The Psychosocial Factors that Influencing Antiretroviral Treatment Adherence
August 19 2017

Liranso Gebreyohannes Selamu firstname.lastname@example.com
Scholar in Medical and Psychiatry Social Work
MangaloreIndia

Mohan S Singhe
Research Guide & journal editor in Social Work
MangaloreIndia

Eyerus Assefa
Social work researcher and ART practitioner in Alert Hospital
Addis AbabaEthiopia

Scholar in Medical and Psychiatry Social Work
Liranso Gebreyohannes Selamu
MangaloreIndia

The Psychosocial Factors that Influencing Antiretroviral Treatment Adherence
NO: 2324-7339August 19 2017CC278EBEE20B678D174A5EBEAE0B968610.14302/issn.2324-7339.jcrhap-16-1316Received : October 03 2016; Accepted : December 12 2016;Antiretroviral TherapyTreatmentAdherence and Psychosocial Factors
The socio-cultural context of illness has become a major research area, and it has made significant contributions to our understanding of the socio-cultural dimensions of illness.In this article, we briefly trace the roots of a sociocultural approach to illness, and we present some of the key findings of socio-cultural organized under main themes.Adherence to antiretroviral therapy drugs in the treatment of HIV infection is complicated because of many psychosocial factors.The aim of the study was to investigate the psychosocial factors involved in noncompliance with ART among people infected with HIV in Alert Hospital in Ethiopia.To achieve its objective, the study utilized a qualitative method to gather direct, inductive and wealthy information from the participants.The study covered interviews with twenty participants.The participants were selected using purposive sampling technique.The collected data was categorized and analyzed thematically based on the research objective.The results of the study indicated that the major psychological and social factors such as stigma and discrimination, social support, substance abuse, subjective norms, belief system and perceived behavioral control, and various cultural factors may uniquely contribute to deeper and potential barriers to ART adherence.Evaluating changes in the level of knowledge health workers trained in adherence measurements and concerned bodies work for providing relevant and updated information about ART issues for the followers in a convincing way.Therefore, the study has concluded that health workers in all facilities that provide ART would be trained in adherence counseling through formal training.

Introduction

The Human Immune Virus (HIV) has created a vast challenge throughout the world.A report at end of 2012 showed that approximately 34 million people were living with HIV worldwide (UNAID, 2012) 12 .The epidemic continues to be more severe in Africa than any other country in the world.Almost half of the deaths from Acquired immune deficiency syndrome (AIDS) related illness in 2012 occurred in Africa.According to HAPCO (2012) 5 , 1.1million people are living with HIV with Marked regional variations.AIDS is one of the most destructive epidemics the world has ever witnessed.Presently an estimated 33.4 million people are living with HIV worldwide, nearly two-thirds of these live in sub-Saharan Africa.Antiretroviral therapy (ART) has shown to delay progression to AIDS, resulting in a greater and more sustained virologic and immunologic response and improve survival (UNAID, 2012) 12 .

In sub-Saharan Africa, there has been a dramatic increase in the number of HIV/AIDS patients on antiretroviral treatment from just 100,000 persons in 2003 to 3.9 million in 2009 involving close to 40% of those in need of the treatment.Two sub-Saharan Africa countries, Botswana and Rwanda, have achieved universal access target (treatment coverage of 80% or more of patients in need) at the end of 2009, while countries such as Ethiopia, Zambia, Namibia, and Senegal are moving closer to the same target having covered 50-80% of patients in need of treatment (Ayalu & A. Reda, 2011) 1 .Since access to ART is vital, it is equally important to ensure the patients adherence to the prescribed regimen.Adherence in this sense is defined as the "extent to which client's behavior matches with the prescribed health care regimen as agreed through a shared decision making process between the client and the health care provider" (WHO, 2003) 15 .Successful ART provision thus requires not just medical attention alone but also long term social and psychological support, including encouraging and monitoring adherence (Hope and Israel, 2007). 17propriate use of antiretroviral therapy (ART) has improved the health of many HIV positive individuals otherwise may have died.Notably, the efficacy of any treatment depends on sustained high levels of adherence to ART.But ART regimens are often complicated and can include varying dosing schedules, dietary requirements, and adverse effects.Adherence is a major predictor of the survival of individuals living with HIV/AIDS and poor adherence to treatment remains a major obstacle in the fight against HIV.From the perspective of service delivery, treatment nonadherence undermines the efficient distribution of resources and huge expenditure by international organizations including the United States President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund and the World Bank (Pennington, 2007). 18cording to WHO (2010) 16 , the interventions target adherences was tailored to the demands that experienced by the patients with that specific illness.As a result, it is important for health care providers to assess those factors that impact negatively on adherence.In order to improve adherence the health care providers should first ascertain treatment readiness, otherwise treatment may be given to patient who are not ready to follow the regime.In addition, patients should be advised on how to take their treatment.Patients who show less than 80% compliance require increases adherence support knowledge regarding the effect of Anti retroviral medication on viral load is a better predictor of adherence than the patient's level of education (Duranteetal, 2003) 3 .

There are several psychosocial factors that are directly or indirectly affecting adherence.These are social and psychological factors may lead to non adherence has serious consequences both on the individual and the society.If there is poor adherence then there is a higher risk that drug resistance will develop, which will result in need for second-line drug treatment.When people living with HIV require second line treatment, it can be ten times more expensive than first line drugs (WHO, 2010) 16 .

Studies have however shown that youth are more prone to poor adherence increasing their risk and heightening risk for early mortality.Globally, young people constitute more than half of those infected by HIV with reports estimating that over 6000 youth get infected with HIV every day (UNAIDS, 2005) 13 .This increasing number of young people getting infected means there are more young people being initiated into treatment programs.Behaviours associated with adherence such as taking doses at the same time every day, following food restrictions and skipping doses as a result of irregularity in routines remain a challenge to youth living with HIV (Reisner, 2009) 10 .

The socio-cultural context of illness has become a major research area, and it has made significant contributions to our understanding of the socio-cultural dimensions of illness.In this article we briefly trace the roots of a socio-cultural approach to illness, and we present some of the key findings of socio -cultural organized under main themes.HIV medications can have some significant, long-term side effects.While many of these side effects are treatable, some can be long-term.The client needs to tell the healthcare provider about any side effects, so that he or she can decide the best course of treatment for both the HIV disease and the side effects.Most of those involved in the movement to slow the spread of AIDS and to improve the quality of life of those living with HIV view stigma and discrimination as human rights violations requiring redress.Both organizations and individuals have taken various actions to address stigma; however, these actions often have not been grounded in a broad biosocial understanding of stigma and AIDS-related discrimination (UNAIDS, 2007) 11 .

In Ethiopia primary health care Kagee (2004)   6 resulting in high rate of relapse rehospitalisation of disease and mortality.Non-adherence studies are still in the exploratory phase, especially in Ethiopia and as a result, explanations for this phenomenon are not yet fully developed.Adherence that is sub-optimal results in replication of the virus, which promotes the development of drug resistance HIV-variants, leading to treatment failure as well as limited options for future therapy (Louie and Markowitz 2010) 8 .Therefore, this study was tried to assess the psychosocial factors affecting ART adherence among young people living with HIV in Alert Hospital in Ethiopia.

The result of the study may also help those Hospitals and organizations working on more effectively and efficiently service empower, and use internal and external resources to develop strong sustainable programmatic responses to minimize the psychosocial factors that influence ART adherence among PLWHA in sustainable ways.Besides, it is hoped that the results of this study may provide some information on the present psychosocial factors that influence ART adherence for those who are interested in conducting further investigation on the issue under discussion.Moreover, the study may help to identify the strengths and weaknesses regarding ART service challenges.This will be built upon the strengths and work hard to improve the shortcomings.

Finally, since the relevant and feasible recommendations are forwarded to add scientific values on the existing strategies, programs, services and practices specific to the present psychosocial factors that influence ART adherence which will help to enhance the psychosocial wellbeing of ART stakeholders, all concerned government agencies, NGOs, the academic community, and associations working on ART and ART participants themselves benefit from this study.

Methods

The research design refers to the structure of an inquiry whose role is to minimize the chance of drawing incorrect causal inferences from the data (Creswell et  al., 2007)  2 .The study was employing a qualitative method to make the description of the existing psychological and social factor that affects ART Adherence in Alert hospital.There are a number of reasons for choosing a qualitative research methodology for this particular study.Firstly, qualitative research is considered to be an appropriate methodology for researchers whose research questions lead them towards an 'inductive' or 'data-driven' approach-that is, to look at what is going on and try to make sense of that by testing out themes and patterns.Secondly, the qualitative method of data collection and analysis provides rich information and meanings which are not always accessible through the quantitative method of data collection (Creswell et al., 2007)  2 .

In this study, two data sources were employed, namely, young people between 25-35 years-old twenty participants were included in the study to get more effective responses to the psychosocial factors involved in not-compliance with ART among people infected with HIV in the Hospital.Because it was assumed that their understanding level was good to describe their experiences.Moreover, young people undergo a developmental period of experimentation, risk taking and confronting a host of choices with regard to identity formation, relationships, sexual behaviour and drugs and substance abuse (Raiser et al, 2009) 10 .

According to (Durrhin & Painter, 2006)  4 , purposive sampling is often used when looking for rare and particular types of participants.In light of this, the sampling technique was employed to identify all of the respondents with rich information appropriate for this study.Young people living with HIV, 25-35 years-old twenty participants were selected using a purposive sampling technique.Through these associates and references of the participants, it was finally possible to accumulate a sufficient data to check more deeply on the psycho social factors involved in non-compliance with ART among people infected with HIV in the study area.

To collect data from the respondents, the researchers utilized semi-structured interview.According to Mugenda (2003) 9 , semi-structured interview is easier to answer and analyze for unambiguous responses.Furthermore, a great advantage of the semi-structured interview, according to Kruger (1988) as cited in Yolandi  (2003)  [19,20] mentioned that is its flexibility, which allows the researchers to grasp more fully the participant's practice than would be possible through the implementation of a more rigid methodological technique.Based on this, a semi-structured interview guide was drawn up for each interview in order to elicit and acquire rich information relevant to meet the objective of the study.

According to Durrhin and Painter (2006)  4 , data collection procedures refer to the process followed by the researcher to collect the necessary information.The researcher with the help of coordinator of the Hospital contacted and selected participants'.Selected participants were informed and asked their permission to participate in the study.

To obtain an informed consent from the respondents, the researchers explained the consent form which includes issues about the purpose of the research, confidentiality, rights of informants, duration of discussions, and note taking.Hence, most of the respondents agreed to participate in the study.The average amount of time the interviews took with each participant was from 45 to 55 minutes.

The interviews were conducted in collaboration with one staff member who has a strong attachment with the researchers.After the respondents were selected they were interview by using the Amharic version of the interview guided by the researchers.After the data was collected, it was transcribed from Amharic to English.The dictations and translations were also carefully reviewed for consistency.Some corrections were made.Then transliterates were read numerous times to gain better understandings of the responses of participants.Field's notes were translated from Amharic to the English language.The transcribed data was organized in themes according to the research questions themes.Then after, the findings of the study were analyzed based on the psychosocial factors involved in not-compliance with ART among people infected with HIV.

Moreover, a themes and sub-themes were discussed in categorized and summarized forms of major themes based on the research questions of the study.

Finally, the research result categories or clusters were summarized into major themes.Some selected respondents' stories were presented in quotations to see the turning points of psychosocial care and support issues.Hence, thematic data analysis was employed in this study.As (Kumar, 2008)  7 stated theme analysis was a good fit for qualitative research.

Results

The purpose of the study was to explore influence of psychosocial factors on ART adherence among young people living with HIV in Alert Hospital.This part of study presents the major findings as follows.

In Table 1: an overview of sex and educational background information on respondents.Among the total twenty participants, five of them (two male and three females) were illiterate.Only two female participants have an elementary education.In addition, four (one male and two females) of the participants are educated at junior high school level (grade 5-8).Furthermore, eight (three males and three females) have attended high school education (grade 9-12) while four (two males and two females) have attended Grade 12+ levels.Table 2: an overview of religion and marital status information of the participants described.Almost all participants reported that feeling of depression; anger and suicide are presented because of their tendency to occur either in isolation in reaction to being diagnosis with HIV.After being diagnosis with HIV, the participant's reaction to the news varied from depression, anger, denial, fear and suicide to acceptance; most of the participant who experienced difficulty.They did not get counseling, adhered poorly to the medication on refused to take ART.

Also, six participants have reported that their spouse refuse to use condoms.The initial reaction of most of the women to the diagnosis was acceptance; the difficulty was with their partners.They refused to get tested for HIV and insisted that they were not sick, so they continue living as if nothing has changed.In line with this: I lost my boyfriend before two years by AIDSrelated illness.But, I was diagnosed while I was pregnant (Fm, 2).

Furthermore, fear of dying and not being able to raise their children was expressed by many of the participants.Three participants were mentioned that they had been through stages where they experienced fear constantly.They attributed this to a fear of rejection and dying.Thoughts of leaving their children without a mother, being unable to raise them, and leaving them without someone who would love and take care of them it is the source of many women fear.

I refuse to take ART medication, because, I believe that it exposed me to suffer anxiety and depression.Also, I don't accept the conditions.Already, I was affected psychologically (Fm, 8).

The information collected from participants also shows that they had not accepted that they were HIV positive by the time that they were interviewed.Because they stated that they already accepted HIV as part of their lives.Also, the data shows that adherence behaviour such as regular follow-ups and taking the medication as prescribed indicated a degree of acceptance of the diagnosis.The following extract, from one male participant, illustrates the more:

Already, I know my status before one year back, I live alone, most of the time I easily become hopeless and suffer depression because of disease condition and isolation.Also, I lose my weight and exposed to body weakness (Mp, 6).

Other participants also indicated that abused by sexually, physically and because of refuses to use condoms.In line with this, the following quote, illustrates the above challenges of the participants: Currently, I live with my sister.My husband passed away by AIDS-related illness before five years ago and then I was diagnosed.I believed that I have infected because of a refusal of condoms, I also abused physically (FP, 5).However, the following citation illustrates inconsistent with the above: I see ART as right, but you know, everyone goes with the belief of a person if a person believes that it will help, but if a person is not trusting it, has a negative belief about it, then it will not help (FP, 7).

Furthermore, respondents illustrated that they were experienced different psychological problems such as stigma and rejection from the society.The participants mentioned the fear of being stigmatized and others finding out that they were HIV-positive as reasons for their social withdrawal as well as for their unwillingness to collect their medication.They were reluctant to take their medication because they fear being seen there by people who know them.As a result, these participants prefer to keep to themselves alone.

The following citation strengthens this idea: "I disclose my real status, especially to those who don't know me.Because I believed that they talk about me in their groups and when I join them they act as if they don't mind (Mp, 1).Moreover, the following citation also illustrates more in relation to the above: "I cannot take my drugs when people are seeing.I always go and hide and take them.Otherwise, people start to speak very softly about me all the time (FP, 3).

The other important thing that emerged from the participants was the refusal of condom usage.Most of the participants stated that they do not want to use condoms because it is against their culture.They also reported that using condoms removes the joy of sexual experience; all of these participants stated that they never used condoms before being diagnosed.Additionally, all the participants indicated that experiencing side effects from the medication.This was also one of the reasons given for non-compliance.

The unpleasant nature of the side effects, especially sickness, vomiting, weakness, diarrhea these side effect increase reluctance to adhere well.

"  Moreover, there are only very few studies that investigate adherence.The aim of the research was to assess the challenges of adherence to ART and to identify the factors that contribute to poor adherence.Current estimates of adherence studies indicate that despite earlier fears of poor medication adherence.In line with this, the following quote illustrates the above challenge of ART medication.

Many people told me many things.They told me that the medicine has very shocking behaviour; it claims life while on sleep; it causes blindness and deafness; it results in bruises and it removes hair; and so on.Therefore, for the fear of such bad things I kept the medicine with me without taking it for many days (Mp, 7) Furthermore, the above-aforementioned reality in line with Ayalu & A. Reda (2011),1 research result that health system barriers affect adherence, especially a regular and timely supply of medication to patients.An unreliable supply of medications can severely reduce patient adherence rates.These include not use of new monitoring mechanisms, infrastructure, staffing, training of counsellors, community support systems, and suitable drug formulations.

All respondents reported disclosure of their status to others.In fact, except one participant reported that they had someone in their household who knew about their treatment.Respondents rarely reported stopping the medication because of family pressure or stigma.

Although one subject indicated that fear of stigma in the workplace contributed to his inability to request time off to collect medication, another respondent stated that pressure and fear of disclosure did not affect her decision:

One of the reasons I stopped treatment might be because of transportation costs, but not side effects or fear of disclosure, because there are people in my street who know my status and my friends.No, no one has pressurized me to stop my pills (FP, 3).In contrast to other studies in the literature, the cost of medication was not an important barrier among respondents because patients obtained ART and healthcare at clinics free of charge.However, transfer patients reported that transportation costs influenced treatment retention.The majority of transfer patients lowered transportation costs by changing clinic.Possible interventions to overcome financial barriers include providing stipends or vouchers to patients to cover transport costs.Additionally, a treatment plan designed to accommodate less frequent appointments and drug pick up, could reduce patient costs and reduce the time burden that ART places upon patients.

On the other hand, most participants informed that rejection and stigmatization after disclosing the condition.They lost loved one because of HIV, rejection, and stigmatization from other has been described as contributing to non-compliance.In addition, they illustrated that negative reactions from community members make them withdraw entirely from any contact with the community, and rely entirely on the support of family members, as one respondent confided:

At first, I got so scared to tell people because of the stigma but ever since I started on ART they have begun to wonder what has happened.In fact, I hear some say why they don't inject her and put her to rest otherwise she is going to finish everybody.Because of these, I remained alone.So I remained with only a few of my family members who I cooperate with.My intimate friend advised me to tell our family members about it.In fact, these helped me so much when I told them I became free about my status and up to now I have a lot of courage and strength with the ART (FP, 8).Furthermore, the following citation also illustrates more in relation to the above: "My wife abandoned me the moment I disclosed my status to her.She left me with the children.And to make it worse, my own family said I deserved harsh treatment because I infected my wife with the fatal virus."(Mp, 3)

Additionally, they indicated that the involvement of family, friends and others in helping the patient to deal with the disease.In some cases the family members distanced themselves from issues pertaining to HIV/AIDS, better understanding from family and friends has been cited as being helpful in improving compliance to treatment.

However, not all children are equally supportive, as shown in the following complaint:

"It is only my young children who give help.They cook for me and bring me whatever I send them.But my elder children neglected me yet I told them about my status (FP, 1).

Most participants indicated that the different belief system of participants and their families also emerged as one of the issues that contribute to noncompliance.Lack of trust in the ART medications and trust in spiritual bases were considered.Most of the participant default treatment because of traditional beliefs and become sick as a result.The following excerpt, from one participant, illustrates further:

When I was discussing with one fellow member about ART, she has told me that she lack trust in the ART medications.So, Satan is using the ART to attract the PLWHA into committing faithlessness (Mp, 3).

Respondents overwhelmingly reported that ART has low improved their health status and quality of life.Nevertheless, despite improved health from taking ART and worse health when treatment is stopped, serious barriers to treatment remained: transport costs, time needed for treatment and logistical challenges were barriers to treatment, whereas stigma around HIV/AIDS and side effects associated with ART were discussed.Also, the participants described that a number of causes that forced them to delay taking the ART on time, because of failure in meeting the needs triggered in relation to food and other prescribed orders of the physician.Some of the major causes stated by participants based on the frequency of response from higher to lower include: involvement in long lasting social responsibility like mourning and wedding; lack of financial support which can be used to cover the food and related needs that have to be responded in the process of taking ART as a lifelong therapy; forgetfulness and long travel were among the causes discussed by participants of the study.

Additionally, participants of the study indicated that because of fear of stigma and discriminations forwarded from their community, they delay the time for taking ART in occasions where the member of the family are around their home for any social reason .In addition, eight participants who said that the nature of their work is one of the major causes that adversely contributed to the delay in taking the medicine on time.They said that because of the attached stigma and discrimination, they do not take their medicine at their workplace for not being seen taking the medicine.Consequently, however, their disclosure has resulted in stigma and discrimination on them.

Therefore, except the PLWHA who haven't disclosed their zero-positive either for their relatives or for their friends, all of the respondents went through a trial of stigma.Besides, respondents tremendously reported that lack of knowledge regarding adherence to the ART regimen also seemed to affect the notion of what to do if one forgot to take ART at the prescribed time, which is essential information to provide when dispensing ART.The majority of the participants were found not to have experienced side-effects during their treatment.Knowledge regarding side-effects seemed not to have been sufficiently covered, with most of the participants still ignoring the possibility that they might experience side-effects, and not concerning themselves about ensuring that they knew what to do if they did experience them.

Furthermore, participants reported that because of the tiresome nature of work they engage in, they sleep earlier and sometimes miss taking the medicine.Few of the participants have stated that the nature of their work in making them tired so that they do not have any time to involve in community affairs.In addition, as we have seen so far in the findings, the respondents of this study have different knowledge and understandings about HIV/AIDS related issues including ART.It is obvious that their attitude, understanding, and knowledge about the pandemic would have its own impact on the implementation of ART medication.

Discussion

The study was tried to assess the psychosocial factors affecting ART adherence among young people living with HIV in Alert Hospital.Compliance remains one of the major challenges in managing medication for those patients living with HIV/AIDS.A qualitative research method was applied in order to assess the major psychosocial factors that affect adherence to antiretroviral treatment.The participants were selected using purposive sampling technique.Twenty participants between 25-35 years old were included in the study.The data were collected by means of semi-structured interview and focus group discussion.The data were analyzed thematically.The themes emerged and compared with integrated with the literature.To this end, the study has used in-depth interview, and focus group discussion of the researcher to collect data from twenty people who are purposely selected for the study.

Liranso Adherence Counselling Model

There is consistency between this study and USAID (2011)14, stigma and discrimination were among the biggest challenges for HIV patients as they would be reluctant to get treatment, care, and support for fear of alienation.Preventing and reducing stigma is vital so that people are not discouraged from using and helping others on ART.Because of stigma, patients are forced to take their medications in secrecy increasing the likelihood of non-adherence Figure 1.

Stigma has emerged as an important reason for defaulting from treatment.Similarly, traditional medication is appearing to interfere with ART for most patients although several patients reported taking traditional medication both in addition to and as a substitute for ART.Many patients reported feelings of stress, but few associated their stress with a reduced capacity to adhere to their medication regimen.Some patients reported that negative side effects led them to discontinue treatment.The result has revealed some of the major psychosocial factors that affect adherence to antiretroviral therapy based on self-report of participants.

Conclusion

The strength of this study depends on the qualitative data, in which researchers' present views about adherence by reporting statements from the study participants themselves.As we have seen in the findings and discussion parts, HIV/AIDS-related psychosocial factors involved in not-compliance with ART have several implications on the life of the respondents.Particularly in connection with using ART, the respondents have different experiences.Major psychosocial factors involved in not-compliance in using ART are identified and discussed.The results of the study showed that the major psychosocial factors that affect adherence to antiretroviral therapy based on selfreport of participants.

Some of the factors are social stigma and discrimination, belief system, depression, anxiety, distress side effects from the medication (lack of trust in the ART medications) were described more.These concerns require consideration in cycle with the patient focused psychosocial concerns raised here.Efforts to minimize constraints and improve adherence levels will require the efforts of the community, health workers, and patients as well as Government commitment to resolve key structural problems.

From the findings, it is also possible to conclude that the psychosocial factors affecting ART adherence among young people living with HIV in Alert Hospital are health illiteracy, stigma, poor social support, substance abuse, attitudes, subjective norms, and perceived behavioural control, and various cultural factors may uniquely contribute to a deeper potential barriers to ART adherence.

medicine and she was told to discontinue antiretroviral medication while taking the traditional medication" (FP, 4).According to Ayalu & A. Reda (2011)1, currently, there is no gold standard for measuring adherence.Because of this, most of the studies included used the most common forms of adherence assessment patient recall and pill count which have recognized ART medication.It is further challenged by various social and clinical obstacles where inadequate suppression of viral replication by ART are resulting due to poor adherence to therapy, the low potency of the antiretroviral regimens, viral resistance to antiretroviral medications, and pharmacokinetic interactions causing inadequate drug delivery.

Ayalu & A. Reda (2011)1 also stated that the challenges of adherence to ART identified include factors related to patients and their families, socioeconomic factors, medication, and health care systems were indicated.This has implications for interventions to improve ART adherence and therefore the program needs to address these interrelated and multidimensional factors.In other words, ensuring adherence to treatment and retention requires an understanding of the multiple barriers that patients face and developing interventions that overcome these barriers.

Table 1 :
1

overview of sex andeducational background informationof respondentsLevel ofSexEducation MaleFemaleNo %No%Illiterate210315Grade 1-4--210Grade 5-815210Grade 9-12315315Grade 12+210210Total8 10012100
My mother has enough knowledge about traditional medicine.She influenced me to use traditional

Table 2 :
2
An overview of religion and marital status information of the participants

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Socio-Economic Position and Suicidal Ideation in Men
Published: 31 March 2017

Jane Pirkis
Centre for Mental Health, Melbourne School of Population and Global Health
University of Melbourne
3010MelbourneAustralia

Dianne Currier email@example.com
Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health
University of Melbourne
3010MelbourneAustralia

Peter Butterworth firstname.lastname@example.com.
Centre for Mental Health, Melbourne School of Population and Global Health
University of Melbourne
3010MelbourneAustralia

Allison Milner email@example.com.
Centre for Mental Health, Melbourne School of Population and Global Health
University of Melbourne
3010MelbourneAustralia

Anne Kavanagh email@example.com.
Centre for Mental Health, Melbourne School of Population and Global Health
University of Melbourne
3010MelbourneAustralia

Holly Tibble firstname.lastname@example.com.
Centre for Mental Health, Melbourne School of Population and Global Health
University of Melbourne
3010MelbourneAustralia

Jo Robinson email@example.com
School of Population and Global Health
Centre for Health Equity
Melbourne

University of Melbourne
3010MelbourneAustralia

Matthew J Spittal email@example.com.
Centre for Mental Health, Melbourne School of Population and Global Health
University of Melbourne
3010MelbourneAustralia

International Journal of Environmental Research and Public Health Article

Socio-Economic Position and Suicidal Ideation in Men
Published: 31 March 2017Received: 27 February 2017; Accepted: 29 March 2017;* Correspondence: firstname.lastname@example.com; Academic Editors: Rory O'Connor and Gwendolyn Portzkysocio-economic positionsuicidal ideationdisadvantage
People in low socio-economic positions are over-represented in suicide statistics and are at heightened risk for non-fatal suicidal thoughts and behaviours. Few studies have tried to tease out the relationship between individual-level and area-level socio-economic position, however. We used data from Ten to Men (the Australian Longitudinal Study on Male Health) to investigate the relationship between individual-level and area-level socio-economic position and suicidal thinking in 12,090 men. We used a measure of unemployment/employment and occupational skill level as our individual-level indicator of socio-economic position. We used the Index of Relative Socio-Economic Disadvantage (a composite multidimensional construct created by the Australian Bureau of Statistics that combines information from a range of area-level variables, including the prevalence of unemployment and employment in low skilled occupations) as our area-level indicator. We assessed suicidal thinking using the Patient Health Questionnaire (PHQ-9). We found that even after controlling for common predictors of suicidal thinking; low individual-level and area-level socio-economic position heightened risk. Individual-level socio-economic position appeared to exert the greater influence of the two; however. There is an onus on policy makers and planners from within and outside the mental health sector to take individual-and area-level socio-economic position into account when they are developing strategic initiatives.

Introduction

Inequities in health are of major concern to policy-makers and practitioners across the board. Health inequities can be thought of as the subset of inequalities-or differences-in the health of individuals and groups that are value-based and underpinned by injustice, unfairness or avoidability [1]. A major driver of health inequities is socio-economic position. Socio-economic position is a complex construct which relates to the differential opportunities individuals, households and communities have to access the resources that enable good health. Different indicators of socio-economic position capture different components of this construct at an individual level. For example, education best captures human capital in terms of the capacity of individuals to access and understand information. Education also shapes people's job opportunities and future income. Occupation has traditionally been thought of as a measure of social status depending on the prestige of the particular occupation. Occupation also captures exposure to physical, and potentially psychological, workplace hazards. Occupation is a strong determinant of health status, particularly for men. Employment status is a major determinant of health, reflecting social status as well as access to material and psychosocial resources, while income level reflects the material resources of individuals and households [2]. It is also possible to measure area-level indicators of socio-economic position, using indicators like the percentage of an area's population with low levels of education or on low incomes. Area-level measures encapsulate the social and economic resources within areas. Health outcomes show different patterns according to the indicator of socio-economic position used.

In the suicide prevention field, a number of studies have explored inequities in suicide and, to a lesser extent, non-fatal suicidal outcomes (i.e., suicide attempts and suicidal ideation). As in other areas of health, socio-economic position, as assessed by different indicators, has been a major focus. Platt provides an excellent overview of these studies in his chapter in the recently published International Handbook of Suicide Prevention [3]. Individual-level studies consistently show over-representation in suicide statistics and heightened risk for non-fatal suicidal behaviour in individuals who are unemployed [4][5][6], work in unskilled jobs or jobs with poor psychosocial working conditions [7][8][9], have insecure housing [10,11] and relatively low levels of educational attainment [10,12,13]. Area-level studies produce less consistent findings, with some studies showing that relatively deprived areas (as assessed by average income, for example) have higher suicide or suicide attempt rates than more affluent areas, and others finding no such relationship [3,12,14].

Understanding the different contributions and potential interactions between individual-and area-level socio-economic position is important for the design of suicide prevention programs. Relatively few studies have been conducted, however, that consider the impact of individual-and area-level socio-economic position simultaneously, at least in general adult populations, although some studies have been done [3,[15][16][17]. Two plausible hypotheses have been advanced, taken from the broader literature on health inequities. One is that area-level socio-economic position may compound individual-level socio-economic position, with the two acting in an additive fashion and maximising the risk. Under this scenario, those in the lowest socio-economic positions in areas of the greatest disadvantage would be at the greatest risk. The second hypothesis is that there may be a more complex interaction between individual-level and area-level socio-economic position, such that the effect of individual-level socio-economic position might be more pronounced in areas of lower socio-economic position (i.e., greater advantage). This might play out in circumstances where individuals who are in low status occupations are at greater risk if they perceive themselves to be surrounded by peers in higher status occupations than if they perceive themselves to reflect the norm for their area. Similarly, unemployed individuals may be more marginalised if they are living in more affluent areas, or, conversely, they may benefit from the additional resources available to them [18].

We had the opportunity to contribute further to knowledge in this area by investigating the relationship between individual-level and area-level socio-economic position and suicidal ideation in a nationally representative cohort of men because of our involvement in Ten to Men, the Australian Longitudinal Study on Male Health [19,20]. We used a composite measure of unemployment/employment and occupational skill level. Our aim was to determine whether each of these factors demonstrated an independent association with suicidal ideation and, if so, how the two might work in combination.

Our focus on men was deliberate. Three quarters of all suicides in Australia are by males [21]. Occupation is a well-described measure of men's social status and social status has been strongly linked to suicide. Unemployed men-who arguably have the lowest social status-have an extremely heightened risk of suicide [22]. Examining the impact of these indicators of socio-economic position for men at the individual-and area-level, and focusing on suicidal ideation rather than suicide, could provide useful information to guide future suicide prevention activities.

Materials and Methods

The approach we used in Ten to Men has been described in detail elsewhere [19,20]. Here we provide a brief overview of the sampling and recruitment strategy and the data collection process. We also describe the variables we used in the current analysis, and the analysis strategy itself.

Ten to Men was approved by the University of Melbourne Human Research Ethics Committee (HREC 1237897 and HREC 1237376). Ten to Men data are available at the Australian Data Archive (DOI:10.4225/87/587ebdbc851b1.)

Sampling and Recruitment

In Ten to Men, we recruited a cohort of 15,988 males aged 10-55 in 2013/14 using a stratified, multi-stage, cluster random sampling strategy. We approached the full complement of households (n = 104,884) in 622 randomly-selected statistical areas (SA1s) from across Australia. SA1s are the smallest unit for which the Australian Bureau of Statistics will release census data, and have populations ranging from about 200 to 800. In total, we made contact with 81,400 (78%) of these households and identified 33,724 (32%) as having at least one male resident of the appropriate age. Ultimately, we identified 45,510 'in scope' males in these households, so the 15,988 who agreed to be part of the cohort and returned usable data represented a response fraction of 35%. For the purposes of the current study, we focused on the 13,884 18-55 year-old men in the cohort.

Data Collection

At recruitment, we collected baseline (Wave 1) data from the 18-55 year-old via self-complete questionnaires. These men were asked questions that covered five broad domains (physical health, mental health and wellbeing, health behaviours, social determinants of health, and health service utilisation and health knowledge).

Primary Outcome: Suicidal Ideation

Our primary outcome was a single item taken from the Patient Health Questionnaire (PHQ-9) [23]. This question asks "Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?" Responses to this question are: (a) not at all; (b) several days; (c) more than half the days; and (d) nearly every day. Scores are assigned from 0 to 3, respectively. For the purposes of our analysis, we considered those who scored 1 (i.e., were bothered by these thoughts for several days or more) or more to be experiencing suicidal ideation. It is worth noting here that this single PHQ-9 item has been shown to have good specificity and reasonable sensitivity when compared to a structured clinical interview [24], and was recently shown to predict suicide risk in a large-scale register-based study of (predominantly male) Veterans Administration (VA) patients in the United States [25].

Exposure Variables: Individual-Level and Area-Level Socio-Economic Position

We measured individual-level socio-economic position by considering responses to questions on employment status and occupation type. The employment status question asked: "Are you currently: (a) employed/working for profit or pay; (b) unemployed and looking for work; or (c) neither working nor looking for work?" Those who indicated they were employed were asked: "What is your current occupation (in your main job)?" and given the opportunity to provide a free text response. These responses were then coded according to the Australian and New Zealand Standard Classification of Occupations (ANZSCO) by occupational skill level: (a) low (sales, machinery workers, and labourers); (b) medium (technical and trade workers, community and personal service workers, and clerical and admin workers); and (c) high (managers and professionals) [26]. We created a single variable that was designed to represent a gradient of individual-level socio-economic status by combining these responses into the following categories: (a) unemployed; (b) working in low skilled occupation; (c) working in medium skilled occupation; and (d) working in high skilled occupation.

We measured area-level socio-economic position using the Index of Relative Socio-economic Disadvantage (IRSD) [27]. The IRSD is one of four composite indexes in the Socio-Economic Indexes for Areas (SEIFA), created by the Australian Bureau of Statistics to summarise the social and economic conditions of areas (in our case, SA1s) using census information. The IRSD focuses on disadvantage. It is a multidimensional construct that reflects the disadvantage of individuals, families and dwellings within areas. It is constructed using data reduction techniques (principal component analysis) to combine information from a range of variables assessing the prevalence within areas of unemployment, employment in low skilled occupations, low income, low levels of educational attainment, overcrowding, and other social correlates of disadvantage. A low IRSD score is indicative of relatively greater disadvantage, and a high IRSD score denotes relatively lesser disadvantage. The Australian Bureau of Statistics distributes SA1s in Australia into quintiles based on the IRSD; SA1s in Quintile 1 are the most disadvantaged and SA1s in Quintile 5 are the least disadvantaged. We used these values for our study.

It is worth noting here that we deliberately chose our individual-level indicator of socio-economic position on the basis of it having a degree of consistency with our area-level indicator. As noted, unemployment and employment in low skilled occupations feature as measures that are used to build up the composite IRSD index.

Covariates

We also controlled for the influence of a number of socio-demographic and clinical covariates, largely selecting these on the basis that they have been shown in previous studies to be associated with suicidal ideation in males. These were age, marital status, region of residence, level of social support, alcohol use and depression. The way in which each of these was operationalised is described below: Region of residence was defined using the Remoteness Area classification of the Australian Statistical Geography Standard (ASGS), which splits SA1s into: (a) major cities; (b) inner regional areas; and (c) outer regional areas [28]. • Level of social support was taken from the emotional/informational support sub-scale of the Medical Outcomes Survey Social Support Survey (MOS-SS). This asks about how often various kinds of social support are available to the respondents and generates a scaled score from 0 to 100. Higher scores denote greater social support [29]. • Alcohol use was measured by the Alcohol Use Disorders Identification Test (AUDIT). The AUDIT assess alcohol consumption, drinking behaviours and alcohol-related problems, and classifies respondents' alcohol use as: (a) harmful/hazardous; and (b) not harmful/hazardous [30]. • Depression was ascertained by a two questions that were taken from the Australian Health Survey. The first of these asked "Has a doctor or other health professional ever told you that you had depression?" Those who answered "yes" to this were then asked "Have you been treated for or had any symptoms of depression in the past 12 months?" Those who again answered "yes" were deemed to have experienced depression in the past 12 months [31].

Analysis

We conducted univariate and multivariate logistic regression analyses to evaluate the strength of association between individual-level and area-level socio-economic position and suicidal ideation. In each multivariate analysis, we controlled for the alternative measure of socio-economic position and for each of the other covariates. Based on the regression model coefficients, we also calculated the probability of suicidal ideation for each grade of individual-level socio-economic position within each quintile of area-level socio-economic position.

All data were analysed using Stata (Version 13.1) [32].

Results

In order to be included in the current analysis, the men in the cohort had to have provided data that allowed us to classify them on the basis of the primary outcome (suicidal ideation) and the main exposure variables (individual-level and area-level socio-economic position). This meant that we excluded those who had missing data on the suicidal ideation variable or the individual-level socio-economic position variable; it was not possible for them to have missing data on the area-level socio-economic position variable because this variable was automatically generated on the basis of the SA1 in which they lived. We also excluded those who indicated that they were neither working nor looking for work (n = 829), because it was not possible to classify this group as unemployed or working in one of the three occupational skill levels.

In total, we were able to use data from 12,090 (87%) of the 13,884 18-55 year-old in the Ten to Men cohort for the current study. The sample included representation from men of varying ages, with 23.8% aged 18-29 years, 27.4% aged 30-39 years, 31.5% aged 40-49 years, and 17.3% aged 50-55 years. Table 1 shows the distribution of the sample on the outcome and exposure variables. In total, 8.6% had experienced suicidal thoughts in the past two weeks. In terms of individual-level socio-economic position, 9.3% were unemployed, 23.2% were working in low skilled occupations, 32.7% were working in medium skilled occupations, and 34.7% were working in high skilled occupations. They were fairly uniformly distributed across more and less socio-economically disadvantaged areas, with around one fifth living in SA1s in each IRSD quintile (17.3% in Quintile 1, 18.6% in Quintile 2, 23.2% in Quintile 3, 21.0% in Quintile 4, and 19.9% in Quintile 5).  Table 2 gives additional detail about the two main exposure variables, individual-level and area-level socio-economic position. It shows that within each quintile of area-level disadvantage, there was a broad spread of individual-level socio-economic status. For example, 19.1% of the men living in SA1s in Quintile 1 (SA1s of greatest socio-economic disadvantage) were working in occupations of the highest skill level. Similarly, 5.9% of the men living in SA1s in Quintile 5 (SA1s of least socio-economic disadvantage) were unemployed, and a further 14.5% were working in low skilled occupations.  Table 3 shows the results of the logistic regression analyses. In the univariate analysis, individual-level and area-level socio-economic position were both predictive of suicidal ideation, with lower socio-economic status being associated with higher odds of experiencing suicidal ideation. In each case, after controlling for the alternative indicator of socio-economic position and the other covariates, both individual-level and area-level indicators of socio-economic position remained significant, although the magnitude of the area-level effect reduced substantially.  Figure 1 builds on the findings in Table 3 by describing the probability of suicidal ideation by individual-level and area-level socio-economic position. It shows that within each quintile of area-level disadvantage there is a gradient of risk, such that the probability of suicidal ideation is highest for unemployed men and lowest for men working in high skilled occupations. The picture is similar for each quintile, reinforcing the relative importance of individual-level socio-economic status.

Discussion

This study aimed to explore whether individual-level and area-level socio-economic position are associated with suicidal thinking in men, and if so, whether one compounds the other. We found that even after controlling for other common predictors of suicidal thinking, low individual-level and area-level socio-economic status heightened risk. Individual-level socio-economic position-as measured by unemployment/employment and occupational skill level-appeared to exert the greater influence of the two, however.

Mechanisms by Which Low Individual-Level and Area-Level Socio-Economic Status May Contribute to Suicidal Thinking

As with other areas of health, it is easy to see how low individual-level socio-economic status might contribute to suicidal thinking. We know from elsewhere in the suicide prevention literature that life stressors can sometimes act as a trigger, particularly if underlying or longer-standing risk factors are already present [33]. Some of the ways in which individual-level socio-economic disadvantage manifests itself in relation to employment and occupational skill level-the indicators we used herecertainly qualify as life stressors. For example, those who are unemployed or working in low skilled occupations may experience financial strain, powerlessness, frustration and disrespect [34,35], all of which may act as potential tipping points.

Similarly, it is possible to see how the role of area-level socio-economic status may play out, with, for example, poorer areas having less in the way of infrastructure and services that may help to prevent individuals getting to the point where they view suicide as an option. For instance, areas of relatively greater socio-economic disadvantage may be less well served by mental health services. Perhaps even more importantly, other social, economic, cultural and physical features of these areas may also have a negative impact on the sense of wellbeing of their residents [36]. These features might include, for example, high levels of inter-generational poverty, community norms that foster stigma and discrimination, and built environments with poor amenity that promote social isolation. In a final analysis, we tested for an interaction between individual-level and area-level socio-economic position, controlling for covariates. We found no evidence of such an association (p = 0.98).

Discussion

This study aimed to explore whether individual-level and area-level socio-economic position are associated with suicidal thinking in men, and if so, whether one compounds the other. We found that even after controlling for other common predictors of suicidal thinking, low individual-level and area-level socio-economic status heightened risk. Individual-level socio-economic position-as measured by unemployment/employment and occupational skill level-appeared to exert the greater influence of the two, however.

Mechanisms by Which Low Individual-Level and Area-Level Socio-Economic Status May Contribute to Suicidal Thinking

As with other areas of health, it is easy to see how low individual-level socio-economic status might contribute to suicidal thinking. We know from elsewhere in the suicide prevention literature that life stressors can sometimes act as a trigger, particularly if underlying or longer-standing risk factors are already present [33]. Some of the ways in which individual-level socio-economic disadvantage manifests itself in relation to employment and occupational skill level-the indicators we used here-certainly qualify as life stressors. For example, those who are unemployed or working in low skilled occupations may experience financial strain, powerlessness, frustration and disrespect [34,35], all of which may act as potential tipping points.

Similarly, it is possible to see how the role of area-level socio-economic status may play out, with, for example, poorer areas having less in the way of infrastructure and services that may help to prevent individuals getting to the point where they view suicide as an option. For instance, areas of relatively greater socio-economic disadvantage may be less well served by mental health services. Perhaps even more importantly, other social, economic, cultural and physical features of these areas may also have a negative impact on the sense of wellbeing of their residents [36]. These features might include, for example, high levels of inter-generational poverty, community norms that foster stigma and discrimination, and built environments with poor amenity that promote social isolation.

Implications for Policy and Practice

Around the world, national and local suicide prevention strategies have placed insufficient emphasis on socio-economic position as a risk factor for suicide and non-fatal suicidal behaviours and thoughts. Platt argues for a redirection of policy focus in this regard, noting that care should be taken about the approach. In particular, he notes that governments should weigh up the relative merits of targeting individual-level or area-level disadvantage. His view is that targeting individuals within areas will yield the greatest benefits [3]. Our findings lend support to this assertion, which is consistent with the thrust of the recent World Health Organization report Preventing Suicide: A Global Imperative [37].

Area-level suicide prevention efforts are gaining traction because of the popularity of systems-based approaches delivered through initiatives like the European Alliance against Depression and the OSPI-Europe project [38]. In Australia, we have one such initiative, known as Lifespan (http://www.lifespan.org.au/). These initiatives take suicide prevention strategies for which there is a reasonable evidence base and deliver them to whole communities in a co-ordinated, integrated manner. The idea is that the whole is greater than the sum of the parts, and that by using a systematic approach-as opposed to a more disjointed, piecemeal one-greater benefits will ensue. Typically, areas that are selected for these systems-based initiatives are those which have high rates of suicide and/or suicide attempts; often, but not always, these will also be socially disadvantaged areas.

The suicide prevention initiatives in these area-level initiatives usually cover the full gamut of universal interventions (target whole populations, with the aim of favourably shifting risk factors across the entire population), selective interventions (interventions target those who are not yet manifesting suicidal thoughts or behaviours, but exhibit risk factors that predispose them to do so in the future) and indicated interventions (which are designed for those who are already beginning to display suicidal thoughts or behaviours, usually identified through screening programs or by clinical presentation). In the current context, there would seem to be opportunities for selective interventions that target those whose individual-level socio-economic position puts them at risk, doing so within area-level initiatives. This would mean that individuals with low socio-economic status would be targeted in socio-economically disadvantaged areas, but also, potentially, in better-off areas.

The way in which these policy and practice implications might be operationalised for men requires some thought. In areas of low socio-economic status, consideration might be given to how to increase the availability of mental health and suicide prevention services in general, and how to ensure that they are attractive and accessible to men in particular. Of course, efforts beyond the health and mental health systems will also be required in these areas. These might include urban regeneration or economic renewal programs (e.g., in areas where there have been widespread downturns in male-dominated industries like construction, car manufacturing or mining). They might also include efforts to improve the conditions in which men in these industries are working [39].

Unemployed men and men in low status occupations in these or other areas might be targeted through tailored programs. Again, some of these programs might be delivered through the mental health system; we know that men respond differently from women to some forms of psychotherapy, so gender-specific approaches may be required. Other programs may be broader in focus and aimed at addressing disadvantage itself. These might include training and education programs designed to upskill unemployed men or men working in relatively low skilled occupations.

Study Limitations

Our study had several limitations which must be acknowledged here. Firstly, we used a measure of individual-level socio-economic position that comprised a composite of unemployment/employment and occupational skill level. As noted above, there are different ways of conceptualising socio-economic position, and our indicator is just one of these. Some might argue that our individual-level indicator and our area-level indicator were not sufficiently well aligned, and that they capture different components of the construct of socio-economic position. It is worth noting here, however, that unemployment/employment and occupation skill level are both used by the Australian Bureau of Statistics to build the aggregate area-level IRSD, creating some level of comparability.

Secondly, and on a related point, we relied on a single measure of individual-level socio-economic position, rather than exploring a fuller set of individual-level indicators. This means that we cannot comment on the extent to which unemployment/employment and occupational skill level act as a proxy for or behave differently from other individual-level indicators of socio-economic position. Having said that, it is worth noting that we conducted a sensitivity analysis (not reported here) which used a measure of financial stress as the individual-level indicator of socio-economic position, and that this analysis yielded similar results to our primary analysis.

Thirdly, we used data from a single wave of Ten to Men and therefore were only able to conduct cross-sectional analyses, which limits the extent to which we can ascribe causality to the observed associations between individual-level and area-level disadvantage and suicidal ideation. We have now completed our second wave of data collection and are poised to conduct our first set of longitudinal analyses.

Fourthly, there may have been issues in terms of our covariates. As noted, we chose these because they have consistently been shown to be predictors of suicidal ideation. Some may also have had a relationship with the exposure (i.e., our unemployment/employment and occupational skill level variable), which raises questions about whether our selected covariates acted as confounders or mediators. There is an argument that we may have over-controlled for some of those which acted as mediators, thereby underestimating the effect of unemployment and relatively lower skilled occupations on suicidal ideation.

Finally, there are a range of other limitations that relate to Ten to Men itself. These include a reliance on self-report, and the fact that the sampling strategy meant that males in remote areas and/or who were not proficient in English were under-represented.

Conclusions

This study provides new insights into the association between individual-level and area-level indicators of socio-economic position and suicidal thinking in men, albeit on the basis of a very particular indicator of individual-level socio-economic position (a composite indicator based on unemployment/employment and occupational skill level). Previous studies in this area have tended to focus on suicide as an outcome; relatively few have considered suicide attempts, and fewer still have examined suicidal ideation. This is important because suicidal thoughts and behaviours are often conceptualised as occurring on a continuum, which means that intervening with those who are thinking about suicide may mean that subsequent non-fatal, and fatal, suicidal acts can be averted. Our study showed that individual-and area-level disadvantage both place men at risk for suicidal ideation, with the former exerting a particularly strong influence. Further work is required to determine whether our results hold up using different methods (e.g., hierarchical modelling techniques). Assuming they do, there is an onus on policy makers and planners from within and outside the mental health sector to take this into account when they are developing strategic initiatives.

Author Contributions: Jane Pirkis, Peter Butterworth, Dianne Currier and Matthew J. Spittal conceived the analysis; Matthew J. Spittal and Holly Tibble analyzed the data; all authors contributed to interpretation of the results; Jane Pirkis prepared the manuscript; Peter Butterworth, Dianne Currier, Matthew J. Spittal, Allison Milner, Jo Robinson Holly Tibble and Anne Kavanagh provided critical review and revisions to the manuscript. All authors approved the final manuscript.

Conflicts of Interest:

The authors declare no conflict of interest.

•
Age was classified into four broad groupings: (a) 18-29; (b) 30-39; (c) 40-49; and (d) 50-55. • Marital status was dichotomised: (a) married/de facto; and (b) never married/widowed/ divorced/separated. •

Figure 1 .
1Int. J. Environ. Res. Public Health 2017, 14, Probability of suicidal ideation by individual-level and area-level disadvantage *. * Adjusting for age, marital status, region of residence, level of social support, alcohol use and depression.

Figure 1 .
1Probability of suicidal ideation by individual-level and area-level disadvantage *. * Adjusting for age, marital status, region of residence, level of social support, alcohol use and depression.

Table 1 .
1Distribution of the sample (n = 12,090) on outcome and exposure variables.Sample Characteristics
Value

Suicidal ideation (past 2 weeks)-n (%)
Yes
1036
(8.6%)
No
11,054 (91.4%)

Individual-level disadvantage-n (%)
Unemployed
1123
(9.3%)
Low skilled occupations
2810
(23.2%)
Medium skilled occupations
3956
(32.7%)
High skilled occupations
4201
(34.8%)

Area-level disadvantage-n (%)
Q1 (Most disadvantaged)
2094
(17.3%)
Q2
2245
(18.6%)
Q3
2803
(23.2%)
Q4
2541
(21.0%)
Q5 (Least disadvantaged)
2407
(19.9%)

Table 2 .
2Individual-level and area-level disadvantage.Area Disadvantage
Quintile

Unemployed
n (%)

Low Skilled
Occupations
n (%)

Medium Skilled
Occupations
n (%)

High Skilled
Occupations
n (%)

Total
n (%)

Q1 (Most disadvantaged)
368 (17.6%)
651 (31.1%)
674 (32.2%)
401 (19.1%)
2094 (100%)
Q2
236 (10.5%)
634 (28.2%)
785 (35.0%)
590 (26.3%)
2245 (100%)
Q3
227 (8.1%)
656 (23.4%)
883 (31.5%)
1037 (37.0%)
2803 (100%)
Q4
149 (5.9%)
521 (20.5%)
853 (33.6%)
1018 (40.1%)
2541 (100%)
Q5 (Least disadvantaged)
143 (5.9%)
348 (14.5%)
761 (31.6%)
1155 (48.0%)
2407 (100%)
Total
1123 (9.3%)
2810 (23.2%)
3956 (32.7%)
4201 (34.7%)
12,090 (100%)

Table 3 .
3Univariate and multivariate predictors of suicidal ideation (past 2 weeks).Predictors

Univariate Models
Multivariate Model

Odds Ratio (95% CI)
p-Value
Odds Ratio (95% CI)
p-Value

Individual-level disadvantage
<0.001
<0.001
Unemployed
4.19 (3.44-5.10)
1.83 (1.40-2.37)
Low skilled occupation
1.79 (1.50-2.15)
1.35 (1.09-1.68)
Medium skilled occupation
1.40 (1.18-1.67)
1.21 (0.98-1.48)
High skilled occupation
1.00
1.00

SEIFA
<0.001
0.030
Q1
2.07 (1.67-2.58)
1.32 (1.00-1.73)
Q2
1.86 (1.50-2.32)
1.52 (1.17-1.98)
Q3
1.53 (1.23-1.90)
1.38 (1.07-1.78)
Q4
1.43 (1.14-1.79)
1.39 (1.07-1.80)
Q5
1.00
1.00

Age
<0.001
0.044
18-29
1.00
1.00
30-39
0.68 (0.58-0.81)
0.75 (0.60-0.94)
40-49
0.70 (0.59-0.83)
0.80 (0.64-1.00)
50-55
0.70 (0.58-0.86)
0.73 (0.56-0.94)

Marital status
<0.001
<0.001
Never married/widowed/separated
2.36 (2.07-2.69)
1.48 (1.24-1.77)
Married/defacto
1.00
1.00

Region of residence
0.228
0.491
Major cities
1.00
1.00
Inner regional areas
1.13 (0.97-1.32)
0.94 (0.78-1.13)
Outer regional areas
0.98 (0.83-1.17)
0.89 (0.72-1.09)

Level of social support (MOSS-SS)
0.97 (0.97-0.98)
<0.001
0.98 (0.97-0.98)
<0.001

Alcohol use
<0.001
<0.001
Not harmful/hazardous
1.00
1.00
Harmful/hazardous
1.73 (1.51-1.98)
1.58 (1.35-1.84)

Depression
<0.001
<0.001
No depression in past 12 months
1.00
1.00
Depression in past 12 months
6.45 (5.60-7.44)
5.33 (4.52-6.30)

© 2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Acknowledgments:The research on which this paper is based was conducted as part of the Australian Longitudinal Study on Male Health (Ten to Men). We are grateful to the Australian Government Department of Health for funding and to the boys and men who provided the survey data. Ten to Men is managed by the University of Melbourne. Ten to Men data are the intellectual property of the Commonwealth.
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