ORIGINAL ARTICLE

Parasuicide in a low-income country: results from

three-year hospital surveillance in Nicaragua
Trinidad Caldera1,3, Andrés Herrera2,3, Ellinor Salander Renberg3 and Gunnar Kullgren3
1
Department of Mental Health, 2Department of Preventive Medicine and Public Health, University of León UNAN, León, Nicaragua,
3
Department of Clinical Sciences, Division of Psychiatry, WHO Collaborating Centre, Umeå University, Umeå, Sweden

Scand J Public Health 2004; 32: 349–355

Aims: A study was undertaken to assess the incidence of parasuicide in Nicaragua, to identify groups at risk, and to describe
the characteristics of parasuicides, such as methods used and seasonal and diurnal patterns. Method: All hospital-admitted
parasuicide cases in the area of León, Nicaragua, were assessed over a three-year period using standardized instruments.
Results: Two hundred and thirty-three parasuicide cases were identified in the catchment area giving a parasuicide rate of
66.3/100,000 inhabitants per year based on the population 10 years and older. Corresponding figure for 15 years and older
was 71.3. A majority were females (68.8%), who were significantly younger than the males (mean 20.8 years vs. mean 24.6
years). The highest rates were found in the age group 15 – 19 years with a female rate three times higher than the male rate
(302.9 vs. 98.9). Pesticides, a highly lethal substance, were used as method in 19.1% of the attempts. Consistent seasonal
variation with peaks in May – June and September – October were found over the years. Among parasuicide cases, 46.5%
had been in contact with the healthcare system within 6 months before attempting suicide. Conclusions: Parasuicides
represent a significant health problem among young people in Nicaragua. Preventive efforts should be directed especially
towards the life situation for young girls, limitation of availability of suicide means, increased awareness in schools
concerning suicidal problems, as well as improved management of patients with mental health problems within primary
healthcare.
Key words: hospital surveillance, Nicaragua, parasuicide, seasonal pattern, sociodemographic characteristics.

Ellinor Salander Renberg, Department of Clinical Sciences, Division of Psychiatry, Umeå University, SE-901 85 Umeå,
Sweden. Tel: z46 90 785 6323, fax: z46 90 13 53 24. E-mail: ellinor.salander.renberg@psychiat.umu.se

reported to occur most frequently among young

BACKGROUND
Suicidal behaviour has become increasingly recog-
nized by the World Health Organization as a major
public health problem. In the younger age groups,
suicide is now one of the leading causes of death in many
countries. Every year close to one million people die from
suicide – almost as many deaths as caused by traffic
accidents. Suicidal behaviour is considered a major
public health problem also in low-income countries
(1). The National Mental Health Committee in
Nicaragua estimates that suicide rates have increased
threefold from year 1992 to year 2000.
The rate for attempted suicide, the most evident risk
factor for completed suicide (2 – 4), is so far difficult
to estimate. In Nicaragua only a few studies on
parasuicide attempts were reported during the 1990s.
The first study (5) used data from the register of the
emergency room at the León hospital and two smaller
studies were performed in the Northern and Western
part of the country (6, 7). Suicide attempts were
people between 15 and 25 years of age. Whereas
females are in majority among suicide attempters in
most European studies (8), no clear gender difference
was observed in the Nicaraguan studies. A common
method used was a very serious one, namely ingestion
of pesticides. From the perspective of prevention, it is
noteworthy that 88% had visited a general practitioner
within 6 months before the suicide attempt. These
studies focused on mere prevalence data and are
hampered by small sample sizes and less standardized
methodology.
AIMS
Few studies have systematically examined parasuicides
in low-income countries. The overall aim of present
study is to assess the incidence of parasuicides in
León, Nicaragua, to identify sociodemographic
groups at risk and to examine other characteristics
of parasuicides in this region.

# Taylor & Francis 2004. ISSN 1403-4948 Scand J Public Health 32

DOI: 10.1080/14034940410029496
350 T Caldera et al.
To allow for international comparisons, this study
used research protocols and instruments developed
within the framework of the WHO/EURO Multi-
center Study on Parasuicide, initiated during the 1980s
(8 – 10).
METHODS
Study area
The municipality of León covers an area of 820 km2
and according to the last Nicaraguan census report
(1998) the region has 161,530 inhabitants, of whom
77% live in the urban area. The gender distribution is
48% males and 52% females. Among those older than
15 years, 54% are females, of whom 59% are single.
The annual population growth is estimated at 3.15%.
The unemployment rate has been very high and is
estimated to be around 50% in the León area and even
higher in the rural part of the study area. For more
than 10 years until the mid-1990s, Nicaragua was in a
state of war with an economy strictly controlled by
the government. Conditions were poor for all citizens.
During recent years the country has opened up to
international markets, leading to huge gaps between
socioeconomic classes and also inequity in terms of
health (11).
The educational system is based on the primary
school, which is mandatory and free of charge. The
illiteracy rate is 21% for women and 20% for men.
Children attend primary school in the urban area
from 6 to 13 years and in rural areas 2 years later.
However, many children and adolescents quit school
much earlier. In León, which is much dominated by
its university, students in the age group 6 to 30 years
represent about 56% of the population.
The hospital HEODRA (Hospital Escuela Oscar
Danilo Rosales Argüello) is located in the city of León
and is the only healthcare facility with inpatient care
services in the region, apart from a few very small
private clinics which do not offer emergency services.
In the study area, the municipality of León, there are
also three primary healthcare centres.
Mental Health services are composed of a commu-
nity mental healthcare unit, offering outpatient
services (12) and a consultant psychiatrist at the
HEODRA hospital where a few beds are assigned for
psychiatric patients. Patients requiring more intensive
psychiatric inpatient treatment are referred to the
mental hospital in Managua, the capital of Nicaragua,
90 km from León. Primary healthcare centres have
very limited resources to care for mentally disordered
patients and we have in previous studies shown that
mental health problems are often overlooked (13).
Scand J Public Health 32
Design
The study covers the municipality of León where cases
in need of medical treatment after a suicide attempt
are referred to the emergency unit of HEODRA
hospital, with very few exceptions. All hospital-
admitted cases of parasuicide according to the ICD-
10 definition (9) living in the study area were
interviewed following the standardized monitoring
procedure developed within the WHO/EURO multi-
centre study. In addition to basic demographic
information the interview covered information on
method used, place, and time of the day when the
attempt took place.
As soon as possible after the patients had been
admitted and defined as a parasuicide case (usually
within 24 – 48 hours), the interviews were performed
in the emergency room or on a clinical ward. One
trained nurse, who for several years has been
responsible for the general epidemiological surveil-
lance system at the hospital, performed all interviews.
Inclusion in the study was based on informed consent.
All patients under 15 years old were interviewed after
informed consent by relatives or tutor. Patients who
refused to be interviewed (12%) gave consent for
inclusion of data from clinical records. The study was
approved by the ethical committee at the medical
faculty, university of León.
The present study reports on data from the first three
years of monitoring, from March 1999 to February 2002.
For statistical analyses the Mann – Whitney test was used
to compare means of continuous variables and a
chi-square test was used to compare distributions.
RESULTS
During the three-year period a total of 326 persons
were admitted to the HEODRA hospital after
deliberate self-harm. After exclusion of 17 cases of
completed suicides and 76 cases living outside the
study area, 233 parasuicide cases were included in the
analyses, giving a parasuicide rate of 66.26/100,000
inhabitants per year based on the population 10 years
and older. The corresponding figure for 15 years and
older was 71.3. Females were in the majority (68.8%)
with an overall male to female ratio of 1:2.3. In the
age groups 10 – 14 years and 15 – 24 years, the ratios
were 1:9.5 and 1:2.7, respectively. The proportions
were inverted for the age group 25 – 34 years and
45 – 54 years with a male/female ratio of 1:0.9 and
1:0.8, respectively. Females were significantly younger
with a mean age of 20.8 years compared with 24.6
years for males (z~3.575; pv0.001). As regards
family structure, females were almost twice as likely
to be living with their parents (x2~13.895; pv0.05).
 Parasuicide in a low-income country 351

In terms of economic activity there were significant
gender differences: a larger proportion of males as
compared with females were employed (48.8% vs.
13.2%; x2~34.47; pv0.001) whereas a larger propor-
tion of females were students (52.3% vs. 31.8%;
x2~15.28; pv0.001). There was a clear predominance
of Catholics (78%), whereas 12% reported they had no
religious belief.
Rates of parasuicides per 100,000 inhabitants per
year by sex and age groups are given in Table I. The
highest rates for both genders were found in the age
group 15 – 19 years.
In Table II suicide methods are divided into four
main categories, and the predominant method was
drug intoxication, followed by ingestion of pesticides.
There were no gender differences (x2~2.08; p~0.557)
or age differences (F~1.36; p~0.254) in method used
for parasuicide.
In almost all cases the suicide attempt occurred at
home. Close to 80% had had previous contact with
health facilities, most of them during the past 6
months. Among females younger than 25 years of age,
54 out of 118 individuals (45.7%) had had recent
healthcare contact within 6 months, and among men
older than 34 years of age, 8 out of 10 (80.0%) had
had such contact.
Seasonal peaks of parasuicide occurred in May – June
and September – October, as shown in Fig. 1. Within
the hours of the day, parasuicides occurred most
frequently between 1100 and 1300 hours and 1900 to
2100 hours (Fig. 2).
DISCUSSION
This is the first Nicaraguan study to use a standar-
dized method enabling international comparisons. It is
shown that Nicaraguan parasuicide rates are quite
similar to rates in most European regions (8),

Table I. Person-based age and gender rates per 100,000 inhabitants of total hospital admitted parasuicide cases

Male Female Total

n % Rate n % Rate Total % Rate

10 – 14 2 2.8 6.02 20 12.4 61.65 22 9.4 33.49

15 – 19 27 37.5 98.93 86 53.4 302.90 113 48.5 203.70
20 – 24 15 20.8 70.08 25 15.5 102.96 40 17.2 87.55
25 – 29 7 9.7 42.68 7 4.3 34.67 14 6.0 38.26
30 – 34 10 13.9 69.14 9 5.6 51.94 19 8.2 59.17
35 – 39 5 6.9 39.64 6 3.7 40.20 11 4.7 32.69
40 – 44 2 2.8 20.26 4 2.5 35.40 6 2.6 28.34
45 – 49 2 2.8 26.75 3 1.9 34.14 5 2.1 30.52
50 – 54 2 2.8 36.33 0 0 2 0.9 16.70
55z 0 0 1 0.6 4.32 1 0.4 2.55

Table II. Method, place of suicide attempt and previous healthcare contacts

Male Female Total

n~72 31.2% n~161 68.8% n~233 %

Method
Non-narcotic/Other drugs 45 65.2 114 73.1 159 70.7
Pesticide 16 23.2 27 17.3 43 19.1
Sharp object 2 2.9 5 3.2 7 3.1
Othersa 6 8.7 10 6.4 16 7.1
Place
Street 5 7.9 4 2.7 9 4.3
Home 55 87.3 138 93.9 193 91.9
At work 2 3.2 5 3.4 7 3.3
Jail 1 1.6 1 .5
Previous healthcare contacts
None 13 22.0 25 17.5 38 18.8
v6 months 27 45.8 67 46.8 94 46.5
w6 month v12 months 16 27.1 41 28.7 57 28.2
w12 months 3 5.1 10 7.0 13 6.5

Scand J Public Health 32

352 T Caldera et al.

Fig. 1. Seasonal variation in suicide attempts.

Fig. 2. Diurnal variation in parasuicide attempts.

including high rates among young people, in particular study 1989 – 92 (8, 15), the highest male to female
among young girls. However, our setting differs some- ratio was 1:1.8 reported among those 15 – 24 years
what from European countries. From the WHO/EURO old, which should be compared with a ratio of 1:2.7 in

Scand J Public Health 32


Nicaragua. Since the attempt rate was 210/100,000 per
year for women aged 15 to 24 years, similar to the
rates presented in other studies (8, 15), it is rather a
low male rate that constitutes a unique pattern in
Nicaragua.
Gender differences in suicidal behaviour in the
literature are mainly attributed to gender-specific social
behaviours (16), leading to differences in choice of
method, different socialization associated with different
coping strategies (17), and different exposure to risk
factors, in particular depression (18, 19), but also
sexual abuse (victimization) among girls (20, 21).
Previous studies in Nicaragua have shown that for
unmarried girls living at home, often with several
generations in the same household, sexual abuse and
unwanted pregnancies are important problems (22).
We have also in a previous study in León showed that
domestic violence contributes to mental distress
among young married women (23), possibly leading
to suicidal behaviour.
An interesting finding is the pronounced differences
between high suicide attempt rates among young
females and very low rates among older females, a
pattern not described in high-income countries. Our
interpretation is that girls in the youngest age group
have, compared with older women, been exposed to a
changing Nicaraguan society where traditional values
very much have been challenged. This phenomenon
might be similar to what Durkheim (24) presented in
his famous study more than 100 years ago. He
described a situation where rapid changes of the social
regulation in a society lead to an increase in a specific
type of suicide, namely anomic suicides.
Very few people lived alone, which is to be expected
in Nicaraguan society where often several generations
live in the same household (25). Only one-third of the
individuals had children, which could be linked to
suggestions from other studies that having small children
offers protection from parasuicide attempts (3).
Most cases declared an occupation as student or
housewife, while only 10% reported they were
unemployed, which contrasts with the overall unem-
ployment rate, estimated to be around 50% in the
study area. It is possible that individuals reported they
were employed even though they had only very
temporary part-time jobs, for example in the
market. In general, we failed to show any association
between socioeconomic problems and parasuicide
attempts, in contrast with the European studies
where attempters more often belonged to social
categories associated with social destabilization and
poverty (8).
Concerning methods used to attempt suicide, the
most challenging finding from a preventive perspective
is that pesticides were used by as much as one-fifth of
Parasuicide in a low-income country 353
all cases with no gender differences and equally often
in the urban and rural areas. Pesticide intoxication is
also reported to be a leading method in completed
suicide in the region. Discussing our findings with
authorities in the community has, among other things,
contributed to initiatives aimed at making pesticides
less available in the shops.
During all three years there was a consistent
seasonal pattern with peaks of attempts around
June and November, respectively. These peaks coin-
cide with the end of semesters in school when
examinations take place and grades are decided.
One hypothesis worth further exploring is that
pressure in school and school failures might con-
tribute to suicidal behaviour among young students.
Almost half of the attempters had had contact with
a healthcare facility within six months before their
suicide attempt, seemingly offering opportunities for
prevention. However, we lack sufficient information
on healthcare contacts in the corresponding age
groups in the general population, as well as informa-
tion concerning reasons for visiting healthcare ser-
vices, to fully judge the importance of this finding.
Nevertheless, we know from previous studies that a
current mental disorder, in particular depression, is a
major risk factor for not only completed suicide but
also suicide attempts (26). At the same time we have
shown in a previous study in Nicaragua that doctors
in primary healthcare are likely to overlook mental
health problems (13). A future task could therefore be
to improve identification and treatment of depression
in primary healthcare, which has been a successful
approach in high-income countries (27). Anecdotal
information, to some extent supported by previous
studies in the area (28), indicates that problems related
to sexual abuse bring girls to primary healthcare.
Improved management of girls with this experience is
likely to be important in prevention of suicide attempt
(29).
Finally, concerning reliability of the data, it is
reasonable to assume that there were cases during the
study period that were never referred for any
treatment, and cases visiting only healthcare centres,
even if they were reportedly very few. No attempt was
made to include these cases in the study, in
accordance with experiences from other studies
within the WHO/EURO project, restricting the
study to include only cases admitted to hospital.
The nurse responsible for identifying and interviewing
cases had for many years been responsible for the
routine surveillance system in the emergency unit of
the hospital and we believe coverage to be complete in
terms of cases detected. Furthermore, a limitation of
the present study is that we had to restrict our study
base to the municipality of Leon thereby excluding
Scand J Public Health 32
354 T Caldera et al.
more typical rural areas. Also, the study area is not
representative of Nicaragua as a whole; Leon is a
university city strongly dominated by young students.
CONCLUSION
Parasuicides also represent a significant health pro-
blem in a low-income country such as Nicaragua.
Young girls in particular are at risk. Pesticides are
commonly used for intoxication and measures should
be taken to make these toxic agents less available.
Restricted availability of drugs is also warranted.
Seasonal variations seem to indicate that problems
related to school are of importance, a finding that
warrants further research. Almost half of all cases
have had fairly recent contact with healthcare services
before attempting suicide. Staff in all healthcare
facilities should be better trained to explore suicidal
ideation and behaviours and identify and manage
possibly related mental health problems or other
factors pertaining to suicidal behaviour.
ACKNOWLEDGEMENTS
The study was supported by grants from the
Developing Country Research Council in Sweden.
The authors want to thank Julio Rocha for his
assistance in data collection, and the patients who
participated in the interviews.
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Accepted 04 01 09
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