Urban/rural inequalities in suicide in Scotland, 1981-1999

Although suicide accounts for a small percentage of deaths in Scotland (1.4% in 1999), it has been steadily increasing over the last two decades. In the US, Australia, England and Wales the greatest rises in suicide for this time period, occurred in rural areas. This study describes the pattern and magnitude of urban/rural variation in suicide in Scotland, examines methods of suicide within differing geographies and looks at trends in suicides over time. Scotland is split into four rurality types. Suicide data for all areas of Scotland (apart from Grampian which underwent changes in postcode sector boundaries in 1996) are investigated using Standardised Mortality Ratios (SMRs) and multilevel Poisson modelling, adjusting for age, sex and deprivation. SMRs for 1981-85, 1989-93 and 1995-99 are created across the four geographies, using the populations of Scotland in 1983, 1991 and 1997 as the standard populations (SMR=100). The highest rates in 1995-99 are seen in "remote rural" areas, SMR=125 (95% confidence interval 107-146). Models adjusted for age and deprivation show significantly greater risk of male suicide in remote rural areas relative to urban areas and significantly lower risk of female suicide in accessible rural areas. The method of suicide varies across ruralities for both males and females. The study considers how the relationship between suicides and rurality varies over time and how methods of suicide vary across different ruralities. The steepest rises in suicide amongst men, adjusting for age and deprivation, were seen to occur in accessible rural areas, however highest rates remain in remote rural areas.     

Further increases in rural suicide in young Australian adults: secular trends, 1979-2003

This study investigates changes in Australian urban-rural suicide differentials over time in the context of overall declines in (male) suicide in the late 1990s, and determines the extent to which differences in socio-economic status (SES) account for observed urban-rural trends. Suicide data were stratified for the period 1979-2003 by metropolitan, rural and remote areas and examined across five quinquennia, centred on each Australian census from 1981 to 2001. Suicide rates (per 100,000) were adjusted for confounding by sex, age, country-of-birth and the mediating effects of area SES, using Poisson regression models. Male suicide rates in metropolitan, rural and remote areas diverged significantly over time, especially in young males (15-24 years). Young male suicide rates increased significantly in metropolitan, rural and remote areas over 1979-1998, and in the most recent period (1999-2003) increased further in remote areas from 38.8 (per 100,000) to 47.9 (23% increase). In contrast suicide rates in rural areas decreased from a peak of 27.5 to 19.8 (28% decrease), and in metropolitan areas from a peak of 22.1 to 16.8 (24% decrease). Similar divergence in the 1999-2003 quinquennium, though of a lesser magnitude, was also evident for males aged 25-34 years. Female suicide rates in the earlier part of the period were significantly lower in rural and remote areas than in metropolitan areas, particularly for those aged 25-34 years, then increased in rural and remote areas to converge with female suicide rates in metropolitan areas. Adjusting for SES in addition to age and country-of-birth reduced urban-rural suicide differentials in both males and females, consistent with SES being an intermediary between rural residence and suicide. Nevertheless, urban-rural differences remained statistically significant. These results show that the largest urban-rural male suicide differentials for the 25-year study period occurred in the most recent period (1999-2003), in the context of decreasing male suicide rates overall.     

The geography of despair among 15-44-year-old men in England and Wales: putting suicide on the map

OBJECTIVE: To investigate the spatial patterning and possible contributors to the geographical distribution of suicide among 15-44- year-old men. DESIGN: Small-area analysis and mapping of geo-coded 1988-94 suicide mortality data and 1991 census data using random-effects smoothing. SETTING: 9265 electoral wards in England and Wales (mean population of men aged 15-44- years: about 1220). MAIN RESULTS: Two main patterns emerged: (a) in all of the 10 most densely populated cities studied, suicide showed a "bull's-eye" pattern with rates highest in the inner-city areas and, in some cases, low rates in the peripheries, and (b) suicide rates were high in coastal areas, particularly those in more remote regions. Possible indicators of social fragmentation, such as the proportion of single-person households in an area, were most strongly and consistently associated with rates of suicide in both urban and rural areas. Levels of unemployment and long-term illness accounted for some of the coastal patterning. Although characteristics of areas accounted for more than half of the observed variability, substantial between-area variability in rates remained unexplained. CONCLUSIONS: The area characteristics investigated here did not fully account for the higher suicide rates observed in the most rural or remote areas. Alongside social and economic aspects, rural life itself may have an independent effect on the risk of suicide. A greater understanding of local geographies of suicide, and particularly the possible interactions between characteristics of people and their environments, might assist the design of prevention strategies that target those areas (and their characteristics) where risk is concentrated.     

Urban/rural inequalities in suicide in Scotland, 1981–1999

Although suicide accounts for a small percentage of deaths in Scotland (1.4% in 1999), it has been steadily increasing over the last two decades. In the US, Australia, England and Wales the greatest rises in suicide for this time period, occurred in rural areas. This study describes the pattern and magnitude of urban/rural variation in suicide in Scotland, examines methods of suicide within differing geographies and looks at trends in suicides over time.Scotland is split into four rurality types. Suicide data for all areas of Scotland (apart from Grampian which underwent changes in postcode sector boundaries in 1996) are investigated using Standardised Mortality Ratios (SMRs) and multilevel Poisson modelling, adjusting for age, sex and deprivation. SMRs for 1981–85, 1989–93 and 1995–99 are created across the four geographies, using the populations of Scotland in 1983, 1991 and 1997 as the standard populations (SMR=100). The highest rates in 1995–99 are seen in “remote rural” areas, SMR=125 (95% confidence interval 107–146). Models adjusted for age and deprivation show significantly greater risk of male suicide in remote rural areas relative to urban areas and significantly lower risk of female suicide in accessible rural areas. The method of suicide varies across ruralities for both males and females. The study considers how the relationship between suicides and rurality varies over time and how methods of suicide vary across different ruralities. The steepest rises in suicide amongst men, adjusting for age and deprivation, were seen to occur in accessible rural areas, however highest rates remain in remote rural areas.     

Urban-rural inequalities in ischemic heart disease in Scotland, 1981-1999

OBJECTIVES: We sought to describe the pattern and magnitude of urban-rural variation in ischemic heart disease (IHD) in Scotland and to examine the associations among IHD health indicators, level of rurality, and degree of socioeconomic deprivation. METHODS: We used routine population and health data on the population aged 40-74 years between 1981 and 1999 and living in 826 small areas (average population=5600) in Scotland. Three IHD health indicators-mortality rates (deaths per 100,000 population), rates of continuous hospital stays (discharges per 100,000 population), and rates of mortality in the hospital or within 28 days of discharge (MH+) were analyzed with multilevel Poisson models. A 4-level rurality classification was used: urban areas, remote small towns, accessible rural areas, and remote rural areas. RESULTS: Rates of mortality, continuous hospital stays, and MH+ increased with area socioeconomic deprivation. After adjustment for population age, gender, and deprivation, the relative risk of IHD mortality in remote rural areas was similar to that of urban areas in 1981; the relative risk of a continuous hospital stay was significantly lower (relative risk [RR] = 0.70; 95% confidence interval [CI] = 0.64, 0.76) and the relative risk of MH+ was higher (RR=1.18; 95% CI=1.04, 1.35) in remote rural areas. Mortality and MH+ declined for all ruralities over time. However, MH+ remains highest in remote rural areas and remote towns. CONCLUSIONS: Low standardized ratios of IHD continuous hospital stays and mortality in remote rural areas mask health problems among rural populations. Although absolute and relative differences between urban and rural rates of MH+ have diminished, the relative risk of MH+ remains high in remote rural areas.     

中国人群自杀水平的变化趋势和地理分布特点

目的 深入和全面了解中国的自杀模式方法及其变化趋势。方法 使用全国疾病监测系统资料,回顾中国不同地区、不同性别、不同年龄人群的自杀水平和变化趋势,并对自杀死亡水平的地理分布进行验证。结果 1991～2000年中国人群自杀死亡处于稳定状态,没有明显下降,依然是中国人群,特别是农村人群的主要卫生问题。在农村所有地区,依然保持女性自杀死亡高于男性。在农村人群中,15～34岁有一自杀死亡高峰的独特模式,但该年龄组农村女性自杀死亡率开始呈下降趋势,对总自杀水平还没有形成显著影响。结论 目前在东中部农村地区,特别靠近几省交界地区,人群自杀死亡率普遍偏高,可能与传统文化、经济水平等因素有关,农药作为主要的自杀手段也是一个不可忽略的重要因素。未来的20年,随着社会的发展和变革,中国的独特自杀模式将会逐步发生改变。     

Suicide in Portugal: Spatial determinants in a context of economic crisis

This study compares the existing statistical association between suicide mortality and the characteristics of places of residence (municipalities), before and during the current economic crisis, in Portugal. We found that (1) the traditional culture-based North/South pattern of suicidal behaviour has faded away, while the socioeconomic urban/rural divide has become more pronounced; (2) suicide is associated with higher levels of rurality and material deprivation; and (3) recent shifts in suicidal trends may result from the current period of crisis. Strategies targeting rural areas combined with public policies that address area deprivation may have important implications for tackling suicide.     

Geography of suicide in Taiwan: spatial patterning and socioeconomic correlates

In industrialised Western nations suicide rates tend to be high in inner city areas and socially fragmented neighbourhoods. Few studies have investigated spatial variations in suicide in non-Western settings. We estimated smoothed standardised mortality ratios (1999-2007) for suicide for each of the 358 Taiwanese districts (median population aged 15+: 27,000) and investigated their associations with area characteristics using Bayesian hierarchical models. The geographic distribution of suicide was similar in men and women; young people showed the greatest spatial variation in rates. Rates were highest in East Taiwan, a mostly mountainous rural area. There was no evidence of above average rates in large cities. Spatial patterns of method-specific suicide rates varied markedly, with solids/liquids poisonings showing the greatest geographic variation and hangings the least. Factors most strongly associated with area suicide rates were median household income, population density and lone-parent households. Spatial patterning of suicide in Taiwan differed from that observed in Western nations. Suicide prevention strategies should take into account unique local patterns.     

Have urban/rural inequalities in suicide in New Zealand grown during the period 1980–2001?

Previous studies have noted that in many countries there has been a disproportionate increase in suicide in rural areas, contributing to greater urban/rural inequalities in health. This paper evaluates whether this trend was also apparent in New Zealand during the 1980s and 1990s, a period of rapid social and economic change. Using suicide incidence data for the period 1980-2001, we investigate whether urban/rural status had an effect upon rates of suicide independently of socioeconomic deprivation. While both male and female suicide rates were significantly higher in urban than rural areas in 1980-1982, by the end of the 1990s, urban/rural differences in suicide rates were not significant. The narrowing of urban/rural differences was, to some extent, a result of the growth in suicide rates in more isolated rural communities and small rural service centres. Recent geographical variations in suicide in New Zealand are therefore to a large extent similar to trends observed elsewhere, but are less marked. Potential explanations are offered for the fluctuating urban/rural inequalities in suicide including compositional arguments, rural restructuring and economic decline, social isolation and health service utilisation.     

Why are suicide rates rising in young men but falling in the elderly?-- a time-series analysis of trends in England and Wales 1950-1998

Suicide rates doubled in males aged <45 in England and Wales between 1950 and 1998, in contrast rates declined in older males and females of all ages. Explanations for these divergent trends are largely speculative, but social changes are likely to have played an important role. We undertook a time-series analysis using routinely available age- and sex-specific suicide, social, economic and health data, focussing on the two age groups in which trends have diverged most-25-34 and 60+ year olds. Between 1950 and 1998 there were unfavourable trends in many of the risk factors for suicide: rises in divorce, unemployment and substance misuse and declines in births and marriage. Whilst economic prosperity has increased, so too has income inequality. Trends in suicide risk factors were generally similar in both age-sex groups, although the rises in divorce and markers of substance misuse were most marked in 25-34 year olds and young males experienced the lowest rise in antidepressant prescribing. Statistical modelling indicates that no single factor can be identified as underlying recent trends. The factors most consistently associated with the rises in young male suicide are increases in divorce, declines in marriage and increases in income inequality. These changes have had little effect on suicide in young females. This may be because the drugs commonly used in overdose-their favoured method of suicide-have become less toxic or because they are less affected by the factors underlying the rise in male suicide. In older people declines in suicide were associated with increases in gross domestic product, the size of the female workforce, marriage and the prescribing of antidepressants. Recent population trends in suicide appear to be associated with by a range of social and health related factors. It is possible that some of the patterns observed are due to declining levels of social integration, but such effects do not appear to have adversely influenced patterns in older generations.     

Epidemiological aspects of suicide among the young in selected European countries.

Trends in reported suicide rates were analysed for the ages 5-24 years in 21 selected European countries in 1970-74 and 1980-84. In children the precision of the rates was found to be low though there appeared to be a trend to increased suicide in boys. In adolescent and young adult males, however, there was a definite increase in suicide over the period studied, and this was much more marked than in females, in whom the rates had declined in eight countries. The Belgian situation was investigated in detail. Increases were most pronounced in 20-24 year-old males. Around 1981, about half of youth suicides were committed by firearms and medicaments, and these methods showed the largest increases in risk. The estimated under-reporting error diminished with increasing age and over the past ten years. It was larger in females, but did not bias the trends substantially. On the aggregated level, youth suicide was found most strongly associated with indicators of anomie and social isolation. The relevance of these findings in the search for determinants and for preventive strategies is discussed.     

Population profile of India: past,present and future

India's 846.3 million people, who comprise 16% of the world population, inhabit just 2.4% of the total world area. India is the 2nd most populous country in the world. 74% of people live in 600,000 villages that follow traditional social and cultural practices. Population growth peaked during 1961-1981 at 2.2%/year. It began to fall slightly during 1981-1991 to 2.1%/year. Even though those younger than 15 years old comprise the largest population age group (39.6%), the group is decreasing (42% in 1971). India's dependency ratio is 0.9 for both children and the elderly and 0.8 for children alone. India has an excess number of males (929 females/1000 males), due largely to discrimination against females. Pregnancy and child birth are responsible for female death rates peaking at ages 15-29. Delayed marriages are more common than in the past (6.6% in 1981 and 19% in 1961). Most internal migration is from rural area to rural area (especially for females leaving their parents' home to go to that of their husband's) and rural area to urban area. Population density varies by state from 10 people/sq. km. to 6319 people/sq. km (mean = 267/sq. km.). Total fertility is 3.9 in rural areas and 2.7 in urban areas. 71% of births have a birth interval of less than 3 years. The 1985-1990 death rate in India compares to that of developed countries (9.8 vs. 10), but its infant mortality rate is still high (79 vs. 15). The population projections for 2001-2006 of the Standing Committee on Population Projections are 1003.1 million for population size, 23 for birth rate and 7.8 for death rate. It expects the population to stabilize (i.e., 0 growth rate) at 1.5 billion around 2080. This figure is much less than that of the World Bank's projection.     

Increasing inequalities in risk of murder in Britain: trends in the demographic and spatial distribution of murder, 1981-2000

This study analyses demographic and spatial factors that underlie the rise in murder rates seen in Britain between 1981 and 2000 and considers the possible contribution of a public health approach to the understanding of murder. Comparison of murder rates by age group and sex finds that increases occurred only among males aged 5-59 years, and were greatest among males aged 20-24 years. Analysis of the relationship with poverty at the area level, using the Breadline Britain index and deciles based on wards, demonstrates that increases in murder rates were concentrated in the poorest areas. Rates of murder have risen in the same population groups and areas that have experienced increases in suicide and may be associated with worsening social and spatial inequality.     

Increasing rural-urban gradients in US suicide mortality, 1970-1997

OBJECTIVES: This study examined rural-urban gradients in US suicide mortality and the extent to which such gradients varied across time, sex, and age. METHODS: Using a 10-category rural-urban continuum measure and 1970-1997 county mortality data, we estimated rural-urban differentials in suicide mortality over time by multiple regression and Poisson regression models. RESULTS: Significant rural-urban gradients in age-adjusted male suicide mortality were found in each time period, indicating rising suicide rates with increasing levels of rurality. The gradient increased consistently, suggesting widening rural-urban differentials in male suicides over time. When controlled for geographic variation in divorce rate and ethnic composition, rural men, in each age cohort, had about twice the suicide rate of their most urban counterparts. Observed rural-urban differentials for women diminished over time. In 1995 to 1997, the adjusted suicide rates for young and working-age women were 85% and 22% higher, respectively, in rural than in the most urban areas. CONCLUSIONS: The slope of the relationship between rural-urban continuum and suicide mortality varied substantially by time, sex, and age. Widening rural-urban disparities in suicide may reflect differential changes over time in key social integration indicators.     

Substance Abuse by Youth and Young Adults in Rural America

ABSTRACT:  Purpose: Addressing substance abuse in rural America requires extending our understanding beyond urban-rural comparisons to how substance abuse varies across rural communities of different sizes. We address this gap by examining substance abuse prevalence across 4 geographic levels, focusing on youth (age 12-17 years) and young adults (age 18-25 years). Methods: The analysis is based on 3 years (2002-2004) of pooled data from the National Survey on Drug Use and Health. We measure rurality using a four-tier consolidation of the 2003 Rural-Urban Continuum Codes: urban, rural-adjacent, rural-large, and rural-small and medium. Findings: Rural youth have higher alcohol use and methamphetamine use than urban youth and the more rural the area, the higher the use. Rural young adults living in rural-large areas have higher rates of substance abuse than their urban peers; those living in the most rural areas have nearly twice the rate of methamphetamine use as urban young adults. Rural youth are more likely than urban youth to have engaged in the high-risk behavior of driving under the influence of alcohol or other illicit drugs. Conclusions: Higher prevalence rates, coupled with high-risk behavior, place rural youth and young adults at risk of continued substance use and problems associated with this use. Rural community infrastructure should be enhanced to support substance abuse prevention and intervention for these populations.     

Rural/urban mortality differences in England and Wales and the effect of deprivation adjustment

Perceptions that rural populations are inevitably healthier and live longer than urban populations are increasingly being challenged. But very few publications have investigated the extent to which these putative differences can be explained by variation in area composition. Existing publications have tended to use conventional deprivation measures, often thought to mask rural deprivation by favourable averages. Further, they have typically been based on large and variably-sized geographical units, or confined to studies of a single region or cause of death. This study examines differences in mortality between rural and urban areas in the entire population of England and Wales for 2002-2004. It uses the most up-to-date small geographical units of similar size and homogeneity of population together with the recently-introduced Rural and Urban Area Classification, and adjusts for five different deprivation measures (including modern composite indices). The causes of death investigated were all-cause mortality, cancer, lung cancer, respiratory disease, circulatory disease, suicide and accidents. Particular points of focus for the study were the potential for interaction between deprivation and rurality, and the importance of choice of deprivation measure in quantifying the relationships between mortality, rurality and deprivation. Choice of deprivation measure was not found to alter the substantive conclusions of any analysis, and little evidence for differential effects of deprivation in rural and urban areas was uncovered. Differences between rural and urban areas in all-cause, circulatory disease and cancer mortality could largely be accounted for by adjusting for deprivation. For these causes of death, therefore, rural populations were not found to be inherently healthier than their urban counterparts. However, substantial residual differences between rural and urban areas were found in comparisons of mortality from lung cancer and respiratory disease, mortality being lower in rural areas. Stronger relationships between rurality and mortality were found in 'village and dispersed' settlements.     

Urban and rural suicide differentials in migrants and the Australian-born, New South Wales, Australia 1985--1994.

We estimated risk of suicide in adults in New South Wales (NSW) by sex, country of birth and rural/urban residence, after adjusting for age; we also examined youth suicide (age 15-24 years). The study population was the entire population of NSW, Australia, aged > or =15 years during the period 1985-1994. Poisson regression was used to examine the relationship between predictor variables and the risk of suicide, with the focus on migrant status and area of residence. A significantly higher risk of suicide was found in male migrants from Northern Europe and Eastern Europe/former USSR, compared to Australian-born males; a significantly lower suicide risk occurred in males from Southern Europe, the Middle East and Asia. In female migrants, those from UK/Eire, Northern Europe, Eastern Europe/former USSR and New Zealand exhibited a significantly higher risk of suicide compared to Australian-born females. A significantly lower risk of suicide occurred in females from the Middle East. Male migrants overall were at significantly lower risk of suicide than the Australian-born, while female migrants overall had a significantly higher risk of suicide than Australian-born females. Among migrant males overall, the rural-urban suicide risk differential was significantly higher for those living in non-metropolitan areas (RR = 1.9; 95% CI: 1.7-2.1). Suicide risk was significantly higher in non-metropolitan male immigrants from the UK/Eire (RR = 1.4; 95% CI: 1.1-1.7), Southern Europe (RR = 1.7; 95% CI: 1.2-2.4), Northern/Western Europe (1.5; 95% CI: 1.2-1.9), the Middle East (RR = 3.8; 95% CI: 1.9-7.8), New Zealand (RR = 1.4; 95% CI: 1.0-1.8) and 'other' (RR = 2.6; 95% CI: 1.9-3.5), when compared to their urban counterparts. There was no statistically significant difference in suicide risk between rural and urban Australian-born males. For female suicide, significantly lower risk was found in female immigrants living in non-metropolitan areas who were from Northern/Western Europe (RR = 0.7; 95% CI: 0.4-0.96), as well as the Australian-born (RR = 0.7; 95% CI: 0.6-0.8), when compared to their urban counterparts. The non-metropolitan/metropolitan relative risk for suicide in female migrants overall was not significantly different from one. Among male youth there was a significantly higher suicide risk in non-metropolitan areas, with a relative risk estimate of 1.4 for Australian-born youth (95% CI: 1.2-1.5) and 1.7 for migrant youth (95% CI: 1.2-2.4), when compared with metropolitan counterparts. We conclude that suicide among migrant males living in non-metropolitan areas accounts for most of the excess of male suicide in rural NSW, and the significantly lower risk of suicide for non-metropolitan Australian-born women does not apply to migrant women.     

四川省1993-2002年自杀死亡的流行病学分析

目的对四川省综合疾病监测系统1993-2002年自杀死亡监测资料进行流行病学分析,以期掌握自杀死亡概况,为发展预防和控制死亡的策略提供依据。方法采用EXCEL录入整理数据,用PEMS3.0对1993-2002年10年的自杀死亡监测资料做流行病学分析结果10年平均自杀死亡率14.72/10万,女性高于男性,农村高于城市,15～25岁及60岁以后自杀死亡率较高,自杀方式以服毒和上吊居多,原因以家庭纠纷和久病不愈居多,时间上以春夏居多。结论四川省综合疾病监测系统自杀死亡率低于估计的全国自杀死亡率;自杀预防控制重点人群为女性,重点地区为农村,重视青少年和中年人群的预防,主要策略为发展社区卫生、加强健康教育、加强农药管理。     

Alcohol consumption predicts the EU suicide rates in young women aged 15-29 years but not in men: analysis of trends and differences among early and new EU countries since 2004

The aims of this study were to study suicide rates in youths aged 15-29 years in the European Union (EU), to identify differences between early members and new members to the EU since 2004, and to evaluate the association between alcohol-related variables and suicide rates, while controlling for indicators of social stress. We explored temporal trends in age-adjusted suicide rates for youths aged 15-29 years resident in EU nations since 1980. Social changes in EU nations were associated with increased inequalities between the countries in suicide, especially in male youths (new/early EU members: relative risk = 1.55; 95% confidence interval: 1.48/1.61). Pure alcohol consumption predicts suicide rates in female youths, whereas social stress related to violence against youths predicts suicide rates in male youths. EU political and heath agencies should devise policies to prevent youth suicide with a focus on alcohol misuse and societal stress associated with violence against youths.     

Suicide trends among youths and young adults aged 10-24 years--United States, 1990-2004

In 2004, suicide was the third leading cause of death among youths and young adults aged 10-24 years in the United States, accounting for 4,599 deaths. During 1990-2003, the combined suicide rate for persons aged 10-24 years declined 28.5%, from 9.48 to 6.78 per 100,000 persons. However, from 2003 to 2004, the rate increased by 8.0%, from 6.78 to 7.32, the largest single-year increase during 1990-2004. To characterize U.S. trends in suicide among persons aged 10-24 years, CDC analyzed data recorded during 1990-2004, the most recent data available. Results of that analysis indicated that, from 2003 to 2004, suicide rates for three sex-age groups (i.e., females aged 10-14 years and 15-19 years and males aged 15-19 years) departed upward significantly from otherwise declining trends. Results further indicated that suicides both by hanging/suffocation and poisoning among females aged 10-14 years and 15-19 years increased from 2003 to 2004 and were significantly in excess of trends in both groups. The results suggest that increases in suicide and changes in suicidal behavior might have occurred among youths in certain sex-age groups, especially females aged 10-19 years. Closer examination of these trends is warranted at federal and state levels. Where indicated, health authorities and program directors should consider focusing suicide-prevention activities on these groups to help prevent suicide rates from increasing further.