women, suicide and culture in tajikistan: identifying and addressing correlated factors presented...
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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
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Alisher Latypov, MA, MHSCountry Program Director
Global Program on PsychiatryTajikistan
Irene Jillson, Ph.D.Adjunct Assistant Professor
Georgetown University School of Nursing and Health Studies
Washington, [email protected]
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UzbekistanKyrgyzstan
ChinaKhojent
Dushanbe
SOGD R
EGIO
N
GORNO-BADAKHSHAN
Afghanistan
HATLON REGION Khorog
Kurgan-Tube
RepublicRepublic ofof TajikistanTajikistan
Afghanistan
Uzb
ekis
tan
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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
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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
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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
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WHAT IS KNOWN ABOUT FEMALE SUICIDE IN
TAJIKISTAN?
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"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)
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RESPONSES FROM RESPONSES FROM HEALTH CARE HEALTH CARE
PROVIDERS AT THE PROVIDERS AT THE REPUBLICAN BURN REPUBLICAN BURN
CENTERCENTER
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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
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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
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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
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METHODS OF ATTEMPTED METHODS OF ATTEMPTED SUICIDESUICIDE
Significant differences by rural/urban areas:
Rural: self-immolation and drowning
Urban: gas, overdosing on medications
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IN THEIR OWN WORDS: IN THEIR OWN WORDS: TAJIK WOMEN’S TAJIK WOMEN’S
EXPERIENCE WITH EXPERIENCE WITH ATTEMPTED SUICIDEATTEMPTED SUICIDE
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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
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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)
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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
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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.
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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
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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.
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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
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PROPOSED APPROACHES TO SUICIDE PREVENTION
IN LOW-INCOME COUNTRIES
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Developing/adapting brief screening instruments (ensuring language and cultural relevance)
Developing/adapting practical, evidence-based approaches to treatment of mental health disorders
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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
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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
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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
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PROPOSED APPROACHES TO EVALUATING SUICIDE
PREVENTION TO ELICIT CULTURALLY APPROPRIATE, EVIDENCE- BASED PRACTICE
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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
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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
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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