Regional variation in suicide rates in Sri Lanka between 1955 and 2011: a spatial and temporal analysis

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Abstract

Background

Between 1955 and 2011 there were marked fluctuations in suicide rates in Sri Lanka; incidence increased six-fold between 1955 and the 1980s, and halved in the early 21st century. Changes in access to highly toxic pesticides are thought to have influenced this pattern. This study investigates variation in suicide rates across Sri Lanka’s 25 districts between 1955 and 2011. We hypothesised that changes in the incidence of suicide would be most marked in rural areas due to the variation in availability of highly toxic pesticides in these locations during this time period.

Methods

We mapped district-level suicide rates in 1955, 1972, 1980 and 2011. These periods preceded, included and postdated the rapid rise in Sri Lanka’s suicide rates. We investigated the associations between district-level variations in suicide rates and census-derived measures of rurality (population density), unemployment, migration and ethnicity using Spearman’s rank correlation and negative binomial models.

Results

The rise and fall in suicide rates was concentrated in more rural areas. In 1980, when suicide rates were at their highest, population density was inversely associated with area variation in suicide rates ( r = −0.65; p < 0.001), i.e. incidence was highest in rural areas. In contrast the association was weakest in 1950, prior to the rise in pesticide suicides ( r = −0.10; p = 0.697). There was no strong evidence that levels of migration or ethnicity were associated with area variations in suicide rates. The relative rates of suicide in the most rural compared to the most urban districts before (1955), during (1980) and after (2011) the rise in highly toxic pesticide availability were 1.1 (95% CI 0.5 to 2.4), 3.7 (2.0 to 6.9) and 2.1 (1.6 to 2.7) respectively.

Conclusions

The findings provide some support for the hypothesis that changes in access to pesticides contributed to the marked fluctuations in Sri Lanka’s suicide rate, but the impact of other factors cannot be ruled out.

Related collections

Most cited references 26

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Is Open Access

The global distribution of fatal pesticide self-poisoning: Systematic review

David Gunnell, Michael Eddleston, Michael R Phillips … (2007)

Background Evidence is accumulating that pesticide self-poisoning is one of the most commonly used methods of suicide worldwide, but the magnitude of the problem and the global distribution of these deaths is unknown. Methods We have systematically reviewed the worldwide literature to estimate the number of pesticide suicides in each of the World Health Organisation's six regions and the global burden of fatal self-poisoning with pesticides. We used the following data sources: Medline, EMBASE and psycINFO (1990–2007), papers cited in publications retrieved, the worldwide web (using Google) and our personal collections of papers and books. Our aim was to identify papers enabling us to estimate the proportion of a country's suicides due to pesticide self-poisoning. Results We conservatively estimate that there are 258,234 (plausible range 233,997 to 325,907) deaths from pesticide self-poisoning worldwide each year, accounting for 30% (range 27% to 37%) of suicides globally. Official data from India probably underestimate the incidence of suicides; applying evidence-based corrections to India's official data, our estimate for world suicides using pesticides increases to 371,594 (range 347,357 to 439,267). The proportion of all suicides using pesticides varies from 4% in the European Region to over 50% in the Western Pacific Region but this proportion is not concordant with the volume of pesticides sold in each region; it is the pattern of pesticide use and the toxicity of the products, not the quantity used, that influences the likelihood they will be used in acts of fatal self-harm. Conclusion Pesticide self-poisoning accounts for about one-third of the world's suicides. Epidemiological and toxicological data suggest that many of these deaths might be prevented if (a) the use of pesticides most toxic to humans was restricted, (b) pesticides could be safely stored in rural communities, and (c) the accessibility and quality of care for poisoning could be improved.

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Self poisoning with pesticides.

Michael Eddleston, Michael R Phillips (2004)

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The impact of pesticide regulations on suicide in Sri Lanka.

Thilini Fernando, M Hewagama, W Priyangika … (2007)

Between 1950 and 1995 suicide rates in Sri Lanka increased 8-fold to a peak of 47 per 100,000 in 1995. By 2005, rates had halved. We investigated whether Sri Lanka's regulatory controls on the import and sale of pesticides that are particularly toxic to humans were responsible for these changes in the incidence of suicide. Ecological analysis using graphical and descriptive approaches to identify time trends in suicide and risk factors for suicide in Sri Lanka, 1975-2005. Restrictions on the import and sales of WHO Class I toxicity pesticides in 1995 and endosulfan in 1998, coincided with reductions in suicide in both men and women of all ages. 19,769 fewer suicides occurred in 1996-2005 as compared with 1986-95. Secular trends in unemployment, alcohol misuse, divorce, pesticide use and the years associated with Sri Lanka's Civil war did not appear to be associated with these declines. These data indicate that in countries where pesticides are commonly used in acts of self-poisoning, import controls on the most toxic pesticides may have a favourable impact on suicide. In Asia, there are an estimated 300,000 deaths from pesticide self-poisoning annually. National and international policies restricting the sale of pesticides that are most toxic to humans may have a major impact on suicides in the region.

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Author and article information

Contributors

Duleeka W. Knipe: dee.knipe@bristol.ac.uk

Prianka Padmanathan:

ORCID: http://orcid.org/0000-0003-1292-6575

prianka.padmanathan@bristol.ac.uk

Lal Muthuwatta: l.mutuwatte@cgiar.org

Chris Metcalfe: chris.metcalfe@bristol.ac.uk

David Gunnell: d.j.gunnell@bristol.ac.uk

Journal

Journal ID (nlm-ta): BMC Public Health

Journal ID (iso-abbrev): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-2458

Publication date (Electronic): 14 February 2017

Publication date PMC-release: 14 February 2017

Publication date Collection: 2017

Volume: 17

Electronic Location Identifier: 193

Affiliations

[1 ]ISNI 0000 0000 9816 8637, GRID grid.11139.3b, South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, , University of Peradeniya, ; Peradeniya, Sri Lanka

[2 ]ISNI 0000 0004 1936 7603, GRID grid.5337.2, School of Social and Community Medicine, , University of Bristol, ; Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK

[3 ]ISNI 0000 0001 0662 2351, GRID grid.419368.1, , International Water Management Institute, ; 127, Sunil Mawatha, Pelawatt, Battaramulla, Sri Lanka

Author information

Prianka Padmanathan http://orcid.org/0000-0003-1292-6575

Article

Publisher ID: 3961

DOI: 10.1186/s12889-016-3961-5

PMC ID: 5310090

PubMed ID: 28196502

SO-VID: 19ed1a3c-e36b-4092-bccd-308d5a20b547

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 24 December 2015

Date accepted : 17 December 2016

Custom metadata

ScienceOpen disciplines: Public health

Keywords: suicide,pesticides,sri lanka,spatial,temporal,regional,socioeconomic,poisoning,epidemiology

Data availability:

ScienceOpen disciplines: Public health

Keywords: suicide, pesticides, sri lanka, spatial, temporal, regional, socioeconomic, poisoning, epidemiology