The one-month and lifetime prevalence of non-fatal suicidal behaviour in our sample of young Black-African men living in low-resource communities in SA was lower than the prevalence reported for men in the general population of the country. Data collected in the South African Stress and Health Survey between 2002 and 2003, estimated lifetime prevalence of suicidal ideation, suicidal plans and suicidal attempts at 8.0, 3.3 and 1.8% respectively, in a nationally representative sample of males [33].
Thirty percent of our sample reported clinically significant symptoms of depression over the one-week period prior to assessment, as indicated by a score of greater than 16 on the CES-D. This is significantly higher than the prevalence of Major Depressive Disorder (MDD) typically found in the general population of the country. Tomlinson et al. [31], for example, reported lifetime and one-month prevalence rates for MDD of 9.7 and 4.9%, respectively. It is not immediately apparent from our data why the prevalence of clinically significant symptoms of depression would be so marked among our study population, although this may in part reflect the adverse socio-economic conditions under which these young men live and the high levels of hopelessness which accompanies their lack of economic opportunities.
In this study, symptoms of depression were significantly associated with food insecurity, having been fired, and having two or more financial dependants. Our finding that poverty-related variables and food insecurity were significantly associated with symptoms of depression in a community sample of men living in peri-urban settlements in SA, is consistent with other literature from LMICs [34]. It is significant that most participants reported low incomes, were dissatisfied with their income, and were financially responsible for two or more others. Socio-economic stressors, especially financial stress, are known to increase the likelihood of developing symptoms of depression [35, 36], which may account for the observed association between poverty and depressive symptoms, and the high rates of depressive symptoms in our sample.
Although food insecurity and job losses were associated with depressive symptoms, the causal pathway of the relationship among these variables is unknown. It is possible that depression might cause a person to be fired from their job (as a result of missing work or not fulfilling work-related requirements), but it is equally possible that being fired from one’s job might give rise to depressive symptoms [37], and both pathways might well apply to different people. Future longitudinal studies could assess the temporal relationship between measures of poverty and measures of depression to help shed light on the interaction of these variables in community samples of young men living under conditions of poverty.
We found that non-fatal suicidal behaviour was significantly associated with a range of poverty-related measures, including not having a toilet on the premises, having previously been fired, and food insecurity. Non-fatal suicidal behaviour in this sample was not, however, associated with other poverty-related variables such as availability of water, access to electricity, being unemployed, past month income, income in the past three months, satisfaction with income, receiving financial assistance from a partner or parent, longest length of employment, number of jobs in the last year, and number of financial dependants. This suggests that while poverty may indeed account for some of the variance in non-fatal suicidal behaviour, it would seem that there may be specific aspects of poverty that are important determinants of non-fatal suicidal behaviour in this sample, rather than poverty per se.
It is not clear from our data why variables such as not having a toilet on the premises, having previously been fired, and food insecurity would be associated with non-fatal suicidal behaviour. However, such experiences are typically associated with shame, loss of dignity, and hopelessness [38], which may explain why they would be associated with non-fatal suicidal behaviour. A large body of literature has shown associations between suicidal behaviour and shame [39]. It is significant that in this community, problems related to unemployment, low income, frequent changes of jobs and receiving financial assistance from a partner or parent, are endemic and may thus constitute more of a shared experience among young men and consequently may not precipitate intense feelings of shame. This is an area that may warrant further investigation in order to better understand what it is about these particular experiences of poverty that precipitate non-fatal suicidal behaviours among young men living under conditions of endemic poverty [20].
It is very significant that when we included measures of depression in our analysis of predictors of non-fatal suicidal behaviour, we found that symptoms of depression were by far the most significant predictor of non-fatal suicidal behaviour. In our data, symptoms of depression were a better predictor of non-fatal suicidal behaviour than any of the wide variety of poverty-related variables we considered. This finding is significant in the light of literature which contests the importance of psychiatric factors in the aetiology of suicide [15,16,17,18]. In spite of claims made in the critical suicidology literature (often without empirical evidence) about the primacy of socio-economic and cultural factors over psychiatric factors in the aetiology of suicide in LMICs [18], our data highlight the importance for policy makers to focus on psychiatric issues, like depression, in public health suicide prevention programmes, especially amongst those living in low-resource communities.
We know from five decades of epidemiological research that there are risk factors correlated with suicidal behaviour [2]; for example, being homeless, identifying as gay, being male, having a psychiatric illness, being poor, and having access to lethal means of self-harm [1]. In this study, we focused on a group who are all considered to be at high risk of suicide by virtue of the fact that they are poor Black African men who experience prejudice and face few opportunities to fulfil their male roles [1,2,3, 7, 9, 40]. Our data show clearly that among such a high-risk group, being fired, experiencing symptoms of depression and food insecurity are strongly associated with an increased risk of non-fatal suicidal behaviour. This finding supports the assumption that interventions to reduce the morbidity and mortality associated with non-fatal suicidal behaviour in this high-risk group of young men living under conditions of poverty need to be focused on proximal factors, such as promoting access to psychiatric care to reduce depressive symptoms, food security, re-employment and job security. Future research assessing the pathways between these particular experiences of poverty, symptoms of depression, and non-fatal suicidal behaviour will help identify the causal determinants of non-fatal suicidal behaviour in low resource contexts, helping provide more specific targets for suicide prevention interventions.
Limitations
Data for this study were collected from two low-resource peri-urban communities in the Western Cape province of SA. As such, it is not clear how representative the findings are of other low-resource communities, particularly those in rural areas. A further limitation of this study is the inclusion of suicidal ideation and suicidal behaviour within the definition we used of non-fatal suicidal behaviour. It is possible that there are different risk factors for suicidal ideation and suicidal behaviour, and that these two phenomena should be investigated separately. This would, however, require further studies with very large sample sizes, as the base rate of suicidal behaviour is extremely low, making it difficult to yield enough statistical power to investigate how suicidal behaviour is influenced by the interaction between a wide variety of potential independent variables.
The meaning attributed to suicidal behaviour and the language used to describe these phenomena is shaped by cultural and contextual factors [41]. The language used in the C-SSRS which we utilised to assess non-fatal suicidal behaviour in this study was developed by researchers in the USA. Consequently, the instrument may have failed to capture cultural nuances in the descriptions of suicidal ideation and non-fatal suicidal behaviour.
While this study considered a wide range of poverty-related measures, it did not utilise a composite index of wealth or consider the value of household assets owned. It may be helpful for future studies in this area to incorporate a wealth index and not only consider measures of income as a proxy for poverty.