Mehran Rostami|Abdollah Jalilian|Ramin Rezaei-Zangeneh|Arash Salari
Factors associated with the choice of suicide method in Kermanshah Province, Iran
Kermanshah University of Medical Sciences|Razi University|Kermanshah University of Medical Sciences|Iranian Legal Medicine Organization
original articlefactors associated choice suicide method kermanshah province iran mehran rostami abdollah jalilian ramin rezaeizangeneh arash salari mehran rostami deputy treatment kermanshah university medical sciences kermanshah iran abdollah jalilian department statistics razi university kermanshah iran ramin rezaeizangeneh deputy treatment kermanshah university medical sciences kermanshah iran arash salari member legal medicine research center iran kermanshah provincegeneral office legal medicine kermanshah iran published online4 feb 2016httpsdoiorg1051440256494720167sectionspdf toolsadd favoritesdownload citationtrack citations shareshare onfacebooktwitterlinked inredditemail aboutabstractbackground identification factors choice suicide methods important understanding phenomenonobjectives aimed quantify effect gender age living area education level marital status choice suicide method among residents kermanshah province west irandesign crosssectional study completed suicides march 2006 september 2013setting kermanshah province iranmethods data extracted suicide forms electronic files forensic medicine organization total 1901 1138 men suicide cases identified preliminary analysis multinomial logistic model fitted data test quantify impact influential factor choice suicide method relative risk suicide method hanging reference method estimated calculating relativerisk ratios multinomial logistic modelmain outcome measures relative risk suicide selfimmolation drug toxic poisoning firearmsresults found women higher relative risk men suicide selfimmolation intentional drug poisoning toxic poisoning relative risk suicide selfimmolation intentional drug poisoning higher urban residents young individuals hand men rural residents higher relative risk suicide firearmconclusion kermanshah province impact rapid social changes women availability firearms rural areas drugs urban households require attention suicide prevention planninglimitations lack data prevented analysis factors may influential choosing suicideintroductionsuicide complex multifaceted public health problem one leading causes death worldwide12 global burden disease studies predict death selfinflicted injury move 17th 2002 14th place 2030 ranking global mortality3 suicide one major causes disabilityadjusted life years dalys iran showed increasing trend 1990 201045 addition substantial heterogeneities reported distribution suicide rate method suicide across provinces iran suicide prevalent western provinces67 example kermanshah province populated western province iran 1374 per 100 000 population second highest suicide mortality rate country6although hanging predominant method suicide countries preferred suicide methods vary across globe national subnational levels due cultural economic social differences289 instance available culturally favorable suicide methods asian countries show different pattern western countries10 general availability accessibility popularity socioacceptability211 mental health problems1214 seem major determinants choice suicide method also studies show demographic variables gender age group education level significantly influence choice suicide method1517 one opportunities suicide prevention identification effective factors choice suicide method area91113 fact improved knowledge risk protective factors choice suicide method guide prevention planning decisionmakingthe main aim study investigate gender age living area education level marital status influence choice suicide method among residents kermanshah province march 2006 september 2013 particularly interested identifying significant risk protective factors choice suicide method ito raise community awareness guide prevention planning decisionmakingmethodsstudy populationkermanshah province located west iran among provinces low socioeconomic status6 estimated unemployment rate 105 contribution countrys gross domestic product 17 201318 area 24 998 square kilometers 14 counties 31 cities towns 86 rural districts19 based 2011 census population housing conducted every 10 years statistical center iran population province 1 945 227 residents 26 iranian population mainly kurdish ethnic background urbanization rate approximately 7019 younger people largest group population 55 population age 30 figure 1 province still suffers post iraniraq war trauma social dislocation undergoing rapid urbanization social transformationfigure 1 population pyramid kermanshah province according 2011 census population housingdownload figurestudy designthis crosssectional study completed suicides kermanshah province 90month study period march 2006 september 2013 anonymized deidentified completed suicide data study extracted electronic file provincial forensic medicine organization fmo suicide forms encoded according international classification diseases tenth revision icd10 according iranian law reported suspected suicide cases need examined certificated forensic pathologist certificates must registered fmo20 thus quality registered suicide data considered reliable included study identified cases born resided kermanshah province excluded cases reside province autopsy tests forensic pathologist indicated cause death suicidemeasuresfor case birth certificate id book source demographic variables reported fmo suicide registration forms gender male female age group 1019 2029 3039 40 years living area rural urban marital status never married married others education level illiterate primarymiddle school high schooldiploma university degree significant parent partner relative friend knew subject well source recoding fmocompleted suicide forms others category marital status included cases widowed divorced separated unspecified marital status age structure population fact majority iranian suicide victims age 30 years21 age categorized 1019 2029 3039 40 years data occupational status cases inaccurate large number missing values reason although occupational status important factor include set demographic factors purpose study suicide methods categorized 1 hanging 2 intoxication poisoning toxic poisoning 3 intentional drugpoisoning 4 selfimmolation 5 firearms 6 methods methods category included relatively uncommon suicide methods suicide wristcutting jumping height drowning gassing unspecified means thus methods category contains less violent less lethal methods missing data demographic factors cases negligible less 10 records thus analyses performed available datathe burial permit name surname deceased removed dataset analysis comply ethical concerns anonymity informed consent unnecessary private information deceased used analysisstatistical analysiswe considered choice suicide method response dependent variable possibly influenced demographic factors gender living area age group marital status education level begin used likelihoodratio chisquare test independence examine pairwise association response variable demographic factors12 constructed suitable statistical model explore relationship response variable influential factors relativerisk ratio choosing selfimmolation hanging based gender females relative males isand based living area urban residents relative rural residents issince response variable choice suicide method categorical unordered used multinomial logistic regression also known polytomous logistic regression model examine effect influential factor choice suicide method adjusting influential factors22 hanging favored method suicide chosen genders chosen baseline reference category response variable multinomial model based fitted multinomial logistic regression model relativerisk ratio rrr demographic factor choice suicide methods hanging estimated moreover 95 confidence intervals relativerisk ratios p values null hypothesis obtained23 analyses study conducted using stata se version 12 stata corp college station tx usa 2011 significant level p value05resultsa total 1901 1138 men 763 women cases identified 75year study period 115 maletofemale ratio age range 10 96 years old table 1 study period 2006 2013 chosen confirmed suicide data available authors years time conducting study common suicide method men women hanging 417 followed selfimmolation 259 intentional drug poisoning 125 hanging firearms military rifles majority cases frequent among men selfimmolation hanging frequent among women figure 2 age group 2029 years peak age range suicide methods except methods category figure 3 reflects depth youth suicide issue province2124figure 2 proportions suicide methods males femalesdownload figurefigure 3 proportions suicide methods among different age groupsdownload figuretable 1 distribution number percentage completed suicide cases kermanshah province suicide method demographic factorshanging n793n selfimmolation n493n drugpoisoning n237n firearms n210n toxicpoisoning n123n others n45n gendermale605 76387 176156 658177 84377 62636 800female188 237406 82481 34233 15746 3749 200living arearural131 16572 14611 4652 24813 1068 178urban662 835421 854226 954158 752110 89437 822age group year101998 12490 18336 15234 16314 1162 442029271 344226 459133 564103 49347 38810 2223039189 23991 18538 16130 14320 16517 37840231 29385 17329 12342 20140 33116 356education levelilliterate163 207133 27121 8924 11533 2733 67primarymiddle school379 482248 505132 55995 45453 43821 467high schooldiploma220 28098 20068 28879 37830 24815 333university degree24 3112 2415 6411 535 416 133marital statusnever married384 486196 399144 610128 61253 43823 511married350 443276 56283 35271 34054 44618 400others56 7119 399 3810 4814 1164 89the others category marital status includes cases widowed divorced separated unspecified marital statusthe likelihoodratio chisquare test independence confirmed associations choice suicide method gender living area age group education level marital status statistically significant figure 4 consequently probabilities choosing suicide methods different men women residents urban rural regions among different age groups educational levels marital statusfigure 4 statistics p values likelihoodratio chisquare tests independence association factor choice suicide methoddownload figurethe relativerisk ratios demographic factors choice suicide methods hanging corresponding 95 confidence intervals p values reported table 2 estimated relativerisk ratios table 2 present risks onelevel change factor probability choosing five suicide methods relative probability suicide hanging relative risk choosing selfimmolation hanging women 1332 times higher men urban residents 158 times higher rural residents similarly see relative risk choosing selfimmolation hanging 155 married relative never married 044 education level high schooldiploma relative illiteracy means relative risk choosing selfimmolation hanging married individuals 155 times higher never married individuals illiterates 1044227 times high schooldiploma graduates also relative risk choosing selfimmolation hanging 06 3039 age group 035 40 age group relative 1019 age group means 3039 40 year age groups respectively reduces relative risk choosing selfimmolation hanging 167 286 times 1019 year age group relativerisk ratios significantly p value 05 different 1 hence risk choosing selfimmolation hanging higher women men urban residents rural residents married individuals never married individuals illiterates high schooldiploma graduates young 30 older adults 30 relativerisk ratio selfimmolation hanging 2029 year age group p value952 education level primarymiddle school p value 062 significantly different 1 implies relative risk choosing selfimmolation hanging 1019 2029 year age groups illiterates primarymiddle school graduatestable 2 estimated relativerisk ratios rrr 95 confidence intervals p values versus null hypothesis based fitted multinomial logistic regression modelfactorslevelsrrr95 cip valuetoxic poisoninggendermale10 referencefemale183120281005living arearural10 referenceurban179097330063age group101910 reference20291220632365583039073033162445 40101044229986education levelilliterate10 referenceprimarymiddle school078045136384high schooldiploma074039141363university degree115038342804marital statusnever married10 referencemarried111068182670others157075331232drug poisoninggendermale10 referencefemale174124245001living arearural10 referenceurban398210756001age group101910 reference20291350862131933039060034107083 40046011114020education levelilliterate10 referenceprimarymiddle school170097296062high schooldiploma133073242352university degree276119642018marital statusnever married10 referencemarried097067141877others071032156395selfimmolationgendermale10 referencefemale13329861799001living arearural10 referenceurban158109229015age group101910 reference20291010681519523039060036097038 40035020061001education levelilliterate10 referenceprimarymiddle school069047102062high schooldiploma044028069001university degree062026144262marital statusnever married10 referencemarried155113214007others059036103054firearmsgendermale10 referencefemale056037086008living arearural10 referenceurban056038082003age group101910 reference20291090681747323039047026085013 40062033119155education levelilliterate10 referenceprimarymiddle school135078234283high schooldiploma179100319049university degree232095565065marital statusnever married10 referencemarried097064145873others100047214994othersgendermale10 referencefemale124056273592living arearural10 referenceurban077034172524age group101910 reference202919204191041030396361362974019409501874828007education levelilliterate10 referenceprimarymiddle school5261441930012high schooldiploma7691992972003university degree249152711770001marital statusnever married10 referencemarried052024101082others107032355910null hypothesis rrr10 hanging baseline reference method statistically significant results p05 bolded detailed model parameters available online httpdocsgooglecomdocumentd1eeqjfv5tgty7ydnxgnxzrvy4khklv9yktdsahxwrygpubfollowing argument relative risk choosing toxic poisoning hanging women 183 times higher men relative risk choosing intentional drug poisoning hanging 174 times higher women men 398 times higher urban residents rural residents 1046217 times lower 40 year age group 1019 year age group 276 times higher university graduates illiterates relative risk choosing firearms hanging 1056179 times higher men women 105618 times higher rural residents urban residents 1047213 times lower 3039 age group 1019 age group 179 times higher high schooldiploma graduates illiterates finally relative risk choosing suicide methods hanging increases significantly increasing age education see table 2the overall relativerisk ratios demographic factors associated choice suicide methods shown table 3 based results conclude four specific factors significantly associated choice selfimmolation hanging study period gender rrr1355 95 ci 10071823 living area rrr157 95 ci 109226 risk factors age group rrr072 95 ci 061085 education rrr085 95 ci 077094 protective factors choice drug poisoning hanging gender rrr167 95 ci 120234 living area rrr407 95 ci 215771 significant risk factors age group rrr069 95 ci 057084 significant protective factor choice firearms hanging education rrr116 95 ci 103130 significant risk factor age group rrr077 95 ci 063093 gender rrr057 95 ci 037087 living area rrr056 95 ci 039082 significant protective factors choice toxic poisoning hanging gender rrr189 95 ci 124288 significant risk factor finally choice others suicide methods hanging older age group rrr199 95 ci 134295 increasing education rrr155 95 ci 125193 significant risk factorstable 3 overall relativerisk ratios rrr 95 confidence intervals p values null hypothesis demographic factors associated choice suicide methods based fitted multinomial logistic regression modelselfimmolationdrug poisoningfirearmstoxic poisoningothersgenderrrr1355167057189115p value00100300900373095 ci10071823120234037087124288053250living arearrr15740705618080p value01500100306158395 ci109226215771039082097331036178age grouprrr072069077095199p value00100100869500195 ci061085057084063093075121134295marital statusrrr101087095122074p value91238077428235395 ci07913064118069131085177039140education levelrrr085106116095155p value00228201748800195 ci077094095119103130082110125193null hypothesis rrr10 hanging baseline reference method statistically significant results p05 boldeddiscussiondiscussion notable causes completed suicide beyond scope paper nationwide study iranian population covering period 20062010 reported gender age education level associated suicide method17 study aimed quantify effect gender age living area education level marital status choice suicide method kermanshah province population study periodhanging often considered easily available acceptable suicide method less likely misclassified accidental undetermined death25 general prevention suicide hanging extremely difficult thus study used hanging baseline suicide method estimated relativerisk ratios choosing suicide methods hanging based gender age education living area marital status findings show women likely men choose intentional drug poisoning toxic poisoning hanging suicide intentional drug poisoning living urban areas higher relative risk living rural areas attributed fact drugs available urban households rural households easy access means suicide influences choice11 hand age protective factor suicide drug poisoning means risk suicide drug poisoning higher young individuals older individuals unlike developed countries suicide prevalent among older people average age suicide victims iran estimated 29 years26in line past research findings27 firearm ranked fourth used method suicide two times common men women also found rural areas relative risk choosing suicide firearm hanging 18 times higher urban areas explained availability need firearms rural areas restricting access could advantageousselfimmolation women living developing countries prevalent developed countries28 women iran affected social changes conflict traditional modern values2930 previous studies mentioned selfimmolation common method suicide among young iranian women particularly west country24283134 confirmed findings relative risk choosing selfimmolation hanging around 13 times higher women men advancing age increasing education acted preventive factors according findings relative risk selfimmolation urban residents higher rural residents observation could consequence increasing urbanization province result rapid migration rural population urban areas changes living environment usually adequately coupled concomitant cultural adaptationthe results also show relative risk selfimmolation higher married individuals nevermarried individuals unlike universal perspective marriage protective factor behavioral disorders26 iran married may one underlying motivating factors suicidal behaviors among young people one potential causes problem unemployment among young people results economic constraints low socioeconomic status35 unemployment one predisposing factors family conflicts among married couples another issue social stigma divorce iranian society insistence continuation marital life among maladjusted young couples exposes marital problems family conflicts two factors wellknown risk factors suicide iran39 noteworthy major depression similar iran prevalent among married compared unmarried individuals36because lack data influential factors mental health problems major depressive disorders schizophrenia bipolar disorders mood anxiety disorders substance abuse economic status quality life included study gain better understanding research needed evaluate effect psychosocial factors choice suicide method kermanshah provincecompeting intereststhe authors declare competing interests workarticle references1 liu ky suicide 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