WOMEN SUICIDE AND CULTURE IN TAJIKISTAN IDENTIFYING AND

WOMEN, SUICIDE AND CULTURE IN TAJIKISTAN: IDENTIFYING AND ADDRESSING CORRELATED FACTORS Presented at: American Public Health Association 133 d Annual Meeting Philadelphia, Pennsylvania December 10 -14, 2005

Alisher Latypov, MA, MHS Country Program Director Global Program on Psychiatry Tajikistan alytypov@gip-global. org Irene Jillson, Ph. D. Adjunct Assistant Professor Georgetown University School of Nursing and Health Studies Washington, D. C. iaj@georgetown. edu

Republic of Tajikistan Khojent Kyrgyzstan in a ista bek Uz Dushanbe Ch n SO GD RE GI ON Uzbekistan GORNO-BADAKHSHAN Kurgan-Tube HATLON REGION Afghanistan Khorog tan nis ha Afg

STUDY RESEARCHERS, LOCATION, AND TIMING Ø Study conducted Øvoluntarily by Dr. Alisher Lytypov and Dr. Irene Jillson Øin Dushanbe, Tajikistan and surrounding rural areas Øin 2004

STUDY PURPOSE Ø Long-range: to design cost-effective, community-based prevention approaches Ø Short-term: ØTo explore the reasons for suicide generally and self-immolation specifically among women in Tajikistan ØTo explore use of a qualitative approach to exploring this sensitive topic in Tajikistan

STUDY METHODS Qualitative, including Ø Semi-structured interviews conducted with Ø 6 health providers at a major burn treatment facility in Dushanbe Ø 15 women attending a health clinic in Dushanbe Ø Review of available policy and other documents

WHAT IS KNOWN ABOUT FEMALE SUICIDE IN TAJIKISTAN?

1. "Every month, about 30 women are taken to a Dushanbe hospital with severe burns from such suicide attempts. " (Shabad, 1998) 2. “ 47 people killed themselves in the Sogd region in the first 6 months of 2003…” 1. “The average 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)

RESPONSES FROM HEALTH CARE PROVIDERS AT THE REPUBLICAN BURN CENTER

REPORTED ATTEMPTED CASES IN 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

RESPONSE OF HEALTH CARE SYSTEM ØFew mental health services at any level ØFew mental health providers ØMinimal training of physicians and nurses to respond to attempted suicides in villages ØMinimal prevention services

PROFILE OF DOCUMENTED CASES OF ATTEMPTED SUICIDE Ø Age Øbetween 16 and mid-30 s Ø Education Ø 8 attended or completed university education Ø 5 completed 8 th grade or less Ø 2 completed high school Ø Rural and urban residents

METHODS OF ATTEMPTED SUICIDE Significant differences by rural/urban areas: ØRural: self-immolation and drowning ØUrban: gas, overdosing on medications

IN THEIR OWN WORDS: TAJIK WOMEN’S EXPERIENCE WITH ATTEMPTED SUICIDE

PERSONAL EXPERIENCE WITH SUICIDE Ø All of the respondents have either attempted suicide or have had suicidal thoughts Ø All of the respondents Øpersonally know at least one woman who has committed suicide and several know more than one; Ølive in a community in which at least one woman has committed suicide; for several, more than one woman has done so

PERCEPTION OF REASONS THAT WOMEN COMMIT SUICIDE ØDomestic violence, polygamy ØFinancial problems/unemployment of husbands ØProblems with mother-in-law/sister(s)-inlaw ØAdultery (cheating)

PERCEPTION OF REASONS THAT WOMEN COMMIT SUICIDE Ø Alcohol abuse Ø Mental disorders Ø Among young girls, when their boyfriend has sex with them, promising to marry, but does not keep his word Ø “copycatting” other women’s example (social learning)* *Identified by providers at Burn Center

PERCEPTION OF REASONS THAT WOMEN COMMIT SUICIDE Ø General Feelings Of Unhappiness and lack of resources/services for care Ømost women Ødo nothing, Øuse “self-care” (e. g. , listening to music, talking with friends), or Øgo to a local healer Ønone had been to a trained “modern” health provider.

REASONS FOR SUICIDE OF FRIEND/COMMUNITY MEMBERS Ø Marital discord/problems/arranged marriage Øthe husband had married “a second wife” Øfriend had epilepsy; when she was 15 her parents arranged her marriage to a relative

REASONS FOR SUICIDE OF FRIEND/COMMUNITY MEMBERS Ø Economic situation/family problems ØA 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. Ø Social strictures ØOne of the respondent’s best friends committed suicide, leaving a note saying that she did it because her family was too strict with her.

HOPE FOR THE FUTURE Ø Most respondents said that they did not know about the future. Ø Those who commented on the future were negative in terms of both their own future and that of women in Tajikistan generally

PROPOSED APPROACHES TO SUICIDE PREVENTION IN LOW-INCOME COUNTRIES

ØDeveloping/adapting brief screening instruments (ensuring language and cultural relevance) ØDeveloping/adapting practical, evidence-based approaches to treatment of mental health disorders

ØTraining community health workers, primary care physicians and nurses in detection and screening and early intervention techniques ØCertifying competency of providers to address needs of both genders and all ages

ØCollecting data to ensure nationallevel awareness of problem and serve as basis for policy formulation ØEnsuring systems in place to protect confidentiality of women seeking prevention/treatment

Ø Integrating mental health/suicide prevention and care with primary care Ø Creating a network of community-based mental health services, assuring availability of quality (and safe) services at all levels Ø Convening community-based groups to discuss contributing factors in the community that can be addressed at the community, regional and national level

PROPOSED APPROACHES TO EVALUATING SUICIDE PREVENTION TO ELICIT CULTURALLY APPROPRIATE, EVIDENCE- BASED PRACTICE

ØUse of mixed method, participatory evaluation ØDevelop/adapt language and culturally-appropriate semistructured instrument to assess services relevant to Øsuicide prevention, and Øtreatment of those who have attempted suicide

Ø Develop standard protocol to conduct Øethnographic interviews Øgatherings of women (focus groups) Øcontextual analysis of immediate and surrounding community(ies) Ø Training and engagement of community health workers to conduct interviews

1. Engage health and social service decision-makers, providers and community members in evaluation process 2. Develop process for use of data/information in 1. planning for health and social services 2. addressing socio-economic issues that are co-factors in the suicide epidemic