Abstract

Suicide rates have risen in the last two decades and the endemic remains a pressing social concern. There are nearly 45,000 suicides and 1.2 million suicide attempts per year in the United States. Current mitigation efforts are generally focused on mental health and subsequent psychiatric analysis. They have largely been ineffective in reversing the rise in suicide rates. However, suicide remains a significant problem that can be approached with a new lens. Social factors such as the prevalence of guns, media reporting, and classification systems are still poorly understood, especially when compared to conventional mental health strategies. This paper analyzes how the individualistic concept of suicide produces misunderstandings, how these misunderstandings hinder progress, and how solutions that acknowledge the public and social factors controlling suicide can help mitigate the growing suicide crises.

Introduction

When twenty-eight-year-old Kevin Baldwin released himself off the side of the Golden Gate Bridge, he felt the shocking reality that “everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.” Baldwin represents one of the millions of Americans who attempt suicide each year. In 2020, according to the CDC, there were 45,979 suicides and nearly 1.2 million suicide attempts in the United States, while suicide rates had slowly risen to 13.5 suicides per 100,000, making it a leading cause of death and a prominent social issue within the nation. Nevertheless, Baldwin’s attempt and his subsequent survival also reflect key misunderstandings about suicide that reveal the potential for new mitigation approaches.

There are several fundamental misunderstandings of the suicide endemic which shape the public understandng of the problem. These include the following: the belief that suicides are long thought-out, premeditated actions, that people who attempt will inevitably reattempt, that mental illness is always tied to suicide, that we can best predict (and understand) suicide from a psychopathological perspective, and lastly, that suicide is an issue predominantly tied to the individual. As such, mitigation efforts, which are often focused on the examination of individuals and individual mental health issues, remain limited given these misconceptions. They continue to fixate on individual assessment, when in reality, the suicide endemic is more nuanced and complex than this conventional approach proposes. Furthermore, the over-fixation on an individualistic lens distracts the public from a relatively feasible, attainable, and immediate set of strategies for mitigating suicide, ones that are often overlooked in the vast response to a national mental health issue.

Given this, a reconsideration of suicide mitigation efforts is necessary. Rather than fixate on individual-level approaches, we can better tackle the problem with a broader understanding of the larger social factors that are at play. this paper explores the misconceptions surrounding suicide and their realities using a thorough analysis of the research on suicide. It details how misconceptions inhibit mitigation strategies, and how more immediate and sensible strategies can be instituted through a better understanding of crucial social determinants of suicide.

Contemporary Misconceptions Regarding Suicide

Introduction

A mere google search, using keywords, can quickly reveal public misconceptions regarding suicide; A browser finds images focused on individuals, often contemplating on their own, and displaying mental distress. There is rarely acknowledgment of public or social factors that may be involved, and the concept of individual mental illness is the dominant framing.

Suicides are Long Thought Out and Inevitable Events

Whether it is Vanity Fair describing Robin Williams’ suicide as the result of a “long and difficult decline” or the Rolling Stone describing Kurt Cobain’s from the perspective of a “downward spiral”, conventional knowledge surrounding suicide and its most famous cases displays a perspective of deliberation, decline, and inevitability. While mental health struggles often precede suicides, a hindsight bias is employed in the aftermath of a suicide attempt. Mental health issues are prescribed as superordinate, or lone, causes of prolonged and unavoidable paths to suicide. Therefore, working with the mental health model, individuals are thought to engage in a prolonged or continued contemplation stage before moving towards suicidal behaviors. This idea creates the conception of inevitable and elongated decline, often presenting as the cause surrounding celebrity and community suicides. On the contrary, there is nothing inevitable about a suicide attempt. Many attempts unfold in short periods and out of temporary crises that provoke immediate and impulsive suicidal actions. (Deisenhammer et al., 2009) analyzed eighty-two patients admitted after a suicide attempt and found that nearly 74% of patients had found the jump from a decision to an attempt to be short (10 minutes or less) and 47% traversed the entire suicidal process (including consideration, decision, and action) within ten minutes of first consideration. Furthermore, researchers concluded, “The process from the emergence of suicidal thoughts to the accomplishment of a suicide attempt, and thus the time for intervention, generally is short”. Another study (Williams et al., 1980 ), analyzing visits to Australian hospitals, noted that a considerable majority of suicidal behavior was impulsive and that nearly 40% of analyzed subjects had acted within five minutes of suicidal premeditation.

These studies provide insight into the impulsive and erratic nature of suicides that is not recognized within mitigative and informational discussions surrounding suicides and suicide attempts. Instead of a calculated decision, a suicide attempt can be characterized by a temporary heightening of turmoil and vulnerability. Interestingly, suicide notes, another concept behind the idea of thought-out suicides, are indeed more rare than conceded by popular understanding. Of nearly 3,000 suicides analyzed in a six-year study by the American organization of suicidology, a small proportion, slightly above 18%, left a suicide note (Cerel et al., 2014). Serving as an indicator of a thought-out process, the lack of suicide notes highlights a propensity for rapid decision-making concerning suicide. As such, suicide attempts are often impulsive, arrive at times of heightened susceptibility and vulnerability, and are all but inevitable. This evidence opposes the common conception of deliberate suicidal processes. It is one of the central realities facing one of the more significant misconceptions surrounding suicide and hindering its mitigation strategies.

More Attempts Will Follow Suicide Failures

In a Harvard opinion survey published in 2006, nearly 74% of respondents believed that if individuals who attempted suicide via jumping off the Golden Gate Bridge had been deterred, they would have been able to complete suicide at another time and through other means regardless. This survey points to another misunderstanding surrounding suicide, the belief that individuals who attempt suicide will often reattempt if their first attempt is non-fatal. In this fashion, this understanding suggests that suicide mitigation can be a futile and overwhelming process. By extention, it follows that treatment should occur within the context of repeated attempts by individuals who continue to present suicidal behaviors and who may inevitably reach a fatal attempt by sheer force of will, regardless of mitigation strategies. However, within the knowledge that suicides are oftentimes impulsive decisions, the realities presented can compound into a more nuanced and hopeful understanding. Nearly nine of every ten individuals who attempt suicide but survive will not die of suicide at a later date. A study ( Owens et al., 2018) affirmed this understanding when it found that in nine years following a suicide attempt, only 7% of patients within a series of studies and databases had fatally relapsed, and nearly 70% never reattempted.

Coming back to the topic of Golden Gate attempters, an analysis (Seiden, 1978) found that of five hundred and fifteen individuals who attempted suicide at the Golden Gate Bridge but had been deterred or survived, only about 10% (35/515) had gone on to die by suicide at a later date. This study supposes a near 90% post-attempt survival rate, one which the public, and respondents in the survey mentioned above, do not acknowledge. As such, it can be supposed that with proper rehabilitation and support, individuals who attempt suicide, survive, and progress past the lapse of vulnerability will be less likely to reattempt than common knowledge suggests and unlikely to reattempt at large. Therefore the mere idea of suicidal inevitability within individuals who have attempted is inaccurate and detrimental to mitigation strategies, and the assumption that reattempts are common distracts from the necessity of preventing suicide means and attempts on hand, as well as from other mitigation strategies.

Mental Health is the Only Factor in Suicide

While there are ties between mental health and suicide, and mental health approaches remain necessary, they are not the only routes toward mitigation. An undivided fixation on specific mental health issues in suicide prevention can be misguided and ineffective. Nevertheless, in common understanding and mitigation efforts, suicide and mental health are often conjoined in an unbreakable manner, and as such, mitigation efforts lack diversity under the mental health context. For example, an overwhelming majority of suicide charities are centered on a mental health approach, and some of the most popular online communities can demonstrate this phenomenon. The With Hope Foundation is focused on “suicide prevention through improving mental health awareness.” At the same time, the Alliance of Hope Community Forum is a forum monitored by “Mental Health Professionals”, and the Morgan Meier foundation describes suicide as “the reaction of extremely intense feelings of loneliness, worthlessness, hopelessness, or depression” to name a few.

Of course, these approaches or claims are not wrong, but these approaches are limited. There is a stark over-fixation on mental health within these communities and little acknowledgment of more nuanced realities surrounding suicide and its prevention. In fact, for many mental health issues, there is a lower prevalence of suicide than accepted, with disorders like substance abuse, schizophrenia, and depression featuring a suicide risk assessment of around 5-8%. This finding, in contrast to an approach fixated on mental health alone, encourages a stress-diathesis model, which analyzes both individual disposition and environmental influence, suggesting that suicide is more multi-factorial than common perceptions around mental health suggest (Brådvik, 2018). Furthermore, in a study of suicidal ideation in psychiatric patients, researchers (Burgess & Hawton 1998) concluded that “the suicidal wishes of psychiatric patients are not always the result of an easily treatable and reversible mental illness or necessarily of any mental illness at all,” making clear that within these psychiatric patients, other factors influenced suicide to create a more nuanced basis for suicide prediction. Further studies (Brent et al., 1993), (Brent et al., 1993), discover a strong link between suicide and the presence of firearms, and highlight instances of suicide victims without psychiatric conditions, but who are most influenced in their decision to attempt suicide by the presence of firearms rather than mental illness. Therefore, while mental health remains a significant and robust connection with suicide, there remains space for analyzing other factors. This conception becomes especially apparent when constructing predictive and preventive measures, in which the connection between suicide and mental health has not been transferred, and the usage of mental health strategies lacks efficacy. This understanding leads us to the next major misconception.

We can best predict and mitigate suicide through psychiatric or mental health analysis alone

Since mental health is the primary fixation within the study of suicide, predictive and preventative measures are generally focused within the same context. This fixation can be seen through the statements of the organizations above and many organizations in general, in which mental health and the amelioration of mental health crises galvanize their efforts. These are sound efforts toward a broader attack on the suicide endemic. However, within the scope of predictive measures, which are necessary for ameliorating the suicide endemic, psychiatric and individual analysis, contrary to how they are commonly seen, are ineffective in predicting suicidal behaviors. In a meta-analysis of nearly three-hundred and sixty-five studies (Franklin et al., 2017), researchers found that predictive measures based on common risk factors (mental health issues, mental disorders, etc.) were only slightly better than chance for all outcomes and that no broad category could accurately predict far above chance levels. Furthermore, studies rarely examined the combined effect of multiple risk factors, and the researchers found that risk factors analyzing internal psychopathology accounted for a dominant 25% of all risk factor analyses. This led the researchers to suggest a multi-factor approach via algorithmic methods. As such, current single-factor prediction methods, structured mainly on mental health practices, are not effective alone, and there remains a necessity for multi-factor analysis to supersede a fixation on psychiatric analysis. Continuing, another study (Noch et al., 2022) analyzed clinician assessments, predicting one-month and six-month risk factors of a little over eighteen-hundred patients admitted to an emergency department, and found that clinician prediction was little better than chance at anticipating which of the patients would go on to attempt suicide within the time frame. It therefore becomes problematic to endorse mitigating efforts on the single factor analysis of individuals’ mental and psychiatric status, which has been fixated on in both research and shared understanding, and has distracted from other efforts through its sheer domination of the study of suicide. Instead, a multi-factored and open approach, acknowledging public and social causes of suicide, can be used in conjunction with preexisting strategies to access more immediate and attainable solutions.

Suicide is a problem tied to the individual

The effects of the various misconceptions above compound into a general focus on the individual, and the absolvement of the public, within a suicide endemic that can also be approached through a community lens but is often not. Risk factors, predictive measures, and treatment generally rely on individual examination and individualistic context. This focus manifests in focus on individual assessment and sometimes individual blame. Often, treatment and prediction efforts will include examinations of psychiatric conditions, recent life events, substance use habits, relationship happenings, job loss, family history, and more. On the other hand, aggregate suicide statistics, patterns, and trends indicate that suicide can be considered a public and social problem and can be mitigated as such. For example, per 2020 NCHS data briefs, stark disparities remained within suicide rates regarding demographic factors such as location and gender. Rural male suicide rates rose to 30.7 per 100,000 by 2018, while urban rates were at 21.5 per 100,000. Female rural and urban suicide rates reached 8.0 and 5.9 suicides per 100,000, respectively. As such, there remain significant social and demographic disparities within the suicide endemic along both geographical and gendered lines. Further, as a 2019 NCHS data brief highlighted, disparities exist along racial and ethnic lines. Suicide rates for American Indian and Alaskan Native populations (33.8 per 100,000 for men and 11.0 per woman), as well as for Whites (28.2 per 100,000 for men and 7.9 per woman), proved to be significantly higher than figures for other racial and ethnic populations such as Hispanic populations (11.2 per 100,000 for men, 2.6 for women) and African American populations (11.4 per 100,000 men, 2.8 for women). Another study ( Ellison et al., 1997) found a religious homogeneity index to be inversely related to suicide rates, while further studies (Baller & Richardson, 2002) found evidence suggesting that the geographical clustering of suicides in France and the United States was caused by the influence of both social integration and imitation factors. These studies support the understanding that suicide prevalence depends on compounding circumstances much more significant than just the individual, such as culture, social networks, access to means, environmental influence, geographical situation, gender socialization, and more. As such, there is strong evidence suggesting that suicide is influenced on a social and public level and can therefore be treated on a social and public basis. Furthermore, an over-fixation on an individualistic lens in the analysis and mitigation of suicide can be misguided, and distract from more attainable public solutions, such as the ones we will discuss below.

The Shortcomings of Current Mitigation Strategies

Introduction

The suicide endemic is growing, and current understandings and strategies, often solely fixated on individual analysis and ignorant of social and public factors, have not been practical enough. From 2000 to 2020, suicide rates in the United States rose nearly 30%, per the CDC. Not only have current mitigation efforts failed to minimize the existing suicide endemic, but they have also failed to prevent its growth; there remain difficulties that encumber mitigation efforts. Current strategies constructed on the common misconceptions outlined above are faced with mitigation difficulties that face these misconceptions. Furthermore, limitations of healthcare infrastructure within the privatized systems of the United States limit the efficacy of strategies solely based on the prediction and treatment of suicide through a psychiatric approach or the assessment of a mental health crisis. As such, on an aggregate level, the current, overly individualistic approach to suicide research, treatment, and prediction struggles to slow and reverse the suicide endemic due to difficulties we will discuss below.

Stigma

Despite the more than one thousand suicides at the Golden Gate Bridge since its opening, its only recently approved suicide barrier is yet to be completed. As mentioned in the expository New Yorker article ‘Jumpers,’ when a then engineer, Roger Grimes, protested along the Golden Gate Bridge in 1976 for the construction of a suicide barrier, his sign was met with flying soda cans and people telling him to jump himself, even in what can still be described as among the most progressive cities in our nation. Thus, the collection of misconceptions and the individualistic approach towards the suicide endemic produce a stigma that significantly impairs national mitigation efforts. As the British Journal of Psychiatry lamented, “the stigma around suicide remains just high enough to discourage people from discussing their suicidal thoughts” (Jadros & Jolley 2018). Ultimately, this runs in conjunction with the individualistic approach; when the roots of suicide are said to come from the individual, whether spoken or unspoken, the individual becomes partially culpable by societal standards.

Furthermore, alongside the discussion of suicide, moral weakness remains an understanding held by common thought, while individual pathology might be the equivalent in the more educated realms of research. Ultimately, stigma is harmful to the cultivation of public interest in mitigating suicide and treating suicide patients. In an analysis of public opinions, researchers have found the stigma toward Non-Suicidal Self Injury (NSSI) within sample populations to be significant to the extent that it may impact help-seeking behavior (Lloyd et al., 2018).

Furthermore, social acceptance of suicide is negatively correlated with suicide rates, in which nations and regions where suicidal behaviors are stigmatized have been found to maintain higher suicide rates (Schomerus et al., 2014). As such, the stigma around suicide is harmful to the broader treatment of the suicide endemic and is also largely present in our society. If mitigation efforts are to be reformed, public responsibility and involvement in the suicide endemic must be analyzed and accepted to relieve the blockading influence of stigma on the individual, and allow for the crafting of more immediate solutions.

Practical Inabilities

Alongside stigma, there remain practical limitations plaguing the current models and approaches to suicide. As outlined, beliefs that suicidal individuals often have a mental illness, engage in the process of deliberation, and progress through a state of inevitable deterioration do not run in conjunction with reality. As such, mitigating efforts that solely dedicate themselves to these conceptions, such as those focused on clinical prediction and analysis of the individual, have failed to prevent the growth of the suicide endemic. Practical limitations include the lack of preventative measures in the context of the rapid suicidal decision, the inability of physician-based prevention, and the ineffectiveness of general medical and clinical approaches toward the unique case of suicide. To start, the impulsive disposition of suicide, as discussed above, means that preventative measures would be most successful if focused on aiding the individual during crises rather than the more complex undertaking of ameliorating suicide in its early stages. Since, per the CDC, firearm deaths make up nearly half of all suicides, this could include reducing access to means in our social environment, like firearms, in order to block an individuals ability to attempt suicide while in a temporary crises. Currently, many preventative measures involve medical prediction that employs earlier mitigative strategies. However, as noted before, psychiatric practitioners are largely ineffective when asked to stretch their disciplinary limits and predict suicidal behaviors that are often the product of temporary crises. General practitioners prove to be similarly ineffective; Of 286 cases of suicide examined in a study (Pearson et al., 2009), 91% of individuals contacted their general practitioner within a year of committing suicide, but in only 27% of cases were concerns reported prior to the suicide, leading researchers to conclude that “Consultation prior to suicide is common but suicide prevention in primary care is challenging.” As such, while there remains a focus on psychiatric prevention of suicide, the medical professionals most often contacted by suicidal patients have not produced ameliorating results within the strategies of suicide prevention in the earlier stages. Continuing further, the use of psychiatric strategies (Mehlum et al., 2006) and psychological treatments (Brown, Jager-Hyman 2014), including therapy and pharmaceutical treatments, are either ineffective at mitigating suicide or in need of further improvement, leading further researchers (Large, 2018) to conclude that “Refraining from the temptation to predict suicide in clinical psychiatric practice might even assist suicide prevention.” In this sense, the commonly accepted notions of suicide and its prevention, including the processing of patients through routinized healthcare avenues, and mediums of individual prediction, consultation, and treatment, prove to be limited by a series of practical limitations that drawback to the realities behind the misunderstood suicide endemic. As researchers (Cole-King, Lepping) have enunciated, we need to ask ourselves ‘What can be done to prevent this person harming themselves today, this week, this month?” and move past the desire for an outright and clinical “cure” toward suicide when there are approachable and multidisciplinary methods available.

The Inadequacies of the Public Health Care System in Mitigating Suicide

Another, albeit less mentioned, question behind the mitigation of suicide through an individualistic and psychiatric lens would be our nation’s ability to provide widespread access to the clinical methods necessitated by such a model. Nearly one in every five (53 million) Americans suffer from varying mental illnesses. Nevertheless, studies analyzing the National Comorbidity Survey indicate that only 15.3% of respondents received minimally adequate treatment for severe mental illness (Wang et al., 2002). Meanwhile, in a report on suicide mitigation strategies, the CDC laments that “relatively few people in the US with mental health disorders receive treatment for those conditions.” Furthermore, a large proportion, two-thirds, of physicians reported that they could not get outpatient mental health care for patients, which is nearly two times that of other services, due to inadequate insurance coverage (Cunningham et al., 2009). As such, there remain healthcare and insurance barriers to providing mental health care at a rate that current strategies necessitate. Even further, in an aggregate analysis, our current healthcare system, even if made available to all, may not have the capabilities to combat a national mental health crisis; over 155 million Americans, often in low-income communities, live in Health Professional Shortage Areas (HPSAs), or areas with inadequate mental health infrastructure and capabilities. It seems unfortunately and unjustly predictable that treatments would tend not to reach those of lower socio-economic status, especially in our privatized healthcare system, but even more jarring is the fact that treatments are not reaching the severely mentally ill patients who would be at the highest risk for suicide. These are two glaring wrongdoings within the broader incapabilities of our healthcare system and its necessity for suicide prevention. Therefore, if current strategies necessitate large-scale mitigation of the suicide endemic through a parallel, clinical movement against the mental health crises, they remain hindered by our inability, through coverage and healthcare delivery difficulties, to provide access to clinical treatment and prevention of suicide for all. This understanding further necessitates the need for more diverse and attainable prevention methods outside of the current model.

Immediate and Practical Prevention Methods

Introduction

We live in a society with several complex social problems, but suicide does not have to be one. There are many attainable and immediate ways to prevent and mitigate suicide and circumvent the debilitating circumstances around the suicide endemic. In this paper, we have discussed the presence of a harmful over-fixation on individualistic, psychiatric approaches to suicide mitigation; however, through a public and social lens, we can create a multidisciplinary approach and achieve more immediate gains in suicide mitigation. Continuing on the theme of public responsibility, we will discuss the following immediate and practical solutions toward suicide mitigation that move past the individualistic view and incorporate the realities behind the suicide endemic.

Reducing Means Toward Suicide

To most immediately combat the suicide endemic, restricting means remains the most viable pathway. This strategy aligns with the argument we have laid out; if suicides come at impulsive moments of vulnerability, and are unlikely to be followed by further attempts, then restricting an individual’s ability to attempt or complete suicide on hand becomes incredibly important to mitigative efforts. Most importantly, limiting access to firearms, which prove to be tools of no return, would prove the most effective policy for reducing suicide rates. Of all suicides in 2020, nearly 53 % involved a firearm (CDC). Furthermore, of all suicide methods, firearms remain the most lethal, at around an 83% fatality rate as opposed to lower rates for suffocation/hanging (61.4%) and significantly lower rates for Poisoning (1.5%) and cutting/piercing (1.2%), which represent the other most common means toward suicide (Spicer & Miller, 2000). Continuing, several studies show that the presence of firearms can have an inflating effect on suicide rates; in case-control studies, guns were twice as likely to be found in the homes of those who had made fatal attempts (Brent et al., 1991), and further research finds that the relationship between suicide and the presence of any firearm within a household are significant (Brent et al., 1993). On an aggregate level, regions of the United States with high gun ownership were found to possess suicide rates nearly 14% higher than regions with low gun ownership (Miller et al., 2002), while studies controlling for regional culture variation found that short-term exposure or visiting regions with high gun ownership, by outside residents, was found to have a positive effect on suicide rates (Shrira & Christenfield, 2010). As such, we know that guns have a significant, and potentially causal, effect on suicide on an individual and aggregate level— as the Harvard School of Public Health states, “Every study that has examined the issue to date has found that within the US, access to firearms is associated with increased suicide risk.” In regards to the progression from restricted methods to available methods, it has been further demonstrated that many individuals will not progress past or substitute their favored method, which often exists, if they find it restricted (Hawton, 2007). Furthermore, it is known that restriction of means has proven successful at reducing suicide rates in the past; suicide rates fell with the restriction of access to carbon-monoxide methods via charcoal in Hong Kong (Yip et al., 2010), regulation of lethal pesticides often used in Sri Lanka (Gunnell et al., 2007), and the decades’ long progression from monoxide usage in domestic gas in the United Kingdom (Kreitman, 1976). The restriction of means, mainly firearms, remains a necessary strategy in suicide prevention through both quantitative and qualitative understandings of suicide. If our nation is willing to reduce means, such as by taking steps to reduce firearm access or building suicide barriers in places like the Golden Gate Bridge, it can incorporate an understanding of the public power and responsibility within the suicide endemic. Its subsequent recognition of suicide means can be an effective preventative strategy, which accepts the overwhelming numerical and contextual evidence toward a more holistic approach regarding suicide prevention.

Optimizing Media Output and Suicide Contagion

Media reporting on suicide has been demonstrated to strongly correlate with suicide rates. As such, the optimization of media output concerning suicide contagion is necessary. Generally, suicide contagion can be understood within social learning theory, in which individuals are influenced by imitation effects and social tides larger than themselves, and can produce suicide clusters as a result. In this sense, regulating media output can be a powerful mitigative tool. In a 1979 study, to be followed by further studies (Kuezz et al., 1986), (Michel et al., 1995), Dr. David D. Phillips found a positive correlation between front-page or marked reporting styles of suicide and an increase in suicide rates, an effect he dubbed the “The Werther Effect” (Phillips, 1974). The Werther Effect remains the basis for suicide contagion theories and can be accessed for mitigative strategies. Meanwhile, in an international comparative study, nations where suicide is reported in a more discouraging light (The United States, Finland, and Germany), have been found to have lower suicide rates than nations that portray suicide in a more open light (Hungary and Japan) (Fekete et al., 2001). Furthermore, researchers (Niederkrotenthaler et al., 2010) have found that repetitive reporting of suicides and suicide myths also correlates with increased rates, while reporting of suicidal thoughts that are not followed by a suicide attempt correlates with decreased rates. Therefore, there remains an influence of media reporting on suicide contagion, but there is further evidence supporting the fact that reporting guidelines can prove beneficial. During a spike in suicide attempts on Viennese subways in the 1980s, the implementation of media reporting guidelines and restrictions proved successful at reducing subway suicides by nearly 75% over several years (Sonneck et al., 1994). In the opposite fashion, when California Highway Patrol and local newspapers used to keep a running suicide count for the Golden Gate Bridge, landmark numbers like 500 and 1000 were met with cases of suicide frenzy. As a result, many organizations, including charities and the CDC, have offered guidelines for newspapers and media corporations to use to aid media regulations. Nevertheless, in a study analyzing the acceptance of basic guidelines set forth by the Samaritans, an organization from the UK that deals with mental health and suicide, it was deduced that 199 of the 229 articles examined failed to comply with one of the said guidelines, such as mentioning support sources or avoiding excessive or influencing details (Utterson et al., 2017). Thus there remains room for improvement within the reporting of suicide. Media reporting has been demonstrated to positively and negatively influence suicide rates, depending on how it is displayed. The narrative surrounding individuals within our societies can influence their suicidal vulnerability. Therefore, we must accept the public responsibility of establishing proper reporting and journalistic guidelines, via the acceptance of suggestions put forth by knowledgable organizations, to combat another of the many social influences on suicide effectively.

Creating More Standardized Data Collection and Classification Methods

Another difficulty that plagues suicide mitigation efforts is the struggle that our society experiences in tracking and classifying suicide cases. If suicide efforts are to be adequately addressed and organized, data sets behind suicide research, and further action, must be accurate and standardized. Lack of resources, lack of information, communal stigmas, ambiguous classification systems, and the perplexing nature of suicide are all barriers that can hamper the classification of individual suicides and create inaccuracies in aggregate measures of suicide. (Silverman, 2016) captures the difficulties of suicide classification systems in the face of widespread moral and procedural ambiguity in the field of suicidology. Meanwhile, on an aggregate level, African American and Hispanic suicide rates have been found to experience excessive rates of suicide misclassification due to cultural differences in classification, explaining the misleading gap in White and African American suicide rates ( Wang et al., 2010). In the past, studies have indicated a social construction of suicide rates and a range of misclassification. (Pescolindo & Mendelsohn, 1986) Highlighted the influence on suicide rates by the social organizations or groups tasked with counting them and the presence of widespread and consistent miscalculation at the hands of responsible agencies. Furthermore, (Douglas, 1967) demonstrated the principle that suicide rates are often constructed by external social factors, while statistics experience widespread error as a result. For example, From 1985 to 1989, suicide rates in New York City fell substantially due to policy changes in the New York City Chief Medical Examiner’s Office, which was engaging in preservative practices in the face of backlash and criticism at the time (Witt, 2006). These shifts affected efforts to measure or quantify suicide behavior or approach mitigating strategies, and demonstrate the malleability of suicide statistics in the face of broader social movements. As such, even the most advanced nations struggle to compose suicide statistics. To better understand or approach the suicide endemic, we must accept standard approaches to classification and provide practitioners with the resources to properly examine cases of suicide. It is imperative to construct an objective classification and nomenclature system, which currently does not exist, that can avoid the variation present in suicide classification systems.

Reform of Cultural Influences Behind Suicide Ignorance:

Everything from the language we use to the narratives we create can impact our ability to mitigate suicide rates in the United States. In an expressly individualistic culture, our understanding of and interactions with suicide can become harmful. As we have seen earlier, there are many specific misconceptions surrounding suicide, but our society also engages in broader malpractice as a whole. The obsessive individualism that the United States has grown around makes it almost inevitable for our strategies against suicide to be so focused on the individual and mental health strategies. As such, the difficulty of releasing this rugged individuality disposes us to focus our efforts on the individual’s well-being, not the communities and demographics that encircle them. Much in the American tradition, each individual is seen as a carrier of their outcome, and each instance of suicide is seen as its outlying case. Whether spoken or unspoken, individuals are cast off, blamed even, for what is seen as a pathology of their mind or weakness of their disposition. Because social solutions do not fall within the cultural paradigm of individuality, they are often displaced by a hyper-fixation on the individual, which does run in conjunction with our societal values. Nevertheless, as we have argued, suicide is as much an affliction of the individual as it is a social failure, and suicide is a unique tragedy that the United States cannot force its cultural values upon. If we can find the humility to deviate from our cultural values when approaching its suicide endemic, we can more effectively combat a social issue of our time. We could do this by providing social support, easy access to crisis management, restricting suicide means, creating more accepting discussions on suicide, and more. However, while there are many solutions available, to approach them or move on to the solutions we have highlighted in this paper, we must start by reforming our nation’s thoughts on the individual and suicide. We must absolve the individual of its scrutiny in the suicide endemic and move past our cultural beliefs to craft a more knowledgeable and viable strategy against suicide.

Conclusion

The suicide endemic and our efforts to mitigate it remain oriented around individuals and individual-level approaches. Moving forward, we must first adjust and update our understanding of the suicide endemic; contrary to the individualistic fixation on mental health, the individual is not culpable in the broader social patterns that influence their propensity for suicide, and current approaches reveal how suicides are regulalrly misunderstood. Our current mitigation strategies, bogged down by practical limitations and stigma, must be reformed to accept the broader social responsibility and act accordingly by accessing strategies that challenge the current methods. We can do this by accepting the realities and strategies we have displayed behind our theme of societal solutions. If we broaden our view of suicide and its mitigation, we can approach a public health issue that has too often been considered intractable, and make progress towards reform and change. In this sense, we can persevere in the face of what might feel like an overwhelming number of social problems today.

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About the author

Victor Josifovski

Victor is a senior at Los Gatos High School. He is a huge history buff, and enjoys reading, everything from Orwell, to Hemingway, to Dostoevsky. Victor also enjoys playing basketball, both through clubs and his school team. He coaches youth sports in his free time.

The post Suicide Mitigation: Moving from an Individualistic Lens to a Collective Analysis in Preventing Suicides appeared first on Exploratio Journal.

Abstract

Our study is aimed to address to the problem of low HPV vaccine coverage rate among Hong Kong female citizens in different social levels. According to the Hong Kong Cancer Statistic Website, the prevalence and mortality rate of cervical cancer among Hong Kong female citizens does not show a decrease trend, which draws us the attention of the severeness of this disease. The key to solve the problem is to increase the HPV vaccine coverage rate among female citizens. Our analysis is carried out from three perspectives, including government, society and individuals. Each factors are analyzed from two opposite perspectives–enablers and barriers. Recommendations are also provided for dealing with the issue in the future. Improving the program coverage range, solving the high cost of HPV vaccine and promoting more information regarding the disease are at great necessity in dealing with this problem. 

Keywords: human papillomavirus, HPV, vaccination, Hong Kong 

Introduction

Cervical cancer, mostly caused by HPV, has high infection risk among woman. “Cervical cancer was the eighth commonest cancer among females in Hong Kong and accounted for 3.0% of all new cancer cases in females in 2019. In 2020, a total of 159 women died from this cancer, accounting for 2.6% of female cancer deaths.”(HP, Jan. 4^th, 2022, “Cervical Cancer”). Female around the world are under the risk of getting cervical cancer, and from the statistic, this trend is continuous, which needs well treatment. Therefore, studying this topic is at great necessity. We specifically focused on Hong Kong as a target city to investigate the situation of HPV vaccination. And our main focus is mentioned below.

HPV vaccine is now designed and shows the effectiveness in curing cervical cancer. HPV has been a popular topic in Hong Kong, both attributed to the vaccine availability and promotion. Before the Covid-19 pandemic, thousands of people in the mainland traveled to Hong Kong annually to take vaccination because of the 9-valent vaccine availability. Since the 9-valent vaccine can be taken from age nine to forty five, It has been the most decisive factor that affects people’s preference of taking vaccine in Hong Kong. The rate of infection with HPV rapidly increases after thr first sexual intercourse. Therefore, only vaccine in Hong Kong can better prevent cervical cancer for high risked age group. Prevalence and mortality trends from cancer registry data in Hong Kong show a stable high rate. Therefore, it is important and necessary to draw more attention on this disease and promotion on the HPV vaccine, which is the most effective way for prevention. Addressing to cervical cancer’s severeness, its symptoms and consequence would be fatal. Moreover, the high risk of getting it makes it a more worth-study disease. Since HPV leads to 90% of cervical cancer, the necessity of taking HPV vaccination can effectively decrease the risk of getting this disease. Even though the HPV vaccination program in Hong Kong shows its advantage, its coverage rate is far less than it is supposed to have. As a result, finding out all these barriers and improve them can increase HPV vaccine coverage rate, and substantially reduce risk of cervical cancer. Also, knowing all enablers gives people a direction to further maintain and improve the actions towards cervical cancer prevention. In this article, we use statistics and information from related articles to analyze the enablers and barriers of HPV vaccination uptake among Hong Kong female citizens. 

Methods

For the enablers, our article based on results reorganized from the questionnaires that were previously designed to find out factors that encourage people to take this vaccine. Factors are categorized from three social levels: government, society and family. We analyze how each level of the society can lead to people’s action to take vaccine. Based on the result, we come up with recommendations that can be taken in the future for maintaining such advantages. For barriers, we also analyzed from above three social levels. Aiming to find out factors that hinder people from taking the HPV vaccine. We stress advice and potential action society can take to improve the coverage rate. 

Data on cervical situation in Hong Kong are collected from Hong Kong Cancer Statistic Center, and information regarding people’s attitudes are obtained from questionnaire answered by parents regarding HPV vaccine knowledge and attitudes towards vaccination uptake. Using these data, we analyze barriers from the family aspect.

The incidence rate and mortality rate from 2010 to 2019, people aging from 20 to 65+ perform a relatively stable trend. The rate are still high, and the situation does not see a obvious improvement even after the introduction of HPV vaccination. In order to decrease the incidence and mortality rate in the near future, the most urgent problem to solve is the vaccine coverage. (Fig 1)

Overview of Enablers and Barriers

The main enablers and barriers from a Government perspective are related to promotion, health insurance schemes, students’ vaccine uptake programs. The main enablers and barriers from a societal perspective are vaccine availability in hospitals and clinics, and social environments on HPV vaccine uptake. The main factors affecting HPV vaccine uptake from families perspectives are people’s attitudes towards the vaccine cost, the awareness and concern about the vaccine safety and also the effectiveness of the HPV vaccine (Table 1). The following paragraphs address main enablers and barriers and recommendations for improved HPV vaccination uptake. 

Cost as an important factor for HPV vaccination

Enabler for young children, but barrier for older female. 

This mainly comes from government and family levels. Hong Kong government has address HPV vaccine program through female citizens, especially children in primary school. The Centre for Health Protection announced in 2018 that from 2019 to 2020 school year, eligible female primary school students under suitable age will taken HPV vaccine under Hong Kong Childhood Immunisation Programme. This action can both be enabler but at the same time a barrier. Primary school children can be prevented from getting cervical cancer by being protected by HPV vaccine without any cost. Therefore, parents do not need to concern about the cost of the vaccine. As a result, this new generation can be protected almost without future risk of getting cervical cancer. Even though new generation can be protected, those who are already expired from eligible age groups are still risky. Since female at older age are not covered in such program, they have to pay extra money to take vaccine. However, the market price of the HPV vaccine is more than $7000, which is a burden for most families. This inconsistent relationship still exist and should be solved, or it will be a continuous barriers for people aged from 45 to 60 for at least many years. The further approach to include all aged group female into similar program needs to take into consideration. 

Knowledge courses are needed and media outreach 

Enabler for future but barrier currently

Government’s promotion can also act as a encouragement, letting more citizens be aware of cervical cancer and thus uptake HPV vaccine. Information regarding HPV is abundant in Hong Kong, and this can be seen from the public websites designed specifically for cervical cancer. Basic knowledge like symptoms, risk groups and treatments are available through Hong Kong HPV website and Hong Kong Cancer Statistic website. The simple access to such information is for sure an enabler for citizens to attach HPV vaccine. Furthermore, since many people each year come from the mainland to Hong Kong to get the HPV vaccine, we found that online registers are available and easy to find. Government’s attention and promotion related to cervical cancer risk and prevention can play an important role in turning the course of the currently increasing worrying disease’s situation. 

After the survey of finding out the proportion of people never heard of HPV vaccine before, it shows that only few people never heard before. (Fig 2) Therefore, it shows that HPV vaccine is famous in Hong Kong, and most people at least have some knowledge about it. This will create a positive environment for improving HPV vaccination program and increasing protection among female citizens in Hong Kong at risk of cervical cancer.  

Aiming to analyze factors influencing HPV vaccination uptake, it is essential to understand the overall situation of cervical cancer prevalence among different age groups in Hong Kong. Based on our data collected, the following results are specifically address to parents and children. We hope that by analyzing this group of people, we can inform improvements for future HPV vaccination programs to increase vaccination coverage, hence reduce cervical cancer incidence and mortality among the whole population at risk(female citizen in Hong Kong)

The first factor is the consideration of safety of HPV vaccine. From the result provided by parents, most of them hold that the safety is a influential factor that affect their decision on vaccine uptake. Still many people care about this factor is partially attributed to the uncovering range of HPV vaccine, which wipes out people’s confidence. From experiment carried out before testing the safety of 9-valent HPV vaccine, the result is optimistic– “Administration of a 3-dose regimen of 9vHPV vaccine to adolescent girls and young women 12-26 years of age who are prior qHPV vaccine recipients is highly immunogenic with respect to HPV types 31/33/45/52/58 and generally well tolerated.” Therefore, it is known that it is people themselves do not understand the safety of HPV vaccine, but not the problem of the vaccine. As a result, doing more promotion on HPV vaccine’s security is necessary to improve the vaccine coverage rate. The effectiveness can also be ensured based on previous study, “ The 9vHPV vaccine prevented infection and disease related to HPV-31, 33, 45, 52, and 58 in a susceptible population and generated an antibody response to HPV-6, 11, 16, and 18 that was noninferior to that generated by the qHPV vaccine.” As a result, the promotion is now the most essential. (Fig 2)

Another factor comes to people’s worries on cost. From Fig X, it shows that more than half of respondents really cares about the cost of HPV vaccine. This result shows the proportion that I previously imagined since the government now provides primary school students’ free uptake of HPV vaccine. Therefore, only about half of people really care about the price. However, for other aged group, the proportion of influential would be much higher. If this vaccine cost a lot, it becomes a burden for most of people, and therefore discourages people to take the dose. Moreover, from the data collected through the internet, we found that HPV vaccine are taken mostly in private clinic in Hong Kong for people not benefit from the program, priced from $6630 to $7800 for total three doses of 9-valent HPV vaccine. This is a huge expense for many family. Therefore, it is a problem of cost that hinders many family from getting their daughters vaccinated. 

Even though the government now provides a program that enables primary school students take this vaccine for free, but the coverage rate can be hard to increase since other aged groups are not included in this program and cost is still a concern for most of them. In conclusion, the cost is still a barrier for most aged group people. Government can consider adding this program into people’s health insurance. But this still needs a long way to go since it need to include several factors, including the cost-effectiveness and governments’ budget. however, it is said that the current cost-effectiveness is maximized according to total benefit analysis by several studies. “This analysis predicts that the current HPV vaccination strategy can be considered cost-effective and will provide maximum health benefit.” Thus, this potential solution need to think about whether the total benefit can be retained. The balance between them need to be considered. 

Moreover, government’s promotion have two sides. For one side that act as the barrier, it is the lack of promotion from public media and education, but this result is only given from the answer of parents. Therefore, the result is quite limited, which cannot use to reflect the whole population. The above image shows peoples’ answers towards a particular question in the questionnaire: How did you learn about HPV vaccination? Mass media. Almost all people choose the answer no, which means public media does not act as a promoter of HPV vaccination. However, mass media is one of the most effective bridge connecting citizens and government. Tones of information can be provided through media, and it is the most common way for people to sense the surrounding issues. Using media to promote HPV vaccine and teaching information regarding it can be a potential way for people to learn about the importance of taking HPV vaccine, and thus shifts many people’s attitudes towards the vaccine safety, effectiveness and necessity. Therefore, using mass media properly on this issue can make a difference. At least, this group of people can learn more about HPV vaccine and its necessity. 

Extending age target group is crucial

Enabler for children under the program, but barrier for adult female who is not included

Another barrier is also play on particular age group–women at older age who are at the highest risk of getting cervical cancer, depending on sexual behavior. From Fig 1, it is apparent that women aged from 45 to 64 occupy the largest portion in every year’s new cases. Their proportion ranges from 40% to 60%, which almost half of all age groups that suffer from this disease(Fig 1, ). However, the eligible age of taking HPV vaccine ranges from 9 to 45. Therefore, the delay between recommended age for HPV uptake and age group at highest risk of disease is one barrier. This means that people who never take HPV vaccine before age 45 cannot get the protection when coming to ages with highest infection risk. This shows the barrier of the vaccine itself, but also emphasizes the importance of promoting vaccine uptake in new generations. As a result, continue developing the vaccine is necessary but needs sufficient time to reach the purpose, which can be beneficial for making the vaccine possible to cover more aged group people. 

However, for this point on extending the target group is much more challenging than previous solutions. People’s concern and understanding towards cervical cancer and HPV vaccine are things that needed to be solve at first, which may facilitate the further coverage of HPV vaccination. Therefore, using media as a promoter should be carried out firstly. For the cost and vaccine ability of extending the target group is the most crucial but difficult thing that government need to concern about. As a result, we suggest that the previous two factors can be solved before this one. 

Conclusion

In conclusion, the statistics regarding cervical cancer among Hong Kong female citizens alarms us the importance and urgency on improving the HPV vaccine coverage rate. By analyzing data collected from questionnaires answered by parents and children among Hong Kong citizens, we address to the vaccination coverage problem from three aspects, and each includes the enablers and barriers. Through different social level, from government to society and individuals, we also come up with several recommendations for people to apply in the future for improvements of vaccine coverage rate among Hong Kong female citizens. The analysis from this particular group of people can be a reflection on nowadays’ coverage problem, and the results and analysis draw from this age group can extend to all Hong Kong female citizens. By improving the consistency between HPV vaccine program and female’s age group is of great necessity in solving this issue. Moreover, the consideration of knowledge promotion by government and family members can also improve the situation. From the vaccine itself, extending its age target group can be helpful even though it needs time to develop in the future. 

References

[1]Cheung, T.H., Cheng, S.S.Y., Hsu, D.C. et al. The impact and cost-effectiveness of 9-valent human papillomavirus vaccine in adolescent females in Hong Kong. Cost Eff Resour Alloc 19, 75 (2021). https://doi.org/10.1186/s12962-021-00328-x

[2]A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women DOI: 10.1056/NEJMoa1405044

[3]Hospital Cancer Registry Hong Kong https://www3.ha.org.hk/cancereg/

[4]Centre for Health Protection(HP) https://www.chp.gov.hk/en/healthtopics/content/25/56.html

[5]Yuen WWY, Lee A, Chan PKS, Tran L, Sayko E. Uptake of human papillomavirus(HPV) vaccination in Hong Kong: Facilitators and barriers among adolescent girls and their parents. PloS One. 2018;13:e0194159. doi: 10.1371/journal.pone.0194159

[6]Tran L. Uptake of HPV Vaccination in Hong Kong. Harvard Dataverse; 2018. doi: 10.7910/DVN/866CZH

About the author

Yichi Zhang

Yichi is currently in 11th grade at the High School Affiliated to Renmin University of China. Her passion for public health started two years prior, while taking the course of”Pandemic, Epidemic and Outbreak” at JHU summer school. In her spare time, she enjoys drawing particularly in the style of Georgia O’Keefe, playing tennis, and swimming.

The post Enablers and barriers of human papilloma virus (HPV) vaccination among female Hong Kong citizens: Secondary data analysis of school program questionnaires appeared first on Exploratio Journal.

Abstract

From past times to recent times antibiotic resistance has emerged as a global threat. Antibiotic resistance has mainly affected the progress in health care, food industries and ultimately life expectancy. Almost all regions of the world are suffering from these antibiotic resistant diseases. This is mainly due to the movement of people, animals and goods across borders and countries. The emergence of different species of bacterium like Staphylococcus aureus, Enterococcus faecium, Streptococcus pyogenes, Staphylococcus pneumonia and more by adapting various defense mechanisms, has lead to the development of resistance towards antibiotics like Penicillin and Methicillin. This resistance is mainly caused by the presence of two important genes called mec-A that codes the PBP2a protein. mec-A and PBP2a are known to confer resistance, but the mechanism of resistance remains unclear. Further study of the mechanism has the potential to develop a new generation of antibiotics. Here, we have investigated the structural biology basis of PBP2a antibiotic resistance and the contribution of the genetic background of resistant S. aureus strains. It has been found that PBP2a confers resistance through its Ser403 residue in its active site, but that PBP2a is not sufficient to drive resistance. Genetic studies have identified an additional gene responsible for conferring PBP2a-based resistance, that is the bla gene that codes a beta lactamase. The presence of bla genes along with mec-A is important for effective activity of the PBP2a protein, as the presence of mec-A alone showed insufficient activity of the PBP2a protein. Western blot analysis of PBP2a expression in different S. aureus strains determined, that the concentration of PBP2a protein was high in cells containing plasmids that carried both mec-A and bla genes and low concentration of PBP2a was found in cells containing plasmids carrying only the mec-A gene.

Introduction

Antibiotic resistance is a property where a bacteria becomes resistant to antibiotics that are designed to kill them. Bacteria can escape inhibitory effects of drugs by acquiring certain mechanisms of resistance. There are several problems that are caused due to the persistent increase in the antibacterial resistance in bacteria. Antibiotic resistance occurs naturally by random mutations (Julin Davis and Dorothy Davis, 2010) through the process of natural selection and also can occur by selective pressure on the bacterial population (Alfredo Tello, et al. 2012). If a resistant gene is generated, it can be transferred from one strain to another by exchange of plasmids through horizontal gene transfer (HGT). During this process of acquiring resistance the antibiotics act as environmental pressure, due to which bacteria undergo certain mutations for its survival. When such strains proliferate, they produce progeny that are resistant towards various antibiotics by evolving certain resistance mechanisms.

Over usage of antibiotics, usage of broad spectrum antibiotics, incorrect diagnostics, unwanted prescription, wrong usage of antibiotics by patients and use of antibiotics in cattle feed for enhancing early growth, are mainly responsible for antibiotic resistance. It was discovered that the lexA gene is mostly responsible for these mutations (Charlie Ye Mo, 2016). A bacteria called Staphylococcus aureus is one of the major resistant pathogens, which is responsible for causing various diseases. Later on it became known as MRSA that was first detected in Britain in 1961, which is resistant to the methicillin antibiotic. Later in 1991, 4% of fatal cases of infections were recorded and rose to 37% by 1999 in the UK. In the USA 50% of the Staphylococcus aureus were resistant to tetracycline, penicillin, methicillin and erythromycin. Vancomycin used to be an effective drug at that period for Staphylococcus aureus but in the late 1990’s intermediate strains were detected with moderate resistance to Vancomycin at 4 μg/ml, which was named Vancomycin intermediate Staphylococcus aureus. In Japan in 1996 the first case was identified with a strain which is resistant to Vamcomycin at >16 μg/ml and the second case was found in the USA in 2002 (Susana Gardete and Alexander Tomasz, 2014 july).

In the late 1990’s new antibiotics like oxazolidinone and linezolid were found to be effective against MRSA. In 2003 Staphylococcus aureus resistance to linezolid was observed. CA-MRSA, community acquired MRSA, is the most common antimicrobial drug resistant pathogen found in US hospitals and became part of Endemic infections at that time. Along with MRSA there are other bacterial strains that are found to have resistance including Enterococcus faecium (penicillin resistant), in 1983, (vancomycin resistant) Enterococcus in 1987 and linezolid resistant Enterococcus in the late 1990’s. However group A Streptococcus pyogenes remained sensitive to penicillin. Later penicillin resistant Staphylococcus pneumonia emerged worldwide. The main gene responsible for beta lactamase and penicillin resistance is mec-A which encodes PBP2a proteins.

There are several problems caused by increasing antibiotic resistance that have become a major threat in various sectors including health, food, security, clinical sectors, agricultural sectors, It is most commonly prevalent among frontline workers like military officers, hospital staff and patients. It can affect anyone of any age, gender and any country. It occurs naturally, but misuse of antibiotics in humans and animals accelerate this process. Due to antibiotic resistance, the effectiveness of antibiotics is decreasing. As a result, it is becoming difficult to treat various diseases including pneumonia, tuberculosis, gonorrhea and salmonellosis.It leads to higher medical costs, longer hospital stays and increased mortality. Plasmids are one of the major important vectors which are responsible for spreading resistance among the strains in soil in agroecosystems. PBR3222 is one such resistant plasmid which carries genes for tetracycline and ampicillin resistance. HGT is one of the most common mechanisms by which bacteria either acquire or exchange resistance from other bacteria. Mobile genetic elements (MGE) like integrons (which are gene cassettes) usually carry antibiotic resistant genes to bacterial plasmids and transposons. Most of this resistance is due to the presence of certain proteins and genes, mainly the mecA gene which was originated from coagulase negative Staphylococci and is associated with a mobile genetic element called Staphylococcal chromosomal cassette mec (secmec) and integrates in the Staphylococcal chromosome. mecA encodes for the PBP2a protein, which is a transpeptidase and has a low affinity for beta lactam antibiotics like methicillin and tetracycline. PBP2a being a transpeptidase is involved in the continuous synthesis of the cell wall during antibiotic attack. PBP2d protein along with beta lactamases are mainly responsible for the broad spectrum resistance in MRSA.

Discussion

The genes mec-A for the PBP2a protein and bla gene for beta lactamases are mainly responsible for resistance in bacteria like MRSA. To know the mechanism behind the resistance and to study the location and properties of the active site, the study of crystalline structures of PBP2a is very important (Lim and colleagues, 2002). For the crystallization process, cells were grown on m9 medium to which 50 g of protein solution containing thr, leu, met, selenomethionine were added per liter of culture. After 15 minutes, protein expression was induced and the colonies were subjected to further purification by hydrophobic affinity chromatography and gel filtration exchange chromatography by adding 0.1% thiodiglycol. Cells were lysed and native Staphylococcus aureus (Sau) PBP2a was extracted as a soluble protein by a purification process using a hydroxyapatite column.

Further purification was done by gel filtration chromatography on a sepharyle 1000 column apparatus, which is equilibrated with 5 mM NaHCO3. Extraction of PBP2a was carried out using a hanging drop vapour diffusion method. Then, exposure of PBP2a with chemical compounds like NaCl, PEG and HEPES at pH 7 led to the formation of crystals and the crystals were extracted by a cryopreservation technique in which the N terminal anchor of PBP2a was replaced with a methionine and was observed under electrospray mass spectrometry. When beta lactams are introduced, they inhibit beta lactam sensitive PBP’s. Strains containing PBP2a have low affinity for beta lactams, conferring antibiotic resistance by the continuous synthesis of the cell wall, which prevents the cell from lysis. Beta lactam antibiotics like penicillin and methicillin are substrate analogs of PBPs and catalyze the process of cell wall lysis and eventually lead to death. However,acquisition of mec-A genes by MRSA confers resistance. The mec-A gene is highly conserved among MRSA isolates with > 90% sequence identity and encodes the PBP2a protein. This PBP2a is resistant to beta lactam and does not have any sensitive analogs or homologs. It has a large molecular mass of 78 kD and belongs to class B PBPs which usually have broad spectrum for methicillin and other beta lactam antibiotics. This study on the crystal structure of PBP2a reveals the structural features responsible for its beta lactam resistance and provides important insights for the design of novel antibiotics against MRSA. Sau PBP2a has a transmembrane anchor which can be removed for the studying of beta lactam binding kinetics without affecting the beta lactam activity. The soluble derivative residues of PBP2a were determined by MAD method (Mean Absolute Deviation) using selenomethionine substituted protein. The extraction of this molecule has revealed structural conformations of the PBP2a protein and the location of active sites present within the non penicillin binding domain in the PBP2a. The active site along with the serine 403 at the N terminal helix of the alpha2 fold of Sau PBP2a along with a conserved oxidation hole containing serine 403 and Thr 600 as a nitrogenous backbone.During the acylation of beta lactam, the serine active site is mostly responsible for the process of inducing resistance towards the antibiotic. However, continuous acylation of serine molecules leads to dehydration. And may result in decreasing the activity of the active site, resulting in cell lysis and death. In order to make this process continuous, the serine 403 associated with the N terminal end of lys 406, present in beta lactam carboxylate enzyme. This forms hydrogen bonds, thus helping the serine present in the active site undergo deacylation, to further continue the process of cell wall protection by nucleophilic attack during the resistance mechanism.

This serine-lysine bond promotes the PBP2a conformational change, thus providing unfavourable conditions for the antibiotic to attack the complex. The low affinity binding towards the beta lactam induces slow acylation, leading to a rate limiting step responsible for the beta lactam resistance in MRSA. In normal methicillin sensitive PBPs, higher acylation rates are one of the major reasons for the antibiotic sensitivity and lead to cell death.

Location and function of the mec-A gene

The mec-A gene is located on a mobile chromosomal cassette called secmec. In this paper (Katayama, et al. 2003), use of naive cells (strains without mec-A genes) and experienced hosts (methicillin susceptible strains in which mec-A was excised) was mainly done to demonstrate the expression of mec-A genes and PBP2a protein activity towards the beta lactam resistance. A plasmid called pYK-20 was used as a carrier for the mec-A gene and was introduced into experienced and naive strains. The excision of this mec-A gene from the methicillin resistant strain was done by CC5-1, CC5-2 restriction enzymes and were introduced into the different vector plasmids like pYK-644, pYK-20, Hind 3, Coln plasmid, pNR-5542 and pCN-2278 and some of the plasmids were introduced with both mec-A and bla genes. These plasmids were amplified using PCR and these plasmids were introduced into naive hosts and experienced hosts through the process of micropropagation and growth curves were measured to screen for the transformants containing the plasmid vectors. These cells were grown on nafcillin containing media to test for antibiotic resistance. Naive cells containing the plasmids that carried only mec genes showed weak growth of 2.5% and the naive cells containing plasmids which are introduced with both mec-A and bla genes showed resistance to nafcillin. Transformed experienced strains showed normal resistance as that of parents containing mec-A genes. Taken together, these experiments suggest resistance is driven by transformants containing the plasmids with both mec-A genes and bla genes, indicating that combined activity of mec-A and bla are required for resistance. As, the experienced strains showed resistance and the naive cells did not express due to the host barrier. Tranformants were then tested to analyse the expression of the PBP2a protein by western blot. After the electrophoresis separation the separated proteins are loaded onto the nitrocellulose membrane containing monoclonal anti PBP2a antibodies. The desired PBP2a proteins bind with the antibodies. After the washing the unwanted proteins are removed. The secondary labelled antibodies are introduced and bind to the desired protein-antibody complex and develop colour and the PBP2a are visualised as thick bands depending upon the concentration under autoradiography. It was observed that Colnex with pYK 20 showed the maximum PBP2a production indicating high resistance, containing a plasmid carrying both mec and bla genes.

Conclusion

Both PBP2a and beta Lactamases are important for antibiotic resistance, and the structural confirmation of Ser403 present in the active site of the PBP2a protein is most important to confer proper and effective resistance towards the antibiotics. As in the studies we observed that the cells with plasmids carrying both mec and bla genes showed more resistance than cells with plasmids containing a single gene. What this suggests is although PBP2a is required for antibiotic resistance, it is not sufficient to induce resistance. In fact, additional genes such as bla are also required to induce resistance. More studies and research on new antibiotics targeting Ser403 and the active site of PBP2a, possibly designing new antibiotics towards PBP2a and designing antibiotics that target bla gene products would be effective. Combinatorial antibiotic treatment targeting both PBP2a and bla may help in effective treatment towards these antibiotic resistant diseases.

References

Julin Davis and Dorothy Davis, September 2010. Origins and Evolution of Antibiotic Resistance.Microbiol Mol Biol Rev. V 74(3): 417–433.

Alfredo Tello, Brain Austin and Trevor C Telfer, Aug 2012. Selective pressure of antibiotic pollution on bacteria of importance to public health. PubMed.

Charlie Ye Mo, January 2016. Make Antibiotics Great Again: Combating Drug Resistance By Targeting Lexa, A Regulator Of Bacterial Evolution. Researchgate.

Susana Gardete and Alexander Tomasz, Jul 1 2014. Mechanisms of vancomycin resistance in Staphylococcus aureus. The journal of clinical investigation, V 124(7): 2836–2840.

Daniel Lim and Natalie C. J. Strynadka, 21 October 2002. Structural basis for the -lactam resistance of PBP2a from methicillin-resistant Staphylococcus aureus. Nature structural biology, Volume 9: 870-876.

Yuki Katayama, Hong-Zhong Zhang, Dong Hong, and Henry F. Chambers, 23 June 2003. Jumping the Barrier to -Lactam Resistance in Staphylococcus aureus. JOURNAL OF BACTERIOLOGY, p. 5465–5472.

About the author

Harshini Balaga

The post Antibiotic resistance in Staphylococcus aureus and its adverse effects on global health appeared first on Exploratio Journal.

Abstract

In COVID-19, older adults have been disproportionately vulnerable to illness, death, and psychosocial repercussions. The proposed study aims to explore intersections between the COVID-19 pandemic and ageism among youth. Young adults recruited from the United States will read one of the three passages framing the pandemic in terms of its effects on the U.S. overall, the elderly of the U.S., or the young population of the U.S. and then complete critical measures of COVID-19 attitudes and behaviors. Participant ageist attitude will be included as a moderating variable and perception of the coronavirus as a personal threat will be included as a mediating variable. Conditional process models will be used to examine the direct and indirect effects of risk information on vaccine hesitancy and public health behaviors via the mechanisms of pandemic threat perception across levels of age bias. It is predicted that framing the pandemic in terms of its danger towards young adults will increase reported intentions to adhere to public health guidance via the mechanism of increased perceived threat, particularly for those high in ageism. Potential findings will have strong social, political, and cultural implications for establishing sustainable healthcare systems and intergenerational relationships.

Keywords: ageism, COVID-19, coronavirus, risk perception, public health, information framing

The COVID-19 pandemic has changed nearly all aspects of the daily lives of most individuals, yet those above 65 are disproportionately affected. Through August 2021, older adults have consistently been more prone to pandemic-related illness and death than younger people (Surveillances, V, 2020; Covid et al., 2020); they account for less than 20% of all COVID-19 cases but more than 70% of deaths worldwide (WHO, 2021). Older adults are vulnerable not only to negative physical effects of the coronavirus but also to long-term psychosocial repercussions due to social isolation. 

Along with the COVID-19 pandemic, there has been a parallel surge of ageism: from the media’s benevolent portrayal of the older population as a frail, vulnerable group, to hostile discrimination and abuse (Swift et al., 2021). The elderly face detrimental health impacts while having to cope with isolation, loneliness, anxiety, and depression (Banerjee et al., 2020; Bergman et al., 2020). The emergence of ageist attitudes and intergenerational divides have led to critical mental health ramifications on older adults. 

Additionally, non-compliance behaviors among adolescents exacerbate the negative impacts on public health. Adolescents are commonly identified with more non-compliance with preventive policies, especially with social distancing, than other age groups (Harris et al., 2021; Nivette et al., 2021; Roy-Chowdhury et al., 2020). Young adults are less likely to display severe COVID-19 symptoms and often consider themselves as immune and invulnerable to the virus (Ayalon et al., 2021; Surveillance, V, 2020). Therefore, as young adults frequently engage in social activities, those infected have high potential of transmitting the virus to others, which ultimately puts the elderly at risk (Andrews et al., 2020).  Recently, the Delta variant has become a pressing concern, as infection rate and hospitalization increase dramatically among the younger population (NBC, 2021). Internationally, health officials have been stressing the importance of adhering to health and safety guidelines. However, compliance to recommended health behaviors may be contingent on one’s attitude towards older adults. Accordingly, the current study sought to investigate the conditional indirect effects of reminders of coronavirus risk on adherence to pandemic-related public health behaviors (i.e., vaccine hesitancy, staying home, mask-wearing, physical distancing) as moderated by young adults’ ageism and mediated by perceptions of coronavirus risk.  

Participant Ageism

Prior research has demonstrated that ageist attitudes are often strong predictors of adolescent risk-taking behaviors. Young individuals with higher age bias also tend to report higher levels of risk behaviors (e.g., drug use, alcohol use, sexual behaviors) in daily life (Popham, et. al., 2011; Kennison, et. al., 2012). This is consistent with the terror management theory, which suggests that adolescents with strong ageism may attempt to dissociate themselves from their future older selves by seeking experiences that stimulate sensations of youth, strength, and invulnerability (Popham, et. al., 2011). Thus, the present study hypothesizes that youth with higher levels of ageism will also be more likely to engage in risky behaviors and subsequently report lower levels of engagement in COVID-19 protective behaviors. Although little research has been conducted on the specific effects of ageism on COVID-19-related health behaviors in youth, studies indicate that ageist attitudes may be a predictor of behavior change during the pandemic (Vale, 2020). 

Risk Information and Risk Perceptions

Risk information indirectly results in attitude and behavior modifications by increasing risk perception and altering emotional responses. Risk information, in the form of novel risk information or reminders of previously-known risks, is positively associated with levels of risk perceptions over time (Gerrard et al., 1999). Numerous studies have found that youth behaviors in risk-taking contexts, such as smoking and sexual behaviors, are responsive to risk information, especially when that information is personally relevant (Dupas, 2011; Gilbert et al., 2017). Moreover, authentic risk perceptions signal the need for preventive measures, and thus influence people’s decision-making and catalyze health behavior modifications in daily life and clinical settings (Edwards, et. al., 2001; Schmälzle, et. al., 2017). Amid past pandemics, such as the MERS outbreak in South Korea and the H1N1 influenza in Britain, increase in the public’s perceived susceptibility to the virus predicted increased preventive behaviors (Bish et al., 2010; Choi et al., 2018). In the COVID-19 pandemic, those perceiving greater risks also tend to report higher compliance with recommended health and safety precautions (de Bruin et al., 2020). Therefore, the present study intends to investigate the link between risk information, risk perceptions, and behaviors in the framework of the coronavirus pandemic.

Research Hypothesis: We hypothesize a conditional indirect effect of exposure to information about the increasing risk of the coronavirus for young adults on COVID-19 health attitudes and behaviors (i.e., vaccine hesitancy, staying home, mask-wearing, physical distancing) that will be moderated by participant ageism and mediated via the mechanism of increased perceptions of personal threat. We predict that exposure to information about the increasing risk of the coronavirus for young adults will cause participants to report increased coronavirus threat perception, which results in reduced vaccine hesitancy and increased health behaviors. 

Method

Participants

Participants will be recruited from undergraduate university subject pools from various universities in different areas of the United States. Participants will report their age, gender, race, and political orientation.

Measures

Ageism. Ageism will be measured on the 13-item Ambivalent Ageism Scale (AAS) validated (e.g., Cary et al., 2017) and used (e.g., Vale et al., 2020) by numerous peer-reviewed research studies. An example item is, “It is good to tell old people that they are too old to do certain things; otherwise they might get their feelings hurt when they eventually fail.” Participants will respond to each item on a 7-point Likert scale from 1 – “Strongly Disagree” to 7 – “Strongly Agree,” resulting in a range of possible values on the composite variable from 13 to 91. Higher value indicates greater level of ageism. See Appendix A.

Risk-information. Risk-information will be a manipulated (experimental) independent variable. Participants will be randomly assigned to three condition groups. In each condition, participants will be provided with information that emphasize the continued pandemic-related risks, its widespread impacts, and the importance of vaccination and safety measures. Participants in the threat to older population condition (Condition 2) will read a passage of information emphasizing the continued vulnerability and risks for the older population. Participants in the threat to younger population condition (Condition 3) will read a passage emphasizing the increased vulnerability and risks for the younger population. More details are reported below under “Procedure” and full text is available in Appendix B.

COVID-19 threat perceptions. COVID-19 threat perceptions will be assessed using the 7-item Fear of Coronavirus-19 Scale (FCV-19S) (Ahorsu et al., 2020). The reliability of the scale is validated in different populations (e.g., Perz et al., 2020). An example item is, “I am afraid of losing my life because of coronavirus-19.” Participants will respond to each item on a 5-point Likert scale from 1 – “Strongly Disagree” to 5 – “Strongly Agree,” resulting in a possible range of values from 7 to 35. Higher value indicates greater pandemic-related threat perceptions. See Appendix C.

COVID-19 health attitude and behaviors. Attitudes toward COVID-19 vaccinations will be assessed using three items, “All universities should mandate coronavirus vaccines for all students who are medically able to be vaccinated”, “Employers should mandate vaccinations for all workers who are medically able to be vaccinated, regardless of how otherwise young and healthy those workers are”, and “Everyone who is medically able to receive a vaccine should choose to be vaccinated.” Participants will respond to each item on a 7-point Likert scale from 1 – ”Strongly disagree” to 5 – “Strongly agree.” COVID-19 health compliance behaviors will be evaluated using a 3-items assessing how the framing manipulation has prospectively changed their likelihood to engage in certain behaviors, selected from public health recommendations by the World Health Organization (WHO, 2021), including: (i) stay at home, (ii) adhere to physical distancing (1.5-2m), and (iii) wear a face mask. Participants will indicate on a 7-point Likert scale, from 1 – “I will be much less likely to do this” to 7 – “I will be much more likely to do this,” resulting in a range of values from 3 to 21. 

Procedure

Participants will complete an informed consent document and are randomly assigned to read one of the three passages containing information on the number of cases, deaths, and hospitalization among (1) the U.S. population, (2) older adults, and (3) younger adults. All three passages will contain information regarding the rise in cases since the summer of 2021, the threat of the more contagious Delta variant, and the effectiveness of vaccination and preventive behaviors such as social-distancing and mask wearing. Then, participants will report to measures of COVID-19 threat perception, health attitudes, and health behaviors. Finally, participants will complete measures of demographic and personal characteristics (i.e., age, gender, and race) and read a debriefing statement regarding the purpose of the study.

Results

Conditional direct and indirect effects will be examined using PROCESS Model 8 (Hayes, 2013) with risk information as the primary independent variable (x); age-related bias as the moderator (w); perceived coronavirus threat as a mediator (m). Vaccine hesitancy was as the dependent variable (y1) in the first analysis and reported adherence to public health behaviors as the dependent variable (y2) in the second analysis. All indirect effects were computed for each of 10,000 bootstrapped samples and were considered significant if their 95% confidence intervals did not include zero (these bootstrapped effects do not produce exact p values). Non-dichotomous variables were mean centered. The conceptual models are illustrated in Figures 1 and 2. 

Discussion

The current study was designed to investigate whether ageism and framing the impact of the coronavirus pandemic in terms of the increased risk of young adults, rather than of the general population or the older population, would predict greater coronavirus threat perception, reduced vaccine hesitancy, and increased health behaviors. We expect that participants with high age bias will report less compliance behaviors and that participants receiving information regarding young adults will also report less compliance behaviors. Overall, we expect to be able to conclude that age bias and framing of risk information have a strong influence on public health outcomes, such as vaccine hesitancy and compliance to safety guidelines.

Implications

The results of this study (if consistent with the hypothesis) will have significant implications for public health and social policy. Ageism in young adults promotes reckless behaviors that jeopardize lives and entire healthcare systems. Reminders of pandemic-related risk that are age-specific and relevant effectively induce attitude modifications and reduce risk behaviors in youth. This accentuates the need for stronger social efforts, including mitigation and information campaigns targeted at young adults (Kolbe, et. al., 1993). In addition, fostering a culture that promotes the value of the lives of older people and reduces the youth obsession that feeds into anti-elderly bias is paramount, especially in a rapidly aging society (Ng & S. H., 1998; North, et. al., 2012; Meisner & B. A., 2021). 

Limitations

The study relies on participants’ self-reported response as a measurement of COVID-19 vaccine attitudes and health compliance behaviors. Therefore, the conclusions drawn from this study may be limited by the use of self-reported responses which might not accurately reflect actual behaviors, as participants may be unable or unwilling to report accurate estimates. Additionally, one’s vaccine hesitancy also varies across time, place, and vaccines, yet the assessment of vaccine hesitancy in this study lacks specific vaccine context, thus the results might not generalize to other countries or populations. 

Future Directions 

The proposed experiment assesses the effects of risk information on COVID-19 health attitudes and behaviors in the short term. Future research may examine whether the observed effects generalize across contexts and to what extent the effects are durable. As research demonstrates that manipulation of information in clinical settings affects patients’ decision-making and health outcomes (Edwards et al., 2001), future research could investigate the effects of framing pandemic-related risk information on public attitudes during the coronavirus pandemic. Future research may also explore the relationship between ageism, risk information, and response (i.e., attitudes and behaviors) in different age groups. 

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About the author

Vanessa Yu

Vanessa is an 11th grader at the United World College of South East Asia in Singapore. She is interested in social psychology, mathematics, and physics and also enjoys making and appreciating art.

The post Can Framing the Pandemic as Dangerous to the Young Reduce Non-Compliance Behaviors Among Young Adults in the COVID-19 Pandemic? An Examination of Age-Related Bias appeared first on Exploratio Journal.