Development and evaluation of communication interventions to prevent suicidal attempts (Phrase l) (in Thai language)

This study is the first stage under the project of development and evaluation concerning the effectiveness of measures to prevent self-harm in Thailand. The problem conditions, involved factors, signals prior to self-harm and measures to prevent self-harm in selected province were studied. The study results illustrate the problems of inaccessibility to medical services and social assistance of people with mental health problems, lack of knowledge, understanding and awareness as well as skill in observing the physical signs of people who should be helped.

This study recommended three measures: 1) the development of a communication pattern to assemble knowledge, understanding and awareness in mental health problems and signals prior to self-harm, as well as skill in observation and assistance, 2) the development of a manual for community leaders and healthcare volunteers that would increase communication and allow them to work more closely together, and 3) the development of a well publicized and serviceable telephone counseling hotline system that is readily available to the public in their area.

  Background: Suicidal action is a considerable health problem in Thailand. In 2009, 3,634 completed suicides were reported by the Department of Mental Health (DMH); this is approximately 5.7 per 100,000 of the population. Most of these cases were members of the labour force aged between 30 and 40 years of age; this consequently created a huge economic loss for the country.   The DMH has continually initiated and implemented a number of interventions aimed at preventing and controlling the problems. As a result, the rate of completed suicides during 2001-2009 declined. However, focusing on specific areas, the overall rate is still high (approx. 15 per 100,000 of the population). Moreover, an assessment of the effectiveness of the interventions, which is crucial for the selection and allocation of resources for the prevention and control of suicidal actions, has never been performed. In order to design a decent evaluation study, a formative research to explore and understand current problems and contexts at a community level is suggested.   Objectives: This is the first sub-study of a research for the development and evaluation of effective interventions for suicide prevention, aiming to explore existing problems and factors related to suicidal actions at both individual community and health facility levels; it also endeavors to discover suicide warning signs and stakeholders’ views towards suicidal actions as well as suggestions for appropriate suicide prevention strategies at a community level. This information will be used to formulate recommendations for the development of a suitable intervention package, which will then be implemented and evaluated in the subsequent studies.   Methods: Researchers considered completed suicide profiles over a 5-year period (2005-2009) and found that the highest suicide rate was observed in Lumphun province. Thus, two communities from a district with a high rate of completed suicides in the province were selected as study areas. Apart from the rate of completed suicides, geographical matters and cooperation from local people were taken into account in the selection of the study area. Qualitative and quantitative research approaches were employed. The process consisted of (1) a review of suicidal action profiles and a study of the communities’ basic information from secondary sources; (2) a community study including informal interviews, direct observations, and participation in community activities; (3) a questionnaire survey; (4) in-depth interviews with attempted suicide cases and high-risk suicide cases, and with close friends/relatives of completed suicides, attempted suicide cases, and the high-risk group; and (5) focus group discussions among health volunteers, community members and leaders.  The field work was carried out from November 2010 to January 2011.   Findings: Inaccessibility to healthcare services and social support are significant burdens for people with mental health problems. A lack of awareness and understanding of this health problem and the skills to screen and refer patients to health facilities among health volunteers, community members and leaders was observed. Diagnosing the problems with medical technologies seemed to be very difficult due to the nature of the health condition; moreover, it is impossible and impractical for medical doctors to play an active role in monitoring the problem. Therefore family members and close friends are the most suitable gate keepers to monitor, screen, diagnose and refer cases to health professionals. Findings concerning the factors related to the suicidal actions from these communities were not different from those of former studies and fit appropriately with the suicide factors framework, which consists of social-related factors, i.e. social norms, cultures and lifestyle behaviours, supporting factors for suicidal actions, risk behaviours, and stimulating factors. The availability of alcohol, its consumption, and people’s drinking patterns were also significant factors.   Suicide warning signs discovered from this study were also in line with the findings of previous studies. The warning signs in this study were divided according to four communication types: direct verbal communication, e.g. informing family members of planned suicidal action; indirect verbal communication, e.g. asking family members to help complete outstanding responsibilities or saying goodbye; direct non-verbal communication, e.g. preparing the means for suicidal actions; and indirect non-verbal communication, e.g. wearing new outfits for preparation of death. Although a number of signs were presented, most family members/close friends did not recognize them so preventive actions were not performed. It was also found that suicidal actions occurred within 24 hours of the signs being communicated.   Recommendations: In response to the main findings, i.e. inaccessibility to healthcare services and a lack of awareness and skills to deal with the situation when people with mental health problems are diagnosed, three recommendations are proposed: (1) to create a strategy and means of communication, e.g. the use of local public announcements, radio or other means to educate and provide information to community members, that provide information including warning signs, guidelines for dealing with depression and suicidal cases, a mental health hotline, and tips for stress management; (2) to develop supporting tools for health volunteers and community leaders, e.g. guidelines for the management of mental health problem cases that are coherent with existing health professional guidelines as well as suitable for the community context and able to respond to the different needs of local people; and (3) to improve and promote mental health hotline systems.