Evaluation of the suicide registration system in Maputo and Matola, Mozambique, 2016-2018

Eduardo Mangue Chicanequisso^1,2,&, Ivandra Magaia², Virgílio Ceia Francisco³, Érika Valeska Rossetto⁴, Cynthia Sema Baltazar²

 

¹Field Epidemiology and Laboratory Training Program, ²National Institute of Health, Maputo, Mozambique, ³Maputo Central Hospital, Maputo, Mozambique, ⁴MassGenics, assigned to Mozambique Centers for Disease Control Prevention, Maputo, Mozambique

 

 

^&Corresponding author
Eduardo Mangue Chicanequisso, Field Epidemiology and Laboratory Training Program, Mozambique, National Institute of Health, Maputo, Mozambique, P.O. Box 264, Maputo, Mozambique. edu.chicanequisso@gmail.com

 

 

 

 

Suicide is a conscious act of self-annihilation, carried out by someone who is in a vulnerable situation and who perceives it as the best solution to get out of unbearable psychological pain [1]. It constitutes a major public health problem worldwide and is one of top causes of death in the population aged 15-34 years [2]. It is estimated that, globally, close to 800,000 people die due suicide per year [3,4], and the World Health Organization (WHO) recognizes suicide has a public health priority [5].

 

Several factors that leads to suicide have been persistently observed across countries and cultures. These factors include the presence of mental disorder, family history of psychopathology, depression, stressful life, traumatic events, young or old age, low socioeconomic status, and previous suicide attempts [6,7].

 

At the global level there are scarce data available and the quality of data on suicide and suicide attempts available is suboptimal. So far, there are no reliable data from most African countries to assess the magnitude of the problem of suicide. The problem of poor-quality data is not unique to suicide. Given the sensitivity and stigma surrounding suicide, it is likely that suicide and suicide attempts are underreported and misclassified at the health facility and community level [8].

 

Over 70 percent of suicides in the world are believed to occur in low and middle income countries (LMIC´s)[5]. In 2012, a report for the WHO estimated Mozambique had a suicide rate of 27.4/100 000 inhabitants, ranking the country as having the highest prevalence of suicide on the African continent and the 7th in the world. With a rate over double the global average of 11.4 per 100 000, the situation has improved over the years. For example, in 2016 the suicide rate was estimated at 8.4/100 000 inhabitants [3].

 

The non-existence or fragmentation of suicide record systems in most LMIC´s makes it difficult to assess the magnitude of the problem in these regions. Therefore, there is a need for improved and expanded surveillance of suicide in order to provide sufficient evidence for its prevention. Several criteria and guidelines were established to assist the process of evaluating the functionality of the Suicidal Health Surveillance Systems (HSS).

 

It was essential to evaluate the Suicide Registration System in the cities of Maputo and Matola (SRSMM) to have an overview of the system (including data flow) and assess the suicide burden in the population. If effective, the system can be used to identify the age groups and areas most affected by suicide.

 

 

Study design

 

In this research, suicide is defined as “death caused by self-directed injurious behavior with any intent to die as a result of the behavior” [9].

 

For this descriptive evaluation we reviewed the electronic database from the Legal Medicine Service (LMS) at the Maputo Central Hospital (HCM), the reference health facility for all cases of extra-hospital deaths (including suicides) that occurred in Maputo (capital city of Mozambique and the main urban area) and Matola City (adjacent to Maputo), from 2016 to 2018. HCM is the only facility that has organized and systematic data on suicides on a national level.

 

System attributes

 

Based on the Centers for Disease Control and Prevention (CDC) updated guidelines for evaluating public health surveillance systems 2001, we used the following five attributes to assess the performance of the LMS database: simplicity, data quality, representativeness, stability, and usefulness. The choice of this method is because it allows gathering reliable evidence on the performance of the surveillance system [10]. For example: Is the system useful? Should the system be continued? These types of questions can be addressed by looking at key components of the system. The evaluation parameters used were by Moliner et al, adapted and used in different evaluation [11]. The quality data was classified based on parameters adapted from the research on completeness of the information system for elderly suicide in the State of Bahia, Brazil [12]. For each evaluated attribute, the evaluation criteria are found in the results table 2.

 

Data collection

 

In order to access the system´s attributes, we developed a semi-structured questionnaire to interview a coroner medical, a criminalist, a data typist and a psychiatric to collect information on the usefulness of the surveillance system and assessment of the system's attributes. The questionnaire had 4 sections and was directly linked to collection and recording data process. Permission to carry out the study was sought and granted by the health institutions. No names were used on the questionnaires, and the information was only available to those who were involved in the study.

 

Ethical considerations

 

This study was conducted thanks to the approval by Maputo Central Hospital after a letter for the release of data was sent. Secondary data was used for this study and no ethical clearance was required; Verbal consent of the key informants was obtained before the interview was conducted.

 

 

Description of the system

 

The Mortality Health Information System (SIS-MOR) was established between 2008-2009, with mandatory certification as causes of death[13]. This system was subdivided into the Hospital Death Registration Information System (SIS-ROH) administered by the Maputo Central Hospital and the Extra-hospital Death Registration Information System (including suicides) managed by the Pathological Anatomy Forensic Medicine Service. Its main task is to identify the cause of death and the legal medical etiology.

 

When a suicide occurs in community, the local non-governmental authorities (community leader, head of block) inform the local police, which in turn activates a team from the National Criminal Investigation Service (SERNIC), which who through a criminalist, confirms the death, collects preliminary data, and removes and sends the body to the LMS/HCM.

 

Upon the dead body entering the LMS/HCM, the coroner medical records the death and performs the autopsy. After the autopsy, three copies of the death certificate (DC) are issued, the original is delivered to the family for legal purposes, and the second and the third remain in the local archive.

 

Key Findings

 

Between 2016 and 2018, 289 suicide cases were registered in Maputo and Matola. In 2016, 2017 and 2018 there were 154 cases, 66 cases and 69 cases reported respectively Figure 1. During this time period, the rate of suicide in Maputo and Matola was 14.3, 6.1 and 6.4 per 100 000 people, respectively.

 

The largest proportion of cases of suicide between 2016 and 2018 was reported among men (75.8%), from ages range of 20-29 (31.8%). The majority of cases were from Maputo City (64.0%), had completed primary education (44.6%), were single (86.9%) and were self-employed (56.1%). The most common methods of suicide were hanging and consumption of sub-organic chemicals with 249(86.2%) and 29 (10.0%) cases respectively Table 1.

 

Evaluation Results

 

Simplicity: The structure, functionality and its actors are well defined at each stage, namely: i) SERNIC:on-site expertise and removal of the body; ii) Forensic doctors: autopsy and identification of the type and cause of death; iii) LMS: database and DC emission. The system is a complex one because the items evaluated scored 6.0 points due to data sources and several intervening entities Table 2.

 

Data quality: A total of 2810 fields observed in the assessment, of which (3.4%) presented some type of problem in filling in the variable. A total 96.6% fields were filled out properly, which classifies the SRSMM as excellent data quality. The following variables contained no blank entries, resulting in100 percent completeness: province, district, sex, age, marital status, mechanism, date and time of the event. Data on occupation and education were 93.2% and 72.7% complete, respectively Table 3

 

Representativeness: The system is able to identify all population groups and subgroups in which cases, by person, time and place. All suicide deaths were mapped by Maputo city districts (Kampfumo, Kamaxakeni, Lhamankulo, Kamavota, KaMubukwana, Katembe Kanyaka) and Matola City Figure 2. The total data reported representativeness was classified in 95.8%. Maputo City had a representativeness of 64% and Matola 36.0%. Only the Kanyaka district in Maputo City did not report data Figure 2.

 

Stability: According to the interviews, the system has never stopped working since its creation. There is no specific legislation that regulates suicide deaths (0 points). Besides the fact that the system is able to provide data in a regular basis, data demonstrated that it remained unrecorded for 4 months of 2017 Figure 1, the system as classified has regular (2 points).

 

Usefulness: The system is useful for monitoring suicide cases, scoring10 points, distributed as follows: identify the type and cause of death (4points); identify the population affected by suicide (4 points); contribution to the detection and prevention of suicide (2 points). All respondents (100%) alluded to the fact that the system is useful for clarifying the cause of death and the circumstances surrounding it. They also considered the system important for improving the vital records system Table 1.

 

 

This is the first research of evaluation of suicide system in Mozambique using the CDC surveillance system guidelines in Mozambican capital city of Maputo. The conclusion of this evaluation proved that the SRSMM is complex, it has good data quality, is representative (per person, time and place) and is useful for improving vital statistics.

 

In this study, most suicide cases occurred in men. This result is aligned with the literature where about three-quarters of all suicide deaths occur in single men [3,6,14-16]. Men generally prefer more fatal methods, such as hanging, jump from high places, while women tend to less fatal methods, resulting in more suicide attempts [17-19]. In our evaluation, most suicide cases occur in young adults from 20-29(31.8%). At the global level, most reported cases occur in young men. Besides the fact that little is understood about what motivates young males, most reasons are attribute to mental disorders, family factors, gender stereotype [20] (men are often seen as "tough" and "strong") and others. Also, it could be due to countries´ differing “age pyramids” [21]. Due to cultural and religious factors, suicides can represent an unknown percentage of reported deaths.

 

In Mozambique, there is a multitude of institutions involved in the investigation and reporting of suicide cases. This include the police, SERNIC, Legal Medicine which results in several sources of data on the same case.

 

In this evaluation, data quality was excellent. However, as in other African settings, we found key data elements are frequently missing or not collected[22]. This critical information includes details of the event, such as risk and protective factors, place of occurrence, alcohol and/or drug abuse, as well as individual and family medical history: mental, previous suicidal behavior, and psychiatric [4,9,23].The system does not collect or report self-harm or suicide attempts. Those missing data are necessary to enhance the usefulness of the system.

 

Representativeness of SRSMM in each city was considered high according to the defined parameters. Kanyaka district (island) is a place of difficult access and with low population density, which may have contributed to the lack of data.

 

From the public health point of view, there is a relationship between suicide attempts and the suicidal act itself. Therefore, these manifestations of the desire to kill must be treated as soon as possible. Thus, it is necessary to investigate the causes of suicide and suicide attempts[12]. It is necessary to implement surveillance system focused on suicide attempts, as noted by others[4,7]. Analysis on prevalence, social characteristics, and mental health of those involved are needed to monitor trends and define appropriate prevention strategies for integration in social and health programs.

 

 

The SRSMM was considered a complex system, useful for monitoring suicide cases and had good data quality. The deficits pointed out in this assessment should trigger changes in order to make the system more functional. Important steps must be taken to increase data integrity, to improve the quality of information about the circumstances of deaths, and to better identify risk groups. Mozambique does not have a comprehensive vital registration system at the national level. Also, a national suicide attempt surveillance system needs to be developed.

 

The most frequent cases of suicide were male individuals, young age, low education and allied to self-employment or precarious employment. The findings suggest the need for in-depth research using primary data on factors associated with suicide. These findings may also contribute to better targeting of health interventions, optimizing resources and efforts, especially in the prevention of suicide.

 

 

The authors declare no competing interests.

 

 

EMC participated in all stages, from project preparation until to the final writing of manuscript. IM participate in the supervision of the activity. CB provided and a critical review of the report and the manuscript. All authors read and approved the final version of the manuscript.

 

 

The authors would like to thank the entire team that works for the reduction and control of suicides: Wilza Fumo, Flávio Mandlate and Edna Lichucha, as well as the key informants; Ernesto Majone and mappers Rui cossa and Edna Zimba. The authors would also like to thank Kristen Heitzinger, and McCabe Carter for their revision.

 

 

Table 1: General characteristics of individuals who committed suicide, SRSMM 2016-2018

Table 2: Attributes assessed from the suicide data base, Maputo and Matola City, 2016-2018

Table 3: Assessment of completeness of suicide data, Maputo-Matola, Mozambique, 2016-2018

Figure 1: Monthly trends in suicides by year, RSSMM 2016-2018

Figure 2: Map of suicide distribution by district in Cities of Maputo and Matola

 

 

1. Sousa GS de, Silva RM da, Figueiredo AEB, Minayo MC de S, Vieira LJE de S. Circumstances surrounding the suicide of elderly people. Interface - Comun Saúde Educ. 2014; 18:389-402.https://doi.org/10.1590/1807-57622013.0241 . Google Scholar


2. World Health Organization (WHO). The word health report 2001. Mental Health: New Understanding, new hope. Chapter 2: Burden of mental and behavioral disorders impact of disorder. WHO. 2001. Accessed August 2019.


3. World Health Organization. Suicide in the world: Global Health Estimates. WHO. 2019. Accessed February 2019.


4. World Health Organization. Practice manual for establishing and maintaining surveillance systems for suicide attempts and self-harm. WHO. 2016. Accessed August 2019.


5. World Health Organization. Suicide. WHO. Accessed March 2020.


6. Wagenaar BH, Raunig-Berhó M, Cumbe V, Rao D, Napúa M, Sherr K. Suicide Attempts and Deaths in Sofala, Mozambique, From 2011 to 2014. Crisis. 2016 Nov; 37(6):445-453.https://doi.org/10.1027/0227-5910/a000383 PubMed | Google Scholar


7. Brasil, Conselho Federal de Medicina (CFM). Suicídio: informando para prevenir / Associação Brasileira de Psiquiatria, Comissão de Estudos e Prevenção de Suicídio. Brasilia, CFM. 2014. Accessed August 2019.


8. Rockett IR, Thomas BM. Reliability and sensitivity of suicide certification in higher-income countries. Suicide Life Threat Behav. 1999; 29(2):141-149.https://doi.org/10.1111/j.1943-278X.1999.tb01052.x . Google Scholar


9. Crosby AE, Ortega L, Melanson C. Self-directed Violence Surveillance: Uniform Definitions and Recommended Data Elements. CDC. 2011. Accessed November 2019.


10. Centers for Disease Control and Prevention (CDC). Updated Guidelines for Evaluating Public Health Surveillance Systems. CDC. 2001. Accessed September 2019.


11. Mota DM, Freitas DRC, de Araújo WN. Evaluation of the System of Sanitary Vigilance of Blood at the federal level, Brazil, 2007. Cienc Saude Coletiva. 2012; 17(1):191-202.https://doi.org/10.1590/S1413-81232012000100021 Google Scholar


12. Rios MA, Anjos KF dos, Meira SS, Nery AA, Casotti CA. Completeness of the information system on suicide mortality in the elderly in the state of Bahia. J Bras Psiquiatr. 2013; 62(2):131-138. Google Scholar


13. Jambi/ MOASIS (Mozambican Open Architecture Standards and Information Systems). Sistema de Registo Civil e Estatísticas Vitais de Moçambique: Relatório de Avaliação do Registo de Óbitos e Causas de Morte. MOASIS. 2014. Accessed October 2019.


14. Sutherland G, Milner A, Dwyer J, Bugeja L, Woodward A, Robinson J, Pirkis J. Implementation and evaluation of the Victorian Suicide Register. Aust N Z J Public Health. 2018; 42(3):296-302.https://doi.org/10.1111/1753-6405.12725 . Google Scholar


15. Fowler KA, Jack SPD, Lyons BH, Betz CJ, Petrosky E. Surveillance for Violent Deaths -National Violent Death Reporting System, 18 States, 2014. MMWR Surveill Summ. 2018 Feb 2; 67(2):1-36.http://dx.doi.org/10.15585/mmwr.ss6702a1 PubMed | Google Scholar


16. Beringuel BM, Costa HV, Silva AP, Bonfim CV. Mortalidade por suicídio no Estado de Pernambuco, Brasil (1996-2015). Revista Brasileira de Enfermagem. 2020; 73(suppl 1):e20180270. https://doi.org/10.1590/0034-7167-2018-0270 . Google Scholar


17. Mergl R, Koburger N, Heinrichs K, Székely A, Tóth MD, Coyne J, Quintão S, Arensman E, Coffey C, Maxwell M, Värnik A, van Audenhove C, McDaid D, Sarchiapone M, Schmidtke A, Genz A, Gusmão R, Hegerl U. What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries. PLoS One. 2015 Jul 6; 10(7):e0129062.https://doi.org/10.1371/journal.pone.0129062 PubMed | Google Scholar


18. Värnik A, Kõlves K, van der Feltz-Cornelis CM, Marusic A, Oskarsson H, Palmer A, Reisch T, Scheerder G, Arensman E, Aromaa E, Giupponi G, Gusmäo R, Maxwell M, Pull C, Szekely A, Sola VP, Hegerl U. Suicide methods in Europe: a gender-specific analysis of countries participating in the "European Alliance Against Depression". J Epidemiol Community Health. 2008 Jun; 62(6):545-51.https://doi.org/10.1136/jech.2007.065391 PubMed | Google Scholar


19. Elnour AA, Harrison J. Lethality of suicide methods. Inj Prev. 2008; 14(1):39-45.http://dx.doi.org/10.1136/ip.2007.016246 . Google Scholar


20. Bilsen J. Suicide and Youth: Risk Factors. Front Psychiatry. 2018 Oct 30; 9:540.https://doi.org/10.3389/fpsyt.2018.00540 PubMed | Google Scholar


21. Wasserman D, Cheng Q, Jiang GX. Global suicide rates among young people aged 15-19. World Psychiatry. 2005 Jun; 4(2):114-20. Google Scholar


22. Mathers CD, Fat DM, Inoue M, Rao C, Lopez AD. Counting the dead and what they died from: an assessment of the global status of cause of death data. Bull World Health Organ. 2005; 83(3):171-177. Google Scholar


23. Data and Surveillance Task Force of the National Action Alliance for Suicide Prevention. Improving national data systems for surveillance of suicide-related events. Am J Prev Med. 2014 Sep; 47(3 Suppl 2):S122-9.https://doi.org/10.1016/j.amepre.2014.05.026 PubMed | Google Scholar