Barriers to help-seeking from healthcare professionals amongst women who experience domestic violence:A qualitative study in Sri Lanka

BACKGROUND: Domestic violence (DV) is a major global public health problem which is associated with significant adverse consequences. Although Sri Lankan women who experience DV receive treatment from healthcare professionals (HCPs) for DV related physical and psychological problems, disclosure of DV within health services is quite low. This study explored barriers to disclosure of DV to HCPs among Sri Lankan women who experience DV. METHOD: This qualitative study took place in the Central Province of Sri Lanka. Twenty women who had experienced DV were recruited from Gender Based Violence Centers (Mithuru Piyasa Centers) and a toxicology unit of the two selected hospitals. Participants were purposefully selected using maximum variation sampling technique. In-depth interviews were conducted until data saturation was reached. Interviews were recorded, and analyzed using thematic analysis. RESULTS: Survivor related barriers to help seeking included women’s lack of knowledge and perceptions about the role of HCPs, lack of confidence in HCPs, fear of repercussions, personal attitudes towards DV, and their love and loyalty towards the perpetrator. Women preferred it if HCPs initiated discussions about DV, and they valued it when HCPs could be confidential and protect their privacy, and give enough time for DV related issues during consultations. A perpetrator related barrier was the controlling behavior of the perpetrator. Social stigma and social and cultural norms about the role of women emerged as the socio-cultural constraints to disclosure. CONCLUSIONS: Barriers to help seeking for DV from HCPs exist at individual, healthcare level, and societal level. Community programs are needed to increase women’s access to healthcare services and interventions should be implemented to develop effective, preventive, and supportive strategies at the healthcare system level. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12889-022-13116-w

Non-fatal self-poisoning in Sri Lanka

Non-fatal self-poisoning is a significant public health problem in Sri Lanka. Hospital admission rates due to non-fatal self-poisoning in Sri Lanka have increased since the 1990s, while rates of completed suicides have decreased. Pesticide ingestion among males was the most common pattern of self-poisoning, but recent studies suggest that this is changing. However, little current data is available on non-fatal self-poisoning in Sri Lanka. Psychosocial factors such as psychiatric morbidity, suicide intent, and the likelihood and predictors of recurrence have not been extensively investigated. Accordingly, the aims of this thesis on non-fatal self-poisoning in Sri Lanka are to: 1) investigate the associated socio-demographic factors, substances ingested, psychiatric morbidity and level of suicidal intent; 2) investigate why people carry out acts of non-fatal self-poisoning; 3) describe the longitudinal sequelae over one year, in terms of repetition and suicidal ideation; and, 4) examine potential methods for minimizing rates of non-fatal self-poisoning in Sri Lanka. To achieve these aims, this research program is organized into several sections as follows: A systematic review of 27 studies of non-fatal self-poisoning in Sri Lanka; semi-qualitative interviews of 24 persons who had recently carried out acts of non-fatal self-poisoning; a large cross-sectional survey of 949 persons admitted to hospital after non-fatal self-poisoning, conducted over 14 months; and a one-year follow-up survey of 335 participants. Ethical approval for the study was obtained from the Australian National University and the University of Peradeniya, Sri Lanka. Several key findings emerged overall. Non-fatal self-poisoning in Sri Lanka has begun to resemble the pattern of Western countries, in that most who attempted poisoning were young (majority below 25 years), female, and the most commonly ingested substance was medicinal drug overdoses. One-third of males had ingested pesticides. As described previously in the literature, most acts of non-fatal self-poisoning occurred in the context of distress associated with recent interpersonal conflict; the desire to escape, or to die, emerged as motivational themes. A new finding was that over 50% admitted to hospital after non-fatal poisoning were depressed, and almost one-third of males had alcohol misuse. Male gender, a history of prior suicide attempts, depression, and hopelessness were significant predictors of high suicidal intent. Most participants endorsed potential preventive strategies such as talking to a close friend or family member, distraction activities and recollection of the adverse consequences of the index self-poisoning attempt. Contrary to expectations, the rate of repetition at one year was low, being only 2.7%. These findings suggest that non-fatal self-poisoning should be a national priority in Sri Lanka and that an integrated, multi-level approach towards prevention should be implemented. In particular, the data suggest that primary prevention programs are required to increase community awareness and primary-care treatment of depression, promote safe drinking, and help young people develop interpersonal skills and distress tolerance. Secondary prevention might include screening and targeted management of high-risk individuals who have attempted self-poisoning. Restriction of access to pesticides should be continued. Further research is needed to explore the effectiveness and acceptability of preventive strategies

Characteristics of non-fatal self-poisoning in Sri Lanka: A systematic review

Background The rate of non-fatal self-poisoning in Sri Lanka has increased in recent years, with associated morbidity and economic cost to the country. This review examines the published literature for the characteristics and factors associated with non-fatal self-poisoning in Sri Lanka. Methods Electronic searches were conducted in Psychinfo, Proquest, Medline and Cochrane databases from inception to October 2011. Results 26 publications (representing 23 studies) were eligible to be included in the review. A majority of studies reported non-fatal self-poisoning to be more common among males, with a peak age range of 10–30 years. Pesticide ingestion was the most commonly used method of non-fatal self-poisoning. However three studies conducted within the last ten years, in urban areas of the country, reported non-fatal self-poisoning by medicinal overdose to be more common, and also reported non-fatal self-poisoning to be more common among females. Interpersonal conflict was the most commonly reported short-term stressor associated with self-poisoning. Alcohol misuse was reported among males who self-poisoned, and data regarding other psychiatric morbidity was limited. Conclusions The findings indicate that pesticide ingestion is the commonest method of non-fatal self-poisoning in Sri Lanka, and it is more common among young males, similar to other Asian countries. However there appears to be an emerging pattern of increasing medicinal overdoses, paralleled by a gender shift towards increased female non-fatal self-poisoning in urban areas. Many non-fatal self-poisoning attempts appear to occur in the context of acute interpersonal stress, with short premeditation, and associated with alcohol misuse in males. Similar to other Asian countries, strategies to reduce non-fatal self-poisoning in Sri Lanka require integrated intervention programs with several key aspects, including culturally appropriate interventions to develop interpersonal skills in young people, community based programs to reduce alcohol misuse, and screening for and specific management of those at high risk of repetition following an attempt of self-poisoning

Characteristics of non-fatal self-poisoning in Sri Lanka: a systematic review

BACKGROUND: The rate of non-fatal self-poisoning in Sri Lanka has increased in recent years, with associated morbidity and economic cost to the country. This review examines the published literature for the characteristics and factors associated with non-fatal self-poisoning in Sri Lanka. METHODS: Electronic searches were conducted in Psychinfo, Proquest, Medline and Cochrane databases from inception to October 2011. RESULTS: 26 publications (representing 23 studies) were eligible to be included in the review. A majority of studies reported non-fatal self-poisoning to be more common among males, with a peak age range of 10–30 years. Pesticide ingestion was the most commonly used method of non-fatal self-poisoning. However three studies conducted within the last ten years, in urban areas of the country, reported non-fatal self-poisoning by medicinal overdose to be more common, and also reported non-fatal self-poisoning to be more common among females. Interpersonal conflict was the most commonly reported short-term stressor associated with self-poisoning. Alcohol misuse was reported among males who self-poisoned, and data regarding other psychiatric morbidity was limited. CONCLUSIONS: The findings indicate that pesticide ingestion is the commonest method of non-fatal self-poisoning in Sri Lanka, and it is more common among young males, similar to other Asian countries. However there appears to be an emerging pattern of increasing medicinal overdoses, paralleled by a gender shift towards increased female non-fatal self-poisoning in urban areas. Many non-fatal self-poisoning attempts appear to occur in the context of acute interpersonal stress, with short premeditation, and associated with alcohol misuse in males. Similar to other Asian countries, strategies to reduce non-fatal self-poisoning in Sri Lanka require integrated intervention programs with several key aspects, including culturally appropriate interventions to develop interpersonal skills in young people, community based programs to reduce alcohol misuse, and screening for and specific management of those at high risk of repetition following an attempt of self-poisoning

Socioeconomic and geographic correlates of intimate partner violence in Sri Lanka: Analysis of the 2016 Demographic and Health Survey

Intimate partner violence (IPV) is a serious public health issue and violation of human rights. The prevalence of IPV in South Asia is especially pronounced. We examined the associations between socioeconomic position (SEP), geographical factors and IPV in Sri Lanka using nationally representative data. Data collected from Sri Lanka’s 2016 Demographic and Health Survey were analysed using multilevel logistic regression techniques. A total of 16,390 eligible ever-partnered women aged 15-49 years were included in the analysis. Analyses were also stratified by ethnicity, type of violence, neighbourhood poverty and post-conflict residential status for selected variables. No schooling/primary educational attainment among women (OR 2.46 95% CI 1.83-3.30) and their partners (OR 2.87 95% CI 2.06-4.00), financial insecurity (OR 2.17 95% CI 1.92-2.45) and poor household wealth (OR 2.64 95% CI 2.22-3.13) were the socioeconomic factors that showed the strongest association with any IPV, after adjusting for age and religion. These associations predominately related to physical and/or sexual violence, with weak associations for psychological violence. Women living in a post-conflict environment had a higher risk (OR 2.96 95% CI 2.51-3.49) of IPV compared to other areas. Ethnic minority women (Tamil and Moor) were more likely to reside in post-conflict areas and experience poverty more acutely compared to the majority Sinhala women, which may explain the stronger associations for low SEP, post-conflict residence and IPV found among Tamil and Moor women. Policies and programs to alleviate poverty, as well as community mobilisation and school-based education programs addressing harmful gender norms may be beneficial. Trauma informed approaches are needed in post-conflict settings. Further exploratory studies investigating the complex interplay of individual, household and contextual factors occurring in this setting is required

Sex education and self-poisoning in Sri Lanka: an explorative analysis

BACKGROUND: Self-harm and suicide are important causes of morbidity and mortality in Sri Lanka, but our understanding of these behaviours is limited. Qualitative studies have implicated familial and societal expectations around sex and relationships. We conducted an explorative analysis using case-control data to investigate the association between sex education and self-poisoning in Sri Lanka. METHODS: Cases (N=298) were self-poisoning inpatients on a toxicology ward, Teaching Hospital Peradeniya. Controls (N=500) were sex and age frequency matched to cases and were outpatients/visitors to the same hospital. Participants were asked whether they had received sex education, and to rate the quality and usefulness of any sex education received. Logistic regression models adjusted for age, sex, and religion quantified the association between receipt, quality and usefulness of sex education and self-poisoning. We tested whether the associations differed by sex. RESULTS: Roughly 1-in-3 cases and 1-in-5 controls reported having not received sex education. Individuals who did not receive sex education were nearly twice as likely to have self-poisoned than those who did (OR 1.68 (95% CI 1.11-2.55)). Those who reported the sex education they received as not useful were more likely to have self-poisoned compared to those who reported it useful (OR 1.95 (95% CI 1.04-3.65)). We found no evidence of an association between self-poisoning and the self-rated quality of sex education, or that associations differed by participant sex. CONCLUSION: As sex education is potentially modifiable at the population-level, further research should aim to explore this association in more depth, using qualitative methods and validated measurement tools. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12889-021-12374-4

Clinical and psychosocial factors associated with domestic violence among men and women in Kandy, Sri Lanka

Domestic violence (DV) is a violation of human rights with adverse intergenerational consequences on physical and mental health. Clinical and psychosocial correlates of DV have been documented internationally, but evidence from South Asia is limited, especially among men. This is a nested cross-sectional study of the control population (N = 856) of a large case-control study in Kandy, Sri Lanka. Multivariable logistic regression models were conducted to estimate the association between clinical and psychosocial factors and experience of DV. Overall associations were examined and stratified by sex and type of abuse. Overall, 19% (95% CI 16%-21%) of the sample reported DV of any form in past year, with a similar prevalence being reported in both men (18% 95% CI 14%-22%) and women (19% 95% CI 15%-23%). Depression symptoms (adjusted OR [AOR] 3.28 95% CI 2.13-5.05), suicidal ideation (AOR 6.19 95% CI 3.67-10.45), prior diagnosis of a mental illness (AOR 3.62 95% CI 1.61-8.14), and previous self-harm (AOR 6.99 95% CI 3.65-13.38) were strongly associated with DV, as were indicators of perceived poor social support (AOR range 2.48-14.18). The presence of in-laws (AOR 2.16 95% CI 1.34-3.48), having three or more children (AOR 2.15 95% CI 1.05-4.41) and being divorced/separated/widowed were also strongly associated with DV (AOR 2.89 95% CI 1.14-7.36). There was no statistical evidence that any associations differed by sex. A multi-sectoral approach is needed to address DV in this context. Enhanced coordination between DV support services and mental health services may be beneficial. Further research and support for men as well as women is needed

Childhood adversity and deliberate self-poisoning in Sri Lanka:a protocol for a hospital-based case-control study

Introduction Childhood adversity (CA) has been suggested as a key risk factor for suicidal behaviour, but evidence from low/middle-income countries is lacking. In Sri Lanka, CA, in the form of child maltreatment or as a consequence of maternal separation, has been highlighted in primarily qualitative or case series work, as a potentially important determinant of suicidal behaviour. To date, there have been no quantitative studies to investigate CA as a key exposure associated with suicidal behaviour in Sri Lanka. The aim of the research is to understand the association between CA and suicidal behaviour in Sri Lanka and to identify potentially modifiable factors to reduce any observed increased risk of suicidal behaviour associated with CA. Methods and analysis This is a hospital-based case-control study. Cases (n=200) will be drawn from individuals admitted to the medical toxicology ward of the Teaching Hospital Peradeniya, Sri Lanka, for medical management of intentional self-poisoning. Sex and age frequency-matched controls (n=200) will be recruited from either patients or accompanying visitors presenting at the outpatient department and clinic of the same hospital for conditions unrelated to the outcome of interest. Conditional logistic regression will be used to investigate the association between CA and deliberate self-poisoning and whether the association is altered by other key factors including socioeconomic status, psychiatric morbidity, current experiences of domestic violence and social support. Ethics and dissemination Ethics approval has been obtained from the Ethical Review Committee of the Faculty of Medicine, University of Peradeniya, Sri Lanka. Researchers have been trained in administering the questionnaire and a participant safety and distress protocol has been designed to guide researchers in ensuring participant safety and how to deal with a distressed participant. Results will be disseminated in local policy fora and peer-reviewed articles, local media, and national and international conferences

Childhood adversity and self-poisoning:A hospital case control study in Sri Lanka

This is the final version. Available on open access from Public Library of Science via the DOI in this recordData Availability: The research data is available as follows: Data are available at the University of Bristol data repository, data.bris, at https://doi.org/10.5523/bris.37pg6mv6x35r12b98aoq4blcgs.” In a reference list: Knipe, D., Kidger, J. (2020): Data from ACE & Self harm Sri Lanka (10-2020). https://doi.org/10.5523/bris.37pg6mv6x35r12b98aoq4blcgs. The dataset appears in the repository catalogue, on Explore Bristol Research, and in the DataCite registry.Introduction Adverse childhood experiences (ACE) have been recognized as an important risk factor for suicidal behaviour among adults, but evidence from low and middle-income countries is lacking. This study explored associations between ACE and hospital admission due to non-fatal self-poisoning in Sri Lanka. Methods This was a case-control study. Adults admitted to a tertiary care hospital for medical management of self-poisoning were included as cases, and age and sex matched controls were recruited from the outpatient department. ACE were measured using the World Health Organization’s Childhood Adversity Scale. Logistic regression models adjusting for age, sex, ethnicity, and religion were used to quantify the association between ACE and self-poisoning. Results The study included 235 cases and 451 controls. Cases were 2.5 times (95% CI 1.8, 3.6) more likely to report an ACE than controls and had higher ACE scores. Childhood physical abuse (OR 4.7, 95% CI 1.2, 19.0) and emotional abuse or neglect (OR 3.7, 95% CI 1.3, 10.1, and 3.7, 95% CI 2.3, 6.0 respectively), increased the risk of self-poisoning in adulthood, as did witnessing household violence (OR 2.2, 95% CI 1.4, 3.4), growing up in a household with a mentally ill or suicidal household member (OR 2.1, 95% CI 1.2, 3.4), and experiencing parental death/separation/divorce (OR 3.1, 95% CI 2.0, 4.9) as a child. Conclusions Reducing exposures to ACEs should be a priority for prevention of suicide and self-harm in Sri Lanka. Innovative methods to increase support for children facing adversity should be explored.Medical Research Council (MRC)Elizabeth Blackwell Institute for Health Research, University of BristolWellcome Trus