regression model, which were superstition (OR=6.644,95%CI=1.002～44.075), family suicide history (OR=26.010, 95%CI=3.074-220.061), hopelessness (OR=1.147,95%CI=1.097～1.200) and negative life events (OR=4.302,95%CI=1.359～13.621).2) High risk assessment score modelY=hopelessness×1-family economic status×3.8+negative lifeevents×11.6+superstition×14.4+family suicide history×25The Receiver Operator Characteristic Curve (ROC) area of this model was 0.948. The model's sensitivity and specificity were 0.840 and 0.917, so the power of its prediction was good.Conclusions1. The characteristics of suicidal behavior for rural female suicides: Rural female tended to commit suicides indoor by ingestion of poison and hanging, with low preparation and intent. Suicides happened mainly after family conflicts or acute stress.2. Main risk factors for rural female suicides Four factors were found to have association with rural female suicides by unconditional Logistic regression model, which were believing in superstition, positive family suicide history, hopelessness and negative life events. By analysis of interactions, there were positive interactions between hopelessness and negative life events.SuggestionsPositive and effective control measures should be combined with risk factors, such as controlling the feasibility of pesticides maybe by prohibition of highly toxic pesticides, and accelerating the development of township factories to improve the living standards of rural people. Rural female need to improve their educational level and at the same time scientific propaganda are used to improve their ethical level. Organizations, like women's federation and community service station are needed to provide psychological counseling for rural female. Primary care needs to be improved to deal with emergency events. Social security system needs to become mature to provide basic medical security and living allowance for rural elder people.