Melissa Pearson

Prospective policy analysis: how an epistemic community informed policymaking on intentional self poisoning in Sri Lanka.

BackgroundPolicy analysis is often retrospective and not well suited to helping policy makers decide what to do; in contrast prospective policy analysis seeks to assist in formulating responses to challenging public policy questions. Suicide in Sri Lanka is a major public health problem, with ingestion of pesticides being the primary method. Previous policy interventions have been associated with reduced mortality through restricting access to the most toxic pesticides. Additional means of reducing access are still needed.MethodsThe prospective policy analysis comprised two stages. The first used a consensus activity within a well defined policy community to generate and frame policy options. The second broadened the analysis to include other stakeholders. We report the consensus activity with seven actors from agriculture, health, and academia. Policy options were identified through two rounds of discussion along with ratings by each participant on their degree of support for each option. Data were analysed quantitatively and discussions analysed with Nvivo 8 to code prominent and recurrent themes.ResultsThe main finding was the strong support and consensus for two proposals: further regulation of pesticides and the novel idea of repackaging pesticides into non-lethal doses. Participants identified several factors that were supportive of future policy change including a strong legislative framework, good links between agriculture, health and academia, and a collaborative relationship with industry. Identified barriers and potential threats to policy change included political interference, difficulties of intersectoral collaboration, acceptability of options to the community, difficulty of implementation in rural communities and the challenge of reducing mortality.ConclusionsThe development and consideration of policy options within this epistemic community reflected an appreciation and understanding of many of the factors that can facilitate or thwart policy change. The understanding of context, evidence and ideas, implementation and impact influenced how the participants considered and rated the options. Use of epistemic community actors identified the level of support for each option, helped elaborate the particularities of context, as well as the power and influence of ideas. Further examination of the potential barriers and opportunities for these options will determine if broader consensus, involving a wider range of stakeholders, can be achieved and policy change promoted.

Policymaking ‘under the radar’: a case study of pesticide regulation to prevent intentional poisoning in Sri Lanka

Background Suicide in Sri Lanka is a major public health problem and in 1995 the country had one of the highest rates of suicide worldwide. Since then reductions in overall suicide rates have been largely attributed to efforts to regulate a range of pesticides. The evolution, context, events and implementation of the key policy decisions around regulation are examined. Methods This study was undertaken as part of a broader analysis of policy in two parts—an explanatory case study and stakeholder analysis. This article describes the explanatory case study that included an historical narrative and in-depth interviews. Results A timeline and chronology of policy actions and influence were derived from interview and document data. Fourteen key informants were interviewed and four distinct policy phases were identified. The early stages of pesticide regulation were dominated by political and economic considerations and strongly influenced by external factors. The second phase was marked by a period of local institution building, the engagement of local stakeholders, and expanded links between health and agriculture. During the third phase the problem of self-poisoning dominated the policy agenda and closer links between stakeholders, evidence and policymaking developed. The fourth and most recent phase was characterized by strong local capacity for policymaking, informed by evidence, developed in collaboration with a powerful network of stakeholders, including international researchers. Conclusions The policy response to extremely high rates of suicide from intentional poisoning with pesticides shows a unique and successful example of policymaking to prevent suicide. It also highlights policy action taking place ‘under the radar’, thus avoiding policy inertia often associated with reforms in lower and middle income countries.

Effectiveness of household lockable pesticide storage to reduce pesticide self-poisoning in rural Asia: a community-based, cluster-randomised controlled trial

Summary Background Agricultural pesticide self-poisoning is a major public health problem in rural Asia. The use of safer household pesticide storage has been promoted to prevent deaths, but there is no evidence of effectiveness. We aimed to test the effectiveness of lockable household containers for prevention of pesticide self-poisoning. Methods We did a community-based, cluster-randomised controlled trial in a rural area of North Central Province, Sri Lanka. Clusters of households were randomly assigned (1:1), with a sequence computer-generated by a minimisation process, to intervention or usual practice (control) groups. Intervention households that had farmed or had used or stored pesticide in the preceding agricultural season were given a lockable storage container. Further promotion of use of the containers was restricted to community posters and 6-monthly reminders during routine community meetings. The primary outcome was incidence of pesticide self-poisoning in people aged 14 years or older during 3 years of follow-up. Identification of outcome events was done by staff who were unaware of group allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT1146496. Findings Between Dec 31, 2010, and Feb 2, 2013, we randomly assigned 90 rural villages to the intervention group and 90 to the control group. 27 091 households (114 168 individuals) in the intervention group and 26 291 households (109 693 individuals) in the control group consented to participate. 20 457 household pesticide storage containers were distributed. In individuals aged 14 years or older, 611 cases of pesticide self-poisoning had occurred by 3 years in the intervention group compared with 641 cases in the control group; incidence of pesticide self-poisoning did not differ between groups (293·3 per 100 000 person-years of follow-up in the intervention group vs 318·0 per 100 000 in the control group; rate ratio [RR] 0·93, 95% CI 0·80–1·08; p=0·33). We found no evidence of switching from pesticide self-poisoning to other forms of self-harm, with no significant difference in the number of fatal (82 in the intervention group vs 67 in the control group; RR 1·22, 0·88–1·68]) or non-fatal (1135 vs 1153; RR 0·97, 0·86–1·08) self-harm events involving all methods. Interpretation We found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning. Other approaches, particularly removal of highly hazardous pesticides from agricultural practice, are likely to be more effective for suicide prevention in rural Asia. Funding Wellcome Trust, with additional support from the American Foundation for Suicide Prevention, Lister Institute of Preventive Medicine, Chief Scientist Office of Scotland, University of Copenhagen, and NHMRC Australia.

Prevention of suicide with regulations aimed at restricting access to highly hazardous pesticides: a systematic review of the international evidence

BACKGROUND Pesticide self-poisoning accounts for 14-20% of suicides worldwide. Regulation aimed at restricting access to pesticides or banning highly hazardous pesticides is one approach to reducing these deaths. We systematically reviewed the evidence of the effectiveness of pesticide regulation in reducing the incidence of pesticide suicides and overall suicides. METHODS We did a systematic review of the international evidence. We searched MEDLINE, PsycINFO, and Embase for studies published between Jan 1, 1960, and Dec 31, 2016, which investigated the effect of national or regional bans, and sales or import restrictions, on the availability of one or more pesticides and the incidence of suicide in different countries. We excluded other interventions aimed at limiting community access to pesticides. We extracted data from studies presenting pesticide suicide data and overall suicide data from before and after national sales restrictions. Two reviewers independently assessed papers for inclusion, extracted data, and assessed risk of bias. We undertook a narrative synthesis of the data in each report, and where data were available for the years before and after a ban, we pooled data for the 3 years before and the 3 years after to obtain a crude estimate of the effect of the ban. This study is registered through PROSPERO, number CRD42017053329. FINDINGS We identified 27 studies undertaken in 16 countries-five low-income or middle-income countries (Bangladesh, Colombia, India, Jordan and Sri Lanka), and 11 high-income countries (Denmark, Finland, Germany, Greece, Hungary, Ireland, Japan, South Korea, Taiwan, UK, and USA). Assessments largely focused on national bans of specific pesticides (12 studies of bans in six countries-Jordan, Sri Lanka, Bangladesh, Greece [Crete], South Korea, and Taiwan) or sales restrictions (eight studies of restrictions in five countries- India, Denmark, Ireland, the UK and the USA). Only five studies used optimum analytical methods. National bans on commonly ingested pesticides in five of the six countries studied, including four studies using optimum analytical methods, were followed by reductions in pesticide suicides and, in three of these countries, falls in overall suicide mortality. Greece was the only country studied that did not show a decrease in pesticide suicide following a ban. There were no high-quality studies of restricting sales to people for occupational uses; four of the seven studies (in three of the five countries studied-India, Denmark, and the USA) showed sales restrictions were followed by decreases in pesticide suicides; one of the two studies investigating trends in overall suicide mortality reported a fall in deaths in Denmark, but there were also decreases in suicide deaths from other methods. INTERPRETATION National bans on highly hazardous pesticides, which are commonly ingested in acts of self-poisoning, seem to be effective in reducing pesticide-specific and overall suicide rates. Evidence is less consistent for sales restrictions. A worldwide ban on the use of highly hazardous pesticides is likely to prevent tens of thousands of deaths every year. FUNDING None.

Challenges and opportunities of a paperless baseline survey in Sri Lanka

BackgroundPersonal digital assistants (PDAs) have been shown to reduce costs associated with survey implementation and digitisation, and to improve data quality when compared to traditional paper based data collection. Few studies, however, have shared their experiences of the use of these devices in rural settings in Asia. This paper reports on our experiences of using a PDA device for data collection in Sri Lanka as part of a large cluster randomised control trial.FindingsWe found that PDAs were useful for collecting data for a baseline survey of a large randomised control trial (54,000 households). We found that the PDA device and survey format was easy to use by inexperienced field staff, even though the survey was programmed in English. The device enabled the rapid digitisation of survey data, providing a good basis for continuous data quality assurance, supervision of staff and survey implementation. An unexpected advantage was the improved community opinion of the research project as a result of the device, because the use of the technology gave data collectors an elevated status amongst the community. In addition the global positioning system (GPS) functionality of the device allowed precise mapping of households, and hence distinct settlements to be identified as randomisation clusters. Future users should be mindful that to save costs the piloting should be completed before programming. In addition consideration of a local after-care service is important to avoid costs and time delays associated with sending devices back to overseas providers.DiscussionSince the start of this study, PDA devices have rapidly developed and are increasingly used. The use of PDA or similar devices for research is not without its problems; however we believe that the universal lessons learnt as part of this study are even more important for the effective utilisation of these rapidly developing technologies in resource poor settings.

Is socioeconomic position associated with risk of attempted suicide in rural Sri Lanka? A cross sectional study of 165,000 individuals

Background Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high-income countries, but this association is unclear in low-income and middle-income countries. Methods We investigated the association of SEP with attempted suicide in a cross-sectional survey of 165 233 Sri Lankans. SEP data were collected at the household (assets, social standing (highest occupation of a household member), foreign employment and young (≤40 years) female-headed households) and individual level (education and occupation). Respondent-reported data on suicide attempts in the past year were recorded. Random-effects logistic regression models, accounting for clustering, were used to investigate the association of SEP with attempted suicide. Results Households reported 398 attempted suicides in the preceding year (239 per 100 000). Fewer assets (OR 3.2, 95% CI 2.4 to 4.4) and having a daily wage labourer (ie, insecure/low-income job; OR 2.3, 95% CI 1.6 to 3.2) as the highest occupation increased the risk of an attempted suicide within households. At an individual level, daily wage labourers were at an increased risk of attempted suicide compared with farmers. The strongest associations were with low levels of education (OR 4.6, 95% CI 2.5 to 8.4), with a stronger association in men than women. Conclusions We found that indicators of lower SEP are associated with increased risk of attempted suicide in rural Sri Lanka. Longitudinal studies with objective measures of suicide attempts are needed to confirm this association. Trial registration number NCT01146496; Pre-results.

Feasibility of hair sampling to assess levels of organophosphate metabolites in rural areas of Sri Lanka

Measuring chronic pesticide exposure is important in order to investigate the associated health effects. Traditional biological samples (blood/urine) are difficult to collect, store and transport in large epidemiological studies in settings such as rural Asia. We assessed the acceptability of collecting hair samples from a rural Sri Lankan population and found that this method of data collection was feasible. We also assessed the level of non-specific metabolites (DAPS) of organophosphate pesticides in the hair samples. The median concentration (pg/mg) of each DAP was: diethyl phosphate: 83.3 (IQI 56.0, 209.4); diethyl thiophosphate: 34.7 (IQI 13.8, 147.9); diethyl dithiophosphate: 34.5 (IQI 23.4, 55.2); and dimethyl phosphate: 3 (IQI 3, 109.7). Total diethylphosphates were recovered in >80% of samples and were positively correlated with self-reported pesticide exposure.

Taking stock -- what is known about suicide in Sri Lanka: a systematic review of diverse literature.

BACKGROUND Suicide is and has been a major public health problem in Sri Lanka and has generated a wide range of literature. AIMS This review aimed to systematically appraise what is known about suicide in Sri Lanka. The patterns and content of articles were examined and recommendations for further research proposed. METHOD The paper describes the systematic search, retrieval, and quality assessment of studies. Thematic analysis techniques were applied to the full text of the articles to explore the range and extent of issues covered. RESULTS Local authors generated a large body of evidence of the problem in early studies. The importance of the method of suicide, suicidal intention, and the high incidence of suicide were identified as key foci for publications. Neglected areas have been policy and health service research, gender analysis, and contextual issues. CONCLUSION The literature reviewed has produced a broad understanding of the clinical factors, size of the problem, and social aspects. However, there remains limited evidence of prevention, risk factors, health services, and policy. A wide range of solutions have been proposed, but only regulation of pesticides and improved medical management proved to be effective to date.

The role of private pesticide vendors in preventing access to pesticides for self-poisoning in rural Sri Lanka

In 15% to 20% of self-poisoning cases, the pesticides used are purchased from shops just prior to ingestion. We explored how pesticide vendors interacted with customers at risk of self-poisoning to identify interventions to prevent such poisonings. Two strategies were specifically discussed: selling pesticides only to farmers bearing identity cards or customers bearing pesticide ‘prescriptions’. Vendors reported refusing to sell pesticides to people thought to be at risk of self-poisoning, but acknowledged the difficulty of distinguishing them from legitimate customers; vendors also stated they did want to help to improve identification of such customers. The community did not blame vendors when pesticides used for self-poison were purchased from their shops. Vendors have already taken steps to restrict access, including selling low toxic products, counselling and asking customer to return the next day. However, there was little support for the proposed interventions of ‘identity cards’ and ‘prescriptions’. Novel public health approaches are required to complement this approach.

Vendor-based restrictions on pesticide sales to prevent pesticide self-poisoning - a pilot study.

BackgroundIn South Asia, up to 20% of people ingesting pesticides for self-poisoning purchase the pesticide from a shop with the sole intention of self-harm. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such high-risk individuals. We aimed to test the feasibility and acceptability of vendor-based restrictions on pesticide sales for such high-risk individuals.MethodsWe conducted a pilot study in 14 (rural = 7, urban = 7) pesticide shops in Anuradhapura District of Sri Lanka. A two-hour training program was delivered to 28 pesticide vendors; the aim of the training was to help vendors recognize and respond to customers at high risk of pesticide self-poisoning. Knowledge and attitudes of vendors towards preventing access to pesticides for self-poisoning at baseline and in a three month follow-up was evaluated by questionnaire. Vendors were interviewed to explore the practice skills taught in the training and their assessment of the program.ResultsThe scores of knowledge and attitudes of the vendors significantly increased by 23% (95% CI 15%–32%, p < 0.001) and by 16% (95% CI 9%–23%, p < 0.001) respectively in the follow-up. Fifteen (60%) vendors reported refusing sell pesticides to a high-risk person (non-farmer or intoxicated person) in the follow-up compared to three (12%) at baseline. Vendors reported that they were aware from community feedback that they had prevented at least seven suicide attempts. On four identified occasions, vendors in urban shops had been unable to recognize the self-harming intention of customers who then ingested the pesticide. Only 2 (8%) vendors were dissatisfied with the training and 23 (92%) said they would recommend it to other vendors.ConclusionsOur study suggests that vendor-based sales restriction in regions with high rates of self-poisoning has the potential to reduce access to pesticides for self-poisoning. A large-scale study of the effectiveness and sustainability of this approach is needed.