Abstract

 This research has been conducted in two phases. Each phase is described separately.

 The First Phase

Background

The coastal area of Suriname, particularly the Northwestern part is mainly agricultural. The use of pesticides is widespread and is considered normal. The yearly pesticide imports have doubled over the past 10 years to 1.6 million liters- more than three liters for every citizen. The national pesticide policies and regulations are becoming stricter, however, these policies are not enforced, farmers do not follow regulations and control is almost absent. More than 50% of suicides in the most western and isolated district of Nickerie are pesticide –induced (mostly by ingesting paraquat). Research shows that more than 90% of suicide attempts can be considered as impulsive actions following a sudden, frightening sense of entrapment.

Goal

To develop a community-based participatory, novel and safe pesticide storage, use and disposal intervention that can be sustained by the community. The intervention should assist in protecting and enhancing the community’s health and reduce all adverse health effects, including suicide. Within the overall goal, the intervention is also aimed at decreasing the number of suicide attempts and suicides, committed by taking pesticides.

The specific aims are:

Aim 1: Conduct a community needs assessment to characterize the factors influencing use, misuse, including as a suicide agent and option for safe storage and disposal of pesticides.

Aim 2: Develop an innovative, community lay health educator intervention and implementation roadmap.

Aim 3: Implement a sustainable Pesticide Health Promotion Ambassador (PHPA) Program with community leaders to promote safe pesticide use and storage.

The study Protocol was approved by Suriname’s Human Subject Protection Board and the Institutional Review Board of Tulane University.

Method

Phase I of the project consisted of conducting a needs assessment to characterize community perceptions through focus groups and validated questionnaires.

The six focus groups that were convened centered on the following domains:

a) Pesticide availability and management;

b) Community Health;

c) Mental health, suicides and support;

d) Psychosocial factors;

e) Needs and assets;

f) Characteristics of pesticide interventionists.

Focus group recurring themes were identified using Atlas Ti. All questionnaires were translated and approved by the respective Boards. Prior to the focus group sessions, all participants were asked for consent and administered a standard demographic questionnaire.

Results

The following are some key recurring themes identified:

a) There is a consensus that pesticide are inadequately handled, misused and overused, but that they are necessary to protect and obtain viable crops.

b) Another issue of concern within the community is how pesticides are disposed of and stored, and that the community is getting sick from the overuse and misuse of pesticides.

c) Focus groups stated that the most important health problems were chronic diseases, such as diabetes, high blood pressure and cancer.

d) The participant reported that overuse of drugs and alcohol within the community. Mental health issues are also a reported problem.

e) Participants agreed that pesticide safe-use rules have to be implemented. These include pesticide accessibility, use and storage use.

f) Within the community, people do not discuss their mental problems or stressful matters in live. There are few stress relief activities within the community and alcohol and drug use or pesticide-induced suicide are a way in which people address stress issues.

g) Intervention strategies have to include education about the proper use of pesticides and about the different aspects of mental health. Community health ambassadors may combine both areas; they should be well educated, discrete, trustworthy and easy to reach.

Conclusions

The results of the first project provide us with more knowledge on key issues and help in developing the second phase of the intervention project.

Education as well as stricter regulation of obtaining pesticides and community health ambassadors may assist in enhancing community health and reduction of suicides in the second phase of the project.

The Second Phase

Background: see above phase I.

Methods

The proposed study is designed in three independent phases with all research receiving approval from Tulane University and the Government of Suriname’s Institutional Review Board.

Phase 1: Characterization of factors influencing pesticide use, access and disposal.

• Convened focus groups (N=67)
• A psychosocial survey battery included a Socio-Demographic questionnaire, the SF-36@ Health Survey and the Coping with discrimination Survey.
• Survey data were scored and interpreted using basic correlative and descriptive analysis.

Phase 2: Develop an intervention for the safe storage and use of pesticides in Eastern Nickerie’s agriculturally –driven society.

Phase 3: Design training model for community lay (mental) health workers to disseminate safety education and public health follow-up.

Conclusions

• Suriname represents communities new to CBPR approach and participants were empowered through their role in developing a sustainable homegrown intervention.
• Focus group data from the study suggests that the pesticide risk in Suriname  may be a unique public health problem setting them apart from their Caribbean counterparts.
• Stigma may be an important factor in mental health service seeking and utilization. However little work on stigma has been conducted in Suriname.
• Focus group data revealed conceptual themes related to:
  • Community members’ definitions of stigma
  • Emotional response towards those with mental illness
  • Behavioral responses towards those with mental illness
  • Perceptions of and beliefs about mental illness
  • The CDS Scale results demonstrate that participants may rely on their self-capacity to grow and learn from their experiences. Dedicating themselves to educating people to become better prepared to deal with discrimination.

Future Direction

1. More in-depth mixed-method research is required to further explore the rich differences across cultures, the peculiarities in the ethnic distribution of pesticide use and the psycho-social and environmental influences on mental health.
2. The knowledge obtained during Phase 1 will be used as a roadmap to tailor a competency based intervention program, integrating mental health, environmental health, pesticide management and mobile health technology
3. Mobile health technology plays a role in improving care and can be used in support of suicide prevention (Mahmud et al 2010 & Luxton et al 2010). Yet no mobile health technology interventions have been implemented using trusted community members as interventionists, emphasizing the need of further research in this area.
4. The Caribbean Consortium for Research in Environmental and Occupational Health (CCREOH) addresses access and use of pesticides in large and small- scale agriculture under an NIH-grant  (# 1RZ4TW009561).