Rurality and Risk of Suicide Attempts and Death by Suicide among People Living in Four English-speaking High-income Countries: A Systematic Review and Meta-analysis

Abstract

Objective: Previous research indicates a potential relationship between rurality and suicide, indicating that those living in rural areas may be at increased risk of suicide. This relationship has not been reviewed systematically. This study aims to determine whether those living in rural areas are more likely to complete or attempt suicide. Method: This systematic review and meta-analysis included observational studies based on people living in Canada, the United States, the United Kingdom, and Australia. Data sources included PubMed, EMBASE, PsycINFO, and Google Scholar from January 2006 to December 2017. Studies must have compared rural and urban suicide or suicide attempts. Nonprimary research articles were excluded. Results: A total of 6,259 studies were identified and 53 were included. Results indicate that males living in rural areas are more likely to complete suicide than their urban counterparts (RR = 1.41, 95% CI, 1.21 to 1.64, I 2 = 96%). Females in rural areas are not significantly more likely to complete suicide (RR = 1.16, 95% CI, 0.98 to 1.37, I 2 = 79%). Among studies that only reported combined estimates, rural individuals are more likely to complete suicide (RR = 1.22, 95% CI, 1.11 to 1.33, I 2 = 98%). There is no association found between rurality and suicide attempts (RR = 0.93, 95% CI, 0.73 to 1.19, I 2 = 85%). Conclusions: Those living in rural areas are more likely to complete suicide, with some studies indicating that only rural males are more likely to complete suicide; these findings are relatively consistent across all four countries. Public health initiatives should aim to overcome geographic variation in completed suicide, with a particular focus on rural males.