title: Association of socio-economic position and suicide/attempted suicide in low and middle income countries in South and South-East Asia - a systematic review.
abstract: BACKGROUND
  Forty percent of the world's suicide deaths occur in low and middle income countries (LAMIC) in Asia. There is a recognition that social factors, such as socioeconomic position (SEP), play an important role in determining suicidal risk in high income countries, but less is known about the association in LAMIC.
  
  
  METHODS
  The objective of this systematic review was to synthesise existing evidence of the association between SEP and attempted suicide/suicide risk in LAMIC countries in South and South East Asia. Web of Science, MEDLINE, MEDLINE in Process, EMBASE, PsycINFO, and article reference lists/forward citations were searched for eligible studies. Epidemiological studies reporting on the association of individual SEP with suicide and attempted suicide were included. Study quality was assessed using an adapted rating tool and a narrative synthesis was conducted.
  
  
  RESULTS
  Thirty-one studies from nine countries were identified; 31 different measures of SEP were reported, with education being the most frequently recorded. Most studies suggest that lower levels of SEP are associated with an increased risk of suicide/attempted suicide, though findings are not always consistent between and within countries. Over half of the studies included in this review were of moderate/low quality. The SEP risk factors with the most consistent association across studies were asset based measures (e.g. composite measures); education; measures of financial difficulty and subjective measures of financial circumstance. Several studies show a greater than threefold increased risk in lower SEP groups with the largest and most consistent association with subjective measures of financial circumstance.
  
  
  CONCLUSIONS
  The current evidence suggests that lower SEP increases the likelihood of suicide/attempted suicide in LAMIC in South and South East Asia. However, the findings are severely limited by study quality; larger better quality studies are therefore needed.
  
  
  BACKGROUND
  PROSPERO 2014: CRD42014006521.
authors.affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. dee.knipe@bristol.ac.uk.|South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka. dee.knipe@bristol.ac.uk.
authors.forename: Duleeka W
authors.initials: DW
authors.lastname: Knipe
authors.affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. Robert.Carroll@bristol.ac.uk.
authors.forename: Robert
authors.initials: R
authors.lastname: Carroll
authors.affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. Kyla.Thomas@bristol.ac.uk.
authors.forename: Kyla H
authors.initials: KH
authors.lastname: Thomas
authors.affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. ap12219@bristol.ac.uk.
authors.forename: Anna
authors.initials: A
authors.lastname: Pease
authors.affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. D.J.Gunnell@bristol.ac.uk.|South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka. D.J.Gunnell@bristol.ac.uk.
authors.forename: David
authors.initials: D
authors.lastname: Gunnell
authors.affiliation: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK. Chris.Metcalfe@bristol.ac.uk.
authors.forename: Chris
authors.initials: C
authors.lastname: Metcalfe
mesh_terms: D001208:Asia / Q000453:epidemiology; D005260:Female; D006801:Humans; D012307:Risk Factors; D012959:Socioeconomic Factors; D013405:Suicide / Q000706:statistics & numerical data*; D013406:Suicide, Attempted / Q000706:statistics & numerical data