Abstract
Background:
Adolescent suicide is an important public health issue. Suicidal ideations are often the precursor of suicide and can be targeted by appropriate and timely interventions.
Aims and Objectives:
To determine the prevalence of suicide ideation and to study its predictive factors among school going adolescents.
Materials and Methods:
This cross-sectional study was carried out in selected senior secondary schools in Shimla district of Himachal Pradesh, India. A pre-validated, self-administered questionnaire was used for data collection. Both descriptive and inferential statistics were applied using Epi info software for windows (CDC Atlanta) software for windows.
Results:
A total of 218 study subjects (30.9%; confidence interval = 27.6–34.5%) had suicide ideation. Discussing problems with parents (adjusted odds ratio [AOR] =0.5), having good relations with school teachers (AOR = 0.6) and helpful classmates (AOR = 0.6) lowered the odds of having suicidal ideations. On the contrary, adolescents having worrying issues in family (AOR = 2.5), verbally or physically abused (AOR = 2.8) and body image conscious (AOR = 1.8) had increased odds of suicidal ideations.
Conclusions:
Suicidal ideation is a common experience among adolescents residing in Shimla district of North India. The supportive environment at home and in school decrease its vulnerability.
Keywords: Adolescents, predictors, suicidal ideation
Suicide is a leading cause of death among adolescents. Suicidal ideation is a term used for thoughts about unusual preoccupation with committing suicide. It is a risk for consecutive suicide attempt and completed suicide. Suicides can be prevented, if suicide ideations and its predictors are recognized and timely action is initiated.[1,2]
Globally, studies suggest that family support is a crucial part of the overall social support for the adolescents. An interactive environment at home is critical for the maintenance and normal development of the child. Similarly, studies have been reported the protective role of the supportive school environment in helping adolescent's adjustment in the society. Few studies have focused directly on individual variables such as sadness and verbal or physical abuse in predicting adolescent suicidal behavior.[3,4]
The existing literature on adolescents’ suicides ideation in India lacks the comprehensive individual, family and school environment variables associated with it. With this background, we studied the prevalence of suicide ideation and its predictors among school going adolescents.
MATERIALS AND METHODS
This cross-sectional study was carried out among adolescent school children of both sexes, aged of 14–19 years in urban field practice area of Indira Gandhi Medical College, Shimla, Himachal Pradesh, North India. The study area (Boileuganj Ward No. 7 of Shimla Municipal Corporation) is located nearly 10 km from the medical college and has 10 high and senior secondary schools. The study was carried over a period of 14 months (September 2012 to November 2013). The sample size was estimated based on the formula of n = 4pq/L2. Since, no previous study was available from the study area, the value of “p” (prevalence of behavioral, physical, and emotional risk factor among adolescents) was selected as 50%, absolute error 5%, design effect 2, and a nonresponse rate 20%. The sample size worked out for 720 school adolescents. Stratified cluster sampling was used to draw this representative sample of students from classes 9th to 12th in 10 randomly selected schools in the study area. The study population was divided into four strata from grade 9th to 12th. In all, there were 38 clusters (classes) from which 21 clusters (primary sampling unit) were selected with probability proportionate to size sampling. Finally, 36 students were selected from each class using a lottery method of randomization.
In the present study, we used the term suicide ideation to refer to a desire for death/committing suicide. The single item question was “Have you ever seriously thought about killing yourself in the past 12 months.” The predictors were assessed for individual (feeling sad, verbal/physical abuse, self-hurting tendency, and body image conscious), family (share problem with family and worrying issue in family), and school environment (falling grades, good relation with teachers, and helping attitude of classmates).
A pre-validated, self-administered questionnaire was used for data collection. Before administering the questionnaire by the principal investigator, all participants were reassured about the anonymity of their responses to the questionnaire. During the survey administration, it was ensured that class teacher was not present in the classroom. Only those students who present on the day of administration of the questionnaire were included. No second attempt was made to cover up the absentees.
Data was analysed using Epi info Software for Windows 3.5.1 (Centre for Disease Control, Atlanta) for windows. The dependent variable, suicide ideation was dichotomous (1 = yes, 0 = no). Binary logistic regression was employed to regress various predictor variables on suicide ideation. Formal approval was obtained from the State Education Department of Himachal Pradesh and the Principal of the selected schools. Informed written consent was taken from all the study participants and their parents/guardians. The study was approved by the ethical committee of Indira Gandhi Medical College, Shimla.
RESULTS
A total of 720 students were administered the questionnaire. Out of them, 15 did not answer the question of suicide ideation and hence dropped from the analysis. The remaining sample of 705 adolescents was evenly distributed between males 361 (51.2%) and females 344 (48.8%). A total of 385 (54.6%) were in the age group 14–15 years while the remaining 320 (45.4%) were in age group 16–19 years.
In the descriptive analysis, 218 (30.9% confidence interval = 27.6–34.5%) had suicide ideation in the past 12 months. Significantly more females (128; 37.2%) were having suicide ideation as compared to males (90; 24.9%). Adolescents in the age group of 16–19 years (121; 37.8%) were significantly having more suicide ideation as compared to those aged in the group of 14–15 years (97; 25.2%). Children of higher educated mothers had less suicidal ideations (162; 29.9%) as compared to their counterparts (56; 34.1%) [Table 1].
Table 1.
Sociodemographic, family, school and individual factors of adolescents having suicidal and nonsuicidal thoughts
The logistic regression model revealed that discussing problems with parents (adjusted odds ratio [AOR] =0.5), having good relations with school teachers (AOR = 0.6), and helpful classmates (AOR = 0.6) lowered the odds of having suicidal ideations. On the contrary, adolescents having worrying issues in family (AOR = 2.5), verbally or physically abused (AOR = 2.8), and body image conscious (AOR = 1.8) had increased odds of suicidal ideations [Table 2].
Table 2.
Logistic regression model predicting factors associated with suicidal ideations among adolescents
DISCUSSION
The present study estimated that nearly one-third of the adolescents experience suicide ideation. This estimation is higher than, what is reported in various studies in worldwide. A youth risk behavior survey from Thailand reported that 12% had suicidal thoughts.[5] Rudatsikira et al. in their study in Guyana estimated the prevalence of suicidal ideation among school going adolescents to be 18.4%.[6] Zhang et al. in his study on Chinese adolescents reported 18.5% of students had suicide ideation.[7] Similarly, a meta-analysis by Evans et al. reported that the average rate of adolescents reporting suicide thoughts in the past 1-year in the Western countries was 19.3%.[8] A study from India reported done by Siddharth et al. reported the prevalence of lifetime suicidal ideation as 12%.[9]
In the present study, females were more likely to have suicidal ideas than males. This observation is consistent with studies done by Chen et al. and Liu et al. in Chinese adolescents.[10,11] The gender paradox may be explained by the fact that adolescent females feel shy in discussing their views and problems with peers or families resulting in feeling of being socially isolated. Furthermore, research shows that although adolescent boys may have less suicidal thoughts, but their ideas translate into more completed suicides cases. Also, we observed that with an increase in age the social thoughts increased. Similar to this finding Garrison reported that suicidal thoughts increase progressively from junior to high school class students.[12]
Our study found a significant relation of self-harm tendency and physical/verbal abuse with suicidal ideation. Similar to our finding, a study by McGee et al. reported that thoughts of self-harm accounted for suicidal ideation.[13] Kaplan et al. in their study established the contribution of physical abuse to increased risk for suicidal behaviors among adolescents.[14] We identified helpful classmates, good relation with teacher and sharing problem with family decreased the risk of adolescent suicidal ideations. Similar to our observation, a study by Fleming et al. in New Zealand, reported that caring parents and teachers were associated with decreased rates of suicide attempts.[15]
This study has few limitations. Firstly, the cross-sectional design of the study does not establish a causal relationship for which future longitudinal studies are suggested to be done. A second limitation is the use of a single question on suicide ideation as an outcome measure in this study that may have underestimated or overestimated the numbers. However, we believe that the estimates from this study can be a basis for future research using validated scales.
CONCLUSION
Adolescent suicidal ideation is a common experience among adolescents residing in Shimla district of North India. Creating a supportive environment both in school and at home will help adolescents to express their feelings. This will translate into reducing such negative incidents. Furthermore, it is suggested that there should be a mechanism by which adolescents who suffer from verbal or physical abuse are able to report it and seek timely redressal. For tackling negative body image counselling and supportive therapy need to be done. Finally, it is recommended that, in the study area, the current national policies and programs for adolescents under Reproductive and Child Health Program prioritize the suicide ideation prevention related agenda.
Financial support and sponsorship
Funding from NRHM, Himachal Pradesh, India.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
We thank the National Rural Health Mission, Himachal Pradesh, India for funding the research.
REFERENCES
- 1.Suicide Definitions: Self-Directed Violence. [Last accessed on 2014 Feb 23]. Available from: http://www.cdc.gov/violenceprevention/suicide/definitions.html .
- 2.Suicide and Suicide Attempts in Adolescents. [Last accessed on 2014 Feb 23]. Available from: http://www.pediatrics.aappublications.org/content/105/4/871.full .
- 3.Pfeffer CR, Klerman GL, Hurt SW, Lesser M, Peskin JR, Siefker CA. Suicidal children grow up: Demographic and clinical risk factors for adolescent suicide attempts. J Am Acad Child Adolesc Psychiatry. 1991;30:609–16. doi: 10.1097/00004583-199107000-00013. [DOI] [PubMed] [Google Scholar]
- 4.Pillai A, Andrews T, Patel V. Violence, psychological distress and the risk of suicidal behaviour in young people in India. Int J Epidemiol. 2009;38:459–69. doi: 10.1093/ije/dyn166. [DOI] [PubMed] [Google Scholar]
- 5.Ruangkanchanasetr S, Plitponkarnpim A, Hetrakul P, Kongsakon R. Youth risk behavior survey: Bangkok, Thailand. J Adolesc Health. 2005;36:227–35. doi: 10.1016/j.jadohealth.2004.01.013. [DOI] [PubMed] [Google Scholar]
- 6.Rudatsikira E, Muula AS, Siziya S. Prevalence and associated factors of suicidal ideation among school-going adolescents in Guyana: Results from a cross sectional study. Clin Pract Epidemiol Ment Health. 2007;3:13. doi: 10.1186/1745-0179-3-13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Zhang P, Roberts RE, Liu Z, Meng X, Tang J, Sun L, et al. Hostility, physical aggression and trait anger as predictors for suicidal behavior in Chinese adolescents: A school-based study. PLoS One. 2012;7:e31044. doi: 10.1371/journal.pone.0031044. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Evans E, Hawton K, Rodham K, Deeks J. The prevalence of suicidal phenomena in adolescents: A systematic review of population-based studies. Suicide Life Threat Behav. 2005;35:239–50. doi: 10.1521/suli.2005.35.3.239. [DOI] [PubMed] [Google Scholar]
- 9.Sidhartha T, Jena S. Suicidal behaviors in adolescents. Indian J Pediatr. 2006;73:783–8. doi: 10.1007/BF02790385. [DOI] [PubMed] [Google Scholar]
- 10.Chen PC, Lee LK, Wong KC, Kaur J. Factors relating to adolescent suicidal behavior: A cross-sectional Malaysian school survey. J Adolesc Health. 2005;37:337. doi: 10.1016/j.jadohealth.2004.10.018. [DOI] [PubMed] [Google Scholar]
- 11.Liu X, Tein JY, Zhao Z, Sandler IN. Suicidality and correlates among rural adolescents of China. J Adolesc Health. 2005;37:443–51. doi: 10.1016/j.jadohealth.2004.08.027. [DOI] [PubMed] [Google Scholar]
- 12.Garrison CZ. The study of suicidal behavior in the schools. Suicide Life Threat Behav. 1989;19:120–30. doi: 10.1111/j.1943-278x.1989.tb00371.x. [DOI] [PubMed] [Google Scholar]
- 13.McGee R, Williams S, Nada-Raja S. Low self-esteem and hopelessness in childhood and suicidal ideation in early adulthood. J Abnorm Child Psychol. 2001;29:281–91. doi: 10.1023/a:1010353711369. [DOI] [PubMed] [Google Scholar]
- 14.Kaplan SJ, Pelcovitz D, Salzinger S, Mandel F, Weiner M, Labruna V, et al. Adolescent physical abuse and risk for suicidal behaviours. J Interpers Violence. 1999;14:976–88. DOI: 10.1177/088626099014009005. [Google Scholar]
- 15.Fleming TM, Merry SN, Robinson EM, Denny SJ, Watson PD. Self-reported suicide attempts and associated risk and protective factors among secondary school students in New Zealand. Aust N Z J Psychiatry. 2007;41:213–21. doi: 10.1080/00048670601050481. [DOI] [PubMed] [Google Scholar]