Gendered risk factors associated with self-harm mortality among youth in South Africa, 2006-2014.
The prevalence and determinants of health and mortality patterns among youth (15-24 years of age) differ by sex. Research has shown that the prevalence of infectious disease is higher among young females in SA than among males, while injury-related mortality is higher among males. [11,12] It has also been found that gendered differences in socioeconomic status, as well as cultural norms and practices, contribute to the health discrepancies between males and females. [13-15] With regard to self-harm mortality, little other than rates is known of the sex-specific determinants among youth in SA.
To identify the sex-specific risk factors associated with self-harm mortality among youth in SA. Although under-reporting of suicide is a concern noted by many researchers, [16-18] this study pooled together 9 years of data in order to obtain a sample size reasonable enough for robust statistical analysis.
Self-harm is defined as any act of intentional self-poisoning or self-injury, regardless of motivation, and self-harm mortality is a death resulting from such an act.  This study examined self-harm mortality among youth for the period 2006-2014. Both males and females were included, and data were from the national death notification forms (DNFs) collated by Statistics South Africa. These data are anonymised by Statistics South Africa before becoming available for public download, i.e. the study was an analysis of secondary data available in the public domain. The data were not collected by the author and there was no need for institutional review board approval. The study sought to identify sex-specific determinants of self-harm/suicide among youth in SA.
All deaths from self-harm causes of youth aged 15-24 years (N=1 122) were analysed. All DNFs where there was completed information on the age, sex and cause of death (ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th revision) codes X60-X84) were included. The percentage of cases with missing information on sex over the period was 0.5% (n=2 104). These forms were not included in the analysis.
Analysis of specific types of self-harm makes it possible to quantify the extent to which these behaviours are contributing to the mortality of youth and to examine differences by sex. In the ICD-10 these types have been grouped into various forms of poisoning (X60-X69), hanging, strangulation and suffocation (X70), drowning and submersion (X71), firearm use (X72-X74), explosive material or use of fire (X75-X77), sharp or blunt object use (X78-X79), jumping or falling from a height or a moving object (X80-X81), and other means (X82 X84). A full list of the ICD-10 codes can be found online (http://apps.who.int/classifications/icd10/browse/2010/en).
Frequencies, percentages, cause-specific mortality rates and proportional mortality ratios (PMRs) were used to describe the differences in self-harm mortality by sex, age group, highest level of education, province of death, and pregnancy status among females. Logistic regression models showing odds ratios (ORs) were used to identify sex-specific risk factors.
Trends in self-harm mortality among youth in SA from 2006 to 2014 are shown in Fig. 1. The graph shows that males had consistently higher rates of self-harm mortality than females. Further, rates for male youth have been increasing since 2010, while rates among females declined in 2013 before increasing in 2014. For all youth there was a noticeable decline in 2010, followed by an increase.
Table 1 shows that the prevalence of self-harm mortality among males was highest in the older age group (20-24 years), while among females it was highest in the younger age group (15-19 years). Youth with secondary education had the highest PMR among both males and females. In every province there was a higher percentage of male deaths compared with females. KwaZulu-Natal had the highest proportions of mortality among males and females, and the proportion of self-harm mortality was higher among youth who were SA citizens than among those whose citizenship is unknown. Of females who died from self-harm causes, almost 10% were pregnant.
Hanging was the main cause of self-harm mortality among youth (Table 2), for males and females and in both of the age groups. Poisoning was the second most common cause. However, among males causes other than hanging constituted ~20% of deaths, while among females there was less variability, with poisoning accounting for 40.2% of deaths among 15-19-year-olds and 39.2% among 20-24-year-olds. Use of firearms was uncommon among both males and females (3.9% and 2.3%, respectively).
The odds of self-harm mortality according to pregnancy status, province of residence, citizenship status, education and age among females are shown in Fig. 2. Among females, secondary education (OR 1.4 (95% confidence interval (CI) 0.4-1.4)), being a non-SA citizen (OR 1.7 (95% CI 0.3-1.4)), residing in the Northern Cape (OR 1.7 (95% CI 0.6-0.8)) or KwaZulu-Natal (OR 1.4 (95% CI 0.3-2.4)) and being pregnant (OR 1.3 (95% CI 0.3-1.3)) were associated with increased odds of self-harm mortality.
The odds of self-harm mortality among males according to province of residence, citizenship status, education and age are shown in Fig. 3. Among males, residing in the Northern Cape (OR 1.9 (1.7-2.1)), KwaZulu-Natal (OR 1.5 (1.3-1.7)), North West (OR 1.75 (1.3-1.7)) and Mpumalanga (OR 1.3 (1.2-1.7)) were associated with increased odds of self-harm mortality.
The purpose of this study was to identify the sex-specific determinants of youth mortality due to self-harm behaviours in SA. Males had higher rates of self-harm mortality than females. This result is similar to a report showing that 75% of all self-harm deaths in SA were of males.  A more recent study found that 80% of all self-harm deaths in the country were of males.  A possible reason for this is related to gender differences in health-seeking behaviour. While globally females have higher levels of mental health illness related to self- harm behaviours, such as depression, they also have better health seeking behaviours for these illnesses than males, which reduce the risk of self-harm mortality.  Other behaviours that exacerbate self-harm are the excessive use of alcohol and illicit drug use, which are more prevalent among males (3.6%) than females (2.2%). [23,24] Hanging was the main cause of self-harm mortality among youth for both males and females. This is consistent with an older study in SA on the causes of self-harm mortality in all age groups.  A possible reason for hanging being relatively common is that it is regarded as a 'clean method' that does not cause harm to the body (e.g. bloodshed and dismemberment), requires little planning, and is an accessible method that does not require weapons or pharmaceuticals, which can be difficult to access.  In contrast to these findings, however, one study found that pesticide poisoning is currently the most common method of self-harm mortality worldwide.  Among youth in SA, poisoning was found to be the second most common cause of self-harm mortality among both males and females. Poisons used in SA are often commonly used household items, including bleach, detergents and pesticides, to which females have daily access. 
With regard to age, rates of self-harm mortality were higher among older youth aged 20-24 years than in the younger group. Other studies conducted in SA have reported similar results. [29,30] Youth face a number of social, economic and health challenges that contribute to self-harm behaviours, including the emotional and mental stress associated with high unemployment rates, poverty, HIV/AIDS, educational difficulties, physical and emotional abuse, parental separation and substance abuse. [31,32]
Pregnancy increases the likelihood that young females in SA will commit suicide. Fertility rates among youth in SA are high, with one study showing that 36.6% of females aged 15-24 years have at least one child.  Further, of women aged 15-24 years, a high proportion (32.4%) are single mothers.  Self-harm ideation and behaviours could therefore be the result of young women feeling abandoned by their partners, stigmatised by their families, and constrained financially.
The study findings are of particular significance to policies, programmes and the medical community. The programmes mentioned earlier in the article and the National Youth Policy (2015 2020) would benefit from the results of this study by identifying subgroups that are at increased risk of self-harm mortality, so that strategies can be expanded and itemised to reach specific groups of youth. The medical community can benefit from the results in two ways. First, medical fields such as psychiatry can be informed of key characteristics of youth who are most likely to suffer from mental health illnesses and engage in self-harm behaviours. Second, population-based studies such as this contribute to the ongoing education of the medical community in recognising and treating mental health illnesses.
The study is subject to limitations. First, self-harm is reported on the DNFs and determined by medical professionals. The true intention of the act on the part of the deceased is unknown. Second, there are limited variables available for analysis on DNFs, and for this reason, social and mental health determinants of self-harm mortality could not be ascertained. Finally, because few cases are reported annually, data needed to be pooled to increase the sample size for this study. The problem associated with this is that annual changes in the sociopolitical environment and their influences on self-harm mortality could not be analysed.
There is a difference in levels of self-harm mortality between young males and females in SA, suggesting that a uniform approach to awareness and prevention programmes will not reduce mortality rates. Further, since self-harm behaviours are intrinsically linked to mental health disorders, sex-specific approaches to the detection and treatment of these illnesses should be developed. Pregnant youth especially should be screened for mental health disorders, including depression, as a means of preventing self-harm mortality. With cause-specific mortality rates increasing among youth, there is also a need for more social support to assist those who are struggling. While national awareness campaigns do exist, such as the Mental Health Awareness Month in October each year, more is needed in the form of peer groups and counselling services across the country. Finally, the results of this study indicate that a few areas of future research can be recommended. First, more research on the self-harm behaviours of pregnant youth needs to be done. This study could not ascertain whether some of these deaths were not botched attempts at pregnancy termination that resulted in death, rather than intentional acts of suicide. Identifying the intention of these behaviours is pivotal to the implementation of successful prevention strategies. Second, a study that includes more information on the social and sociopolitical determinants of self-harm mortality would explain and better predict trends seen in youth mortality over time. Finally, a qualitative study of youth with suicidal ideation and those who have attempted self-harm behaviours in the past would help explain the epidemiology of self-harm mortality risk factors reported in this article.
Author contributions. Sole author.
Funding. This work was partially funded by the Andrew W Mellon Foundation and the University of the Witwatersrand, Johannesburg, South Africa.
Conflicts of interest. None.
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Accepted 24 August 2017.
N de Wet, PhD
Demography and Population Studies, Schools of Social Sciences and Public Health, University of the Witwatersrand, Johannesburg, South Africa
Corresponding author: N de Wet (firstname.lastname@example.org)
Caption: Fig. 1. Trends in self-harm mortality amongyouth (age 15-24 years) by sex in South Africa, 2006 2014. (CSMR = cause-specific mortality rate.)
Caption: Fig. 2. Adjusted odds ratios of self-harm mortality according to pregnancy status, province of residence, citizenship status, education and age among young (15-24 years of age) females in South Africa.
Caption: Fig. 3. Adjusted odds ratios of self-harm mortality according to province of residence, citizenship status, education and age among young (15-24 years of age) males in South Africa.
Table 1. Frequency (n), row percentage (%) and PMR distribution of self-harm mortality by individual characteristics of youth in SA, 2006-2014 Characteristic Total (N=1 122 Males (N=818) n PMR n % PMR Age (yr) 15-19 456 40.6 272 59.7 33.3 20-24 666 59.3 546 82.0 66.8 p-value 0.000 0.000 Highest level of education None 23 2.1 19 82.6 2.3 Primary 99 8.8 75 75.8 9.2 Secondary 521 46.4 360 69.1 44.0 Tertiary 98 8.7 76 77.6 9.3 Unknown 381 33.9 288 75.6 35.2 p-value 0.000 0.000 Province of death Western Cape 120 10.7 95 79.2 11.6 Eastern Cape 119 10.6 71 59.7 8.7 Northern Cape 147 13.1 105 71.4 12.8 Free State 32 2.9 23 71.9 2.8 KwaZulu-Natal 441 39.2 312 70.8 38.1 North West 54 4.8 46 85.2 5.6 Gauteng 34 3.0 26 76.5 3.2 Mpumalanga 95 8.5 75 79.0 9.2 Limpopo 66 5.9 52 78.8 6.4 Outside SA 3 0.3 3 100 0.4 Unknown 11 1.0 10 90.9 1.2 p-value 0.000 0.000 Pregnancy status (females) Yes 8 9.3 -- -- -- No 78 90.7 -- -- -- Total 86 -- -- -- p-value 0.000 Characteristic Females (N=304) n % PMR Age (yr) 15-19 184 40.4 60.5 20-24 120 18.0 39.5 p-value 0.000 Highest level of education None 4 17.4 1.3 Primary 24 24.2 7.9 Secondary 161 30.9 53.0 Tertiary 22 22.5 7.2 Unknown 93 24.4 30.6 p-value 0.000 Province of death Western Cape 25 20.8 8.2 Eastern Cape 48 40.3 15.8 Northern Cape 42 28.6 13.8 Free State 9 28.1 3.0 KwaZulu-Natal 129 29.3 42.4 North West 8 14.8 2.6 Gauteng 8 23.6 2.6 Mpumalanga 20 21.1 6.6 Limpopo 14 21.2 4.6 Outside SA 0 0 0 Unknown 1 9.1 0.3 p-value 0.000 Pregnancy status (females) Yes 8 100 9.3 No 78 100 90.7 Total 86 p-value 0.000 PMR = proportional mortality ratio; SA = South Africa. Table 2. Types of self-harm mortality by sex and age group, 2006-2014 Age group Males (yr) Cause Deaths, n (%) 15-24 Hanging 652 (79.7) 2 Poisoning 90 (11.0) 3 Firearm 32 (3.9) 4 Other 28 (3.4) 5 Jumping/falling 5 (0.6) 6 Explosive material/fire 4 (0.5) 7 Object (sharp/blunt) 4 (0.5) 8 Drowning 3 (0.3) Total 818 15-19 1 Hanging 215 (79.0) 2 Poisoning 28 (10.3) 3 Firearm 13 (4.8) 4 Other 13 (4.8) 5 Drowning 1 (0.4) 6 Explosive material/fire 1 (0.4) 7 Jumping/falling 1 (0.4) Total 272 20-24 1 Hanging 437 (80.0) 2 Poisoning 62 (11.4) 3 Firearm 19 (3.5) 4 Other 15 (2.8) 5 Object (sharp/blunt) 4 (0.7) 6 Jumping/falling 4 (0.7) 7 Explosive material/fire 3 (0.6) 8 Drowning 2 (0.4) Total 546 Age group Females (yr) Cause Deaths, n (%) 15-24 Hanging 150 (49.3) 2 Poisoning 121 (39.8) 3 Other 18 (5.9) 4 Firearm 7 (2.3) 5 Drowning 6 (2.0) 6 Jumping/falling 2 (0.7) 7 Explosive material/fire 0 8 Object (sharp/blunt) 0 Total 304 15-19 1 Hanging 85 (46.2) 2 Poisoning 74 (40.2) 3 Other 12 (6.5) 4 Drowning 6 (3.3) 5 Firearm 6 (3.3) 6 Jumping/falling 1 (0.5) 7 Explosive material/fire 0 Total 184 20-24 1 Hanging 65 (54.2) 2 Poisoning 47 (39.2) 3 Other 6 (5.0) 4 Firearm 1 (0.8) 5 Jumping/falling 1 (0.8) 6 Drowning 0 7 Explosive material/fire 0 8 Object (sharp/blunt) 0 Total 120 Age group Total (yr) Cause Deaths, n (%) 15-24 Hanging 802 (71.5) 2 Poisoning 211 (18.8) 3 Other 46 (4.1) 4 Firearm 39 (3.5) 5 Drowning 9 (0.8) 6 Jumping/falling 7 (0.6) 7 Explosive material/fire 4 (0.4) 8 Object (sharp/blunt) 4 (0.4) Total 1 122 15-19 1 Hanging 300 (65.8) 2 Poisoning 102 (22.4) 3 Other 25 (5.5) 4 Firearm 19 (4.2) 5 Drowning 7 (1.5) 6 Jumping/falling 2 (0.4) 7 Explosive material/fire 1 (0.2) Total 456 20-24 1 Hanging 502 (75.4) 2 Poisoning 109 (16.4) 3 Other 21 (3.2) 4 Firearm 20 (3.0) 5 Jumping/falling 5 (0.8) 6 Object (sharp/blunt) 4 (0.6) 7 Explosive material/fire 3 (0.5) 8 Drowning 2 (0.3) Total 666
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|Author:||de Wet, N.|
|Publication:||South African Medical Journal|
|Date:||Dec 1, 2017|
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