【作者】 周锐；

【导师】 张杰；

【作者基本信息】 山东大学 ， 社会医学与卫生事业管理， 2014， 博士

【摘要】 研究背景自杀(suicide)是指个人在意识清楚的情况下,自愿采取伤害、结束自己生命的行为。据世界卫生组织数据,全世界每年大约有100万人死于自杀。全球自杀死亡率为16/10万,平均每40秒钟就有一个人自杀。我国的自杀率在20多年前为23/10万,但是在过去20多年中呈下降趋势,全国总自杀率从1987年的17.65/10万降到了2008的6.60/10万。由于人口基数大,自杀死亡的绝对人数占世界第一位。自杀已成为第五位的死亡原因,是15至34岁人群首位死因。其中农村的自杀率是城市的3倍,全国70%以上的自杀发生在农村。目前,自杀已成为一个非常严重的公共卫生问题和社会问题。自杀既与生物、精神心理因素相关,又与个人所处的文化背景及社会环境密切相关。已发现的与自杀相关的社会因素包括社会经济因素、社会文化因素、社会关系因素、社会支持因素和社区环境因素几种类型。已有的关于自杀的研究大都是建立在西方人群的心理特点和社会状况的基础上,不能很好的解释中国自杀的根源和自杀模式。而且多集中在对自杀危险因素的罗列和排序上,缺乏系统的思考和提炼。扭力理论是解释中国式自杀根源的最佳理论模型。该理论认为,扭力共有四种不协调的压力源。这种不协调的压力在导致自杀行为的过程中会受到社会因素的干预或强化。由于社会因素这个中间因素的存在,大部分有不协调压力体验的人并没选择自杀。这些社会调节因素包括经济生活状况、受教育程度、社会地位、家庭背景及宗教信仰等。社会因素先于自杀行为和不协调压力的关系而存在。自杀与不协调压力之间的关系可能会被社会调节与社会整合等因素所缓解。如果个人在面临比较大的不协调压力的时候,拥有在家庭、工作、学校等社会体制中的良好的整合,就会降低自杀的风险。但是现有的社会危险因素的研究大多是根据社会学或者心理学的概念进行形而上学的理论上的分析和推理,或是进行社会调查后的描述性分析。很少采取深入量化的手段进行验证。因此对自杀的社会影响因素尤其是中国农村青年自杀的社会影响因素进行的全面的调查和深入分析是很有必要的。研究目的1.测量和分析相关社会因素,了解农村青年自杀行为的社会因素的分布情况,比较农村青年自杀人群与正常对照人群之间在社会因素分布上的差别。2.研究社会因素与研究区域农村青年自杀的关系,衡量各类型社会因素对自杀的影响程度,发现自杀行为的社会保护因素和危险因素。3.采用结构方程模型技术探索并构建自杀的社会影响因素模型,采用量化的手段对自杀的社会危险因素进行验证。研究方法在综合考虑全国各省(市)社会经济条件、地理分布位置等因素的基础上,选择辽宁(北部工业省)、山东(东部工农业省)、湖南(南部农业省)作为研究现场,从这三个省随机抽取16个县或县级市,通过序贯抽样的方法抽取从2005年10月1日至2008年6月30日期间自杀死亡的15-34岁的农村居民,自杀者名单来自这16个县的疾病预防控制中心死因监测系统。在对自杀病例进行调查的同时,在自杀者的邻村随机选取同年龄段的正常农村居民作为自杀死亡者的对照纳入本次研究。每例自杀死亡者及对照都访谈两位信息人。资料收集采用病例对照研究,同时结合心理解剖方法,采取面对面访谈形式完成。研究结束时共收集到自杀死亡病例392例,有效对照416例。调查工具包括：1、目标人一般情况,包括性别、年龄、教育水平(上学年数及最高学历)、健康状况、精神状况、家庭成员自杀史(有无)、储藏农药情况等。2、经济因素,包括：劳动或工作情况,每个星期在家庭之外的地方工作多少小时,每天花在家务事上面的时间有几个小时,个人年收入,家庭年平均收入,有无自己的财产,财产的价值,与村里其他人相比家里的经济状况。3、文化因素,包括宗教信仰、信不信神、信不信人有来世、是否是共产党员或团员(共产主义信仰)、价值观冲突、儒家思想对男人的部分规范、儒家思想对女性的规范和性别平等观念。4、社会关系,包括婚姻状况、夫妻关系、子女数量、是否独居、是否住集体宿舍、是否与岳父、岳母/公公、婆婆一起住、是否与父母一起住、与岳父/公公的关系、与岳母/婆婆的关系、与父母的关系、在家庭中的地位。5、社会支持,包括社会支持量表(Duke Social Support Index, DSSI)和遇到困难时是否能得到相关人员的支持来测量。6、社区环境,采用社区压力与问题(Comunity Press and Problem)量表,包括住房.犯罪.贫富差距.教育.贪污腐败、家庭生活不和睦、交通、医疗保健、就业保障、民族歧视或冲突、污染、吸毒、酗酒、虐待配偶或儿童、生活质量、人身安全、赌博和迷信问题。7、信息人半定式访谈提纲。包括自杀者自杀的详细过程,自杀前后发生的事情,自杀者自杀的原因等。对于计量资料,根据数据类型采用两独立样本t检验、Mann-Whitney U检验(即Wi lcoxon秩和检验)。对于计数资料,根据数据类型采用Pearson Chi—square检验、Fisher确切概率法。采用单因素及多因素Logistic回归分析测量具体的社会因素对自杀的影响程度,明确其保护因素和危险因素。采用结构方程模型来评估不同类型社会影响因素对自杀的影响。研究结果1、自杀组与对照组在人口学特征、社会经济因素、社会文化因素、社会关系因素、社会支持因素和社区环境因素的分布方面大都存在显著的差异。2、根据单因素分析的结果,自杀的社会危险因素包括：包括家庭经济状况；宗教信仰、儒家思想对女人的部分规范的认同、价值观冲突；夫妻关系差、独居、与岳父/公公、岳母/婆婆、父母的关系差、在家庭中的地位低；社区存在家庭生活不和睦、交通问题、医疗保健问题、就业保障问题、酗酒问题；自杀的保护因素包括：包括家庭年平均收入高；有共产主义信仰、性别平等观念；已婚、子女数量多；社会交往情况、可觉察社会支持、工具性支持好,遇到困难时有家人、朋友、上级(老师)、同事(同学)、邻居的支持；社区的污染问题。3、样本总体纳入自杀的社会影响因素多因素logistic回归模型的社会因素变量有16个,社会经济因素有2个变量被纳入模型,分别是家庭年平均收入(0R=0.699)、家庭经济状况(0R=1.429)；社会文化因素有3个变量被纳入模型,分别是宗教信仰(0R=2.048)、共产主义信仰(OR=0.752)、儒家思想对女人的部分规范(OR=2.997)；社会关系因素有5个变量被纳入模型,分别是婚姻状况(0R=0.260)、夫妻关系(0R=2.371)、子女数量(0R=0.619)、与父母的关系(0R=2.171)、在家庭中的地位(OR=1.667)；社会支持因素有4个变量被纳入模型,分别是社会交往(OR=0.445)、可觉察社会支持(OR=0.073)、家人的支持(0R=0.245)、上级或老师的支持(OR=0.332)；社区环境因素有2个变量被纳入模型,分别是就业保障问题(0R=1.440)、酗酒(0R=1.479)。男性组最终纳入模型的社会因素变量有12个,社会经济因素有2个变量被纳入模型,分别是个人年收入(0R=O.839)、家庭经济状况(0R=2.081)；社会文化因素2个变量被纳入模型,分别是宗教信仰(0R=8.159)、儒家思想对男人的部分规范(0R=1.972)；社会关系因素3个变量被纳入模型,分别是婚姻状况(0R=0.110)、夫妻关系(0R=4.528)、与父母的关系(0R=2.442)；社会支持因素有3个变量被纳入模型,分别是可觉察社会支持(0R=0.017)、工具性支持(0R=0.004)、同事同学的帮助(0R=0.204)；社会环境因素有2个变量被纳入模型,分别是医疗保健问题(0R=1.366)、交通问题(OR=1.966)。女性组最终纳入模型的社会因素变量有13个,社会经济因素没有变量被纳入模型；社会文化因素2个变量被纳入模型,分别是共产主义信仰(0R=0.221)、儒家思想对女人的部分规范(0R=1.120)；社会关系因素6个变量被纳入模型,分别是夫妻关系(0R=2.652)、子女数量(OR＝0.315)、独居(0R=7.895)、与婆婆的关系(0R=2.210)、与父母的关系(0R=2.217)、在家庭中的地位(0R=1.327)；社会支持因素有3个变量被纳入模型,分别是可觉察社会支持(OR=0.036)、朋友的帮助(0R=0.328)、上级或老师的帮助(0R＝0.254)；社区环境因素有3个变量被纳入模型,分别是就业保障问题(OR=1.893)、酗酒(OR=1.717)、迷信(OR=0.620)。4、社会影响因素与自杀关系的结构方程模型显示,在指向自杀的危险因素中,社会关系因素的路径系数最大为0.87；其次为社会文化因素,其路径系数为0.69；然后是社会经济因素其路径系数为0.63,最后是社会支持因素和社区环境因素,路径系数分别为0.49和0.46。同时社会经济因素与社会关系因素的相关程度比较大,社会关系因素与社会支持因素相关系数较大。研究结论及意义1、社会经济因素中,导致自杀组与对照组经济差别的是个人及家庭收入、财产价值等直接反映经济情况的指标。家庭经济状况差是自杀的危险因素,家庭年平均收入水平高是农村青年自杀的保护因素。因经济因素直接或间接造成家庭矛盾和纠纷是自杀的主要原因之一。2、社会文化因素中的宗教信仰、儒家思想对女人的部分规范的认同、价值观冲突是农村青年自杀行为的危险因素。有宗教信仰、对儒家思想对女人的规范认同越高、价值观冲突越强,则农村青年自杀的可能性越大。社会文化因素中的共产主义信仰、性别平等观念是自杀行为的保护因素。相信共产主义、性别平等观念越强,则农村青年自杀的可能性越低。3、在影响自杀行为的社会关系因素中,夫妻关系差、独居、与父母、岳父/公公、岳母/婆婆等长辈的关系越差、在家庭中的地位越低是农村青年自杀的危险因素。已婚、子女数量较多是其自杀的保护因素。其中,夫妻关系和与父母的关系是影响农村青年自杀行为的最重要的两种关系。4、表示社会支持情况的社会交往、可觉察社会支持、社会工具性支持及亲人朋友的支持是自杀的保护因素,社会交往越好、可觉察社会支持越高、社会工具性支持越好,遇到困难时能得到家人朋友上级老师同事同学邻居的帮助,农村青年自杀的可能性越低。在所有社会人际关系的帮助和支持中,家人的支持所占的比例最大,占所有帮助来源的70%以上。家人的支持是对预防自杀的最有效的保护因素。5、社区环境因素中的家庭生活不和睦、交通问题严重、医疗保健问题严重、就业保障问题严重、酗酒问题是自杀的危险因素,以上这些问题越严重,则自杀的可能性越大。6、在自杀的各类型的社会影响因素中,社会关系因素是影响最大的因素,其次为社会文化因素,然后是社会经济因素。社会经济因素会直接导致自杀,还会通过影响社会关系因素而导致自杀。社会关系因素会直接导致自杀,还会通过影响社会支持因素而导致自杀。更多还原

【Abstract】 BackgroundSuicide is behavior by individuals who fully understand the fatal consequences of this action and choose conscious self-destructive behavior leading to death. Approximately1,000,000people die by suicide every year. The rate of suicide was16per100,000people, or one suicide every40seconds. In China, the suicide rate was23per100,000people over twenty years ago, but the rate has trended down over the past twenty years, from17.65per100,000people in1987to6.60per100,000people in2008. The absolute number of suicides in China ranked the top of the world, with suicide being the fifth common cause of death and the number one cause of death for individuals aged15-34, with more than70%of the suicides occurring in rural areas.Suicide has been a very serious major public health issue and social problem. It is associated with biological, mental psychological factors, as well as being closely related to the individual’s cultural background and social environment. The social factors that have been found related with suicide include economic factors, culture factors, social relation factors, social support factors and community environment factors.At present, most of the studies on suicide were based on western psychological characteristics and social conditions so they could not explain the exact cause and model of Chinese suicide. These studies focused on the specific risk factors and a litany of facts. The studies on the social factors of suicide were mostly metaphysical theory analysis and reasoning based on the concept of sociology or psychology, or the descriptive analysis of social investigations. It’s essential to conduct comprehensive investigation and do deep analysis for social factors of suicides, especially Chinese rural youth suicides.Objectives1. To measure and analyse the social factors of Chinese rural young suicides according to the existing measurement tools and to compare the differences of social factors between rural youth suicide and normal controls.2. To explore the complex relationship between different social factors and suicide, to evaluate the impact of social factors on rural young suicide, and to find the social protect factors and social risk factors.3. To build the social influence model on suicide using structural equation modeling techniques. MethodsTaking the socioeconomic conditions, geographical location, etc into consideration, we conducted this study in Liaoning (Industrial province, in northern China), Shandong (Industrial and agricultural province, in Eastern China) and Hunan (Agricultural province, in southern China). Sixteen counties were randomly selected from these three provinces. From October1,2005to June30,2008, rural youth suicides ranging in age from15-34were selected using sequential sampling. The list of suicide originated from the death monitoring system of Chinese Centre for Disease Control and Prevention. At the same time, people of the same age, living in the neighboring community, were randomly selected as controls. For every suicide and control, two knowledgeable informants were selected to provide their information. The case-control study was adapted and a psychological autopsy method was used for information collection. Totally392suicides and416controls were included in this study by face to face interview using questionnaires.The instruments involved in this study included:1. general information of informants, including gender, age, education years, health condition, mental health, family suicide history, pesticide stored in the family;2. economic factors, including employment, hours working off home per week, hours working home chores per day, personal annual income, family annual income, family asset, family asset value, status of family in village;3. cultural factors, including religion, whether believe in superstition or afterlife, party or league member, Value Conflict Scale, the Criterion of Confucianism Affect on Men, the Criterion of Confucianism Affect on Women, Gender Equality;4. Social Relation, including marital status, spousal relation, number of children, whether or not live alone, whether or not live in dorm, whether or not live with parents/in laws, relation with parents, relation with father-in-law, relation with mother-in-law, status in family;5. social support, measured by Social Support Inventory and whether or not be supported by relations when meeting difficulties,6. community environment, measured by Community Press and Problem, including housing, crime, poverty, etc;7. half-set interview outline, including the process of suicide, the events before and after commit suicide, the causes that led people to commit suicide, etc.For numerical variables, t test or Mann-Whitney U test was applied according to the distribution types of data. For categorical variables, Chi-Square test or Fisher’s exact test were used to estimate probabilities. Univariate and multivariate analysis by conditional logistic regression analysis were used to measure the influence of specific social factors on suicide, and to explore risk social factors and protect social factors of suicide. Social factor influencing suicide structural equation model was established to estimate the influence of different types of social factors on suicide.Result1. There were significant differences between the suicide and control groups in most general information, economic factors, culture factors, social relation factors, social support factors and community factors.2. According to the result of single factor analysis, the social risk factors of suicide include low status of family in village, believe in religion, the criterion of Confucianism effect on women, value conflict, poor spousal relation, live alone, poor relation with parents/father-in-law/mother-in-law, low status in family, community family disputes, community transportation problem, community health care problem, and community job security problem and alcohol abuse problem. The social protect factors of suicide include high family annual income, party or league member, strong concept on gender equality, marriage, higher number of children, high level of social interaction, more perceived social support, more social tool support, support from family/friend/superior/teacher/workmate/schoolmate/neighbor when facing difficulties, and low community pollution.3. For the whole sample, nineteen social factor variables were extracted and included in the multivariate logistic regression equation. Two of them were from economic factors, they were family annual income (OR=0.699), status of family in village (OR=1.429); three of them were from cultural factors, they were religion (OR=2.048), party or league member (OR=0.752), the criterion of Confucianism affect on women (OR=2.997); five of them were from social relation factors, they were marital status (OR=0.260), spousal relation (OR=2.371), number of children (OR=0.619), relation with parents (OR=2.171), status in family (OR=1.667); four of them were’from social support factors, they were social interaction (OR=0.445), perceived social support (OR=0.073), support from family (OR=0.245), support from supervisor/teacher (OR=0.332); two of them were from community factors, they were job security problem (OR=1.440) and alcohol abuse problem (OR=1.479).For male sample, twelve social factors variables were extracted into the multivariate logistic regression equation. Two of them were from economic factors, they were personal annual income (OR=0.839), status of family in village (OR=2.081); two of them were from culture factors, they were religion (OR=8.159), the criterion of Confucianism affect on men (OR=1.972); three of them were from social relation factors, they were marital status (OR=0.110), spousal relation (OR=4.528), relation with parents (OR=2.442); three of them were from social support factors, they were perceived social support (OR=0.017), tool support (OR=0.004), support from workmate/schoolmate (OR=0.204); two of them were from community factors, they were health care problem (OR=1.366) and transportation problem (OR=1.966).For the female sample, thirteen social factors variables were extracted into the multivariate logistic regression equation. None of them were from economic factors. Two of them were from culture factors, they were party or league member (OR=0.221) and the criterion of Confucianism affect on women (OR=1.120); six of them were from social relation factors, they were spousal relation (OR=2.652), number of children (OR=0.315), live alone (OR=7.895), relation with mother-in-low (OR=2.210), status in family (OR=1.327); relation with parents (OR=2.217); three of them were from social support factors, they were perceived social support (OR=0.036), support from friend (OR=0.328), support from supervisor/teacher (OR=0.254); three of them were from community factors, they were job security problem (OR=1.893), alcohol abuse problem (OR=1.717) and superstition (OR=0.620).4. As shown in the Social factor influencing suicide Structural equation model, in the path diagram where factors pointed at suicide, social relation factors had the highest path coefficient which was0.87, followed by social culture factors0.69, social economy factors0.63, social support factors0.49, and community factors0.46. Social economy factors were correlated with social relation factors. Social relation factors were correlated with social support factors. Conclusion1. Among the economic factors, it was the direct reflection index of economic conditions such as personal or family annual income and family value etc. that led to the economic difference between suicides and controls. Low status of family in village was the risk factor of suicide and high family annual income was the protective factors for rural youth suicide. Family conflicts and disputes directly or indirectly caused by economic factors were the main cause of suicide.2. Among culture factors for rural young suicide, the risk factors of suicide included religion, the criterion of Confucianism affect on women and value conflict. The higher the level of religiosity, the higher the identity to criterion of Confucianism affects on woman and the stronger the conflict of value, the more likely rural youth suicide. The protective factors included being party or league member and strong concept on gender equality.3. Among social relation factors for rural young suicide, the risk factors included poor spousal relation, live alone, poor relation with parents/father-in-law/mother-in-law, low status in family. The protective factors included being married and higher number of children. Spousal relation and relation with parents were the two most important social relation factors for rural young suicide. 4. Among social support factors for rural young suicide, the protective factors included social interaction, perceived social support, tool support, family support and friend’s support. The higher the level of social interaction, the more the perceived social support and the tool support, the more the support from family/friend/superior/teacher/workmate/schoolmate/neighbor when meeting difficult, the less likely the rural youth suicide will occur. Among all the support from interpersonal relationship, family support proportion was the highest, accounting for more than70%of all sources of support. It was the most effective protection for suicide prevention.5. Among community factors for rural young suicide, the risk factors included community family disputes, community transportation problem, community health care problem, community job security problem and alcohol abuse problem. The more serious these problems were, the more likely rural youth suicide.6. Among all kinds of social factors for rural young suicide, social relation was the biggest impact factor, followed by culture factors and economic factors. The economic factors might directly lead to suicide or they could indirectly lead to suicide by influencing social relation factors. Social relation factors might directly lead to suicide or they could indirectly lead to suicide by influencing social support factors.更多还原