خودآسیبی عمدی در مناطق شهری و روستایی: مطالعه مقایسه ای ویژگی های شیوع بیماری

Abstract In countries like the UK, people living in urban regions are more likely to suffer poor physical and mental health than rural populations, and to have increased rates of psychiatric disorder. Urban/rural differences in suicidal behaviour have most frequently focussed on variations in the occurrence of suicide. We have investigated rates of deliberate self-harm (DSH) in urban and rural districts of Oxfordshire, England, and compared characteristics of DSH patients resident in these two areas. Information was collected on 6833 DSH episodes by 4054 persons aged 15 years and over presenting to the local general hospital between 2001 and 2005. We found that urban DSH rates were substantially higher than rural rates amongst both males and females aged between 15 and 64 years. This relationship was sustained even when socio-economic deprivation and social fragmentation were taken into account. There was little difference between urban and rural rates for patients aged 65 years and over. Urban DSH patients were more likely to be younger, non-white in ethnic origin, unemployed, living alone, to have a criminal record, to have previously engaged in DSH, and to report problems with housing. Rural DSH patients were more likely to suffer from physical illness, and to have higher suicide intent scores. Results of studies such as this can help identify where resources for preventive initiatives should be primarily directed and also what types of individuals may be at most risk in different areas. However, since variation by area will in part be due to differences at the individual level, further research utilising multi-level modelling techniques would be usefu

Introduction Place of domicile is related to health. Studies of regional health differences in the UK, for example, appear to show that people living in urban areas are likely to experience poorer health than those living in rural districts. Urban dwellers are more likely to rate their health as only fair or poor (Riva, Curtis, Gauvin, & Fagg, 2009), and to experience higher rates of mortality and illness than urban populations (Barnett et al., 2001, Hayes and Gale, 1999 and Levin, 2003), although rates of illness have also been found to be high in remote rural regions (Barnett et al., 2001). Furthermore, common psychiatric disorders, in particular depression, are generally more prevalent amongst urban populations (Lehtinen et al., 2003, Lewis and Booth, 1994, Paykel et al., 2000, Peen et al., 2007, Peen et al., 2010, Riva et al., 2009, Wang, 2004 and Weich et al., 2006). Accounts of regional health differences often draw on two hypotheses about the possible relationship between health and environment: the ‘drift’ and ‘breeder’ hypotheses. The ‘breeder hypothesis’ proposes that exposure to environmental factors – physical, social, and behavioural – has a direct or indirect impact on an individual’s health. Urban stressors that may have a particular impact on mental health include increased noise levels, higher crimes rates, pollution, and an uncared for built environment (Macintyre, Maciver, & Soomans, 1993), whereas rural populations may face different problems particular to their region, such as a lack of employment opportunities or affordable housing, inaccessible public and health services, or increased levels of social isolation. The ‘drift hypothesis’ proposes that persons with certain risk factors for ill-health are more inclined to live in particular types of area, either by moving to, from, or staying put in certain environments (Verheij, 1996). Psychiatric disorder, especially depression is known to be an important risk factor for suicidal behaviour (Haw et al., 2001, Suominen et al., 1996 and Foster et al., 1997), which has also been shown to vary in prevalence in urban versus rural areas. Investigations into rural/urban differences in suicidal behaviour have most often focussed on regional variations in suicide rates. Rural suicide rates have been found to be higher than rates in urban areas in Australia (Caldwell et al., 2004 and Dudley et al., 1998), Austria (Kapusta et al, 2008), Scotland (Levin and Leyland, 2005 and Obafunwa and Busuttil, 1994), and China (Yip, Callanan, & Yuen, 2000). In England and Wales, suicide rates have been reported as highest in remote and rural areas, and inner-city locations (Kelly et al., 1995 and Middleton et al., 2006), but when combined with ‘undetermined’ deaths they have been highest in urban areas (Saunderson, Haynes, & Langford, 1998). More recently, suicide rates amongst males in England were reported as being highest in rural areas after controlling for social deprivation (Gartner, Farewell, Dunstan, & Gordon, 2008). Variation in rates of deliberate self-harm (DSH - any non-fatal intentional self-poisoning or self-injury) between rural and urban areas have been much less thoroughly investigated, but the few studies that have done so indicate that higher DSH rates occur in urban areas in Ireland (Corcoran, Arensman, & Perry, 2007), Finland (Ostamo et al, 1991), and Oxford, UK (Bancroft, Skrimshire, Reynolds, Simkin, & Smith, 1975), and in high density centres in rural districts and urban centres in the USA (Hemsptead, 2006). One possible explanation for the difference in spatial distribution of DSH and suicide rates may lie in the increased likelihood of access to lethal means such as firearms amongst rural populations (Dudley et al., 1998), with a consequent increase in the likelihood that a rural suicide attempt will result in a fatality. Thus rural DSH patients in Finland have previously been shown to use more seriously harmful methods of DSH (Niskanen, Koskinen, Lepola, & Venalainen, 1975). Greater difficulty in accessing emergency medical services from remote and rural areas may have an effect on the likelihood of fatality. There is also the possibility that environmental stressors of living in urban and rural areas may be different (Hayes & Gale, 2000). Isolation and social fragmentation, for example, which are likely to be greater in rural areas, appear to be more strongly associated with suicide than DSH in some studies (Hemsptead, 2006 and Whitley et al., 1999). In this study, we have investigated rates of DSH in urban and rural districts of Oxfordshire, England. As rates of DSH are known to be associated with levels of socio-economic deprivation and social fragmentation (Ayton et al., 2003, Gunnell et al., 1995, Gunnell et al., 2000 and Hawton et al., 2001), both of which are likely to vary in urban and rural locations, we have included measures of deprivation and social fragmentation. In the one previous study of which we are currently aware that has done this a small but significant residual relationship between area type and DSH rates was found after taking into account both deprivation and social fragmentation (Corcoran et al., 2007). So far, little has been reported on differences in characteristics of DSH patients from rural and urban areas; rural DSH patients have been shown to be more likely to use more seriously harmful methods of DSH, to repeat DSH, and to be female in studies from Finland (Niskanen et al., 1975), India, (Kumar, Mohan, Gopinath, & Chandrasekaran, 2006), and Ireland (Lyster & Youssef, 1995). We have also investigated whether there are any differences in demographic and clinical characteristics of individual DSH patients who live in urban and rural areas.

Conclusion We found rates of DSH to be higher in urban than urban areas, even after controlling for socio-economic deprivation and social fragmentation. Although it is not possible to infer individual risk based upon area-level data, awareness of increased risk within certain populations may be useful for informing decisions about the allocation of resources and targeting interventions. Higher DSH rates among urban populations may indicate that preventative initiatives should primarily be targeted within urban areas. As it is possible that this finding is due to differences at the individual level further investigation employing multi-level modelling techniques would be useful in addressing this issue, where population data on DSH is available. Although DSH rates in rural areas were found to be lower, suicidal intent amongst rural DSH patients was higher than for patients living in urban areas. Rural dwellers living with poor health and high levels of deprivation may be hidden by overall measures of health and deprivation; similarly, lower overall prevalence of DSH in rural areas may conceal the existence of individuals with high suicide intent. Psychiatric aftercare is less likely to be provided to DSH patients living in rural areas, indicating that targeted outreach care may be needed for this group.