Rurality and Risk of Suicide Attempts and Death by Suicide among People Living in Four English-speaking High-income Countries: A Systematic Review and Meta-analysis

Abstract

Objective: Previous research indicates a potential relationship between rurality and suicide, indicating that those living in rural areas may be at increased risk of suicide. This relationship has not been reviewed systematically. This study aims to determine whether those living in rural areas are more likely to complete or attempt suicide. Method: This systematic review and meta-analysis included observational studies based on people living in Canada, the United States, the United Kingdom, and Australia. Data sources included PubMed, EMBASE, PsycINFO, and Google Scholar from January 2006 to December 2017. Studies must have compared rural and urban suicide or suicide attempts. Nonprimary research articles were excluded. Results: A total of 6,259 studies were identified and 53 were included. Results indicate that males living in rural areas are more likely to complete suicide than their urban counterparts (RR = 1.41, 95% CI, 1.21 to 1.64, I 2 = 96%). Females in rural areas are not significantly more likely to complete suicide (RR = 1.16, 95% CI, 0.98 to 1.37, I 2 = 79%). Among studies that only reported combined estimates, rural individuals are more likely to complete suicide (RR = 1.22, 95% CI, 1.11 to 1.33, I 2 = 98%). There is no association found between rurality and suicide attempts (RR = 0.93, 95% CI, 0.73 to 1.19, I 2 = 85%). Conclusions: Those living in rural areas are more likely to complete suicide, with some studies indicating that only rural males are more likely to complete suicide; these findings are relatively consistent across all four countries. Public health initiatives should aim to overcome geographic variation in completed suicide, with a particular focus on rural males.

Method-Specific Suicide Mortality Trends in Australian Men from 1978 to 2017

“…It is also pertinent to highlight the relevance of analysing the changes that have occurred in the mechanisms through which suicide is carried out in the different states of the country and over a long period, thus enabling specific patterns to be disaggregated by state, which is the administrative level at which health interventions are usually managed in Australia [4]. Additionally, this study provides information on suicides in the Australian population in four age groups (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49), 50-64 and over 65 years), selecting from all the available data, those who are most affected by this phenomenon.…”

“…Over the period of the study, this trend declines, likely due to improvements in firearm laws since the mid-1980s and urbanisation. Past research has found high rates of suicide by firearms in Australian men in rural areas [ 28 , 32 ], with the possibility of limited access to suicide prevention services in these settings being associated with a greater risk of suicide deaths.…”

Does population density moderate suicide risk? An Italian population study over the last 30 years

“…Higher rural suicide rates have been reported also in China and Austria [10,11]. A recent meta-analysis of data from four English-speaking countries (Australia, Canada, the United Kingdom, and the United States) found higher suicide rates in rural areas among males, with a widening rural-urban discrepancy [12][13][14][15]. Socioeconomic status and social isolation account only in part for this discrepancy in suicide risk [16,17].…”

Factors Related to the Level of Depression and Suicidal Behavior Among Men With Diagnosed Depression, Physically Ill Men, and Healthy Men

“…Research has also found that urbanity/rurality shapes intra-regional differences in suicide ( 65 ). According to a recent study by Barry et al ( 66 ), men living in rural areas are more likely to effectively commit suicide. There are many possible explanations for increased suicide risk in rural areas.…”

“…Country living is often related to a lower socioeconomic status as well as stigmatized attitudes toward visiting mental healthcare facilities [e.g., general practitioner (GP) and psychiatrists], and long travel distances diminish the accessibility to specialized healthcare providers ( 68 ). Several empirical studies emphasized an elevated vulnerability in rural areas, whereas others drew an opposite conclusion ( 66 ). In our study, living in middle-size and small cities is significantly more protective against depression among men than living in large cities.…”