Suicide attempts and behavioral correlates among a nationally representative sample of school-attending adolescents in the Republic of Malawi

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Study Justification:
– Suicide is a leading cause of death among adolescents worldwide.
– Understanding the behavioral correlates of suicide attempts is crucial for developing effective prevention strategies.
– While research on suicidal behavior in high-income countries is extensive, there is a lack of epidemiological knowledge in low-income countries, particularly in Africa.
– This study aims to contribute to the understanding of suicidal behavior in Africa, specifically among adolescents in Malawi.
Highlights:
– The study used a nationally representative sample of school-attending adolescents in Malawi.
– Bivariate and multivariate analyses were conducted to identify associations between suicide attempts and various behavioral variables.
– The results showed that suicide attempters had higher odds of experiencing anxiety, being physically bullied, sustaining serious injuries, and having a greater number of lifetime sexual partners.
– Alcohol use, both at an early age and within the past 30 days, was also associated with suicide attempts.
– These findings have the potential to guide public health interventions for suicide prevention in Africa and similar regions.
– The study highlights the need for further epidemiological research on suicidal behavior in low-income countries.
Recommendations:
– Develop and implement public health interventions targeted at preventing suicide among adolescents in Malawi and similar regions.
– Focus on addressing anxiety, bullying, serious injuries, and risky sexual behavior as potential risk factors for suicide attempts.
– Consider the role of alcohol use in suicide prevention efforts.
– Conduct further epidemiological studies to enhance understanding of suicidal behavior in low-income countries.
Key Role Players:
– Ministry of Health in Malawi: Responsible for coordinating and implementing public health interventions.
– Education authorities: Involved in implementing prevention programs in schools.
– Mental health professionals: Provide counseling and support services for at-risk adolescents.
– Non-governmental organizations (NGOs): Collaborate with government agencies to implement interventions and provide resources.
Cost Items for Planning Recommendations:
– Development and printing of educational materials on suicide prevention.
– Training programs for teachers, healthcare professionals, and community workers.
– Counseling services for at-risk adolescents.
– Awareness campaigns and community outreach activities.
– Research funding for further epidemiological studies.
– Monitoring and evaluation of intervention programs.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study used a nationally-representative sample and conducted both bivariate and multivariate analyses to examine the behavioral correlates of suicide attempts among Malawi adolescents. The findings provide important insights into the associations between suicide attempts and various behavioral variables. However, to further strengthen the evidence, the study could benefit from a more detailed description of the methodology, including information on sampling techniques and data collection procedures. Additionally, it would be helpful to include information on the statistical significance of the associations found in the multivariate analyses. These actionable steps would enhance the transparency and rigor of the study, making the evidence even stronger.

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.

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Based on the information provided, here are some potential innovations that could improve access to maternal health in Malawi:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based systems that provide pregnant women with information on prenatal care, nutrition, and safe delivery practices. These platforms can also send reminders for antenatal visits and provide access to teleconsultations with healthcare providers.

2. Community Health Workers: Train and deploy community health workers to provide maternal health education, conduct prenatal visits, and assist with referrals to healthcare facilities. These workers can also provide postnatal care and support for new mothers.

3. Telemedicine: Establish telemedicine networks that connect healthcare providers in remote areas with specialists in urban centers. This would enable pregnant women in underserved areas to receive expert advice and consultations without having to travel long distances.

4. Maternal Health Vouchers: Implement a voucher system that provides pregnant women with subsidized or free access to essential maternal health services, including antenatal care, delivery, and postnatal care. This would help reduce financial barriers and increase utilization of healthcare services.

5. Maternal Waiting Homes: Build and maintain maternal waiting homes near healthcare facilities to accommodate pregnant women who live far away and need to travel for delivery. These homes would provide a safe and comfortable place for women to stay during the final weeks of pregnancy, ensuring timely access to skilled birth attendants.

6. Transportation Support: Develop transportation initiatives, such as community ambulances or motorcycle taxis, to improve access to healthcare facilities for pregnant women in remote areas. This would address the challenge of long travel distances and inadequate transportation options.

7. Maternal Health Education Programs: Implement comprehensive maternal health education programs in schools, communities, and healthcare facilities. These programs would focus on raising awareness about the importance of prenatal care, nutrition, and safe delivery practices, as well as addressing cultural beliefs and practices that may hinder access to maternal healthcare.

8. Strengthening Healthcare Infrastructure: Invest in improving healthcare infrastructure, including the construction and renovation of healthcare facilities, equipping them with necessary medical supplies and equipment, and ensuring the availability of skilled healthcare providers.

9. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to leverage resources and expertise in addressing maternal health challenges. This could involve initiatives such as public-private partnerships for the construction and management of healthcare facilities or the provision of mobile health services.

10. Data-driven Decision Making: Establish robust data collection and monitoring systems to track maternal health indicators and identify areas of improvement. This would enable evidence-based decision making and targeted interventions to address specific maternal health challenges in different regions of Malawi.
AI Innovations Description
Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Implement targeted interventions for adolescents: Given that suicide attempts are associated with a range of behavioral factors, including anxiety, bullying, and early alcohol use, it is important to develop targeted interventions for adolescents that address these underlying issues. These interventions could include mental health support services, anti-bullying programs, and substance abuse prevention initiatives.

2. Strengthen sexual and reproductive health education: Since the number of lifetime sexual partners was found to be associated with suicide attempts, it is crucial to provide comprehensive sexual and reproductive health education to adolescents. This education should include information on safe sex practices, contraception, and the prevention of sexually transmitted infections. By equipping adolescents with knowledge and resources, they can make informed decisions about their sexual health, reducing the risk of unintended pregnancies and related mental health issues.

3. Improve access to maternal health services: While the study focused on suicide attempts among adolescents, it is important to recognize the potential impact on maternal health. To address this, efforts should be made to improve access to maternal health services in low-income countries like Malawi. This could involve increasing the number of healthcare facilities, training more healthcare professionals, and implementing community-based outreach programs to ensure that pregnant women have access to prenatal care, skilled birth attendants, and postnatal support.

4. Strengthen data collection and research: The study highlights the limited epidemiologic knowledge of suicidal behavior in low-income countries, particularly in Africa. To address this gap, it is important to strengthen data collection and research efforts on maternal health and mental health issues. This could involve conducting more comprehensive surveys, collecting data on a regular basis, and collaborating with international organizations to share findings and best practices.

By implementing these recommendations, it is possible to develop innovative solutions that improve access to maternal health and address the underlying factors associated with suicide attempts among adolescents in low-income countries like Malawi.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health in the Republic of Malawi:

1. Strengthening healthcare infrastructure: Invest in building and upgrading healthcare facilities, particularly in rural areas, to ensure that pregnant women have access to quality maternal healthcare services.

2. Training and capacity building: Provide training and support for healthcare professionals, including midwives and nurses, to enhance their skills in providing comprehensive maternal healthcare services.

3. Community outreach programs: Implement community-based programs to raise awareness about the importance of maternal health and provide education on prenatal care, safe delivery practices, and postnatal care.

4. Mobile health (mHealth) interventions: Utilize mobile technology to deliver maternal health information, reminders, and support to pregnant women and new mothers, especially in remote areas where access to healthcare facilities is limited.

5. Financial incentives: Introduce financial incentives, such as cash transfers or subsidies, to encourage pregnant women to seek antenatal care and deliver in healthcare facilities.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the number of pregnant women receiving antenatal care, the percentage of deliveries attended by skilled birth attendants, and maternal mortality rates.

2. Data collection: Gather data on the current status of maternal health in Malawi, including the baseline values of the identified indicators.

3. Modeling: Use statistical modeling techniques to simulate the potential impact of the recommendations on the identified indicators. This could involve creating scenarios based on different levels of implementation and estimating the resulting changes in the indicators.

4. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the results by varying key parameters and assumptions used in the modeling process.

5. Interpretation and policy implications: Analyze the simulated results and interpret the potential impact of the recommendations on improving access to maternal health. Use these findings to inform policy decisions and prioritize interventions for implementation.

It is important to note that the methodology described above is a general framework and the specific details may vary depending on the available data, resources, and expertise.

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