Gender Differences Related to Attitudes Toward Suicide and Suicidal ...

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This descriptive study examined gender differences related to attitudes toward suicide among randomly selected urban residents. Data was collected using a ...
Community Ment Health J (2016) 52:228–232 DOI 10.1007/s10597-015-9913-1

BRIEF REPORT

Gender Differences Related to Attitudes Toward Suicide and Suicidal Behavior Vijayalakshmi Poreddi1 • Rohini Thimmaiah2 • Rajalakshmi Ramu1 • Sugavana Selvi1 • Sailaxmi Gandhi1 • Ramachandra1 • Suresh Bada Math3

Received: 16 October 2013 / Accepted: 10 August 2015 / Published online: 21 August 2015 Ó Springer Science+Business Media New York 2015

Abstract This descriptive study examined gender differences related to attitudes toward suicide among randomly selected urban residents. Data was collected using a standardized questionnaire through face-to-face interview. Our findings revealed that men hold more pro preventive attitudes to help persons with suicidal thoughts (80.3 %, p = 0.05) and agreed that suicidal attempts are impulsive (78.6 %, p = 0.01). However, they hold permissive attitude to help persons with incurable diseases and expressing death wishes to die (66 %, p = 0.05). A majority of men (78.6 %) than women agreed that ‘‘suicidal attempt is essentially a cry for help’’ (v2 = 11.798, p = 0.05). These gender differences need to be taken into consideration when developing appropriate programs to prevent suicide. Further, decriminalizing the law, high-quality research and raising awareness about suicide prevention among the general population is crucial in developing countries like India. Keywords Attitudes  General population  Suicide  Urban community

& Vijayalakshmi Poreddi [email protected]; [email protected] 1

Department of Nursing, College of Nursing, National Institute of Mental Health and Neuro Sciences, Institute of National Importance, Bangalore 560 029, India

2

Department of Psychiatry, Videhi Medical College, Bangalore, India

3

Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (Institute of National Importance), Bangalore, India

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Introduction Suicide is the most common cause of death worldwide and more than 800,000 deaths are attributed to suicide every year (WHO 2014). Suicide has been defined as ‘‘any deliberate action that has life-threatening consequences and the result of action can be entirely predictable’’ (WHO 2004). According to a 2014 report by the World Health Organization (WHO), 75 % of suicides were among the people from poor or middle-income countries. The suicide rate has increased by 43 % from 35 % in the last three decades (1975–2005) (Vijayakumar 2010). A significant concern is that the majority (71 %) of the individuals who die by suicide were below 44 years of age, which creates a social, emotional and economic burden on society (NCRB 2005). The higher frequency of completed suicides among men and suicidal attempts among women is called gender paradox and may vary significantly between different countries (Mendez-Bustos et al. 2013). In the high income countries like USA, the suicide rate has been about four times higher among men than women, whereas suicide rates among women were higher in the low-middle income countries (AFSP 2013; Phillips et al. 2002). Suicide is a controversial topic disputed in the fields of ethics, law, and medicine (Mo 2011). In India, an attempted suicide is an offense punishable under Section 309 of the Indian Penal Code. Hence, families often do not report suicide or suicidal attempts to avoid legal consequences. They even do not seek any professional help and families seldom reveal about suicides to avoid facing stigma and shame (Vijayakumar 2007). In 2008, the Law Commission of India submitted a review to the government and most importantly, the Mental Health Care Bill, 2013 has made a landmark proactive change, by amending the anarchical law. According to this Bill, ‘a person who attempts suicide shall

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be presumed to be suffering from mental illness at that time and will not be punished under the Indian Penal Code’. By decriminalizing suicidal attempts, families can seek professional help. With regard to attitudes toward suicidal behaviour, gender differences have been well documented. In a study, that examined regional politicians’ attitudes toward suicide, men were more optimistic about preventability of suicide than women (Skruibis et al. 2010). On the contrary, women hold more tolerant attitude towards suicide (Renberg and Jacobsson 2003). Indian studies have focused mainly on socio-demographic, clinical, and psychosocial factors related to attempted suicide with few studies reporting high rates of death by suicide (Abraham et al. 2005; Chowdhary et al. 2007; Prasad et al. 2006; Srivastava and Kumar 2005). Attitudes have a significant impact on suicidal ideation and behavior. Zemaitiene and Zaborskis’s (2005) research suggests that the individuals with more tolerant attitude towards suicide may have a higher risk of engaging in suicidal behaviour. On the contrary, negative attitudes toward suicide may be a protective factor against suicidal behavior (Eshun 2003). Earlier studies investigating attitudes toward suicide clearly indicate attitudinal differences between genders (Eskin 2004; Tang and Yang 2003). Men were found to have more tolerant attitudes toward suicide than women (Dahlen and Canetto 2002). None the less, cultural attitudes regarding suicide may vary by community, population cohort, and throughout time (Salander Renberg et al. 2008). Additional literature suggests that measuring attitudes toward suicide may aid in predicting suicidal behaviour and death by suicide (Joe et al. 2007; Stack and Kposowa 2006). Furthermore, studies have also indicated that changing an individual’s attitude towards suicide is an efficient way to prevent death by suicidal attempts (Sakamoto et al. 2006). There is a growing recognition that suicide is a major health problem; however, there is insufficient literature available on community attitudes toward suicide in India. Given that there is limited access to mental health services in India (i.e. 0.34 mental health professional per 100,000 population), the development of methods to predict and prevent suicide, such as examining the community attitude, is crucial (Vijayakumar 2004). The present study aimed to examine gender differences related to attitudes toward suicide and suicidal behaviour in urban Indian residents.

Materials and Methods This was a cross sectional descriptive survey administered to urban residents in Bangalore, India. The sample was randomly selected from 436 households. Fifty percent of

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the randomly selected households completed the survey. The study criteria for participants included (a) 18 years of age or older; (b) resided in the target community for at least 3–6 months prior to the survey; (c) consented to participate in the study. Exclusion criteria included persons with severe psychiatric illnesses and cognitive disorders. A total of 216 participants were invited to participate in the study; however, the final sample consisted of 172 individuals with 79.6 % response rate. Twenty-one individuals declined to participate in the study; eight of which previously attempted suicide. An additional 23 individuals could not be reached after several home visits. Data Collection Instruments Data was collected using the questionnaire that has two sections; A.

B.

Personal data included information about the gender, age, marital status, family monthly income, education, and religion of participants. The Attitudes towards Suicide questionnaire (ATTS) was used to measure participants attitudes towards suicide and suicidal behavior (Renberg and Jacobsson 2003). The original version of the tool consisted of 61 items in three sections. The items (1–3) in the first section were used to capture personal experiences related to suicidal behavior. The items (4–43) in second section were intended to measure attitudes toward suicide. The items (44–61) in third section were related to elicit participants’ personal information. We have adopted the first and second section of the original questionnaire (37 items) with five point likert scale ranging from 1 = strongly disagree to 5 = strongly agree. The higher scores therefore represent grater agreement with the items (reversed scoring on item 7 and 9). The items no 41–43 were not included for the present study as these items were difficult to assess in Indian context where open discussion about suicide is regarded as taboo. Further, earlier research also supports the inclusion of these items in the present study (Arnautovska 2010; Hjelmeland et al. 2008; Norheim et al. 2013). However these studies have done their own factor analysis.

Data Collection Procedure The questionnaires were conducted in-person at the participants’ residents. The family members were asked about pedigree charting and the head of the family was invited to participate. In Indian culture usually men are bread winners and considered as head of the family. Since the data was collected during working hours women were invited to

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participate in the study. After explaining the purpose of the study, researchers obtained written consent from the participants. English version of the questionnaire was used for the present study due to unavailability of the tool in the local language. Before the data collection, researchers discussed and practiced among themselves about how to ask the questionnaire in the regional language. Finally the items were read aloud to the participants and the responses were marked. Ethical Considerations The study protocol was approved by the Ethics Committee of the concerned hospital, Bangalore. The aim of the study was explained briefly to the participants and written informed consent was obtained. Participation in the present study was voluntary. Participants’ information was kept confidential by giving dummy codes, and those in need were referred for psychiatric consultation.

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‘everyone has at one time or another thought about suicide’ (v2 = 11.037, p = 0.05). Fifty percent of men endorsed the item that there will be ‘‘situations where the only reasonable resolution is suicide’’ (v2 = 12.404, p = 0.05) as well as ‘‘would consider the possibility of taking their life if they were to suffer from a severe, incurable, disease’’ (v2 = 9.942, p = 0.05). Sixty-eight and one tenth percent of women compared to 53.6 % of men selected the item ‘‘suicide happens without warning’’ (v2 = 24.127, p = 0.001) and ‘‘others should not interfere if someone wants to commit suicide’’ (v2 = 14.635, p = 0.01). The vast majority of men (84 %) endorsed ‘‘most people avoid talking about suicide’’ (v2 = 14.995, p = 0.01) and ‘‘Suicidal attempt is essentially a cry for help’’ (v2 = 11.798, p = 0.05). The majority of men (66 %) selected the item ‘‘a person suffering from a severe incurable disease expressing wishes to die should get help to do so’’ (v2 = 11.608, p = 0.05).

Discussion Statistical Analysis The data was analysed using Chi square test, frequencies, and percentages. The frequencies of ‘strongly disagree’/ ‘disagree’, ‘agree’/‘strongly agree’ responses were combined for Chi square analysis purpose.

Results The total population of selected community was 1897 individuals, of whom 47.7 % (n = 905) belonged to 18–65 years age group. Majority (57.38 %) were Muslims followed by Hindus (39.76 %) and Christians (2.86 %). The present study consisted of 172 participants. Of the sample, 67 % were female, 71.7 % were below the age of 35, 82.6 % were married, and 53.5 % identified as Muslim. Nearly half (41.3 %) of the participants were primarily educated (studied up to fifth standard). Socio-demographic variables did not differ significantly between genders. Regarding participants’ suicidal experiences and behaviour, no significant difference was demonstrated between genders. A greater number of men (21.4 %) attempted suicide compared to women (14.7 %). The majority of women (23.3 %) accepted that their family members ‘made suicidal attempts’ and ‘expressed suicidal thoughts’ (31.9 %). Equal number (14.6 %) of men and women stated that they ‘knew someone who committed suicide in their community’. A greater number of men (80.3 and 78.6 %) agreed that ‘‘it is always possible to help a person having suicidal thoughts’’ (v2 = 9.741, p = 0.05) and ‘‘most suicide attempts are impulsive actions’’ (v2 = 13.400, p = 0.01) than women. Similarly the majority (57.1 %) of men than women felt that

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The present study compared gender differences related to attitudes toward suicide and suicidal behaviour in an urban community; as well as highlighted the perceptions of men and women regarding the complex nature of suicide. Attitudes are regarded as an important part of one’s personality and often predictive of one’s behaviours (Larsen and Buss 2002). Measuring individuals’ attitudes toward suicide may be the first step in prevention. This study examined gender differences in attitudes regarding the preventability of suicide, helping an individual with suicidal ideations or behaviours, and permissiveness towards suicide. Results of this study demonstrated significant gender differences in attitudes about suicide. Women tended to disagree that it is not possible to help a person with suicidal thoughts. Similarly, a majority (40.5 %) of women felt that others should not interfere with an individual attempting death by suicide. Our results, in conjunction with prior research, suggest that attitudes toward suicide affect the likelihood that one would aid an individual that was suicidal and seeking help (Arnautovska 2010). In addition, previous studies also reported that people had permissive and allowing attitudes towards suicide (Renberg and Jacobsson 2003). Prior research found that approximately one in five subjects reported a favourable attitude towards suicide as a means to end one’s life, in particular when they were confronted with a severe incurable disease (Farrow et al. 2009; Wright 2012). Research suggests differences between men and women’s attitudes toward suicide regarding: ‘‘permissiveness factor’’ for example, in the case of an individual with an incurable disease (Dahlen and Canetto 2002). Consistent with these

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findings, nearly half (48.2 %) of the men in the sample in the current study disagreed that they would consider taking their life if suffering from an incurable disease. Conversely, other studies did not indicate a difference between men and women regarding the ‘‘permissiveness factor’’ and suicide (Bhuiyan 2006). A population-based survey by National Institute of Mental Health and Neurosciences from India showed that the ratio of completed: attempted suicides were 1:8 (Gururaj et al. 2004).The few studies investigating gender differences in suicidal behaviour in Bangalore, India were based on hospital admissions. The results of this research suggested gender differences in mode and reason for suicide (Kanchan and Menezes 2008; Vishnuvardhan and Saddichha 2012). Our results were consisting with the previously noted research and suggest that a greater number of men (21.7 %) than women have attempted suicide. Our findings and previous research were contradicted by prior finding that revealed more suicidal attempts among women while men were more prone to completed suicides (Mendez-Bustos et al. 2013). In the present study, while 29.1 % of the participants accepted that their family members expressed suicidal thoughts, 19.8 % of them attempted suicides. Similarly, a recent study identified a gap between suicidal behaviours (29.1 %) and suicidal attempts (19.8 %) in India (Bertolote et al. 2005). Previous research also indicates approximately a third of those who have suicidal thoughts make suicidal plans, and roughly another third attempt suicide (Nock et al. 2008). Similar to these findings, the current study indicate that a greater number of women (31.9 %) than men report suicidal thoughts and attempts (23.3 %) among family members. Thus, creating awareness among the general population regarding suicidal thoughts and attempts among family members and others is crucial in reducing suicidal rates. Unlike the preceding research (Skruibis et al. 2010), 67.8 % of men in the current study differed with women regarding whether or not suicidal attempts were not made because of revenge or to punish someone else. Nevertheless, marital/relational problems have been frequently reported as main cause to commit suicide especially among women in Indian studies (Vijayakumar 2007). In the current study, a majority of the men opined that ‘suicide attempt is essentially a cry for help’. These findings were dissimilar to a study that pointed out women than men usually seek attention and help from others to save them from suicidal attempts (Arnautovska 2010). However in the Indian context suicide was considered as illegal and survivor would face jail term of up to 1 year and fine under Section 309 of the Indian Penal Code. From religious perspective, people in India believe that it is ‘‘sin’’ to commit suicide. Because of these reasons, majority of attempted suicides in India are reported to be accidental

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neglecting the necessary of emotional and mental health support to those who have attempted suicide. With decriminalization, not only the patients and families seek mental health care, and it will also help in improving the reporting and generation of better epidemiological data on suicidality (Ranjan et al. 2014). The majority of men agreed that most of people avoid talking about suicide. This could be due to the fact that suicide carries enormous stigma in India like in other countries (Hjelmeland et al. 2008; Knizek et al. 2011). The present study has certain limitations such as; smaller sample size, cross sectional design and restricted to urban community made difficult to generalize the findings. This urban community was selected for the present study considering logistic and feasibility reasons. Further, lack of established tool and the tool was not translated into the local language. Despite these limitations, the present study addresses several shortcomings of previous research from India, which were hospital based and focused mainly on risk factors and the prevalence of suicide. The primary strength of this study was community based random sample. The findings may be helpful in developing educational strategies to prevent suicidal attempts. Future studies need to be conducted using larger sample size and different populations across the country. Qualitative studies would be beneficial to provide further insight into suicide in Indian culture. Our study highlighted that a greater number of men attempted suicide. Furthermore, results of this study indicated that men were more optimistic that suicide is preventable and hold permissive attitudes in regard to suicide in cases of persons with incurable diseases and expressing death wishes than women. In line with previous research, women hold more tolerant attitudes toward suicide. These gender differences need to be taken into consideration when developing appropriate programs to prevent suicide. Decriminalizing the law, conducting high-quality research, and raising awareness are crucial components in changing the attitudes of the general population about suicide in developing countries. Acknowledgments contribution.

We thank all the participants for their valuable

Compliance with Ethical Standards Conflict of interest

None.

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