A qualitative study on perspectives of undergraduate professional students on suicide and recommendations for an effective suicide prevention program

ABSTRACT

Background:

Suicide has become a leading cause of death among 15- to 39-year-olds. Recent data suggests that one student commits suicide every 60 seconds in India. One of the suicide preventive strategies adopted is the introduction of a crisis helpline for students but the effectiveness of this support in preventing suicide remains questionable. Our study aims to find out the perspectives of students on suicide and their recommendations for an effective suicide prevention program.

Method:

A qualitative design with focus group discussions was used to collect data. A universal sampling technique was adopted and the data were analyzed using the framework method.

Results:

A total of 830 students were divided into 70 groups with each group having 12 to 15 students participating in the focus group discussion. Several themes and subthemes emerged from the discussion. Overall, students had a poor understanding of people who attempt suicide, elaborated the factors instigating a person to make a suicidal attempt, barriers to access help and their views on effective crisis intervention service.

Conclusion:

The study identified student perspectives on suicide and the challenges perceived by the students for the effective implementation of a crisis intervention program for suicide prevention.

Suicide remains a significant public health problem globally[1] and has complex multifactorial etiology.[2,3] The total number of suicides in India may vary between 230,000 and 250,000 people annually. The rate of suicide is increasing in India and according to 2016 data, women account for 36.6% of all suicides and men for 24.3% of suicides worldwide.[4] Suicide has become the leading cause of death among younger people between 15- to 39-year-olds.[5] WHO reports that every year around 800,000 people die by suicide which is one person committing suicide every 40 seconds and 79% of suicides occur in low- and middle-income countries.[6]

National Crime Records Bureau data showed 28 student suicides reported every day which is one student committing suicide every hour. Over 13,000 students committed suicide in India last year and over the five years from 2016 to 2021, the number of student suicides in India has risen by 27% (NCRB report 2021). Despite being one of the most advanced states in terms of literacy and health index, Tamil Nadu has the second highest (10%) suicide rate next to Maharashtra.[7] Student suicides once reported mainly during exams and the publication of results has become a daily affair. This increase in trend occurs despite several initiatives taken by the government and NGOs like the introduction of helplines and suicide prevention awareness programs by the individual, regional, and statewide media interaction by mental health professionals.

Qualitative studies from Ghana,[8] India,[9,10] Iran,[11] and Kenya[12] reported interpersonal problem, family issues, financial hardships, academic and societal pressure, high expectancy, and lack of support system to be major reasons for suicide among the young. People with some exposure to mental health problems viewed it as an illness, while others viewed them on moral grounds.[11] Peers, who survived classmate’s suicide, often expressed guilt of not recognizing or being able to save them.[13] Normalizing attitude toward suicide is associated with suicide bereavement and suicide attempt among staffs and students.[14]

Focus on suicide prevention was the world mental health day theme of WHO in 2019 recognizing the magnitude of this global public health problem and reiterating that suicides are preventable with a comprehensive multisectoral approach.[15] Also, there has been consistent reporting of suicide among medical students and doctors in training in the recent past. These incidents once observed to be rare have started occurring at regular intervals in several educational institutions including the institute where the authors work. These untoward occurrences triggered the need for revisiting the suicide prevention strategies at the local level and introducing a robust student-friendly crisis intervention service.

During in-depth interviews and focused group discussions conducted elsewhere[8,10,12] the participants reported creating awareness about suicide and ways to recognize them early, increasing the access to counseling and social support services, educational empowerment, and economic support, encouraging spiritual well-being and decriminalizing suicide there by reducing stigma and restriction of suicide means as measures to curtail the menace of suicide.

The saving and empowering young lives in Europe (SEYLE) awareness program empower pupils by increasing awareness of general mental health and healthy and unhealthy behaviors. Question, Persuade, and Refer (QPR) programs appear promising for suicide prevention, especially in adolescents.[16] Focus group discussions and role plays were adopted in the “Surviving the Teens” method to provide awareness of suicidal burdens, risk factors, helplines, and warning signs to students.[17]

Conducting awareness programs at regular intervals, introducing helplines, gatekeeper training, screening, and follow-up of high-risk students were some of the suicide prevention strategies considered to be introduced locally but the authors wanted to hear from the students about their views about these services before they are implemented as they were the main stakeholders. This study was designed to collect students’ views and opinions about people who attempt or commit suicide, why such incidents happen and how they can be helped. Their views on effective crisis intervention services were also sought. Also, the authors believed that these focus group discussions could be part of local suicide prevention awareness programs.

The main objective of the study was to understand the student perspectives on suicide and understanding the challenges of implementing a crisis intervention program for students in the educational institute with a view to developing manpower and resources to implement the service.

METHODS

A qualitative study design using focus group discussion (FGD) was used to collect data on students’ views and opinions on study parameters.

Participant selection and recruitment: This study was done in a private educational institute in Tamil Nadu located in a rural setting catering to the educational needs of students admitted to Medical, Dental, Engineering, and Nursing courses.

Sampling method: Universal sampling with all the students studying in the institute (approximately 1750) aged more than 18 years of age were approached for inclusion in the study. Due to exams, different class schedules and being absent for personal reasons, 830 students participated in the focus group discussion from December 2019 to March 2020.

The authors chose to include all the students within the educational institute and not restricted the sample according to data saturation for two reasons: 1) the students from different academic years and professional courses may have different views and go through different stressors and 2) the focus group discussion was also used as a method of suicide awareness campaign among the students.

Study procedure: Prior permission from the respective authorities was obtained for conducting the FGD and students were requested for informed consent to participate in the study. The authors used a format with probe questions, follow-up questions, and exit questions to collect data on the study parameters. Faculties interested to be part of the project were identified and divided into five teams with two members for each team one for facilitating the session and another for recording the views of participants verbatim. The authors gave training to team members to facilitate the session to collect relevant data and record the views of study participants to maintain uniformity.

FGDs were planned one week in advance and invitations were sent to students for participation. A typical FGD session lasted for 45 minutes to one hour.

Data analysis: Two of the authors reviewed each transcript of the recorded FGD data independently and one of the authors coded all the data using Microsoft excel charts. These charts were distributed to all the authors to familiarize them and detect themes. A thematic framework was developed and agreed upon by the consensus of all the authors after identifying key themes at a meeting.

The Framework approach[18] was selected as it allowed the qualitative data to be organized in a transparent and systematic way. The framework is a method for analyzing qualitative data and allows both a case and theme-based approach to the analysis, which helps reduce data by summarization while still allowing researchers to compare data across and between cases. It ensures links are retained to the original data which provides a comprehensive and transparent form of data analysis useful when working in research teams. The results have been reported as per the criteria from the COREQ checklist for reporting qualitative research.

Ethical considerations: Ethical approval was obtained from the Institutional ethics committee on 25/11/2019 and the Ref No: KIMS/F/2019/33. The authors explained that non-participation in the study will have no implications on students’ training. The participants were assured of maintaining anonymity and confidentiality at all times.

RESULTS

Focus group discussion group: sample characteristics

The study involved a total of 830 students who participated in the focus group discussion divided into small groups of 12 to 15 students in each group. A total of 70 FGD sessions were conducted with a maximum of five sessions in a day. Fifty-eight percent of the study participants were females. The demographic details of the students from different courses and academic years are given in Table 1.

Table 1.

Demographics of FGD participants

Variable	n
Name of the course
Medical
1st Year	44
2nd Year	89
3rd Year	90
4th Year	88
5th Year	84 (395)
Dental
1st Year	53
2nd Year	82
3rd Year	66
4th Year	51
Interns	38 (290)
B.Sc. Nursing
1st Year	37
2ndYear	40
3rdYear	35 (112)
Engineering
1st Year	33
Gender
Male	342
Female	488

Several themes and subthemes emerged from the focus group discussion [Table 2].

Table 2.

Summary of themes and subthemes from the FGD

Themes emerged from the focus group discussion (FGD)
Theme 1: Understanding of suicide and suicidal attempt
Subthemes: Reasons for the suicidal attempt, deficits with coping or problem-solving abilities of individuals, judgmental statements, concrete meaning and philosophical statement
Theme 2: Awareness of suicide or suicide attempt within the institute Subthemes: Reaction, reflection and action
Theme 3: Reasons why a professional student might attempt or commit suicide Subthemes: Intrinsic and Extrinsic factors
Theme 4: Knowledge of services available for students in crisis
Theme 5: Student’s view on crisis intervention services
Theme 6: Barriers to accessing help during the crisis Subthemes: Stigma and confidentiality
Theme 7: Ways a crisis intervention service could be popularized among students
Subthemes: Social media, advertisement and awareness programs

Theme 1: Understanding of suicide and suicidal attempt

Subthemes: Reasons for the suicidal attempt, deficits with coping or problem-solving abilities of individuals and judgmental statements about the individuals who attempt or commit suicide. Few students gave literal meanings of suicide such as self-death, self-killing, and self-termination. Only one student gave abstract meaning that it is an act of cry for help.

Some of the common judgmental statements include,

‘Stupidity, cowardliness, mistake, insecure, crime, immature, attention-seeking, silly, overthinking, selfishness, an act as a solution to problems, it’s their choice, failure of the society, childish behaviours, the decision was taken in haste, weak heart and being too sensitive

‘Not able to handle pressure, unable to accept failure, intolerant to frustration, lack of confidence, low self-esteem, avoidance, detached from society, lack of decision making, emotional turmoil, escape from stress, scared to face failure and lack of trust were some of the coping defects expressed.

One student shared a philosophical view that “God has given life; he will take it when he wants to, so why rush?”

On a positive note, a couple of students recorded that it is an act to be prevented.

Theme 2: Awareness of suicide or suicide attempt within the institute

Only a few students were aware of recent incidents of suicide on campus while the majority heard it for the first time.

Subthemes: Reaction, reflection, and action.

Immediate reactions of the students on hearing a suicidal act on the campus are ‘anger, shock, sadness, panic, upset, crying, fear, guilt, felt pity, sorry and blank.’ A couple of students had flashbacks and nightmares.

On reflecting on the incident, most of the students tried to find a reason for the act, while few were concerned about the consequences of the act. The responses include,

‘Couldn’t have been a solution, what could be the purpose, impact on parents/loved ones, bring bad reputation to college, how many others were committing a similar act outside’

I would take them for counselling, inform parents, sit and talk, spend time with them, try to solve their problems, make recreational activities available, divert them, not leave them alone, reassurance, tell them they have people to care about, sharing of problems were some of the action statements, the students contemplated during the discussion.

A few students said, “I will slap them, tell them to go and die” while one student said “it’s ok to get help”

Theme 3: Reasons why a professional student might attempt or commit suicide

Subthemes: Intrinsic and Extrinsic factors

In exploring the reasons for student suicide, many students spoke about external factors while few discussed individual vulnerability.

External factors broadly include the following categories: a) Academic—exam failure, fear of exams, academic pressure/workload, assignment, passion, forcing to study a course unwillingly, b) Managerial/Institutional—bullying, comparison, humiliation, shaming, feeling targeted, c) Relationship—rejection, loss, feeling cheated and inability to adapt, d) Lack of support system; from family and friends, and e) career prospects. Few students reported parent-teacher meetings as a trigger and in an engineering course, campus selection was one of the causes.

The intrinsic factors were broadly grouped under the following categories: a) Inferiority complex, b) introverted, c) fear of responsibilities, d) low frustration tolerance, e) inability to cope with stress, f) threatening act, g) feelings of guilt, h) unfulfilled dreams, and i) personal health problems.

Theme 4: Knowledge of services available for students in crisis

Many students were not aware of the existence of a student counselling cell within their premises but were aware of the local mental health services. Few students felt the mentorship program was one way to help in discussing their issues; however, most felt they wouldn’t discuss their problems with their mentor due to a lack of trust and confidentiality issues. None of the students was aware of any crisis helpline numbers provided by the Government or local NGO.

Theme 5: Student’s view on crisis intervention services

Most students preferred to have student volunteers and student-friendly staff as part of the crisis intervention team who could be trained by the mental health team to deal with students in crisis and be the first point of contact. Few dental college students thought including dentists from outside the institute as part of the team could help students deal with academic pressure as they could understand their problems related to academics/workload better and prevent being victimized by the in-house staff.

Few students felt that the services should be flexible and that they should not force students to disclose their personal details, the option of availing only of telephone help.

Theme 6: Barriers to accessing help during a crisis

Subthemes: Stigma and confidentiality

Majority of the students worried about the stigma of accessing help. Fear of being judged, isolation by peers, preferred counselling in places other than psychiatry OPD like canteen or library, counselling by trained non-mental health professionals.

Statements about confidentiality include, authorities/management will come to know, parents may be informed without their consent, being sent out of the hostel, being targeted by faculties, and lack of trust.

Few students wondered about, the free availability and accessibility of the services, whether the services would help and their willingness to share their problems.

Theme 7: Ways a crisis intervention service could be popularized among students

Subthemes: Social media, advertisement, and awareness programs

Preference for social media including, creating a Facebook page, blog, website, mobile app, and short films was the popular method followed by advertisement through the brochure, posters, placards, fancy helpline numbers, foam boards in common places, and hostel premises.

The proper launch event, campaign rally, fun games, role plays, FGD, awareness memes, and education during clinical postings are some of the awareness programs that students thought would help in popularizing the service. The involvement of student volunteers in the crisis team could keep their peers become more aware of the services.

DISCUSSION

Student suicides continue to rise despite several awareness programs, counselling services, and helpline numbers. This study was undertaken to identify the needs and understand the perspective of students before implementing a robust crisis intervention service locally. Students actively participated in the focus group discussion as it involved small groups that encouraged more interaction. Facilitators obtained the views of all the students in the group even students who were shy and hesitant. Clarification was obtained for the ambiguous responses and the facilitator responded to the questions from the students. Most of the students felt that the session was interesting, felt reassured and had an opportunity to vent out their feelings. Few students said they were demystified and cleared of their misconceptions on this important and sensitive topic. Some students even requested similar sessions to be organized at regular intervals.

This study highlighted the poor understanding of students about people who attempt or commit suicide. Negative judgmental statements and blaming the act as personal weakness warrant significant attitudinal change among the student population. Reassuringly, one student responded that it could be a cry for help. The authors believe that poor understanding is just a reflection of attitude and understanding of mental health among the general public.

Findings from the study demonstrated the dormant nature of the existing counselling cell and that the services are mostly reactive rather than proactive. In a few instances when the services were actively involved after an incident, students felt threatened rather than reassured due to the punitive consequences.

Perception of academic stress as one of the most common reasons for suicide attempts has been found in earlier studies done in India.[19,20] In addition to academic stress, our study also identified certain aspects of the institutional policies with respect to managing students contributing to student suicide. This needs to be addressed by a policy change by understanding the student’s difficulties and taking into account of the views of the other stake-holders (i.e., faculties, parents, and administrators) in decision-making.

The themes of stigma and confidentiality about mental health among students were the main barriers to accessing help. These views are no different from the general population and consistently found in other studies.[21,22] Incorporating the student’s views, including them as volunteers, adaptive, and innovative ways of working could help in breaking these barriers and improve the accessibility of the services.

The students acknowledge that none of the services would serve their purpose if it is not utilized properly. They suggested that taking the help of digital technology and social media which the student population is familiar with and comfortable would improve accessibility at times of crisis. This has been suggested in one of the recent reviews done in this area.[23]

Overall, this study demonstrated the need for regular awareness programs (such as stress management/time management), change in attitude from the students and management, involvement of student volunteers, and proactive crisis intervention service would help prevent further suicides in the educational institute.

Strengths and weaknesses of the study

This study used an appropriate research design with a larger sample size involving students of different professional courses. Focus group discussion was an effective way of capturing the views and opinions of study participants and was adopted in this study. This study was done in a private educational institute and so not generalizable to the student population. Also, the study included students from professional courses only. The results need to be interpreted with caution considering the impact of subjectivity on the part of the researchers despite all attempts to avoid such bias. FGD among staff and faculties could have helped to identify and understand any contrasting views about academic and institutional stressors.

CONCLUSION

This study has highlighted several themes and subthemes to understand the perspectives of student suicide and consider them before implementing a crisis intervention program locally. Inclusion of student and staff volunteers as gatekeepers, gatekeeper training, continuations of awareness programs, innovative ways of advertising the service among students and most importantly, appropriate inclusion of management, and parents in crisis intervention protocol would go a long way in the prevention of student suicide.

Financial support and sponsorship

Self-Funding.

Conflicts of interest

There are no conflicts of interest.