Abstract
Adolescence is the time of greatest risk for the first onset of suicidal behaviors. This study aimed to identify the risk and protective factors associated with suicidal ideation among Malaysian adolescents. Data from the 2012 Malaysia Global School-based Student Health Survey, a nationwide study using a 2-stage cluster sampling design, were analyzed. The survey used a self-administered validated bilingual questionnaire and the Depression Anxiety and Stress Scale. The prevalence of suicidal ideation was 7.9%. Analysis revealed that suicidal ideation was positively associated with depression, anxiety, stress, substance use, being bullied, and being abused at home, either physically or verbally. In addition, suicidal ideation was significantly higher among females and among the Indians and Chinese. Having close friends and married parents were strongly protective against suicidal ideation. Understanding the risk and protective factors is important in providing comprehensive management for suicidal ideation.
Keywords
Introduction
The World Health Organization (WHO) estimated that 1 million people died from suicide in the year 2000. 1 Suicide is the fourth leading cause of death among adolescents aged 15 to 19 years worldwide. 2 In Malaysia, it was reported that 16.2% of all suicide cases in the year 2009 were among those aged 15 to 24 years. 3
Acts of self-harm that do not have a fatal outcome, also known as suicidal behaviors, comprise suicidal ideation, plans, and attempts. 4 Suicidal ideation is a recognized precursor to suicide attempts, which may result in completed suicide.5,6 Studies among Asian countries observed prevalences of suicidal ideation ranging from 6.1% in Thailand to 17.1% in the Philippines.7,8 Locally, a study in Negeri Sembilan in 2000 noted a prevalence of suicidal ideation of 7.0%. 9
Numerous contributing factors to suicidal behaviors have been identified. Studies noted that adolescents experiencing mental health problems (depressive symptoms and anxiety disorders) and adolescents abused physically are at increased risk of suicidal behaviours. 10 Evidence has also highlighted the association between substance abuse and suicide attempts. 11 Studies have also found a significant relationship between positive communication within family members and lower prevalence of suicidal behavior, but drew inconclusive results on association with parents’ cohabitational marital status. 12
In Malaysia, nationally representative data on suicidal ideation are still lacking. Therefore, this study aimed to determine the prevalence of suicidal behaviors and identify its associated factors, which can assist in the early identification of “at-risk” adolescents for the planning of both suicide prevention and intervention strategies.
Methods
Sampling
This study was part of the 2012 Malaysia Global School-based Student Health Survey (GSHS). The survey used a 2-stage cluster sample design. A total of 234 schools were selected from a sampling frame of 2344 government secondary schools in Malaysia. In each state, schools were selected with a probability proportionate to school enrolment size. Classes in the selected schools were selected using systematic random sampling, and all students in the selected classes were invited to participate in this survey. Each student’s record was attached with the weighting factor for adjustment of nonresponse. Detail methodology was explained in another article. 13
This study has been approved by both the Ministry of Health’s Research & Ethics Committee and the Ministry of Education’s Ethics Committee. Parental consent forms were distributed to all students from selected classes, and nonconsenting students were considered as nonresponses. A validated, bilingual, self-administered, and anonymous questionnaire was used. Data collection was conducted from February 23, 2012, to April 26, 2012. The GSHS data were representative of all students attending Forms 1 to 5 in Malaysia.
Variable Definitions
Forms were based on the school’s class system at government secondary schools. Remove/Form 1 is generally for adolescents aged 12 to 13 years, Form 2 for 14 year olds, Form 3 for 15 year olds, Form 4 for 16 year olds, and Form 5 for 17 year olds. Suicidal ideation was defined as “ever seriously considered attempting suicide in the past 12 months” prior to the survey. Based on the Depression Anxiety and Stress Scale (DASS21) scoring system, respondents were considered as having stress if they had moderate levels of stress or more (score of 38 and above), having anxiety if they had moderate levels of anxiety or more (score of 20 and above), and had depression if they had moderate levels of depressive symptoms or more (score of 28 and above). 14
For consumption of substance, current consumption was defined based on consumption in the last 30 days prior to the survey. Respondents were considered as current drinkers if they consumed at least 1 drink containing alcohol in the last 30 days, while current smokers were defined as having smoked cigarettes or other tobacco products for at least 1 day in the last 30 days, whereas current drug users were defined as having used drug(s) 1 or more times in the last 30 days prior to the survey.
Respondents were reported as having been bullied if they were bullied on 1 or more days in the last 30 days prior to the survey. Physical abuse at home was defined as being hit by someone at home that resulted in a mark or an injury. Verbal abuse at home was reported if someone at home said hurtful or insulting words to the student.
Respondents were reported as having had a close friend if they had at least one close friend at school. Peer support was defined as students in school who were kind and helpful most of the time or always in the past 30 days. Parental support was categorized into 4 categories. Based on their behavior in the last 30 days prior to the survey, respondents who reported that their parents or guardians had always or most of the time checked to see if their homework was done were categorized as having parental or guardian supervision, those who reported that their parents or guardians had always or most of the time understood their problems and worries were categorized as having parental or guardian connectedness, those whose parents or guardians had always or most of the time really knew what they were doing with their free time were categorized as having parental or guardian bonding, and those with parents or guardians who had never or rarely went through their things without their approval were categorized as having parental or guardian respect for privacy.
Data Analysis
Data analysis was done using the Statistical Package for Social Science (SPSS) software version 21. 15 Sampling weights, based on the sampling fractions derived from the final sample size, and the population of eligible respondents for the school Form was applied in the analysis. A complex sampling design was used to produce prevalence estimates and 95% confidence intervals for univariate, bivariate, and multivariate analysis. Chi-square test was used to determine the statistically significant difference between the variables. Simple logistics were used to determine the association of the variables. Finally, the variables of interest, sociodemographics, stress, anxiety, depression, alcohol use, drug use, smoking, being bullied, home abuse, peer support, and parental support, were included in the multivariate logistic regression model. The findings were presented as crude and adjusted odds ratio with a 95% confidence interval and P value <.05.
Results
A total of 25 174 out of 25 507 students responded to this module, with a response rate of 99.1%. By gender, 49.6% of respondents were males. A total of 60.2% were Malays, 20.6% Chinese, 6.8% Indians, and 10.4% Bumiputera from Sabah and Sarawak, with the remaining 1.7% from other ethnicities in Malaysia. Almost equal percentage of students found by school Forms (class).
The prevalence of reported suicidal ideation was 7.9% (95% confidence interval [CI] = 7.3-8.6). Multivariate analysis using logistic regression revealed that suicidal ideations were positively associated with depression (adjusted odds ratio [aOR]: 2.26; 95%CI: 1.97-2.58), anxiety (aOR: 1.27; 95%CI: 1.12-1.45) and stress (aOR:1.65; 95%CI: 1.42-1.93), physical or verbal abuse at home (aOR: 2.12; 95%CI: 1.82-2.47 and 1.90; 95%CI: 1.68-2.16, respectively), being bullied (aOR: 1.67; 95%CI: 1.45-1.90), and substance use: current smokers (aOR: 1.63; 95%CI: 1.36-1.96) and current drinkers (aOR: 1.55; 95%CI: 1.28-1.87). In addition, suicidal ideations were significantly higher among females (aOR: 1.58; 95%CI: 1.40-1.80), respondents of Indian and Chinese ethnicity (aOR: 2.31; 95%CI: 1.89-2.82 and 1.87; 95%CI: 1.60-2.18, respectively), and adolescents of divorced/widowed parents (aOR: 1.29; 95%CI: 1.09-1.52). Having a close friend was noted as being strongly protective against suicidal ideations (aOR: 0.55; 95%CI: 0.43-0.70), while parental caring attitudes were not related (Table 1).
Factors Associated With Suicidal Ideation Among Malaysian Adolescents a .
Abbreviations: CI, confidence interval; OR, odds ratio.
Subtotal are not consistent because of missing data.
Significance P value <.05 for bivariate and multivariate analysis.
Adjusted for all other variables.
1 = reference group.
Discussion
The prevalence of suicidal ideation in 2012 (7.9%) was almost similar to an earlier nationwide study done in 2010 (7.8%). 16 The Malaysian prevalence on suicidal ideation was lower compared to that of Vietnam (16.9%), 17 the Philippines (16.3%), 18 and Thailand (8.8%) 19 but higher compared to Cambodia (6.2%). 20 Suicidal ideation and attempts are precursors of completed suicide. The WHO estimated that suicidal attempts were 20 times more frequent than a completed suicide. 1 In addition, the suicide registry in Malaysia reported an almost similar rate of completed suicide among adolescents. 3 As such, the actual prevalence of suicidal ideation among Malaysian adolescents may possibly be much higher than that reported in this study. The cultural and religious values of these adolescents might influence their responses in this survey, as suicide is prohibited by Islam and Christianity; religions represented by more than half of the respondents.
This survey revealed that the prevalence of suicidal ideation in Malaysia did not worsen since the past few years. This situation may be because of the success of various programs carried out by governmental and nongovernmental agencies. Since 2011, the Ministry of Health had initiated the Healthy Mind Programme at schools. This program focuses on the early identification of at-risk students through screening, early detection of symptoms, identification of stress factors, counseling, and early referral to a psychiatrist, where necessary. 21 Nongovernmental organizations, such as Malaysian Mental Health Association, have also played their roles in creating public awareness and in the advocacy for provisions of better mental health services. 22
Suicides among adolescents are contributed by various factors. Planning of the intervention strategies should be holistic and should be targeted to the adolescents and their environment. Our survey had revealed that the “at-risk” adolescents are females, of Chinese and Indian ethnicity, and from broken families. Various studies had also observed the female preponderance of suicidal ideation.23 -26 The higher rate among respondents of Indian ethnicity has been consistently reported in other studies in Malaysia. 27
Our survey observed that suicidal ideation was significantly higher among adolescents with mental health problems, abuse, and substance usage. Mental health problems, particularly depressive symptoms, are an established risk factor for suicidal behaviours.24,25,28 The association between being bullied and family violence with suicidal ideation was also found in other studies.23,28,29 The link between substance use and suicidal ideation had also been noted in various studies.18,23,28
Our study observed only the protective effect of having a close friend against suicidal ideation, while the protective effect of a positive family environment was not significant, even though it was documented in various other studies.19,23
Strengths and Limitations
The strength of this study is the analysis based on a large nationally representative sample that allowed for a reliable inference to Malaysian adolescents within a similar age-group. This survey also used an anonymous standard GSHS and DASS21 questionnaire, which is advantageous for international comparison. This survey used a validated bilingual questionnaire (English and Bahasa Malaysia), which is acceptable by school-going adolescents.
One limitation of this study is its cross-sectional nature, which prevented the identification of causal relationships between the identified factors and suicidal ideation.
Conclusion
Suicidal ideation among adolescents is a public health problem in Malaysia. This study observed the importance of identifying “at-risk” adolescents: having mental health problems, substance use, and victims of violence. Intervention programs for these “at-risk” adolescents should be holistically targeted toward alleviating its risk factors and promoting the protective factors.
Footnotes
Acknowledgements
The authors would like to thank the Director General of Health, Malaysia, for his permission to publish this article. We would also like to thank the Ministry of Education, the students who participated and those who were involved in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of the article: Research was funded by the Ministry of Health Malaysia and World Health Organization (WHO), Geneva, Switzerland.