How, when and where to intervene in self-harm in youth in low- and middle-income countries: Thinking beyond healthcare systems

Abstract

Background

Low- and middle-income countries (LMICs) account for 78% of global suicides. Self-harm is the clearest antecedent of suicide. The health and social systems have struggled to provide adequate evidence based help to young people with self-harm. In addition, the negative attitudes towards those who self-harm in these settings interfere with help-seeking behaviour.

Aims and method

In our submission of a comment, we discuss the reasons for thinking beyond healthcare systems in LMICs to address self-harm in youth and the possible ways to achieve it.

Results and conclusion

We truly believe that harnessing the potential of social systems such as schools is important for addressing self-harm in LMICs. We present our arguments in favour of feasible measures that can be implemented to achieve this.

Almost one in five adolescents in low- and middle-income countries (LMICs) had suicidal thoughts, made a suicide plan or made a suicide attempt in the past 12 months (16.9%, 17.0% and 17.0%, respectively) in Global Schoolbased Student Health Survey (Uddin et al., 2019). Evidence from high-income countries (HICs) suggests only a minority of young people with self-harm present to health systems. In United Kingdom, for every adolescent suicide, approximately 370 adolescents presented to hospital for self-harm and 3,900 adolescents reported self-harm in the community (Geulayov et al., 2018). Although exact proportion of young people presenting to healthcare from those who self-harm in the community in LMICs is not known, it is likely to be similar if not less than that seen in HICs. This is partly due to limited access to publicly funded mental health care in LMICs, especially in rural communities, with a much smaller mental health workforce of psychiatrists, nurses, psychologists and social workers even in urban areas as compared to HICs (Rathod et al., 2017).

Furthermore, young people who present to healthcare systems have to deal with many challenges. For example, lack of adolescent specific offerings and competence of the health systems (i.e. care competence) make it difficult for them to get the desired help (Kruk et al., 2022). Psychopharmacology remains a standard treatment for most mental health problems even in children and adolescents with an extremely limited availability of psychological interventions (Rathod et al., 2017). This coupled with the low motivation for psychological therapy in youth with self-harm results in high attrition rates among those presenting to hospital for mental health services (Aggarwal et al., 2021). Additionally, user experiences suggest that many young people with self-harm feel unheard and their experiences with any psychological interventions are negative (Aggarwal et al., 2020).

Social systems such as schools are another point of contact for young people with self-harm where resourcing of prevention and intervention activities can make a difference. However, lack of structures and supports result in the school staff feeling ill equipped to either intervene or work towards preventing self-harm in LMICs (Evans & Hurrell, 2016). Other barriers such as the time that staff can allocate to individual students interfere with the opportunities for detection and disclosure. Most often, they escalate instances of harm through hierarchical structures or parents to be managed by experts outside, mostly in health systems, without trying to assess the situation (Evans & Hurrell, 2016). With extremely limited systematic enquiry in the experiences of young people with self-harm in social systems in LMICs, it is difficult to know about their expectations from such contacts in schools. Global evidence suggests that young people with self-harm value communication with the school teachers and being listened to (McAndrew & Warne, 2014). However, lack of intimacy in the relationship with the teachers, concerns about breach of confidentiality and fears of being considered as ‘attention-seeking’ may prevent them to seek help in the schools (Evans & Hurrell, 2016). Self-harm in specific, and mental health in general remains a topic not covered as part of curriculum for students in schools in LMICs resulting in extremely limited exposure to information. In this context, broadly based preventive intervention programmes for self-harm in schools using whole-school approaches may empower both students and teachers to deal with instances of self-harm without feeling unduly burdened or being singled out. At the same time, engaging with families and communities may promote timely help and reduce stigma (Evans & Hurrell, 2016).

One such universal educational intervention trialled across 10 European Union Country schools (Saving and Empowering Young Lives in Europe [SEYLE] study) is Youth Aware of Mental Health Programme (YAM) (Wasserman et al., 2015). YAM included 3-hr of role-play sessions with interactive workshops combined with a 32 page booklet that students can take home, six educational posters displayed in each participating classroom and two 1-hr interactive lectures about mental health at the beginning and end of the intervention. YAM aimed at changing negative perceptions and improving coping skills of students to handle adverse life events and stressors that often trigger suicidal behaviour. In SEYLE study, YAM significantly reduced incident suicide attempt and severe suicidal ideations compared to control group at 12-months followup (Wasserman et al., 2015). Gatekeeper training programmes for school staff may help them learn about the suicidal warning signs, improve their skills to assess at-risk students and increase the likelihood of them intervening when required (Mo et al., 2018).

Limited integration and co-ordination between social systems such as schools and health systems is another challenge that results in compromised care of young people with self-harm in LMICs. For example, teachers have limited knowledge about the available mental health resources and referral options for students with mental health problems. Similarly, mental health clinicians don’t have the capacity to contact the schools for additional information or to organise adequate support for the students due to the excessive workload (Petagna et al., 2023). In many healthcare settings across LMICs, clinical decision-making for child and adolescent mental health is informed by an adult mental health paradigm that doesn’t involve important components such as school liaison and observation (Petagna et al., 2023). New care pathways can be established for young people with self-harm by involving service users and caregivers at the service-level in direct development of policies or services, and training them to act as liaison workers across systems to allow the use of human resource available in many LMICs. The protective role of sociocultural factors unique to LMICs can be harnessed by incorporating them in the available interventions or adapting the available evidence-based interventions to suit the local context. Although difficult to implement, grading of psychopathology to allow low intensity interventions to be delivered in social systems such as schools might ease the strain of the overburdened health systems.

To conclude, thinking beyond healthcare systems and making social systems, especially schools, more equipped to intervene in youth self-harm in LMICs might improve user experiences, engagement and outcomes in young people with self-harm. Additionally, redesigning service delivery for youth self-harm in health systems using evidence-based cost-effective models can improve the outcomes and ease the burden. A shared vision for transformation across systems is required to make many of the changes mentioned above. Although these changes may strain the systems initially, they are likely to prove to be of great value in ensuring an adequate care for young people with self-harm in LMICS.