Early Adversity & Self-Harm in Tunisian Prisoners: Mediated by Recent Violence Exposure?

Abstract Introduction Despite the high number of incarcerated individuals, limited research addresses their mental health needs. Childhood exposure to social adversities (social ACEs) is linked to self-directed violence, yet the mechanisms remain poorly understood. This study aimed to explore whether recent exposure to violence mediates the relationship between social ACEs and self-directed violence among incarcerated males in Tunisia. Methods We conducted a cross-sectional study in April 2023 among male inmates in a Tunisian civil prison. Participation was voluntary, anonymous, and self-administered; illiterate participants were assisted by investigators. Social ACEs were assessed using the WHO's validated Arabic ACE questionnaire. Exposure to in-prison violence included psychological and physical forms. Self-directed violence was subdivided into suicidal behaviors and self-harm. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale. Results Among 540 participants (response rate 74.6%, mean age 33.75±10.89 years), 35% had recent suicidal thoughts and 45.9% reported self-harm. Nearly all (96.8%) had experienced at least one social ACE. Anxiety and depression were present in 83.2% and 79.6%, respectively. Over half experienced recent violence, mainly psychological. A dose-response effect was found: self-directed violence risk increased with the number of ACEs. After adjusting for anxiety and depression, recent violence mediated 24% of the relationship between social ACEs and self-directed violence (p = 0.01). Conclusions Social ACEs significantly contribute to self-directed violence among prisoners, with recent violence as a key mediator. Targeted interventions are needed to break this cycle within correctional settings. Key messages • Childhood social adversities are linked to self-harm and suicidal behavior in Tunisian prisoners, with recent in-prison violence acting as a key mediator. • Given high rates of social ACEs, mental distress, and prison violence, trauma-informed care is urgently needed to break the cycle of violence among incarcerated populations.