Underestimated suicide burden in Fiji: narrative-based death certificate reassignment identifies exceptionally high suicide rates among Fijians of Indian descent — The Association Specialists
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  3. Underestimated suicide burden in Fiji: narrative-based death certificate reassignment identifies exceptionally high suicide rates among Fijians of Indian descent

Underestimated suicide burden in Fiji: narrative-based death certificate reassignment identifies exceptionally high suicide rates among Fijians of Indian descent (23858)

Christine Linhart 1 , Vineet Chand 2 , Serene Shrestha 1 , James Kalougivaki 3 , Vikas Arya 4 , Andrew Page 5 , Richard Taylor 1 , Stephen Morrell 1
  1. University of New South Wales, Sydney, RANDWICK, NSW, Australia
  2. Data Analysis and Management Unit, Fiji Ministry of Health and Medical Services, Suva, Fiji
  3. Forensic Pathology Unit, Fiji Police Force, Suva, Fiji
  4. Centre for Mental Health and Community Wellbeing, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
  5. Translational Health Research Institute, Western Sydney University, Sydney, New South Wales, Australia

Background: Suicide in Fiji is likely underestimated because injury deaths are often not correctly certified and coded for intent. We quantified under-ascertainment by comparing officially recorded suicides with suicides inferred from free-text cause-of-death narratives on death certificates.

Methods: We analysed unit-record deaths in Fiji’s National Mortality Database among people aged ≥15 years, 2015-23 (n=67,402). Officially recorded suicides were deaths with an underlying cause coded as intentional self-harm (ICD-10 X60–X84). Additional probable suicides were identified using prespecified reassignment rules applied to cause-of-death text narratives. Age-specific and directly age-standardised rates per 100,000 were estimated by sex and ethnicity.

Findings: The officially recorded age-standardised suicide rate was 6·7 (95%CI 5·3–8·1) per 100,000 in males and 2·6 (1·8–3·4) in females. Most reassigned deaths were hangings or pesticide self-poisonings. After reassignment, rates increased to 24·0 (21·4–26·6) in males and 9·2 (7·8–10·6) in females, around three to four times the official estimates. Among Fijians of Indian descent, rates were 49·4 (45·1–53·8) in males and 22·8 (19·7–25·8) in females, compared to iTaukei at 7·9 (6·5–9·2) in males and 2·5 (1·7–3·2) in females. Age-specific patterns differed by ethnicity, but rates were higher across all age groups among Fijians of Indian descent compared to iTaukei.

Interpretation: Routine mortality data substantially underestimate suicide in Fiji. Reassignment of probable misclassified suicides revealed a much higher burden, particularly among Fijians of Indian descent. Suicide surveillance in Fiji should include routine analysis of mortality data disaggregated by sex and ethnicity, periodic review of likely misclassified deaths, and strengthening of death certification and coding practices. Prevention responses should be culturally informed and prioritise groups at highest risk.