Risk Factors For Suicidal Ideation Research Articles

Longitudinal Impact of Perfectionism on Suicidal Ideation among Chinese College Students with Perceived Academic Failure: The Roles of Rumination and Depression

Objective Suicide has become a nonnegligible cause of death among emerging adults, and academic performance is one of the most significant factors in Chinese college students’ suicidal ideation. Based on this, we examined the risk and protective sides of perfectionism on suicidal ideation among college students with perceived academic failure experiences. Method In the current study, a total of 674 Chinese college students (63.6% females, M age = 19.96, SD = 1.31) with perceived academic failure in the past six months participated in a survey and completed self-report measures assessing perfectionism, rumination, depression, and suicidal ideation twice with a six-month interval. Results Negative perfectionism was a risk factor for suicidal ideation, while positive perfectionism had an opposite effect. In addition, intrusive rumination, deliberate rumination, and depression serially mediated the association between positive/negative perfectionism and suicidal ideation. Conclusion The results indicated perfectionism has both positive and negative sides to suicidal ideation. Clinicians might be aware of the risk and protective components of perfectionism when intervening with suicidal ideation among college students with perceived academic failure experiences.

Burnout, depression, and suicidal ideation among physicians before and during COVID-19 and the contribution of perfectionism to physicians' suicidal risk.

There is limited data regarding the prevalence of suicidal risk among physicians during COVID-19, and the risk factors relating to it. Dominant risk factors for suicide among physicians are depression and burnout. Maladaptive perfectionism may also serve as a profound risk factor for suicidality among physicians and may aggravate symptoms of distress under the challenges of COVID-19. This study aims to evaluate current suicidal risk, suicidal ideation, depression, and burnout before and during COVID-19 among physicians in Israel, and to identify the best sets of correlates between perfectionism and burnout, depression and suicidal ideation, during these time periods. A sample of 246 Israeli physicians (160 before COVID-19 and 86 during COVID-19) completed online surveys assessing lifetime suicidal risk, suicidal ideation during the last year and current suicidal ideation, depression, burnout symptoms and maladaptive perfectionism. More than one-fifth of the sample (21.9%) reported high suicidal risk (Lifetime suicidal behaviors). More than one-fourth (27.2%) reported suicidal ideation during the last 12 months; and 13.4% reported suicidal ideation during the last 3 months. In addition, more than one-third (34.6%) exhibited moderate-severe levels of depressive symptoms and more than a half of the sample reported burnout symptoms. Maladaptive perfectionism was positively correlated with current suicidal ideation, burnout, and depression. Moderated serial mediation analysis demonstrated indirect effect of perfectionism on suicidal ideation by its impact on burnout and depression only during COVID-19. Before COVID-19, physicians were more likely to experience depressive symptoms. Physicians in Israel are at increased risk for depression and suicidal ideation, regardless of the COVID-19 pandemic. Maladaptive perfectionism was found to be a risk factor for burnout, depression, and suicidal ideation. During the first waves of the pandemic, physicians were less likely to experience depressive symptoms. However, among physicians who were characterized with high maladaptive perfectionism, depression served as a significant risk factor for suicidal ideation during the pandemic, which places these individuals at increased risk for suicidality. These results highlight the importance of implementing intervention programs among physicians to reduce suicidal risk and to better identify rigid perfectionism and depressive symptoms.

Borderline personality disorder and depression severity predict suicidal outcomes: A six-month prospective cohort study of depression, bipolar depression, and borderline personality disorder.

Suicide risk is high in patients with major depressive disorder (MDD), bipolar disorder (BD) and borderline personality disorder (BPD). Whether risk levels of and risk factors for suicidal ideation (SI) and suicide attempts (SA) are similar or different in these disorders remains unclear, as few directly comparative studies exist. The relationship of short-term changes in depression severity and SI is underinvestigated, and might differ across groups, for example, between BPD and non-BPD patients. We followed, for 6 months, a cohort of treatment-seeking, major depressive episode (MDE) patients in psychiatric care (original n = 124), stratified into MDE/MDD, MDE/BD and MDE/BPD subcohorts. We examined risks of suicide-related outcomes and their risk factors prospectively. We examined the covariation of SI and depression over time with biweekly online modified Patient Health Questionnaire 9 surveys and analysed this relationship through multi-level modelling. Risk of SA in BPD (22.2%) was higher than non-BPD (4.23%) patients. In regression models, BPD severity was correlated with risk of SA and clinically significant SI. During follow-up, mean depression severity and changes in depression symptoms were associated with SI risk regardless of diagnosis. Concurrent BPD in depression seems predictive for high risk of SA. Severity of BPD features is relevant for assessing risk of SA and SI in MDE. Changes in depressive symptoms indicate concurrent changes in risk of SI. BPD status at intake can index risk for future SA, whereas depressive symptoms appear a useful continuously monitored risk index.

Prevalence and factors associated with suicidal ideation among students taking university entrance tests: revisited and a study based on Geographic Information System data.

A previous study identified students taking Bangladeshi university entrance tests as a vulnerable group at a higher risk of suicidal behaviours before the COVID-19 pandemic. However, the impact of the pandemic on the magnitude of these behaviours among this population remains unexplored. This study aimed to investigate the prevalence of suicidal ideation and associated factors among Bangladeshi university entrance test takers following the pandemic. In addition, an approach based on Geographic Information System (GIS) data was used to visualise the distribution of suicidal ideation across the country. A cross-sectional approach was used to collect data among participants taking the entrance test at Jahangirnagar University in September 2022. Using SPSS, data were analysed with chi-squared tests and binary regression, and ArcGIS was used to map the results across the nation. The study revealed a prevalence of 14.4% for past-year suicidal ideation, with 7.4% and 7.2% reporting suicide plans and attempts, respectively. Notably, repeat test-takers exhibited a higher prevalence of suicidal behaviours. Significant risk factors for suicidal ideation included urban residence, smoking, drug use, COVID-19 infection and deaths among close relations, depression, anxiety and burnout. The GIS-based distribution indicated significant variation in the prevalence of suicidal ideation across different districts, with higher rates observed in economically and infrastructurally deprived areas. Urgent measures are needed to address the high prevalence of suicidal behaviours among students taking university entrance tests students in Bangladesh, particularly in light of the COVID-19 pandemic. Enhanced mental health support, targeted prevention efforts and improved resources in economically disadvantaged regions are crucial to safeguard the well-being of these students.

PSYCHOLOGICAL RISK FACTORS OF SUICIDAL IDEATION AMONG ACID ATTACK SURVIVORS IN PAKISTAN: A THEMATIC APPROACH

The purpose of the present study was to investigate the psychological risk factors of suicidal ideation among acid attack survivors in Pakistan. Through purposive sampling, interview responses of sixteen acid attack survivors with the age range between 18-45 years, who had experienced this incident within the past 3 years were qualitatively analyzed. The sample was collected from Lahore, Multan, Rawalpindi, Islamabad, and Faisalabad. For the analysis and interpretation of the data thematic analysis was used as it provides in-depth information of the research. The results indicated that the psychological risk factors common among acid attack survivors with suicidal ideation include depression, low self-esteem, perceived stigma, and PTSD. The emergent subthemes were hopelessness, helplessness, loneliness, inadequacy, lack of family support, self-hatred, worthlessness and being a burden on others. The coping strategies that emerged are emotion focused coping, problem focused coping and religious coping. As one of the few studies looking into the psychological factors risking suicidal tendencies in an often-overlooked population, the study offers guidance for future intervention plans for preventing suicidal tendencies among acid attack survivors in Pakistan. Practical implications for practitioners and future research directions for scholars are also discussed. Keywords: Acid attack survivors, qualitative research, thematic analysis, psychological risk factors, suicidal ideation

Frequency of and Potentiating Risk Factors for Suicidal Ideation Among Medical Students of Rawalpindi Medical University in the Year 2021

Frequency of and Potentiating Risk Factors for Suicidal Ideation Among Medical Students of Rawalpindi Medical University in the Year 2021

Loneliness as a Risk Factor for Suicidal Ideation and Depressive Mood Among Korean Adolescents in 2020–2021

Suicide is the leading cause of death among Korean adolescents. There is a growing interest in the role of loneliness as a risk factor for suicide ideation and depressive symptoms. However, little is known in the Korean context. This study analyzed a total of 109,796 respondents from the Korea Youth Health Behavior Survey in 2020 and 2021. Multiple logistic regression models were implemented to test the association between loneliness and either of suicidal ideation and depressive mood. Covariates included demographic characteristics, school enrolled, household income, living arrangement, self-rated health, and the number of times treated for violence. Adjusted odd ratio (OR) and 95% confidence intervals (CI) were computed. 12.0% of adolescents reported to have felt lonely frequently and 3.0% always. 11.8% and 26.0% had suicidal ideation and depressive mood, respectively. The prevalence of suicidal ideation was higher in the always-lonely adolescents (52.6%) than in the frequently-lonely adolescents (35.1%). The always-lonely adolescents were nearly 30 times more likely to have suicidal ideation (OR=30.7; 95% CI, 27.1 – 34.8) and to feel depressed (OR=32.5; 95% CI, 29.2 – 36.4) than adolescents who felt never lonely. In conclusion, Loneliness was a major risk factor for suicidal ideation and depressive mood among Korean adolescents. Monitoring and addressing the condition of loneliness may help reduce suicidal ideation and depressive mood.

Correlates of Suicidal Ideation Among Sexual Minority Male Students in a Nigerian University

Sexual minority men report higher suicidal ideation compared to heterosexual men. As a consequence of the high levels of stigma in Nigeria and most of sub-Saharan Africa, few studies have investigated psychosocial risk factors for suicidal ideation in these settings. The present study aimed to fill this research gap by identifying factors associated with suicidal ideation among Nigerian sexual minority men. Eighty-one sexual minority men were assessed for suicidal ideation, sociodemographic and family background, sexuality-related, minority stress, and psychosocial factors. Childhood adversity, minority-stress factors, and all three psychosocial (intimate partner violence, alcohol use problems and depressive symptoms) variables were significantly associated with increased suicidal ideation (ΔR2= 11%, 15% and 20%, respectively). Our findings highlight the importance of known risk factors for suicidal ideation as well as factors specific to sexual minority men. Recognising these factors may help in identifying young sexual minority men who may require further support in high-stigma settings such as Nigeria.

Neural reactivity to threat impacts the association between bullying victimization and suicide risk in youth

Bullying victimization is a risk factor for suicidal ideation, suicide behaviors, and death by suicide in youth. However, not all victims of bullying report suicidal thoughts and behaviors, suggesting that there may be certain subgroups who are at high risk for suicide. Neuroimaging studies suggest that individual differences in neurobiological threat reactivity may contribute to increased vulnerability to suicide, particularly in the context of repeated exposure to bullying. The purpose of the present study was to examine the unique and interactive effects of past-year bullying victimization and neural reactivity to threat on suicide risk in youth. Ninety-one youth (ages 16–19) completed self-report measures of past-year bullying victimization and current suicide risk. Participants also completed a task designed to probe neural reactivity to threat. Specifically, participants passively viewed negative or neutral images during functional magnetic resonance imaging. Bilateral anterior insula (AIC) and amygdala (AMYG) reactivity to threat/negative images (>neutral images) was used to capture threat sensitivity. Greater bullying victimization was associated with increased suicide risk. There was also a bullying by AIC reactivity interaction such that among individuals with high AIC reactivity, greater bullying was associated with increased suicide risk. Among individuals with low AIC reactivity, there was no association between bullying and suicide risk. Results suggest that youth with increased AIC reactivity to threat may be particularly vulnerable to suicide in the context of bullying. These individuals may represent a high-risk group for subsequent suicide behavior and AIC function may be a promising objective prevention target.

Suicidal ideation and associated risk factors among COVID-19 patients who recovered from the first wave of the pandemic in Wuhan, China.

Symptoms of psychiatric, neurological, and physical illnesses with post-COVID syndrome could increase suicidal ideation (SI) and behavior in Corona Virus Disease 2019 (COVID-19) survivors. However, information on the level of SI among COVID-19 survivors in China is still limited. To assess the prevalence and risk factors of SI among COVID-19 survivors in Wuhan, China. The cross-sectional study was carried out among former COVID-19 patients in Jianghan District (Wuhan, China) from June 10 to July 25, 2021. SI, fatigue, stigma, sleep disorder, resilience, peace of mind, and social support of the participants were measured by the SI-related item, Fatigue Scale (FS-14), short version of COVID-19 Stigma Scale, Pittsburgh Sleep Quality Index (PSQI), The Peace of Mind Scale (PoM), The Resilience Style Questionnaire (RSQ) and two single separate items for measuring social support. Logistic regression was utilized to identify associated factors of SI. Mediation analysis was performed to assess the potential mechanisms between psychological factors and SI. A total of 1,297 participants were included in this study. 6.7% of them reported SI. Marriage (AOR = 0.389, P = 0.003) and peace of mind (AOR = 0.854, P < 0.001) were negatively associated with SI. History of psychological or emotional counseling before COVID-19 infection (AOR = 1.889, P = 0.049), fatigue (AOR = 1.110, P = 0.007), higher self-reported COVID-19 related stigma (AOR = 1.054, P = 0.003) and sleep disorder (AOR = 1.112, P = 0.001) were positively associated with SI. Consideration should be taken into account to develop appropriate alleviating measures such as mindfulness-based cognitive therapy to reduce the rates of SI among COVID-19 survivors and improve their resilience to cope with the personal impact of the COVID-19 pandemic.

Suicidal ideation in Chinese adults with schizophrenia: associations with neurocognitive function and empathy

BackgroundSuicidal ideation is common among people diagnosed with schizophrenia spectrum disorders and may be related to neurocognitive, social cognitive, and clinical variables. This study aimed to investigate the relationships between suicidal ideation and both neurocognitive function and empathy.MethodsThe sample for this cross-sectional study comprised 301 schizophrenic patients aged 18–44 years. All participants were administered the Beck Scale for Suicide Ideation—Chinese Version (BSI—CV), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), the Interpersonal Reactivity Index (IRI), and the Positive and Negative Syndrome Scale (PANSS). The demographic and clinical data of the patients were also collected.ResultsIn total, 82 patients reported suicidal ideation. Compared to patients without suicidal ideation, patients with suicidal ideation showed significant differences in the IRI-Personal Distress subscale, PANSS-General Psychopathology symptom scores, and suicide attempts. Moreover, there were moderating effects of neurocognitive function and empathy on the relationship between suicide attempts and suicidal ideation.ConclusionsThese results indicate that the personal distress component of empathy, general psychopathology symptoms and suicide attempts are independent risk factors for suicidal ideation in Chinese adults with schizophrenia. Moreover, neurocognitive function may also be related to suicidal ideation through a moderating relationship. In order to reduce suicidal ideation among patients with schizophrenia, early screening of empathy and neurocognitive function is essential.

Assessing Trends and Risk Factors of Suicidal Ideation in Young People During the COVID-19 Pandemic Through Quarterly Monitoring in The Netherlands.

Introduction:The COVID-19 pandemic has impacted populations internationally, through infections and consequences of infections, and by the countermeasures to prevent the spread of the coronavirus. Concerns exist surrounding the impact of the COVID-19 pandemic on the mental health of youths in the Netherlands. Consequently, we studied quarterly trends and risk factors of suicidal ideation among Dutch youths from September 2021 onwards.Method:The Network GOR-COVID-19, a research group consisting of different organizations, monitors the effect of the COVID-19 pandemic on population health. As one element of this monitoring, quarterly data collections have been undertaken since September 2021 from a panel of youths (12 – 25 years of age) representative of the Dutch population. Online questionnaires collect data on self-reported health and wellbeing. We analyzed a selection of demographic, social activity, and mental health variables as potential risk factors for self-reported suicidal ideation in the previous three months. We assessed trends, performed longitudinal analyses, and conducted logistic and random forest regressions per quarterly round of data collection. Analyses were weighted for age, sex, educational level, and province where appropriate.Results:Approximately 4,500 youths participated in each quarterly questionnaire, with some participating more than once. Results showed substantial increases in self-reported suicidal ideation during and immediately after the third lockdown in the Netherlands in December 2021, rising from 9% to 17%, then slowly decreasing to 16% in May/June 2022, and to 13% in September 2022. In all multivariable analyses variables relating to mental health were indicated as risk factors. The strongest associations were seen in those experiencing mental health complaints and loneliness. Demographic variables were not strongly associated with suicidal ideation.Conclusion:The monitoring conducted by The Network GOR-COVID-19 enables the tracking of trends in the impact of the COVID-19 pandemic on the mental health of Dutch youths in The Netherlands.

Longitudinal investigation of the presence of different trajectories and associated health and socio-economic determinants, for participants who report suicidal ideation within a community-based public health survey

ObjectiveGiven the paucity of evidence-based research investigating different suicidal ideation profiles and trajectories, this project sought to investigate health and socio-economic factors associated with the presence of suicidal ideation and...

Associations Between Family Factors, Social Integration, and Suicidal Ideation Across the Life Course of an Urban African American Cohort.

Suicide is a problem on the rise but not studied extensively among African Americans. It is critical to identify risk factors for suicidal ideation to reduce risk. This study examines whether family and social factors over the life course predict suicidal ideation among African American adults in midlife. We conducted multiple logistic regression analyses on data from a longitudinal cohort of African Americans first assessed in childhood to identify associations with suicidal ideation in midlife (ages 33-42). Findings suggested living without one's mother in childhood (vs. living with mother alone; aOR = 3.69, p = .017) and parental rule-setting in adolescence (aOR = 0.79, p = .047) were associated with suicidal ideation. Having a lifetime drug disorder (aOR = 2.19, p = .046) or major depression by young adulthood (aOR = 3.58, p < .001) was also associated with an increased risk of suicidal ideation. Findings highlight the importance of intervention for children in mother-absent homes for improving mental health outcomes. Family interventions that promote parental rule-setting and addressing drug problems and depressive symptoms early in the life course offer an area for intervention to reduce suicide over the long term.

Stress and suicidal ideation among first-generation farmers: A cross-sectional study with 1,288 farmers in Georgia.

The suicide rate among farmers is higher than that of the overall working population. Literature on farmer mental health in Georgia (GA) has been scarce and mostly focused on suicide as a result. Literature on stressors or coping are mostly qualitative studies. This study looks at the influence of being a first-generation farmer on farm-related stressors and coping mechanisms. This cross-sectional study inventories mental well-being, stressors, and coping mechanisms for different types of farmers in GA, USA. The online survey ran from January 2022 through April 2022. Participants (N = 1,288) were asked about demographics, work descriptors, health care access, specific stressors, stress levels, and coping mechanisms. Two-thirds of our sample were first-generation farmers. First-generation farmers had a higher stress score on average, as well as being more likely to feel depressed, and feel hopeless. They also showed less diverse coping mechanisms than generational farmers, with alcohol in their top 3 coping mechanisms. First-generation farmers were also much more likely to experience suicidal ideation: 9% daily and 61% at least once in the past year (vs generational: 1% daily; 20% once in the past year). Binary logistic regression indicated that having more diverse coping mechanisms is a protective factor against suicidal ideation within the previous year. The same model indicated that being a farm owner or farm manager, being first-generation, being unhappy with one's role, feeling sad or depressed, and feeling hopeless were all risk factors. First-generation farmers experience more stress and exhibit more risk factors for suicidal ideation than generational farmers.

Disability and Suicidal Ideation among Indigenous Adults in Canada: Cultural Resources as Contingencies

Objectives The present study asks: Is disability associated with suicidal ideation among Indigenous adults in Canada? And if so, do cultural resources—as measured by cultural identity affect, cultural group belonging, cultural engagement, and cultural exploration—modify this association? Methods Data were from a nationally representative sample of First Nations peoples living off-reserve, Métis, and Inuit across Canada—the 2017 Aboriginal Peoples Survey (N = 16,125). A series of weighted logistic regression models were performed. Results Indigenous adults with disabilities were significantly more likely than those without disabilities to report suicidal ideation, even after controlling for socio-demographic characteristics and physical and mental health conditions. At the same time, people with multiple disabilities were at greater risk for suicidal ideation, with the largest association among those with five or more disabilities. Furthermore, the detrimental association between disability status and suicidal ideation attenuated among those who reported cultural group belonging. In a similar vein, the buffering role of cultural group belonging was also observed in the association between the number of disabilities and suicidal ideation. Conclusions This study provides compelling evidence that disability is a risk factor for suicidal ideation among Indigenous adults and that cultural group belonging plays a stress-buffering role in this relationship.

Prevalence, Correlates, and Risk Factors of Suicidal Ideation and Attempts in Turkey

Prevalence, Correlates, and Risk Factors of Suicidal Ideation and Attempts in Turkey

Effects of social deprivation on risk factors for suicidal ideation and suicide attempts in commercially insured US youth and adults

We used US nationwide commercial insurance claims data (2011–2015) to study the effect of social deprivation on clinical and demographic risk factors for suicidal ideation (SI) and suicide attempts (SA) among US youth and adults < 65 years, after having a mental health or substance use disorder-related outpatient encounter. Neighborhood social deprivation level was summarized by the quintile of social deprivation index (SDI) at individuals’ zip code level. Cox proportional hazard models were used to evaluate the effect of social deprivation on demographic and clinical risk factors for SI and SA. The study cohort consisted of 317,383 individuals < 65 years, with 124,424 aged < 25 (youth) and 192,959 aged between 25 and 64 (adults). Neighborhood social deprivation impacted risk factors for SI and SA differently for youth and adults. Among youth, SDI interacted with multiple risk factors for both SI and SA. The effects of the risk factors were larger on youth from middle socioeconomic neighborhoods. Among adults, risk of SI was the strongest in the most deprived neighborhoods, but risk of SA did not vary by neighborhood deprivation level. Our findings suggest community-based suicide prevention initiatives should be tailored according to neighborhood deprivation level and the targeted individual’s age to maximize the impact.

TOPSIS for Analyzing the Risk Factors of Suicidal Ideation Among University Students in Malaysia

Globally, suicide is a major public health issue. Suicide is the first or second reason for death among college and university students. The suicide rate among university students is relatively high in Malaysia. Numerous risk factors exacerbate suicidal ideation. Therefore, it is critical to gain as much insight as possible into the risk factors for suicidal ideation among university students and prioritize them based on the importance level. Therefore, students with a high risk for suicide can be identified, and earlier precautions can be taken to assist the students. In this paper, 18 determinants of suicidal ideation were discovered through the systematic literature review, and these factors were then ranked according to the seriousness using the TOPSIS method. The results showed that previous suicide attempts, mental disorders, and negative life events were the most influential factors leading to suicide. In contrast, gender and the residential area had the least impact. The result enables the government, relevant stakeholders, and policymakers to develop comprehensive multisectoral strategies that can prevent suicide effectively.

Effects of geography on risk for suicidal ideation and suicide attempts among commercially insured children and youth in the US

IntroductionTo study the effects of geography on risk for suicidal ideation and suicide attempts among commercially insured children and youth in the USEffects of geography on risk for suicidal ideation and suicide attempts among commercially insured children and youth in the USObjectivesFew studies have examined the impact of geography on risk factors for suicidal ideation (SI) and suicide attempts (SA). This study used a national representative sample to study how geography may influence the relationships of risk factors for SI and SA in commercially insured children and youth.MethodsThe sample was a nationwide retrospective cohort study of 124,424 patients &lt;25 years using commercial claims from four major insurance companies (Aetna, Humana, Kaiser Permanente, and UnitedHealthcare) in the US. The index visit was a mental health or substance use (MH/SUD) outpatient encounter between January 2014 and June 2015. SI and SA were defined by having an ICD-9 diagnosis code within one year after the index visit. Risk factors in the models were demographic and clinical risk factors, including prior psychiatric diagnoses, prescriptions, and healthcare services utilization. Patients’ geographic regions were assigned to one of the nine divisions defined by the US Census Bureau. We used survival analysis to evaluate the effects of geography on risk factors for SI and SA.ResultsAt each follow-up time period (post 7-, 30-, 90-, 180-, and 365-day), rates of SI and SA varied by geographic division (p&lt;0.001). The Mountain Division consistently had the highest rates for both SI and SA (5.44%-10.26% for SI; 0.70%-2.82% for SA). Having MH emergency department (ED) visits in the past year increased the hazard ratio of SI by 28%-65% for children and youth residing in the New England, Mid-Atlantic, East North Central, West North Central, and East South Central Divisions. The main effects of geographic divisions were significant for SA (p&lt;0.001). Risk of SA was lower in New England, Mid-Atlantic, South Atlantic, and Pacific (HRs=0.57, 0.51, 0.67, and 0.79, respectively) and higher in the Mountain Division (HR=1.46).ConclusionsChildren and youth residing in the Mountain Division had the highest prevalence of SI and SA and the highest risk of SI after having MH ED visits. Studies of indicators of access to MH ED care and other social determinants of health may clarify the reasons for SI and SA geographic differences.Disclosure of InterestNone Declared