Implementation of a comprehensive surveillance system for recording suicides and attempted suicides in rural India

Abstract

IntroductionWHO reports that 78 of the 140 low-income and middle-income countries (LMICs) do not have a registration system for suicides and attempted suicides. Absence of data on suicide and attempted suicide in LMICs, which account for 79% of suicides worldwide, is a major impediment in understanding the magnitude of the problem and formulating prevention strategies to reduce suicide and self-harm. A comprehensive surveillance system has the potential to address this data gap. The objective of this study is to describe the development of a comprehensive surveillance system in rural India by adding a community based component and reflect on its added value in obtaining data on suicide and attempted suicide compared with relying only on hospital and police records.MethodThe comprehensive system consists of three components. Community surveillance involved collecting information on suicides and attempted suicides from third party key informants such as village heads, teachers, priests, shopkeepers, private physicians, private hospitals and community health workers. The second component consisted of data from public health facilities. The final component consisted of suicide data from police records. Information was collected for a period of 12 months from August 2018 to July 2019 from 116 villages (population 377 276) in Gujarat, India.ResultsAn average of 710 community informants were interviewed each month (mean: 6.72 informants per village). The community surveillance system identified 67 cases of suicide compared with 30 cases by hospital and police records (Cochran’s Q test 67.9 p<0.01) and 70 attempted suicides compared with 51 from the hospital and police records (Cochran’s Q test 66.6 p<0.01).DiscussionThis is the first report of implementing a large-scale comprehensive surveillance system for suicide and attempted suicide in a LMIC. The combination of community surveillance system and official data from hospital and police records addresses the problem of under-reporting of suicide and suicide attempts in India and other LMIC.

Public health surveillance through community health workers: a scoping review of evidence from 25 low-income and middle-income countries

“… 39 Although most studies focused on specific infectious diseases including HIV/AIDS, 20 malaria, 15 18 37–39 tuberculosis (TB), 16 19 Ebola, 12 neglected tropical diseases (NTDs) 13 24 26 and COVID-19, 34 others focused on maternal and child health, 14 25 29–32 35 general health/overall mortality 17 21 23 33 and specific outcomes such a suicide. 28 Once data charting was completed, we synthesised results by identifying the most commonly described roles, challenges and impacts and categorised these based on similarity. For example, among included studies, we grouped together roles related to data, engaging with communities, health education and those connected to testing and treatment.…”

“…Drawing on innovative approaches for capturing data that might otherwise go unreported such as verbal autopsy, 42 the routine integration of CHWs in surveillance systems has the potential to provide data beyond the traditional maternal and child health outcomes to include data on outcomes such as suicide. 28 …”

“… 21 In other cases, CHWs may find themselves in uncomfortable positions because while their closeness to the community allows them to share their lived experience and better connect with community members, they may also be perceived as ‘informants’ in their surveillance work. 28 In some cases as well, CHWs may find themselves in high-risk situations where community members refuse to cooperate with them or resist their attempts at data gathering or sample collection. 19 Across the multiple cultural contexts of included studies, challenges related to community engagement often emerged in rural contexts compared with urban contexts thus requiring CHW cultural competence to navigate.…”

“… 24 In cases where CHWs have the capacity to test and treat, they have effectively not only provided information to aid surveillance but successfully ended outbreaks as in the case of malaria outbreaks in Santo Domingo. 39 For data that are often extremely hard to find in LMIC contexts such as suicide data 28 and data on injuries, 33 the use of CHWs has played a role in providing such critical information for health systems while ensuring that those in rural and remote communities are included in such surveillance. 29 31 CHWs’ community engagement skills also help to facilitate cooperation from community members leading to effective surveillance and the sustainability of public health surveillance efforts.…”

Suicidal ideation and behavior in youth in low- and middle-income countries: A brief review of risk factors and implications for prevention

“…Moreover, the misclassification of deaths and limited accessibility to emergency health services disproportionately affect young women in LMICs ( 80 ). Where the registration system is lacking, more effective community surveillance systems are essential to better understand patterns of suicide attempts across different LMIC settings ( 81 , 82 ). This approach harnesses community action through building community capacity, while pragmatically recognizing the finite health resources in LMICs.…”