Background Epidemiological studies show rates of self-harm through injury or poisoning vary substantially between different social contexts. Socio-economic deprivation predicts risk at individual and community level. However, despite high poverty rates, London has low rates of self-harm overall and contains highly deprived areas with paradoxically low rates. Using the stress process model as a theoretical framework, we explore why one such community exposed to multiple, chronic stressors, might nonetheless appear to have low rates of self-harm.
Methods This study forms part of a wider mixed methods project which used clinical data on service use following self-harm to calculate age standardised incidence rates by small-area in South East London, 2009–2016. These were combined with the Index of Multiple Deprivation to identify a case study area that was persistently deprived with below average self-harm rates. Semi-structured interviews were conducted with fourteen people working, paid or as volunteers, within community organisations serving the area. Two focus groups were conducted with 12 people currently resident in the area. Topic guides covered aspects of the area that impacted mental health positively and negatively, how people locally responded to distress and attitudes and responses to self-harm. A thematic analysis was conducted, with themes generated following discussion between two independent coders.
Results The case-study area was ethnically diverse, with a large Black population, which was reflected in the study sample. Participants reported that people in the community were exposed to multiple, chronic stressors related to marginalised social statuses and the social environment, with significant impacts on mental health. These were partly buffered by social resources related to community solidarity and an understanding of stressors as communal challenges, as well as a culture of self-reliance amongst individuals. However, identifying oneself as mentally ill, especially through being known to have intentionally harmed oneself or attempted suicide, was described as highly risky. Doing so would diminish a person’s social status in this context, exposing them to additional stressors during interactions within their community and with services. Consequently, people tended to hide mental distress and respond with behaviours less obviously linked to mental illness than self-harm.
Conclusion The stressors experienced by this deprived, ethnically diverse urban community acted to both make self-harm less common and reduce help-seeking following it, despite mental distress being common. When measuring mental health need in a population the influence of social context on reported outcomes needs to be considered to avoid reinforcing existing health inequalities.
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