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Sex-specific suicide mortality in the South African urban context: The role of age, race, and geographical location
Stephanie Burrows, Marjan Vaez and Lucie Laflamme Scand J Public Health 2007 35: 133 DOI: 10.1080/14034940600975773 The online version of this article can be found at: http://sjp.sagepub.com/content/35/2/133

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Scandinavian Journal of Public Health, 2007; 35: 133139

ORIGINAL ARTICLE

Sex-specific suicide mortality in the South African urban context: The role of age, race, and geographical location

STEPHANIE BURROWS1, MARJAN VAEZ2 & LUCIE LAFLAMME1

Division of Social Medicine, Department of Public Health Sciences, and 2Section for Personal Injury Prevention, Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden
1

Abstract Aims: This study investigates the importance of sociodemographic and geographical characteristics for suicide risks in the South African urban context. Suicide epidemiology is under-researched in low- and middle-income countries, and such knowledge is important not only for local and national policy, but also for a global understanding of the phenomenon. Methods: Sex-specific crude and adjusted odds ratios (95% confidence intervals) for suicide by age, race, and city are assessed using logistic regression. Cases aged 45+ years, classified as Coloured (a category denoting mixed racial origin), and living in Cape Town are used as reference groups. Additionally, the proportion of leading suicide methods within groups was estimated (95% confidence intervals). Results: For males, compared with each reference group, the odds of suicide are significantly higher during middle adulthood, among Asians and particularly among Whites, and among residents of all but one city. Patterns for women differ in magnitude and distribution. Suicide odds are significantly higher in all age groups, particularly 1524 years, among Whites, and among residents of all other cities, particularly Nelson Mandela or Buffalo City. Males living in Tshwane and Black females have lower odds of suicide. The distribution of methods across age, race, and city groups varies little for males but substantially for females. Conclusions: Age, race, and city play independent roles in sex-specific suicide rates. As for high-income settings, age, race, method and city are important in sexspecific suicide in the urban South African context. Possible underlying mechanisms deserve greater attention for contextrelevant preventive efforts.

Key Words: Gender, sociodemographic groups, South Africa, suicide methods, suicide mortality, transition

Background Sex is an established sociodemographic marker for health outcomes, including suicide mortality. In most countries, suicide rates are higher among males than females [1]. China is a notable exception, with very high rates recorded for females, particularly rural young women [2]. Globally, male suicide rates tend to increase with age, while for females the rates can peak instead in middle age or, particularly in developing countries and minority groups, among young adults [1]. Yet, in recent decades increases in young male and declines in female rates have been observed in some countries [3,4]. Attempts to explain these shifts remain exploratory but a range

of social changes are likely to have played an important but differential part [5]. South Africa, with the dramatic sociopolitical changes accompanying the dismantling of apartheid and their likely differential impact on the various sociodemographic groups within the country, is an interesting setting in which to examine the relationship between social changes and suicide. Trend studies are made difficult, however, as national death statistics are not available historically for all sociodemographic groups in all regions, and as data for suicide deaths are not available since 1992, following a change to the Births and Deaths Registration Act inhibiting the specification of the manner of injury death. What is known from the period 196890 (i.e.

Correspondence: Stephanie Burrows, Karolinska Institutet, Department of Public Health Sciences, Division of Social Medicine, Norrbacka 2nd floor, Sweden. Tel: +46 8 737 3780. Fax: +46 8 737 3878. E-mail: stephanie.burrows@ki.se (Accepted 24 August 2006) ISSN 1403-4948 print/ISSN 1651-1905 online/07/020133-7 # 2007 Taylor & Francis DOI: 10.1080/14034940600975773

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S. Burrows et al. and geographical location in explaining suicide for males and females in a South African urban context. Given the consistency in the suicide patterning across sociodemographic groups discussed above, it is expected that age and race will independently play a role in the direction of the patterning. Furthermore, given the different levels of development in the cities and their population compositional differences, we anticipate that city will play a role in the outcomes. For similar reasons, it is anticipated that method of suicide used will have a different patterning across groups for males and females.

during the apartheid regime) is that changes occurred over time and were more marked in males, namely increases in the young, particularly for Whites, and increases for Whites older than 64 years. Only proportional mortality rates could be calculated for Blacks (198090), given the limited and poor quality of mortality and population data for this group, and homeland territories were excluded [4]. The absence of inclusive and longitudinal nationallevel suicide mortality data has meant that information on suicide is derived mostly from intermittent studies in different regions. South African studies examining suicide across sex almost invariably present these results in race-specific groups. These show that the differences between males and females vary considerably across race groups, and, where examined, also across age groups [6]. The studies mentioned above almost exclusively use data from the apartheid era. With the development of an injury surveillance system at the end of the 1990s (the National Injury Mortality Surveillance System NIMSS; see also below), group-specific rates are available for several municipalities in the country where the system has full coverage [7,8]. For the first time, comparisons are made possible between all sociodemographic groups for the same time period and same geographical level. We know from studies using these data [6] that, as found in research using apartheid-era data, male suicide rates are consistently higher than those of females across race and age groups; Whites generally have higher rates and, unlike the other race groups, these are higher among older age groups; and rates are high among young Asians, especially females. In addition, regional urban differences in both the magnitude and distribution of suicide mortality across race and sex groups have been found in a previous study [9]. Indeed, social, economic and health development has not been uniform across regions [10] and may partly account for differential effects on suicide for diverse sociodemographic groups. In addition to contextual factors, method of suicide used may also be an important explanatory factor since differences in suicide across sociodemographic groups may be somewhat related to it. Besides the established tendency for females to use less violent methods, whether suicides by various methods differ across other demographic groupings remains relatively unexplored [11].

Material and methods Selected variables and data treatment The study is cross-sectional and covers the years 200103. At present there are no suicide data available for the whole of South Africa. All geographical locations for which NIMSS has full coverage were included in the study. They are some of the largest cities in the country, with high population density; extensive development; and high economic activity [10]. With the names of their historical urban centres and population size in 2001 [12], these cities are: City of Cape Town Metropolitan Municipality (Cape Town; 2.1 million); City of Johannesburg Metropolitan Municipality (Johannesburg; 2.5 million); City of Tshwane Metropolitan Municipality (Pretoria; 1.5 million); eThekwini Metropolitan Municipality (Durban; 2.2 million); Nelson Mandela Metropolitan Municipality (Port Elizabeth; 0.7 million) and Buffalo City Local Municipality (East London; 0.6 million). Census 2001 data provide the sex-, age-, and race-specific population figures for these municipalities [12]. The census data have been statistically adjusted for undercount on the basis of a nationwide post-enumeration survey [13]. City-based data on suicide mortality were extracted from the NIMSS. The system collates information that arises from medico-legal postmortem investigations, such as demographic variables of the deceased, spatial and temporal details of the injury event, and the manner and external cause of death [7,8]. Since starting at 10 selected study sites in 1999, the system has increased its caseload with each successive year. Suicide cases occurring from the beginning of 2001, when the six cities achieved full coverage, until the end of 2003, the date of the latest available data, are included. As current estimates for the annual national number of injury deaths fall between 60,000 and 70,000 [8], the data collected by the six cities

Aims With the transitional setting in mind, the current study aims to investigate the importance of age, race,

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Sex-specific suicide mortality in urban South Africa accounts for 32% to 37% of these deaths. Suicide contributes 8% of them. Selected cases include definite suicides only, based on decisions made by medical practitioners performing autopsies. Cases were excluded if sex and/or race and/or age of the victim were missing (n5580, 11.5%); and if aged under 15 years (n575), given the small number of suicide deaths at such ages relative to other age categories. The ages of victims were grouped into four categories, 1524, 2534, 3544, 45+, to place greater focus on younger age groups where increases for males have been observed both locally [4] and internationally [3,5]. Also, the age structure of the population in South Africa is that of a developing country with proportionally more young than older people; and life expectancy at birth for 2005 is estimated to be 47 years [14]. In the six cities, the proportion of 15+ years population in the 1524, 2534, 3544, and 45+ age categories are 27%, 26%, 20%, and 26%, respectively. All racial categories used in South Africa (Coloured, Asian, Black, White) were included. As leading methods, firearm, hanging, and poison ingestion suicides were selected and all remaining suicides grouped into an other category. We know from a previous study [9] that there is a strong association between suicide method used and individual city. Therefore, cities were grouped into three categories according to their overall suicide rate, so that we could explore whether particular

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methods are associated with urban suicide levels. An average rate for all cities was first calculated. Cities were then classified as having average levels of suicide if their rate fell within the standard deviation of the average rate (eThekwini, Tshwane, Nelson Mandela), below average levels (Cape Town) or above average levels (Johannesburg, Buffalo City). Data analysis All analyses were performed for males and females separately. Logistic regression was performed to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for suicide mortality by age group, race, and city. Both crude and adjusted ORs were compiled. Those aged 45+, Coloureds, and Cape Town respectively, were treated as the reference groups. Data processing was performed using SPSS (Version 13.0). The proportion of leading suicide methods within each sociodemographic and city group was estimated by 95% confidence intervals (CIs). The study was approved by the Medical Research Council of South Africas Ethics Committee.

Results Crude and adjusted ORs for suicide mortality by sociodemographic variables and geographical location, for males and females separately, are presented

Table I. Crude and adjusted odds ratios (ORs) with 95% CIs for suicide mortality by age, race, and geographic location, for males and females separately Males Crude OR (95% CI) Age (years) 45+ 3544 2534 1524 Race group Coloureds Blacks Asians Whites City Cape Town Johannesburg Tshwane eThekwini Nelson Mandela Buffalo City
a

Females Crude OR (95% CI) Adjusted OR (95% CI)a

Adjusted OR (95% CI)a

1 1.06 (0.961.16) 1.22 (1.121.33) 0.79 (0.710.87) 1 1.23 (1.101.38) 1.90 (1.632.21) 2.28 (2.022.57) 1 1.20 0.84 1.26 1.17 1.51

1 1.18 (1.071.30) 1.41 (1.291.54) 0.91 (0.821.00) 1 1.14 (1.001.29) 1.69 (1.432.00) 2.31 (2.032.62) 1 1.17 0.77 1.23 1.18 1.63

1 1.36 (1.131.64) 1.26 (1.041.53) 1.09 (0.891.35) 1 0.83 (0.671.03) 1.57 (1.162.12) 2.57 (2.06,3.21) 1 1.47 1.39 1.46 1.75 1.49

1 1.30 (1.05,1.61) 1.63 (1.341.98) 1.81 (1.502.19) 1 0.60 (0.470.76) 1.14 (0.811.59) 2.30 (1.812.92) 1 1.78 1.50 1.86 2.04 2.19

(1.091.33) (0.740.95) (1.141.39) (1.021.34) (1.311.75)

(1.051.30) (0.680.88) (1.101.37) (1.021.36) (1.401.90)

(1.191.82) (1.091.77) (1.181.81) (1.332.30) (1.082.06)

(1.412.23) (1.161.94) (1.462.38) (1.552.69) (1.563.07)

Adjusted for all variables in the table.

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S. Burrows et al.
Table II. Distributions of method of suicide by age group, race, and city suicide levels, for males and females separately Males n53,577 % (CI) Age (years) 45+ Hanging Firearm Poison ingestion Othera 3544 Hanging Firearm Poison ingestion Othera 2534 Hanging Firearm Poison ingestion Othera 1524 Hanging Firearm Poison ingestion Othera Race group Coloureds Hanging Firearm Poison ingestion Othera Blacks Hanging Firearm Poison ingestion Othera Asians Hanging Firearm Poison ingestion Othera Whites Hanging Firearm Poison ingestion Othera Cities by suicide levels Below average Hanging Firearm Poison ingestion Othera Average Hanging Firearm Poison ingestion Othera Above average Hanging Firearm Poison ingestion Othera Females n5831 % (CI)

in Table I. For males, when adjusting for all other variables, the significantly reduced odds for the youngest age group disappears, while those for 25 34- and 3544-year-olds increase and are both significant (OR51.41, CI 1.291.54; OR51.18, CI 1.071.30, respectively). Compared with Coloureds, the higher odds of suicide for Blacks are no longer significant after adjustment, while that for Asians decreases but remains 69% higher. For Whites there is little change before and after adjustment; the odds remain more than double that for Coloureds (OR52.31, CI 2.032.62). Tshwane is the only city with reduced odds compared with Cape Town both before and after (OR50.77, CI 0.680.88) adjustment. Adjusting for the other variables slightly decreases the odds of suicide for most cities but does not change their significance or direction. The change for Buffalo City is noteworthy not only because of an increase rather than decrease in the odds, but also the confidence interval no longer overlaps those for the other cities, distinguishing this city as having particularly high suicide odds compared with the others. Age group-, race-, and city-based odds ratios for females differ from those of males, in both magnitude and distribution. When adjusted odds ratios are calculated, suicide odds increase for the two youngest age groups, particularly the 1524 group, from no difference to 81% greater odds compared with the oldest group. Compared to Coloureds, the reduced risk for Blacks becomes significant (OR50.60, CI 0.470.76), the odds ratio for Asians is no longer significant, and that for Whites decreases slightly. As for males, odds are most pronounced among Whites (OR52.30, CI 1.81 2.92). Compared with Cape Town, the significantly higher likelihood of suicide for females in all other cities increases after adjustment to at least 50% higher (in Tshwane) but to more than double the odds for some cities (in Nelson Mandela and Buffalo City). Odds ratios are greater than those for males. Buffalo City shows the greatest odds for both sexes. For males overall, 47% of all suicides are hangings, 31% firearms, and 9% poison ingestion. For females overall, poison ingestion is more prominent (31%) than hangings (27%) and firearms (19%). Further differences for males and females in the distribution of these methods within sociodemographic and city groups are given in Table II.
Table II. Continued.
a Overall the category other predominantly includes gassing, jumping, burning, and sharp object suicides, but the proportion of each varies substantially across groups.

37.4 35.7 10.1 16.8 46.1 28.7 10.1 15.1 49.0 31.9 7.8 11.3 56.9 25.2 7.2 10.8

(34.240.7) (32.539.0) (8.212.4) (14.419.6) (42.549.8) (25.532.1) (8.112.6) (12.617.9) (46.151.8) (29.334.7) (6.49.5) (9.613.3) (53.360.4) (22.228.4) (5.59.3) (8.713.2)

18.9 28.6 32.1 20.4 18.2 17.5 35.1 29.2 25.8 16.9 28.9 28.4 40.6 13.7 30.9 14.8

(13.825.2) (22.535.5) (25.839.2) (15.126.9) (12.625.4) (12.124.7) (27.743.2) (22.337.2) (20.332.1) (12.422.6) (23.235.4) (22.734.9) (34.646.9) (9.818.6) (25.337.0) (10.819.9)

48.3 24.9 13.1 13.7 59.0 24.7 6.2 10.2 52.4 28.4 11.0 8.2 22.5 45.3 11.2 21.0

(43.153.6) (20.529.7) (9.917.2) (10.417.8) (56.761.2) (22.826.7) (5.27.4) (8.911.6) (46.758.0) (23.633.8) (7.915.1) (5.511.9) (19.925.2) (42.248.5) (9.413.4) (18.523.7)

18.3 8.7 63.5 9.6 39.2 7.9 22.4 30.5 44.4 11.1 30.6 13.9 13.2 36.0 30.9 19.9

(11.627.3) (4.316.2) (53.472.5) (5.017.4) (34.144.6) (5.311.4) (18.227.2) (25.835.7) (32.956.6) (5.321.3) (20.542.7) (7.224.5) (9.717.6) (30.741.7) (25.836.4) (15.724.9)

48.6 27.9 9.9 13.6 49.8 30.6 8.5 11.1 43.5 32.3 8.4 15.9

(44.852.4) (24.631.4) (7.812.4) (11.216.5) (47.352.2) (28.432.9) (7.210.0) (9.612.8) (40.7,46.2) (29.734.9) (6.910.1) (14.018.1)

22.1 13.2 44.9 19.9 31.3 18.0 30.6 20.1 23.8 22.7 26.0 27.5

(15.630.1) (8.320.4) (36.453.6) (13.727.7) (26.936.0) (14.522.1) (26.335.3) (16.524.4) (19.029.4) (18.028.2) (21.031.7) (22.333.2)

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Sex-specific suicide mortality in urban South Africa For males of all ages except 45+ years, and for Coloureds, Asians, and Blacks, hangings are significantly higher than firearm suicides. For all age groups and these three race groups, use of both these methods is significantly greater than any other method. For Whites, firearm suicides predominate, and the frequency of hanging suicides does not differ significantly from other methods (three-quarters of which are gassing suicides). Irrespective of the suicide level of cities, hanging suicides predominate, followed by firearm suicides. For females, method choice varies substantially across sociodemographic and city groups, yet there is little differentiation between methods within these groups. Although there is a tendency for females frequently to use poison ingestion, in no age group is it significantly higher than all other methods. Hanging is also common, particularly in younger age groups, and firearm use is common in older age groups. Coloureds are the only group showing a clear tendency to use a particular method: poison ingestion. Hanging is more frequent among Asians and Blacks, in addition to poison ingestion and other methods, respectively. Unlike the other races, White females use firearms as well as poison ingestion. Poison ingestion is more frequent than all other methods in cities with lower than average suicide levels, while both hanging and poisonings are most common in cities with average suicide levels.

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Discussion Main findings In the post-apartheid transitional urban setting, little is known regarding the relative distribution of suicide mortality in sociodemographic groups and how this differs for the sexes. In addition to the individual contribution of age, race, and geographical location to a better understanding of suicide mortality for each sex, this study shows that the size of the effect of these variables differs somewhat for males and females. Age and geographic location have greater effects for females than males. The odds of committing suicide as a Black or Asian differ according to sex, while Whites of both sexes have odds of similar magnitude. The differential suicide mortality across sociodemographic groups and geographic locations suggests that influences underlying them vary, or that in the face of common adverse influences the different groups have varying expressions of protective factors [5,15]. The results may be better understood in light of factors related to the sociopolitical transition in South Africa.

For females, the stress associated with the changing role of women in society may explain the greater importance of age compared with males. This would be more likely to affect the younger age groups, as they enter the work market in an economy with high unemployment. The greater odds of suicide among middle-aged individuals corresponds with other studies that find this group to be particularly affected by sociopolitical changes [1618], while the high odds for young women (1524 years) is in line with the peak in rates seen for this group in developing countries globally [1]. The HIV/AIDS pandemic plaguing South Africa may be an important underlying influence on the male and female distribution of suicide mortality across age found in the current study. HIV prevalence is not equally distributed across all groups and regions, and there are numerous similarities between its distribution and that of suicide seen here. For example, it is higher for females than males for ages 15 to 34, but higher for males in older ages, and young females aged 1524 years in particular contribute high numbers of new infections [19]. Studies internationally [20] and in South Africa [21] have shown a link between the disease and increased suicidal behaviour, with a peak risk period 36 months after diagnosis of infection with HIV [21]. Although post-apartheid Whites largely continue to have better living conditions, adapting to the removal of their politically defined privileged social position may increase the likelihood of suicide [22]. Lack of an external source of blame for hardships, due to expected high quality of life, has been proposed to explain the higher suicide mortality among Whites, compared with Asians and Coloureds who adhere to religions proscribing suicide; and to Blacks who have close family ties and cultural taboos against suicide [4]. The little more than a decade since the dismantling of apartheid has been insufficient to correct all historical inequalities. Apartheid laws meant that the various sociodemographic groups were differentially treated and non-White residence was restricted to particular areas. Buffalo City includes some of these territories that were designated as tribal homeland areas. This municipality saw little growth between the two census years of 1996 and 2001, and consequent increased unemployment levels. In contrast, a number of indicators suggest that Cape Town is the most advantaged city with the lowest percentage of people without formal housing, of households without water, of unemployed people, and with the highest per capita municipal budget [10]. Reviews of studies [2325] demonstrate that

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S. Burrows et al. international and local research, and is particularly pertinent for South Africa given its poor historical record for statistics keeping, at least for some population groups. This would be a concern in the current study if suicide statistics are more reliable for particular sociodemographic groups, for particular suicide methods or if the bias were unevenly distributed across cities. It is possible that certain suicides (especially poisonings) are systematically missed. The unintentional, but particularly the undetermined, death category may contain a number of misclassified suicides, and these manners of death were not included in the current study. For the six cities, rates of undetermined deaths are very similar in size and distribution to the suicide rates, and are significantly higher in Buffalo City and Nelson Mandela. Excluding undetermined deaths in the analyses may have underestimated the suicide odds for these cities. However, a study examining the accuracy of the NIMSS data for one city, Tshwane, found that few undetermined deaths were in fact suicides [6]. Additionally, the sensitivity, specificity, and predictive values were generally high, and varied only slightly across sociodemographic groups. The reliability of the data needs to be checked in the other cities as it possibly varies across regions, and such variation could bias inter-city comparisons. An additional concern is that small caseloads for some groups reduce the robustness of the results. Other known risk factors for suicide, such as mental illness, alcohol or drug use, and unemployment, are not included in the study. Risk factors for suicide have been shown to differ by sex [26] and may be useful in explaining the outcomes found. In assessing the importance of geographical location in sex-specific suicide, the study focused on urban areas. As studies indicate that suicides in rural and urban areas differ by sex and age group [2728], the impact of age, and possibly race, on sex-specific suicide in rural South Africa may differ from the patterns presented here. Rural data, when available, will allow us to explore whether the patterns seen are specific to urban areas or would reflect those of the country as a whole. The absence of longitudinal data means that conclusions can only be drawn for this point in time. As more data become available, the link between social changes and suicide can be assessed more fully. Conclusions Including all race groups and controlling for individual sociodemographic and contextual variables,

such contextual characteristics both impact on health and have effects independent of individual characteristics. The current study confirms this for both males and females at the city level. As for a previous South African study conducted at the suburb level, contextual influences were greater for females than males [22]. This greater effect for females may be linked to their lower social status compared with men, particularly in the smaller, lessdeveloped cities where change may be slower and traditional values more persistent. During apartheid ones social standing was, first and foremost, defined by ones race but, with consistent discrimination against women, sex has also been an important determinant of social status. Understanding the mechanisms behind the importance of particular locations for sex-specific suicide is difficult without detailed information for each of the cities on, for example, number and utilization of mental health facilities. It may be that the higher odds in Buffalo City are related to lower numbers and poorer access to such facilities than some of the other cities. The launching in 2002 of the South African Cities Network [10] that aims to encourage the exchange of information, experiences, and best practices on urban development and city management among a network of municipalities, including the six in this study, will, it is hoped, generate much needed data on city-level factors likely to influence health outcomes. As expected [11], females overall tend to use less violent methods (i.e. poison ingestion) compared with males. Possible explanations for the excess of violent suicide in males include greater suicidal intent, aggression, knowledge regarding violent methods, and less concern about bodily disfigurement [2]. We find little relation between method and the suicide distribution within sex, indicating that method chosen provides little explanation for understanding the within-sex differences in suicide levels across age, race, or city group. In terms of prevention, targeting particular methods is likely to have broad effects across several sociodemographic groups for males. For females, efforts need to target several methods or groupspecific efforts are required. The high numbers of hanging suicides are a cause for concern, given the limited known possibilities for prevention.

Limitations The issue of the reliability and validity of suicide mortality data has been raised repeatedly in both

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Sex-specific suicide mortality in urban South Africa the study shows that age, race, and city play important roles in explaining sex-specific suicide in a South African urban context. For the metropolitan areas covered herein, the magnitude and distribution of these contributions are in the direction of what could be expected based on other South African studies both during and after apartheid. While there are (expected) differences between males and females in the method used, method does not reveal much about the differential sociodemographic and geographic patterning within sex. The identification of groups and regions at greatest risk provides targets for further research investigating underlying mechanisms and for context-relevant preventive initiatives. Acknowledgements The authors are grateful to the staff at the mortuaries and the MRC/UNISA Lead Programme for Crime, Violence and Injury involved in the data collection and city boundary determinations for the NIMSS. Financial support for the work came from the Karolinska Institutet. There are no conflicts of interest. References
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