Abstract
Background
A growing global concern is that suicide research has paid little attention to young people with disabilities, particularly, in low- and middle-income countries (LAMICs). We aimed to estimate the 12-month prevalence of suicidal ideation and attempt and describe some associations among deaf adolescents in Ghana.
Methods
This is a cross-sectional anonymous self-report survey involving a nationally representative random sample of 450 school-going deaf adolescents. Data analysis included bivariate and multivariable approaches.
Results
The overall 12-month prevalence of suicidal ideation was 19·3% (95% confidence interval [CI] = 15·8–23·3) and suicidal attempt was 15·6% (95% CI = 12·3–19·2). Although alcohol use and parental divorce were strongly associated with increased odds of both suicidal ideation and attempt, high subjective mental well-being was associated with reduced odds of both suicidal ideation and attempt. Living with no parents and being a final year student were associated with suicidal ideation, while male gender was associated with suicidal attempt.
Conclusions
The prevalence of suicidal behaviours among school-going deaf adolescents in this study compares with estimates among in-school non-deaf adolescents in Ghana and other LAMICs in Africa, and also highlights the need for prevention efforts against the onset of suicidal ideation and possible transition to attempt and suicide among deaf adolescents.
Keywords: deaf adolescents, Ghana, suicide, suicidal attempt, suicidal ideation
Introduction
The World Health Organization (WHO) defines suicidal behaviour as ‘a range of behaviours that include thinking about suicide (or ideation), planning for suicide, attempting suicide and suicide itself’.1 Globally, suicide is the second leading cause of death among 15–19-year-olds,1,2 with 79% of the annual world-wide suicide-related mortality reported in low- and middle-income countries (LAMICs).1,3,4 Across the general population, suicidal ideation is a strong risk for attempting suicide; attempted suicide represents the single significant risk for suicide.1,5,6
Given that disabilities are associated with negative physical and mental health outcomes, persons with functional disabilities—related to hearing and sight—have been found to be at an increased risk of attempted suicide, suicide and other emotional and behavioural problems.7–12 However, there is a growing global concern that suicide research has paid little attention to young people with disabilities, especially, in LAMICs: in particular, much of our understanding of suicidal behaviours among deaf adolescents is based on evidence from high-income countries.9,11,13–18
We performed and updated a systematic search for literature (We searched Global Index Medicus, Index Medicus for South-East Asia Region, PsycINFO, African Journals OnLine, MEDLINE and African Index Medicus up to July 2020, using keywords [e.g. (‘suicide ideation’ OR ‘suicidal ideation’ OR ‘self-harm ideation’ OR suicid* OR self-injur* OR mental) AND (deaf children OR ‘deaf adolescents’ OR ‘deaf young people’ OR disability OR adolescen* OR child* OR students OR teen* OR ‘young adults’ OR youth OR pupils)]. We did not apply any date or language restrictions. Our geographic search filter to identify countries in within low- and middle-income context included names of the countries in both English and languages relevant to the countries. We supplemented the searches by reviewing references and forward citations of relevant articles.) from Africa to contextualize the current study. Apart from relevant studies involving school-going non-deaf adolescents, we found neither published primary studies nor systematic reviews or meta-analyses with included studies involving deaf adolescents from African countries.19–25
Among in-school non-deaf adolescents, recent regional systematic reviews and meta-analyses suggest that relative to other LAMICs, the 12-month prevalence estimate of suicidal ideation (20.4%, 95% confidence interval [CI] = 17.3, 23.6) is higher in sub-Saharan Africa, while the pooled estimate of suicidal attempt (19.3%, 95%CI = 14.2, 24.4) is comparable to what pertains in LAMICs within the Western Pacific region (20.5%, 95%CI = 14.3, 26.7).20–23 The evidence also suggests that suicidal behaviours among adolescents are multicausal, with specific risk and protective factors existing at the personal level (e.g. female gender, alcohol and substance use, depression), family context (e.g. parental understanding, conflict with parents), school (e.g. schoolwork problems, bullying victimization) and other social relationship contextual factors (e.g. break-up, sexual abuse victimization, peer support).21–23
In Ghana, only one study has reported social discrimination as a critical reason for suicidal ideation among adult mothers with physical disabilities.26 Evidence also suggests that although deaf adolescents have access to health facilities in Ghana, professional health care is hampered by communication barriers such as the lack of sign language interpreters.27
Taken together, considering that the reduction of suicide-related deaths has been given special priority in the sustainable development goals, it is important to contribute sound and timely research evidence, particularly, among young vulnerable groups such as deaf adolescents in LAMICs to inform intervention and prevention efforts.
Aims of study
-
(i)
Estimate the 12-month prevalence of suicidal behaviours (Suicidal behaviours denote two outcomes in this study: suicidal ideation and suicidal attempt.) among school-going deaf adolescents (Schools for the deaf in Ghana are typically attended by young people with moderate to profound hearing loss. Based on the definition by Sawyer et al. (2018), we used the term adolescents to mean individuals aged 10–24 years. [Sawyer, S. M., Azzopardi, P. S., Wickremarathne, D., & Patton, G. C. (2018). The age of adolescence. The Lancet Child & Adolescent Health, 2(3), 223–228. doi:10.1016/S2352-4642(18)30022-1].) in Ghana.
-
(ii)
Identify the common and unique factors associated with suicidal behaviours among school-going deaf adolescents in Ghana.
Methods
Design, setting and participants
The community-agreed recommendations of Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guided the design and reporting of this study.28 We conducted a cross-sectional survey, using a self-report anonymous questionnaire, among deaf students attending Junior High Schools (JHSs) (In Ghana, Junior High Schools have a 3-year duration and are targeted at young people aged 12–14 years, but due to significant delayed school enrolment of young people with disabilities, typically, late and older adolescents aged 15–24 years are also predominantly found at this level of basic education in special schools in Ghana.) in Ghana. At the time of designing this study (August 2019) there were 1030 students across all the 13 JHSs for the deaf in the country. We predetermined a minimum sample size of 288, using Yamane’s (1967) formula for proportions, with 0·05 level of precision.29 We used a two-stage cluster sampling approach to firstly select seven JHSs for the deaf with probability proportional to enrolment size across the 16 administrative regions of Ghana. In stage 2, classes were randomly selected with all students in each class eligible to participate in the survey. Figure 1 summarizes the school selection and sampling of participants for this study. We approached and invited 468 participants, but 450 provided complete data included in the final analysis, representing a response rate of 96.1% (171 females and 221 males; aged 13–24 years; mean = 18.4; standard deviation = 2.60; modal age = 18).
Fig. 1 .
Summary of school selection and participant sampling for survey.
Outcome measures
Two outcome variables were included in this study: suicidal ideation and attempt. In order to facilitate comparison, we adopted two single-items from the 2012 Ghana WHO-Global School-based Health Survey (WHO-GSHS),30 one each to measure suicidal ideation and attempt. Specifically, the item, ‘during the past 12 months, did you ever seriously consider attempting suicide?’ was used to measure suicidal ideation; the responses were dichotomized as No (0) or Yes (1). Suicidal attempt was measured with the question ‘during the past 12 months, how many times did you actually attempt suicide?’ The responses were ‘0’, ‘1’, ‘2 or 3’, ‘4 or 5’ and ‘6 or more times’. Consistent with most published analyses of the WHO-GSHS data from sub-Saharan Africa,20–24 we applied a binary recoding to this item for analysis, No (no attempt = 0) and Yes (one or more attempts = 1).
Exposure variables
This study involved 12 items assessing personal, family, school and interpersonal factors found in the 2012 Ghana WHO-GSHS to be associated with suicidal behaviours as risk and protective factors (see in Supplementary Table 1). For example, alcohol use (never drink alcohol or ≥1 drinks), parental divorce (no/yes), schoolwork problems (no/yes), bullying victimization (no/yes) and break-up (no/yes). Also, this study adopted one item from the 5-item Duke University Religion Index (DUREL) to measure religious participation: ‘How often do you attend church or other religious meetings?’ with response rating options ranging from (1) ‘never’ to (6) ‘more than once per week’.31 Considering the strong association between suicidal behaviours, and psychological functioning, life satisfaction and one’s ability to develop and maintain mutually beneficial social relationships,32 we adopted the 14-item Warwick-Edinburgh Mental Well-being Scale (WEMWBS) to assess subjective mental well-being.13,33 It is a 5-score scale, from ‘none of the time’ [1] to ‘all of the time’ [5] (e.g. ‘I’ve been feeling optimistic about the future’), with the possible total score ranging from 14 to 70 points. Higher scores indicate better mental well-being. Internationally, the WEMWBS has demonstrated strong internal consistency and a satisfactory Cronbach’s alpha;34 the Cronbach’s alpha in the current study was 0·83. Also, as shown in Supplementary Table 1, eight socio-demographic variables were included (e.g. gender, age, family structure). Prior to administration, the questionnaire was expert reviewed by two basic school Ghanaian Sign Language teachers and an adolescent suicide researcher.
Procedure
The survey took place from October 2019 to January 2020. The survey was administered to participants in their school’s assembly hall or a larger classroom, with sitting arrangement spaced by reasonable distance to ensure privacy. We clarified participants’ queries in the Ghanaian Sign Language—the sign language that is used for the instruction and examination of deaf students at all levels of education in Ghana. Averagely, the completion of the questionnaire lasted between 55 and 75 min. After completing the survey, each student placed their answered questionnaire in an opaque box before exiting the hall.
Data analysis
All data analyses were performed using the Statistical Package for Social Sciences (SPSS version 26.0 for Windows). As the loss of cases due to missing data was <5%, the list-wise deletion of missing data strategy was applied.35 The coding of the variables included in our statistical analysis and proportion of missing data are shown in Supplementary Table 1. The data analysis proceeded in two stages. Firstly, we performed descriptive analysis by applying frequencies, proportions and the Pearson’s Chi-square tests (
and point-biserial correlation (rpb) tests to examine the bivariate relationships between suicidal behaviours and the exposure variables and socio-demographic factors. Secondly, adjusted multivariable logistic regression analyses examining the possible associations between suicidal behaviours and the specified correlates and socio-demographic variables were performed. As recommended by leading logistic regression modelling experts, the candidate correlates were entered in the multivariable logistic regression models regardless of their statistically significant bivariate relationship with the outcome variables.36–38 The socio-demographic variables were included as covariates. We reported the results of the logistic regression as odds ratios with 95% confidence intervals (CI) and P-values. Statistically significant results were also determined using P < 0·05.
Ethics
This study was approved by the Department of Psychology Research Ethics Committee, University of Ghana, Accra. We followed the ethical procedures of the Ghana Education Service (GES) for conducting research involving students in special schools in Ghana. The Special Education Unit of GES and heads of all the participating schools permitted this study. Each participant signed a written consent form prior to responding to the survey; parents/guardians of underage participants provided consent and we obtained the assent of participants younger than 18 years, prior to responding to the survey.
Results
Prevalence estimates and bivariate associations of suicidal behaviours
The overall 12-month prevalence estimate of suicidal ideation was 19·3% (95% CI = 15·8–23·3) and suicidal attempt was 15·6% (95% CI = 12·3–19·2). More males than females reported suicidal ideation (female = 17·0% [11·7–23·4]; male = 20·8% [95% CI = 16·2–26·0]) and attempt (female =12·3% [95% CI = 7·8–18·2]; male = 17·6% [95% CI = 13·3–22·5]). Overall, we found statistically significant bivariate associations between suicidal behaviours and most of the socio-demographic factors and exposure variables included in this study—see Tables 1 and 2.
Table 1.
Chi-square tests assessing the bivariate associations, stratified by suicidal behaviour
| Suicidal ideation in the previous 12 months | Suicidal attempt in the previous 12 months | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Variable | Sample distribution | No | Yes | No | Yes | ||||
| n (%) | n (%) | n (%) |
|
P-value | n (%) | n (%) |
|
P-value | |
| Socio-demographic variables: | |||||||||
| Gender | 0·997 | ·318 | 2·252 | ·133 | |||||
| Female | 171 (38·0) | 142 (83·0) | 29 (17·0) | 150 (87·7) | 21 (12·3) | ||||
| Male | 279 (62·0) | 221 (79·2) | 58 (20·8) | 230 (82·4) | 49 (17·6) | ||||
| Deafness status | 8·083 | ·004 | 5·685 | ·017 | |||||
| Postnatal | 168 (37·3) | 124 (73·8) | 44 (26·2) | 133 (79·2) | 35 (20·8) | ||||
| Congenital | 282 (62·7) | 239 (84·8) | 43 (15·2) | 247 (87·6) | 35 (12·4) | ||||
| Grade: | 3·239 | ·198 | ·691 | ·708 | |||||
| JHS 1 | 216 (48·0) | 181 (83·8) | 35 (16·2) | 181 (83·8) | 35 (16·2) | ||||
| JHS 2 | 73 (16·2) | 59 (80·8) | 14 (19·2) | 64 (87·7) | 9 (12·3) | ||||
| JHS 3 | 161 (35·8) | 123 (76·4) | 38 (23·6) | 135 (83·9) | 26 (16·1) | ||||
| Family structure | ·002 | ·965 | |||||||
| Father has 1 wife | 318 (72·6) | 255 (80·2) | 63 (19·8) | 273 (85·8) | 45 (14·2) | 2·246 | ·134 | ||
| Father has >1 wife | 120 (27·4) | 96 (80·0) | 24 (20·0) | 96 (80·0) | 24 (20·0) | ||||
| Living arrangement: | 12·592 | ·002 | 15·037 | ·001 | |||||
| Live with both parents | 240 (54·4) | 201 (83·8) | 39 (16·3) | 215 (89·6) | 25 (10·4) | ||||
| Live with one parent | 124 (28·1) | 104 (83·9) | 20 (16·1) | 103 (83·1) | 21 (16·9) | ||||
| Live with no parents | 77 (17·5) | 51 (66·2) | 26 (33·8) | 55 (71·4) | 22 (28·6) | ||||
| In romantic relationship | 4·643 | ·031 | 13·382 | <·001 | |||||
| No | 250 (56·3) | 211 (84·4) | 39 (15·6) | 225 (90·0) | 25 (10·0) | ||||
| Yes | 194 (43·7) | 148 (76·3) | 46 (23·7) | 150 (77·3) | 44 (22·7) | ||||
| Religious group | 7·232 | ·007 | 18·712 | <·001 | |||||
| Christian | 333 (74·5) | 278 (83·5) | 55 (16·5) | 296 (88·9) | 37 (11·1) | ||||
| Muslim | 114 (25·5) | 82 (71·9) | 32 (28·1) | 82 (71·9) | 32 (28·1) | ||||
| Personal and lifestyle variables: | |||||||||
| Weekly alcohol use | 29·037 | <·001 | 302 (88·6) | 39 (11·4) | 21·204 | <·001 | |||
| Never drink alcohol | 341 (77·0) | 293 (85·9) | 48 (14·1) | 71 (69·6) | 31 (30·4) | ||||
| ≥1 drink | 102 (23.0) | 63 (61·8) | 39 (38·2) | ||||||
| Family factors: | |||||||||
| Parental divorce | 24·652 | <·001 | 20·079 | <·001 | |||||
| No | 296 (66·8) | 258 (87·2) | 38 (12·8) | 266 (89·9) | 30 (10·1) | ||||
| Yes | 147 (33·2) | 99 (67·3) | 48 (32·7) | 108 (73·5) | 39 (26·5) | ||||
| Conflict with parents | 7·907 | ·005 | 10·023 | ·002 | |||||
| No | 277 (62·7) | 235 (84·8) | 42 (15·2) | 246 (88·8) | 31 (11·2) | ||||
| Yes | 165 (37·3) | 122 (73·9) | 43 (26·1) | 128 (77·6) | 37 (22·4) | ||||
| School factors: | |||||||||
| Schoolwork problems | 4·813 | ·028 | 4·184 | ·041 | |||||
| No | 129 (29·1) | 112 (86·8) | 17 (13·2) | 116 (89·9) | 13 (10·1) | ||||
| Yes | 314 (70·9) | 244 (77·7) | 70 (22·3) | 258 (82·2) | 56 (17·8) | ||||
| Bullying victimization | 8·368 | ·004 | 6·071 | ·014 | |||||
| No | 202 (44·9) | 175 (86·6) | 27 (13·4) | 180 (89·1) | 22 (10·9) | ||||
| Yes | 248 (55·1) | 188 (75·8) | 60 (24·2) | 200 (80·6) | 48 (19·4) | ||||
| Interpersonal adversities: | |||||||||
| Break-up | 298 (66·2) | 2·786 | ·095 | 5·280 | ·022 | ||||
| No | 152 (33·8) | 247 (82·9) | 51 (17·1) | 260 (87·2) | 38 (12·8) | ||||
| Yes | 116 (76·3) | 36 (23·7) | 120 (78·9) | 32 (21·1) | |||||
| Physical abuse victimization | 37·398 | <·001 | 15·445 | <·001 | |||||
| No | 292 (64·9) | 260 (89·0) | 32 (11·0) | 261 (89·4) | 31 (10·6) | ||||
| Yes | 158 (35·1) | 103 (65·2) | 55 (34·8) | 119 (75·3) | 39 (24·7) | ||||
| Sexual abuse victimization | 28·224 | <·001 | 25·863 | <·001 | |||||
| No | 365 (82·6) | 310 (84·9) | 55 (15·1) | 322 (88·2) | 43 (11·8) | ||||
| Yes | 158 (35·1) | 45 (58·4) | 32 (41·6) | 50 (64·9) | 27 (35·1) | ||||
Note: 
= Chi square
Table 2.
Point-biserial tests assessing the bivariate associations, stratified by suicidal behaviour
| Suicidal ideation in the previous 12 months | Suicidal attempt in the previous 12 months | |||||
|---|---|---|---|---|---|---|
| Variable | n | rpb | P-value | n | rpb | P-value |
| Socio-demographic variables: | ||||||
| Age | 450 | ·076 | ·106 | 450 | ·095 | ·044 |
| Personal and lifestyle variables: | ||||||
| Subjective mental well-being | 450 | −·250 | <·001 | 450 | −·282 | <·001 |
| Religious participation | 444 | −·132 | ·005 | 444 | −·163 | ·001 |
| Family factors: | ||||||
| Parental checking of homework | 443 | −·154 | ·001 | 443 | −·064 | ·177 |
| Parental understanding | 447 | −·125 | ·008 | 447 | −·123 | ·009 |
| Parental monitoring | 445 | −·063 | ·187 | 445 | −·014 | ·775 |
| Parental intrusion of privacy | 446 | −·018 | ·712 | 446 | −·037 | ·434 |
Note: rpb = point biserial coefficient
Deaf adolescents who reported physical abuse victimization, weekly alcohol use, sexual abuse victimization and parental divorce were more likely to report suicidal ideation and attempt during the previous 12 months (Table 1). However, participants who reported high subjective mental well-being, frequent religious participation and high parental understanding were less likely to report both suicidal ideation and attempt (Table 2).
Multivariable associations
As shown in Table 3, although weekly alcohol use and parental divorce were strongly associated with increased odds of both suicidal ideation and attempt, high subjective mental well-being emerged as a strong correlate of reduced odds of both suicidal ideation and attempt. While living with no parents (AOR = 2·358; 95% CI = 1·027, 5·414, P = ·043), being in JHS 3 (AOR = 2·145; 95% CI = 1·004, 4·584, P = ·049), and being deaf postnatally (AOR = 0·408; 95% CI = 0·205, 0·811, P = ·011) were uniquely associated with increased odds of suicidal ideation, frequent parental checking of homework (AOR = 0·601; 95% CI = 0·448, 0·806, P = ·001) was associated with reduced odds of suicidal ideation. Males were about two times likely than females to report suicidal attempt during the previous 12 months (AOR = 2·262; 95% CI = 1·032, 4·961, P = ·042)—see Table 3.
Table 3.
Multivariate associations, stratified by suicidal behaviour
| Suicidal ideation in the previous 12 months | Suicidal attempt in the previous 12 months | |||||||
|---|---|---|---|---|---|---|---|---|
| Variables in model | β | AOR | 95% CI | P-value | β | AOR | 95% CI | P-value |
| Socio-demographic variables: | ||||||||
| Gender | ·434 | 1·543 | ·767, 3·105 | ·224 | ·816 | 2·262 | 1·032, 4·961 | ·042 |
| Age | ·000 | 1·000 | ·866, 1·155 | ·998 | ·038 | 1·038 | ·888, 1·215 | ·638 |
| Deafness status | −·897 | ·408 | ·205, ·811 | ·011 | −·386 | ·680 | ·322, 1·437 | ·312 |
| Grade: | ||||||||
| JHS 1 | Reference | Reference | ||||||
| JHS 2 | ·870 | 2·387 | ·947, 6·014 | ·065 | ·202 | 1·224 | ·433, 3·462 | ·704 |
| JHS 3 | ·763 | 2·145 | 1·004, 4·584 | ·049 | −·044 | ·957 | ·420, 2·184 | ·917 |
| Family structure | −·458 | ·632 | ·296, 1·349 | ·236 | ·129 | 1·138 | ·522, 2·479 | ·745 |
| Living arrangement: | ||||||||
| Live with both parents | Reference | Reference | ||||||
| Live with one parent | −·721 | ·486 | ·216, 1·095 | ·082 | ·305 | 1·357 | ·602, 3·058 | ·462 |
| Live with no parents | ·858 | 2·358 | 1·027, 5·414 | ·043 | ·891 | 2·437 | ·971, 6·116 | ·058 |
| In romantic relationship | ·057 | 1·059 | ·499, 2·249 | ·881 | ·100 | 1·105 | ·493, 2·480 | ·808 |
| Religious group | −·200 | ·819 | ·383, 1·749 | ·606 | ·608 | 1·836 | ·846, 3·986 | ·125 |
| Personal and lifestyle variables: | ||||||||
| Subjective mental well-being | −·052 | ·949 | ·915, ·984 | ·005 | −·079 | ·924 | ·884, ·965 | <·001 |
| Religious participation | −·038 | ·963 | ·806, 1·150 | ·676 | −·121 | ·886 | ·736, 1·067 | ·201 |
| Weekly alcohol use | ·950 | 2·585 | 1·211, 5·520 | ·014 | 1·010 | 2·745 | 1·251, 6·025 | ·012 |
| Family factors: | ||||||||
| Parental divorce | ·792 | 2·208 | 1·121, 4·346 | ·022 | ·779 | 2·180 | 1·028, 4·623 | ·042 |
| Conflict with parents | ·185 | 1·203 | ·594, 2·438 | ·607 | ·338 | 1·402 | ·652, 3·015 | ·386 |
| Parental checking of homework | −·510 | ·601 | ·448, ·806 | ·001 | −·123 | ·885 | ·648, 1·207 | ·439 |
| Parental understanding | −·019 | ·981 | ·744, 1·294 | ·892 | −·001 | ·999 | ·725, 1·376 | ·994 |
| Parental monitoring | ·026 | 1·026 | ·788, 1·336 | ·850 | ·132 | 1·142 | ·840, 1·552 | ·398 |
| Parental intrusion of privacy | ·106 | 1·112 | ·867, 1·425 | ·403 | ·005 | 1·005 | ·758, 1·331 | ·975 |
| School factors: | ||||||||
| Schoolwork problems | ·405 | 1·500 | ·674, 3·338 | ·321 | ·305 | 1·356 | ·564, 3·264 | ·496 |
| Bullying victimization | ·233 | 1·262 | ·626, 2·543 | ·515 | ·069 | 1·071 | ·496, 2·312 | ·861 |
| Interpersonal adversities: | ||||||||
| Break-up | −·293 | ·746 | ·341, 1·630 | ·463 | −·287 | ·750 | ·329, 1·713 | ·495 |
| Physical abuse victimization | 1·273 | 3·572 | 1·795, 7·108 | ·000 | ·430 | 1·537 | ·728, 3·244 | ·260 |
| Sexual abuse victimization | 1·029 | 2·798 | 1·253, 6·250 | ·012 | ·678 | 1·969 | ·832, 4·663 | ·123 |
| Nagelkerke pseudo R2 | ·433 | ·402 | ||||||
| Cox & Snell R2 | ·272 | ·229 | ||||||
| Hosmer-Lemeshow GOF test (sig·) | 3·93 (·863) | 7·66 (·467) | ||||||
| Overall percentage correctly classified | 85·8 | 88·7 | ||||||
Note: β = beta value; AOR = adjusted odds ratios; CI = Confidence Interval; GOF = goodness of fit
Discussion
Main findings of this study
Across the total sample, nearly two in 10 participants reported suicidal ideation, while one out of 10 participants reported suicidal attempt in the previous 12 months. The factors associated with suicidal ideation and attempt were multi-contextual: personal, family and school related. Although alcohol use and parental divorce were strongly associated with increased odds of both suicidal ideation and attempt, high subjective mental well-being was associated with reduced odds of both suicidal ideation and attempt. Living with no parents, being a final year student and being deaf postnatally were strongly associated with increased odds of suicidal ideation, while male gender was associated with increased odds of suicidal attempt. Although age showed positive associations with suicidal ideation and attempt, these associations did not reach the desired statistical significance.
What is already known on this topic
Most of what is already known about this topic is from high-income context, with earlier systematic reviews identifying no studies from LAMICs.8,13 Earlier evidence from high-income countries suggests that lifetime estimates of suicidal ideation among deaf adolescents ranges widely between 4.6 and 44%, while 12-month attempted suicide ranges between 1.7 and 18%.13 Recently, a county-wide cross-sectional study from the USA has reported a 12-month prevalence estimates of attempted suicide (14.9%) among deaf adolescents.11 Generally, major depression, family dysfunction, low academic performance, alcohol use, peer victimization and peer relationship difficulties and sexual abuse victimization have been reported as significant associations of suicidal ideation and attempt among adolescents with functional disabilities in high-income countries.11,13,14,39 The only available study reporting evidence from a low-income country is a recent school-based cross-sectional survey from Pakistan that reports lifetime suicidal attempt (19%) and 12-month suicidal ideation (17%) among school-going deaf adolescents.15
What this study adds
This study represents a pioneering attempt at providing evidence on suicidal behaviours among deaf adolescents from Ghana; the evidence could be potentially informative for more expansive epidemiological studies from Ghana and other sub-Saharan African countries. Although the prevalence estimates and associated factors of suicidal behaviours in the current study are comparable to those reported among in-school non-deaf adolescents in Ghana and other countries in sub-Saharan Africa,19–24 the adjusted multivariate logistic models of the current study have shown two new specific evidence: (1) there is a significant negative association between subjective mental well-being and both suicidal ideation and attempt, and (2) adolescents with congenital deafness are less likely to report suicidal ideation, compared to adolescents of postnatal deafness. These underscore the need for universal and targeted prevention efforts aimed at improving the mental well-being of school-going deaf adolescents in Ghana. Put together, although further studies (including qualitative research) are needed to explore the lived experiences and meanings of suicidal behaviours among school-going deaf adolescents in Ghana, the evidence of the current study could be pointing to the possibility that both adolescents without disabilities and those with disabilities may be faced with common multiple distress and challenges of health, education, growth and development, and family and social adversities in sub-Saharan Africa.40–44
Limitations of this study
Considering that in cross-sectional surveys both the outcome and exposure variables are measured at the same point in time, it stands to suggests that the evidence reported in this study cannot support causal inferences.45 Although the use of single-item measures affords the opportunity of screening a larger sample at one point in time for suicidal behaviours, single-item measures have the potential of leading to misclassification of suicidal behaviour.46,47 Relatedly, the self-report approach used (instead of a diagnostic approach) might have yielded less reliable responses in respect of suicidal ideation and attempt. Furthermore, besides the high tendency of nondisclosure among young people in suicide research,48 some participants in this study might have also provided socially desirable responses due to the highly stigmatized and criminalized nature of attempted suicide in Ghana.49,50 While these limitations provide a critical basis for cautious interpretations of the findings, the inclusion of a nationally representative sample of deaf students in JHSs in Ghana could make the findings a good reflection of the national prevalence and associated factors of suicidal ideation and attempt among deaf students attending JHSs.
Conclusions
The prevalence of suicidal ideation and attempt among deaf adolescents in this study compares with estimates among non-deaf adolescents in Ghana and other LAMICs in Africa, but also highlights the need for targeted and universal prevention efforts against the onset of suicidal ideation and possible transition to attempt and suicide among deaf adolescents.
Data availability statement
The data underlying this article will be shared on reasonable request to the corresponding author.
Conflict of interest
The authors declare that they have no competing interests.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Authors’ contributions
E.Q. and D.F. contributed to the study concept and design; E.A., C.H.-M., J.F. and O.A. conducted the data collection; E.Q. performed statistical analysis of the data; J.A.-A. and K.O.A. contributed to the interpretation of the results; E.Q., D.F., E.A., C.H.-M., J.F. and O.A. drafted the manuscript and D.F., E.A., J.A.-A. and K.O.A. critiqued the manuscript for important intellectual content. All the authors contributed to the revision of the manuscript and approved the final version.
Supplementary Material
Acknowledgements
We wish to thank all the Special Education Unit of the Ghana Education Service and heads of all the participating schools who granted permissions for this study. We also thank parents/guardians of the underage participants who consented for their wards to participate in this study. Finally, we thank all the students contributed data about their suicidal behaviours to this study.
Emmanuel Nii-Boye Quarshie, Research fellow in youth self-harm and suicide prevention
Daniel Fobi, PhD candidate in deaf education
Emmanuel Kwasi Acheampong, Lecturer in deaf education
Cyril Mawuli Honu-Mensah, Lecturer in audiology
Joyce Fobi, Teaching assistant in deaf education
Obed Appau, Principal research assistant in deaf education
Johnny Andoh-Arthur, Lecturer in community psychology and suicidology
Kwaku Oppong Asante, Senior lecturer in health psychology
Contributor Information
E N B Quarshie, School of Psychology, University of Leeds, Woodhouse, LS2 9JT, Leeds, UK; Department of Psychology, University of Ghana, P.O. Box LG 84, Legon, Accra, Ghana.
D Fobi, School of Education, University of Leeds, Woodhouse, LS2 9JT, Leeds, UK.
E K Acheampong, Department of Special Education, University of Education, P.O Box 25, Winneba, Ghana.
C M Honu-Mensah, Department of Special Education, University of Education, P.O Box 25, Winneba, Ghana.
J Fobi, Department of Special Education, University of Education, P.O Box 25, Winneba, Ghana.
O Appau, Department of Special Education, University of Education, P.O Box 25, Winneba, Ghana.
J Andoh-Arthur, Department of Psychology, University of Ghana, P.O. Box LG 84, Legon, Accra, Ghana.
K Oppong Asante, Department of Psychology, University of Ghana, P.O. Box LG 84, Legon, Accra, Ghana.
References
- 1. WHO . Preventing suicide, a global imperative. Geneva: WHO, 2014. [Google Scholar]
- 2. WHO . Suicide: key facts. 2019. from https://www.who.int/news-room/fact-sheets/detail/suicide (5 March 2020, date last accessed).
- 3. Bachmann S. Epidemiology of suicide and the psychiatric perspective. Int J Environ Res Public Health 2018;15(7):1425. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Naghavi M, Global Burden of Disease Self-Harm Collaborators . Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the global burden of disease study 2016. BMJ 2019;364:l94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Klonsky ED, May AM, Saffer BY. Suicide, suicide attempts, and suicidal ideation. Annu Rev Clin Psychol 2016;12:307–30. [DOI] [PubMed] [Google Scholar]
- 6. Turecki G, Brent DA, Gunnell D et al. Suicide and suicide risk. Nat Rev Dis Primers 2019;5(1):1–22. [DOI] [PubMed] [Google Scholar]
- 7. De Leo D, Hickey PA, Meneghel G et al. Blindness, fear of sight loss, and suicide. Psychosomatics 1999;40(4):339–44. [DOI] [PubMed] [Google Scholar]
- 8. Stevenson J, Kreppner J, Pimperton H et al. Emotional and behavioural difficulties in children and adolescents with hearing impairment: a systematic review and meta-analysis. Eur Child Adolesc Psychiatry 2015;24(5):477–96. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Fellinger J, Holzinger D, Sattel H et al. Correlates of mental health disorders among children with hearing impairments. Dev Med Child Neurol 2009;51(8):635–41. [DOI] [PubMed] [Google Scholar]
- 10. Van Gent T, Goedhart AW, Treffers PD. Self-concept and psychopathology in deaf adolescents: preliminary support for moderating effects of deafness-related characteristics and peer problems. J Child Psychol Psychiatry 2011;52(6):720–8. [DOI] [PubMed] [Google Scholar]
- 11. Moses T. Suicide attempts among adolescents with self-reported disabilities. Child Psychiatry Hum Dev 2018;49(3):420–33. [DOI] [PubMed] [Google Scholar]
- 12. Milner A, Bollier A-M, Emerson E et al. The relationship between disability and suicide: prospective evidence from the ten to men cohort. J Public Health 2019;41(4):707–13. [DOI] [PubMed] [Google Scholar]
- 13. Turner O, Windfuhr K, Kapur N. Suicide in deaf populations: a literature review. Ann Gen Psychiatry 2007;6(1):26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Gryglewicz K, Bozzay M, Arthur-Jordon B et al. A silenced population: uncovering correlates of suicidal-related behavior among deaf and hard-of-hearing youth. Crisis 2017;38(6):433–42. [DOI] [PubMed] [Google Scholar]
- 15. Akram B, Batool M. Suicidal behavior among the youth with and without sensory impairment: prevalence and comparison. OMEGA-Journal of Death and Dying 2020;81(3):393–403. [DOI] [PubMed] [Google Scholar]
- 16. Van Gent T, Goedhart AW, Hindley PA et al. Prevalence and correlates of psychopathology in a sample of deaf adolescents. J Child Psychol Psychiatry 2007;48(9):950–8. [DOI] [PubMed] [Google Scholar]
- 17. Titus JC, Schiller JA, Guthmann D. Characteristics of youths with hearing loss admitted to substance abuse treatment. J Deaf Stud Deaf Educ 2008;13(3):336–50. [DOI] [PubMed] [Google Scholar]
- 18. Margaret Brown P, Cornes A. Mental health of deaf and hard-of-hearing adolescents: what the students say. J Deaf Stud Deaf Educ 2015;20(1):75–81. [DOI] [PubMed] [Google Scholar]
- 19. Aggarwal S, Patton G, Reavley N et al. Youth self-harm in low-and middle-income countries: systematic review of the risk and protective factors. Int J Soc Psychiatry 2017;63(4):359–75. [DOI] [PubMed] [Google Scholar]
- 20. Uddin R, Burton NW, Maple M et al. Suicidal ideation, suicide planning, and suicide attempts among adolescents in 59 low-income and middle-income countries: a population-based study. The Lancet Child & Adolescent Health 2019;3(4):223–33. [DOI] [PubMed] [Google Scholar]
- 21. Biswas T, Scott JG, Munir K et al. Global variation in the prevalence of suicidal ideation, anxiety and their correlates among adolescents: a population based study of 82 countries. EClinicalMedicine 2020;82(24). doi: 10.1016/j.eclinm.2020.100395. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Campisi SC, Carducci B, Akseer N et al. Suicidal behaviours among adolescents from 90 countries: a pooled analysis of the global school-based student health survey. BMC Public Health 2020;20(1):1–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Quarshie ENB, Waterman MG, House AO. Self-harm with suicidal and non-suicidal intent in young people in sub-Saharan Africa: a systematic review. BMC Psychiatry 2020;20(234):1–26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Asante KO, Kugbey N, Osafo J et al. The prevalence and correlates of suicidal behaviours (ideation, plan and attempt) among adolescents in senior high schools in Ghana. SSM-Population Health 2017;3:427–34. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Lim K-S, Wong CH, McIntyre RS et al. Global lifetime and 12-month prevalence of suicidal behavior, deliberate self-harm and non-suicidal self-injury in children and adolescents between 1989 and 2018: a meta-analysis. Int J Environ Res Public Health 2019;16(22):4581. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Acheampong AK, Aziato L. Suicidal ideations and coping strategies of mothers living with physical disabilities: a qualitative exploratory study in Ghana. BMC Psychiatry 2018;18(1):1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Senayah EA, Mprah WK, Opoku MP et al. The accessibility of health services to young deaf adolescents in Ghana. Int J Health Plann Manage 2019;34(1):e634–e45. [DOI] [PubMed] [Google Scholar]
- 28. Vandenbroucke JP, Von Elm E, Altman DG et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. PLoS Med 2007;4(10):e297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Yamane T. Statistics: an introductory analysis, 2nd edn. New York: Harper and Row, 1967. [Google Scholar]
- 30. WHO . Global school-based student health survey (GSHS). 2019. https://www.who.int/ncds/surveillance/gshs/ghana/en/ (10 January 2018, date last accessed).
- 31. Koenig HG, Büssing A. The Duke University religion index (DUREL): a five-item measure for use in epidemological studies. Religions 2010;1(1):78–85. [Google Scholar]
- 32. Hawton K, Saunders KE, O'Connor RC. Self-harm and suicide in adolescents. The Lancet 2012;379(9834):2373–82. [DOI] [PubMed] [Google Scholar]
- 33. Clarke A, Friede T, Putz R et al. Warwick-Edinburgh mental well-being scale (WEMWBS): validated for teenage school students in England and Scotland. A mixed methods assessment. BMC Public Health 2011;11(1):487. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Stewart-Brown S. The Warwick-Edinburgh Mental Well-Being Scale (WEMWBS): performance in different cultural and geographical groups. In: Keyes CLM (ed). Mental Well-Being: international contributions to the study of positive mental health. London: Springer, 2013, 133–50. [Google Scholar]
- 35. Graham JW. Missing data analysis: making it work in the real world. Annu Rev Psychol 2009;60:549–76. [DOI] [PubMed] [Google Scholar]
- 36. Sun G-W, Shook TL, Kay GL. Inappropriate use of bivariable analysis to screen risk factors for use in multivariable analysis. J Clin Epidemiol 1996;49(8):907–16. [DOI] [PubMed] [Google Scholar]
- 37. Babyak MA. What you see may not be what you get: a brief, nontechnical introduction to overfitting in regression-type models. Psychosom Med 2004;66(3):411–21. [DOI] [PubMed] [Google Scholar]
- 38. Linsell L, Malouf R, Morris J et al. Risk factor models for neurodevelopmental outcomes in children born very preterm or with very low birth weight: a systematic review of methodology and reporting. Am J Epidemiol 2017;185(7):601–12. [DOI] [PubMed] [Google Scholar]
- 39. Butcher E, Dezateux C, Cortina-Borja M et al. Mental health in young people with hearing loss: longitudinal analysis of the millennium cohort study. J Epidemiol Community Health 2019;73(1):A27. [Google Scholar]
- 40. Blum RW. Youth in sub-Saharan Africa. J Adolesc Health 2007;41(3):230–8. [DOI] [PubMed] [Google Scholar]
- 41. Owen JP, Baig B, Abbo C et al. Child and adolescent mental health in sub-Saharan Africa: a perspective from clinicians and researchers. BJPsych International 2016;13(2):45–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Adjei JK, Saewyc EM. Boys are not exempt: sexual exploitation of adolescents in sub-Saharan Africa. Child Abuse Negl 2017;65:14–23. [DOI] [PubMed] [Google Scholar]
- 43. African Union . State of Africa’s population 2017: Keeping rights of girls, adolescents and young women at the centre of Africa’s demographic dividend. Addis Ababa, Ethiopia: African Union, 2017. [Google Scholar]
- 44. Harber C. Schooling in Sub-Saharan Africa: Policy, practice and patterns. Cham, Switzerland: Springer, 2017. [Google Scholar]
- 45. Woodward M. Epidemiology. Study design and data analysis. London, UK: CRC Press, Taylor & Francis Group, 2014. [Google Scholar]
- 46. Millner AJ, Lee MD, Nock MK. Single-item measurement of suicidal behaviors: validity and consequences of misclassification. PLoS One 2015;10(10):e0141606. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47. Hom MA, Joiner TE Jr, Bernert RA. Limitations of a single-item assessment of suicide attempt history: implications for standardized suicide risk assessment. Psychol Assess 2016;28(8):1026–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48. De Luca S, Yan Y, Lytle M et al. The associations of race/ethnicity and suicidal ideation among college students: a latent class analysis examining precipitating events and disclosure patterns. Suicide Life Threat Behav 2014;44(4):444–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.The Parliament of Ghana. Criminal Offences Act of Ghana. Act 29, 1960. Accra, Ghana: Assembly Press, 1960. [Google Scholar]
- 50. Osafo J, Akotia CS, Andoh-Arthur J et al. Attempted suicide in Ghana: motivation, stigma, and coping. Death Stud 2015;39(5):274–80. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article will be shared on reasonable request to the corresponding author.