“A Stich In Time Saves Nine”: Reflection Of General Practitioners’ Attitude Towards Suicide Prevention

1 Ph.D Research Scholar, Department of Psychiatric Social Work, NIMHANS, Bangalore

2 Associate Professor, Department of Psychiatric Social Work, NIMHANS, Bangalore

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*Address for Correspondence: Dr.Vranda M N, Associate Professor, Department of Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences, Bangalore-560029, email id: vrindamn@gmail.com
Abstract

Background:Viewing from a public health perspective, suicide is one of the growing concerns around the world. Most of the countries’ suicide prevention strategies focus on the multi-sectoral interventions using various stakeholders, in which health sector has a significant role and platform for the effective suicide prevention strategies. The unique features of primary health care scenario hold the availability, affordability, and accessibility which connect the community with the primary care sector on a first priority basis. The current study explores the attitude of general practitioners’ regarding suicide prevention Methods: Twelve in-depth interviews were conducted among general practitioners working in the primary health care centers both in the public and private sectors in Urban Bengaluru, Karnataka. A qualitative research design was employed and data was analysed using thematic analysis approach. Results:This study highlights the negative attitude towards the suicide, moral attitude towards helping process, religious sentiments and view towards decriminalization of suicidal act. Conclusion:In the current scenario, it is imperative toincorporate need based training and sensitization programmes for the health care providers which aids in evidence based suicide prevention strategies and practice in the primary health care sector.

Key words: General practitioner, Attitude, Suicide Prevention

Background

Public health is one of the major focused areas of every state, in which strategies are organized and planned in accordance with the promotion of health, prevention of ill health and curative measures for the eradication of existing health hazards. Irrespective of the measures taken by the various governments and international organizations the act of suicide continues to be a growing public health issue all over the world. Suicide is the act of deliberately killing oneself, which accounted for 1.4% of all deaths worldwide, making it the 15th leading cause of death in 2012 (WHO,2012) and it is multifactorial phenomenon which demands multi-level interventions for the prevention aspects and better strategies involving various stakeholders in the community. India is one of the countries with highest number of suicide in which southern India constituted the major part. In Karnataka, the number of people ending their life in a voluntary or deliberate act  has  varied  from  12000  to  13000  per  year  during  the  years  2005-2007 (NCRB,2011). Under Bengaluru Injury Surveillance Programme (BISP) during 2007, 2417 suicides were registered with police.

In consideration of multi sectorial collaboration in suicide prevention, health system has a responsible role in the practical aspect of suicide prevention where the community directly keeping in touch with the formal primary health care sector, on the other hand, General Practitioners’ are the first professional who are readily accessible for the community in meeting health care needs, hence the identification and prevention of suicidal act become more important in this scenario. Viewing the contemporary social situation, the various researches helped to increase the knowledge about the suicidal act and epidemiology also contributed to understand the risk and protective factors associated with the suicidal behaviour (McLean, J., Maxwell et al 2008). It clearly indicates that the theoretical understandings are clear at an academic level but the implementation of prevention strategies, decentralization of ideas, and   capacity buildings are relatively lacking from a practical point of view.

Primary care centers can act as a key setting for suicide prevention in which health professionals have an important role to play in preventing suicide (Saini, P., Windfuhr et al,2010). The attitude of general practitioners regarding suicide and its prevention is integral and central in the process of exploring the possibility of the same in the primary health care set up. Attitude is described as a psychological tendency often expressed by evaluating a specific entity with an element of favour or disfavour. It always consist of affective and cognitive components (Eagly, A. H., &Chaiken, S,2007)

The current study explore the attitude of general practitioners with regard to people with suicidal ideas, offering of help, attitude associated with the responses, religious sentiments and views associated with the decriminalization of suicide. It also tries to understand the training needs and gaps in the primary health care sector associated with the suicide prevention efforts and strategies.

Methodology

Setting: The study was carried out in primary health care centres-both private and public sector in Urban Bengaluru district of Karnataka, India. The health care centers were listed and later approached by the researcher, in which 3 health care centres in public sector and 6 centers in private sector involved in the research process.

Study Design: Research protocol along with the informed consent form submitted to the Institutional Ethics Committee, Behavioural Science Division, NIMHANS. A qualitative research design was adopted. Qualitative approach helps the researcher to understand the phenomenon under study in a non-numerical way and beyond the cause effect or co relational angle which helps the respondents to elaborate on their responses rather than fixing in to limited options. The researcher employed non-random judgement sampling for the selection of respondents. The researcher has approached the General Practitioners, those who were willing to participate in the study, informed verbally about the interests and aims of the research, and were also given an information sheet explaining the nature of the study and recruited after obtaining written informed consent.

Indepth interview Guide:

 An in-depth interview guide with open ended questions was used to explore the attitude of general practitioners’ regarding suicide prevention. The interview guide consist of questions related general practitioners feelings or attitude towards a person who is having suicidal, their socio -cultural belief towards suicidal behaviours in general, how do they handle a patient with suicidal behaviour in their clinic and what their training needs.

The interview guide was content validated by 8 mental health professionals from the Behavioural Sciences, NIMHANS, Bengaluru. India.

Twelve in depth interviews were conducted and determined by the data saturation where in researcher identified instances of similarities and repetitions in the collected data. Twelve in-depth interviews constitute 3 respondents from the public sector and 9 respondents from the private sector.  Interviews were held over a 4-month period, between November 2015 and February 2016.  Interviews lasted between 70  minutes  to  90  minutes,  and  were  conducted  in quiet settings within their hospital premise where there was minimal chance  disturbance. The in-depth interview data were recorded and later transcribed for the analysis.

Results

 Data was analysed by employing thematic analysis approach. It is a flexible qualitative method which helps in identifying and deriving themes from the data. A theme is a meaningful essence that runs through the data as a basic topic that the narrative is about. For thematic analysis, the researcher followed a systematic process; the data was coded and organized, involving the identification of themes through careful reading and re-reading of the transcribed interviews. The researcher identified verbatim which coded and grouped as themes. Themes which were similar and overlapping with other themes were again condensed and re-grouped. Attitude part four themes were emerged:

  1. Negative attitude towards suicide
  2. Moralistic attitude regarding help and recovery perspective
  3. View towards De-criminalization of suicide
  4. Religious sentiments towards suicide

Negative Attitude towards Suicide:

In exploring attitude towards suicide and people who having suicidal ideas most of the GPs initial reaction were identified as negativistic in nature. Majority of the general practitioners called  suicidal  people  as  fools,  cowards,  self -centred  people  and  sinners  which indicates extreme negativism towards the suicide and suicidal people. GPs also reported  suicide as escapism  from the realities of life and most of them felt that  for  attempting  suicide  it  needs  one  minute  courage  and  the  same  time  for continuing life that courage should be there in throughout the life. The researcher has identified that only small amount of respondents ‘perceived suicide from a health care point of view and viewed from mental health perspective.

“Whenever people  come  with  the  suicidal  ideas,  I  always  get  a  bunch  of negativism from that person, they are so pessimistic and they don’t have the word  hope  in  their  dictionary.  I think they are very self-centred, and they can’t think beyond that” (Female, GP).

“Suicide  very  clearly  I  can  say  that  it  is  a  foolish  act,  the  people  who  are expressing  or  threatening  their  family  or  significant  others  in  the  name  of suicide, they are really burden to the family and community also, they will do all the drama because they want attention from others or they want to fulfill their needs by threatening family members.”(Male, GP).

“Most  of  the  time  people  don’t  have  a  trust  in  their  own  life  and  opt  the suicide; I feel they are very much scared to live by thinking about the future problems  and  the  amount  of  distress  they  are  experiencing  in  the  present. People commit suicide because they don’t want to live, they don’t want to face problems” (Male, GP).

Moralistic Attitude Regarding help and Recovery Perspective:

Many of the respondents believed in the moral responsibility of health care providers to save life of the people irrespective of caste, class, religion, social status. The majority of the respondents felt that whether the suicidal person is self-centred  or  demanding  person,  irrespective  of  the  baseline  issues,  general practitioners are ready to provide basic professional help which is highly influenced on  the  concept  of  morality. Moreover,  the  moralistic  attitude  of  the  general practitioners  limited  to  the  professional  help  which  is  not  having  any  kind  of empathetic attitude or realization of the sufferings and pain of the people. GPs reported that showing empathy towards the suicidal person will not benefit in the clinical point of view, most of them believed that rather than empathy, empowerment is needed and the professional help reach to the level where people can think and act in a rational way. In a broader sense the attitude of the general practitioners regarding suicide,  suicidal  people  and  suicide  prevention  varies  between  a  continuum  of  negativistic and moralistic perspective.

“If a person comes in front of me reporting suicidal ideas, inside my mind I will feel angry and irritation, but definitely I will not show those things on the face, definitely I will help the person, I will enquire about the issues and I will provide what all I can do.  The person may be anyone, from any back ground; I always feel giving a moral support is important.”(Female, GP).

From a health care point of view I believe it is my duty  to  help  a  person  if  he/she  comes  in  front  of  me,  if  I  am  avoiding  them definitely I failed in following a moral duty of a doctor.”(Male GP).

View towards De-criminalization of Suicide:

Majority  of  the  GPs  felt  that  de-criminalization  of  suicide  increase  the  rate  of  the suicide and most of them agreed that it is a TUGLAK reform which will not benefit in the  way  to  prevent  or  reduce  the  suicidal  risk.  Many  of  the  respondents  highly criticized  the  de-criminalization  of  suicidal  act,  concluded  that  that it  will  increase burden  on  the  general  practitioners  or  those  who  are  working  in  the  medical  field. Majority of the general practitioners believed that criminal tag of suicide acted as a prevention  strategy  and  the  removal  of  criminal  tag can  easily  lead  a  person  for  opting suicide as a final solution to his/her problems.

“I think suicide should remain as a criminal activity, then there will be some fear associated with that, some scared element should be there to prevent that act.  If  we  de-  criminalize  it is  like  giving  license  to  people,  we  are  paving comfortable  way  for  committing  suicide”(Female GP)

“In  my  opinion  it  will  be  a  foolish  act  like  suicide,  at  policy  level  you  are making changes, before that you should think what will be its reflection on the society?  People will misuse that.  After de- criminalization, how we will introduce suicide in front of society? At least now we can say it’s a criminal act, so after this we can say that it’s personal act or what? I will not agree with this” (Male GP).

Religious Sentiments towards Suicide:

Majority  of  the  GPs  irrespective  of  their  religious  beliefs  responded  that  suicide happen  only  when  the  individual‘s  spiritual  and  religious  side  weakens,  and  the distance  from  the  god  act  as  a  predictor  of  the  suicidal  behaviour.  All  respondents responded  in  a  way  that  none  of  the  religion  advocates  for  the  suicidal  act  and everyone beliefs suicide as a great sin one human being can do in the life time.

“I think most of the suicidal people have no idea about their own existence. When  we  look  in  to  the  suicidal  act  people  commit  suicide  because  of  3 important miseries, one is Adyathmika: which is the suffering of a body which may  be  in  the  form  of  diseases,  physical  disabilities  etc.  Second one isAdhidaiviga:  which is the sufferings from the other kind and the third one is Adhibowdhiga:  which is sufferings from the others. If a person cannot tolerate with  the  above  mentioned  miseries  they  will  go  for  suicide,  which is  against natural law and it is the biggest sin, if a person commit suicide he/she become a  Adrupthaathma  means unsatisfied soul, this people never get  moksha  and they have to suffer after leaving the body.”(MaleGP)

“My religious scripts go against the suicidal act. No were mentioned suicide is allowed or encouraged to get salvation. Being a Muslim, I am always stands against suicide; it is a moral duty also. Life is precious, we are not supposed to take that, if we take we should have the capacity to give back; we don’t have that capacity so we are not eligible to take that.” (Female GP).

“I don’t believe that any religion will advocate for the suicidal act. My  religion stands for  the  welfare  of  the  entire  humanity  and  not  for  the  destruction  of  human self.  I  think  those  who  go  for  suicide  they  don’t  have  firm  belief  in  their religion  and  they  don’t  have  any  trust  in  god.  If they have belief in their religion they will not go for the suicidal act.” (Male GP).

Discussion:

The current study highlights the attitude of general practitioners’ regarding suicide and its prevention aspects. Attitude is one of the factors which have great impact on the actions of a person, particularly regarding the health care sector it greatly involved with the delivery of quality service.

The attitude associated with the suicide and suicidal people seems to be negative in nature, where in GPs identified it as an act followed by the cowards, sinners and fools and majority of GPs reported getting angry while listening to people having suicidal ideas. One study from Nicaragua aimed at exploring how primary health care professionals in Nicaragua perceive young people‘s mental health problems and suicidal problems. This study also revealed that doctors and nurses were reluctant to deal with people presenting with suicidal problems at the primary health care, feelings of incompetence and attitudinal differences also reported (Medina, C. O., Kullgren, G,2014)Many studies have focused on the prevalent attitudes of health professionals towards people with suicidal behaviors, suggesting that negative attitudes, criticism and devaluation are predominant among these professionals(Samuelsson, M., &Åsberg, M,2002)

With regard to the help and recovery perspective, irrespective of negativistic personal attitude towards suicide, GPs’ reflected a moralistic attitude which is associated with the professional responsibility. Another qualitative study from Ghana, also reported moralistic attitude of nurses and approach of suicide prevention from a proscriptive perspective, the attitudes of health workers toward suicide and suicide prevention seemed to be transiting between morality and mental health (Osafo, J., Knizek, B. L,2012)

De-criminalization of suicide appeared as a destructive action as per the opinion from the GPs.Majority  of  the  general  practitioners believed that criminal tag of suicide, acted as a prevention strategy and the removal of criminal tag easily led a person to opt for suicide as a final solution for his/her problems. The GPs tend to give a religious explanation for the incidents of suicide and explained people with suicidal ideas from a spiritual point of view.

Limitations of the Study:

The study represents general practitioners working in public and private sectors, and those who given written informed consent for participation. Most of the general practitioners in public sector were unwilling to participate in the study due to apprehension associated with recording of the interview, which led to unequal representation of the public and private sector participation in the study. There are several factors like age, gender and years of working experience etc are not controlled during the participant selection, which may have impact on the aspects explored in the study.

Conclusion & Implications:

Considering from a public health point of view, suicide prevention is one of the practical strategy to reduce the rate of completed suicides, where in GPs having an increased role in assessing and preventing the suicidal act. Attitudinal differences and opinions having a considerable impact on the quality services providing in the health care sector.In the current scenario, it is imperative toincorporate need based training and sensitization programmes for the general practitioners which aids in evidence based suicide prevention strategies and practice in the primary health care sector. The mental health aspect of suicide needs to be highlighted and the mental health professionals having a professional responsibility to widen the territory of capacity building and awareness creation from the grass root level.

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