Abstract
Suicidal ideation is a common and growing concern among students globally. Students who have academic pressure, social transitions, and personal relationship issues are likely to face distressing thoughts in their lifetime. This study aimed to assess help-seeking sources and perceptions toward suicidal ideation among undergraduate students. A web-based cross-sectional study was conducted involving 422 undergraduate students. The general help-seeking questionnaire was used to determine help-seeking intentions. Frequencies, percentages, and standard deviations were calculated to determine individual characteristics. Univariate logistic regression was used to determine the factors associated with help-seeking intentions. All the tests were performed at a 95% of confidence interval (CI), and variables with P-values <.05 were considered statistically significant. This study found that 58.5% and 38.4% of the participants were extremely likely to seek help from traditional healers and parents, respectively. Gender was significantly associated with intimate partner (odds ratios [OR] = 1.5, CI = 1.0–2.2), and traditional healer (OR = 0.3, CI = 0.1–0.5). Parents (OR = 0.5, CI = 0.3–0.8) and family members (OR = 0.4, CI = 0.2–0.6) were significantly associated with education. Age (OR = 1.6, CI = 1.1–2.4) and family type (OR = 1.8, CI = 1.1–3.0) were significantly associated with self-help preferences. Fear of criticism (34.2%) and stigma (20.3%) were the most common barriers to seeking help for any mental problems. The study findings suggested informal sources were more favorable sources for help-seeking than professional sources among students. School-based psychosocial interventions should be conducted to reduce fear of criticism and stigma among students while seeking help for any mental problems from any sources.
Keywords: help-seeking sources, intentions, Nepal, suicidal ideation, undergraduate students
1. Introduction
Suicidal ideation is a broad concept that includes deliberate actions directed by an individual’s thoughts and self-harming activities, ultimately leading toward self-harm or suicide.[1] Suicide is a global and serious public health problem and was the fourth leading cause of death among the 15 to 29 years of age group in 2019.[2] More than 7,00,000 people take their own lives and many more people attempt suicide.[2]
The progression towards suicidal ideation starts with psychological or emotional pain, intensifies when this pain surpasses connectedness, and culminates in strong suicidal ideation, leading to a potential suicide.[3] Interaction between different factors, such as social, economic, educational, occupational, and environmental factors, influences suicidal thoughts.[4] Insomnia, sadness, anxiety, and psychosis are all treatable mental illnesses that are brought on by suicidal thoughts among students.[5]
High rates of suicidal thoughts among undergraduates may be attributed to the constant pressure of balancing personal and professional life, with a significant factor being the high unemployment rate, causing financial crises.[6] Due to the inability to handle academic pressure, personality, and unwanted feelings, students have to face distressing thoughts and try to attempt suicide.[7] However, most of the individuals who have attempted suicide never come in contact with health institutions, but it can be avoided with the help and support of family members, peers, and the community.[8]
Help-seeking behavior among students suffering from suicidal tendencies is very low, which is due to low literacy about mental illness, the high impact of social taboos, ignorance, and the risk of being isolated in society.[9] Several studies found that individuals with higher education expectations, familial or partner stress, and risky behaviors such as bullying, are at a greater risk of having suicidal thoughts.[10,11] Persistent hesitation to seek professional help may contribute to the gradual escalation of students’ mental problems, including depressive disorder, anxiety, and stress. This escalation could potentially make suicide seem like a viable option.[12] However, the weight of the life-threatening prospect encourages students to reconsider and opt for the more acceptable choice of seeking professional help.[12]
Awareness of the importance of positive help-seeking intentions among students can significantly reduce the number of deaths.[13] Many studies have revealed that suicide attempts and suicidal ideas are on the rise at an alarming rate among students.[14–16] It was reported that 80% of the total population, including students, require mental healthcare by the National Mental Health Survey, 2020, in Nepal.[17]
Several studies indicated that further social and environmental aspects should be explored that have a major influence on the choice of individuals to seek help.[14,18] To the best of our knowledge, a limited number of investigations have been conducted to explore the association between suicidal ideation and help-seeking behavior among students in Nepal. This study aimed to assess help-seeking intentions toward suicidal ideation among undergraduate students.
2. Materials and methods
2.1. Study design and setting
A cross-sectional study was conducted among the colleges of Kathmandu University (KU) School of Science in the Kavrepalanchok district. This university offers more than 200 undergraduate, graduate, and postgraduate programs.[19] It includes 7 schools and colleges, consisting of the School of Management, the School of Law, the School of Education, the School of Medical Science, the School of Engineering, and the School of Science.[19]
2.2. Study population
The study involved undergraduate students from KU academic programs. Undergraduate students above 18 years were included in this study.
2.3. Sample size and sampling
The single population proportion formula (n = Z2pq/d2) was applied to determine the sample size for this study.[20] A sample size (n) of 384 was obtained by assuming a 50% proportion of students with help-seeking intentions, 95% confidence interval (CI), and 5% margin of error. The final sample size was 430 after adding a 10% nonresponse rate.
Identification numbers and additional information of students were obtained from the Dean’s office and the information officer of KU. Then, a convenient sampling technique using social media such as Gmail, Facebook, and WhatsApp were employed to select participants through an online Google form.
2.4. Tools and techniques
Help-seeking intentions of participants were determined by using the general help-seeking questionnaire.[21] It has a 7-point Likert scale response ranging from extremely unlikely to extremely likely.[18,22] A pretesting was conducted among 10% of the sample size to ensure internal reliability and consistency of the study tool. A Cronbach’s alpha coefficient of 0.81 was obtained, which is similar to the previous study, that is, 0.85.[21]
The questionnaire was divided into 3 sections. The first section included participants’ characteristics such as age, sex, ethnicity, religion, educational background, year of bachelor’s, type of family, and place of residence. The second and third sections were regarding sources of help-seeking, that is, professional and informal sources, reasons for not seeking help, duration for help-seeking, and previous experiences while seeking help for suicidal ideation. Professional sources were the personnel who were certified as mental health professionals. Informal sources included intimate partners, parents, friends, family members, and self-help preferences.
To measure help-seeking intention, a score of “7” indicated extremely likely, “6” little likely, “5” likely, “4” neutral, “3” unlikely, “2” little unlikely, and “1” extremely unlikely.[21] Then the participants’ score was computed by adding the scores. A score above “5” or higher was considered high propensity, and a score below “5” was considered low propensity to contact the relevant source in this study.[21]
2.5. Data collection
Participants were asked to complete an online Google Form, which was distributed through social media platforms. It was ensured that only one response per participant was allowed through the “Limit to 1 response” option.
2.6. Data management and analysis
Collected data were cleaned, filtered, validated, and cross-checked in an Online Google Sheets. Then, the entered data was exported to IBM Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk) version 25 for data analysis. Participant characteristics were described using frequencies and percentages. The factors associated with help-seeking intentions toward suicidal ideation were assessed by using univariate logistic regression analysis. All the tests were conducted at a 95% CI, and variables with P-values <.05 were set as statistically significant for the variables.
2.7. Ethical approval
This study was reviewed and approved by the Ethical Review Board of Nepal Health Research Council [reference number: 3368]. A letter of support was also taken from the Dean’s office of KU. The purpose and objective of the study were mentioned on the first page of Google Forms. E-consent was taken from each participant before obtaining information. All the information was kept anonymous and confidential. An opportunity was provided to withdraw from the study at any time.
3. Results
3.1. Characteristics of the participants
A total of 430 students participated in this study and most of them belonged to the age group 18 to 20 years. A nearly equal proportion of males (53.1%) and females (47.9%) participated. Most of the participants belonged to the Brahmin/Chhetri ethnic group (58.3%) and followed the Hindu religion (89.5%; Table 1).
Table 1.
Individual characteristics of participants (n = 430).
| Characteristics | Number (n) | Percentage |
|---|---|---|
| Age (in completed years) | ||
| 18–20 | 241 | 56.1 |
| 21–23 | 189 | 43.9 |
| Gender | ||
| Female | 202 | 46.9 |
| Male | 228 | 53.1 |
| Ethnicity | ||
| Brahmin/Chettri | 251 | 58.3 |
| Janajati | 136 | 31.6 |
| Madhesi | 32 | 7.4 |
| Others | 11 | 2.5 |
| Religion | ||
| Hindu | 385 | 89.5 |
| Buddhist | 28 | 65.0 |
| Others | 17 | 39.5 |
| Educational background | ||
| Engineering | 217 | 50.4 |
| Health science | 129 | 30.0 |
| Administration and management | 70 | 16.9 |
| Others | 14 | 3.2 |
| Current year of bachelor | ||
| First | 122 | 28.3 |
| Second | 124 | 28.8 |
| Third | 168 | 39.0 |
| Fourth | 16 | 3.9 |
| Type of family | ||
| Nuclear | 324 | 77.3 |
| Joint/extended | 106 | 22.7 |
| Staying with | ||
| Alone | 71 | 16.5 |
| With friends | 129 | 30.0 |
| With parents | 230 | 53.5 |
3.2. Help-seeking toward suicidal ideation
3.2.1. Professional sources
Most participants were extremely likely to seek help from traditional healers (58.5%), psychiatrists (29.4%), doctors (27.3%), and psychologists (21.3%) as their choice of professional help for suicidal ideation. On the contrary, most participants (20.1%) were extremely unlikely to seek help from psychologists and psychiatrists (Fig. 1).
Figure 1.
Help-seeking from professional sources.
3.2.2. Informal sources
More than one-third (38.4%) were extremely likely to seek help from parents, followed by self-help (29.4%), friends (29.1%), intimate partner (26.8%), and family members (26.3%). While most of the participants (34.1%) were extremely unlikely to seek self-help for suicidal ideation (Fig. 2).
Figure 2.
Help-seeking from informal sources.
3.3. Association between individual characteristics and help-seeking preferences toward suicidal ideation
The study showed that gender was significantly associated with seeking help from an intimate partner (odds ratios [OR] = 1.5, CI = 1.0–2.2) and a traditional healer (OR = 0.3, CI = 0.1–0.5; Table 2).
Table 2.
Association between gender with help-seeking preferences.
| Preferences | Intimate partner | Traditional healer | ||||||
|---|---|---|---|---|---|---|---|---|
| High propensity, n (%) | Low propensity, n (%) | P-value | OR (95% CI) | High propensity, n (%) | Low propensity, n (%) | P-value | OR (95% CI) | |
| Gender | ||||||||
| Male | 101 (44.2) | 127 (55.8) | .04* | 1.5 (1.0–2.2) | 176 (77.1) | 44 (23.9) | .00* | 0.3 (0.1–0.5) |
| Female | 75 (37.1) | 127 (62.9) | 1 | 189 (93.5) | 21 (6.6) | 1 | ||
Meanwhile, other independent variables were not associated with other help-seeking sources.
CI = confidence interval, OR = odds ratios.
P-value significantly associated at the level of .05.
3.4. Association between education and help-seeking preferences
This table shows that education was significantly associated with parents (OR = 0.5, CI = 0.3–0.8) and family members (OR = 0.4, CI = 0.2–0.6) for help-seeking toward suicidal ideation (Table 3).
Table 3.
Association between education with help-seeking preferences.
| Preferences | Parent | Family member | ||||||
|---|---|---|---|---|---|---|---|---|
| High propensity, n (%) | Low propensity, n (%) | P-value | OR (95% CI) | High propensity, n (%) | Low propensity, n (%) | P-value | OR (95% CI) | |
| Education | ||||||||
| Medical | 34 (26.3) | 95 (73.7) | .00* | 0.5 (0.3–0.8) | 38 (29.5) | 91 (70.5) | .00* | 0.4 (0.2–0.6) |
| Nonmedical | 123 (40.8) | 178 (59.2) | 1 | 152 (50.5) | 149 (49.5) | 1 | ||
Meanwhile, other independent variables were not associated with other help-seeking sources.
CI = confidence interval, OR = odds ratios.
P-value significantly associated at the level of .05.
3.5. Association between age and family type with help-seeking preference
Age was significantly associated with self-help as a help-seeking preference (OR = 1.6, CI = 1.1–2.4). Likewise, family type was also significantly associated with self-help preference (OR = 1.8, CI = 1.1–3.0; Table 4).
Table 4.
Association between self-help seeking preference with age and family type.
| Preference | Self-help | P-value | OR (95% CI) | |
|---|---|---|---|---|
| High propensity, n (%) | Low propensity, n (%) | |||
| Age (yr) | ||||
| 18–20 | 117 (50.2) | 124 (49.8) | .01* | 1.6 (1.1–2.4) |
| 21–13 | 66 (35.0) | 123 (65.0) | 1 | |
| Family type | ||||
| Nuclear | 139 (43.0) | 185 (57.0) | .01* | 1.8 (1.1–3.0) |
| Joint/extended | 40 (37.7) | 66 (62.3) | 1 | |
Meanwhile, other independent variables were not associated with other help-seeking sources.
CI = confidence interval, OR = odds ratios.
P-value significantly associated at the level of .05.
3.6. Duration for help-seeking toward suicidal ideation
Half of the participants preferred to seek help immediately (51.7%), and one-third preferred to wait for a month (29.4%) to seek help. In contrast, about 8% of the participants were identified as those who would never seek help even if they faced any suicidal ideation (Fig. 3).
Figure 3.
Duration of help-seeking toward suicidal ideation.
3.7. Reasons for not seeking help toward suicidal ideation
Figure 4 shows that the major reasons for not seeking help were fear of criticism (34.2%) and stigma (20.3%) towards mental health in the community.
Figure 4.
Reasons for not seeking help toward suicidal ideation.
3.8. Previous help-seeking experience
In this study, only 11.3% of the participants sought help when they experienced thoughts of attempting suicide. Among them, the majority sought help from a doctor (43.7%) and a psychiatrist (37.5%). More than half (58.3%) found that the services were extremely helpful when they visited health professionals for help (Table 5).
Table 5.
Experience of help-seeking towards suicidal ideation among the participants.
| Characteristics | Number (n) | Percentage | |
|---|---|---|---|
| Did you seek help from anyone when you have thoughts of suicide? (n = 430) | Yes | 48 | 11.3 |
| No | 382 | 88.7 | |
| Do you know which type of health professional(s) you have seen? (n = 48) | Doctor | 21 | 43.7 |
| Psychiatrist | 18 | 37.5 | |
| Other (Nurse, Ayurved) | 9 | 11.2 | |
| How helpful was the visit to the health professionals? (n = 48) | Extremely helpful | 28 | 58.3 |
| Helpful | 8 | 16.6 | |
| Neutral | 6 | 12.5 | |
| Unhelpful | 4 | 0.8 | |
| Extremely unhelpful | 2 | 0.4 | |
4. Discussion
In this study, a significant proportion of students were more likely to seek help from traditional healers than professionals like psychologists. Similarly, 44.6% of the participants were likely to seek help from traditional healers in Ethiopia, which is slightly less than this study.[23] Meanwhile, 75.6% of participants favored seeking help from traditional healers in Japan, which is higher than in this study.[24] This is because individuals experiencing suicidal ideation frequently seek the assistance of traditional healers, relying on the belief that these healers possess the ability to provide support during a suicide crisis.[25,26] In addition, a decline in seeking professional help occurs due to inadequate social/family support and negative societal attitudes in the community.[12,23]
The most preferred source of informal help was parents, followed by self-help and friends in this study. The finding is coherent with similar studies conducted in Canada[27] and Thailand.[28] Participants preferred parents and friends as a favorable choice for sharing personal and emotional problems. A high degree of connectedness can diminish suicidal thoughts by fostering a greater likelihood of seeking help from parents and friends, who provide valuable support and information, creating a safe space.[12,28] This strengthened connection enhances the student’s trust in the personal and emotional guidance related to seeking help from their parents and friends.[12,18] Similar to this study, students also preferred self-help books and the Internet when they faced any problems in the United States.[29]
This study demonstrated that males were 1.5 times more likely to seek help from their intimate partner as their informal source of help compared to females. This finding is similar to young men in Australia[18] and Canada,[30] where they preferred informal sources. This is due to suicidal ideation being more common in male students than females in Nepal.[15] This is also because males are more likely to be reluctant to discuss the problem and have a hard time opening up to people until they find their comfort space, which usually happens with their intimate partner.[31] Meanwhile, this study demonstrated that males had lower odds of seeking help from traditional healers compared to their counterparts. This finding is similar to a study carried out in Nepal, where female patients visited traditional healers more often than males.[26] The difference in the findings is attributed to the mental health stigma affecting both genders, manifesting in different ways.[32] Males tend to avoid seeking help due to the fear of being labeled as weak; meanwhile, females tend to avoid seeking professional help in fear of being labeled as unbalanced and broken.[33]
Nonmedical students were more likely to seek help from informal sources like parents and family members than medical students. This difference in preference among different fraternities in our study might be because nonmedical students are more likely to seek help from informal sources due to their inadequate knowledge about mental health issues like suicidal ideation.[34] However, a study in Ethiopia revealed that the educational background was not significantly associated with the help-seeking behavior of the students.[35] Similarly, studies conducted in Ethiopia[36] and the United States[37] revealed that the educational background of the students did not determine their preference regarding professional and informal help-seeking. Similarly, a study done in Sri Lanka has criticized that even though medical students have comparatively more virtue regarding professional help-seeking, they failed to put knowledge into practice, so they are forced to seek help from informal sources[34]
In this study, the younger age group had 1.6 times more odds of seeking help from self-help than the rest of the age group. It is supported by a study done in Hong Kong, which reported that those who sought help online were younger than those who sought help from informal sources for suicidal ideation.[10] This is because young people believe that anonymity, avoiding embarrassment, and social support a benefits of online help sources.[10] Despite the rise of online support platforms, many countries lack legal guidelines for the quality of online therapists, leaving vulnerable individuals at risk of inappropriate mental health services.[10]
Almost half of the participants preferred to seek help immediately, and 29.4% of participants would wait at least a month. This delay is due to their hesitancy to talk about their feelings, emotions, and thoughts, followed by embarrassment.[38] Unfortunately, 7.6% of participants would not seek help even if they faced any suicidal ideation, but in developed countries like the United States[29] and Thailand[28] the proportion of students not seeking any help was much lower, that is, <1% and <2%, respectively. A positive attitude and higher intention to help-seeking occur when individuals have higher mental health literacy. They were aware if they had a history of any mental illness, where to seek treatment, and if the disorder was treatable.[39]
The main reasons for not seeking help were fear of criticism and stigma towards mental health in this study. Multiple barriers, such as social visibility, lack of anonymity, the culture of self-reliance, the social stigma of mental illness, and the pre-labeled taboo, persisting in society, might contribute to a delay in help-seeking.[40] Furthermore, the cost of treatment and failure in client-oriented satisfaction also hinder help-seeking.[40]
This study reported that students encountered positive interactions when reaching out to doctors and psychiatrists during past episodes of suicidal ideation, which is in coherence with studies conducted in Nepal[41] and Ethiopia.[14] Over half of the students indicated a preference for seeking assistance from psychologists and/or counselors when dealing with suicidal thoughts in this study, which is slightly lower than in the previous study regarding anxiety.[41] Moreover, individuals may prefer informal support from social networks to avoid stigma.[12] The study highlights the need to promote professional help-seeking preferences among students. Furthermore, providing mental health counselors inside educational institutions could be beneficial in preventing such situations among undergraduate students.[13]
5. Strengths and limitations
To the best of our knowledge, this study is among the first to examine how students in Nepal seek help when they are contemplating suicide. Some of the results were self-reported, which could lead to bias in the results. Since this study is web-based, there’s a possibility of information bias. Due to the cross-sectional study, the cause-and-effect relationship between variables was not measured.
6. Conclusion
The study’s findings highlighted that students prefer help-seeking more from informal sources rather than a professional if they face suicidal ideation. The findings of this study highlighted the importance of school-based psychosocial interventions to encourage students to seek help from professional sources like psychologists/counselors, and psychiatrists. The existence of fear of criticism and stigma towards mental problems among students were major barriers that cause delays in seeking help among students. Such social issues can be eliminated by conducting community-based mental health awareness programs.
Acknowledgments
The authors express gratitude to the Department of Public Health, Om Health Campus, Purbanchal University, Nepal, for providing an opportunity to conduct this study. We thank Kathmandu University School of Science, Nepal, for their guidance during the research project. Special thanks are extended to the individuals who provided their time and effort.
Author contributions
Conceptualization: Richa Aryal, Manish Rajbanshi.
Data curation: Richa Aryal.
Formal analysis: Richa Aryal, Manish Rajbanshi.
Investigation: Richa Aryal.
Methodology: Richa Aryal, Manish Rajbanshi.
Resources: Richa Aryal.
Software: Manish Rajbanshi.
Supervision: Manish Rajbanshi.
Validation: Manish Rajbanshi.
Writing – original draft: Richa Aryal.
Writing – review & editing: Manish Rajbanshi.
Abbreviations:
- CI
- confidence interval
- KU
- Kathmandu University
- OR
- odds ratios
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Aryal R, Rajbanshi M. Help-seeking intentions towards suicidal ideation among undergraduate students of Nepal: A cross-sectional study. Medicine 2025;104:33(e43909).
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