Socioeconomic position and suicidal behaviour in rural Sri Lanka: a prospective cohort study of 168,000+ people.

PURPOSE: Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high income countries, but this association is not established in low- and middle-income countries (LMIC). METHODS: We investigated the association of SEP with suicidal behaviour in a prospective cohort study of 168,771 Sri Lankans followed up for episodes of attempted suicide and suicide. SEP data were collected at baseline at the household and individual level at the start of the follow-up period. We used multilevel Poisson regression models to investigate the association of SEP at community, household and individual levels with attempted suicide/suicide. RESULTS: Lower levels of asset ownership [IRR (95% CI) suicide 1.74 (0.92, 3.28); attempted suicide 1.67 (1.40, 2.00)] and education [suicide 3.16 (1.06, 9.45); attempted suicide 2.51 (1.70, 3.72)] were associated with an increased risk of suicidal behaviour. The association of these measures of SEP and attempted suicide was stronger in men than women. Individuals living in deprived areas [1.42 (1.16, 1.73)] and in households with a young female head of household [1.41 (1.04, 1.93)] or a temporary foreign migrant [1.47 (1.28, 1.68)] had an elevated risk of attempted suicide. Farmers and daily wage labourers had nearly a doubling in risk of attempted suicide compared to other occupations. CONCLUSIONS: Improved employment opportunities, welfare and mental health support services, as well as problem-solving skills development, may help support individuals with poorer education, farmers, daily wage labourers, individuals in young female-headed households and temporary foreign migrant households.

Attempted suicide in Sri Lanka - An epidemiological study of household and community factors.

BACKGROUND: An individual's suicide risk is determined by personal characteristics, but is also influenced by their environment. Previous studies indicate a role of contextual effects on suicidal behaviour, but there is a dearth of quantitative evidence from Asia. METHODS: Individual and community level data were collected on 165,233 people from 47,919 households in 171 communities in rural Sri Lanka. Data were collected on individual (age, sex, past suicide attempts and individual socioeconomic position (SEP)) and household (household SEP, pesticide access, alcohol use and multigenerational households) level factors. We used 3-level logit models to investigate compositional (individual) and contextual (household/community) effects. RESULTS: We found significant variation between households 21% (95% CI 18%, 24%) and communities 4% (95% CI 3%, 5%) in the risk of a suicide attempt. Contextual factors as measured by low household SEP (OR 2.37 95% CI 2.10, 2.67), low community SEP (OR 1.45 95% CI 1.21, 1.74), and community 'problem' alcohol use (OR 1.44 95% CI 1.19, 1.75) were associated with an increased risk of suicide attempt. Women living in households with alcohol misuse were at higher risk of attempted suicide. We observed a protective effect of living in multigenerational households (OR 0.53 95% CI 0.42, 0.65). LIMITATIONS: The outcome was respondent-reported and refers to lifetime reports of attempted suicide, therefore this study might be affected by socially desirable responding. CONCLUSIONS: Our study finds that contextual factors are associated with an individual's risk of attempted suicide in Sri Lanka, independent of an individual's personal characteristics.

Is socioeconomic position associated with risk of attempted suicide in rural Sri Lanka? A cross-sectional study of 165†000 individuals.

BACKGROUND: Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high-income countries, but this association is unclear in low-income and middle-income countries. METHODS: We investigated the association of SEP with attempted suicide in a cross-sectional survey of 165 233 Sri Lankans. SEP data were collected at the household (assets, social standing (highest occupation of a household member), foreign employment and young (≤40 years) female-headed households) and individual level (education and occupation). Respondent-reported data on suicide attempts in the past year were recorded. Random-effects logistic regression models, accounting for clustering, were used to investigate the association of SEP with attempted suicide. RESULTS: Households reported 398 attempted suicides in the preceding year (239 per 100 000). Fewer assets (OR 3.2, 95% CI 2.4 to 4.4) and having a daily wage labourer (ie, insecure/low-income job; OR 2.3, 95% CI 1.6 to 3.2) as the highest occupation increased the risk of an attempted suicide within households. At an individual level, daily wage labourers were at an increased risk of attempted suicide compared with farmers. The strongest associations were with low levels of education (OR 4.6, 95% CI 2.5 to 8.4), with a stronger association in men than women. CONCLUSIONS: We found that indicators of lower SEP are associated with increased risk of attempted suicide in rural Sri Lanka. Longitudinal studies with objective measures of suicide attempts are needed to confirm this association. TRIAL REGISTRATION NUMBER: NCT01146496; Pre-results.

Fifth-year hemodynamic performance of the prima stentless aortic valve.

BACKGROUND: The medium-term hemodynamic performance of stentless valves has not been widely reported, particularly in comparison with in vitro studies. Therefore, we have assessed prospectively the hemodynamics of the Edwards Prima valve in its fifth year after implantation in the aortic position, and compared the results with those at 1 month after implantation and also with in vitro data. METHODS: Thirty-five patients (age, 77 +/- 6 years; 19 men) were prospectively studied by Doppler echocardiography at 1 month and 52 +/- 8 months after implantation of a Prima stentless valve. Valve hemodynamics were assessed by measuring the mean pressure gradient, mean valve resistance, and effective orifice area. Left ventricular systolic function was quantified by ejection fraction, the degree of hypertrophy by ventricular mass index, and the ratio of ventricular wall thickness to cavity radius as a measure of ventricular geometry. RESULTS: With a mean valve size of 24.6 +/- 2.2 mm in the fifth year after implantation, the mean pressure gradient was 6.2 +/- 3.5 mm Hg, the mean valve resistance, 29 +/- 16 dyne x s(-1) x cm(-5)), and the effective orifice area was 2.05 +/- 0.50 cm2. Compared with 1 month after operation, there was a 47% decrease in mean valve resistance (p = 0.002) and a 39% increase in effective orifice area (p = 0.001). Furthermore, both effective orifice area and mean valve resistance in the fifth year did not differ from their in vitro counterparts, whereas the left ventricular ejection fraction (0.64 +/- 0.14), the left ventricular mass index (119 +/- 49 g/m2), and the ratio of ventricular wall thickness to cavity radius (0.44 +/- 0.13) were within the normal range. CONCLUSIONS: This study suggests that the Prima valve is a reliable stentless aortic bioprosthesis. This is supported by a favorable medium-term clinical outcome, durable hemodynamic performance, and normal mean values of left ventricular ejection fraction and mass index in the fifth year after implantation.

Motivations relating to family planning in Sri Lanka.

PIP: Indifference to family planning in Sri Lanka stems from a number of institutional factors. Family planning advocates in Sri Lanka constitute a small group of Westernized individuals who are alienated from the traditional cultural patterns of Sri Lanka society. The majority of Sri Lanka se. In traditional Sinhalese culture 1) marriages were easily dissolved; 2) fidelity was not highly valued; 3) polyandrous marriages were relatively common; 4) large families were desired; and 5) abortion and infanticide were practiced. Although the traditional culture is no longer intact, many low income Sinhalese still adhere to some elements of traditional culture and most still want to have large families. In recent years, some of the inhabitants of Sri Lanka became westernized, and most of these individuals now constitute the middle class. The middle class adopted an extremely rigid morality which they have attempted to impose on the lower class Sinhalese. The middle class tends to oppose abortion and fears that contraceptive availability will lead to promiscuous behavior. Both the middle and lower classes tend to associatefamily planning with the Tamil segment of the population. The Tamil immigrated to Sri Lanka from India, and their presence and power have always been resented and feared by theSinhalese. Many Sinhalese believe that family planning is a politically motivated attempt on the part of the Tamil to reduce the number of Sinhalese in the population. Although family planning is integrated into the government's maternal and child welfare program, resistance to family planning, especially among the lower classes, remains high. At the present time only 19% of all married women less than 50 years old practice contraception. The national family program made only a minor contribution to the recently observed decline in the fertility rate. The major factor involved in the decline was a growing pattern of delayed marriage.^ieng