2012
Drs. Radha Ramjatan, MD
ADEK University of Suriname in
collaboration of Tulane University, Nw. Orleans, Louisiana.
Affiliated at Stg.RGD
Measurement of Health-Related-Quality-of-Life and Perceived Discrimination An Indirect Risk Factor Analysis for Pesticide-Induced
Suicides in the Eastern Nickerie District
Abstract
Background and significance: Nickerie with high agricultural activity is burdened by very high suicide rates of 47/100,000 and suicide attempt rates of 207/100,000. Almost 44 % is committed by pesticide ingestion. Interventions, like safe storage and use of pesticides may assist in reducing the number of pesticide-induced suicides. This applies to so-called “impulsive” suicide attempts. To date, local activities on safe pesticide use had limited success by the community at large, making achieving sustainability difficult.
Methods: Focus group meetings were held in a needs assessment phase for qualitative data.
For quantitative data, two surveys, the SF-36v2 , to measure the health-related-quality-of-life and the SEE survey, to measure the perceived discrimination of the participants, was
conducted. Data were analyzed by composing 2x2 tables and calculating odds ratios, chi- square tests and Fisher tests using SPSSv19 software.
Results: Age groups 15-30, 30-45 and 45-60 years are at risk for poor mental health. Physical health is poor in Paradise. Low educated people are at risk for poor physical, poor mental and poor overall health. Alcohol and drugs use happen more among low educated participants, age groups 15-29 and above 60 years, in Henar, survivors and males. Awareness is more in age groups 15-44 and above 60 years and high-educated ones. Feelings expressions are more by low educated ones, while less by age group 15-29 years and males. Passive behavior is more among low educated ones, those above 45 years and in Paradise. Feelings of guilt are more among high-educated ones, those of 15-29 years, in Paradise and Nw. Nickerie and females.
Attacking behavior is more among 15-44 and above 60 years, in Paradise and Nw. Nickerie and females.
Conclusions: Low education is a risk factor for poor physical, mental and overall health. Age is a risk factor for poor mental health. Residence is a risk factor for poor physical health. Low
education is a risk factor for alcohol and drugs, not being aware, feelings of guilt and being passive. Age is a risk factor for alcohol and drugs use, feelings of guilt, being passive, feelings expressions and attacking people. Residence is a risk factor for alcohol and drugs use, not being aware, feelings of guilt, being passive and attacking people. Gender is a risk factor for alcohol and drugs use, feelings of guilt, being passive, feelings expressions, and attacking people.
Recommendations: Focus should be on mental health care for young and low educated people through enforcement, awareness to break the taboo and reduce other barriers and easy access.
Creating different education opportunities to increase the education level and efforts to increase physical health in Paradise and the young; alcohol and drugs use awareness activities among people at risk and considering all observed associations of awareness, being passive and expressing feelings, to tailor intervention strategies can lower the pesticide-induced suicides rates. Training of health ambassadors, creating a “buddy” network, applying e-health by means of electronics and smart phones at short term and long-term phases can result in a decrease of the pesticide-induces suicides in Nickerie.
Table of Contents
Abstract ... 2
Background and Significance ... 4
Goals ... 5
Methods / Study Design ... 7
Data Analysis ... 8
Results ... 13
F=Female; M= Male; A&D = Alcohol & Drugs use; FE= Feelings Expression; GF = Guilty Feelings ... 20
Discussion ... 20
Conclusions ... 28
Recommendations ... 30
Acknowledgements ... 32
Bibliography ... 33
Background and Significance
A recent epidemiological study revealed very high suicide rates of 47/100,000 (5-year median) and attempted suicide rate of 207/100,000 (5-year mean, 2000-2004) (Graafsma, T. et al, 2006, 2011) in the Nickerie District, located in the western of Suriname, while the rate for Suriname as a whole is 18/100,000. Almost 50 % of all suicides of Suriname occur in the District Nickerie.
These suicide rates and attempted suicide rates in Nickerie are particularly notable because of the fact that 49 % are male and 44 % are committed by ingestion of pesticides (Graafsma, 2006; Bertolote, 2006). It has been hypothesized by previous researchers that the high rates of suicide and attempted suicides are influenced by the rigidity of the Hindustani religion in addition to high levels of poverty, alcoholism, family problems and social fragmentation among
Hindustani population. The impact of pesticide use on people and the environment in Suriname is directly linked to the degree of agricultural activity as well as the current lack of education among farmers regarding safe pesticide use. Nickerie is mainly agricultural driven and so the use of pesticides is very common among farmers. In comparison, self – poisoning with pesticides accounts for about one third of all suicides worldwide. Despite the problems in estimating the global burden of pesticide poisoning, we may safely assume that we are
confronted with millions of cases of pesticide poisoning, hundreds of thousands of which results in deaths each year in low- and middle-income countries. Evidence from other countries also indicates that interventions, like safe storage and use of pesticide may assist in reducing the number of suicides committed by ingesting pesticides – if measures are taken in cooperation with local communities. This evidence applies in particular to so-called “impulsive” suicide attempts. Research in Nickerie shows, that most suicide attempts undertaken here indeed have an impulsive nature (Graafsma, 2006; Van Spijker, 2009; Eltink, Graafsma and Kerkhof, 2010).
To date, local activities on safe pesticide use had limited success by the community at large, making achieving sustainability difficult. While the incidence of pesticide-induced suicide rate in Suriname stays very high and the incidents of young people dying from pesticide intoxication is an ongoing dreary event, we see that the Suriname government is lacking in taking any action to lessen this burden. Research in the eastern of Nickerie, is being carried out since 2010 by the Integrated Pesticide Management Intervention Project (IPMIP) led by Dr. M.Y. Lichtveld, MD, MPH. IPMIP focuses on suicide intervention through community-based participation. The overall goal of this research project is to develop a community-based participatory, novel and safe pesticide storage, use and disposal intervention that can be sustained by the community. Any intervention has a greater chance of success if the community accepts it and cooperates in participation. That is why the CBPR- community-based participatory research - design has been chosen to overcome this challenge. The intervention should assist in protecting and enhancing the community’s health and reduce all adverse health effects, including pesticide-induced suicide and suicide attempts. Evidence in other countries exists demonstrating safe pesticide use and economic development not only is possible, but if pursuit in a holistic fashion can be mutually beneficial. Some intervention methods to lower these two problems of how to manage pesticides at best as well as how to prevent suicide by pesticides include the use of locked boxes, or restricting who can access the pesticides. However, scientists have not yet discovered how effective these methods can be. Furthermore, there is still little knowledge about how to prevent suicide at best. By collecting data from the focus groups in July 2011, we got a better understanding of the community’s needs and their assets. However, we still have no idea of how the community in the Eastern District Nickerie perceives their physical and mental well- being. Good science demand that this has to be measured, rather than assuming that the overall physical and especially mental well-being of the community may be poor; especially in a geographic area with such high pesticide-induced rates, where there may be a need for mental health. The last held needs assessment with the focus groups revealed that chronic diseases
like Diabetes, hypertension, cancer, respiratory illnesses are important problems within their community. Regarding the subject of mental health, stressful situations are not taken seriously and there is a fear of stigmatization of being labeled as instable or insane by the community if people want to discuss their mental problems. People address their mental health problems by using alcohol and drugs or by ingesting pesticides as a final solution, according to the focus group participants. As reasons of mental problems, the community thinks that family problems are prevalent as well the strictly set gender roles and relation problems (IPMIP preliminary progress Report, 2012). Especially in combating any method of suicide, it is necessary to know how the community thinks about their own health-related-quality-of-life; their physical and
mental health well-being. This will be measured by the Short Form-36 (SF-36v2) questionnaires, which will reveal the overall view of health-related-quality-of-life (HRQoL) well-being in this community. A Scale of Ethnic Experience (SEE) questionnaire will also be carried out, which measures the way of how the community perceives discrimination. This is very important to know, because the fear for stigmatization is prevalent in this community if people get access to mental health; i.e. if access to mental care will be made easy as an intervention, this (the perceived discrimination) will greatly impact the utilizing of mental health services in this community. Moreover, research shows that perceived discrimination was associated with over five times higher odds of a suicide attempt in US (Gomez, 2011). Another research shows that female gender and perceived discrimination is positively correlated with suicide attempts (Cheng, 2010) and that perceived discrimination is associated with several negative mental health outcomes, such as suicidal ideation (Hwang, 2008). All these three measurements, physical health, mental health and coping with discrimination; knowing these beforehand will help us to lay out the intervention strategy with a greater chance of sustainability; moreover, after measuring these scores, before implementing any intervention, it will be possible to
measure the outcome of any intervention. SF-36v2 questionnaires and SEE questionnaires can be used as a monitoring instrument of intervention, e.g. if repeated after 1 or 5 year, we will be able to see if there is an improvement in physical and/or mental health well-being and coping with discrimination.
Goals
There are two objectives for this part of study. One objective is to measure how the community thinks about their own health-related-quality-of-life; their physical and mental health well-being.
These variables will be measured by the SF-36 questionnaire; a survey of the health-related- quality-of-life. The second objective is to measure the perceived discrimination for
representative residents in the eastern community of the Nickerie District. This will be measured by the SEE questionnaire.
Objectives:
a. Objective 1- Measurement of the health-related-quality-of-life.
1. Gender may be a risk factor.
Research (Graafsma, 2006) has shown that 75 % of all suicides and 49 % of all suicide attempts in Suriname involved males. Therefore, males should have low health-related well-being compared to females especially a worse mental health.
2. Age may be a risk factor.
Research (Graafsma, 2006) has shown that 75 % of the suicides in Nickerie involved people less than 46 years of age and around 90 % of the persons attempting suicides were also less than 46 years of age. Therefore, the overall or mental health well-being among younger people should be lower compared to older people.
3. Residence may be a risk factor.
Research (Kirby, 1997) has shown that suicides may happen more in the residential areas, where people work more with pesticides. Therefore, residence may be a risk factor for a poor overall and/or mental health well-being.
4. Education may be a risk factor.
Research (Ameerbeg, 2004; Graafsma, 2006), has shown that people with a lower education commit more suicide than people with a higher education. Therefore, people with a low education may have a poor health related well-being compared to high- educated people.
b. Objective 2 - Measurement of perceived discrimination.
1. Gender may be a risk factor.
The assumption is that in the case of discrimination:
- Males use more alcohol and drugs than females.
- Females are more aware of discrimination.
- Females are more liable to talk about their feelings than males do.
- Males react more by attacking others.
- Females feel guiltier that they are the reason.
- Females are more passive than males.
2. Age may be a risk factor.
The assumption is that in a case of discrimination:
- Young people use more alcohol and drugs than older people do. Research has shown (Kirby), that alcohol and drugs abuse is an antecedent of suicide in the young.
- Young people are not aware of discrimination compared to older people.
- Young people do not talk about their feelings.
- Young people react by attacking the other person.
- Young people do not feel guilty that they are the reason for a discrimination incident.
- Young people are not passive.
3. Residence may be a risk factor.
The assumption is that regarding alcohol and drugs use, awareness, feelings
expression, feeling guilty, attacking or being passive in the case of discrimination, there is a relation to the residential area.
4. Education may be a risk factor.
The assumption is that people with a low education use more alcohol and drugs, are not aware of discrimination, do not express their feelings, do not feel guilty, attack other people and /or are more passive in the case of discrimination than high-educated people.
Methods / Study Design
The research focused on the Eastern District Nickerie with a population of 10,323. By assuming four person households, the study population was selected from approximately 2580
households. Participation in the study was voluntary. Eligible participants had to be 18 years or older and had to reside in eastern District Nickerie for at least one year within the last five years.
As in the phase I needs assessment, the same recruitment technique was followed. We have already the list of participants of 72 participants, and used that in order to recruit the same persons if possible; they have already signed the informed consent letter. At first, the
participants were contacted by telephone and invited for the follow-up focus group session, only after asking their consent if they still want to participate. One day before the meeting, they received a reminder call. Fifty-nine (59) participants participated in this follow-up research.
Some of the earlier participants were not able to participate, due to illness or being on travel or holidays. At first, preliminary data of research of Phase 1, the needs assessment, were shared with the participants; followed by a request to answer the SF-36 questionnaire, which toke approximately 20 minutes. For most of the participants, we explained or translated the questions in Sarnami to the participants if there was a need to. After that, the SEE questionnaire was answered, which toke about 20 minutes. Therefore, each meeting consisted of three parts:
feedback on the findings of the focus groups; administering the two questionnaires; and questions they may have. Each meeting took about 1 ½ to 2 hours.
The SF-36v2 Survey
Conduct the Short Form-36 (SF-36v2) questionnaire within the focus groups, to know how the representatives in the Eastern District of Nickerie perceive their own physical and mental health.
The SF-36 Form (SF-36v2) measures eight concepts: general health (GH), physical functioning (PF), role limitations due to physical health (RP), bodily pain (BP), vitality (VT), social
functioning (SF), role limitations due to emotional problems (RE), and general mental health (MH). The eight concepts in detail that are measured are the following (See Appendix Sf-36v2):
• General Health perceptions (GH) (Question 1, 2, and 11 a, b, c, d),
• Physical Functioning (PF) (Questions 3 a, b, c, d, e, f, g, h, i, j),
• Role limitations due to physical health (RP) (Questions 4 a, b, c, d),
• Bodily Pain (BP) (Question 7, 8),
• Role limitations due to emotional problems (RE) ( Questions 5 a, b, c)
• Social Functioning (SF) (Question 6, 10),
• Vitality (VT) (Question 9 a, e, g, i)
• General mental health (MH) (Questions 9, b, c, d, f, h).
This form uses the five point Likert scale. This survey asks about the participants’ own view about his/her health. This information will help keep track of how the participant feels and how well he or she is able to do his or her activities. Two summary measures of physical (PCS) and mental (MCS) health are constructed from the eight scales. PCS (Physical Component
Summary) is the summary of General health, physical functioning, role limitations due to physical health and bodily pain, are primarily measures of physical health (Questions 1, 2, 3, 4, 7, 8, and 11). MCS (Mental component Summary) is the summary of general mental health, role limitations due to emotional problems and social functioning and vitality; are primarily measures of mental health (Questions 5, 6, 9, and 10) (Gandek).
The SEE Survey
Conduct the Scale of Ethnic Experience (SEE) questionnaire within the focus groups, to know how the representatives in the Eastern District of Nickerie perceive discrimination.
The SEE (Scale of Ethnic Experience) questionnaire measures the way in which the community perceives discrimination. This is very important to know, because the fear for stigmatization is prevalent in this community if people get access to mental health; i.e. if access to mental care will be made easy as an intervention, this (the perceived discrimination) will greatly impact the utilizing of mental health services in this community. This SEE Form is based on a six point likert scale and has 25 statements/ questions; and each question has six options to choose:
ever like me/ a little like me/ sometimes like me/ often like me/ normally like me/ always like me.
The SEE survey measures the following variables (See Appendix SEE):
• Need/ use alcohol or drugs to overcome problems related to discrimination (Questions 3, 8, 13, 18, and 23); hereby noted as alcohol and drugs use (A&D).
• Are aware about discrimination and help other in this awareness (Questions 1, 6, 11,16, and 21); hereby noted as awareness (A).
• Difficulty in expressing feelings (Questions 2, 12, and 17); hereby noted as feelings expressions (FE).
• Are emotionally involved with discrimination; by either attacking or defending (Questions 4, 9, 14, 19, and 24); hereby noted as attack (Att.).
• Feelings of Guilt (Questions 5, 10, 15, 20, and 25); (GF)
• Being Passive (Questions 7, and 22) (P).
Data Analysis
Descriptive Analysis
Sample characteristics were measured to look for the frequency of each hypothesized risk factors. For gender, the absolute number and the percentage of males and females were calculated from the 59 participants in this study. For age, the absolute numbers and
percentages were calculated for each age category of 15-29, 30-44, 45-59 and above 60 years.
For residence the number and percentages for each residence, Henar, Paradise and Nw.
Nickerie was calculated. Education level was categorized in two levels, low education and high education. Low education was defined as to have followed no education at all to education at Mulo or LBGO level; every education above this level is defined as high education level. The absolute numbers and percentages were calculated for low and high education level. From the SEE survey, the sum of each of the variables, (alcohol and drugs use, awareness, feelings expressions, attacking behavior, feelings of guilt and being passive), were calculated.
Analytic Analysis
Likert scale is an ordinal scale of measurement, so calculation of a numerical average or mean value is not valid (Hall, 2012). One method is to analyze these Likert scaled survey is to
categorize the data in two groupings, good and bad (health) and look for the frequency
distribution in each category (SPSS, 2012). PCS (Physical Component Summary), MCS (Mental Component Summary) and obviously the Overall Health well-being are summarized data, and they are analyzed likewise using the chi-square tests. The same strategy was followed for analysis of the SEE survey. The data were categorized in yes and no and the sum was calculated for each variable; each sum of variable was analyzed for each hypothesized risk factor to look for associations. Every grouping of the data led to a 2 x 2 table, so calculation of the odds ratio was possible, besides the Chi-square tests.
Note: as these two surveys were carried out in focus group settings, which are a convenient sampling, the analysis is not generilizable to the general population. However, by selecting six focus groups in this community, you increase the sensitivity; in addition, by selecting and composing the focus groups, the task group tried to create some homogeneity in the sample population especially in Henar and in Paradise.
The SF-36 survey
For the analytic analysis for each question there was a cut off in the (five) options, leaving the options of two, like good or bad. The cut off was defined for each question. Several articles were searched to look, understand and interpret the Sf-36 form (Ware,1998, 2001; Wang, 2008;
Gundgard, 2006; Marsh, 2002; Sepideh, 2007).
1. In general would you say your health is: excellent/ very good/good/fair/ poor.
Case definition of:
Good is: excellent/ very good/ good;
Bad is: fair / poor.
2. Compared to one year ago, how would you rate your health in general now?
Much better now than one year ago/somewhat better now than one year ago/about the same as one year ago/somewhat worse now than one year ago/much worse now than one year ago.
Case Definition of:
Good is: much better now than one year ago/somewhat better now than one year ago/about the same as one year ago;
Bad is: somewhat worse now than one year ago/much worse now than one year ago.
3. The following questions are about activities you might doing during a typical day. Does your health now limit you in these activities? If so, how much? The choices are:
yes, limited a lot/yes limited a little/No, not limited at all.
Case definition of:
Good is: no, not limited at all;
Bad is: yes, limited a lot/yes limited a little.
a. Vigorous activities, such as running lifting heavy objects, participating in strenuous sports.
b. Moderate activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.
c. Lifting or carrying groceries.
d. Climbing several flights of stairs.
e. Climbing one flight of stairs.
f. Bending, kneeling, or stooping.
g. Walking more than a mile.
h. Walking several hundred yards.
i. Walking one hundred yards.
j. Bathing or dressing yourself.
4. During the past four weeks, how much of the time you had any of the problems with your work or other regular daily activities as a result of your physical health? The choices are:
All of the time/most of the time/some of the time/a little of the time/none of the time.
Case definition of:
Good is: a little of the time/none of the time;
Bad is: all of the time/most of the time/some of the time.
a. Cut down on the amount of time you spent on work or other activities.
b. Accomplished less than you would like.
c. Were limited in the kind of work or other activities.
d. Had difficulty performing the work or other activities(e.g. it took extra effort) 5. During the past four weeks, how much of the time have you had any of the following
problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? The choices are:
all of the time/most of the time/some of the time/a little of the time/none of the time.
Case definition of:
Good is: a little of the time/none of the time;
Bad is: all of the time/most of the time/some of the time
a. Cut down on the amount of time you spent on work or other activities.
b. Accomplished less than you would like.
c. Did work or other activities less carefully than usual.
6. During the past four weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? The choices are: Not at all/ slightly/moderately/quite a bit/extremely.
Case definition of:
Good is: Not at all/ slightly;
Bad is: moderately/quite a bit/extremely.
7. How much bodily pain have you had during the past 4 weeks? The choices are:
none/very mild/mild/moderate/severe/very severe.
Case definition of:
Good is: none/very mild;
Bad is: mild/moderate/severe/very severe.
8. During the past 4 weeks, how much did pain interfere with your normal work (including both you work outside the home and housework)? The choices are: not at all/a little bit/moderately/quite a bit/extremely.
Case definition of:
Good is: not at all/a little bit;
Bad is: moderately/quite a bit/extremely.
9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks…And the choices for the following questions are: all of the time/most of the time/some of the time/a little of the time/none of the time.
a. Did you feel full of life?
b. Have you been very nervous?
c. Have you felt so down in the dumps that nothing could cheer you up?
d. Have you felt calm and peaceful?
e. Did you have a lot of energy?
f. Have you felt downhearted and depressed?
g. Did you feel worn out?
h. Have you been happy?
i. Did you feel tired?
For questions b,c,f,g, and i, the case definition of:
Good is: a little of the time/none of the time;
Bad is: all of the time/most of the time/ some of the time For questions a,d,e,and h, the case definition of : Good is: all of the time/most of the time;
Bad is: some of the time/a little of the time/none of the time.
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc)? The choices are: All of the time/most of the time/some of the time/a little of the time/none of the time.
Case definition of :
Good is: a little of the time/none of the time;
Bad is: all of the time/most of the time/some of the time.
11. How true or false is each of the following statements for you? The choices are: definitely true/ mostly true/don’t know/mostly false/definitely false.
a. I seem to get sick a little easier than other people.
b. I am as healthy as anybody I know.
c. I expect my health to get worse.
d. My health is excellent.
For statements a and c, the case definition for:
Good is: mostly false/definitely false;
Bad is: definitely true/ mostly true/do not know;
For statements b and d, the case definition for:
Good is: definitely true/ mostly true;
Bad is: do not know/mostly false/definitely false.
These were all the questions of the SF36v2 form survey.
PCS is the sum of each of the chosen answer of the questions 1, 2, 11, 3 (all a – j), 4, 7, and 8.
This gave the sum of good PCS and the sum of bad PCS.
MCS is the sum of each of the chosen answer of the questions 9, 5, 6, and 10.
This gave the sum of good MCS and the sum of bad MCS.
The total sum of PCS and MCS gave the sum of good and the sum of bad overall health.
SEE-Survey
The following statements/ questions were measured;
1. I make people aware of discrimination.
2. I do not talk about my feelings with other people.
3. By using alcohol or drugs, I try not to think about it.
4. I react by attacking other people’s stupid persuasions.
5. I am wondering what I did wrong, what provoked this incident.
6. I am teaching myself to be better prepared on discrimination.
7. I stopped trying to do something.
8. I use alcohol or drugs to shift my mind.
9. I go for a discussion with the involved person.
10. I am wondering if I have done something insulting to the other person.
11. I try to stop discrimination at community level.
12. I find it hard to seek emotional support by other people.
13. I do not use alcohol or drugs to forget discrimination.
14. I do not provoke the other directly.
15. I am wondering if I have done something wrong.
16. I help people to be better prepared with coping with discrimination.
17. I have nobody to go for support.
18. I do not use alcohol or drugs to overcome this.
19. I try not to fight with the person who attacked me.
20. I belief, that I caused the incident.
21. I make other people aware of the negative impact of discrimination.
22. I have no idea what to do.
23. I use alcohol or drug to knock out my feelings.
24. I directly confront the person who attacked me.
25. I do not think that I caused the incident.
These were all the statements of the SEE form.
Each question had six options to choose:
ever like me/ a little like me/ sometimes like me/ often like me/ normally like me/ always like me.
For the analysis, there was a cut off in the first two options and the last four options. Dependent of the question the first two was either yes or no and the last four options was no or yes.
The different variables (alcohol and drugs use, awareness, feelings expressions, attacking behavior, feelings of guilt and being passive) were lumped together. Each variable is the sum of the chosen answer of the different questions. This gave the sum of yes and the sum of no for each variable.
• Alcohol and drugs use (Questions 3, 8, 13, 18, and 23).
• Awareness (Questions 1,6, 11,16, and 21);
• Expressing feelings (Questions 2, 12, and 17);
• Attacking behavior (Questions 4, 9, 14, 19, and 24).
• Feelings of guilt (Questions 5, 10, 15, 20, and 25).
• Being passive (Questions 7 and 22).
For both the SF-36 and SEE survey, the following hypothesized risk factors were analyzed:
gender, age, residence and education level.
For both the SF-36 and the SEE surveys, the sums were used to calculate the Pearson’s Chi- Square test, along with the p-value and the Fisher’s Exact Test, because the sample size of 59 participants is too small, and the odds ratio to look for associations with the hypothesized risk factors. The threshold for the p-value was p< 0.05. Every grouping of the data led to a 2 x 2 table, so calculation of the odds ratio was possible, besides the Chi-square tests. Data analysis
is done using the SPSS v 19.0 software. There will be descriptive analysis and an analytic analysis. See the appendix for detailed analysis and the outcome.
Results
The sample characteristics are shown in Table 1. Fifty and nine people participated in this study. Of these, 62.7 % of the participants consisted of males and 37.3 % of females. Almost 72 % of the participants are in the age group 30 -59 years. Only 8.5 % are in the age group 15 - 29 years and 16.9 % are in the age group above 60 years. Paradise has the lowest group of participants, with 25.4 % and the two other places have equal participants of 22 (37.3%). Level of education was obtained the previous year (phase 1). Of the participants, two from focus group 6 could not be traced back to look for their education level. So, only 57 participants are used for calculations regarding education level. Low education is defined as to have no education at all to education at maximum the MULO/LBGO level and high education is
education above this level. Almost 61% of the participants have a low education, whereas 39 % has a high education.
Table 1
Demographic characteristics of Focus Group Participants
Freq. Percentage of
sample (N=59)
Gender
Female 22 37.3
Male 37 62.7
Age Group
15 – 29 5 8.5
30 -‐ 44 17 28.8
45 – 59 27 45.8
> 60 10 16.9
Residence
Henar 22 37.3
Paradise 15 25.4
Nw. Nickerie 22 37.3
Education *
Low 35 61.4
High 22 38.6
* n= 57 for this percentage calculation The SF-36 Survey
Risk factors for poorer health; physical mental and overall health are shown in Table 2. The risk, as odds ratios and levels of significance are shown.
Education level
Education level show significantly associated relationship with physical, mental and overall health status. Low-educated participants have significantly poorer physical health compared to
high-educated participants with odds-ratio of 1.637 (p < 0.001) of having a poor physical health.
Low-educated participants have significantly poorer mental health compared to high-educated participants with an odds-ratio of 1.364 (p < 0.05) of having a poor mental health. Low-educated participants have a significant poorer overall health compared to high-educated participants with
odds-ratio of 1.766 (p < 0.001) of having a poor overall health.
Age group
Age groups of the participants show significant results regarding mental health.
Participants of age group 15 -29 years have significantly poorer mental health compared to all those of the other age groups of 30-44, 45-59 and above 60 years with odds-ratio of
respectively 1.997 (p < 0.05); 1.968 (p < 0.05) and 3.344 ( p < 0.001) of having a poor mental health. Those of both age groups of 30-44 and 45-59 years show significant poorer mental health compared to those of the age group above 60 years with odds-ratio of respectively 1.675 (p < 0.05) and 1.699 (p < 0.05) of having a poor mental health. Those of age groups 30 – 44 and 45-59 years show no significant difference in mental health with odds-ratio of 1.014 (p >
0.05). Regarding physical health, those of age group above 60 years have significantly poorer physical health compared to those of age group 45-59 years with odds-ratio of 1.599 (p < 0.05) of poor physical health. Table 2 shows odds-ratio of 0.626 (p < 0.05) of having a poor physical health of age group 45-59 upon age group above 60 years. Participants of the age groups 15-29 and 30-45 years have a better physical health than those of the age group above 60 years with odds-ratio of respectively 0.759 (p > 0.05) and 0.763 (p > 0.05) of having a poor physical health.
This is not surprising as older people have a worse physical health compared to younger age groups (see appendix Table 2). When we look at the overall health well-being of the
participants, which is the complete picture of mental and physical well-being together, we see that those of age group 15-29 have significantly poorer overall health than those of the age group 45-59 years with odds-ratio of 1.479 (p < 0.05) of having a poor overall health. These participants have also poorer overall health than those of the age groups 30-44 and > 60 years with odds-ratio of respectively 1.313 (p > 0.05) and 1.363 (p > 0.05) of having a poor overall health. There are no significant differences between all the other comparisons with the different age groups.
Residence
Participants from Paradise have significantly poorer physical health compared to participants of Henar with odds-ratio of 2.691 (p <.001) and Nw. Nickerie with odds-ratio of 2.854 (p < 0.001) of having a poor physical health. The focus groups in residence Nw. Nickerie was composed differently than the focus groups in the residences Henar and Paradise; this means that these focus groups, named as the Leaders group and the Survivors group, miss the homogeneity of the focus groups from Henar and Paradise. After stratifying Nw. Nickerie, analysis shows that participants from Henar and Paradise have significantly poorer physical health than the
participants from the Leaders group with odds-ratio of respectively 1.716 (p < 0.05) and 4.618 (p
< 0.001) of having a poor physical health. Those of Paradise have significantly poorer physical health compared to those of the survivors group with odds-ratio of 2.155 (p < 0 .001) of having a poor physical health, whereas, those from Henar have better physical health than those from the Survivors group with odds-ratio of 0.801 (p > 0.05) of having a poor physical health. There are no significant differences between the different residences regarding mental health (see table 2). There is no difference in mental health between the participants from Henar and Paradise with an odds-ratio of 1.058 (p > 0.05) of poor mental health in Henar compared to Paradise. Participants from Henar and Paradise have a better mental health than those from Nw. Nickerie with an odds-ratio of respectively 0.887 (p > 0.05) and 0.838 (p > 0.05) for having
a poor mental health. To control for confounding of the two differently composed focus groups in Nw. Nickerie are stratified. Those of both Henar and Paradise have poorer mental health than those of the Leaders group with an odds-ratio of 1.555 (p > 0.05) and 1.469 (p > 0.05)
respectively of having a poor mental health. Those of the Survivors group have significantly poorer mental health compared to the participants of Henar and Paradise with odds-ratio of respectively 1.634 (p < 0.05) and 1.730 (p < 0.05). Participants from Paradise have significant poorer overall health than participants from Henar with odds-ratio of 1.310 (p < 0.05) and Nw.
Nickerie with odds-ratio of 1.292 (p < 0.05) of having a poor overall health. After stratifying Nw.
Nickerie, we see that participants from Henar and Paradise have significantly poorer overall health compared to the participants of the Leaders group with odds-ratio of respectively 1.638 (p
< 0.05) and 2.144 (p < 0.001) of having a poor overall health. Those from Henar have
significantly better overall health than those from the survivors group with odds-ratio of 0.724 (p
< 0.05) of having a poor overall health. The other comparisons are not significant different with
odds-ratio of almost 1.0 (see Appendix table 2).
Gender
There is no significant difference between males and females in physical health with odds-ratio of 1.119 (p > 0.05) for females of having a poor physical health, mental health with odds-ratio of 1.239 (p > 0.05) for females of having a poor mental health and overall health with odds-ratio of
1.166 (p > 0.05) for females of having a poor overall health.
Because of the small sample size of participants, the found associations with statistically non- significance merit a more in-depth research with a large sample to look for a true non-
significance of associations.
Table 2.
Health Related Quality of Life for Gender, Age group, Residence and Education, their Odds Ratios for bad health, the Pearson’s Chi-‐square tests and Significance
Variables Odds Ratio-‐Bad Pearson’s Chi-‐Square p-‐Value Fisher’s Exact Test
Age -‐ PCS
45-‐49 vs > 60 0.626 8.030 0.005 0.005
Age -‐ MCS
15-‐29 vs 30-‐ 44 1.997 6.440 0.011 0.013
15-‐29 vs 45-‐ 59 1.968 6.795 0.009 0.012
15-‐29 vs > 60 3.344 16.110 0.000 0.000
30-‐44 vs > 60 1.675 4.975 0.026 0.033
45-‐49 vs > 60 1.699 5.997 0.014 0.017
Age -‐ OH
15-‐29 vs 45-‐ 59 1.479 5.486 0.019 0.025
Residence -‐ PCS
Henar vs Paradise 0.371 39.621 0.000 0.000
Paradise vs Nw.Nick 2.854 44.289 0.000 0.000
Henar vs FG 3 1.716 7.168 0.007 0.008
Paradise vs FG 3 4.618 53.344 0.000 0.000
Paradise vs FG 6 2.155 19.350 0.000 0.000
Residence -‐ MCS
Henar vs FG 6 0.612 6.489 0.011 0.012
Paradise vs FG 6 0.578 6.805 0.009 0.012
Residence -‐ OH
Henar vs Paradise 0.764 5.406 0.020 0.023
Paradise vs Nw.Nick 1.292 4.886 0.027 0.031
Henar vs FG 3 1.638 10.624 0.001 0.001
Henar vs FG 6 0.724 7.045 0.008 0.008
Paradise vs FG 3 2.144 23.694 0.000 0.000
Education
Low vs High PCS 1.637 15.080 0.000 0.000
Low vs High MCS 1.364 4.136 0.042 0.043
Low vs High OH 1.766 33.725 0.000 0.000
* Only significant results are in this table; for detailed results see the Appendix of this table.
PCS= Physical Component Summary; MCS= Mental Component Summary; OH= Overall Health; FG3=
Focus Group 3 (Leaders group); FG 6= Focus group 6 (Survivors Group).
The SEE Survey
Regarding the variables of the SEE survey; the measures of discrimination, we see that only nine associations are significant (Table 3). All the calculated odds-ratios, the Pearson’s Chi- Square test and their significance are in the appendix of table 3.
Age Group Awareness
Participants of age group 30-44 are significantly more aware about discrimination than
participants of age group 45-59 years with odds-ratio of 3.143 (p < 0.05) for being aware. Those of age group 15-29 are more aware than those of the age groups 30-44 and 45-59 years with odds-ratio of respectively 1.195 (p > 0.05) and 3.755 (p > 0.05). Those of age group 30-44 are more aware than those of age group > 60 years with odds-ratio of 1.567 (p > 0.05), while those of the age groups 15-29 and 45-59 years are less aware than those of age group > 60 years with odds-ratio of respectively 0.187 (p> 0.05) and 0.499 (p > 0.05) of being aware.
Alcohol and drugs use
Participants of the age group 15-29 use more alcohol and drugs than those of the age groups 30-44 and 45-59 years with odds-ratio of respectively 1.797 (p > 0.05) and 1.859 (p > 0.05) of alcohol and drugs use, while those of the age groups 30-44 and 45-59 years use less than those of the age group > 60 years with odds-ratio of respectively 0.557 (p > 0.05) and 0.538 (p
> 0.05) of alcohol and drugs use. Alcohol and drugs use among those of age group 15-29 and those of > 60 years are not significantly different with odds-ratio of 1.000 (p > 0.05); just like those of age group 30-44 and above 60 years with odds-ratio of 1.034 (p > 0.05).
Feeling expressions
Participants of the age group 15-29 years are less likely to express their feelings than those of the age groups 30-44 with odds-ratio of 0.357 (p > 0.05), 45-59 with odds-ratio of 0.446 (p >
0.05) and > 60 years with odds ratio of 0.475 (p > 0.05) of expressing their feelings. Those of age group 30-44 years are more likely to express their feelings than those of the age groups 45- 59 years with odds-ratio of 1.250 (p > 0.05) and those of > 60 years with odds-ratio of 1.330 (p
> 0.05) of expressing their feelings. There is no difference between those of the age group 45- 50 and those of age group > 60 years with odds-ratio of 1.064 (p > 0.05).
Attack
Participants of the age group 15-29 years have more attacking behavior than those of age group 30-44 with odds-ratio of 1.220 (p > 0.05) and those of age group 45-59 with odds-ratio of 1.791 (p > 0.05). Those of age group 30-44 have more attacking behavior than those of age group 45-59 years with odds-ratio of 1.468 (p > 0.05). Those of the age groups 30-44 and 45-59 years have less attacking behavior than those of age group > 60 years with odds-ratio of
respectively 0.796 (p > 0.05) and 0.542 (p > 0.05) of attacking people in the case of
discrimination. There is not much difference between the age groups 15-29 and > 60 years in attacking behavior with odds-ratio of 0.971 (p > 0.05).
Feelings of guilt
Participants of the age group 15-29 years have more feelings of guilt than those of the age groups 30-44 with odds-ratio of 1.867 (p > 0.05), those of 45-59 with odds-ratio of 2.000 (p >
0.05) and those of > 60 years with odds-ratio of 1.266 (p > 0.05). Those of age groups 30-44 and 45-59 years have less feelings of guilt than those of age group > 60 years with odds-ratio of respectively 0.678 (p > 0.05) and 0.633 (p > 0.05). Those of the age groups 30-44 and 45-59 years differ not so much with odds-ratio of 1.071 (p > 0.05).
Passive
Participants of age group 15-29 behave more passive than those of age group 30-44 years with odds ratio of 1.429 (p > 0.05), while they behave less passive than those of age groups 45-59 and > 60 years with odds-ratio of respectively 0.793 (p > 0.05) and 0.2500 (p > 0.05). Those of age group 30-44 years behave less passive than those of age groups 45-59 and > 60 years with odds-ratio of respectively 0.555 (p > 0.05) and 0.175 (p > 0.05). Those of age group 45-59 years behave less passive than those of age group > 60 years with odds-ratio of 0.315 (p >
0.05).
Table 3
Discrimination variables and Gender, Age groups, Residence and Education; Chi-‐Square tests, p-‐value and Fisher’s Exact test.
Variables Odds Ratio Pearson’s Chi-‐Square p-‐Value Fisher’s Exact Test
Age -‐ Awareness
30-‐44 vs 45-‐59 3.143 7.845 0.005 0.007
Age -‐ Passive
30-‐44 vs > 60 0.175 7.687 0.006 0.010
Residence – A&D
Henar vs FG 3 2.413 4.141 0.042 0.051
Residence-‐ Awareness
Henar vs FG 3 13.784 70.239 0.000 0.000
Paradise vs FG 3 7.275 38.835 0.000 0.000
Residence -‐ Attack
Henar vs FG 6 0.479 4.282 0.039 0.052
Residence -‐ Passive
Paradise vs FG 3 4.491 5.689 0.017 0.036
Education
Low vs High FE 2.063 4.450 0.035 0.046
Low vs High G F 0.553 5.792 0.016 0.021
* Only significant results are in this table; for more details see the Appendix of this table.
A&D=Alcohol & Drugs use; FE = Feelings Expression; GF= Guilty Feelings; FG3= Focus Group 3 (Leaders group); FG6 = Focus Group 6 (Survivors Group)
Residence
Alcohol and drugs use
Participants from Henar use more alcohol and drugs than those from Paradise with odds-ratio of 1.444 (p > 0.05) of alcohol and drugs use. Those of Paradise use less alcohol and drugs than those from Nw. Nickerie with odds-ratio of 0.748 (p > 0.05) of alcohol and drugs use, while there is not much difference between those from Henar and Nw. Nickerie with odds-ratio of 1.073 (p >
0.05) of alcohol and drugs use. The focus groups of Nw. Nickerie were composed differently than those of the other residence. The focus groups from Nw. Nickerie consisted of a focus group with persons in a leadership position and a focus group with survivors of pesticide- induced suicides and relatives of pesticide-induces victims. They miss the homogeneity of the focus groups of Henar and Paradise. To look for confounding of these two focus groups in Nw.
Nickerie, This residence was stratified in the leaders group and the survivors group. Participants from Henar have significantly more alcohol and drugs use than those of the leaders group with odds-ratio of 2.413 (p > 0.05). Those from Paradise have also more alcohol and drugs use than those from the leaders group with odds-ratio of 1.682 (p > 0.05). Participants from both Henar and Paradise have less alcohol and drugs use than those from the survivors group with odds- ratio of respectively 0.876 (p > 0.05) and 0.610 (p > 0.05).
Awareness
Participants from Henar are more aware than those from Paradise with odds-ratio of 1.895 (p >
0.05) of being aware of discrimination. Those from Paradise are less aware than those from Nw.
Nickerie with odds-ratio of 0.539 (p > 0.05) of being aware. There is not much difference between those of Henar and those from Nw. Nickerie with odds-ratio of 1.021 (p > 0.05). To look for confounding of the two groups from Nw. Nickerie, the following associations were found.
Participants from both Henar and Paradise are more aware than those from the leaders group with odds-ratio of respectively 13.784 (p > 0.05) and 7.275 (p > 0.05) of being aware about discrimination. They are less aware than those from the survivors group with odds-ratio of respectively 0.842 (p > 0.05) and 0.444 (p > 0.05) of being aware about discrimination.
Feelings expression
There is not much difference between the participants of the different residences in expressing their feelings. Those of Henar are less likely to express their feelings than those from Paradise with odds-ratio of 0.896 (p > 0.05) and those from Nw. Nickerie with odds-ratio of 0.958 (p >
0.05) of expressing their feelings. Those from Paradise and Nw. Nickerie are nearly equal with odds-ratio of 1.068 (p > 0.05). After stratification, we see that participants from both Henar and Paradise are less likely to express their feelings than those from the leaders group with odds- ratio of respectively 0.745 (p > 0.05) and 0.831 (p > 0.05). They are more likely to express their feelings than those from the survivors group with odds-ratio of respectively 1.152 (p > 0.05) and 1.286 (p > 0.05).
Attack
Participants from Henar are less likely to attack than those from Paradise and Nw. Nickerie with odds-ratio of 0.738 (p > 0.05) and 0.703 (p > 0.05). Those of Paradise are less likely to attack than those from Nw. Nickerie with odds-ratio of 0.952 (p > 0.05). After stratification we see that participants from both Henar and Paradise are more likely to attack than those from the leaders group with odds-ratio of respectively 1.107 (p > 0.05) and 1.500 (p > 0.05), and they are less likely to attack than those from the survivors group with odds-ratio of respectively 0.479 (p <
0.05) and 0.679 (p > 0.05).
Feelings of guilt
Participants from Henar have less feelings of guilt than those from Paradise and Nw. Nickerie with odds-ratio of respectively 0.746 (p > 0.05) and 0.638 (p > 0.05). Those from Paradise have less feelings of guilt than those from Nw. Nickerie with odds-ratio of 0.856 (p > 0.05). After stratification we see that participants from both Henar and Paradise have less feelings of guilt than those from the leaders group with odds-ratio of respectively 0.605 (p > 0.05) and 0.811 (p
> 0.05). They have also less feelings of guilt than those from the survivors group with odds-ratio of respectively 0.662 (p > 0.05) and 0.887 (p > 0.05).
Passive
Participants from Henar are less passive than those from Paradise and Nw. Nickerie with odds- ratio of respectively 0.579 (p > 0.05) and 0.833 (p > 0.05). Those from Paradise are more passive than those from Nw. Nickerie with odds-ratio of 1.439 (p > 0.05). after stratification we see that participants from both Henar and Paradise are more passive than those from the leaders group with odds-ratio of respectively 2.600 (p > 0.05) and 4.491 (p < 0.05) of being passive in the case of discrimination.
Education Level
Low-educated participants have significantly more feelings expression than high-educated participants do with odds-ratio of 2.063 (p < 0.05). They use more alcohol and drugs than the high-educated participants do with odds-ratio of 1.489 (p > 0.05) and they are more passive than the high-educated ones with odds-ratio of 1.668 (p > 0.05). They are less aware than high- educated participants are with odds-ratio of 0.835 (p > 0.05) and have significantly less feelings of guilt than the high-educated ones with odds-ratio of 0.553 (p < 0.05). There is no significant difference between low and high-educated participants in attacking behavior with odds-ratio of 1.011 (p > 0.05).
Gender
Female participants use less alcohol and drugs than male participants do with odds-ratio of 0.879 (p > 0.05). They are slightly less aware than males about discrimination with odds-ratio of 0.958 (p > 0.05) and have less attacking behavior than males do with odds-ratio of 0.867 (p >
0.05). They are less passive than male are in the case of discrimination with odds-ratio of 0.530 (p > 0.05) and their feelings expression is nearly equal compared to the males with odds-ratio of 0.996 (p > 0.05). The female participants have slightly more feelings of guilt than males do with odds-ratio of 1.173 (p > 0.05).
Tab le 4 shows the frequency distribution of the different discrimination variables among the hypothesized risk factors. These were used to calculate the odds ratios and the Pearson’s Chi- Square tests seen in table 3.
Table 4. Hypothesized risk factors and frequency distribution of the discrimination variables.
A & D Awareness F E Attack G F Passive
Gender Y N Y N Y N Y N Y N Y N
F 33 77 91 19 23 43 63 46 66 44 20 24
M 59 121 150 30 37 69 109 69 101 79 44 28
Age
15-‐29 10 15 23 2 3 12 17 8 18 8 5 5
30-‐44 23 62 77 8 21 30 54 31 47 39 14 20
45-‐59 33 92 98 32 28 50 70 59 63 56 29 23
> 60 20 30 43 7 10 19 35 16 32 18 16 4
Residence
Henar 36 69 90 15 21 41 57 47 45 51 21 21
Paradise 20 55 57 18 16 28 46 28 44 31 19 11
Nw.Nick. 36 74 94 16 23 43 69 40 68 41 24 20
Education
Low 61 120 140 31 41 53 100 75 90 93 43 27
High 28 82 92 17 18 48 62 47 70 40 21 22
F=Female; M= Male; A&D = Alcohol & Drugs use; FE= Feelings Expression; GF = Guilty Feelings
Discussion
One objective of this study was to see if gender, age, residence and education level are risk factors for a poor health; a poor physical or a poor mental health as well as a poor overall health. The other objective was to measure the perceived discrimination among the study participants and look if there was a relation between the different risk factors and the different discrimination variables. Risk factors may be thought of as a leading to or being associated with suicide; that is, people “possessing” the risk factor are at greater potential for suicidal behavior.
Protective factors, on the other hand, reduce the likelihood of suicide. They enhance resilience and may counterbalance risk factors. Risk and protective factors may be bio-psychosocial, environmental or socio-cultural in nature. Understanding the interactive relationship between risk and protective factors in suicidal behavior and how this interaction can be modified are challenges to suicide prevention (Móscicki, 1997). Some protective factors for suicide are:
effective clinical care for mental, physical and substance use disorders; easy access to a variety of clinical interventions and support for help seeking; restricted access to highly lethal means of suicide; strong connections to family and community support; support through ongoing medical and mental health care relationships; skills in problem solving, conflict resolution and nonviolent handling of disputes; cultural and religious beliefs that discourage suicide and support self preservation. However, positive resistance to suicide is not permanent, so programs that
support and maintain protection against suicide should be ongoing. Bio-psychosocial risk factors for suicide are mental disorders, particular mood disorders, schizophrenia, anxiety disorders and certain personality disorders; alcohol and other substance use disorders; hopelessness;
impulsive and/or aggressive tendencies; history of trauma or abuse; some major physical illnesses; previous suicide attempt; and family history of suicide. Environmental risk factors are job or financial loss; relational or social loss; easy access to lethal means; and local clusters of
suicide that have a contagious influence. Social-cultural factors are lack of social support and sense of isolation; stigma associated with help-seeking behavior; barriers to accessing health care, especially mental health and substance abuse treatment; certain cultural and religious beliefs (for instance, the belief that suicide is a noble resolution of a personal dilemma);
exposure to, including through media, and influence of others who have died by suicide.
Objective 1- Measurement of the health-related-quality-of-life.
1. Gender
Earlier research (Graafsma, 2006) showed that 75 % of all suicides and 49 % of all suicide attempts in Suriname involved males. This led to the hypothesis that gender might be a risk factor, meaning that males should have a low health-related well-being compared to females, especially a poor mental health among males. This study however, found no significant
relationship between the two genders and health status. The hypothesis that males have a low health related well-being is not true. The slight positive associations of females upon males of having a poor physical, mental and overall health, ranging from 1.12 and 1.24, in this study could not prove that females have a poor health status. Gender was not found to be a risk factor for having a poor physical and /or mental health and poor overall health. However, as this study had only 22 females and 37 males, the sample size is too small to infer definitive conclusions that gender is not a risk factor for having a poor health-related wellbeing.
2. Age
Research (Graafsma, 2006) has shown that 75 % of the suicides in Nickerie involved people less than 46 years of age and around 90 % of the persons attempting suicides were also less than 46 years of age. This led to the hypothesis that the overall or mental health well-being among younger people might be lower compared to older people. Participants above 60 years have a better physical health than participants from the age group 45-59 and albeit not
significant, from the two other younger age groups. This is somewhat surprising, as it is known that older people tend to have a worse physical health than younger people do have. However, young participants of the age group 15- 29 have a lower mental health compared to all the other three age groups. This is also true for overall health. Participants from both the age groups 30- 44 and 45-59 have a lower mental health compared to those of the age group > 60 years.
Mental health care is also a need for people in these two age groups. The hypothesis that younger people have a lower mental health than older people is true. This means that there is a great need for mental health care for this young age group. Research of Graafsma already showed that pesticide –induced suicide is very common in young people. They are truly at risk for committing suicides by ingesting pesticides. Age is a risk factor for having a poor health, especially a poor mental health. This finding correlates with findings of an earlier research, which found that suicide is a leading cause of death among those aged 15-24 (Rutter, 2004;
Berman & Jobes, 1995; CDC, 2002). Suicide is the second leading cause of death among 25-34 year olds and the third leading cause of death among 15- to 24-year olds (LACDMH, 2012;
Web-based Injury Statistics Query and Reporting System (WISQARS), CDC, 2007). Our intervention strategies must focus especially on these age groups in working on a better and easy access to mental health care. It is striking that the young (15-29) are in need of mental health care. Intervention strategies should also focus on activities at school and school related factors. Training of health educators at school for the school members and awareness activities are some of the possibilities. People in age group 30-59 and a part of the age group 15-29 are the working class people and most of them have a family and other social relationships.
Unemployment, financial problems / economic hardships, family discord and conflicts, as well as a recent loss of a spouse or partner through divorce, separation or death can increase suicide
risk (Kirby, 1997; Ameerbeg, 2004; Phillips, 2002; Gouda, 2008). Strategies should be
developed that focuses on awareness at the workplace about lowering the barriers for utilizing mental health, coping with stress, misfortune, and relational problems for this group of people.
3. Residence
Research (Kirby, 1997; Nock, 2006) has shown that suicides may happen more in some residential areas, where people work more with pesticides. This led to the hypothesis that residence might be a risk factor for a poor overall and/or mental health well-being. This study shows that the physical health of participants in Paradise is lower compared to those in Henar and to Nw. Nickerie. However, as the two focus groups of Nw. Nickerie was composed
differently and missed the homogeneity of the focus groups from Henar and Paradise, it was interesting to look if the two focus groups from Nw. Nickerie confounded the results. Participants of both Henar and Paradise have a lower physical health than those of focus group 3, which consist of leaders. This is not surprising, because it is assumed that leaders have a better physical health. Participants from Paradise have a lower physical health than those of focus group 6, which consists of survivors and victims of pesticide-induced suicides. This is surprising, as it has been taught that people who have been a victim of suicide or relatives of suicide victims should have a worse physical health than those who do not have such an experience.
Mental health between the participants of all the three residences appears to be nearly equal.
This is surprising and the hypothesis that suicides happen more in residential areas where people work more with pesticides is not true. Henar and Paradise both are known as places where pesticide use is abundant. After stratifying, we see that mental health of those from Henar and Paradise are better than those of the survivors group and worse than those of the leaders group. This finding is not surprising. Those from Henar and Nw. Nickerie have a better overall health than Paradise. The only striking finding is that participants from Paradise have a poor physical health compared to the participants from the other places. One of the assets of Paradise is that this place has a sports center; JOPO. This finding means that Paradise needs improvement in physical health care despite having a nice sports center.
4. Education
Research (Ameerbeg, 2004; Graafsma, 2006; Nock, 2006, Cheng, 2010), has shown that people with a lower education commit more suicide than people with a higher education. This led to the hypothesis that people with a low education may have a poor health related well-being compared to high-educated people. The results show that low educated participants have a lower physical, mental and overall health well-being than high-educated participants have. The hypothesis that low-educated people have a low health related well-being is true; this is true for physical, mental as overall health as well and correlated with the above-mentioned research findings. This finding correlates also with other research (Kunst, 2005; Gouda, 2008)
Intervention strategies have to focus on low educated people, and curricula have to be written at their level of education.
b. Objective 2 - Measurement of perceived discrimination.
1. Gender
In the case of discrimination different hypotheses was tested regarding gender:
- Males use more alcohol and drugs than females.
- Females are more aware of discrimination.
- Females are more liable to talk about their feelings than males do.
- Males react more by attacking others.
- Females feel guiltier that they are the reason.
- Females are more passive than males.
In this study, we see that females are remarkably negatively associated in being passive. The hypothesis that females are more passive than males is not true. For alcohol and drugs use, awareness, feelings expression and attacking behavior there is only a slight negative
association of females upon males. The hypotheses that males use more alcohol and drugs might be true, as none of the associations found in this study are statistically significant. Alcohol and drugs abuse is higher among males and is associated with a higher suicide risk (Brady, 2006). This correlates with the findings of Ameerbeg, 2004 and Kirby, 1997. The hypotheses that females are more aware and are more likely to talk about their feelings than males do, is not true. Adherence to the traditional male gender role may result in negative attitudes toward help-seeking (Good et al., 1995). Females are positively associated with feeling guilty in the case if discrimination and react more by attacking others. The hypothesis that females feel guiltier than males is true. Whereas the hypothesis that males react more by attacking other is not true. However, because of the small sample size of 59 participants with 22 females and 37 males, more in-depth research with a large sample size can disclose if the resulted small associations between the two sexes are indeed not significant.
2. Age
Different hypotheses were tested for age and the different discrimination variables:
- Young people use more alcohol and drugs than older people do.
- Young people are not aware of discrimination compared to older people.
- Young people do not talk about their feelings.
- Young people react by attacking the other person.
- Young people do not feel guilty that they are the reason for a discrimination incident.
- Young people are not passive.
In this part of the study, we see that age is a risk factor for some variables.
Awareness
Participants from the age group 30-44 are significantly 3 times more aware of discrimination than those from the age group 45- 59 are. That those of 15-29 upon 45-59 and those of 30-44 upon above 60 are positively associated with a higher awareness shows that the hypothesis that younger people are not aware of discrimination is not true. However, this hypothesis is true for those of age groups 15-29 and 45-59 upon above 60 years. This gives an eligible pool of candidates to use their awareness capabilities for intervention in this district.
Alcohol and drugs
Albeit not significant, in this study, we see positive associations in alcohol and drugs use among participants from age group 15-29 compared to those between 30-59 years, while those older
