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2020

Sociodemographic Factors, Culture, and Suicide in Guyana

Kay Shako
Walden University

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 Walden University

College of Health Sciences

This is to certify that the doctoral study by

Kay Shako

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by
the review committee have been made.

Review Committee
Dr. Vasileios Margaritis, Committee Chairperson, Public Health Faculty
Dr. Aaron Mendelsohn, Committee Member, Public Health Faculty
Dr. Richard Palmer, University Reviewer, Public Health Faculty

Chief Academic Officer and Provost

Sue Subocz, Ph.D.

Walden University
2020
 Abstract

Sociodemographic Factors, Culture, and Suicide in Guyana

by

Kay Shako

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Public Health

Walden University

May 2020
 Abstract

Suicide in younger populations is a major public health concern and it significantly

impacts third world countries like Guyana. Some challenges related to suicide are poor

recording of suicide risk factors and customized prevention programs to address this

significant issue. The purpose of this study was to examine which sociodemographic

factors (age, gender, occupation, method of suicide, and region) are associated with

suicide and method of suicide among people aged ≥ 15 years in Guyana. Also, because

studies show that culture plays a pivotal role in suicide, this study investigated if there is

a link between culture (ethnicity/race and religion) and suicide cases in this population in

Guyana. The socioecological model provided the framework for this quantitative study

which used the 2015 cross sectional secondary data from the Guyana Ministry of Public

Health. Bivariate analysis revealed that sociodemographic and cultural factors were

significantly associated with suicide cases in Guyana, with men, aged 23-48 years old,

employed individuals, East Indian and Hindu having the higher suicide proportions. In

addition, regression analysis indicated that men were 3.1 times more likely to commit

suicide by hanging instead of drinking poison compared to females (OR: 3.1, 95%CI: 1.5-

6.7, p < 0.004). The positive social change implications include the identification of

socioeconomic and cultural factors that are associated with suicide. These factors can be

used to provide counselling sessions for the persons who have suicidal behaviors and to

adopt a collaborative approach by World Health Organization, governmental,

nongovernmental organizations and civil society to reduce the prevalence of suicide in

Guyana.
Sociodemographic Factors, Culture, and Suicide in Guyana

By

Kay Shako

Doctoral Study Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Public Health

Walden University

May 2020
 Acknowledgments

I would like to express my gratitude and heartfelt thank you to some special people

who have helped me accomplish this research study. First, Dr. Margaritis, thank you for

providing that consistent oversight and clear direction to this research. Your invaluable

contribution to this study has significantly impacted my doctoral journey. Second, my

Committee Member Dr. Mendelson, thank you for the feedback, and careful attention

given to me in order to produce a research of great quality that would stand the test of

time. Thank you Mr. Richard Palmer, my University Research Reviewer for your

intuitive reviews that has taken this research to another level. Each of you have

contributed significantly to me completing my doctoral journey.

At this point in time, I want to recognize the Ministry of Public Health and the

reviewers of the two institutional boards that accepted my proposal and allowed me to

collect the relevant data on suicide to complete this capstone. Special thanks to the staff

of the statistical department of the MOPH who worked hard to provide the requested data

in a timely manner.

Finally, I would like to extend special thanks to my family, who understood my

doctoral journey and thus allowed me the space, time and support needed so that, I can

write, read, review and edit this capstone.

 Table of Contents

List of Tables.................................................................................................................. iv

Section 1: Foundation of the Study and Literature Review ............................................... 1

Introduction ............................................................................................................... 1

Problem Statement ..................................................................................................... 2

Research Question (s) and Hypotheses ....................................................................... 5

Theoretical Foundations for the Study........................................................................ 6

Nature of the Study .................................................................................................... 8

Literature Search Strategy .......................................................................................... 8

Literature Review Related to Key Variables and/or Concepts .................................... 9

Suicide in the Adolescents and Young Population in Low- and Middle-

Income Countries and Guyana ..................................................................9

Culture and its Relevance to Suicide .................................................................. 11

Common Methods of Suicide in the Adolescents and Young Population ............ 14

Poor Communication Affecting Suicide in Young Population. ........................... 16

Gaps that Contributed to Suicide in Guyana ............................................................. 23

Definitions ............................................................................................................... 24

Assumptions ............................................................................................................ 25

Scope and Delimitations .......................................................................................... 25

Significance ............................................................................................................. 26

Summary ................................................................................................................. 27

Section 2: Research Design and Data Collection ............................................................ 29

i
 Research Design and Rationale ................................................................................ 29

Methodology ........................................................................................................... 30

Population .......................................................................................................... 30

Sampling and Sampling Procedures ................................................................... 30

Instrumentation .................................................................................................. 33

Research Questions and Data Analysis Plan ............................................................. 34

External Validity ................................................................................................ 36

Internal Validity ................................................................................................. 36

Ethical Procedures ................................................................................................... 37

Ethical Concerns ...................................................................................................... 37

Treatment of Data .............................................................................................. 38

Summary ................................................................................................................. 39

Section 3: Presentation of the Results and Findings ....................................................... 40

Data collection of Secondary Data Set ..................................................................... 40

Discrepancies in Data Set......................................................................................... 41

Representativeness of the Sample ............................................................................ 41

Descriptive Statistics ................................................................................................ 42

Results Per Research Question ................................................................................. 46

Summary ................................................................................................................. 51

Section 4: Application to Professional Practice and Implications for Social

Change ............................................................................................................... 53

Interpretation of Findings ......................................................................................... 53

ii
 Findings to SEM Theoretical Framework ................................................................. 58

Limitations of the Study ........................................................................................... 61

Recommendations.................................................................................................... 62

Implications for Professional Practice and Social Change ........................................ 64

Positive Social Change ............................................................................................ 65

Conclusion............................................................................................................... 66

References ..................................................................................................................... 68

iii
 List of Tables

Table 1. Univariate Characteristics of Sociodemographic Factors Associated with Suicide

in Guyana .............................................................................................................. 42

Table 2. Distribution of Suicide Cases by Gender……………………………………… 42

Table 3. Distribution of Suicide Cases by Occupation…………………………………..43

Table 4. Distribution of Suicide Cases by Race/Ethnicity……………………….………43

Table 5. Distribution of Suicide Cases by Religion………………………………..…….44

Table 6. Distribution of Suicide cases by Age……………………………………..…….44

Table 7. Distribution of suicide Cases by Method of Suicide……………………..…….45

Table 8. Distribution of Suicide Cases by Region…………………………..…….……..45

Table 9. Comparison of Suicide Cases Proportion by Gender, Age, Occupation, Method

of Suicide and Region……………………………………………………………...…….48

Table 10. Comparison of Suicide Cases Proportion by Culture (Race/Ethnicity and

Religion) in Guyana ………………………………………………………………….….50

Table 11. Binominal Logistic Regression For Method of Suicide……………………...51

iv
 1
Section 1: Foundation of the Study and Literature Review

Introduction

Suicide is a major public health concern and it may be identified under varying

categories namely: suicide ideation, suicide attempts or suicide (World Health

Organization [WHO], 2014). Suicidal ideation refers to thoughts of suicide and it

precedes suicidal attempts, with more than a third of adolescents in the United States, in

the latter category (suicidal attempts), eventually committing suicide. (Nock et al., 2013).

Further, young people who commit suicide are 16 times more likely to have made a

previous attempt than persons who never commit suicide. (Beautrais, Joyce, & Mulder,

1996). Next, according to Henry (2016), in her article, An Examination of Murder Suicide

in Guyana, murder-suicide findings are not different from suicide findings which show

that suicide in Guyana was mostly committed by young people, being the leading cause

of mortality between 15-24 years old and the leading cause of death for persons in the 25-

44 years age group. (Pan American Health Organization [PAHO]/WHO, 2012).

In this study I investigate which sociodemographic and cultural factors are

associated with suicide in the ≥ 15 years in Guyana. In my study I utilized 2015 data from

the Ministry of Public Health (Ministry of Public Health, 2017), in Brickdam,

Georgetown, investigating the link between the sociodemographic factors (age, gender,

region, method of suicide, and occupation), and suicide in ≥ 15 years old in Guyana.

Also, I explored the role of culture (as measured by race/ethnicity, religion) in

committing suicide in young people in Guyana. Further, there is an urgency to conduct

this study because suicide in the 23-48 years old population is a global public health
 2
concern, and many young people who are depressed can have psychological therapy

which will help them to realize that they do not have to kill themselves, but, to channel

that negative focus into developing life skills, (Depression in Young People, 2017;

Depression in Teens, 2018) that will help them find their purpose, so that they can

contribute to society.

This section comprises of the foundation of the study and literature review as well

as several subsections namely: (a) introduction, (b) problem statement, (c) purpose of

study, (d) research questions (RQ) and hypotheses, (e) theoretical foundation for study

and nature of study, (f) literature search strategy, (g ) literature review related to key

variables and/ or concepts, (h) definitions, (i) assumptions, (j) scope and delimitations,

(k) significance, (l) summary and conclusion of this section.

Problem Statement

Suicide in the young, as well as the older population, is a global public health

concern. According to the Jenkins (2002), there are several reasons contributing to this:

(a) it is the 10th leading cause of deaths in the world; (b) it is as common as deaths from

road traffic accidents; (c) not all suicides that occur from country to country are officially

recorded and the number is very great; (d) suicide causes loss of life; (e) long lasting

psychological trauma for children, friends, and relatives; (f) and finally loss of economic

productivity (para, 1). Next, low to middle income countries are more severely impacted

(WHO, 2017). Further, 78% of global suicide occurred in low to middle income countries

in 2015 and suicide was the second leading cause of death among the 15-25 years old in

these countries (WHO, 2017). Additionally, according to the World Population Review
 3
(2019), which used data provided by the WHO in 2018, Guyana had the third highest rate

of suicides (29.2 per100k), after Lithuania (31.9 per 100k) and Russia (31 per 100k)

(Suicide Rate by Country, 2019). According to WHO (2017), this high rate is a scourge

which gravely concerns the government of Guyana, while this rate significantly affects

Guyana’s population psychological and emotional wellbeing. WHO has indicated that

there is paucity of studies regarding this significant public health issue and it suggests

that mental health services provided in this country should be improved, and the

government has been working closely with the PAHO and WHO to achieve this goal.

Furthermore, in Guyana, according to the Guardian News (2018), there are various

methods used to commit suicide of which ingestion of pesticide is the most frequent. The

main reason for this is that many people are in the farming occupation, and pesticides are

readily available, thus, this contributes to the high rate of suicide. (Guardian News,

2018). The article cited other lethal means of suicide and claimed that restricting access

to firearms, ropes, and poisons is necessary in the prevention of suicide. (para, 7). The

predominant method of suicide was ingestion of poison known as pesticides which are

easily accessible across the 10 regions in Guyana and there is little control over

procurement of this poison (Henry, 2015).

Researchers have suggested that the increased use of specific methods for suicide,

such as hanging, is reflected in the increased suicide rates in the Korean and the U.S.

populations (Park et al., 2014.) Therefore, method of suicide is considered as a strong risk

factor for the completion of suicide and thus needs to be investigated.

 4
Worrel (2014) suggested that culture can be and is used interchangeably with

racial and ethnic identity and these identities are shown to be related to cultural outcomes

and dependent on culture. Therefore, race and ethnicity can be used as a surrogate for

culture when needed (Jenkins, 2014; Worrel, 2014). Further, Beyers (2017) supported

that religion can be used as a cultural identity marker and Edara (2017) described religion

as a cultural system of symbols, while it is also supported that religion is one of the ethnic

descriptors that may be observed to identify ethnicity (Jenkins, 2014). Additionally,

studies support that ethnic/racial religious characteristics protect people against suicide or

increase persons’ vulnerability to suicide and suicide ideation (Lawrence et al., 2016;

Snarr, Heyman, & Slep, 2010). Consequently, investigating the impact of the cultural

factors of ethnicity/race and religion on suicide rates in Guyana, can contribute to the

successful management of this significant public health issue.

Purpose of the Study

The aim of this quantitative study of secondary data was to determine whether

there is an association between the sociodemographic factors (age, gender, occupation,

method of suicide, and region) and the suicide cases in young people in Guyana. Also,

because culture has been shown to play a pivotal role in suicide, it would be interesting to

note if there is any link between culture (ethnicity/race and religion) and suicide cases in

≥ 15 years population in Guyana, because there is lack of studies investigating this topic

in this country. Additionally, to investigate how sociodemographic factors and culture are

associated with the method of suicide. Finally, this study can be used as a baseline for

future studies. The independent variables will be sociodemographic (age, gender,

 5
occupation, method of suicide and region) and cultural factors (race/ethnicity and

religion) and the dependent variable is suicide cases in the ≥ 15 years in Guyana.

Research Question (s) and Hypotheses

Research Question 1: Is there an association between sociodemographic factors

(age, gender, occupation, method of suicide, and region) and suicide cases in the ≥15

years population in Guyana?

H11: There is an association between the sociodemographic factors and suicide

cases in the ≥ 15 years population in Guyana.

H01: There is no association between the socio-demographic factors and suicide

cases in the ≥ 15 years population in Guyana.

Research Question 2: Is there a relationship between culture (assessed by

race/ethnicity and religion) and suicide cases in the ≥15 years population in Guyana?

Ha2: There is a relationship between culture and suicide cases in ≥15 years

population in Guyana

H02: There is no relationship between culture and suicide cases in ≥15 years

population in Guyana.

Research Question 3: Is there an association between the socio-demographic

factors (age, gender, occupation, and region) and culture, and the method of suicide in the

≥15 years population in Guyana?

Ha3: the socio-demographic factors (age, gender, occupation, and region) and

culture are not associated with the method of suicide in ≥15 years population in Guyana.
 6
Ha1: the sociodemographic factors (age, gender, occupation, and region) and

culture are associated with the method of suicide in the ≥15 years population in Guyana.

Theoretical Foundations for the Study

The socioecological model (SEM) guides this study. This theory was first used

by Bronfenbrenner (1979), was modified by Baral, Logie, Grosso, Wirtz, and Beyner

(2013), and suggested by the Centers of Disease Control and Prevention (CDC; 2015) to

explain several public health issues. The SEM examines various factors or levels of

influences such as individual, interpersonal, organizational, community and policy which

either put people at risk or protect them from perpetrating violence (CDC, 2018). The

latter was applied to violence because in order to prevent violence you must act across

multiple levels at the same time to sustain and prevent efforts overtime than any single

level. (para, 2).

The variables used in this study, such as age, gender, ethnicity/race, occupation,

method of suicide, region and religion can be considered as individual and societal

factors that affect suicide prevalence according to this theory. The theory is important to

the study because it identifies structures at each level that can help in the mitigation of

suicidal behaviors in the young population.

According to a study by Miner and De Leo (2010), low income countries are

impacted more by suicide. Further, the authors noted that, in high income countries

suicide in males is predominant, however, suicide is significantly higher in females, in

low income countries such as China, India, and Pacific countries. In terms of age, young

people are at greater risk in India and the Pacific countries, and in Asia this is a growing
 7
concern for the elderly. (Miner & De Leo, 2010). At this point in time, based on the

SEM, it is important to note that 75% of suicide occur in low- to middle-income countries

and the rates of poverty are high in these areas (Bantjes et al., 2016). Researchers have

suggested that there is a relationship between economic variables and suicidal behavior

(Bantjes et al., 2016). Further, in low- to middle-income countries (LMICs), it is

important to understand the relationship between poverty and suicidal behaviors and how

to mediate this relationship to plan effective suicide prevention methods in LMICs

(Bantjes et. al, 2016) Thus, if there is better understanding of the socioeconomic

determinants of suicidal behaviors, this could assist governments and policy makers in

developing interventions at the population level (Bantjes et al., 2016). Next, hanging is

the most common method of suicide in high income countries, but in Asia and the Pacific

a large number of deaths occur through ingestion of agricultural pesticide and inhalation

of burning charcoal fumes (Miner & De Leo, 2010).

Further, according to Vijayakumar (2004), in developing countries, the highest

rate of suicide is found among people younger than 30 years and the male/female ratio

(India 1.4:1, China 1:1.3). The author also claimed that 90% of persons in developed

countries die from suicides while 60-90% of deaths from suicide occur in developing

countries (Vijayakumar, 2004). According to WHO, 30% of suicide globally occur in

India and China, and the Eastern Mediterranean region and Central Asia have the lowest

rates of suicide (Befrienders Worldwide, 2012 -2018). In terms of age globally, the 15-44

years age group accounts for 50% and in the 45 years and over age group 45% and over

was recorded.
 8
Nature of the Study

I have conducted a quantitative study (using data that were collected applying a

cross-sectional method) to investigate whether there is an association between the

sociodemographic factors (age, gender, occupation, method of suicide, and region) and

the suicide cases in young people in Guyana. The independent variables which were

measured are age, gender, occupation, method of suicide, region and ethnicity/race and

religion. The dependent variable was the number of reported suicides. Data were obtained

from the Guyana Ministry of Public Health (MOPH). The time period under study was

January 2015 to December 2015. The type of data for this study took into consideration:

the geographic region in which it was taken, the specified time period, and the population

of interest for the researcher. The population under study were the ≥ 15 years, who

committed suicide during the study period under review.

Literature Search Strategy

Two databases (PubMed and Medline), libraries (Walden University, University

of Surrey), as well as Google Scholar were accessed to review journal articles that

relevant to the topic. Additionally, local news media as found on Google Scholar and in

newspaper articles were used. All information accessed between 2013 and 2018. Key

words were used to ensure that the relevant literature were sought and found. Google

Scholar was utilized further to find sources used in other databases. Some of the key

words used in this study include age, sex, region, method of suicide, region, occupation,

race/ ethnicity, religion, young people, Guyana, sociodemographic factors, culture,

suicide, socioecological model, acculturation . Suicide is a major public health concern

 9
in the ≥15 population in Guyana and there were concerns expressed by our health care

partner, PAHO/WHO, as to the reason why suicide in Guyana is so high.

Literature Review Related to Key Variables and/or Concepts

The areas covered in this literature review include suicide in the young

population, poor communication in the homes of youths who commit suicide, methods

used to commit suicide in the young as well as the older population, culture and its

relevance to suicide. Additionally, the covariates were reviewed namely: age, gender,

region, method of suicide, occupation, race/ethnicity, religion). Finally, the gaps that

contributed to suicide in Guyana will be discussed.

Suicide in the Adolescents and Young Population in Low- and Middle-Income

Countries and Guyana

Suicide is a major public health concern, especially in developing or middle-

income countries. According to Behmanehsh Poor, Tabatabaei, and, Bakhshani (2014),

369 suicide cases were investigated in a study conducted in Sistan and Balouchestan

Province, Southeast of Iran, and this was done to assess the epidemiology and

sociodemographic factors associated with suicide. Behmanehsh et al. showed that (65%)

were females, more likely to be young (43.5% between the ages of 16 to 25 years), and

they were low educational achievers (20.9% and 48.8%, respectively). (Behmanehsh et

al., 2014). Next, self-employed individuals as well as housewives were significant in the

medium and low-income category that committed suicide (Behmanehsh Poor et al.,

2014).
 10
However, in another study done in Ecuador, Chachamovich et al., (2013), found

suicide affects persons from different backgrounds, socioeconomic status, and

educational attainment (para, 5). The authors also postulated that men were three times

more likely to die from suicide (5.3 in women, 13.3 in males), with the mean of suicide

by hanging (51.1%), self-poisoning followed (35.2%), and firearms (7.6%). Further,

according to the Worldatlas (2017), which used data provided by the WHO in 2015, Sri

Lanka and Guyana had the highest rates of suicides (WHO, Suicide rates by country,

2017).

According to the National Suicide Prevention Plan 2015-2020 (2014), published

in December 2014, Guyana was ranked at the top worldwide with an estimated suicide

rate of 44.2/100,000. In Guyana, suicide was the leading cause of death among young

people aged 15-24 years, and the 3rd leading cause of death among persons aged 25-44

years. (National Suicide Prevention Plan 2015-2020, 2014). The most affected age group

was 20-49 years (50%) followed by individuals 13-19 years (16.6%) and greater than 50

years of age (16.6%). (National Suicide Prevention Plan 2015-2020, 2014). Males

committed suicides more frequently, with a proportion of 4:1 and most commonly used

pesticides or herbicides ( > 65% of case) followed by hanging ( > 20%). Next, Guyana

has 10 regions and four out of the 10 are considered hinterland regions (Region 1,

Barima-Waini, Region 7, Cuyuni- Mazaruni, Region 8 Potaro-Siparuni, and Region 9

Upper Takutu-Upper Essequibo) (Regions of Guyana, 2015). The other regions which are

coastland include region 2 Pomeroon- Supenaam, Region 3 Essequibo islands-West

Demerara, Region 4 Demerara-Mahaica ( which houses the city), Region 5 Mahaica-

 11
Berbice, Region 6 East Berbice-Corentyne, and Region 10 Upper Demerara-Upper

Berbice) (Regions of Guyana, 2015). East Indians accounted for > 80% of cases and most

of these cases were concentrated in Regions 2, 6, 3, 4, 5. (National Suicide Prevention

Plan 2015-2020, 2014). The highest suicide rate was in Region 2 (52.7/100,000) followed

by Region (50.8%) and Region 3 (37.3). (National Suicide Prevention Plan 2015-2020,

2014). Therefore, because suicide is a major public health concern globally and in

Guyana, I decided to conduct a study to explore the role of the sociodemographic factors

and culture in committing suicide in the young population in Guyana.

Culture and its Relevance to Suicide

It is important to understand that when someone commits suicide this can be

related to a certain culture. According to Henry (2016), suicidal methods may be related

to culture, and this calls for research on a global level to determine how culture may

impact suicide, and this can help to address the rising rate of suicide, since culture in

itself can provide coping mechanisms for suicide (para, 2). Further, the author stressed,

due to advancement in civilization, coping mechanisms are lost, exposing genetic

predisposition to vulnerable groups, thus, “a system of therapeutic re-culturation is

needed with an emphasis on relevant culture based therapies” (Henry, 2016, para, 2).

Guyana is made up of six racially and ethnically heterogenous group with a population of

784, 948 people. (Guyana population, 2019). East Indians is the largest ethnic group

(44%), Afro-Guyanese (30%), Mixed Heritage (17%), Indigenous Amerindians (9%).

(Guyana Population, 2019). It is reasonable for someone to ask the question whether

there are elements within the Indo-Guyanese subsystem that make them unique in
 12
comparison to the other ethnic groups which influences suicidal behavior among them. In

terms of sexual freedom a higher level of “mechanical solidarity” exists among the Indo-

Guyanese than other ethnic groups (Edwards, 2016). For example, the Afro-Guyanese

have a high level of sexual freedom, because of high levels of “organic solidarity” which

exists within the group. (Edwards, 2016). To this effect, the author claimed that members

within the African group are more opened in their relationships when cheated upon by

their spouses. In fact, this group claimed that in life a man must expect to have “blow and

goadie” meaning that he must expect his partner to cheat on him, and further he has to

have hydrocele. The aforementioned prepares them for acts of infidelity and minimizes

suicidogenic tendencies (Edwards, 2019). The above cultural factors are not present in

the Indo-Guyanese who marry at a younger age and do not have those cultural values

which make them less able to cope with sexual freedom and infidelity in their marriage

(Edwards, 2016). Thus, according to the author, the cultural factors combined influence

high rates of egotistic suicides among Indo-Guyanese (Edwards, 2016). Suffice to say

that, acculturation has greatly impacted the East Indian population and made them more

vulnerable to committing suicide.

Although, culture may play a role in suicide, according to the article, Advancing

Suicide Prevention Research With Rural American Indian and Alaska Native

Populations, there are studies that document the co-occurrence of alcohol and drug use

combined with suicidal behavior among American Indian and Alaska Native and more

than half of them that exhibited suicidal behavior were under the influence of alcohol at

the time. (Wexler et al., 2015). There is evidence consuming alcohol and drugs due to
 13
culture which play an important role in suicidal actions. Thus, according to Pompili et al.

(2010) in a meta-analysis done in the United States, both alcohol and drug use disorders

were strongly associated with suicide. Persons who consume alcohol had a five-fold risk

in committing suicide than social drinkers.

Further, according to Edwards (2016), suicide is linked to culture when he cited

the East Indian ethnic group and compared same to the other groups, he claimed that

Indo-Guyanese subscribes to values and norms that are different to the larger social

system. Next, Edwards claimed that the reasons were two-fold: first he linked their lack

of openness in their relationship which may be considered a closed system. To continue,

Edwards, compared Afro-Guyanese with Indo-Guyanese and claimed they were more

“hostile and repressive” in their relationship on the plantation and they moved away from

the system to be incorporated in the colonial system, while the Indo-Guyanese remained

and developed communities within the structures that were already there.

In addition, acculturation is implied as a causal factor for suicide; however, there

is paucity of research in this field. Nevertheless Caetano et al. (2013), claimed that

suicide is multidimensional attributing several factors among Inuit such as “social and

cultural changes, poverty, geographical isolation, cultural suppression and political

disempowerment” for increase rates of suicide. (Caetano, et al., 2013, para, 7).

Acculturation is the bringing together or a combination of cultural values and practices

between a culture that is dominant and one that is original (Schwartz et al., 2010). Ethnic

identity plays a pivotal role in acculturation because a particular ethnic group finds it

difficult to give up their own traditional culture and become acclimatized in another
 14
group’s culture which is dominant. According to the authors, this period can result in

stress and the particular ethnic group feels negative towards their traditional culture,

experience social marginalization and this brings conflict between the individual and his

family’s cultural expectations (Ahmad, 2018).

Next, there are many researchers who discuss whether religious characteristics

protect people against suicide or increase persons’ vulnerability to suicide and suicide

ideation. Thus, according to Lawrence et al. (2016), among Asian Indian adolescents’

suicide ideation and attempts were higher among Hindus and other religions. Similarly, in

Malaysia suicide ideation was higher in Hindus than Christians (Maniam, Chinna, &

Mariapun, 2013). The authors highlighted this issue in the United States Air Force Army

and claimed suicide ideation was more common among non-Christian religion and lower

in evangelical Christians and Roman Catholic females and male “Other Protestants”

(Lawrence et al. 2016; Snarr, Heyman, & Slep, 2010).

Common Methods of Suicide in the Adolescents and Young Population

Behmanehsh Poor et al. (2014) claimed that the most common method of suicide

was by burning (53.4%), then ingestion (23.8%). Next, the authors cited the case fatality

rate to be 49.6% and this was associated with low income, followed by summer time

suicide, and the common method which was burning. However, according to a study

done in Asia, there are recent trends in suicide which reflect the sociocultural, economic

and religious situations in countries and as such the method may not be equal for all sex

and age subgroups.(Wu, Cheng, & Yip, 2012). According to the authors “charcoal

burning, pesticide poisoning, native plant poisoning, self-immolation, and jumping” are
 15
common methods of suicide (Wu et al., 2012, Para, 1). They further suggested that it may

be cost effective to design safety into technology as a way of suicide prevention. Of

significance, in Guyana, according to the Guardian News (2018), there are various

methods used to commit suicide of which ingestion of pesticide is the most frequent. The

main reason for this is that many people are in the farming occupation, and pesticides are

readily available, thus, this contributes to the high rate of suicide. (Guardian News,

2018). The article cited other lethal means of suicide and claimed that restricting access

to firearms, ropes and poisons is necessary in the prevention of suicide (para, 7).

Next, there seems to be a gender paradox when it comes to suicidal behavior, for

example, males are more likely to complete suicide, while females attempt suicide and

have suicide ideation more (Cash & Bridge, 2009; Freeman et al, 2017). Methods of

suicide vary from country to country, firearms were the leading method of suicide among

youths, followed by hanging/ suffocation and self-poisoning (Cash & Bridge, 2009).

Further, according to Shah and Buckley (2011), there are clear differences in the methods

of suicide between the younger and older population, as well as between age and sex,

because knowing this will help a country to develop different strategies in terms of these

cohorts gaining access to the various methods. For example, the authors in their study

postulated that, hanging, strangulation and suffocation were noted in males, 40.2% and

females 20.1%, drowning and submersion, males 8.2% and females 11.4 %, (Shah &

Buckley, 2011). Finally, other, unspecified drugs and medicaments and biological

substances, males 8% and females 20.4%. (Shah & Buckley, 2011).

 16
Further, Jiang, Mitran, Miniño, and Ni (2015), in their study on racial and gender

disparities using combined data in 2009 and 2013 postulated that firearms was the most

common method followed by suffocation in the non-Hispanic black and non-Hispanic

white adults who committed suicide. Next, the most common method used was

suffocation followed by firearms in the Hispanic, Asian or Pacific Islander and American

Indian or Alaska native (Jiang et al., 2015). For the Asian or Pacific Islander who

committed suicide poisoning and falls were the most common methods, than other race

and ethnicity groups (12.6% and 8.1% of suicide deaths, respectively). (Jiang et al.,

2015). To continue, occupation play an important role in method of suicide.

Thus, according to Milner, Witt, Maheen, & LaMontagne (2017), occupations

whereby people have access to lethal methods need to be controlled. For example,

persons in some occupations that have access to medicines or drugs, firearms and carbon

monoxide are the persons who commit suicide more than those who do not have access to

them (Milner et al., 2017). Additionally, in terms of females who hold such occupations,

they were 3.02 times greater (95% CI 2.60 to 3.50, p < 0.001), than those whose

occupation do not provide such access. (Milner et al., 2017). Likewise males with access

were 1.24 times greater than those without access (95% CI 1.16 to 1.33, p < 0.0001).

Based on the above, it is important for a study to be done on suicide with emphasis on the

young population to examine the common method(s) of suicide.

Poor Communication Affecting Suicide in Young Population.

It is important to mention that although not the primary focus of this study, there

seems to be an issue with communication in the homes of youths who commit suicide as
 17
noted by the United Nations Children’s Fund. In Guyana, based on focus group

conducted by the United Nations Children’s Fund, gaps in communication in the homes

and schools were cited as factors that drive suicide in youths (Lack of Communication

Contributes to Suicide in Guyana, 2016). The article stressed that, the youths who

commit suicide are under psychological stress in a “social context” and cited isolation

from partners, family members and friends and these youths were compared to others

who have close relationships as having a sense of purpose, security and connectedness

(Lack of Communication Contributes to Suicide in Guyana, 2016).

However, according to CDC (2017), suicide affects all youths, but some are of

higher risks than others namely: those with a family history of suicide, mental health

problems, those exposed to alcohol and drug abuse, and seeing another person commit

suicide (para, 3). Additionally, CDC emphasized that having risk factors for suicide does

not mean that the person will commit suicide (CDC, 2017). Further, according to

Quarshie, Osafo, Akotia, Preprah (2015), mass media coverage of adolescent suicide is a

true reflection of the situation. The authors also claimed that the precursors within the

microsystem (family, school), also contributes to young people committing suicide. As

noted previously, there are many factors contributing to suicide in the young population,

future studies need to be done to assess the role of communication in suicide in the young

population. Further, it is important for us to understand that suicide is multidimensional.

Gender and Suicide

Suicide in the young population is global, and varies across different countries,

and in developed countries that have a good data system, the rates are two to three times
 18
higher in boys than girls (Rhodes et al., 2014). The authors claimed that in some

countries, the rates increased for girls and decreased for boys, but it is now reversing

(para, 3). However, Roh, Jung, and Hong (2018), referred to same as gender paradox,

adding that suicidal ideation and attempts are higher in females than in males. Thus, it is

important for this study to explore gender differences in suicide, so that interventions can

be tailored and appropriated to meet the needs of both males and females.

According to Suicide Awareness Voices Education (2018), which used data from

the CDC, male deaths occur four times higher than females and represent 79% of all

suicide deaths in the United States. Further, according to Freeman et. al (2017), their

findings supported the previous research that suicide appears to be a male phenomena

occurring four to five times higher in males across European countries. Although rates of

suicide are usually higher in males than females one exception noted was China with

higher rates of suicides in females (Vijayakumar, 2004). The reason being there is a lack

of regard for suicidal behavior in women since they were viewed as manipulative and not

serious compared to men in which suicidal behavior is dominated by male deaths in all

countries except China (Vijayakumar, 2004). The author also emphasized that women

attempt suicide more than men, but men complete suicide more than women. Due to the

aforementioned there is an under regard for mortality in which women predominate.

(Vijayakumar, 2004). Nevertheless, a significant reason was noted by Varnik (2012),

who claimed that cultural factors and regional differences in socioeconomic status played

major roles. However, the author emphasized that changes will occur as cultural norms

shift and different countries take their own developmental pathways.

 19
Further, according to Wasserman, Cheng and Ziang (2005), female suicide rate

was also seemingly higher in other countries such as Cuba, Ecuador, El Salvador and Sri

Lanka, (para, 1).Further, global suicide rate in young people 15-19 years specifically for

females, between 1979 and 1996, rose to a lesser extent for this cohort in the 18 to 30

countries studied, mainly due to loss of social cohesion, a breakdown in family tradition,

economic instability and unemployment, and an increase in depressive disorder

(Wasserman, Cheng, & Ziang 2005).

Race/Ethnicity and Suicide. Dating back from the 1960s Guyana is a highly

diverse nation with racial discord and violence between the Afro-Guyanese and Indo-

Guyanese (Lacey, Powell Sears, Crawford, Matusko, & Jackson, 2016). Of significance,

China and India were regarded as the major contributors to suicide in the world and these

countries were responsible in 2004 for 54% of suicide in the world. (Varnik, 2012). There

were a few reasons which accounted for this namely: China does not have a

comprehensive reporting system, and the figures on suicide data range are wide. (Varnik,

2012). Secondly, for India their deaths distribution from the nationally representative

sample, were taken from detailed reporting on death studies and “adjusted to the 2008 all

cause envelope” (Varnik, 2012). The author claimed the accuracy of suicide numbers

cannot be ascertained by WHO for both China and India. Further, official figures

presented to WHO are based on 10% of the population and urban along with rural areas

are calculated separately. (Varnik, 2012).

Indo-Guyanese and Suicide. According to the data from the Ministry of Public Health

in Guyana on suicide in 2016, predominantly among the East Indian population in the
 20
rural community of East Berbice Corentyne, 175 persons died by suicide, 73% of these

persons were of East Indian descent, were either unemployed or in the low to middle

income jobs, and 70 (40%) were youths between the ages of 12 and 29 years old

(Ministry of Public Health, 2017). According to Lacey, Powell Sears, Crawford,

Matusko, and Jackson (2016), a study was done in Guyana which show that depressive

disorders were higher for Indo-Guyanese than any other ethnic groups, which may

explain this high prevalence of suicide in this population group.

Afro-Guyanese and suicide. According to a study, mood and anxiety disorders

were more predominant in persons of African American descent and Caribbean Blacks

(Lacey, Powell Sears, Crawford, Matusko, & Jackson, 2016). On the contrary, Edwards

(2016), suggested that because the Africans are more “hostile and repressed”, also much

more open in conversation (based on history), they are less likely to commit suicide in

comparison to other ethnic groups. These contradictory results indicate the need of

further research on the impact of race/ethnicity on suicide in Guyana.

Age groups and suicide. According to Quinlan-Davidson et al. (2014), in their

study Suicide Among Young People in the Americas, countries with the highest total

mortality rates among young people (10-24 years) were Guyana, Suriname, Nicaragua,

El Salvador, Chile, and Ecuador. This was followed by countries with the lowest

mortality rates Mexico, Venezuela, Cuba, Brazil, and the U.S. territory of Puerto Rico

(Quinlan-Davidson et.al, 2014). Further, according to Behmanehsh Poor, Tabatabaei, &

Bakhshani, (2014), in a total of 369 suicide cases investigated, the age range mostly

affected was young persons (43.5% between the ages of 16 to 25 years). They were
 21
either illiterate or just received a primary school education (20.9% and 48.8%,

respectively). (Behmanehsh Poor, Tabatabaei, & Bakhshani, 2014).

Young adults and suicide. Alcohol may be a contributory factor for suicide in

young people in Guyana. Thus, according to a World Health Organization report in 2010,

almost 80% of adolescent population had their first drink before 14 and some even try

alcohol before elementary school (Rawlins & bishop, 2018). Further, although alcohol

use in adolescent suicide is not widely researched, studies have shown that excessive

alcohol use in young people is a contributor to suicidal ideation and attempts (para, 17).

Next, it is important to understand that suicide in the young is mostly attributed to

ingestion of poison (Guardian News, 2015). Thus, according to Henry (2015), this is so

because of the easy access to pesticides since there is no control to procurement of this

poison.

Older adults and suicide. Suicide in older adults (especially 65 years and older)

is also a major public health concern and it is mostly due to depression which is very

prevalent in this age group (Karlin, 2014). The author claimed that older adults with

depression and mental disorders receive treatment at low rates and cited a national study

which found 1 in 10 older Americans who received treatment. In Guyana, one of the

reasons for suicide in the elderly is when they feel lonely and abandoned and have no one

to turn to for guidance or companionship thus there is likelihood of increase depression

resulting in suicide. (Guyana Chronicle, 2014). A striking similarity was found between

cause for suicide in the older adults in Guyana and the United States. Thus, according to

Karlin (2014), there is social isolation and limited social support in the older population.
 22
Paraquat Poisoning and Suicide According to Stabroek News (2018), Guyana imports

155 tons of paraquat annually, which is a pesticide used by farmers in Guyana and

worldwide. This is affordable and effective and farmers cannot find an alternative to this

product for their plants (Stabroek News, 2018). To this effect, out of the 150-200 suicide

deaths in Guyana, 70% die by ingestion of paraquat poisoning since many persons in this

type of occupation utilize this. Between 2009-2015, another author claimed more than

36% of all deaths was by poisoning, however, there was an increasing trend of suicide for

all categories, and deaths by poisoning decreased. (Henry, 2015). Hanging accounted for

41% of deaths by suicide in 2014. The author continued that methods used were

poisoning, hanging, shooting and stabbing.

Further, according to WHO 30% of global suicides are due to pesticides self

poisoning (systematic review of world data 1990-2007), and these occurred mostly in low

to middle income countries, making it one of the most used method for suicide globally

(Lee, Roser, & Ortiz-Ospina, 2018). In China, barbecue charcoal was used to produce

carbon monoxide as a means of suicide and it became the most common method in eight

years. (Lee, Roser, & Ortiz-Ospina, 2018).

“Regions and Religion Dual Role in Suicide Guyana” study has 10 regions and

according to data from Ministry of Public Health (2017), regions two and six have the

highest rates of suicide. In region 6 (East Berbice Corentyne), there are many people of

Hindu of Indian descent and suicide is usually portrayed in Guyana as largely as a

phenomenon of Hindu (Fox News World, 2014). The article also claimed suicide tend to

be higher in rural than urban area (Fox News World, 2014). According to Chabrol
 23
(2016), suicide attempts were also high in Christians, Hindus and Muslims. Thus, it can

be inferred that suicide is not only high in East Indians who are Hindus, but also in other

race/ethnicities, so this is important for a study to be conducted to understand the role of

culture or the association of culture (race/ethnicity and religion) on suicide in young

people.

Gaps that Contributed to Suicide in Guyana

Due to the research gap that exists, the government of Guyana recognized the

need for crafted plans to mitigate suicide in Guyana in both, the young and elderly

population. This research gap is the main reason why a research in Guyana is critical in

order for us to mitigate the effects of suicide.

Next, according to the Department of Public Information (2017), the Mental

Health Action Plan 2015-2020, focuses on community mental health care changing from

institutionalized mental health care to community mental health care. Additionally, many

non-specialist doctors are continuously trained in mental health to combat the major

mental health issues people are experiencing (para, 4). According to the article

Decriminalize Suicide (2017), Junior Minister of Public Health, Dr. Karen Cummings

said the advent of the above unit saw Guyana dropped from its world rated position as the

country with the highest suicidal in the world. In support of the aforementioned, crude

data from the World Health Organization in 2015 show , Sri Lanka had the highest rate

35.3 per 100,000 inhabitants, followed by Lithuania 32.7 per 100, 000, Democratic

People’s Republic of Korea third with 32.0 and, Guyana fourth with 29.0. (WHO,

2017).Despite the above, suicide still remains a public health concern in Guyana
 24
especially in our young population. Thus, there is still need for this research to be done

because as noted earlier in the Socioecological Model, there are various levels of

influences such as individual, interpersonal, organizational, community and policy which

either put people at risk or protect them from perpetrating violence (CDC, 2018)

Definitions

Acculturation: This occurs when someone adopts the cultural practices and

beliefs of another culture, but still retains his/her own culture. (What is acculturation?

2018)

Culture: The behavior, practices, and values of a defined group of people,

including music and arts that make them unique to another group (Zimmerman, 2017)

Ethnicity: People who live within a certain location that have their own culture

(Bhopal, 2004). This is relevant to the study in the use of Afro-Guyanese or Indo-

Guyanese.

Vulnerable groups: According to WHO (2002). Vulnerability is the degree to

which a population, individual or organization is unable to anticipate, cope with, resist

and recover from the impacts of disasters”. (WHO, 2002).Vulnerable groups include

Children, pregnant women, elderly people, malnourished people, and people who are ill

or immunocompromised. (para, 2).

Hostile and repressive: The people were openly resistant (Merriman Webster,

2018), based on the government’s confinement of their political and civil freedom.

(Davenport, 1999: 92)

 25
Therapeutic re-culturation: This occur when adoptees reclaimed their culture

which became mixed with other cultures that were different from their birth and races.

(Baden, Treweeke, & Ahluwalia.2012).

Assumptions

One of the main assumptions of this study is that the SEM provides a

framework in order for one to understand that suicide prevention and reduction involves

an interplay of factors at various levels namely: individual, interpersonal, organizational,

community and policy (CDC, 2018). Data were cross sectional and collected from all 10

regions in Guyana, through the records department of each region. It is uncertain to what

extent, this may affect the validity and reliability. Data were validated through the

statistical department of the Ministry of Public Health (2017), therefore I assume that this

validation was sufficient. Also, I assume the responses to the questions were accurate and

correct.

Scope and Delimitations

This is a secondary data analysis using data that were collected using a cross-

sectional method focused on the subpopulation (adolescents and youth people) residing in

Guyana, surveyed between the period January to December 2015. The SEM was chosen

because it provides multiple levels of influences that can help address the issue of suicide

in ≥ 15 years population from a broader perspective extending right up to the policy

level.
 26
Significance

Guyana’s suicide rate is troubling and no one factor can be regarded as the cause

for suicide, but a combination of several factors. Thus, according to Aljajeera (2016), the

University of Guyana, discovered issues such as those related to relationship, political

instability, escalating crime rate and poverty. An area that is missing in Guyana, is to

understand that there is an interplay of factors that cut across various levels and are

responsible for suicide, namely individual, relationship, community and societal factors

CDC, 2015). In Guyana, there seemed to be some similarities in the socio demographic

factors that exist in the study by Behmanehsh Poor, Tabatabaei, and Bakhshani (2014) in

South East Iran. For example, the people who committed suicide, according to the data

from Ministry of Public Health in Brickdam, Guyana, were mostly young people from

the low to medium income group, and can be considered low educational achievers

(Ministry of Public Health, 2017). The common method of ingestion in the MOPH data

was ingestion of poison, compared to the common method of suicide which was burning

in the data from South East Iran (Behmanehsh Poor, Tabatabaei, & Bakhshani, 2014).

For this research to be unique, we looked to see if there is any association

between suicide prevalence and culture and the socio-demographic factors namely: age,

gender, occupation, method of suicide, region and ethnicity. This is important because

there may be some distinctive features or characteristics that exist among the various

cultures that drive suicide in one culture in comparison to another. This significance can

be examined from the Guyana perspective. Thus, the research outcomes can guide the

researcher to inform policy makers on the need to establish mechanisms to monitor

 27
persons from various cultures who commit suicide and it can also be used for planning

and preventive measures. (Behmanehsh Poor, Tabatabaei, & Bakhshani, 2014).

In terms of this research contributing to positive social change people may

respond differently to mental health and suicide based on the society and culture from

which they originate. Secondly, with this study I aim to identify potential

socioeconomic and cultural factors that are associated with suicide in adolescent and

youth population in Guyana; these factors can be used to provide counselling sessions for

the persons who have suicidal behaviours, training youths in life learning skills so that

they can find jobs, and finally there needs to be a collaborative approach by WHO,

governmental, non-governmental organizations and civil society to reduce the prevalence

of suicide in this population group in Guyana. In this way, a multidisciplinary approach

to management of suicide can be developed based on the results of this study, including

alleviating the social determinants of health which may play a major role, since the issue

at hand is suicide impacting middle to low income countries more than high income

countries (WHO, 2017).

Summary

In 2015, Guyana recorded the second highest rate of suicide in the world.

(WHO, Suicide rates by country, 2017). The socio-demographic factors may play a

critical role in suicide in the young and older population in Guyana. The people who

commit suicides, included young people, were from the low to medium income group,

can be considered low educational achievers, and the common method of suicide was by

ingestion of poison. Suicide management needs a multidisciplinary approach and as such

 28
the government of Guyana cannot manage this dilemma alone, so it is important that this

research be done so that evidence based strategies can be crafted to assist Guyana to

mitigate the suicide rate in youths as well as the elderly population.

 29
Section 2: Research Design and Data Collection

The aim of this quantitative study of secondary data was to determine whether

there is an association between the sociodemographic factors (age, gender, occupation,

method of suicide, and region) and the prevalence of suicide in young people and the

older population in Guyana. Also, because culture was shown to play a pivotal role in

suicide, it would be interesting to investigate if there is any link between culture

(ethnicity/race and religion) and suicide prevalence in the ≥ 15 years population in

Guyana because there is paucity of studies in this area. Additionally, to investigate how

socio-demographic factors and culture are associated with the method of suicide. In the

previous section, I examined the literature on the association of sociodemographic factors

on the prevalence of suicide in the ≥ 15 years Guyana. Section 2 includes research design

and rationale, methodology which includes population, sampling and sampling

procedures, instrumentation and operationalization, data analysis, threats to validity,

ethical procedures and summary.

Research Design and Rationale

This is a secondary data analysis using data that were collected implementing a

cross-sectional method to determine the association of the sociodemographic factors on

suicide in the young and older population in Guyana. I examined how suicide may differ

according to the key independent variables mentioned above, also how culture may play a

role in occurrence of suicide in the ≥ 15 years population. My data were based on routine

state specific purposes and as such there was no time restriction on the design and data

collection. Further, the research choice is consistent with the research design because the
 30
evidence obtain (secondary data) will enable me, to address the research question as

effectively and unambiguously as possible (Tefry, 2018).

Methodology

This study used the quantitative cross sectional design in order to quantify the

problem of suicide in the ≥ 15 years population in Guyana and transform it into usable

statistics (De Franzo, 2011). To this effect, it can be used to quantify opinions, behaviors,

attitudes, and other defined variables. Quantitative research uses measurable data so that

facts can be formulated and patterns in research can be uncovered. (para 2, De Franzo,

2011). I did not use qualitative data because my study investigated the association

between sociodemographic and cultural factors and the prevalence of suicide, based on

secondary quantitative data. Further, since this research utilized secondary data without

any intervention, there was no need for an experimental design where subjects are

randomly assigned between the test and control group. (Blakstad, 2018).

Population

The population included adolescents and young people aged ≥ 15 years who

committed suicide under the period of study, January 2015 to December 2015. Data were

collected from all 10 regions in 2015 and acquired by Ministry of Public Health (MOPH)

in 2015 for those persons who were surveyed.

Sampling and Sampling Procedures

The MOPH surveillance data included persons who were surveyed nationally and

the subset consisted of the ≥15 years population who resided in Guyana in 2015. No

sampling was done for data, but an established procedure exists at MOPH for data
 31
collection. Thus, according to the MOPH, Health Statistics Unit (2017) standard

operating procedure manual for deaths, data were collected from all 10 administrative

regions namely health posts, health centers, hospitals by a Senior Health Visitor (SHV)

who is attached to each region. Further, he/she is also responsible for ensuring that forms

were correctly and accurately filled by public health personnel attached to the facilities in

his/her region. Next, the SHV submitted signed forms to the regional level via the

Regional Health Officer/Regional Executive Officer, and then to the MOPH, through

Regional Health Services. Further, data were sent to the Statistical Department for data

entry.

Additionally, two epidemiological nurses from MOPH, visited the health centres,

private hospitals and clinics on a routine basis to collect reports and simultaneously

collect surveillance reports via phone from the hinterland regions (Dey, Lewis, Mack,

Haynes, & Elcock, 2017). When all reports were submitted to the stats unit, the

supervisor assigns each report to the relevant staff (data entry or statistical clerk). The

reports were sorted, filed, batch or coded where necessary, and entered on a health

information table, where cleaning, validation are done. Thereafter, statistical tables and

reports were generated.

Data on suicide deaths were collected from death notification forms; the

notification of death form is a standard public health tool for capturing deaths. Every time

someone dies whether be it home or at the hospital the death has to be notified using the

death notification form. (Dey et al., 2017) In addition, similar data on death are being

captured by collecting the death registration forms from General Registry’s Office
 32
(GRO). However, the main tool for capturing deaths is the death registration forms which

are collected electronically from GRO. This is because there is a high number of under

reporting on the death notification form due to health facilities mainly (hospitals) failing

to notify the deaths (Health Statistics Unit, 2017). Further, after cleaning data, same were

exported to Microsoft excel and sent to the Caribbean Public Health Agency (CARPHA)

via the Chief Medical Officer for validation. Further, the manual stated clearly if there are

errors on the registration forms, they are flagged by CARPHA and resent to the MOPH

Statistical unit and the Chief Statistician makes the corrections and the information is

submitted to the CMO to CARPHA. (Health Statistics Unit, 2017). To continue,

CARPHA reviews the corrected data, conducts and processes information for global

analysis. Next, dataset returns from CARPHA free of errors and are stored and processed.

Subsequently, data were used for reporting by categories for example, sex, region, age,

ethnicity etc.). Finally, the senior statistician and other statisticians further analyzed and

prepared bulletin for decision making purposes for stakeholders and policy makers to use

(Health Statistics Unit, 2017).

Sampling frame. The sampling frame included (a) young people and the older

population surveyed in MOPH, (b) youth aged ≥ 15 years, (c) Guyanese primary or

secondary residence (d) survey year 2015, (e) all reported races or ethnicities. The

population sample included the number of young persons who committed suicide during

the period under study.

Procedure and permission for access to data set. I requested and received

permission from the Chief Medical Officer to gain access to the data set on suicide. You
 33
can only gain access to the data through the Institutional Review Board (for research

purposes), or the Chief Medical Officer who facilitated the process. In my written

request, I provided a brief outline and purpose of my study to the Institutional Review

Board, which forms part of the MOPH, requesting access to data on suicide. This

required a data user agreement with the IRB and an affiliated State University for 2015

report and this information will be provided in the ethics section.

Power analysis. While I used secondary data, my sample size was all the valid

cases in the dataset provided by the MOPH. Since there were no similar studies in this

population, a medium effect size of .5 (Laerd Statistics, 2016) and logistic regression was

used to determine the needed sample size to have adequate statistical power ≥ .8

(G*Power Calculator; Faul, Erdfelder, Buchner, & Lang, 2007). Using an alpha of .05

and a satisfactory power of .8, a sample size of at least 400 participants was required.

However, the final received sample size was 220 which can result in a less satisfactory

statistical power.

Instrumentation

I conducted a quantitative analysis of secondary data set collected from all 10

regions and MOPH for routine state specific reasons in 2015 to determine whether there

is an association between the sociodemographic and cultural factors and the cases of

suicide in the ≥15 years population in Guyana. Next, permission was requested from the

Chief Medical Officer who advised the IRB about the release of data on suicide.

Operationalization of variables. The types of variables used in this research are

nominal and continuous and they include: age, sex, race/ethnicity, region, method of
 34
suicide, culture (as measured by race/ethnicity, religion), and occupation. According to

Stat Trek (n. d), nominal variables have no numerical values in terms of magnitude. Thus,

method of suicide, religion, occupation, sex, ethnicity, religion was used to measure by

using nominal variables. Age is continuous variable because it can take on any value in

some range of value and cases of committed suicide is a discrete variable (Types of

Variable, 2018).

Research Questions and Data Analysis Plan

The software that was used to perform all data analysis is version 25 which was

made available for free to Walden Students. It is the Statistical Package for Social

Sciences (SPSS). The suicide survey data obtained by MOPH national database, were

imported into SPSS.

Research Questions and Hypotheses

Research Question 1: Is there an association between sociodemographic factors

(age, gender, occupation, method of suicide, and region) and suicide cases in the ≥15

years population in Guyana?

H11: There is an association between the sociodemographic factors and suicide

cases in the ≥ 15 years population in Guyana.

H01: There is no association between the socio-demographic factors and suicide

cases in the ≥ 15 years population in Guyana.

Research Question 2: Is there a relationship between culture (assessed by

race/ethnicity and religion) and suicide cases in the ≥15 years population in Guyana?
 35
Ha2: There is a relationship between culture and suicide cases in ≥15 years

population in Guyana

H02: There is no relationship between culture and suicide cases in ≥15 years

population in Guyana.

Research Question 3: Is there an association between the socio-demographic

factors (age, gender, occupation, and region) and culture, and the method of suicide in the

≥15 years population in Guyana?

Ha3: the socio-demographic factors (age, gender, occupation, and region) and

culture are not associated with the method of suicide in ≥15 years population in Guyana.

Ha1: the sociodemographic factors (age, gender, occupation, and region) and culture are

associated with the method of suicide in the ≥15 years population in Guyana.

Analysis Techniques

The analysis of the data was consisted of three phases. First, descriptive statistics

(frequencies for nominal variables and mean and standard deviations for continuous

variables) were provided for all the variables of the study. Second, bivariate analysis was

conducted. For RQs 1 and 2, since the dependent variable is a discrete one (suicide

cases), I performed 2-sample z-test to compare two sample proportions of committed

suicide cases in young people in Guyana by each socio-demographic factor (age, gender,

occupation, method of suicide, and region) for RQ1, and by race/ethnicity and religion

for RQ2. For RQ3, binomial logistic regression was conducted having as predictors the

socio-demographic factors (age, gender, occupation, and region) and

 36
culture (race/ethnicity and religion) and as outcome variable was method of suicide

(nominal variable).

External Validity

External validity regards generalizability, representativeness of the sample, setting

and procedures (External and Internal Validity, n. d). According to Dey et al., 2017), the

Senior Health Visitor should ensure that all reports are signed off in the region before

being submitted to MOPH. However, this does not always happen, and information can

flow straight to MOPH. Secondly reports are supposed to be submitted to the Regional

Health Services Department first, then to the Statistical Department in the MOPH,

however, data are sent RHS, Surveillance, MCH, CMO office and Stats unit directly

(Dey, Lewis, Marks, Haynes & Elcock, 2017). Next, the authors claimed that, the main

tool used for capturing deaths is the death registration forms which are collected

electronically from the General Registry’s Office due to the high number of under

reporting from the various health facilities. Nevertheless, since the study sample was

collected from several sites and regions of the country, the results of this study can be

generalizable to the young and older population in Guyana.

Internal Validity

Internal validity is the degree to which the results are related to the independent

variable and no other competing explanation (External and Internal Validity, n. d).Since

this a secondary data analysis using a cross sectional data collection design, the main

concern is that no causal relationships can be confirmed and only associations can be

reported. Therefore, potential causal inferences should be done with caution.

 37
Additionally, internal validity can be confirmed with the use of multivariable analysis to

control confounding as much as possible.

Ethical Procedures

This study is a Walden doctoral project and required a letter of cooperation and a

data use agreement from the MOPH statistical department for a section of the data needed

for the study. Walden IRB approval was also required and received to conduct the study.

The approval number was 04-18-19-0533532. The MOPH IRB was partnered with

another state university and this required an electronic IRB process as per 2017 report.

Permission was sought from the CMO of the MOPH by way of a standardized form for

access to use data. He also instructed the Statistical Department to release data. s

Ethical Concerns

In Guyana, the populations of people recorded with attempts to suicide

are not protected under the laws of Guyana. In fact, the law is antiquated because it does

not take into account that when someone attempts to commit suicide or commits the act,

the reasons are multifactorial. Thus, according the laws of Guyana section 8:01 97,

“Everyone who attempts to commit suicide shall be guilty of a misdeamour and liable to

imprisonment for two years”. (Chapter 8:01 Criminal Law (offences) Act Arrangement, p

53, 1998,). Next, all death registration forms are collected from the General Registry

Office electronically in scanned copies, sent to MOPH Statistical Unit and they are

printed and coded according to the International Classification of Disease Standard (ICD

10 _10 th edition) to ascertain the final cause of death (Health Statistics Unit, 2017).
 38
They are then sent to the Caribbean Publication Agency through the Mort Base System

provided by that agency (Health Statistics Unit, 2017). This process governs all deaths.

All study plans were approved by MOPH IRB on ethical issues after which

Walden approved same. There is no conflict of interest to prevent me from using MOPH

data, since I have never analyzed same to do research on suicide in young people and the

older population in Guyana. I am employed by MOPH which has an IRB and this project

was done as part of my Walden University doctoral study, my employer has no

involvement in it, Walden IRB reviewed and approved the project and a data use

agreement by the MOPH.

Treatment of Data

All secondary data from MOPH, Guyana used in this research were examined

without personal identifiers so as to avoid the ethical issue involving breach. Of

significance, anyone requesting data from MOPH has to follow the rules of data release,

and that is to make a formal request through the Chief Medical Officer which will inform

the IRB, even, the staff at MOPH. Thus, there was no conflict of interest with me

accessing data for my doctoral study from MOPH, Guyana. Next, any breach of data will

be resolved by MOPH, Guyana. When someone commits suicide, it is a stigmatized

condition and vulnerable populations can be negatively impacted. All data used in this

research were saved on two flash drives and encrypted. To avoid security breaches and

protect data, suicide data analyses was performed on a computer that has disk encryption

with no personal identifiers. Next, according to Walden policies, all raw data will be kept

for five years after completion of study.

 39
Summary

In Section 2, I discussed the research design and data collection. Areas included

in that section were research design and rationale, methodology, population, sampling

and sampling procedures to collect secondary data, instrumentation and

operationalization of constructs, data analysis plan, and threats to validity. Additionally,

ethical concerns and breach were highlighted and what steps I will take to address them.

Section two presents the methodology used in my doctoral study and the next section will

reveal the findings of the research study relative to my three research questions.
 40
Section 3: Presentation of the Results and Findings

The purpose of this study was to examine the sociodemographic factors (age,

gender, method of suicide, occupation and region) associated with suicide in the ≥ 15

years population in Guyana. Further, since research shows that culture play a pivotal role

in suicide (Lawrence et al., 2016; Snarr, Heyman & Slep, 2010), I examined if there was

a link between culture (race/ethnicity, religion) and suicide cases in ≥15 years population

in Guyana. Additionally, I explored how sociodemographic factors and culture were

associated with the method of suicide in this population. Section 3 includes the results of

statistical analysis (univariate, bivariate, binominal logistic regression) on data collected

from Ministry of Public Health in Guyana. I provided a brief description on the time

frame for data collection, any discrepancies in the use of secondary data, and statistical

analysis per RQ. I concluded with a summary of results for the three RQs.

Data collection of Secondary Data Set

Data were collected from the 10 administrative regions from health facilities

namely health posts, health centers, district hospitals and regional hospitals and were

submitted the Guyana Ministry of Public Health (Health Statistics Unit, 2017)). A Senior

Health Visitor was assigned to each region and he/she was responsible for forms

correctly and accurately filled by the health care workers in each region. Signed forms

were submitted to the head of every region, then to the MOPH through Regional Health

Services. Thereafter, data were sent to the statistical department.

Data were collected based on routine state specific purposes and as such there was

no time restriction for data collection. Secondary data from the Guyana MOPH were
 41
collected from January 1, 2015 to December 31 2015. The total combined sample size of

the data were 220 in 2015 (Health Statistics Unit, 2017).

Discrepancies in Data Set

Originally, I planned to use 2017 data from the MOPH through the Statistical

Department. However, this was not possible, since the only data available at that point in

time was 2015. Thus, the study was modified for data form January 1, 2015 to December

31, 2015. A discrepancy in the originally received data was the inclusion of some missing

data and the omission of religion variable. So I requested and received this information

from the Regional Health Officers from the 10 administrative regions, for religion and

any other missing data which are available to be submitted to the MOPH through

Regional Health Services department.

Representativeness of the Sample

The study sample was collected from several sites and regions of Guyana, thus,

the results of this study can be generalizable to the young and older population of

Guyana.
 42
Descriptive Statistics

Results show that in 2015, there were N = 220 suicide cases in Guyana. Table 1

below shows the following cases per variable: N = 220, Race/Ethnicity N = 220, Age N =

220, Occupation N = 168 with 52 missing cases. Religion N = 101 and 119 missing cases,

method of suicide N = 211 and 9 missing cases, and region 219 and 1 missing case.

Table 1

Univariate Characteristics of Sociodemographic Factors Associated with Suicide in

Guyana, 2015

Suicide
Gender Occupation Race/Ethnicity age Region method Religion
N Valid 220 168 220 220 219 211 101
Missing 0 52 0 0 1 9 119

From a total of N =220 cases, 72.3 % (N= 159) were males and 27.7% (N=61) were
females. There were no missing cases. Table 2 below shows suicide cases by gender.
Table 2
Distribution of Suicide Cases by Gender

Frequency Percent Valid Percent

Valid Male 159 72.3 72.3
Female 61 27.7 27.7
Total 220 100.0 100.0

Results show that occupation was recorded for N = 168 persons who committed suicide
in 2015. Of that number, 75% (N = 126) were employed and 25% (N = 42) were
 43

unemployed. Missing cases represented 23.6% (N = 52). Table 3 shows the number of
suicide cases by occupation.

Table 3

Distribution of Suicide Cases by Occupation

Frequency Percent Valid Percent

Valid Unemployed 42 19.1 25.0
Employed 126 57.3 75.0
Total 168 76.4 100.0
Missing 52 23.6
Total 220 100.0

As far race/ethnicity is concerned, the Indo-Guyanese accounted for the highest

percentage of suicide cases 81.4 % (N= 179). This was followed by other race/ethnicities
10% (N=22) and Afro-Guyanese 8.6 (N=19). Table 4 shows suicide cases by
race/ethnicity

Table 4

Distribution of Suicide cases by Race/Ethnicity

Frequency Percent Valid Percent

Valid East Indian 179 81.4 81.4
African 19 8.6 8.6
Other 22 10.0 10.0
Total 220 100.0 100.0

Regarding religion, the Hindu religion was most predominant for suicide cases in 2015,
and accounted for 49.5 % (N=50), followed by the Christians 35.6 % (N= 36), Muslim
8.9 % (N= 9), and 5.9 % of cases had no religion. There 54.1% (N=119) suicide cases
missing. Table 5 shows the number of suicide cases by religion.
Table 5

Distribution of suicide Cases by Religion

44

Valid
Frequency Percent Percent
Valid Christian 36 16.4 35.6
Muslim 9 4.1 8.9
Hindu 50 22.7 49.5
No religion 6 2.7 5.9
Total 101 45.9 100.0
Missing 119 54.1
Total 220 100.0

Further, The total number of suicide cases N= 220, and the 23-48 years old age group,
50% (N= 110) represented the highest amount, followed by the 0-22 years old 26.4%
(N=58) and the > 48 years old 23.6% (N=52). Table 6 shows suicide cases by age group.

Table 6

Distribution of Suicide Cases by Age

Frequency Percent Valid Percent

Valid 0-22 years 58 26.4 26.4
23-48 years 110 50.0 50.0
>48 years 52 23.6 23.6
Total 220 100.0 100.0

Drank poison was the most common method of suicide 64.5 % (N=136), followed by
hang self 32.7% (N=69), and other 2.8% (N= 6). Table 7 shows suicide cases by the
method of suicide.
 45

Table 7
Distribution of Suicide Cases by Method of Suicide

Frequency Percent Valid Percent

Valid Drank poison 136 61.8 64.5
Hang self 69 31.4 32.7
Other 6 2.7 2.8
Total 211 95.9 100.0
Missing 9 4.1
Total 220 100.0

Regarding region, of the N= 219 recorded suicide cases by region, 40.6% (N= 89) was
the highest for region 6 (East Berbice/Corentyne), followed by region 4 (Demerara-
Mahaica), 23.7% (N= 52), region 3 (Essequibo Islands-West Demerara), 17.4% (N=38)
region 2 ( Pomeroon-Supenaam) 13.2% (N= 29), region 5 Mahaica-Berbice 2.3 % (N =5)
region 7 (Cuyuni Mazaruni 1.4% (N =3) and region 9 (Upper Takutu-Upper Essequibo),
.5% (N =1) recorded the lowest. Table 8 shows number of suicide cases by region.

Table 8

Distribution of Suicide Cases by Region

Frequency Valid
Percent Percent
Valid Pomeroon-Supenaam 29 13.2 13.2
Essequibo Islands-West 38 17.3 17.4
Demerara
Demerara-Mahaica 52 23.6 23.7
Mahaica-Berbice 5 2.3 2.3
East Berbice-Corentyne 89 40.5 40.6
Cuyuni-Mazaruni 3 1.4 1.4
Upper Takutu-Upper- 1 .5 .5
Essequibo
 46
Upper Demerara-Upper 2 .9 .9
Berbice
Total 219 99.5 100.0
Missing 1 .5
Total 220 100.0

Results Per Research Question

Research Question 1

The first research question asked the following: Is there an association between

the socio-demographic factors (age, gender, occupation, method of suicide and region)

and suicide cases in ≥15 years population in Guyana? Using the two-sample z-test, there

was a statistically significant (p< 0.05) association between all the variables above and

suicide cases (Table 9).

More specifically, the result for gender was statistically significant (z = 9.35, p <

.00001) with suicide cases being higher in males than females as noted in Table 9.

For occupation the result show that this was statistically significant (z= -9.16, p <

.00001, two tailed), with the number of suicide cases being higher in the employed than

the unemployed.

The result was statistically significant for age group 0-22 vs 23-48 (z= -5.09, p<

.00001), and this recorded highest number of suicides, followed by the 23-48 vs > 48

(z=5.74, p <.00001) in 2015. However, this was not statistically significant for the 0-22

vs >48, (z = 6.78, p <.496) which recorded the least number of suicide cases. (Table 9)

For method of suicide, the result was statistically significant for drank poison vs.
 47
hang self (z =6.53, p <.00001) and this recorded the highest, followed by drank poison vs

other (z =.13.41, p <.00001). The least number of suicide cases occurred in the pair group

hang self vs other (z=8.03, p<.00001) as displayed in Table 9.

The results for regions revealed that there was statistical significance for four

regions namely: regions four (Demerara-Mahaica), five (Mahaica- Berbice), (z = 6.66, p

<.00001, two tailed), with regions six (East Berbice- Corentyne), and seven (Cuyuni-

Mazaruni) (z =9.88, p < .00001), recording the highest number of suicide cases in 2015.

Regions four (Demerara- Mahaica), and five (Mahaica-Berbice), although significant,

was marginal in comparison to the other pairs mentioned previously (Table 9).

The regions that were not statistically significant included regions two and three

(Pomeroon-Supenaam and Essequibo Islands-West Demerara) (z = -1.22, p< .222, two

tailed), and regions nine and 10 (Upper Takutu-Upper Essequibo and Upper Demerara-

Upper Berbice) (z = 1.05, p <.29, two tailed). In pairwise comparisons, the least number

of suicide cases occurred in regions nine (Upper Takutu-Upper Essequibo) and 10 (Upper

Demerara-Upper Berbice). This was followed by regions two (Pomeroon- Supenaam)

and three (Essequibo Islands-West Demerara). (Table 9).

Answer to Research Question 1. According to the results above, the null

hypothesis was rejected since the socio-demographic factors of age, gender, occupation,

method of suicide and region were significantly associated with suicide in ≥15 years

population in Guyana.
 48

Table 9

Comparison of Suicide Case Proportions by Gender, Age, Occupation, Method of Suicide and

Region in Guyana (n = 220).

Suicide Cases Sample Pairwise Multiple z value p value

Proportion Proportion (SP) Comparisons
Gender
Male 0.723 Males vs females 9.35 <.00001
Female 0.277
Age
0-22 0.264 0-22 vs. 23-48 -5.09 <.00001
23-48 0.5 0-22 vs. >48 0.678 .496
>48 0.236 23-48 vs. >48 5.74 <.00001
Occupation
Unemployed 0.25 Unemployed vs -9.16 <.00001
Employed 0.75 employed
Method of
Suicide Drank poison vs 6.53 <.00001
Drank poison 0.645 hang self
Drank poison vs 13.41 <.00001
Hang self 0.327 Other
Hang self vs. 8.03 <.00001
Other 0.028 other
Regions
Pomeroon-
Supenaam (2) 0.132
Essequibo Region 2 vs region 3 -1.22 .22
Islands-West
Demerara (3) 0.174
Demerara-
Mahaica (4)
Mahaica-Berbice 0.237 Region 4 vs region 5 6.66 <.00001
(5)
East Berbice- 0.023
Corentyne (6)
Cuyuni-Mazaruni Region 6 vs region 7 9.88 <.00001
(7) 0.406
Upper (Takutu-
Upper-Essequibo 0.014
(9)
Upper Demerara- 0.005 Region 9 vs region 10 1.05 .29
Upper Berbice10) 0.009
 49

Research Question 2

Is there a relationship between culture (assessed by race/ethnicity and religion)

and suicide cases in the ≥15 years population in Guyana? Using the two-sample z-test,

there was a statistically significant (p< .05) association between race/ethnicity and

religion and suicide cases (Table 10). The pairwise comparisons that were statistically

significant and recorded the highest number of suicide cases were East Indians vs

Africans (z= 15.35, p <.00001) and Hindu vs no religion (z= 6.923, p <.00001) for

race/ethnicity and religion, respectively.

Next, East Indian vs other (z=15.03, p <.00001) recorded the second highest

number of suicide cases for race/ ethnicity, similarly Christian vs no religion (z= 5.20, p

<.00001) recorded the second highest number of suicide cases for the pairwise

comparisons for religion. Of significance, the race/ethnicity group, with the pairwise

comparisons, East Indians vs Africans (z= 15.35, p <.00001) and East Indian vs other (z=

15.03, p <.00001) were more than three times higher than Christian vs no religion

(z=5.50, p <.00001) and Christian vs Muslim (z= 4.561, p <.00001). Further, the pairwise

comparisons that were statistically significant, but recorded the least number of suicide

cases in 2015, were Christian vs Hindu (z= -1.99, p .045) and Muslim vs Hindu (z= -6.34,

p <.00001) as noted in Table 10.

Answer to Research Question 2. There was a significant relationship between

culture (race/ethnicity, religion) and suicide cases in young people as well as the older

population in Guyana. Therefore, the null hypothesis for RQ2 was rejected.
 50

Table 10

Comparison of Suicide Case Proportions by Culture (Race/Ethnicity and Religion) in Guyana

(n=220).

Suicide Cases Sample Proportion Pairwise Multiple z value p value

Proportion (SP) Comparisons
Race/ethnicity
East Indian 0.814 E. Indian vs. African 15.35 <.00001
African 0.086 E. Indian vs. Other 15.03 <.00001
Other 0.10 African vs. Other -0.51 <.61006
Religion
Christian 0.356 Christian vs. Muslim 4.561 <.00001
Muslim 0.089 Christian vs. Hindu -1.99 .045
Hindu 0.495 Christian vs. No Rel. 5.20 <.00001
No religion 0.059 Muslim vs. Hindu -6.34 <.00001
Muslim vs. No Rel. 0.814 .417
Hindu vs. No Rel. 6.923 <.00001

Research Question 3

Is there an association between the socio-demographic factors (age, gender,

occupation, and region) and culture, and the method of suicide in the ≥15 years

population in Guyana?

For research question three, I conducted binomial/binary logistic regression

having as predictors age, gender, occupation, region, race /ethnicity and religion and the

outcome variable was method of suicide (nominal binary variable poison vs hanging).

The following assumptions :(a) dependent variable must be dichotomous, (b) one or more

independent variable which must be continuous or categorical, and (c) independence of

observations (Lund Research, 2018) were met. After conducting several regression

analyses using different combinations of the predictors, the best model to significantly
 51
predict method of suicide was the one having as predictors gender and age. More

specifically, there was no evidence for lack of fit for this model according to Hosmer and

Lemeshow’s test (p = .402) although it had a relatively poor predictive ability

(Nagelkerke R2 = .067)

According to the regression results (Table 11), males had 3.1 times the odds to

commit suicide by hanging instead of drinking poison compared to females (OR: 3.1,

95%CI: 1.5-6.7, p <0.004). Therefore, the null hypothesis for RQ3 was rejected.

Table 11

Binomial Logistic Regression for Method of Suicide (Dependent variable) with

Predictors Age and Gender.

95% C.I.for OR
B S.E. Wald df p Odds Ratio Lower Upper
a
Step 1 Males vs. Females 1.135 .389 8.504 1 .004 3.112 1.451 6.676
Age 1.749 2 .417
Constant -1.516 .451 11.306 1 .001 .220
a. Variable(s) entered on step 1: Gender, Age
Summary

In Section 3 the results and findings of my doctoral study are displayed. This

research study collected data from the Guyana Ministry of Public Health, and examined

the sociodemographic factors associated with suicide cases in the ≥15 years population in

Guyana. The dependent variable was suicide cases and the independent variables

included age, gender, occupation, region, method of suicide. It was also important to

examine culture (race/ ethnicity, religion), since this is considered to play a significant

role in suicide, according to the literature. According to the results of the study, the socio-
 52
demographic factors of age, gender, occupation, method of suicide and region, as well as

race/ethnicity and religion were significantly associated with suicide in the young and

older population in Guyana. In addition, males had 3 times the odds to commit suicide by

hanging instead of drinking poison compared to females (OR: 3.1, 95% CI: 1.5-6.7, p

<.004).

A detailed analysis and interpretation of findings of this doctoral study is the topic

of section 4. In the next section the areas presented are the purpose, key findings and

interpretation, limitations, recommendations and conclusion which are relevant to the

doctoral study.
 53
Section 4: Application to Professional Practice and Implications for Social Change

The purpose of this quantitative cross sectional study was to investigate the

association between the sociodemographic factors (age, gender, occupation, region, and

method of suicide) and culture (race/ethnicity and religion) and suicide cases in the ≥15

years population in Guyana. Also, I explored the association between the factors above

and methods of suicide in this population group.

The findings of the two sample z test revealed that there was a statistically

significant relationship between sociodemographic factors as well as culture and suicide.

Also, regarding method of suicide, males had 3.1 times the odds to commit suicide by

hanging instead of drinking poison compared to females. Section 4 includes interpretation

of findings, limitations of study, recommendations for further study, implications for

professional practice and positive social change.

Interpretation of Findings

Findings to Literature

Findings suggested that the sociodemographic factors (age, gender, occupation,

region, method of suicide) are associated with suicide. Also, culture (as measured by race

/ethnicity and religion are associated with suicide. The following subsections present

findings broken down by variables including age, gender, occupation, race/ethnicity,

religion, method of suicide and region.

Age groups. The 0-22 years age group recorded the second highest number of

cases (26.4%) that committed suicide in 2015 and the 23-48 years old (50%), recorded

the highest number of suicide cases. The Guyana Ministry of Public Health data show
 54
that the aforementioned age group, represented the working population who were

employed in the low to middle income category, had more access to lethal methods of

suicide (pesticide) because of the type of occupation (labourers, farmers) they were

employed in (Ministry of Public Health Statistics Unit, 2015). Next, according to the

director Mental Health, U. Richmond (personal communication, January 15, 2020) “the

23-48 years age group have poor coping skills, are involved in impulsive suicide, and

they model previous examples of persons who commit suicide” . She also claimed that

the East Indian race/ethnicity who are vulnerable to suicide, is predominant in this

category. Globally, 78% of suicide occurred in low to middle income countries and

suicide was the second leading cause of death among the 15-25 years old in these

countries (WHO, 2017). Next, Guyana’s National Suicide Prevention Plan 2015-2020

(2014) claimed suicide was the leading cause of death among young people aged 15-24

years. The most affected age group was 20-49 years (50%) followed by individuals 13-19

years (16.6%) and greater than 50 years of age (16.6%). (National Suicide Prevention

Plan 2015-2020, 2014). Other studies which claimed that young people were greatly

impacted by suicide included (Quinlan-Davidson, Sanhueza, Espinosa, Antonio, Cejudo-

Escamilla, and Maddleno, 2014; Behmanehsh Poor, Tabatabaei, & Bakhshani, 2014).

Gender. The results of this study show that 72.3 % of males committed suicide in

2015. In Guyana, this occurs because men are more involved in the farming occupation

and have access to pesticides, also they are involved in impulsive suicide. This was

consistent with a research done by Rhodes, Boyle, Bridge, Sinyor, Links, Tonmyr,

Szatmari, 2014), which claimed suicide rates are two to three times more in males than
 55
females in countries with a good data system. Also, a study done in Ecuador revealed that

men were three times more likely to die from suicide (5.3 in women, 13.3 in males).

(Chachamovich, Haggarty, Cargo, Hicks, Kirmayer, and Turecki, 2013). Further research

has shown that 79% of all male deaths in the US, were due to suicide (Suicide Awareness

Voices Education, 2018). My research study was also supported by the findings of the

National Suicide Prevention Plan 2015-2020, 2014), which postulated that males

committed suicide more frequently 4:1.

Occupation. Results show that the employed accounted for 75% of suicide cases

in 2015. My study was consistent with the findings of Behmanehsh Poor, Tabatabaei, &

Bakhshani (2014) which claimed that suicide mostly occurred in the low to middle

income groups which included the self-employed and housewives. However, this

contrasted with the findings of Chachamovich, Haggarty, Cargo, Hicks, Kirmayer, and

Turecki (2013). The authors claimed that suicide affect persons from different

backgrounds, socio-economic status, and educational achievement. This is also consistent

based on the literature review confirming that suicide is a major public health issue and it

occurs in both the developed and developing countries, irrespective of socioeconomic

status, colour, class, or creed. Chachamovich, Haggarty, Cargo, Hicks, Kirmayer, and

Turecki, (2013 para, 5). Future research is necessary to understand the reasons for these

discrepancies regarding the association between employment status and suicide.

Race/ethnicity. Results revealed that the East Indian population accounted for

81.4% of suicide cases in 2015, other race/ethnicities had less cases of suicide. This may

be explained by the authors Lacey, Powell Sears, Crawford, Matusko, and Jackson
 56
(2016), which claimed that among the various race/ethnicity groups in Guyana,

depressive disorders were the highest amongst the East Indian population. However,

Edwards (2016) claimed that the Afro-Guyanese are more “hostile and repressive”, open

in conversation and that may be suggestive of them committing suicide less than the East

Indian race/ethnicity. These contradictory results indicate the need of further research on

the impact of race/ethnicity on suicide in Guyana.

Religion and suicide. My study results show that 49.5% of suicide cases that

occurred in 2015 were from the Hindu religion followed by the Christian religion with

35.6%. Firstly, it is important to note that the East Indian group predominantly

contributed to the number of suicide cases in 2015, and in terms of religion the Hindu

group contributed significantly to suicide in 2015. Therefore, there seems to be an

inherent link of the East Indians into Hinduism. Thus, according to a research study done

in Guyana, depressive disorder was more prevalent in the East Indian population than any

other group (Lacey, Powell Sears, Crawford, Matusko, & Jackson, 2016). Further when

slavery was abolished in 1838, plantation owners imported East Indians from the lowest

castes of India as indentured servants, and they were relegated to the status lower than

freed African slaves (Rawlins, 2018). There are studies which claimed that ethnic/racial

religious characteristics protect people against suicide or increase persons’ vulnerability

to suicide and suicide ideation (Lawrence et. al 2016; Snarr, Heyman & Slep, 2010).

Further analysis needs to be done to understand the reasons for this association. However,

the results of the present study suggest that there is a link between culture and suicide.
 57
Method of suicide. According to my results, ingestion of poison accounted for

64.5% being the most common method of suicide. This is in accordance to the findings of

Henry (2015), who claimed that pesticides was the most common method of suicide due

to the fact that they are easily accessible and there is no control to the purchase of this

poison. On the other hand, regression analysis revealed males were 3.1 times more likely

to commit suicide by hanging, instead of drinking poison compared to females. This was

consistent with a study done in Asia by Wu, Cheng, and Yip, (2012), which claimed that

recent trends in suicide reflect the sociocultural, economic and religious situations in

countries and as such the method may not be equal for all sex and age subgroups.

Additionally, research has shown that persons who have access to lethal methods of

suicide based on their occupation commit suicide more than those who do not have

access and as such, this should be controlled. (Milner, Witt, Maheen, & LaMontagne,

2017). Males in Guyana chose this specific pesticide because of their occupation involves

more of farming, and they use pesticides regularly in the fields because it is easily

accessible and there are no laws restricting the purchase of this product.

Region and suicide. The study results show that in 2015, 40.6% of the suicide

cases occurred in region 6 (East Berbice, Corentyne), followed by region 4 (Demerara,

Mahaica), and region 3 (Essequibo Islands, West Demerara). My study is consistent with

the article which claimed that suicide tend to be higher in the rural areas than the urban

(Fox News world, 2014). However, the study results did not share similar findings to that

of the National Suicide Prevention Plan 2015-2020 (2014) which claimed that the highest

suicide rate was in region # 2 (Pomeroon- Supenaam) (52.7/100,000) followed by region

 58
#6 (East Berbice-corentyne) (50.8%) and region #3 (East Berbice-Corentyne)(37.3%).

Further studies need to be done to establish why suicide is higher in certain regions when

compared to others.

Findings to SEM Theoretical Framework

I applied the SEM framework as indicated by CDC (2015) to comprehensively

address suicide which is a major public health concern. This research study addressed

multi-levels namely: individual, interpersonal, organizational, community, and policy to

account for the sociodemographic factors associated with suicide in adolescents and

young people in Guyana.

Individual. Suicide tends to affect people from the low to middle income group,

self-employed individuals as well as housewives, low educational achievers who are

likely to be young people. (Behmanehsh Poor, Tabatabaei, & Bakhshani, 2014).

Additionally, suicide affect persons from different backgrounds, socioeconomic status

and educational attainment (Chachamovich, Haggarty, Cargo, Hicks, Kirmayer, and

Turecki, 2013). This suggest the need for focused attention to screening of these

individuals so that they can receive the appropriate care. However, the National Suicide

Prevention Plan 2015-2020 (2014), claimed that equal attention need to be given to

mental and physical health and this will help in the management of care for people who

self-harm. The call was also made for 24-hour response for persons who have mental

health issues. Future investigators need to develop individualized suicide plan for the

various sociodemographic factors namely: age, sex, race/ethnicity religion, method of

suicide and region. Additionally, individuals need to be taught educational and life
 59
training skills divert their thinking and help them to understand their worth, as noted

earlier in this research.

Interpersonal. In Guyana, some adolescents and youths do not feel comfortable

to express their feelings or emotions to their parents or other family members. Research

done on a focus group in Guyana show that some adolescents and youths commit suicide

due to gaps in communication in the homes and beyond (Lack of communication

contributes to suicide in Guyana, 2016). The article cited isolation from partners, families

and friends, as contributory factors. A comparison was made with another group who had

closer families ties and they were referred to as having a sense of purpose, security, and

connectedness (Lack of communication contributes to suicide in Guyana, 2016). For

example, there should be mentoring and peer programs geared towards reducing

conflicts, training in problems solving skills and promoting healthy relationships. Future

investigations need to be done to include marital status or spousal relationships in the

sociodemographic factors associated with suicide.

Organizational. Based on this study, when suicide hit Guyana in 2015, it

mostly affected persons who were employed in the lower income group, and those who

had access to lethal methods of suicide such as poison. Ingestion of poison especially

pesticides was the most common method in the farming occupation, because this is easily

accessible across the 10 regions in Guyana and, there is little control over procurement of

this poison (Henry, 2015). Restricting access to common methods of suicides including

poisons is necessary in the prevention of suicide. (Guardian News, 2018). National

Suicide Prevention Plan 2015-2020 (2014) claimed that suicide risk by occupation may
 60
occur locally and as such organizations and local agencies need to tailor interventions

appropriately for specific groups. Findings from this study suggest the need for local

sectors and organizations to be alert and adapt suicide prevention intervention

accordingly.

Community. When suicide occurred in Guyana in 2015, region 6 (East Berbice,

Corentyne) was mostly affected according to the two sample z test. Guyana is divided

into coastland (Pomeroon-Supenaam (region 2), Essequibo Islands-West Demerara

(region 3), Demerara-Mahaica (region 4), Mahaica-Berbice (region 5), East Berbice-

Corentyne (region 6), Upper Demerara- Upper Berbice (region 10), and hinterland

(Barima-Waini (region 1), Cuyuni-Mazaruni (region 7), Potaro –Siparuni (region 8) and

Upper Takutu-upper Essequibo ( region 9) as noted earlier. Region 4 houses Georgetown,

the city of Guyana. According to Fox News World (2014), suicide tends to occur more in

the rural than urban areas. The aforementioned article also stated that in region 6 (East

Berbice/Corentyne), that there are many Hindus who are of East Indian decent and as

such suicide in Guyana is usually portrayed as a Phenomena of Hindu. (Fox New World,

2014). The National suicide Prevention Plan 2015-2020 (2014), stated in order to prevent

copycat and cluster suicide, post-suicide community prevention level intervention, must

be made available in schools, workplaces and health care settings. Future investigators

need to examine the effects of community level interventions on suicide in Guyana.

Policy. The laws of Guyana governing suicide helps to create or encourage a

climate for suicide. For example, according the laws of Guyana section 8:01 97,

“Everyone who attempts to commit suicide shall be guilty of a misdeamour and liable to
 61
imprisonment for two years”. (Chapter 8:01 Criminal Law (offences) Act Arrangement, p

53, 1998,). This does not take into consideration that the factors contributing to suicide

are multifactorial and there is no “one size fits all” policy here. There needs to be a better

understanding of the socioeconomic determinants of suicidal behaviors, then this will

assist government and policy makers in their decisions at population level. (Bantjes et. al,

2016). Thus, the approach to the management of suicide in Guyana must be multi-

sectoral as mentioned earlier in this study. There must be partnerships with multiple

public sectors namely: health, education, housing, judicial, employment, social as well as

the private sector appropriate to the country situation (National Suicide Prevention Plan

2015-2020, 2014).

Limitations of the Study

There were some limitations with the Ministry of Public Health secondary data set

used in this study. The secondary data collected did not contain all the needed variables,

for example income or educational level. According to Cheng and Phillips (2014), it is

inherent in secondary data analysis that, the available data collected were not intended to

address the present research question and as such important third variables were not

available for analysis. It is important to understand that data with cross sectional study

design when multilevel information is included it can produce bias leading to ecological

fallacy (Subramanian, Jones, Kaddour, & Krieger, 2009). The authors also noted that,

though ecological fallacy may be reduced, population heterogeneity can lead to problems

with interpretation (Subramanian et al., 2009)

 62
The sample size was another challenge because it was smaller than the one

estimated in priori statistical power (final study 220 instead of 400). Too small sample

size can affect the extrapolation of the findings, and too large may affect the way one

detect the differences which will produce statistical differences that are not clinically

relevant (Faber & Fonseca, 2014). Therefore, it is suggested for future studies to include

as many secondary data available as possible regarding this topic.

Next, this study did not include suicide ideation and suicide attempts. These are

important because suicide ideation precedes suicide attempts and the latter eventually

leads to suicide. As noted earlier, young people who commit suicide are sixteen times

more likely to have made a previous attempt commit suicide than those who never

committed suicide (Nock et. al, 2013).

Additionally, for the variables of occupation and religion there were a relatively

high number of missing data. Osborne (2013) emphasized that missing data impact

external validity, unless they are included in the analysis. Therefore, future research is

recommended to include as many cases as possible regarding these variables in relation

to suicide cases in Guyana.

Recommendations

There are several recommendations that would advance the findings for research

on suicide in Guyana. First, increase the number of suicide awareness campaigns in every

region and tailor information specifically to suit each age group. Second, regularly update

data collection format to capture the evolving trends in suicide, so that adequate data are

available to promote future research on suicide. Third, collaboration with all sectors in
 63
Guyana (governmental, non-governmental, private, civil society and the community) for

the management of suicide, since this needs a multilevel approach. Fourth, restrict access

to lethal methods of suicide. For example, the establishment of a procurement and

regulatory framework governing the use of pesticides. Fifth, actively monitor media

reports for sensationalization of suicide. Sixth, increase the number of adolescents and

young people in vulnerable communities being involved in life training skills in order to

help them understand that they can divert their energy to more valuable resources in life.

I recommend the need for further studies of multilevel approach to the management of

suicide in adolescents and young people, as well as the older population. Seventh, the

need for culturally sensitive programs geared towards educating young people and the

entire population on cultural awareness. Eight, I suggest training programs that will allow

the young people, as well as the older population to understand the need to be more open

to issues that are confronting them. Further, since this study show that men were three

times more likely to hang themselves than females, then I would suggest future

comparative studies focusing on the choice of method of suicide between men and

women.

The National Suicide Prevention Plan 2015-2020 (2014), advocated for the timely

referral of women and children so that they can have appropriate care, as well as those

who work with men to identify early signs of suicidal behavior and seek treatment for

them. It is important to understand that the National Suicide Prevention Plan 2015-2020

(2014), was not enforced or fully rolled out across the country as yet, until post 2015. The

aforementioned plan noted that children and young people are considered priority and a
 64
vulnerable population for suicide (National Suicide Prevention Plan 2015-2020, 2014).

To this effect, all areas such as schools, juvenile system and social care settings were

advised to identify situations whereby bullying, poor body image and low self-esteem are

noted in this cohort, so that steps can be taken to protect them reasons that would

promote suicide in this cohort or protect them from committing suicide.

Implications for Professional Practice and Social Change

This section provides recommendations for professional practice and

implications for positive social change relevant to suicide cases in Guyana. Suicide in

2015 has greatly impacted adolescents and young people in Guyana, and the National

Suicide Prevention Plan 2015-2020 (2014) was not even rolled out as yet. This was a

potential missed opportunity for adolescents and young people, and by extension the

wider population, to receive the appropriate care and attention.

Professional Practice

Theoretical. I incorporated the SEM into my research study, in an attempt to

model a cross sectional survey into a socio-ecological system which combines human-

environment interaction from suicide cases. According to Cumming (2014), the majority

of the socioecological systems (SES), answers most of the questions of our time, but

suggested that same lacks an overarching theoretical framework. The author claimed that

if this framework is developed, it will be more comprehensive and the benefits will

include better generalization from individual case studies, help us to know the difference

of important to less important results, and it will ultimately draw on the scientific method

to influence managerial and policy intervention. (Cumming, 2014 .In this way, SES can
 65
be strengthened and we do not have to use SEM alone. This implies that we need to use

several diverse theories involving human interaction and incorporate them into

professional practice

Empirical. I suggest an empirical implication to suicide in adolescents and

young people so that we can find answers to the problems and there can be improvement

in the sociodemographic factors associated with suicide. Bergerson (2014), posited that

the social, economic and physiological factors contribute to suicide and the problems of

suicide cannot be analyzed by using one dimension. The author proposed highlighting the

issue to educate policy makers so that they can assess the current suicide prevention

techniques and make informed decision about how to deal with the suicide phenomenon.

(p 3). Next, it is important to highlight the effects of social media on the mental health of

adolescents and young people. Empirical research exists to show how this cohort

perceive social media and the knowledge resource they receive from the wider social

media to express their view point. (O’Reilly, Dogra, Whiteman, & Huges, 2018).

According to the authors social media is seen as a threat in several ways namely: mood

and anxiety disorders, cyberbullying platform, and a framework for addiction. I suggest

future research to target social media to promote mental health and well-being, as well as

teaching them how to manage challenging situations in their lives.

Positive Social Change

The findings of this research study support Walden’s mission for social change

by understanding the significance of sociodemographic factors, combined with the role of

culture on suicide in adolescents and young people in Guyana. The aim is to use the
 66
results to create a high level of awareness and identify predisposing factors that can lead

to suicide. Thus, at the individual level, there needs to be screening of individuals so that

they can receive appropriate care relevant to age, sex, method of suicide, race/ethnicity,

occupation, religion, and others. At the interpersonal level there is need for mentoring

programs and peer groups geared towards resolving conflicts and improving

relationships. Also training programs in life training skills to help adolescents and youths

to find jobs so that, they can take care of themselves and feel worthy. At the

organizational level, sectors and organizations based on evidence, need to be alert and

adapt prevention intervention suicide programs. Although, not a focus of this study, but

nevertheless must be highlighted, is the need to establish protocols in media reporting to

prevent copycat suicide at the community level. Societal and policy level need effective

guidelines and policies that reduce the socio-demographic factors of suicide across the 10

regions of Guyana, and I am advocating that adolescents and youths have a role in

decision making. In this way, they can voice their opinions on appropriate programs for

youths which can lead to greater involvement and ultimately their development.

Conclusion

I identified the association of the sociodemographic factors of suicide namely:

age, gender, occupation, method of suicide, and region, and the role of culture (as

measured by race/ethnicity and religion) on suicide in the young and older population in

Guyana. The Guyana Ministry of Public Health 2015 data were used. Given the fact that

in this study it was revealed a significant association between culture and suicide cases, it

would be helpful to know the role of culture pre-suicide and post-suicide (for suicidal
 67
attempts). If this information is known, then prevention intervention strategies can be

tailored to suit this time period. There needs to be closer monitoring of suicide ideation

and suicide attempts because these eventually lead to suicide. These may be related to

depression and for many young people, there may be co-occurring condition as noted in

depression and addiction. Thus, according to the article, Suicide in young adults:

Depression, addiction, are primary contributors (2017), depression and alcohol form a

deadly combination and many young people, as well as adults with severe depression turn

to drugs, alcohol and other risky behaviors to drown their psychological, emotional or

spiritual discomfort. Additionally, as it relates to culture, the East Indian race/ethnicity is

inherent in Hinduism and, based on history, this group is more vulnerable to suicide

because they found it hard to adapt to another culture (Henry, 2016). At this point,

training programs transitioning people from their original to the new culture should be

done, so that they will understand and learn how to appreciate other cultures. Finally,

there should strict rules by policy makers and government, on restricting access to lethal

methods of suicide in all work places, as well as persons who are self-employed.

Nevertheless, in order to arrest and mitigate suicide in adolescents and young people, a

call is made for systems thinking in public health, whereby governmental, non-

governmental organizations and civil society will unite to fight this cancer of suicide and

preserve our next generation.

 68
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