women, suicide and culture in tajikistan: identifying and addressing correlated factors presented...

WOMEN, SUICIDE AND WOMEN, SUICIDE AND CULTURE IN TAJIKISTAN: CULTURE IN TAJIKISTAN:

IDENTIFYING AND IDENTIFYING AND ADDRESSING CORRELATED ADDRESSING CORRELATED

FACTORSFACTORSPresented at:Presented at:

American Public Health Association American Public Health Association 133d Annual Meeting133d Annual Meeting

Philadelphia, PennsylvaniaPhiladelphia, PennsylvaniaDecember 10-14, 2005December 10-14, 2005

Alisher Latypov, MA, MHSCountry Program Director

Global Program on PsychiatryTajikistan

alytypov@gip-global.org

Irene Jillson, Ph.D.Adjunct Assistant Professor

Georgetown University School of Nursing and Health Studies

Washington, D.C.iaj@georgetown.edu

UzbekistanKyrgyzstan

ChinaKhojent

Dushanbe

SOGD R

EGIO

N

GORNO-BADAKHSHAN

Afghanistan

HATLON REGION Khorog

Kurgan-Tube

RepublicRepublic ofof TajikistanTajikistan

Afghanistan

Uzb

ekis

tan

STUDY RESEARCHERS, STUDY RESEARCHERS, LOCATION, AND TIMINGLOCATION, AND TIMING

Study conducted voluntarily by Dr. Alisher Lytypov

and Dr. Irene Jillsonin Dushanbe, Tajikistan and

surrounding rural areasin 2004

STUDY PURPOSESTUDY PURPOSELong-range: to design cost-effective,

community-based prevention approachesShort-term:

To explore the reasons for suicide generally and self-immolation specifically among women in Tajikistan

To explore use of a qualitative approach to exploring this sensitive topic in Tajikistan

STUDY METHODSSTUDY METHODSQualitative, includingSemi-structured interviews conducted with

6 health providers at a major burn treatment facility in Dushanbe

15 women attending a health clinic in Dushanbe

Review of available policy and other documents

WHAT IS KNOWN ABOUT FEMALE SUICIDE IN

TAJIKISTAN?

"Every month, about 30 women are taken to a Dushanbe hospital with severe burns from such suicide attempts." (Shabad, 1998)

“47 people killed themselves in the Sogd region in the first 6 months of 2003…”

“The average age of suicides is falling, with most victims typically between 14 and 26 years of age, and women account for the vast majority; many of them are cases of self-immolation.” (Zokirova, 2003)

RESPONSES FROM RESPONSES FROM HEALTH CARE HEALTH CARE

PROVIDERS AT THE PROVIDERS AT THE REPUBLICAN BURN REPUBLICAN BURN

CENTERCENTER

REPORTED ATTEMPTED CASES REPORTED ATTEMPTED CASES IN RECENT PASTIN RECENT PAST

Women attempting suicide presenting to the Dushanbe Burn Center in Dushanbe:

• 45 cases in 2001 • 60 cases in 2002 • 48 cases in 2003• between 15 and 20 cases during the

first 5 months of 2004

RESPONSE OF HEALTH CARE RESPONSE OF HEALTH CARE SYSTEMSYSTEM

Few mental health services at any level

Few mental health providersMinimal training of physicians

and nurses to respond to attempted suicides in villages

Minimal prevention services

PROFILE OF DOCUMENTED CASES PROFILE OF DOCUMENTED CASES OF ATTEMPTED SUICIDEOF ATTEMPTED SUICIDE

Agebetween 16 and mid-30s

Education8 attended or completed university

education5 completed 8th grade or less2 completed high school

Rural and urban residents

METHODS OF ATTEMPTED METHODS OF ATTEMPTED SUICIDESUICIDE

Significant differences by rural/urban areas:

Rural: self-immolation and drowning

Urban: gas, overdosing on medications

IN THEIR OWN WORDS: IN THEIR OWN WORDS: TAJIK WOMEN’S TAJIK WOMEN’S

EXPERIENCE WITH EXPERIENCE WITH ATTEMPTED SUICIDEATTEMPTED SUICIDE

PERSONAL EXPERIENCE WITH SUICIDEPERSONAL EXPERIENCE WITH SUICIDEAll of the respondents have either attempted

suicide or have had suicidal thoughtsAll of the respondents

personally know at least one woman who has committed suicide and several know more than one;

live in a community in which at least one woman has committed suicide; for several, more than one woman has done so

PERCEPTION PERCEPTION OF REASONS THAT OF REASONS THAT WOMEN COMMIT SUICIDEWOMEN COMMIT SUICIDE

Domestic violence, polygamyFinancial problems/unemployment of

husbandsProblems with mother-in-law/sister(s)-in-

law

Adultery (cheating)

PERCEPTION PERCEPTION OF REASONS THAT OF REASONS THAT WOMEN COMMIT SUICIDEWOMEN COMMIT SUICIDE

Alcohol abuseMental disordersAmong young girls, when their

boyfriend has sex with them, promising to marry, but does not keep his word

“copycatting” other women’s example (social learning)*

*Identified by providers at Burn Center

PERCEPTION PERCEPTION OF REASONS THAT OF REASONS THAT WOMEN COMMIT SUICIDEWOMEN COMMIT SUICIDE

General Feelings Of Unhappiness and lack of resources/services for care most women

do nothing, use “self-care” (e.g., listening to

music, talking with friends), or go to a local healer

none had been to a trained “modern” health provider.

REASONS REASONS FOR SUICIDE OF FOR SUICIDE OF FRIEND/COMMUNITY MEMBERSFRIEND/COMMUNITY MEMBERS

Marital discord/problems/arranged marriagethe husband had married “a second

wife”friend had epilepsy; when she was 15

her parents arranged her marriage to a relative

REASONS REASONS FOR SUICIDE OF FOR SUICIDE OF FRIEND/COMMUNITY MEMBERSFRIEND/COMMUNITY MEMBERS

Economic situation/family problemsA woman in the village committed suicide

because there was no money to buy food, her husband migrated to Russia to find a job, but he married another woman there and was not sending money back home to Tajikistan.

Social stricturesOne of the respondent’s best friends

committed suicide, leaving a note saying that she did it because her family was too strict with her.

HOPE FOR THE FUTUREHOPE FOR THE FUTURE

Most respondents said that they did not know about the future.

Those who commented on the future were negative in terms of both their own future and that of women in Tajikistan generally

PROPOSED APPROACHES TO SUICIDE PREVENTION

IN LOW-INCOME COUNTRIES

Developing/adapting brief screening instruments (ensuring language and cultural relevance)

Developing/adapting practical, evidence-based approaches to treatment of mental health disorders

Training community health workers, primary care physicians and nurses in detection and screening and early intervention techniques

Certifying competency of providers to address needs of both genders and all ages

Collecting data to ensure national-level awareness of problem and serve as basis for policy formulation

Ensuring systems in place to protect confidentiality of women seeking prevention/treatment

Integrating mental health/suicide prevention and care with primary care

Creating a network of community-based mental health services, assuring availability of quality (and safe) services at all levels

Convening community-based groups to discuss contributing factors in the community that can be addressed at the community, regional and national level

PROPOSED APPROACHES TO EVALUATING SUICIDE

PREVENTION TO ELICIT CULTURALLY APPROPRIATE, EVIDENCE- BASED PRACTICE

Use of mixed method, participatory evaluation Develop/adapt language and

culturally-appropriate semi-structured instrument to assess services relevant to suicide prevention, and treatment of those who have

attempted suicide

Develop standard protocol to conduct ethnographic interviewsgatherings of women (focus

groups)contextual analysis of immediate

and surrounding community(ies)Training and engagement of

community health workers to conduct interviews

Engage health and social service decision-makers, providers and community members in evaluation process

Develop process for use of data/information in planning for health and social servicesaddressing socio-economic issues that

are co-factors in the suicide epidemic