Clinicians' perspectives on barriers to access to care for self-harm in Pakistan: a qualitative study.
Suicide is a serious global public health problem ranked amongst the leading causes of death in many countries. Up to 75% of all suicides occur in low and middle-income countries where resources and services are limited for treatment and support.
A prior history of self-harm is a risk for suicide In Pakistan, there are more than 100,000 episodes of self-harm annually. Both suicide and attempted suicide are classified as illegal acts, and are socially and religiously condemned.
A multi-centre trial is currently underway to evaluate the clinical and cost-effectiveness of a culturally adapted psychological intervention (C-MAP) in patients with a history of self-harm. The intervention incorporates training in problem-solving skills, delivered over six sessions by psychologists or nurses. A qualitative process evaluation is being conducted to explore the acceptability of the intervention from the perspective of the therapist, clinicians (general practitioners and hospital physicians) and trial patient participants.
Semi-structured interviews conducted with clinicians (general practitioners and hospital physicians in emergency departments and medical wards) from the five sites of the trial were invited to participate in interviews to explore their views of self-harm, management of people who self-harm, barriers to accessing care, and their views on the value and implementation of the C-MAP intervention. Interviews were conducted in Urdu, face-to-face or by telephone and digitally recorded with consent. Interviews were transcribed verbatim and translated. Analysis was conducted by the research team using the principles of constant comparison.
Initial analysis suggests that clinicians recognize the stigma associated with self-harm, which exists in individuals, families and the broader community. Respondents emphasized the medical sequelae and management of self-harm, often seeming to neglect the psychological and emotional consequences. Clinicians describe pre-disposing factors for self-harm as financial worries, interpersonal difficulties and family problems. They highlight how these same factors, in addition to the legal-consequences of self-harm, are key barriers to help-seeking.
Respondents described the limited availability of psychological support and treatment for people who are distressed or who have self-harmed, and their own recognized lack of training and expertise in identifying and managing the psychological problems of people who have self-harmed.
Understanding clinicians’ views on self-harm, and how these align with broader sociocultural contexts is necessary in a culture where self-harm is an illegal act. This study raises an urgent need for public health initiatives to ensure that the importance of mental health and illness are recognized; the need to afford equal status to mental as well as physical health echoing principles of the ‘Parity of Esteem’ initiative in England. We identify the need for training, in Pakistan, of all doctors in the identification and management of mental health problems, including the management of people who self-harm.