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Abstract
In 15% to 20% of self-poisoning cases, the pesticides used are purchased from shops just prior to ingestion. We explored how pesticide vendors interacted with customers at risk of self-poisoning to identify interventions to prevent such poisonings. Two strategies were specifically discussed: selling pesticides only to farmers bearing identity cards or customers bearing pesticide ‘prescriptions’. Vendors reported refusing to sell pesticides to people thought to be at risk of self-poisoning, but acknowledged the difficulty of distinguishing them from legitimate customers; vendors also stated they did want to help to improve identification of such customers. The community did not blame vendors when pesticides used for self-poison were purchased from their shops. Vendors have already taken steps to restrict access, including selling low toxic products, counselling and asking customer to return the next day. However, there was little support for the proposed interventions of ‘identity cards’ and ‘prescriptions’. Novel public health approaches are required to complement this approach.
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Background
Pesticide self-poisoning is a major public health problem in rural Asia, with an estimated 300 000 deaths annually.1 In Sri Lanka, pesticide self-poisoning is the most common method of self-harm and causes the majority of deaths from suicide in rural districts.2 ,3 Easy availability of pesticides in the domestic environment of farming households4 and unrestricted availability from shops has been highlighted as contributing to the problem.
Three South Asian studies have previously reported that 14% to 20% of pesticides used in non-fatal self-poisoning acts had been purchased from a shop shortly before the episode.5–7 However, no research has been performed to study this purchase of pesticides or to determine whether there might be ways to intervene to prevent poisoning events.
In this study, we aimed to explore whether pesticide vendors identified customers contemplating pesticide self-poisoning, and how they responded to these customers. Using this information, the study aimed to assess the possibility of involving pesticide vendors in the prevention of pesticide self-poisoning.
Methods
This study was carried out in 2 districts in Sri Lanka, Hambantota and Anuradhapura, with high incidences of self-poisoning of 315 per 100 0008 and 350 per 100 000,2 ,3 respectively. Five villages with high incidences of poisoning were selected from within these two districts. All pesticide shops located in and around the selected villages were identified for the study. This included 10 shops in Hambantota and 14 shops in Anuradhapura.
A questionnaire-based survey including open and closed questions (see online supplementary appendix 1) was carried out in pesticide shops by two field researchers in Sinhala, the language spoken in the study area. Two strategies were specifically discussed: selling pesticides only to farmers bearing registration cards or customers bearing pesticide ‘prescriptions’. Interviews were carried out with the person who had direct contact with the customer and they lasted 45–60 min. The data from the interviews with the vendors were translated into English and transcribed into Word files (Microsoft, Redmond, Washington, USA). Analysis was performed manually for the qualitative data from the open-ended interviews.
Informed verbal consent was obtained from all participants. The study protocol, including the process of consent, was reviewed and approved by the Medical Research Ethics Committee, University of Ruhuna.
Results
Characteristics of pesticide shops
A total of 24 pesticide shops were identified within the study area, of which 22 owners agreed to be interviewed. Six of the interviewed vendors were women and generally they were working in small-scale to large-scale shops. The pesticide shops in our study varied markedly by function and size as seen in table 1.
Characteristics of the 22 selected pesticide shops, grouped according to their size and function
Registration of the pesticide shops and training of owners
Of the 22 pesticide shops, 19 were registered with the Department of Agriculture. As part of this registration process, owners are required to attend a 1-day training course that focuses on basic knowledge of pesticides, including toxicity, storage, sales practices, and safe handling. At the end of the training course, participants need to pass a written test to fulfil the requirements for registration. Of the 17 vendors who attended training, the majority (14 out of 17, 74%) reported that the current training programme did not contain information about pesticide self-poisoning and they would welcome additional training on how to respond to customers at risk of poisoning themselves. However, the other three vendors implied that the training highlighted the risk issues but did not provide any specific training on how to identify and/or respond.
Identification of customers at risk of poisoning themselves
All interviewed vendors expressed concern about selling pesticides to persons who might use them for self-poisoning. Of the 22 vendors, 20 (91%) could recall, in detail, episodes where customers had come to their shop to purchase pesticides with the intention of poisoning themselves. Some vendors showed reluctance to talk about cases where they had not recognised the customers’ intention and had been informed later about the poisoning attempt.
A male vendor from a major town with around 20 years of experience who ran a large-scale pesticide shop stated:
I have recognized more than 100 customers who were seeking pesticides to poison themselves and prevented them from accessing pesticides. But for about 10 customers, I did not recognize the real intent of the customer when they purchased pesticides and they went on to take the poison.
However, vendors acknowledged that they might not hear about all attempts among customers since information may not get back to them. They thought that there might be many cases where they had sold pesticides without recognising a customers’ intention.
Characteristics of customers intending to use pesticides to self-poisoning
All the vendors perceived that men were more likely than women to purchase pesticides for self-poisoning; four vendors had little or no experience with women customers who intended to poison themselves.
The vendors recognised two broad categories of customers intending to poison themselves. The first group exhibited unusual behaviour such as sadness, excessive sweating, nervousness, shyness, dishevelled appearance, aggressiveness, garbled speech and trembling. The second group appeared to be legitimate purchasers and were hard to recognise as they hid their feelings well.
One medium-scale male vendor from a small city highlighted the difficulties for vendors:
Some customers with suicidal intent are very tricky; they really mislead us and buy pesticides pretending to be in a happy mood. Once they have ingested the pesticide, we feel that we fell in their trap.
Vendors reported that they were suspicious about the intent of customers aged between 13–18 years.
Prevention strategies
The vendors reported a number of practices and strategies to avoid selling pesticides to customers they perceived as being likely to use the pesticides for self-poisoning. One male vendor with 3 years experience who sold non-agricultural items in addition to pesticides commented that:
I am not selling pesticides after 6 pm, even to a well-known customer; I ask him to come the following day.
The vendors’ immediate response to customers perceived to be at risk for self-poisoning varied significantly. A total of 11 out of 22 vendors refused to sell pesticides and requested the customer to leave. One medium-scale vendor reported asking the customer to return the next day, one medium-scale vendor reported selling a non-toxic product, and two male vendors from small cities alerted other vendors or family members and even attempted to take the customer's money to prevent them from accessing pesticides from other outlets. Two male vendors from rural villages reported responding dependant on the situation, and had no specific strategies. Four female vendors and one male vendor reported that they attempted to talk with the customers and listen to their problems, as seen in the following quote:
I try to talk to customers and listen to their problem if I think they are at risk of suicide, except for the customers under the influence of alcohol. If I am unsure, I just sell the customer a non-toxic product.
Vendors were asked for their views on two interventions designed to limit access to pesticides to customers intending to self-poison: farmer ‘identity cards’ and ‘prescriptions’ for pesticides. A farmer identity card system would allow only registered farmers to purchase pesticides. Prescriptions would require farmers to obtain a prescription from an authorised individual or entity to purchase pesticides.
Only one medium-scale vendor supported the idea of identity cards as an effective intervention. Most vendors reported that as they personally knew the majority of their customers, identity cards would not ensure that the product purchased was used for farming. In addition, they stated that other household members sometimes had to purchase pesticides on behalf of the farmer. Overall, the prescription method had some support but vendors felt that it would be difficult to implement due to insufficient numbers of authorised officers.
Our study highlights some of the barriers and facilitating factors to individual and structural suicide prevention strategies with pesticide vendors, as seen in table 2.
Barriers and facilitating factors identified by vendors for interventions involving vendors to prevent self-poisoning in rural Sri Lanka
Community reactions
Vendors revealed that the community and relatives neither blamed the vendor nor took action against them, even when it was known that the poison had been obtained from their shop. Similarly, vendors had no experience of any investigations from either the Department of Agriculture or the police following a death from pesticide self-poisoning.
Discussion
Individual-level suicide prevention strategies are often targeted at individuals considered to be at risk. Gatekeeper training and screening programmes have become popular strategies in vulnerable communities.9 ,10 Structural interventions such as limiting physical access,11 instituting waiting times12–14 and restrictions on package sizes15 ,16 have been used to limit access to highly dangerous means of suicide and have been found to reduce the overall suicide rate. The basis of most of these strategies has relied on creating physical and/or temporal barriers to purchase, and often use inconvenience as a strategy to deter purchase.
Although there is limited support for two proposed interventions; ‘farmers identity cards’ and ‘pesticide prescriptions’, in general, the vendors reported a willingness to be more involved in community prevention and several had already taken steps to restrict access. However, there are significant challenges in identifying vulnerable customers. In addition, there is limited availability of trained mental health professionals17 ,18 available in rural settings and little pressure from the community to change practice. As a result, individual strategies may only be partially effective. However, structural interventions could be implemented in Sri Lanka where the Control of Pesticides Act (1980) regulates all aspects of the sales of pesticides. Further work with the Department of Agriculture is needed to identify effective interventions that could be implemented.
Accessing pesticides through vendors appears to be a common method for self-poisoning in rural Sri Lanka. Some vendors have already taken steps to limit access. Therefore, to some extent, vendors may be interested in acting as ‘gatekeepers’. However, identification of customers who may go on to self-poison remains challenging given the range of pesticide outlets and their proximity to their communities. Thus, individual-level strategies targeted at identifying vulnerable customers may be only partially effective. Structural interventions targeting pesticide sales and purchasing were seen as more acceptable because strategies could be implemented in Sri Lanka and their feasibility should be studied further. Consideration needs to be given to the best way to engage communities to ensure pesticide sales are conducted in a responsible manner.
Limitations
Studying the community perspectives and the interactions between vendors and customers who wanted to purchase pesticides for self-poisoning was not possible in the scope of this study, and the findings are only relevant to rural Sri Lankan settings. In addition, this study was primarily qualitative and aimed at understanding vendor perspectives so we were unable to study the relative importance of each of these factors. Further, the categorisation of customers who were suspected by vendors might be subjective.
What is already known on this subject
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Self-poisoning with pesticides is a major public health burden in Asia
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Easy access to pesticides in rural Asian communities is seen as a contributing factor to high rates of suicide from self-poisoning.
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Several studies have found that around 15% to 20% of pesticides used for self-poisoning had been directly bought from a vendor.
What this study adds
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Pesticide vendors were aware of many individuals who had tried to buy pesticides from them for acts of self-harm.
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Vendors were interested, to some extent, in acting as ‘gatekeepers’.
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Vendors acknowledged the difficulty of distinguishing some customers at risk from legitimate customers but they would like additional training.
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References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendix
Footnotes
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Contributors MW, MP, RP, AHD and FK were involved in designing the study and the format for data collection. MW and RP were responsible for the data collection and data entry. MW was responsible for the data analysis and produced the first draft version of the paper. MP, FK, ME, SJ, SA and AHD contributed input of the revisions of the manuscript. All authors approved and agreed to the final manuscript.
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Funding This work was jointly funded by WHO Sri Lanka and the South Asian Clinical Toxicology Research Collaboration. SACTRC provided the funding through a Wellcome Trust/NHMRC International Collaborative Research Grant GR071669MA.
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Competing interests None.
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Ethics approval Medical Research Ethics Committee, University of Ruhuna.
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Provenance and peer review Not commissioned; externally peer reviewed.