[corresponding author: [email protected]]
IMPROVING NOCOMIT-J PROGRAM AS A RESPONSE OF WOMEN’S AND YOUTH’S SUICIDE CASES SURGE DURING
COVID-19
Hemalia Kusumadewi Universitas Brawijaya
INTRODUCTION
Life is precious, and every human being has the right to live a good life. Although, the perception of reality is different for each person and some of them suffer much compared to the others. This fact has led countless individuals to end their lives, thus suicide emerges as a global concern needed to be tackled immediately. In a year, more than 703,000 people globally passed due to suicide and likely for every suicide there are 20 others made suicide attempt (WHO, 2022). Death by suicide is twice as much as death by homicide, and in 2019 1.3% of global deaths were from suicide (Richie, 2022). This number, however, is mostly concentrated in countries with highest suicide rates. One of the countries that has the highest suicide rate globally is Japan. Research conducted by Okamura, et al (2020) shows that Japan has high suicide rate since the 80s period, with more than 25,000 cases per year between 1983 and 1986 which then increased excessively to 32,863 cases in 1998 and reach the worst peak at 2003 with 34,427 cases which remain above 30,000 until 2011. In 2016 Japan had suicide rate of 18.5 per 100,000 people, although that number has decreased significantly to 15.30 per 100,000 in 2019 (Japan Suicide Rate, 2020). According to Japan’s National Policy Agency, 2019 has 20,116 total suicide cases which by far the lowest suicide count compared to the
ABSTRACT
Suicide has been a long-time national problem for Japan as they hold the record for country with highest suicide rate according to WHO and the problem continues as of current.
COVID - 19 which impacted most nation throughout the world including Japan, has a hand in influencing the increase of suicide rate in Japan. This increase is particularly evident in groups of youth and women who are among the most vulnerable groups in Japan, thus calls for more comprehensive sets of policy for suicide prevention. Currently there are prevention policies existing curRently. Among them there is a policy called NOCOMIT-J that will be the focus of this article. However, the rapid increase of suicide in pandemic time proves that there is an urgent need to improve the policy to suits the complexity of the situation. This paper aims to assess the variables behind the increase of suicide rates in Japan particularly for youth and women in order to use it as a basis calculation to improve the existing suicide prevention policy to focus on the group-specific problems. This paper will use qualitative method of descriptive case studies to analyze the unique factor contributing to women and youth suicide cases in pandemic time and use the result to suggest improvements for NOCOMIT-J policy by analyzing it in the established framework of holistic global mental health policy.
Keywords: COVID-19; Suicide; Women; Youth
previous 10 years. This indicated positive development in suicide prevention program in Japan. The result was possible to be achieved because Japanese governments adopted various measures such as Basic Act on Suicide Prevention, Establishment of Japan Support Center for Suicide Countermeasures (JSSC), ‘A community intervention trial of multimodal suicide prevention program in Japan’ (NOCOMIT-J) and ‘A Randomized Controlled Multicenter Trial of Post-Suicide Attempt Case Management for the Prevention of Further Attempts in Japan’ (ACTION-J) (Okumura, 2021). The adopted measures were proven to be effective, as in 2009 - 2019 there is a consistent decline in Japan’s suicide cases number.
But the case rose back along with the emergence of COVID-19 pandemic. Just as the majority of world’s governments, Japanese governments also focused on preventing the spread of COVID-19 by issuing various restrictions and limiting people’s movements. This unfortunately had induced distress and mental problems due to the impact those restrictions created, such as massive unemployment and loneliness. Research conducted by Sakamoto et al. (2021) has shown that in October 2020 there was a significant increase of suicide rate for all social groups (age, gender-based group) in Japan compared to October 2016 - 2019.
The rate of men suicide cases went from 1.78 suicide death per 100,000 populations to 2.03 October 2020. Meanwhile,the number for women suicide rate has increased from 0.82 in July 2019 to 0.96 in July 2020. While it seems that men group has higher suicide rate increase, women group suicide rate had increased much earlier that is in July 2020 and for both groups suicide rate increased significantly among those under 30 years old. This finding made Sakamoto stated that women and young adults experienced disproportionate mental health or/and suicidal thoughts.
Ueda (2021) found out that the suicide cases of students and homemakers increased exponentially with students peaked in August 2020, while suicide counts of university students has doubled in August and September 2020. Another research done also consistently proves the vulnerability of women and youth (age under 20) groups with women group has 7026 suicides in 2020 compared to 6091 in 2019 and youth has 777 suicides in 2020 from 659 in 2019 (Okamura, 2021). These findings shows that COVID-19 did significantly altered the progress of suicide prevention policy, with women and youth groups became especially vulnerable.
There are few reasons as why women and youth became particularly vulnerable toward mental illness and suicidal ideation in Japan. Women and younger adults are the ones most affected by the economic downturn after social distancing got applied. They make up a large portion of individuals with irregular employments and service industry works which were severely impacted by pandemic which also means young female workers were more likely to have experienced income loss than any other group (Ueda. 2022). The case of youth (children and adolescents) suicide also has always been a concerning issue for Japan as it is the highest death cause for youth even before pandemic hit, and this particular group almost had no decrease in suicide rate at all compared to older groups in times before pandemic (Isumi, 2020). The major factors identified to be youth’s suicide reason are family factors, psychological condition, school, and others. There are also other reasons such as specific bad mental health among housewives, school and social-related stress among adolescents due to
pandemic, and a not-so-good home environment that they need to stay in as social distancing was applied, which would be discussed further down the article.
Japan has gradually recovered from the COVID-19 along with the rest of the world, following the rapid decrease of COVID cases since 2022. The most recent COVID-19 tracker of Japan when this article was written in February 24, 2023 was 15,029 new confirmed cases across Japan that is actually a decrease of 6,200 compared to a week before (Japan Times, 2023). Japan also has opened its border completely in October 11, 2022 and achieving states as one of the country with highest vaccination rate (Mao, 2023). All these indicate that Japan is entering a post-pandemic era, which implies one important thing in regard of suicide cases issue that is the need to return and advance the pre-pandemic decreasing suicide rate.
This is a very important agenda for Japan, as COVID-19 was proven to significant affect the rise of suicide cases and attempts that revert years-long progress. For that to be done, this article argues that Japan needs to improvise the existing suicide prevention program to targets specific groups which are women and youth groups. These groups are the ones most vulnerable to the increase of suicide rate in pandemic, and the reasons behind were that of systematic socio-economic problem in Japan.
Therefore, improvisation of existing policies are needed to accommodate these groups’
needs and address the root causes in order to equitably improve the quality of life for all people in Japan. There is an existing policy that is very potential to solve the existing cause, however it would need many improvements. The policy is called NOCOMIT-J program and this article would prove why improvement is necessary and how those improvements would be applied especially in the transition period of Japan toward the post-pandemic era using the conceptual framework of policy-mix in sustainability transition. This article has a purpose to contribute in improving effectivity of suicide prevention strategies by assessing patterns and existing factors of suicide cases in Japan especially for women and youth groups as the socio-economically vulnerable group of Japan.
ANALYTICAL FRAMEWORK
The process of both policy-making and policy improvement would need a solid framework to create a holistic policy which is suitable with the conditions on the ground.
Khenti, et al (2016) in ‘Developing a holistic policy and intervention framework for global mental health’ proposes a multilevel framework to develop a holistic and sustainable mental health policy that should be able to be applied globally. This framework consists of five components which are; 1) holistic health, 2) cultural and socio- economic relevance, 3) partnerships, 4) collaborative action-based education and learning, and 5) sustainability.
Holistic health examines the complexity of existing variables such as politics, individuals, community, and historical contexts, by exploring the synergies between those variables and many levels (superstructural, policy, community, organizational, interpersonal, individual) of the healthcare system (Khenti, 2016). Cultural and socio-economic relevance emphasizes that understanding the situation surrounding mental health issues is supposed to be a bottom-up approach whereas the knowledge of mental health should be based on the related community. Partnerships refers to the commitment to create partnerships based on trust and equal reciprocity. Collaborative action-based education and learning puts emphasis on identifying and assessing gaps in health-care treatment and policies, as well as the strengths
and opportunities, thus adopting three core methodologies which are adult education, action- oriented learning, and train-the-trainer techniques. Lastly, sustainability refers to effective capacity building and strong partnership that is relevant in every existing local context which is achieved with well-connected previous four components. The framework was created on the basis of the WHO’s mental health action plan 2013-20 that has four objectives, those are; enhancing mental health governance, integrating mental health service to community- based settings, implementing mental health promotion and prevention strategies, and improving mental health research. This framework will be used in assessing the effectiveness and suggesting improvements in the implementation of NOCOMIT-J Program as a response toward the surge of women’s and youth’s suicide cases due to COVID-19 pandemic in Japan.
This research uses a qualitative method which is used to understand a certain case or phenomenon using narrative and holistic data gathered gradually from the beginning until the end of the research (Yusuf, 2014). The method used is descriptive case studies where a descriptive theory framework is established to be used throughout the research and examining the unique factor in the related case (Lune, 2017). The framework established in this article is the framework of mental health policy-making which will be used in analyzing the current ACTION-J policy and how to improve the policy. The specific variables examined here is the youth and women-specific suicide cases in Japan that has raised throughout the pandemic. The data of these cases were gathered and used as tools to support this article’s argument of how youth and women were especially vulnerable and needed further policy improvement to intervene in the cases. This method is used because of its advantage to open a ground for insights and hypotheses that might be pursued in subsequent studies. As the range of potential types of documents open to qualitative data analysis is immense (Rapley, 2018), for data collection this article uses qualitative data collection with documents, journals, books, archives, and internet-based news and articles. This approach’s purpose is to enable easier access of data that can fully support the research.
RESULTS AND DISCUSSION
A. Problems of Women and Youth Suicide in Pandemic-affected Japan
Historically, suicide cases in Japan were more common among men and older people, thus making adult men the highest in fatality due to suicide. From 2019 until 2021, the men group has 22.9 deaths per 100,000 inhabitants rate with the mortality number reaching 14,000 in 2021. This was actually a much better result compared to years before, as in 2018 suicide for men reached 23.2 deaths per 100,000 while in 2017 it reached 24 per 100,000. Although in total women group has significantly lower rate, but since the COVID-19 pandemic women suicide cases had soared significantly compared to men’s cases which remained relatively stable. Women suicide cases in 2019 reached 9.4 deaths per 100,000, but it increased significantly in 2020 to 10.8 deaths per 100,000 then to 11 deaths per 100,000 in 2021. These are all compared to men suicide cases that remains the same throughout those three years.
Research conducted by Nomura, et al (2021) suggests that started from September 2020, women group has higher suicide burden due to COVID-19 pandemic compared to men about 20 - 30% in comparison with the previous year. Ueda, et al (2022) found that the highest increase was found among young women, students, and homemakers (Ueda, 2021).
This means there are some variables contributing in 2020 and 2021 that raised the suicide cases in women group, which this article identifies as the COVID-19 pandemic. These findings are also consistent with past research conducted on this topic (Eguchi et al, 2021;
Nomura et al, 2021; Yoshioka et al, 2022; Ueda et al, 2022).
There are few reason why women suicide cases rose significantly. First, women in Japan are economically more vulnerable. Women dominate fields that are hugely impacted by pandemic such as travel, retail, and service industries, and in temporary low-paid jobs, which made them the main victim of mass unemployment and income loss. International Labor Organization (ILO) reported that women were just around 40% of all people employed before the COVID-19 pandemic, but in 2020 women also suffered 48% of all employment losses, which made the number of employed women significantly much lower compared to employed men (Gardner, 2022). It indicates that this phenomenon of women being much more vulnerable due to te COVID-19 pandemic happened globally and Japan suffered this phenomenon too. The amount of employed women decreased by 490,000 in September 2020 compared to the amount of employed men decreased by 300,000 at the same time.
Second, there is an increase of gender-based violence against women, particularly domestic violence due to long-term lockdown. According to data from UN Women some countries had a wave of increased domestic violence reports, while emergency calls increased up to 25% since restriction of movement measures were conducted. The United Nation Development Programme (UNDP) also recorded the surge of gender-based domestic violence in a few countries such as France, Argentina, Cyprus, Singapore, Canada, Germany, Spain, The UK, and The US. Japan unfortunately has seen an increase in this problem too.
Consultations on family violence to both local and national governments increased by 60%
in Japan since the emergency lockdown were enacted (Tokyo, 2021). During the second wave of the pandemic, suicide rate among women were five times greater than men with housewives as the largest of increase among women group (Tanaka, 2021). These numbers indicate increased problems in Japan’s households, thus making women psychologically more vulnerable due to multiple problems of pandemic and their domestic situations. Those are the factors contributing to increased women suicide cases rate. Lastly, the problem of household for women not only stopped at domestic violence, but also the burden and expectation of parenting and taking care of the house even in lockdown situations.
Temporary closure of schools puts more burden of parenting on women, and it was even worse for mothers who also worked remotely thus multiplying burdens for women that need to cope with both job and housework (Fushimi, 2021). Every variable has shown how women were put in a much more vulnerable situation in the pandemic due to multiplication of problems and burdens that also elevated their level of stress. Based on the existing variables and the increase rate, it can also be concluded that the demographic of young women were especially vulnerable during the COVID-19 pandemic.
With similar predicament, youth suicide cases had increased in the pandemic time. Bersia, et al (2022) identified the rise of suicidal behavior, suicidal ideation, and suicide mortality in 2020 by atleast 10% globally compared to 2019 (Bersia, 2022). Japan also saw a rise of this phenomenon, although the concern over the rise of youth suicide cases have been a primary issue in Japan as it was already an issue even before the COVID-19 pandemic. This is due to the fact that suicide is the number one cause of death among young populations (Goto, 2022). However, the pandemic made things take even more of a downturn. In herem youth
is defined as those under the age of 30. Starting from June 2020, suicide among youth started to increased and continue to be elevated if compared to the times before pandemic. The research done by Goto, et al (2022) focused on youth age 10 - 19 in Japan, observed the increase of suicide from June 2020 until March 2021. Goto then proceed to identify the main causes of the increasing youth suicide, which are classified into four domains; family issue (disagreement with family members/ parents, being abused), youth having mental illness (i.e.
depression and schizophrenia), social concern (relation with friend, lovers, bullied, and other relations), and academic issue (entrance exam, concern about future, grades). Meanwhile Ueda, et al (2021) identified the number of suicides by university students doubled in August and September 2020, respectively 46 cases and 51 cases, compared to the average of cases each month throughout 2017 - 2019 which is 24 cases. Ueda also identified factors behind this finding, which are the economic downturn of pandemic where lots of young people lost their jobs, school closures unfavorable psychological condition (Ueda, 2021). The identified evidences were for example the emerging negative impact of school closure on students whereas between June and July 72% of surveyed students in the research reported symptoms that indicated some form of stress reaction and some university students were suspected to be under stress due to online and isolated learning for a prolonged period and the fact that 29.41% of the students surveyed were depressed.
Everything has existed even since before COVID-19 pandemic. However, the measures and condition of the pandemic made things worse. For instance, the lockdown policy may have exposed youth to trauma from any family members even more, whereas youth did not have any means to escape unlike when they were in school (Goto, 2022). On the other hand, some youth who were socializing daily before the COVID-19 may feel isolated, full of loneliness due to distance between people(Fushimi, 2021) and uncertainty of when the pandemic would end. In addition to the feeling of insecurity and maybe loss due to the pandemic itself, all these problems were worsening the mental state of youth.
Both women and youth have similar factors behind the increase of suicide rate, including the unproportional economic stress, domestic problems, and increased burden due to lockdown measures. Both have their own unique variables in their own demography.
Regardles of that, both increase of women and youth suicide were urgent matters needed to be addressed immediately as it threathen the years-long progress on Japan’s fight against high suicide rate.
B. Identifying the Implementation of NOCOMIT-J Program and Its Relation to Current Problems
The Japanese Multimodal Intervention Trials for Suicide Prevention or J-MISP launched ‘A Community Intervention Trial of Multimodal Suicide Prevention Program in Japan’ or NOCOMIT-J in order to reduce the suicidal behavior in a certain community with community-based approach that focuses on the bonds between people, community support, and the examination of how social factor is a key factor in reducing suicide, with a study for the implementation out in 2008 (Ono, 2008). This program was created based on the nine initiatives in ‘General Principle of Suicide Prevention Policy’ by The Cabinet Office of Japan, which include; (1) research on risk, protective factors, and prevalence for suicidal behaviors;
(2) increased public awareness, (3) human resources for early intervention; (4) community efforts for mental health; (5) better access to mental healthcare, (6) supportive community environments; (7) prevention of suicide re-attempts; (8) support for persons bereaved by suicide, and (9) enhanced public-private partnerships (Nakanishi, 2015). The study specified the elements in the programs which consisted of six policy elements:
1) Founding community support network in the health system, with mechanisms such as conducting meetings between related departments and organizations and forming local coordinating groups in each region and specified community.
2) Primary prevention measures for behavior relating to suicide, such as conducting public awareness campaign, setting up programs which allow residents to communicate and gather, providing training for key persons in each community and workshops for people in the community.
3) Secondary prevention measures for behavior relating to suicide, including screening for high-risk/attempter individuals and forming local counseling services.
4) Aftercare for grieving individuals due to suicide-related loss.
5) Measures focused on individuals with substance/drug/alcohol-related issues and mental illnesses.
6) Prevention measures for individuals with work-related issues.
The result of this program was quite positive, as it has significant impact on the reduction of suicide attempts and self-harm among men, the older adults (age above 30), and the elderly (Okamura, 2021). However, this is exactly the problem that this article identifies.
The policy’s impact was not inclusive even before pandemic, and as women and youth become much more vulnerable during COVID-19 pandemic, the current program is neither sustainable nor holistic to solve the most urgent problem of suicide cases in Japan. The components above also do not target the specific problems revolving youth and women suicide cases, such as school-related problem (bullying, grades, expectations), family-related (domestic abuse, child abuse, disagreement with family members), and women/youth- oriented economic-matter approach. Instead, it focused more on problems most common found on men and adults instead. Another study by Ono, et al (2013) also found that the NOCOMIT-J is more effective in rural areas, but not really suitable for urban areas with high populations.
Arguably, the basic principles made by The Cabinet Office of Japan was comprehensive and implemented in the creation of NOCOMIT-J. However, this principle has not fully implemented the framework of holistic global mental health policy for the current time, that also will be explained in the next section, nor has there been any significant change for the existing policy to be more acceptable in the status-quo as NOCOMIT-J focused at Japan’s high suicide rate among adult men at that time. Therefore, there is a need to improve the policy to suit the unique problem of women and youth suicide cases brought by the pandemic, including improving it to enable an effective implementation in urban areas. The explanation below would suggest that through a framework of holistic global mental health policy.
C. Improving NOCOMIT-J Through The Holistic Global Mental Health Policy Framework
As explained above, there are five main components of the holistic global mental health policy which are holistic health, cultural and socio-economic relevance, partnerships, collaborative action-based education and learning, and sustainability. These components would first examine Japan’s Basic Principles on Suicide Prevention as it is the basis of all existing suicide prevention policy in Japan including the NOCOMIT-J, then continues with examining NOCOMIT-J program to identify what has been fulfilled and what is lacking.
Lastly, suggestion would be presented in accordance to every identifications including the result of identifying the unique variables behind the surge of women’s and youth’s suicide to solidify this article’s main argumentation.
First of all, the nine initiatives lack two components. One is the matrix inside the holistic health component, which is the complexity of historical and political contexts that should be synergized with five levels from superstructural (global, national, and local-existing structure in the society) until individual level; another one is the collaborative action-based education and learning component. The basic principle may has initiative of ‘research on risk, protective factors, and prevalence for suicidal behaviors’, however it does not emphasize the existing complexity and synergies between contexts and levels mentioned in the holistic health component. This point needs to be improved because the relation between contexts and levels is predominant in women’s and youth’s cases, such as the relation between women dominating temporary and service workfield and economic pressures for women, collectively and individually which is very heavy on the context of politics and socio-economic situation in japan and on the superstructural until individual levels of women themselves. The lack of
‘collaborative action-based education and learning’ in the basic principle is evident as there are no initiatives that emphasize the three core-methodologies of this component which are adult education, action-oriented learning, and train-the-trainer techniques. Admittedly, this is a major fatal as education is the foundation of mental health and suicide awareness, existence of understanding between individuals, and prerequisite of effective suicide prevention policy implementation in society. This means the basic principle must be first revised to be in line with the current relevant framework of holistic global mental health policy in order to address women’s and youth’s suicide cases surge.
Second of all, the lacks in the basic principles can be understood as a direct implication of the lacks in NOCOMIT-J as well. But additionally, NOCOMIT-J lacks the ‘cultural and socio-economic relevance’ for women’s and youth’s situation, as it does not target the unique variables surrounding the cause of suicide for women and youth. Aside from that, there is also the problem that NOCOMIT-J can not be effectively implemented in urban areas which is also a concern of socio-economic relevance. The component of ‘partnership’ has existed in NOCOMIT-J, but it can be improved further with the suggestion that will be explained below. The ‘sustainability’ component, which indicates the holistic relation between the other four components, is evidently not fulfilled in the NOCOMIT-J program, as it still lacks a lot in the other components which means there is no solid relation yet between the components of the holistic policy framework inside NOCOMIT-J.
In accordance to identification of problems, unique variables, analyzing the basic principle and NOCOMIT-J through the holistic policy framework, this article would like to suggests an improvement of NOCOMIT-J policy, using the holistic global mental health policy framework, as followed:
1. Improving partnership strategy of NOCOMIT-J especially in urban areas, in accordance with the ‘partnership’ component. This can be done by dividing a certain region/city by blocks, so that the formation of local coordinating groups can be based on this division of blocks. The formation of groups should be based on the principle of sustainable-partnership, by partnering with existing organizations and formal, non-formal institutions related to the contexts and components of mental health. The organizations and institutions are (included but not limited to) local government, local police, schools, universities, large hospitals to small clinics, youth and women organizations, research institutions, and mental health support community. Each of the bodies should send capable member(s) in the local coordinating groups. The local coordinating groups should form a chain-of- command inside the group and connect with other local coordinating groups, both inside and outside the same region.
2. NOCOMIT-J to be used to reinvestigate individuals, most importantly women and youth, that should be traced with the improved local coordinating group chain. These groups shall conduct research on every individual in the blocs by first creating a prioritization list with putting high-risk/ attempters/ have reported a case like bullying or domestic violence, on the top of the list as they are the most vulnerable and need to be constantly paid attention to. The groups can conduct the research in two ways, first by identifying institution or organizations each person are related with to increase efficiency in data-gathering, and secondly to visit people house-per–house that need direct intervention/ communications, that can be done with twice-a-year basis of visit similar to public census data research. This is in accordance with the
‘holistic health’ component that identifies complex contexts and levels among society.
3. Responses in NOCOMIT-J should be aware of cultural and socio-economic context in society, especially for Japan's society that has deeply engraved patriarchal values that leads to high numbers of gender-based violence, domestic abuse, and gender- gap in the workfield. There is also the culture where young people are expected to have high-achievement and outstanding jobs from a young age, which leads to academic pressure, fear of future, and extreme fear of failure. These unique variables surrounding women and youth’s surge of suicide cases which also have been elaborated above are the cultural and socio-economic relevancies that need to be addressed inside policy improvement. Response can be tailored based on those relevancies, such as the creation of women and youth support groups, that also acts as a safety net, in every blocs/regions that focus on facing issues such as domestic abuse, academic stress, or even bullying, where everyone can communicate freely and comfortably without fear.
4. NOCOMIT-J must include education-based mechanisms that can be implemented through various mechanisms, such as mental health campaign, free-public workshops relating to women’s and youth’s unique problems, and recommending local educational institutions (school and university) to directly implement the element of mental health awareness and suicide prevention inside their curriculum,
or alternatively to conduct classes/lectures outside of curriculum on the suicide prevention measures.
CONCLUSION
The surge of women and youth suicide cases in the time of COVID-19 could also be due to the lack of sustainable policy in Japan. As explained above, Japan’s basic principle on suicide prevention measures and NOCOMIT-J still lacks a lot of components according to the holistic global mental health policy framework, to actually address the continuous surge throughout the pandemic time. Suggestions mentioned above are created based on the over- all identifications of unique variables related to women and youth cases, and therefore should be feasible to be implemented in the real-world situation. There is still a limitation of variation of suggestion in policy-improvement according to the uniqueness of every region in Japan that may differ, due to limitation in data. Future research can be conducted on this focus, or further specifying the detail of policy inside NOCOMIT-J or other suicide prevention policy in Japan.
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