|Year : 2022 | Volume
| Issue : 2 | Page : 57-62
Suicidal ideation and associated factors among clients of primary care and religious care centers in Thailand
Karl Peltzer1, Supa Pengpid2
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 Submission||18-Sep-2021|
|Date of Decision||21-Dec-2021|
|Date of Acceptance||15-Jan-2022|
|Date of Web Publication||23-May-2022|
Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
Source of Support: None, Conflict of Interest: None
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|| |
Traditional and faith healers form a major part of the mental health-care workforce worldwide. 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. “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.” “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.”,
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. Suicidal mortality rate is 14 per 100,000 in 2016 in Thailand. For every suicidal death, there are many more persons who engage in suicidal behavior (ideation, plans or attempts). For suicide prevention to work, the epidemiological profile of suicidal ideation in different care settings is needed. Globally, in ten low- and middle-income countries, 2.1% of adults reported suicidal ideation (past 12 months). 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), 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, and among Thai university students 9.0% reported suicidal ideation.
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).
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.,,,,,, 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|| |
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. 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.”
|Figure 1: Schematic presentation of sampling of clients of religious and primary care centers in Thailand|
Click here to view
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, 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.
Suicidal ideation was assessed with the ninth question of the Patient Health Questionnaire-9 (PHQ-9). 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).”
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.” 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. (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. The PHQ-9 has been validated for use in Thailand. 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.” (Cronbach's alpha was 0.91 in this sample).
Somatization disorder was assessed with the “PHQ-15 somatic symptoms (PHQ-15). “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.” (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.”
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.
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|| |
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].
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].
| Discussion|| |
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%), and the prevalence of suicidal ideation in primary care clients was similar to a study among adult women in Thailand (8%), and among Thai university students (9.0%), but higher than in a study among adults in ten low-and middle-income countries (2.1%, past 12 months). Similar rates of suicidal ideation were also found in an adult community sample in England (11%, past 2 weeks), but higher than in Lagos State, Nigeria (7.3%, past 2 weeks), using the same measure of suicidal ideation as in our study.
Consistent with previous research (older age,, not married, lower education. and low social support), 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,,, we did not significant sex differences in the prevalence of suicidal ideation.
In agreement with previous research (anxiety, depression,,, psychological distress, and somatization), 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). In a previous review in low-and middle-income countries, 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, 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. Unlike some previous findings,,, 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.
Suicidal ideation was only assessed with a single item. Despite this being accepted in a number of studies,,, 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|| |
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nortje G, Oladeji B, Gureje O, Seedat S. Effectiveness of traditional healers in treating mental disorders: A systematic review. Lancet Psychiatry 2016;3:154-70.
Peltzer K, Pengpid S, Puckpinyo A, Yi S, Anh le V. The utilization of traditional, complementary and alternative medicine for non-communicable diseases and mental disorders in health care patients in Cambodia, Thailand and Vietnam. BMC Complement Altern Med 2016;16:92.
Adthasit R, Kulsomboon S, Chantraket R, Suntananukan S, Jirasatienpong P. The situation of knowledge management and research in the area of local wisdom in health care. In: Petrakard P, Chantraket R, editors. The Report Situations of Thai Traditional Medicine, Indigenous Medicine and Alternative Medicine 2005–2007. Nonthaburi: Mnat Films; 2007. p. 16-22.
Chan-iam W, Yodmalee B, Nakornriab M. Thai traditional medicine at wat nong ya nang buddhist, Uthai Thani province. J Food Health Bioenviron Sci 2019;12:40-7.
Kaewla W, Wiwanitkit V. Local primary health care by local religious center: A case study of a Mahayana Buddhist temple, Thailand. Ann Trop Med Public Health 2015;8:226. [Full text]
Joe S, Stein DJ, Seedat S, Herman A, Williams DR. Non-fatal suicidal behavior among South Africans: Results from the South Africa stress and health study. Soc Psychiatry Psychiatr Epidemiol 2008;43:454-61.
Borges G, Nock MK, Haro Abad JM, Hwang I, Sampson NA, Alonso J, et al.
Twelve-month prevalence of and risk factors for suicide attempts in the world health organization world mental health surveys. J Clin Psychiatry 2010;71:1617-28.
Peltzer K, Pengpid S. Associations between intimate partner violence, depression, and suicidal behavior among women attending antenatal and general outpatients hospital services in Thailand. Niger J Clin Pract 2017;20:892-9.
] [Full text]
Peltzer K, Yi S, Pengpid S. Suicidal behaviors and associated factors among university students in six countries in the Association of Southeast Asian Nations (ASEAN). Asian J Psychiatr 2017;26:32-8.
Musyimi CW, Mutiso VN, Nayak SS, Ndetei DM, Henderson DC, Bunders J. Quality of life of depressed and suicidal patients seeking services from traditional and faith healers in rural Kenya. Health Qual Life Outcomes 2017;15:95.
Adewuya AO, Ola BA, Coker OA, Atilola O, Zachariah MP, Olugbile O, et al.
Prevalence and associated factors for suicidal ideation in the Lagos State Mental Health Survey, Nigeria. BJPsych Open 2016;2:385-9.
Breet E, Goldstone D, Bantjes J. Substance use and suicidal ideation and behaviour in low and middle-income countries: A systematic review. BMC Public Health 2018;18:549.
Carrasco-Barrios MT, Huertas P, Martín P, Martín C, Castillejos MC, Petkari E, et al.
Determinants of suicidality in the European general population: A systematic review and meta-analysis. Int J Environ Res Public Health 2020;17:4115.
Fässberg MM, Cheung G, Canetto SS, Erlangsen A, Lapierre S, Lindner R, et al.
A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Aging Ment Health 2016;20:166-94.
Mulholland H, McIntyre JC, Haines-Delmont A, Whittington R, Comerford T, Corcoran R. Investigation to identify individual socioeconomic and health determinants of suicidal ideation using responses to a cross-sectional, community-based public health survey. BMJ Open 2021;11:e035252.
Ribeiro JD, Huang X, Fox KR, Franklin JC. Depression and hopelessness as risk factors for suicide ideation, attempts and death: Meta-analysis of longitudinal studies. Br J Psychiatry 2018;212:279-86.
Pengpid S, Peltzer K. Prevalence and correlates of suicidal behavior among a national population-based sample of adults in Kiribati. Asia Pac Psychiatry 2020;13:e12444. [doi: 10.1111/appy. 12444]
Pengpid S, Peltzer K. Common mental disorders among patients attending monk healers and primary health care centres in Thailand: A cross-sectional study. Int J Ment Health Syst 2020;14:78.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
Njiro BJ, Ndumwa HP, Msenga CJ, Kawala T, Matola E, Mhonda J, et al.
Depression, suicidality and associated risk factors among police officers in urban Tanzania: A cross-sectional study. Gen Psychiatr 2021;34:e100448.
Kocalevent RD, Berg L, Beutel ME, Hinz A, Zenger M, Härter M, et al.
Social support in the general population: Standardization of the Oslo social support scale (OSSS-3). BMC Psychol 2018;6:31.
Ali R, Meena S, Eastwood B, Richards I, Marsden J. Ultra-rapid screening for substance-use disorders: The alcohol, smoking and substance involvement screening test (ASSIST-lite). Drug Alcohol Depend 2013;132:352-61.
Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord 2009;114:163-73.
Lotrakul M, Sumrithe S, Saipanish R. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry 2008;8:46.
Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166:1092-7.
Kroenke K, Spitzer RL, Williams JB. The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002;64:258-66.
Pengpid S, Peltzer K. Prevalence and correlates of suicidal behaviour among adults in Malawi: A nationally representative cross-sectional survey in 2017. Int J Ment Health Syst 2021;15:57.
Pengpid S, Peltzer K. Prevalence and correlates of suicidal behaviour among a national population-based sample of adults in Zambia. S Afr J Psychiatr 2021;27:1566.
[Table 1], [Table 2]