Understanding self-harm behaviour in older adults: a systematic review and qualitative study

Two worldwide challenges served as a drive for this research: the reality of an ageing population and the identified need of supporting people who self-harm. Addressing self-harm has been increasingly prioritised due to its social, economic and health impact. Despite lower rates of self-harm in older adults compared to younger populations, this behaviour has shown to have wider repercussions in later life. However, key research questions amongst this age group remain unanswered. The aim of this thesis was to increase the understanding of selfharm in older adults. Specifically, I addressed i) motivations to self-harm behaviour in older adults; ii) barriers and facilitators to access to care; iii) role of the different sources of support. To address the aim of the thesis I start by introducing the research and policy context as well as key definitions and rationale for the study in Chapter 1. In Chapter 2, I provide an introduction to key terms and an overview of characteristics of self-harm. In Chapter 3, I introduce the literature on the characteristics of self harm behaviour in the older adult population through the conduct of a systematic review. After reviewing the absence of current literature exploring motivations and access to care in older adults who self-harm, in Chapter 4, I present the methodology of the qualitative research exploring self-harm in older adults, framed within a critical realist perspective. In Chapter 5, I introduce the specific methods used. A qualitative approach was taken to answer the research questions, using semi structured interviews with two participant groups recruited from community settings: older adults disclosing self-harm behaviour, and third sector workers with experience supporting older adults who self-harm. Follow-up interviews were offered to older adults. Data were analysed using thematic analysis with constant comparison methods. A Patient and Public Involvement and Engagement (PPIE) group contributed to the development and conduct of the research. Findings are presented in Chapters 6 and 7 where I summarise the findings from 24 interviews conducted with 16 participants included in this research (9 older adults and 7 support workers). Narratives from older adults and support workers follow a life-course perspective where self-harm was described as occurring throughout the years as a response to the accumulated life experiences of older adults. Self-harm was described by participants as a response to dealing with different accumulated stressors experienced throughout the lifecourse of older adults: i) adverse childhood events; ii) interpersonal problems; iii) health problems; iv) loss and loneliness. Motivations to self-harm varied within a suicidal spectrum of no suicidal intent to high levels of suicidal intent, where self-harm served different functions to older adults throughout their lives. More specific motivations to self-harm were provided and described as ‘a cry for help’, a strategy to cope or to regain control. Participants described older adults often feeling shame due to self-harm. Chapter 7 explores barriers and facilitators to access to care, describing the process of help-seeking behaviour experienced by older adults. Participants described older adults often living with their self-harm undisclosed due to the shame and stigma experienced, this may result in delayed help-seeking. Furthermore, older adults were described as not identifying their self-harm behaviour as needing a medical consultation, delaying further access to care. When the decision to seek help was made, older adults used different sources of support, ranging from the formal sector (health services, social care and third sector) to the informal sector (family, peers, faith and internet). Barriers and facilitators to access to care were described by participants, ranging from external to internal factors as well as structural barriers and facilitators. Lastly, in Chapter 8 I contextualise the findings with current literature. Strengths and limitations to the study are provided as well as description of the impact of PPIE involvement. Research and policy implications resulting from this research are summarised, highlighting implications for the healthcare, education, social care and third sectors