1. WOMEN, SUICIDE AND CULTURE IN TAJIKISTAN: IDENTIFYING AND ADDRESSING CORRELATED FACTORS Presented at: American Public Health Association 133d Annual Meeting Philadelphia, Pennsylvania December 10-14, 2005

2. Alisher Latypov, MA, MHS Country Program Director Global Program on Psychiatry Tajikistan alytypov@gip-global.org Irene Jillson, Ph.D. Adjunct Assistant Professor Georgetown University School of Nursing and Health Studies Washington, D.C. iaj@georgetown.edu

3. Uzbekistan Kyrgyzstan China Khojent Dushanbe SOGD REGION GORNO-BADAKHSHAN Afghanistan HATLON REGION Khorog Kurgan-Tube Republic of Tajikistan Afghanistan Uzbekistan

4. STUDY RESEARCHERS, LOCATION, AND TIMING Study conducted voluntarily by Dr. Alisher Lytypov and Dr. Irene Jillson in Dushanbe, Tajikistan and surrounding rural areas in 2004

5. STUDY PURPOSE Long-range: to design cost-effective, community-based prevention approaches Short-term: To explore the reasons for suicide generally and self-immolation specifically among women in Tajikistan To explore use of a qualitative approach to exploring this sensitive topic in Tajikistan

6. STUDY METHODS Qualitative, including Semi-structured interviews conducted with 6 health providers at a major burn treatment facility in Dushanbe 15 women attending a health clinic in Dushanbe Review of available policy and other documents

7. WHAT IS KNOWN ABOUT FEMALE SUICIDE IN TAJIKISTAN?

8. "Every month, about 30 women are taken to a Dushanbe hospital with severe burns from such suicide attempts." (Shabad, 1998) 47 people killed themselves in the Sogd region in the first 6 months of 2003… The average age of suicides is falling, with most victims typically between 14 and 26 years of age, and women account for the vast majority; many of them are cases of self-immolation. (Zokirova, 2003)

9. RESPONSES FROM HEALTH CARE PROVIDERS AT THE REPUBLICAN BURN CENTER

10. REPORTED ATTEMPTED CASES IN RECENT PAST Women attempting suicide presenting to the Dushanbe Burn Center in Dushanbe: 45 cases in 2001 60 cases in 2002 48 cases in 2003 between 15 and 20 cases during the first 5 months of 2004

11. RESPONSE OF HEALTH CARE SYSTEM Few mental health services at any level Few mental health providers Minimal training of physicians and nurses to respond to attempted suicides in villages Minimal prevention services

12. PROFILE OF DOCUMENTED CASES OF ATTEMPTED SUICIDE Age between 16 and mid-30s Education 8 attended or completed university education 5 completed 8 th grade or less 2 completed high school Rural and urban residents

13. METHODS OF ATTEMPTED SUICIDE Significant differences by rural/urban areas: Rural: self-immolation and drowning Urban: gas, overdosing on medications

14. IN THEIR OWN WORDS: TAJIK WOMENS EXPERIENCE WITH ATTEMPTED SUICIDE

15. PERSONAL EXPERIENCE WITH SUICIDE All of the respondents have either attempted suicide or have had suicidal thoughts All of the respondents personally know at least one woman who has committed suicide and several know more than one; live in a community in which at least one woman has committed suicide; for several, more than one woman has done so

16. PERCEPTION OF REASONS THAT WOMEN COMMIT SUICIDE Domestic violence, polygamy Financial problems/unemployment of husbands Problems with mother-in-law/ sister(s)-in- law Adultery (cheating)

17. PERCEPTION OF REASONS THAT WOMEN COMMIT SUICIDE Alcohol abuse Mental disorders Among young girls, when their boyfriend has sex with them, promising to marry, but does not keep his word copycatting other womens example (social learning)* *Identified by providers at Burn Center

19. PERCEPTION OF REASONS THAT WOMEN COMMIT SUICIDE General Feelings Of Unhappiness and lack of resources/services for care most women do nothing, use self-care (e.g., listening to music, talking with friends), or go to a local healer none had been to a trained modern health provider.

20. REASONS FOR SUICIDE OF FRIEND/COMMUNITY MEMBERS Marital discord/problems/arranged marriage the husband had married a second wife friend had epilepsy; when she was 15 her parents arranged her marriage to a relative

21. REASONS FOR SUICIDE OF FRIEND/COMMUNITY MEMBERS Economic situation/family problems A woman in the village committed suicide because there was no money to buy food, her husband migrated to Russia to find a job, but he married another woman there and was not sending money back home to Tajikistan. Social strictures One of the respondents best friends committed suicide, leaving a note saying that she did it because her family was too strict with her.

22. HOPE FOR THE FUTURE Most respondents said that they did not know about the future. Those who commented on the future were negative in terms of both their own future and that of women in Tajikistan generally

23. PROPOSED APPROACHES TO SUICIDE PREVENTION IN LOW-INCOME COUNTRIES

24. Developing/adapting brief screening instruments (ensuring language and cultural relevance) Developing/adapting practical, evidence-based approaches to treatment of mental health disorders

25. Training community health workers, primary care physicians and nurses in detection and screening and early intervention techniques Certifying competency of providers to address needs of both genders and all ages

26. Collecting data to ensure national- level awareness of problem and serve as basis for policy formulation Ensuring systems in place to protect confidentiality of women seeking prevention/treatment

27. Integrating mental health/suicide prevention and care with primary care Creating a network of community-based mental health services, assuring availability of quality (and safe) services at all levels Convening community-based groups to discuss contributing factors in the community that can be addressed at the community, regional and national level

28. PROPOSED APPROACHES TO EVALUATING SUICIDE PREVENTION TO ELICIT CULTURALLY APPROPRIATE, EVIDENCE- BASED PRACTICE

29. Use of mixed method, participatory evaluation Develop/adapt language and culturally-appropriate semi- structured instrument to assess services relevant to suicide prevention, and treatment of those who have attempted suicide

30. Develop standard protocol to conduct ethnographic interviews gatherings of women (focus groups) contextual analysis of immediate and surrounding community(ies) Training and engagement of community health workers to conduct interviews

31. Engage health and social service decision-makers, providers and community members in evaluation process Develop process for use of data/information in planning for health and social services addressing socio-economic issues that are co-factors in the suicide epidemic