Help-seeking Behaviours, Access to Care and Suicide among Rural and Urban Populations in Ontario, Canada

Suicide is a significant cause of premature death. Rural populations may be particularly vulnerable for multiple reasons including healthcare access, stigma, and isolation. First, a systematic review and meta-analysis were conducted to examine the association between rurality and suicide and suicide attempts among English-speaking high-income countries. Findings indicated that rural males were more likely to die from suicide than their urban counterparts (RR=1.41, 95%CI=1.21-1.64, I2=96%). Second, in a population-based case-control study of adults living in Ontario, rurality was associated with increased risk of suicide among rural males (AOR=1.70, 95%CI=1.49-1.95). Rurality was also found to be associated with suicide attempts among both males and females (males: AOR=1.37, 95% CI=1.24-1.50; females: AOR=1.26, 95% CI=1.14-1.39). Findings indicated a pattern of increasing risk of suicide and suicide attempts with increasing rurality. The third manuscript examined the association between rurality and help-seeking behaviours. We found that among those who attempted suicide, those living in rural areas were significantly less likely to have visited a psychiatrist prior to attempt compared to those living in urban areas (rural males: AOR=0.49, 95%CI=0.43-0.56; rural females: AOR=0.51, 95%CI=0.46-0.57). We found the same association among those who died by suicide (rural males: AOR=0.42, 95%CI=0.31-0.57; rural females: AOR=0.46, 95%CI=0.29-0.97). Rural males who attempted or died by suicide, and rural females who attempted suicide were less likely to seek help from a general practitioner for mental health purposes. The final manuscript examined the association between travel time to health care and suicide outcomes. Findings suggested that males who must travel longer to hospitals are at a greater risk of suicide compared to those who travel shorter lengths of time (AOR=2.08, 95% CI=1.61-2.69). Longer travel times to psychiatric hospitals also increased risk of suicide among males (AOR=1.03, 95%CI=1.02-1.05). Furthermore, travel time to care was a mediator of the association between rurality and suicide. Together these findings suggest that those who live in rural areas are at increased risk of suicide attempts, and rural males are at increased risk of death by suicide. This dissertation provides insights into how travel time to care and help-seeking may impact risk of suicide in the context of rurality.Ph.D