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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 57-62

Suicidal ideation and associated factors among clients of primary care and religious care centers in Thailand


1 Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan; Department of Research Administration and Development, University of Limpopo, Polokwane, South Africa
2 Department of Research Administration and Development, University of Limpopo, Polokwane, South Africa; ASEAN Institute for Health Development, Mahidol University, Nakhon Pathom, Thailand

Date of Submission18-Sep-2021
Date of Decision21-Dec-2021
Date of Acceptance15-Jan-2022
Date of Web Publication23-May-2022

Correspondence Address:
Karl Peltzer
Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/shb.shb_101_21

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  Abstract 


Introduction: Suicidal ideation is a public health concern. The percentage of prevalence of suicidal ideation found among attendees of primary and religious care centers in Thailand is unclear. The aim of this study was to evaluate suicidal ideation and associated factors among clients of primary care and religious care centers in Thailand. Methods: In a cross-sectional interview survey, 1214 consecutively sampled adult clients from three religious and three primary care centers participated in the study in 2018–2019. They completed information on suicidal ideation, social and demographic factors, chronic conditions, and mental and substance use disorders. Logistic regression was used to assess predictors of suicidal ideation. Results: One in ten clients (10.0%) reported suicidal ideation. The prevalence of suicidal ideation was higher in clients attending religious compared to primary care, but the difference was not significant. In adjusted logistic regression analysis, depressive disorder (adjusted odds ratio [AOR]: 3.49, 3.49, 95% confidence interval [CI]: 1.86–6.56), anxiety disorder (AOR: 6.03, 95% CI: 2.82–12.95), somatization disorder (AOR: 2.03, 95% CI: 1.17–3.53), cancer (AOR: 2.56, 95% CI: 1.02–6.50), and sore joints (AOR: 2.24: 95% CI: 1.16–4.31) were positive associated with suicidal ideation, while secondary education (AOR: 0.39, 95% CI: 0.20–0.77), employed (AOR: 0.52, 95% CI: 0.32–0.85), and high social support (AOR: 0.28, 95% CI: 0.13–0.56) were negatively associated with suicidal ideation. Conclusion: The prevalence of suicidal ideation was higher in clients attending religious care compared to primary care, but the difference was not significant. Factors associated with suicidal ideation include sociodemographic factors, mental disorders, and chronic conditions.

Keywords: Comparative study, primary care, religious care, suicidal ideation, Thailand


How to cite this article:
Peltzer K, Pengpid S. Suicidal ideation and associated factors among clients of primary care and religious care centers in Thailand. Asian J Soc Health Behav 2022;5:57-62

How to cite this URL:
Peltzer K, Pengpid S. Suicidal ideation and associated factors among clients of primary care and religious care centers in Thailand. Asian J Soc Health Behav [serial online] 2022 [cited 2022 Jun 30];5:57-62. Available from: http://www.healthandbehavior.com/text.asp?2022/5/2/57/345818




  Introduction Top


Traditional and faith healers form a major part of the mental health-care workforce worldwide.[1] In a study among out-patients with chronic diseases, including mental disorders, in Thailand, 26.3% had been consulting traditional health practitioners in the past year.[2] “Traditional healers, including spiritual, herbal, and massage healers and traditional midwives, are distributed all over Thailand operating from their homes, religious institutions and health care facilities.”[3] “Buddhist monks who are Thai traditional healers provide treatment, including Thai traditional medicine and indigenous practices, to the public in the Buddhist temple where they reside.”[4],[5]

Suicide is a major global public health concern, with about 800,000 killed by suicide annually, and most (79%) suicides occur in low-and middle-income countries.[6] Suicidal mortality rate is 14 per 100,000 in 2016 in Thailand.[7] For every suicidal death, there are many more persons who engage in suicidal behavior (ideation, plans or attempts).[6] For suicide prevention to work, the epidemiological profile of suicidal ideation in different care settings is needed.[8] Globally, in ten low- and middle-income countries, 2.1% of adults reported suicidal ideation (past 12 months).[9] Few studies investigated suicidal ideation in the adult population in Thailand. For example, among Thai adult women, the prevalence of suicidal ideation was 8% (22 of 284),[10] among women exposed to intimate partner violence in outpatient clinics in the central region of Thailand, 17.6% reported past 12-month suicidal threats/attempts,[11] and among Thai university students 9.0% reported suicidal ideation.[12]

We could not find any study investigating suicidal ideation in a religious care setting in Thailand and in Asia. In a study among attendees of traditional and faith healers in Kenya, the prevalence of suicidal ideation was 5.9% (n = 26).[13]

Factors associated with suicidal ideation may include age, female sex, not married, lower socioeconomic status, low social support, psychosocial distress, depression, anxiety, somatic symptoms, substance use, chronic illness and disability.[14],[15],[16],[17],[18],[19],[20] We assumed that sociodemographic factors, mental problems and chronic conditions influence the prevalence of suicidal ideation in different care settings in Thailand. The aim of this study was to evaluate suicidal ideation and associated factors among clients of primary care and religious care centers in Thailand.


  Methods Top


Sample and procedure

The study design is a cross-sectional study of adult clients attending two different treatment settings, purposely selected monk healers (n = 3) and primary care (n = 3) sites in two regions of Thailand. Clients attending any of the two treatment settings were consecutively screened by trained external interviewers. [Figure 1] shows a recruitment flowchart for the study. Further study procedures are provided elsewhere.[21] Briefly, “purposeful sampling was used to select three monk healers or temples and three primary health-care centers located in four districts of the eastern and central region of Thailand. The inclusion criteria for the selection of the study sites were to have at least five patients a day and the inclusion criteria for the selection of clients or patients were aged 18 years and older. The study was conducted from November 2018 to February 2019.”[21]
Figure 1: Schematic presentation of sampling of clients of religious and primary care centers in Thailand

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Sample size estimation

Using the assumptions of the prevalence of suicidal ideation of 5.9% based on a previous survey assessing suicidal ideation in clients attending traditional and faith healers in Kenya,[13] a minimum sample size of 315 was required (confidence interval [CI] = 95%, acceptable margin of error 3%, minimum cluster size = 105). In this study, we collected more than 580 in each setting, which is more than the minimum sample size.

Measures

Suicidal ideation was assessed with the ninth question of the Patient Health Questionnaire-9 (PHQ-9).[22] Participants were asked “how often over the last 2 weeks they have been bothered by thoughts that they would be better off dead or hurting oneself in anyway. If the responses were either for several days, more than half the days or nearly every day, they were considered to have suicidality (suicidal ideation).”[23]

Socioeconomic data included subjective economic status (extent of debts), employment status, education, sex, age, and marital status.

Support from the social network was assessed with the “Oslo 3-items Social Support Scale (OSSS-3),” covering “the number of people the respondent feels close to the interest and concerns shown by others, and the ease of obtaining practical help from others.”[24] Summed scores were classified into “3–8 = poor, 9–11 = moderate, and 12–14 strong support.” (Cronbach's alpha was 0.76 in this sample).

The “Ultrarapid Alcohol, Smoking, and Substance Involvement Screening Test -Lite” was sourced to measure substance use disorders.[25] (Cronbach's alpha was 0.89 in this sample).

Depressive symptoms were assessed with the PHQ-8, with a cutoff score of 10 indicating clinically significant depressive symptoms.[26] The PHQ-9 has been validated for use in Thailand.[27] Cronbach's alpha for the PHQ-8 was 0.87 in this study.

General anxiety disorder was assessed with the “Generalized anxiety disorder 7-item.”[28] (Cronbach's alpha was 0.91 in this sample).

Somatization disorder was assessed with the “PHQ-15 somatic symptoms (PHQ-15).[29] “The somatic symptoms severity were calculated by assigning scores at 0, 1, and 2 to the response categories of not at all, bothered a little, and bothered a lot for the 15 somatic symptoms, with cut-off scores ≥10 indicating moderate or high somatic symptom severity.”[29] (Cronbach's alpha was 0.84 in this sample).

Chronic conditions include health-care provider-diagnosed “cancer or malignancy of any kind (malignant neoplasms), diabetes or blood sugar, emphysema/asthma, heart attack or angina, hypertension or high blood pressure, sore joints, and stroke.”[21]

Ethical considerations

The study was approved by the “Office of The Committee for Research Ethics (Social Sciences), Mahidol University (No. 2017/055.1403),” and written informed consent was obtained from the participants.

Statistical analysis

Pearson's Chi-square tests were used for comparing the prevalence of suicidal behavior with categorical sociodemographic and health variables. Multivariable logistic regression was used to assess the independent contribution of sociodemographic factors, mental disorders, and chronic conditions to suicidal ideation. Missing data were excluded, and P < 0.05 was considered significant. Data were analyzed using “IBM-SPSS for Windows, version 25 (Chicago, IL, USA).”


  Results Top


Sample characteristics

The sample included 1214 clients, 48.4% attending religious care, and 51.6% attending primary health care. The overall prevalence of suicidal ideation was 10.0%, 10.7% among attenders of religious care and 9.4% among primary care attendees. The majority of participants (57.9%) were 45 years and older, 74.7% were women, 48.0% had secondary or higher education and 27.7% had high social support. Almost one in ten (8.8%) had a substance use disorder, 10.8% depressive disorder, 5.8% anxiety disorder, and 15.9% somatization disorder. In terms of chronic conditions, 25.5% had hypertension, 15.2% diabetes, 4.1% cancer, 5.4% heart attack, angina or stroke, 10.2% bone or joints disorders. The highest prevalence of suicidal ideation was found among participants with anxiety disorder (58.6%), followed by depressive disorder (42.7%) and sedative use disorder (41.2%) (use of sedatives or sleeping medications not prescribed). Suicidal ideation increased with age, lower education, not employed, high in debt, not married, low social support, any substance use disorder, sedative use disorder, sedative use, depressive disorder, anxiety disorder, somatization disorder, hypertension, diabetes, cancer, sore joints, such as arthritis and gout [Table 1].
Table 1: Sample and suicidal ideation characteristics

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Associations with suicidal ideation

In adjusted logistic regression analysis, depressive disorder (adjusted odds ratio [AOR]: 3.49, 3.49, 95% CI: 1.86–6.56), anxiety disorder (AOR: 6.03, 95% CI: 2.82–12.95), somatization disorder (AOR: 2.03, 95% CI: 1.17–3.53), cancer (AOR: 2.56, 95% CI: 1.02–6.50), and sore joints (AOR: 2.24: 95% CI: 1.16–4.31) were positive associated with suicidal ideation, while secondary education (AOR: 0.39, 95% CI: 0.20–0.77), employed (AOR: 0.52, 95% CI: 0.32–0.85), and high social support (AOR: 0.28, 95% CI: 0.13–0.56) were negatively associated with suicidal ideation [Table 2].
Table 2: Associations with suicidal ideation

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  Discussion Top


This is the first study to assess the prevalence and correlates of suicidal ideation in clients attending religious and primary care institutions. The prevalence of suicidal ideation (10.0%, past 2 weeks) was higher in clients attending religious care (10.7%) than primary care attendees (9.4%), but the difference was not significant. The prevalence of suicidal ideation in religious care clients in this study was higher than in a study among attendees of traditional and faith healers in Kenya (5.9%),[13] and the prevalence of suicidal ideation in primary care clients was similar to a study among adult women in Thailand (8%),[10] and among Thai university students (9.0%),[12] but higher than in a study among adults in ten low-and middle-income countries (2.1%, past 12 months).[9] Similar rates of suicidal ideation were also found in an adult community sample in England (11%, past 2 weeks),[18] but higher than in Lagos State, Nigeria (7.3%, past 2 weeks),[14] using the same measure of suicidal ideation as in our study.

Consistent with previous research (older age,[14],[30] not married,[14] lower education.[20] and low social support[16]), we found that social and demographic factors (lower education, not employed, low social support, and in bivariate analysis older age, and high debt status) were associated with suicidal ideation. Unlike some previous studies that found an association between female sex and suicidal ideation,[14],[16],[31] we did not significant sex differences in the prevalence of suicidal ideation.

In agreement with previous research (anxiety, depression,[14],[18],[19] psychological distress,[20] and somatization[14]), mental disorders (depressive symptoms, anxiety disorder, and somatization disorder) were associated with suicidal ideation. Interestingly, anxiety disorder had higher odds (6.03) than depressive symptoms (3.49) of suicidal ideation in this study, which was the reverse in the study in Nigeria (anxiety 1.71 and depression 14.48).[14] In a previous review in low-and middle-income countries,[15] substance use (”alcohol, tobacco, cannabis, illicit drugs, nonmedical use of prescription drugs”) were found associated with suicidal ideation and behavior. In bivariate analysis any substance use disorder, and in particular sedative use disorder, were found associated with suicidal ideation in this study. While a previous study in Zambia,[31] found an association between alcohol use disorder and suicidal behavior, we did not find this association.

The study found a positive association between having cancer, sore joints and in bivariate analysis, hypertension and diabetes with suicidal ideation. Previous research also showed an association between cancer and suicidal ideation.[18] Unlike some previous findings,[20],[30],[31] that found an association between heart attack, angina or stroke and suicidal behavior, we did not find such an association in this study. In a systematic review malignant diseases (perhaps because of the life-threatening nature), pain, and arthritis/arthrosis, but not cardiovascular disease and diabetes, were associated with suicidal behavior among older adults.[17]

Limitations

Suicidal ideation was only assessed with a single item. Despite this being accepted in a number of studies,[14],[18],[23] future studies may include full suicidal ideation scales. Similarly, we assessed common mental and substance use disorders with screening measures, rather that diagnostic interviews, which should be included at least on a sub-sample in future research. Furthermore, the study sites were not randomly selected and could have biased some results.


  Conclusion Top


This is the first comparative study of clients with suicidal ideation attending religious and primary care centers in Thailand. One in ten clients reported suicidal ideation. The prevalence of suicidal ideation was higher in clients attending religious compared to primary care, but the difference was not significant. Factors associated with suicidal ideation included lower education, not employed, low social support, depressive disorder, anxiety disorder, somatization disorder, cancer, and sore joints, while secondary education.

Suicidal ideation is common among attendees of both primary and religious care centers in Thailand. Future research may want to investigate the efficacy of the management of suicidal ideation in the two different care settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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