title: Non-fatal suicidal behaviour in rural Ethiopia: a cross-sectional facility- and population-based study.
abstract: BACKGROUND
  Injury related to self-harm is one of the leading causes of global disease burden. As a formative work for a programme to implement comprehensive mental healthcare in a rural district in Ethiopia, we determined the 12-month prevalence of non-fatal suicidal behaviour as well as factors associated with this behaviour to understand the potential burden of the behaviour in the district.
  
  
  METHODS
  Population-based (n = 1485) and facility-based (n = 1014) cross-sectional surveys of adults, using standardised, interview-based measures for suicidality (items on suicide from the Composite International Diagnostic Interview), depressive symptoms (the Patient Health Questionnaire) and alcohol use disorders (Alcohol Use Disorder Investigation Test; AUDIT).
  
  
  RESULTS
  The overall 12-month prevalence of non-fatal suicidal behaviour, consisting of suicidal ideation, plan and attempt, was 7.9 % (95 % Confidence Interval (CI) = 6.8 % to 8.9 %). The prevalence was significantly higher in the facility sample (10.3 %) compared with the community sample (6.3 %). The 12-month prevalence of suicide attempt was 4.4 % (95 % CI = 3.6 % to 5.3 %), non-significantly higher among the facility sample (5.4 %) compared with the community sample (3.8 %). Over half of those with suicidal ideation (56.4 %) transitioned from suicidal ideation to suicide attempt. Younger age, harmful use of alcohol and higher depression scores were associated significantly with increased non-fatal suicidal behaviours. The only factor associated with transition from suicidal ideation to suicide attempt was high depression score. Only 10.5 % of the sample with suicidal ideation had received any treatment for their suicidal behaviour: 10.8 % of the community sample and 10.2 % of the facility sample. Although help seeking increased with progression from ideation to attempt, there was no statistically significant difference between the groups.
  
  
  CONCLUSIONS
  Non-fatal suicidal behaviour is an important public health problem in this rural district. A more in-depth understanding of the context of the occurrence of the behaviour, improving access to care and targeting depression and alcohol use disorder are important next steps. The role of other psychosocial factors should also be explored to assist the provision of holistic care.
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. abe.wassie@kcl.ac.uk.|Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, Centre for Affective Disorders, King's College London, London, UK. abe.wassie@kcl.ac.uk.
authors.forename: Abebaw
authors.initials: A
authors.lastname: Fekadu
authors.affiliation: Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Girmay
authors.initials: G
authors.lastname: Medhin
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Medhin
authors.initials: M
authors.lastname: Selamu
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Tsion
authors.initials: T
authors.lastname: Shiferaw
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Maji
authors.initials: M
authors.lastname: Hailemariam
authors.affiliation: Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Sujit D
authors.initials: SD
authors.lastname: Rathod
authors.affiliation: Department of Research and Development, HealthNet Transcultural Psychosocial Organisation, Amsterdam, The Netherlands.
authors.forename: Mark
authors.initials: M
authors.lastname: Jordans
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Solomon
authors.initials: S
authors.lastname: Teferra
authors.affiliation: Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa.
authors.forename: Crick
authors.initials: C
authors.lastname: Lund
authors.affiliation: Department of Psychiatry and Mental Health, Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa.
authors.forename: Erica
authors.initials: E
authors.lastname: Breuer
authors.affiliation: Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK.
authors.forename: Martin
authors.initials: M
authors.lastname: Prince
authors.affiliation: Republic of Ethiopia Federal Ministry of Health, Addis Ababa, Ethiopia.
authors.forename: Tedla W
authors.initials: TW
authors.lastname: Giorgis
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Atalay
authors.initials: A
authors.lastname: Alem
authors.affiliation: Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.|Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Hanlon
mesh_terms: D000328:Adult; D019973:Alcohol-Related Disorders / Q000453:epidemiology* / Q000523:psychology; D015897:Comorbidity; D003430:Cross-Sectional Studies; D003866:Depressive Disorder / Q000453:epidemiology* / Q000523:psychology; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012307:Risk Factors; D012424:Rural Population / Q000706:statistics & numerical data*; D059020:Suicidal Ideation; D013406:Suicide, Attempted / Q000523:psychology*; D055815:Young Adult
keywords: Ethiopia; Low and middle income country; Suicidal behaviour; Suicidal ideation; Suicidal plan; Suicide attempt