Association of socio-economic position and suicide/attempted suicide in low and middle income countries in South and South-East Asia - a systematic review

Abstract

Background: Forty percent of the world's suicide deaths occur in low and middle income countries (LAMIC) in Asia. There is a recognition that social factors, such as socioeconomic position (SEP), play an important role in determining suicidal risk in high income countries, but less is known about the association in LAMIC.

Methods: The objective of this systematic review was to synthesise existing evidence of the association between SEP and attempted suicide/suicide risk in LAMIC countries in South and South East Asia. Web of Science, MEDLINE, MEDLINE in Process, EMBASE, PsycINFO, and article reference lists/forward citations were searched for eligible studies. Epidemiological studies reporting on the association of individual SEP with suicide and attempted suicide were included. Study quality was assessed using an adapted rating tool and a narrative synthesis was conducted.

Results: Thirty-one studies from nine countries were identified; 31 different measures of SEP were reported, with education being the most frequently recorded. Most studies suggest that lower levels of SEP are associated with an increased risk of suicide/attempted suicide, though findings are not always consistent between and within countries. Over half of the studies included in this review were of moderate/low quality. The SEP risk factors with the most consistent association across studies were asset based measures (e.g. composite measures); education; measures of financial difficulty and subjective measures of financial circumstance. Several studies show a greater than threefold increased risk in lower SEP groups with the largest and most consistent association with subjective measures of financial circumstance.

Conclusion: The current evidence suggests that lower SEP increases the likelihood of suicide/attempted suicide in LAMIC in South and South East Asia. However, the findings are severely limited by study quality; larger better quality studies are therefore needed.

Systematic review registration: PROSPERO 2014: CRD42014006521.

Fig. 1

Flow chart showing the selection of papers for inclusion in the systematic review. ^aRecords screened by two study authors. ^b142 articles not meeting the inclusion criteria based on the title/abstract screen were checked for eligibility by two study authors. An additional eligibility check was done on 157 papers by a single study author. ^cThere were 3 multi-country publications [–32], resulting in 7 studies

Fig. 2

Forest plots of studies reporting on composite measures of SEP and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam Study design: C – Cohort; CC – Case-Control; X – Cross-sectional Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case-control/cross-sectional studies report odds ratios. *Highest wealth quintile

Fig. 3

Forest plots of studies reporting on access to or ownership of assets and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam Study design: C – Cohort; CC – Case-Control; X – Cross-sectional Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case-control/cross-sectional studies report odds ratios. **Exposure group

Fig. 4

Forest plots of studies reporting on household construction and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam Study design: C – Cohort; CC – Case-Control; X – Cross-sectional Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case-control/cross-sectional studies report odds ratios

Fig. 5

Forest plot of studies reporting on number of years of education and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam. Study design: C – Cohort; CC – Case– control; X – Cross-sectional. Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide. ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case–control/cross-sectional studies report odds ratios

Fig. 6

Forest plot of studies reporting on highest educational qualification and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam. Study design: C – Cohort; CC – Case– control; X – Cross-sectional. Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide. ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case–control/cross-sectional studies report odds ratios

Fig. 7

Forest plot of studies reporting on unemployment and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam. Study design: C – Cohort; CC – Case–control; X – Cross-sectional. Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide. ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case–control/cross-sectional studies report odds ratios

Fig. 8

Forest plot of studies reporting on different occupation types and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam. Study design: C – Cohort; CC – Case–control; X – Cross-sectional. Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide. ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case–control/cross-sectional studies report odds ratios

Fig. 9

Forest plot of studies reporting on income and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam. Study design: C – Cohort; CC – Case–control; X – Cross-sectional. Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide. ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case–control/cross-sectional studies report odds ratios

Fig. 10

Forest plot of studies reporting on financial difficulty and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam. Study design: C – Cohort; CC – Case–control; X – Cross-sectional. Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide. ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case–control/cross-sectional studies report odds ratios

Fig. 11

Forest plot of studies reporting on subjective measures of financial circumstance and suicide/attempted suicide risk. Country: Bang – Bangladesh; Indon – Indonesia; Pak –Pakistan; Phil – Philippines; SL – Sri Lanka; Thai – Thailand; Viet – Vietnam. Study design: C – Cohort; CC – Case–control; X – Cross-sectional. Outcome: A – Attempted suicide only; S – Suicide only; AS – Attempted suicide and suicide. ES: Cohort studies report estimates of relative risk (except for Maselko (2008) which reports odds ratios), and case–control/cross-sectional studies report odds ratios