Abstract
Background:
Recent studies are coming out assessing the relationship between suicide rates and various ecological variables. However, information on the association between suicide rate and ecological variables in India has been limited. We aimed to measure the association of suicide rate with religion, literacy, gross domestic product, human development index, life expectancy, fertility, urbanization, and unemployment in India.
Methods:
We extracted 36 states or union territories of India and their suicide rate, the proportion of Hindu and Muslim populations, literacy rate, per capita gross domestic product (GDP), Human Development Index (HDI), life expectancy, fertility rate, urbanization, and unemployment rate. We assessed the association with rate and other ecological variables mentioned.
Results:
Suicide rates were positively correlated with the percentage of Hindu population in the state (rs = 0.38, p = .022), literacy rate (rs = 0.368, p = .027), and GDP (rs = 0.61, p = .001), whereas they were negatively correlated with fertility (rs = –0.442, p = .039) and unemployment rate (rs = –0.4, p = .015). We did not find any significant association between suicide rate and Muslim populations, HDI, life expectancy, and urbanization.
Conclusion:
This study’s findings identified several associations between ecological variables and suicide rates. However, based on the nature of the analysis, a cautious interpretation and further investigations are warranted.
There is a significant positive association between suicide rate and the density of the Hindu population, literacy rate, and GDP. There is a significant inverse relationship between suicide rate, fertility, and unemployment in India. Multiple ecological variables interact in a complex manner to play a role in suicide.Key Messages
Suicide claims more than 700,000 lives across the world every year. 1 Both globally and in India, it is one of the highest causes of mortality in the age group of 15–39 years.1,2 As per the most recent data available, the average rate of suicide across all age groups is 12 per 100,000 population in India. 3 In India, the most affected population are women between 40 and 49 years of age and men aged 60 years and above, living in urban setups, and having lower educational attainment. Being unemployed and not having a partner have also been found to be associated with higher rates of suicide. 4 However, despite being a major public health problem, not much research has been conducted to understand how the various ecological variables like religion, literacy, per capita gross domestic product (GDP), unemployment, etc. play a role in the suicide rates in India. Ecological studies done in the West have identified a range of socioeconomic and mental health determinants, such as unemployment, religiosity, 5 the presence of substance use, health expenditure per capita, and access to lethal means, 6 to be correlated with suicide. One study identified an inverse association between suicide rate and the Human Development Index (HDI) in 46 Muslim-majority countries. 7
Ecological studies give a population-level perspective of how various social parameters impact the suicide rate in the community population. A clear appraisal of the factors and their strengths of association with suicide rates in the country can help in large-scale policy modifications and primordial prevention. However, there are few such investigations from South Asia, despite the unique socio-cultural contexts of suicide in this suicide-dense region of the world. Hence, we aimed to determine the association of religion, literacy, GDP, HDI, life expectancy, fertility, urbanization, and unemployment with the suicide rates in India.
Methods
We collected data from different openly available sources to assess the association in this ecological study. All the states and union territories of India were taken into consideration in this analysis. Therefore, our analysis included 36 states/union territories of India.
The outcome variables of the study were suicide rate, literacy rate, HDI, gross domestic product, life expectancy, total fertility rate, urban population, and unemployment rate. We extracted suicide rates for each state of India from the latest published (2022) report of the National Crime Records Bureau (NCRB). 3 The literacy rate of each state and union territory was taken from a website that gives the state-wise literacy rate of India. 8 The GDP (constant price), HDI for the year 2021, life expectancy (2015–2019), total fertility rate for the year 2020, urban population in thousands as per the 2011 census, and adjusted unemployment rate for rural and urban areas for each of the states and union territories were taken from the Handbook of Statistics on Indian States by the Reserve Bank of India. 9 The population of Hindus and Muslims (two major religions of India) was taken from the data from the Indian Census 2011.10,11
Statistical Analysis
We conducted the statistical analysis using Stata version 13 and checked the assumptions for the parametric test beforehand. As most of the test variables were not normally distributed, we used non-parametric tests instead. We used Spearman’s correlation to test the correlation between the number of Hindu–Muslim percentages, the number of suicides, the HDI score, and the suicide rate.
Ethical Aspects
We collected data from openly available sources. Therefore, no ethical approval was sought.
Results
The suicide rate was found to be positively correlated with the proportion of Hindu population in the states (rs = 0.38, p = .022), literacy rate (rs = 0.37, p = .027), and GDP (rs = 0.61, p = .001) and negatively with fertility rate (rs = –0.442, p = .039) and unemployment rate in the urban area (rs = –0.4, p = .015). Furthermore, we did not find any correlation between suicide rate and proportions of the Muslim population in the states, HDI, life expectancy, population in urban areas, and unemployment rate in rural areas (p < .05). The results indicate that the suicide rate was higher in states with Hindus, more educated persons, and better economic status. In comparison, it was lower in the states with higher fertility and unemployment rates. A detailed description of the correlation between suicide rate and ecological factors is presented in Table 1.
The Correlation Between the Suicide Rate and Ecological Factors.
Bold indicates p value < .05.
Discussion
This is the first ecological study to explore and understand how various socioeconomic factors affect suicide rates in India. The results show that religion, literacy rate, GDP, fertility rate, and urban unemployment rates have significant correlations with the rates of suicide.
Factors with a Positive Correlation with Suicide Rate
Religion
Our study found that a higher proportion of Hindus in a state correlated with a higher suicide rate. No earlier study has looked into this particular association, as the presence of Hindu-majority states is a unique feature of India. However, suicide rates in Hindu-majority countries such as India and Nepal are higher than the global average. 1 Similarly, it has also been noted that the prevalence of suicidal behavior among Hindus who migrated to other countries is higher than the suicide rate in the native population of those countries.12,13 Studies showed that predominantly Muslim countries had lower suicide rates.7,14 The author proposed various reasons to explain this, including differences in values, beliefs, and socioeconomic status. 14
On the other hand, an older ecological study noted that higher overall religiosity, irrespective of the practiced religion, had a negative correlation with rates of suicide. 15 While it can be theorized that the difference in religious beliefs, values, and levels of religiosity might play a role in developing this association, further individualistic studies might be necessary to test such hypotheses. However, evidence also supports that having strong faith in Hinduism protects against suicide, as a belief in the Hindu philosophy encourages an individual to have a dignified death rather than a death by suicide.12,13
Literacy
We found a positive association between suicide rate and literacy rate. Not many prior ecological studies have attempted to understand the relationship between literacy rates and the rate of suicide. Even though the National Mental Health Survey (NMHS) of India (2016) shows a higher rate of suicide among individuals with lower educational levels, this study shows a positive correlation between literacy rates and suicide rates. 4 An earlier cross-sectional individualistic study from India demonstrated a U-shaped relationship between educational attainment and elderly suicides. 16 The paradoxical relationship reported by the current study might be because of the higher levels of stress related to competitiveness, the stress related to a mismatch between the educational level attained and the nature of employment, and the isolation from family while pursuing higher education.
GDP
In this study, a higher per capita GDP correlated with higher suicide rates. Findings from other studies in this regard have been contradictory. While some authors have noted that a higher income plays a protective role in suicide, others have stated the reverse. 17 In recent global ecological studies, HDI and per capita GDP had a positive correlation with rates of suicide, more so in males than in females. 17 The factors associated with increased per capita GDP may have some bearing on the high suicide rate. People working more, having a higher level of education, and having higher working hours may have a higher GDP, and these factors are closely associated with stress, which might be attributed to higher suicide rates.
Factors with a Negative Correlation with Suicide Rate
Total Fertility Rate
Total fertility rate (TFR) is an internationally used standard demographic indicator to estimate the average number of children a woman would bear over her childbearing years (between 15 and 49 years of age) based on current birth trends. The current mean TFR of India is 2.0, and it varies between 1.3 in Sikkim and 3.0 in Bihar. 18 In this study, TFR was found to correlate negatively with the rate of suicide. This indicates that a higher fertility rate is related to a lower rate of suicide. Another ecological study with global data has evaluated the relationship between TFR and suicide rates and has reported a similar finding. 17 Another international study that assessed the relationship between fertility rates as a marker of social integrity and general population suicide rates found a U-shaped curve on multiple linear regression. 19 The higher fertility rate being a protective factor for suicide might be because TFR is an indirect marker of the rate of marriages and social integrity, both of which have been established as protective factors against suicide. 17 Maybe having kids gives you a purpose in life, and people tend to survive for their kids despite facing several adversities in life. However, being young during pregnancy may be a risk factor for suicidal behavior due to the multiple adversities associated with teenage pregnancy. 20
Unemployment
Unemployment has been globally well documented as a societal problem that leads to multiple negative consequences. However, in our study, unemployment and suicide had a negative correlation, indicating that a higher urban unemployment rate is related to a lower rate of suicide, though there is no significant association of rural unemployment with suicide. While this seems paradoxical, it replicates earlier findings. 17 Our findings may be explained by Simpson’s paradox, which occurs when “groups of data show one particular trend, but this trend is reversed when the groups are combined.” 21 On the other hand, the higher rates of suicide in the employed population might be explained by higher availability of means (like poison for farmers), higher levels of acute work-related and interpersonal stress, and the possibility of higher isolation while being employed in a place away from one’s own family or community.
Variables Without Any Significant Correlation with Suicide Rates
HDI, life expectancy, and urbanization have been identified as important variables affecting the rates of suicide in other ecological studies. 22 While another ecological study covering 46 Muslim-majority countries noted a reverse finding of HDI and suicide rate, 7 in our study, none of these correlated with suicide. This might be because of the limitations related to the data quality used for the analysis and the possibility of “ecological fallacy,” which sometimes negates or exaggerates associations between various variables in ecological studies, making their findings differ from those of individualistic studies. 23 HDI is a composite index with a higher possibility of having Simpson’s paradox. Also, both HDI (highest for Kerala (0.625), lowest for Orissa (0.442)) and life expectancy (highest in females in Delhi (78.0 years) and lowest in males in Chhattisgarh (63.7 years)) have a low range of distribution and variability across the states, which might be another reason for their lack of correlation with the variations in suicide rate. However, even though urbanization has a high level of variability across the states, with only about 10% in Himachal Pradesh and 62% in Goa, this study did not find any association between urbanization and suicide rates. We also did not find any association between the percentage of Muslim populations and the suicide rate. An earlier study also replicated a similar association among 21 Indian states. 14
Implications of the Findings
Our findings indicate the need to investigate the relationship between literacy and suicide further. While at an individual level, poverty and lower educational attainment are well-documented socioeconomic determinants of suicide, at a population level, these relationships appear to be less clear. Higher literacy rates may bring higher expectations and an acute awareness of one’s shortcomings. The possibility that literacy is a confounder also merits further investigation; for instance, higher-literacy states may have better and more reliable methods of collecting suicide statistics. It is also possible that there is an interaction between poverty and literacy and that this interaction is sex specific, as suggested previously. Suicide, being a complex behavioral phenomenon, is largely dependent on several ecological factors. The ecological factors also have complex dynamics with each other. A particular individual with a given ecological factor that might be pro-suicidal interacts with a few other factors that are protective or have no role in the genesis of suicidal behavior. The resultant outcome depends on the intense interaction of these moderating ecological factors.
An important implication of ecological studies, such as ours, is that they enable the identification of high-risk population subgroups for suicide and the key drivers of this risk at the population level. An interesting finding was that a higher per capita GDP correlated with a higher risk of suicide. Though this sounds counter-intuitive, one must note that per capita income metrics have few limitations; they do not consider income inequality and, therefore, may not accurately reflect living standards. Governments and policymakers need to ensure equitable distribution of resources, strengthen welfare systems, and ensure that social security benefits reach those who most need them. Though it is premature to say that such steps may reduce suicide rates, investigations have suggested a cost-benefit advantage for state-funded economic support for people at a high risk for suicide.24,25
Ecological factors play an important role in suicide. However, it is extremely difficult to ascertain any single ecological factor as a cause of suicide. Possibly, the complex interaction of multiple ecological factors contributes to suicidal behavior. Again, all the identified ecological factors do not have a similar impact on the suicidal behavior of an individual. So, one ecological factor (e.g., religion) may be a significant contributor to suicidal behavior in an individual.
In contrast, for another individual, it may not have any significance with regard to their suicide. There might be some moderators (e.g., personality factors such as emotional regulation and impulsivity, socio-cultural and political contexts, and social support) that play a role (Figure 1) between the ecological factors and suicidal behavior. 26-28 Hence, it is important to understand the role of ecological factors along with moderators in the development of suicidal behavior. This will help in planning suicide prevention strategies. Policymakers should consider the ecological factors associated with suicide and may adopt appropriate amendments to the existing policies and support programs for the population at risk for effective suicide prevention.
Ecological Factors Associated with Suicide.
Strengths and Limitations
It is the first ecological study assessing the relationship between suicide rate and several ecological variables in India. However, several important limitations should be considered. First, based on the nature of the study, we need to be careful while considering the association. Second, we collected percentages of Muslim and Hindu populations from the 2011 census, which may change over the years. Similarly, the latest data available was estimated at different points in time. However, we intended to collect the estimates from the most acceptable sources. Lastly, under-reporting of suicides and registration might have their own shortcomings while estimating the suicide rates.
Conclusion
The findings of this study identified several associations between ecological variables and suicide rates. The suicide rate was positively associated with the proportion of Hindu populations, the literacy rate, and GDP, while negatively associated with the fertility rate and urban unemployment. Some associations are empirically supported, while others are counter-intuitive. Therefore, based on the nature of the analysis, a cautious interpretation and further investigations are warranted.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Declaration Regarding the Use of Generative AI
The authors used Grammarly to fix grammatical errors and improve the language by paraphrasing the contents.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.