Abstract
SummaryBackgroundAgricultural pesticide self-poisoning is a major public health problem in rural Asia. The use of safer household pesticide storage has been promoted to prevent deaths, but there is no evidence of effectiveness. We aimed to test the effectiveness of lockable household containers for prevention of pesticide self-poisoning.MethodsWe did a community-based, cluster-randomised controlled trial in a rural area of North Central Province, Sri Lanka. Clusters of households were randomly assigned (1:1), with a sequence computer-generated by a minimisation process, to intervention or usual practice (control) groups. Intervention households that had farmed or had used or stored pesticide in the preceding agricultural season were given a lockable storage container. Further promotion of use of the containers was restricted to community posters and 6-monthly reminders during routine community meetings. The primary outcome was incidence of pesticide self-poisoning in people aged 14 years or older during 3 years of follow-up. Identification of outcome events was done by staff who were unaware of group allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT1146496.FindingsBetween Dec 31, 2010, and Feb 2, 2013, we randomly assigned 90 rural villages to the intervention group and 90 to the control group. 27 091 households (114 168 individuals) in the intervention group and 26 291 households (109 693 individuals) in the control group consented to participate. 20 457 household pesticide storage containers were distributed. In individuals aged 14 years or older, 611 cases of pesticide self-poisoning had occurred by 3 years in the intervention group compared with 641 cases in the control group; incidence of pesticide self-poisoning did not differ between groups (293·3 per 100 000 person-years of follow-up in the intervention group vs 318·0 per 100 000 in the control group; rate ratio [RR] 0·93, 95% CI 0·80–1·08; p=0·33). We found no evidence of switching from pesticide self-poisoning to other forms of self-harm, with no significant difference in the number of fatal (82 in the intervention group vs 67 in the control group; RR 1·22, 0·88–1·68]) or non-fatal (1135 vs 1153; RR 0·97, 0·86–1·08) self-harm events involving all methods.InterpretationWe found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning. Other approaches, particularly removal of highly hazardous pesticides from agricultural practice, are likely to be more effective for suicide prevention in rural Asia.FundingWellcome Trust, with additional support from the American Foundation for Suicide Prevention, Lister Institute of Preventive Medicine, Chief Scientist Office of Scotland, University of Copenhagen, and NHMRC Australia.
Highlights
Pesticide self-poisoning is a major public health problem in rural Asia[1,2] and a substantial burden on health services.[3]
Interpretation We found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning
Interventions working at the patient level, to improve provision of medical care in resource-poor hospitals, are difficult for the most common pesticides used for suicide
Summary
Pesticide self-poisoning is a major public health problem in rural Asia[1,2] and a substantial burden on health services.[3]. WHO recognises pesticide ingestion to be one of the three most important means of suicide worldwide.[2,4] In Sri Lanka, self-poisoning with pesticides is the most common method of self-harm in many rural districts,[5] highly lethal,[6] associated with impulsivity,[7,8,9] and the fifth leading cause of death in 2012.10. Means restriction is a key element of suicide prevention strategies.[11,12,13] Restricting access to common and highly lethal methods of suicide can reduce both methodspecific and all-cause suicide rates.[14,15,16] Such approaches for pesticide self-poisoning include administrative interventions altering behaviour ( the purchase, use, and storage of pesticides) and inter ventions altering the availability of highly hazardous pesticides in the community (through regulatory action to remove such pesticides from agricultural practice).[17] Interventions working at the patient level, to improve provision of medical care in resource-poor hospitals, are difficult for the most common pesticides used for suicide
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