COMMUNITY BASED STUDIES TO INVESTIGATE

RISK FACTORS AND TO DEVELOP A NURSING

INTERVENTION TO REDUCE SUICIDE

THESIS

Submitted to The Tamil Nadu Dr. M.G.R. Medical University

for the award of the Degree of

Doctor of Philosophy
In
Nursing

By

S.D. MANORANJITHAM, M.Sc (N)., R.N., R.M.,

College of Nursing
Christian Medical College
Vellore - 632004
South India

APRIL 2009
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CHAPTER 6

SUMMARY AND RECOMMENDATIONS

The community based studies were carried out in Kaniyambadi block of

Vellore district, Tamil Nadu, Southern India. The Department of community

health, Christian Medical College, Vellore has been operating, a community

health programme in this block for the past five decades.

The qualitative study employed focus group discussion to elicit local

perspectives about suicide in a diverse group of individuals. The psychological

autopsy study is the first community based study from India to use verbal

autopsies for all deaths as part of an ongoing community surveillance

programme. It also employed the standard psychological autopsy procedure and

used a standard structured interview schedule for diagnosis. The intervention

study was a structured educational intervention for school students to enhance

their knowledge and attitude regarding suicide.

6.1. Significant Findings of the study

6.1.1. Perceptions regarding suicide

Many participants particularly emphasized marital discord (14/45), family

problems and interpersonal conflict, while only a minority mentioned mental

disorders as the main cause for suicide.

Participants commonly reported that social and financial difficulties had an

adverse impact on individuals coping, significantly straining relationships and

forcing them to commit suicide.

Participants considered suicide as an option during the time of duress.

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Participants said that poisoning (16/45) and hanging (7/45) were the common

methods of committing suicide, employed by all age groups.

Most participants (20/45) reported that the social impact of suicide was more

in the rural community. They also highlighted the psychological impact of

suicide on families.

Participants knew little about the support services available for suicide

prevention. However, they gave suggestions regarding suicide prevention.

6.1.2. Risk factors for suicide

Widowhood or separated (p = 0.02) was identified as the risk factor for

suicide, which increased the risk by three times.

Lack of close friends during past six months (p = 0.001), ongoing stressors

(p = 0.001) and chronic pain (p = 0.006) were the significant psychosocial risk

factors for suicide.

Being single (p = 0.02) was a significant demographic risk factor associated

with suicide after adjusting for the effects of potential confounders.

Other factors like living alone (Fisher’s exact test p < 0.001) and break in

steady relationship (Fisher’s exact test p < 0.001) were also significantly

associated with suicide but were not present in the control group.

37% (95% CI 27.54 – 46.46) of suicide and 16% (95% CI 8.81 – 23.19) of

controls had at least one Axis I psychiatric diagnosis.

Majority among those who had psychiatric illness had adjustment disorder

(15% in cases and 5% in controls; p = 0.02) and men with alcohol

dependence (16% in cases 7% in controls; p = - 0.04).

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Family history of suicide, previous suicide attempt, and family history of

psychiatric illness, major depressive disorder, Dysthymia and paranoid

schizophrenia were not significantly associated with suicide.

6.1.3. Effectiveness of structured teaching programme regarding suicide for

school children.

There was significant difference found in the intervention group between the

pretest and post test mean score on overall knowledge, attitude regarding

suicide and their ability to identify the severity using case vignettes after the

structured teaching programme ( p = 0.001).

The control group did not have significant difference between the pretest and

post test mean scores on over all knowledge, attitude regarding suicide and

their ability to identify the severity using vase vignettes without the structured

teaching programme.

Intervention and control groups significantly differed on the various aspects of

knowledge regarding suicide such a risk factors (p = 0.002) warning signs

(p = 0.001) beliefs or myths about suicide (p = 0.01) and interventions to

prevent suicide (p = 0.02) after the structured teaching programme.

Three hypotheses were formed on the basis of the objectives and were tested.

The findings are as follows:

H1 - Depression was not common among subjects who committed

suicide.

H2 - Alcohol abuse was more likely to be common among men who

commit suicide than among male controls.

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H3 - The students who received the structured educational intervention

about suicide had greater knowledge about the issues.

The findings of the studies confirmed only the third hypothesis stated.

6.2. Implications of the study

6.2.1. Nursing Practice

Nurses spend a lot of time with patients on a one – to – one basis. Nurses

working in health services like accident and emergency, child and adolescent

mental health and community, offer care to people who engage in suicidal

behaviour. So they need to be well trained in suicide risk and suicide prevention

strategies. Nurses who are the prime care givers to the suicidal should focus on

the interventions regarding safety and alleviation of immediate crisis.

The nurses working at the community play a vital role as teachers,

facilitators, counselors and guides. They should plan and educate the public

regarding suicide prevention. They should take more efforts to strengthen the

interventions aimed at people with a high risk for suicide and those who present

with early warning signs.

A trusting relationship can be developed which may encourage individuals

to reveal concerns, they are reluctant to share even with their family. So, it is an

important part of the nurses to educate the family to pick up changes in behaviour

or cues that can precipitate a suicide attempt. Mass education should be planned

and conducted at periodic intervals to increase the public awareness regarding

suicide.
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School health services are an essential component of community health.

The nurses working in the community need to educate the school students

regarding suicide facts and coping skills. The school teachers can be equipped

with adequate knowledge about adolescent suicide by providing appropriate

training. Nursing as a discipline has a duty and is challenged to provide what is

needed and necessary in helping prevent suicide among this population.

6.2.2. Nursing Education

The educational back ground of the nurses should equip them with the

knowledge necessary to recognize warning signs of suicide and its management.

At present the syllabi of basic nursing courses have a very minimal emphasis on

suicide prevention. The nursing curriculum should include more content on

suicide. The nurses working in the hospital and in the community should be given

in service education to update their knowledge and abilities in identifying people

who are at risk for suicide. The nurse educators should train the students in the

area of counseling people in distress.

6.2.3. Nursing Administration

The nurse administrators should take an active role in developing teaching

modules on suicide that are cost effective, which can be used to educate thess

school children and public. The nurse administrators also should take an active

role in developing policies regarding suicide prevention. Periodical workshops

and conferences can be organized for the nurses to update their knowledge

regarding suicide prevention.

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6.2.4 Nursing Research

The present studies can be done in an urban setting and the risk factors

can be compared between the rural and urban population. The psychological

autopsy can be carried out between living controls, suicide attempters and

suicide victims to understand the issues regarding suicide in depth.

6.3. Recommendations

The present study findings revealed that psychosocial stress and adverse

life events play a major role as risk factors for suicide. The structured teaching

programme was effective and there was a significant increase in the knowledge

and attitude regarding suicide. Following strategies are recommended for

reducing suicide.

1. Conduct regular school health programme on suicide prevention

2. Prepare appropriate teaching modules on suicide to use with different

population.

3. Conduct training programme for school teachers to identify students with

poor coping skills and counsel them.

4. Conduct regular mass education to increase public awareness.

5. Educate the nursing personal in the area of counseling. So that they will

be equipped in dealing with people in distress.

6. Interventions to foster supportive family relationships

7. Reducing the availability of means of suicide

8. Control the access to lethal means of committing suicide.

9. Establish counseling centers in rural areas.

10. Educate the public about mental illness and its treatment.
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11. Support the broad population based socio economic interventions to

improve the overall life standards and social justice.

6.4. Conclusion

The qualitative study revealed that many people in the local community

perceived suicide as an option to get over interpersonal, family and financial

stress among normal individuals as well as among those with mental illness. The

psychological autopsy study documented severe mental disorder only in a

minority of subjects who killed themselves. The psychological autopsy study also

reported that psychosocial stress and social isolation are risk factors for suicide in

the region. The intervention study demonstrated the effectiveness of a structured

educational programme about suicide in improving knowledge and attitude

among students who received the education. Suicide remains as a distinct global

public health problem and the reduction of rates continues to be major concern of

many countries. Knowledge of risk and protective factors can be a guide for

support and prevention of suicide.