The “2017 Cause of Death Statistics” released by Statistics Korea reported suicide as the leading cause of death by injury and the leading cause of all deaths among people aged 10–39 years, that is, the economically active population group (Statistics Korea, 2018).
Despite the decrease in suicide mortality in two recent years (2014–2015), South Korea has shown by far the highest suicide mortality rate among the G20 countries for ten consecutive years (OECD, 2018).
Moreover, according to the “8th National Injury Statistics” recently released by the Korean Centers for Disease Control and Prevention (KCDC), the ratio of the number of deaths to the number of patients admitted to emergency room (ER) was 1.0 to 1.67, which was confirmed by the National Emergency Medical Services Network and Statistics Korea data. A related study (Kim, 2013) reported that the age-standardized ratio of mortality to hospitalization among suicidal patients is 1.0 to 1.28. In another study (Jung, 2017), the ratio of mortality to hospitalization to ER admission was reported to be 1.0 to 1.2 to 2.8, indicating the high severity of suicidal intent in contrast to the ratio of 1.0 to 54.04 to 230.55 for unintentional injuries (Kim et al., 2018).
Even in cases of failed suicide attempts, patients’ physical health and financial problems are likely to worsen than before the suicide attempt. Suicide attempts resulting in sequelae, such as disabilities, incur a socioeconomic burden higher than those resulting in death. According to a study by Lee et al. (2019), the socioeconomic burden related to suicide attempts amounted to 8.328 billion dollars in 2015, of which indirect costs accounted for 99.48% (8.285 billion dollars). Here, indirect costs refer to the total amount arising from the loss of productivity due to consequent diseases and premature death. In
particular, the highest burden was observed among those aged 20–49 years, the most economically active population group.
Moreover, in a survey on the reasons for suicide attempt conducted by the National Police Agency, the most frequent answer was psychological problems, followed by financial problems and health problems (National Police Agency, 2015). In the 2017 National Survey of Senior Citizens, the most frequent reason for suicidal intent was financial problems, followed by health problems. In particular, two or more suicide attempts accounted for 48.6% (Korea Institute for Health and Social Affairs, 2015). From this, it can be inferred that patients with severe injuries from suicide attempts will likely resort to suicide again due to pessimistic views about their aggravated financial and health-related problems.
In his work Suicide, Emile Durkheim claimed that each society has its own collective suicidal tendency and is “predisposed to contribute a definite quota of voluntary deaths.”
He analyzed that a society in which the collective order dissolves due to sudden social progress or decline, leading to a state of anomie, becomes prone to the so-called “anomic suicide” and its annual suicide mortality rate is more likely to be maintained at a certain level compared to other types of suicide. He further argued that since the members of such a society experience the cumulative effect of this social phenomenon, suicide mortality rate increases with increasing age (Emile Durkheim, 2008). South Korea has been repeatedly exposed to situations that may have led to the phenomenon of “anomic suicide.” South Korea experienced rapid economic and social growth since the late 1950s and was critically afflicted by the 1997 Asian financial crisis. Moreover, it has experienced drastic social changes, unprecedented in any other country. Suicide mortality is much higher in South Korea than in other countries. Despite slight fluctuations, suicide mortality has steadily risen, maintaining a certain level (Lee and Kim, 2016). Further, suicide mortality increases with increasing age (Statistics Korea, 2018).
Franklin et al. (2017) suggested the need to modify the research approach, given the
low explanatory power and accuracy of the risk factors identified over the past five decades as causes of suicidal thoughts or behavior. It is, therefore, high time to identify new factors, using new approaches, besides the risk factors that have been reported to date.
As suicide mortality is maintained at a constant level in South Korea as examined above, there is a need to establish not only suicide prevention programs but also intervention programs to control the factors that are likely to exacerbate suicide injury, which often leads to repeated suicide attempts. In particular, considering the effects of major social issues, customs, and tendencies on suicidal ideation, such factors need to be managed by support policies set out and implemented by the government, the largest unit of society. In the Ottawa Charter, the World Health Organization (WHO) also declared that central and local governments should assume responsibility for health issues, including suicide (WHO, 1986).
Injury, including suicide, is caused not by a single factor, but by the interactions of multiple factors. These factors also greatly affect the outcome of the injury. According to Haddon’s Matrix, such factors can be classified into human, vehicle, and environmental factors. Among these, environmental factors can be subdivided into physical, social, cultural, technological, political, economic, and organizational factors (Glenn et al., 2004).
These factors exert their influence in a complex, interactive manner rather than in a parallel, summative way. For example, Diderichsen and Halqvist (1998) reported that social and political environments could continue to affect an individual’s economic status and exposure to a specific risk, and even the incidence and outcome of an injury. Marmot and Willkinson reported that the socioeconomic environment is directly associated with physical environmental factors and the human brain, and thus influences development in early childhood, which has long-term health implications (Marmot, M., & Wilkinson, R.
G. (1999). Social detenninants of health. Oxford University Press, as cited in Kim et al.
(2013)), Developing Health Inequalities Indicators and Monitoring the Status of Health Inequalities in Korea. Korea Institute for Health and Social Affairs).
Of these environmental factors, those managed by the central and municipal/provincial governments are published as “statistical indicators.” A number of studies have recently been conducted using such statistical indicators. A flagship case is the safety index published by the National Disaster Management Research Institute established under the Ministry of Interior and Safety. This safety index is a grade assigned to injury including suicide for each region with the intent to encourage municipalities and regional governments to take political interest in injury. As regards the safety index for suicide, the number of suicide deaths is set as the hazard indicator, and the vulnerability and reduction indicators are added as factors that can influence the score. The equation for calculating the safety index is as follows:
Safety index = 100 – (Hazard indicator + Vulnerability indicator – Reduction indicator)
However, this index does not apply to failed suicide attempts, hampered by data limitation. It was stressed in a study (Shin, 2018) that vulnerability and reduction indicators are only auxiliary indicators and that the factor determinant of the grade is the number of suicide deaths; that is, the hazard indicator, but factors that can contribute to reducing the number of suicide deaths were not presented.
In most suicide-related studies that used statistical indicators as variables in addition to the safety index, socio-environmental factors impacting mortality rate were investigated (Park et al., 2003; Page et al., 2006; Park, 2009; Yoon, 2011; Huh and Choi, 2013; Kang and Lee, 2014; Choi and Park, 2014; Lee and Kim, 2016). Only one study examined the social factors affecting the severity of injury (Choi and Lee, 2013); however, this study is limited to identifying regional factors affecting the transfer to another hospital or death of high-severity patients as a result of all mechanisms of injury, and does not provide suicide-specific information.
As examined above, despite the compelling need to identify the socio-environmental
factors affecting the severity of suicide injuries, research into this topic has not yet been conducted. In an attempt to bridge this research gap, this study aimed to clarify the socio-environmental factors affecting the severity of suicide injuries using statistical indicators published by the central and municipal/regional governments at an interactive multifactorial level.