Menu
Menu
Menu
Menu
Background: Suicide is among the top causes of adolescent mortality worldwide. While correlates of suicidal behavior are better understood and delineated in upper-income countries, epidemiologic knowledge of suicidal behavior in low-income countries remains scant, particularly in the African continent. The present study sought to add to the epidemiologic literature on suicidal behavior in Africa by examining the behavioral correlates of suicide attempts among Malawi adolescents. Methods: A cross-sectional study using a nationally-representative sample extracted from publically-available data was conducted. Bivariate and multivariate analyses were performed to discern associations between suicide attempts and a host of behavioral variables. 2225 records were included in the study. Results: At the multivariate level, suicide attempters had significantly higher odds of being anxious, being physically bullied, having sustained a serious injury and having a greater number of lifetime sexual partners. Alcohol use (at an early age and within the past 30 days) was also associated with suicide attempts. Conclusions: These findings have the potential to guide public health interventions geared toward suicide prevention in Africa and other, similar regions, as well as provide the impetus for future epidemiologic studies on suicidal behavior in low-income countries.
The data for this study were collected in the Republic of Malawi. Malawi is a land-locked south-eastern African country with a Human Development Index rank of 170 out of 186 according to 2011 estimates. It has a population of 15.38 million and a life expectancy of approximately 54 years with almost half of the population aged 0–14 years [19, 20]. In male and female adults aged 15 years and older, the literacy rate was 61.3 % in 2010 [21]. The under-five mortality rate in 2010 was 90.9 per 1,000 people and is steadily decreasing and the maternal mortality ratio has leveled off around 629.0 deaths per 100,000 live births [21]. The life expectancy at birth was 53.5 years for females and 53.4 years for males [21]. On average, 67.7 % of males and females combined completed primary school education; 69.0 % for females and 66.4 % for males [21]. Education is compulsory for primary school, children ages 6 to 14, and, on average, only 29.7 % of males and 28.8 % of females enroll in secondary school (http://www.classbase.com/Countries/Malawi/Education-System, http://www.unicef.org/infobycountry/malawi_statistics.html). In Malawi, 38.8 % of the population has access to improved sanitation facilities compared to 28.2 % in other Sub-Saharan African countries [21]. In Malawi, 11.7 % of people aged 15–49 years old were HIV positive compared to an average of 4.8 % in other Sub-Saharan African countries [21]. We used publicly available data from Malawi obtained through the 2009 Global School-based Student Health Survey (GSHS) and conducted a secondary analysis with the major aim of analyzing behavioral covariates for suicide attempts. The World Health Organization (WHO) in collaboration with United States Centers for Disease Control (CDC) developed the methodology for the GSHS. This survey is administered to school attending adolescents and collects self-reported information on indices pertaining to health risk behaviors and practices. Countries were able to develop a questionnaire unique to their country. In Malawi, 50 government primary schools participated in the survey and 2,359 students in grades (‘Standards’) 7 and 8 aged 11 – 16 years (53.4 % females) participated in the survey with a 100 % school response rate, and a 94 % student response rate [22]. The GSHS employed a two-stage cluster sample design in order to produce a nationally representative dataset. In our analyses presented in this paper, we excluded 134 records with missing age and/or sex information. No student or school identifiers are included in any of the public use data sets. The Ministry of Health in Malawi conducted the survey and at the time of data collection the study was approved at the national level by the Health Research Ethical committee of the Ministry of Health in Malawi. Consistent with the GSHS study protocol [22], questionnaires were administered to all eligible participants in an anonymous, voluntary manner. Written permission had been obtained from each participating school and from all classroom teachers. Parental consent was also obtained. The dependent variable ‘suicide attempts’ was derived from one question in the GSHS: “During the past 12 months, how many times did you actually attempt suicide?”, with response options of “0 times”, “1 time”, “2 or 3 times”, “4 or 5 times”, and “6 or more times”. These responses were dichotomized into ‘zero’ corresponding to “0 time” and the rest were grouped together as ‘1’, representing those students who attempted one or more acts of suicide during the 1 year preceding the survey. For the independent variables we selected contextually pertinent demographic, family characteristics and personal behaviors that have been either associated with suicide attempt in previous studies or constituted involvement in risk taking behaviors linked with poorer mental health. These included age in years, sex, bullying of any form, involvement in physical fights, food deprivation, having been physically attacked, age at sexual debut in years, serious injuries, physical bullying, loneliness, anxiety, suicidal ideation, suicide planning, number of close friends, tobacco use by parents, smoking by other people in the presence of the respondent, and number of lifetime sexual partners. Details on how these variables were created can be found in Table 1. Independent variable derivation from GSHS survey data 2009 Analyses entailed univariate and bivariate analyses. Based on the results of the bivariate analyses, multivariate analyses were performed. Initially, distribution of each selected variable was examined within both categories of suicide, i.e. whether suicide was attempted or not. Crude and adjusted Odds Ratios (OR) along with their 95 % confidence intervals are reported for the strength and direction of associations between suicide and the factors studied. Stata version 12 (StataCorp, College Station, TX, USA, 2011) and the R Statistical Environment (R Development Core Team, 2011) [23] were used for the data analyses.
N/A
