Abstract
Background
Public health understanding of variations in self-harm rates between populations largely relies on routinely collected service use data. Previous work using hospital inpatient admissions following self-harm showed unexpectedly lower rates of self-harm in inner-London despite established associations of area deprivation and social fragmentation with self-harm. This study uses Emergency Department (ED) attendance data, and explores processes that may underlie apparently low rates in inner-city areas.
Method
A dataset of ED attendances following self-harm for 2009-2016 in four South East London boroughs was created using linked electronic patient record data and Hospital Episode Statistics. Age and sex standardised small-area rates of self-harm attendance (SARs) were spatially smoothed using Bayesian models and mapped. Associations with area Index of Multiple Deprivation (IMD) and Congdon Index of social fragmentation were tested. A case-study area in the most deprived quintile nationally with below average SARs was identified. Semi-structured interviews with 14 individuals working in community organisations and two focus groups of 12 local residents were conducted.
Findings
We identified 20,750 ED attendances following self-harm by 12,577 individuals. The ratio of SARs in the highest versus lowest 5% of areas was 2.87 (95% Credible interval, 2.65 to 3.13). Associations with self-harm were found for IMD (rate ratio most versus least deprived quintile 2.07, 1.88-2.26) and social fragmentation (1.39, 1.23-1.56) however there were clusters of low-rate, deprived areas in the inner city.
Preliminary qualitative analysis suggests the case-study population experience significant cumulative stressors and mental health difficulties despite low ED presentation rates. Frequent experiences of violence and an emphasis on being “tough” locally combine with attitudes within the large Caribbean and African populations to self-harm and use of mental health services. These pressures may make people more likely to respond to distress in ways less associated with mental illness and vulnerability, even if they are also damaging. Equally, they make individuals who do self-harm less likely to identify themselves to services.
Interpretation
Relying on service-use data for self-harm risks underestimating the extent of distress and subsequent harmful behaviours in some deprived urban populations already disadvantaged by high levels of victimisation and minority ethnic and migrant status.
Public health understanding of variations in self-harm rates between populations largely relies on routinely collected service use data. Previous work using hospital inpatient admissions following self-harm showed unexpectedly lower rates of self-harm in inner-London despite established associations of area deprivation and social fragmentation with self-harm. This study uses Emergency Department (ED) attendance data, and explores processes that may underlie apparently low rates in inner-city areas.
Method
A dataset of ED attendances following self-harm for 2009-2016 in four South East London boroughs was created using linked electronic patient record data and Hospital Episode Statistics. Age and sex standardised small-area rates of self-harm attendance (SARs) were spatially smoothed using Bayesian models and mapped. Associations with area Index of Multiple Deprivation (IMD) and Congdon Index of social fragmentation were tested. A case-study area in the most deprived quintile nationally with below average SARs was identified. Semi-structured interviews with 14 individuals working in community organisations and two focus groups of 12 local residents were conducted.
Findings
We identified 20,750 ED attendances following self-harm by 12,577 individuals. The ratio of SARs in the highest versus lowest 5% of areas was 2.87 (95% Credible interval, 2.65 to 3.13). Associations with self-harm were found for IMD (rate ratio most versus least deprived quintile 2.07, 1.88-2.26) and social fragmentation (1.39, 1.23-1.56) however there were clusters of low-rate, deprived areas in the inner city.
Preliminary qualitative analysis suggests the case-study population experience significant cumulative stressors and mental health difficulties despite low ED presentation rates. Frequent experiences of violence and an emphasis on being “tough” locally combine with attitudes within the large Caribbean and African populations to self-harm and use of mental health services. These pressures may make people more likely to respond to distress in ways less associated with mental illness and vulnerability, even if they are also damaging. Equally, they make individuals who do self-harm less likely to identify themselves to services.
Interpretation
Relying on service-use data for self-harm risks underestimating the extent of distress and subsequent harmful behaviours in some deprived urban populations already disadvantaged by high levels of victimisation and minority ethnic and migrant status.
| Original language | English |
|---|---|
| Journal | The Lancet |
| Publication status | Accepted/In press - 18 Sept 2019 |