A profound absence of counseling interventions for suicide prevention among youth in Africa: A call to action based on an empty scoping review

Abstract

Objective:

One-third of all global suicide deaths occur among adolescents and young adults, making suicide the second leading cause of death among young people. Nearly 80% of suicide deaths occur in low- and middle-income countries and many African nations have higher rates of suicide compared to global averages. However, interventions are scarce. We conducted a scoping review of counseling interventions for suicide prevention among youth in Africa.

Method:

We performed structured searches of the Medline, Embase, PyscINFO, African Index Medicus, Global Heath Database, and Proquest Dissertations and Theses Global databases. Studies were eligible for inclusion if they described a counseling intervention conducted in Africa, focused on participants under age 22, and included a suicide-related outcome.

Results:

After removal of duplicates, 1808 titles and abstracts were screened and 10 studies were identified for full-text review. Of these, 6 included adult participants and did not disaggregate results for youth, 2 did not describe an intervention, and 2 did not include a relevant outcome. Thus, no studies were eligible for inclusion.

Conclusions:

This empty review highlights the striking absence of published research on a life-threatening public health challenge, representing a distinct call to action for improved efforts in adolescent suicide prevention in Africa.

Introduction

More than 700,000 people die from suicide annually, and one-third of these deaths occur among young people from the ages of 15 to 29, making suicide the second leading cause of death among adolescents and young adults worldwide (Campisi et al., 2020). Approximately 78% of deaths by suicide occur in low- and middle-income countries (LMICs) (Bifftu et al., 2021). The data also show many African nations have higher rates of suicide in comparison to global averages, although the accuracy of these data come into question because of logistical challenges for data collection and potential underreporting due to stigma (Bifftu et al., 2021). Suicidal behavior is illegal in nine African nations, which further contributes to stigma and silence (Adinkrah, 2016; Lew et al., 2022; World Health Organization, 2021). Thus, there is a critical need to allocate more resources to research to provide clarity on the nature of suicidality in Africa, and to support the development of preventative and intervention-based care for suicidality among youth in Africa.

The causes of suicide among youth in Africa are multifaceted and frequently entangled with social, economic, political, and cultural factors. For example, childhood adversities that are more common in LMICs have been linked to increased risk of suicidality, including childhood health challenges, experiences of abuse, and parental death and/or separation (Bruwer et al., 2014). Moreover, food insecurity, poor access to healthcare, and lower socioeconomic status are all associated with depression, a leading cause of suicidality (Nyundo et al., 2020). Young people living in poverty may be required to contribute to income-generating activities, which can hamper academic performance and lead to stress and depressive symptoms (Nyundo et al., 2020). The presence of chronic health conditions such as HIV, along with associated stigmas, may also drive suicidality, as people living with HIV are much more likely to die by suicide than the general population (Ashaba et al., 2018). Studies have shown that living with a stigmatized condition is strongly associated with experiences of discrimination, bullying, and lower academic performances, all of which can contribute to suicide risk (Ashaba et al., 2018).

Individuals who struggle with suicidal ideation are frequently subjected to social stigma, including inaccurate attributions such as being labeled as attention-seeking or lacking self-control (van Zyl, 2020). The criminalization of suicide in many African nations further reinforces stigmatizing attitudes and may promote silence about symptoms and prevent youth from seeking needed support (Adinkrah, 2016; United Global Mental Health, 2021). Negative cultural perceptions of suicide may also contribute to the lack of resources dedicated to treatment and research for people struggling with thoughts of suicide. In contrast to high-income nations, where there are approximately 116 mental health professionals per million people, low and middle-income countries on average have fewer than 3 mental health professionals per million people (Venturo-Conerly et al., 2022). This leads to extreme scarcity of culturally relevant interventions geared towards addressing suicidality among youth in Africa (Knettel, Knippler, et al., 2023), with the majority of what is known about suicide coming from high-income Western countries (Bantjes et al., 2018).

We conducted a scoping review to examine the availability of counseling interventions for suicide prevention among children and adolescents in Africa which is, to our knowledge, the first review on this subject. This was an empty review, meaning that we found no studies eligible for inclusion. In this manuscript, we describe the methods undertaken in the review and the implications of the profound lack of studies on this vital topic, which may motivate the development and testing of greatly needed suicide prevention interventions for youth in Africa.

Method

This scoping review was carried out using the Cochrane Handbook for Systematic Reviews of Interventions (Green & Higgins, 2008). Findings are presented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 2020 statement (Tricco et al., 2018). The review protocol was registered in the OSF database (Protocol # 6753u) prior to extraction.

Data Sources

The databases searched included Medline (PubMed), Embase (Elsevier), PyscINFO (Ebscohost), African Index Medicus (WHO), Global Heath Database (CABI via Ebscohost), and Proquest Dissertations and Theses Global.

Study Selection

The search was developed and conducted by a medical librarian with input from the other authors, and included a mix of keywords and subject headings representing African countries, suicide, and childhood/youth/adolescents. The original searches were conducted on 20 October 2022 and found 2462 citations; search updates were conducted on 11 June 2023 and found 155 additional citations. The full, reproducible search strategies for all included databases are located in Appendix A. Additional references were identified by hand-searching bibliographies of articles during full-text review. After the search, all identified studies were uploaded into Covidence (Veritas, Melbourne, Australia), a web-based platform for managing reviews, and duplicates were removed by the software (n= 809). A final set of 1808 citations were left to be screened in the title/abstract phase.

Studies were eligible for inclusion in the review if they were focused on children, adolescents, or youth, with at least part of the sample under age 22. If studies included participants both under age 22 and participants 22 and older, the youth results needed to be disaggregated and presented separately for the study to be eligible for inclusion. Studies must have been conducted with African youth in an African setting; for example, studies conducted with people of African origin or African migrants in a nation outside of Africa were not eligible.

The study needed to include a counseling intervention (i.e., counseling, psychotherapy, supportive therapy, or psychoeducation), but did not need to be delivered by a mental health professional. For example, task-shared interventions delivered by community health workers or allied professionals were acceptable. The study needed to measure a patient-level outcome related to suicide (i.e., completed suicide, suicidal behavior, suicide attempt, suicidal ideation). Studies of assisted suicide, suicide attacks (e.g., suicide bombing), and non-suicidal self-injury were not eligible. Unpublished articles, including dissertations, theses, conference abstracts, and unpublished manuscripts, were eligible for inclusion.

Only studies from 2001 or later were eligible, as this was the year the World Health Organization published their landmark report, “Mental Health: New Understanding, New Hope,” which is widely considered to be the start of the modern era of global mental health intervention (World Health Organization, 2001). Studies could use quantitative, qualitative, or mixed methods. Studies with fewer than 10 participants, including small case series or case studies, were not eligible. Previous systematic reviews or meta-analyses, commentaries, letters to the editor, opinion pieces, news reports, and study protocols were also not eligible for inclusion. Included studies were limited to English or French, as these were the languages spoken fluently by our team.

We first screened study titles and abstracts and excluded those that clearly did not meet inclusion/exclusion criteria. We then reviewed the full text of the remaining studies and excluded any that did not meet the full inclusion/inclusion criteria. Both title/abstract and full text review were carried out independently by two authors and any disagreements were resolved via discussions in full team meetings until consensus was reached. The study selection process is represented by flowchart as per PRISMA guidelines (Figure 1).

Figure 1.

Review flowchart

Results

The searches yielded a total of 1808 citations after removal of duplicates and 1799 were deemed ineligible during title and abstract screening. The 9 remaining studies were excluded during full-text review, as was 1 additional study identified during bibliography screening.

Among the 10 studies excluded during full-text review, 3 were primarily focused on adult populations and did not disaggregate findings of participants under age 22 (Munetsi et al., 2018; Mutiso et al., 2019; Nakimuli-Mpungu et al., 2020). Three studies did focus on adolescent or young adult participants (Ertl et al., 2011; Jewkes et al., 2014; Muriungi & Ndetei, 2013); however, because the results of youth participants were not disaggregated from adults and were not reported separately, these studies were also ineligible for the current review. Notably, all of these studies were included in our previously published review on interventions for suicide prevention among adults in Africa (Knettel, Knippler, et al., 2023). The remaining studies excluded during full-text review did not describe an intervention (Casale et al., 2019; Wilson-Barthes et al., 2021), or described an intervention but did not report a relevant outcome (Hoffmann, 2006; Mwamuka et al., 2023) (see Appendix B). Thus, no studies were eligible for inclusion in the current review.

Discussion

The objective of this scoping review was to examine the availability of counseling interventions for suicide prevention among children and adolescents in Africa. Our study found no studies eligible for inclusion. Adolescents are among the groups most significantly at-risk for death by suicide worldwide, including in many African nations (Campisi et al., 2020; Demissie & Clayton, 2018; Nyundo et al., 2020). The lack of any documented interventions for this life-threatening problem represents a true failure of the global public health community, and this empty scoping review should serve as a distinct call to action for improved efforts in adolescent suicide prevention in Africa.

Several studies have examined correlates and determinants of suicidal behavior in this population, setting a strong foundation for intervention studies. The next wave of research must seek to develop such interventions, either through adaptation of evidence-based approaches from other settings, or in the creation of novel approaches to meet the specific needs of youth populations in Africa (Robinson et al., 2018). Given the strong prior formative work, such interventions need not focus exclusively on suicide prevention, but should also seek to address associated challenges such as substance use, child abuse, bullying, health challenges, stigma/discrimination, poverty, and other social determinants that may be driving suicidal behavior (Campisi et al., 2020; Nyundo et al., 2020).

The reasons for such a profound lack of attention to suicide research are multifaceted and complex. Nugent and colleagues (2019) describe several common barriers to suicide research, including concerns about recruitment, risk management, liability, informed consent, and the ethical implications of withholding treatment to a subset of participants to establish the effectiveness. These challenges may be amplified in low-resource settings with limited capacity to address suicide risk when it arises, requiring additional support from research staff (Knettel, Amiri, et al., 2023; Knettel et al., 2020).

Venturo-Conerly and colleagues (2022) developed a valuable model for integrating suicide risk assessment and intervention into existing adolescent mental health research in LMIC settings, informed by research from Africa. This includes identifying local resources and a risk protocol prior to study launch, training lay-providers in risk reduction procedures, integrating risk assessment of all study participants, and providing appropriate brief intervention and referral for participants at elevated risk (Venturo-Conerly et al., 2022). Similar principles must now be applied, along with novel treatment approaches, to inform research focused on raising community awareness about suicide, reducing stigma, encouraging help-seeking, and preventing suicide among at-risk youth in Africa. This may include interventions integrated in medical care, schools, social services, or the broader community (Nugent et al., 2019; Robinson et al., 2018).

Our findings should be considered in light of two important limitations. Namely, our searches included only studies published in English and French, as well as studies published in 2001 and later, which may have excluded relevant publications that did not meet these criteria. Additionally, it is possible that unpublished interventions or studies exist on the topic.

Conclusions

This empty review highlights the striking absence of published research on a critical, life-threatening public health challenge. It is imperative for new effort and resources to be dedicated to suicide prevention among youth in Africa, and it is our hope that the global community will step up to meet this challenge.

Data Availability:

Data or details of the underlying processes of this scoping review are available upon request from the corresponding author.