Three years ago the World Health Organisation launched the first ever world suicide report and claimed that Mozambique had the highest suicide rate in Africa at 27.4 per 100,000 people. The Conversation Africa's Samantha Spooner asked Dr. Brad Wagenaar about his research which sought to fill the knowledge gap on Mozambique's suicide attempts and deaths.
How severe is Mozambique's suicide crisis?
Understanding the burden of suicide deaths in Mozambique, other similar Sub-Saharan African countries and in low-and middle-income countries is very challenging. This is primarily due to a lack of readily available measurements from death certificates related to suicide deaths.
In 2014 the World Health Organisation estimated that only 7% of deaths in Mozambique were reported by cause-of-death. Other analyses between 1980-2012 showed that Mozambique failed to make significant progress on the overall quality and completeness of cause of death reporting.
So currently the only way in which researchers can try and work out what's happening is by creating exceptionally complicated statistical models to estimate death rates from samples of available cause-of-death data. Sometimes this means developing estimates from similar countries or creating estimates for death rates in a country that has not a single data measurement.
This approach has led to controversial estimates of death rates, including deaths due to suicide. For example, the WHO estimated that there were 4,360 suicide deaths in Mozambique in 2012, whereas the Institute for Health Metrics and Evaluation estimated that a year later there were only 1,744 such deaths.
All this adds up to is the suggestion that Mozambique has a high suicide rate compared to other countries. But we need sustained investments in public sector health data systems that can accurately maintain and analyse cause-of-death data to confirm this.
Added to this is the fact that when it comes to suicide deaths generally, few studies have been done to accurately measure the potential burden of suicide in sub-Saharan African countries. None have ever been done in Mozambique.
Given high rates of infectious diseases in sub-Saharan Africa - such as tuberculosis, HIV and malaria - the global community has historically neglected causes of death such as suicide. I believe this thinking will change over the next few years as non-communicable diseases become leading causes of death across sub-Saharan Africa.
If we want to promote population health effectively we need to invest in understanding these important non-infectious causes of death, as well as associated disability related to mental illness. Globally, mental illness is the leading cause of disability, yet the vast majority of individuals with mental illness don't receive treatment.
What part of the population is most affected? Did you notice any trends with this?
Our study took place in Sofala, Mozambique. We abstracted all available death and emergency room records to look at patterns in suicide attempts and deaths.
While a novel study, it's limited in that it reflects only individuals who came to the clinic. Our findings might therefore not be representative of individuals who live in very rural areas, or those who didn't make it to a clinic.
When it comes to suicide deaths we found that 48% were under 26 years of age, and 16% were under 18. We also found that there were two male suicide deaths for each female.
But we found the opposite gender patterns when we looked at suicide attempts, with 2.2 females for each male suicide attempt registered in the emergency room.
This is a pattern seen across most countries in the world. Females tend to attempt suicide more frequently than males, but tend to use less deadly methods such as ingestion of pills. Males tend to attempt suicide less frequently, but tend to use more violent methods such as hanging.
*What methods were most common and why do you think this was? *
The most common method of suicide attempt (66%) was rat poison.
Over 54% of suicide deaths used poisoning, with the most common individual poisoning method being rat poison. Hanging was used in 43% of cases. Males were significantly more likely to die by hanging, whereas women were significantly more likely to use poisoning by a toxic substance.
This could explain the gender differences observed whereby women attempt more often, but paradoxically tend to make up a lower proportion of suicide deaths. This can at least be partially explained by our finding that in Mozambique, women tended to use less lethal methods such as poisoning, whereas men appear to attempt less often but use more lethal methods such as hanging.
Why do you think the country has such a high suicide rate?
We really don't know and don't have definitive data to ensure that the statistical models estimating high suicide rates across Mozambique are accurate.
Suicide rates vary dramatically across the world. Known risk factors for higher suicide rates include; difficulties in accessing health care - especially mental health care, easy availability of the means of suicide (such as access to rat poison), inappropriate media reporting that tends to sensationalise suicide, and the stigma against people who seek help for suicidal behaviour or mental health and substance use problems.
All of these risk factors may be acting in Mozambique's increased suicide rates.
Do you know of anything that's being done to tackle this?
The Ministry of Health in Mozambique has recently developed a national suicide prevention plan that focuses on:
Investments in the collection of data on suicide
Training of health professionals in the recognition of suicide risk factors and the management of cases of suicidal thoughts and attempted suicide
Raising awareness among the community to decrease stigma related to mental health problems and suicidal behaviour.
In addition, Mozambique is one of the only countries in sub-Saharan Africa, and one of the only low and middle-income countries globally, to have already scaled-up mental health care delivered by psychiatric technicians. These technicians receive two years of training specifically in treating mental disorders, and are placed at district level primary care clinics. They serve as a key component of suicide prevention and intervention.
But very few studies have been done around suicide prevention and intervention across sub-Saharan Africa. We need sustained investments in the developing and testing of suicide prevention interventions in this region to avoid unnecessary suffering and death.
Bradley Wagenaar receives funding from the US National Institutes of Health.
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