Suicidal ideation among students of the 7th, 8th, and 9th grades in the state of Lara, Venezuela: the Global School Health Survey.
Subject: Adolescentes (Investigacion cientifica)
Adolescentes (Analisis de casos)
Comportamiento suicida (Investigacion cientifica)
Comportamiento suicida (Analisis de casos)
Comportamiento suicida (Factores de riesgo)
Latinoamericanos (Investigacion cientifica)
Latinoamericanos (Analisis de casos)
Latinoamericanos (Aspectos psicologicos)
Authors: Granero, Ricardo
Poni, Esteban
Poni, Carolin
Pub Date: 12/01/2008
Publication: Name: Puerto Rico Health Sciences Journal Publisher: Universidad de Puerto Rico, Recinto de Ciencias Medicas Language: Spanish Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 Universidad de Puerto Rico, Recinto de Ciencias Medicas ISSN: 0738-0658
Issue: Date: Dec, 2008 Source Volume: 27 Source Issue: 4
Geographic: Geographic Name: Puerto Rico; Venezuela
Accession Number: 189052224
Full Text: Background: Suicidal behavior among adolescents is not a well-explored public health problem. Health policy decision-making on suicidal behavior needs reliable information on the prevalence of suicidal ideation (SI) and its associated risk factors to produce health promotion and prevention programs.

Methods: The Global School Health Survey is a self-administered survey done on a random probabilistic sample among students of the 7th, 8th, and 9th grades in the Lara State, Venezuela, school period 2003 to 2004. Point prevalence of SI and associated factors were included and the odds (OR) of having SI was calculated given selected factors.

Results: Two-thousand seventy (2070) respondents, of which 13.5% reported having SI in the last 12 months, and in females more than males (14.6% vs. 11.7%). The OR for SI, according to an associated risk factor, were among (a) females: age [greater than or equal to] 14 years (2.2), worries (3.42), loneliness (8.8), ever had sexual intercourse (5.58), alcohol (8.43) and (b) males: having only one or non close friends (3.69), alcohol (12.36), ever had sexual intercourse (2.73).

Conclusion: Behavioral risk factors are relatively new in the field of surveillance systems; therefore, results on SI should be cautiously taken into consideration and a wide discussion should be encouraged as we learn how to best use the results for health promotion and disease prevention.

Key words: Adolescents, Latinos, School, Suicidal Ideation, Suicide, Venezuela

Resumen

La conducta suicida entre los adolescentes es un problema de salud publica no bien explorado. La toma de decisiones en las politicas de salud necesitan informacion confiable sobre la prevalencia de la ideacion suicida (IS) y los factores de riesgo asociados con el objetivo de crear programas que promuevan la salud y la prevencion. Se determino la prevalencia y los "odds" de presentar IS de acuerdo a ciertos factores, mediante una encuesta autoadministrada (Encuesta Mundial de Salud Escolar) en una muestra probabilistica tomada al azar, de alumnos de Imo, 8vo y 9no grado del sistema escolar del Estado de Lara, Venezuela, durante el periodo 2003-2004. Dos mil setenta (2070) respondieron, el 13,5 % presento IS en los ultimos 12 meses, la prevalencia de IS fue mayor en el sexo femenino (14,6% vs. 11,7%). Los "odds" de presentar IS de acuerdo a un factor de riesgo asociado y separados por sexo fueron: a) Hembras: edad mayor de 14 aoos (2, 2), preocupaciones (3, 42), soledad (8, 8), haber tenido relaciones sexuales (5, 58), alcohol (8, 43) y b) Varones: tener un solo amigo cercano o ninguno (3, 69), alcohol (12, 36), haber tenido relaciones sexuales (2, 73). Los factores del comportamiento son relativamente nuevos en los sistemas de vigilancia. De manera que los resultados de IS deben ser discutidos ampliamente y ser cautelosos en cuanto a su interpretacion en el proceso de entender como usarlos de la forma mas productiva en la promocion de la salud y prevencion del suicidio.

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Suicide, defined as any fatality due to an intentional self-inflicted injury, among adolescents is an important health and social problem in many countries. Worldwide, about 4 million adolescents attempt suicide annually, resulting in at least 100,000 deaths (1-3). According to the World Health Organization (WHO), suicide ranks high amongst all causes of death in youth aged 15-19: 3rd in Africa, South-East Asia, Western Pacific, and Europe; 4th in the Americas; and 18th in the Eastern Mediterranean region (4). Fortunately, suicide is a potentially preventable cause of premature death; consequently, surveillance systems should collect information on suicide risk factors and used as a base for public health initiatives aimed at reducing its burden in our populations.

Compared with other suicidal behaviors (such as contemplation, planning, attempt, and consummation), suicidal ideation (SI) i.e., any kind of thought focused on self-inflicted death (5) is gaining more interest as a risk factor for suicide (6). SI is the most common of all suicidal behaviors (7). Even if considering that only a minority of ideators ever engages in overt self-harm, most suicides and parasuicides (i.e., attempted suicide) have engaged in suicidal thoughts prior to their acts (8). Many cases ending in suicide action begin as an ideation (9). SI has been used as a health marker among adolescents, not only as a risk factor for suicide (7, 10-13), but also as a predictor for suicidal behavior and other psychological problems later in adult life (14-16).

Despite its public health importance, most population-based epidemiological studies that address the health of youth, provide little if any information on SI and its risk factors (17-19). In the case of Latin American adolescents, these reports are almost nonexistent (20-21). To the best of our knowledge, this article presents information for the first time on suicide-related issues from a large sample of adolescents from Venezuela.

Methods

The Global School Health Survey (GSHS) is an international surveillance initiative based on the school system designed to monitor selected aspects of health and health determinants among youth under an international protocol (22). The GSHS is an initiative of the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) of the United States of America, in a global alliance with governmental and nongovernmental organizations (23-25).

The GSHS follows the methodology of the Global Youth Tobacco Survey (GYTS), a pioneer global behavioral surveillance system. In particular, the methodology of the Lara State Venezuelan GSHS has been described elsewhere (26-27). In summary, the sampled population is comprised of students enrolled in grades 7th through 9th of school year 2003-2004. The sample design had two stages: the first one consisted of sampling schools with a probability of selection proportional to the school enrollment size and the second stage consisted of randomly selecting classes from the 7th, 8th and 9th grades and within each selected class, all students were invited to participate. The GSHS protocol was approved by the Ethical Committee of ASCARDIO. The authorities of each school provided permission to administer the GSHS. The privacy of the students and their free anonymous participation was assured. The GSHS was administered by personnel of the Cardiovascular Diseases Program Lara State, Venezuela, Ministry of Health (CVDP-MH) and ASCARDIO.

The questionnaire of GSHS has a core of questions common to all places where the GSHS is applied as well as questions to address specific needs of the Lara State, Venezuela. Both are presented in modules to address health areas: sexual behavior, tobacco use, nutrition, violence, mental health, physical activity and hygiene, among others. The core questions were developed by WHO and CDC. The specific questions for the students in Lara State were developed by personnel of the CVDP-MH and ASCARDIO. The Spanish version of the survey core was validated in the following way: (a) review by experts; (b) pilot test; and (c) student focus groups. Consistency among the versions of the questionnaire (Spanish and English) was assessed by comparing versions done by independent translators. Trained-personnel administered the GSHS following the procedures described in the manual.

The literature refers to "Suicidal Ideation" [SI] as the contemplation of a desire to die or to take steps toward killing one self (5). In our study, SI was assessed by the following two questions: A- "During the past 12 months, did you ever seriously consider attempting suicide?" and B- "During the past 12 months, did you make a plan about how you would attempt suicide?" Those students who answered "NO" to both questions were classified as "without suicide ideation", and those that selected "YES" to any of the two questions, were classified as "with suicide ideation."

Seven domains and their respective risk factor (RF) and protective factor (PF) were considered. We explored SI in connection with (a) gender (male as a PF); (b) age ([greater than or equal to] 14 as a RF); (c) school related problems (with senior grades [8th and 9th] and school performance as RFs); (d) loneliness (with felt lonely and [less than or equal to] 1 close friend as RFs); (e) worries and social insecurities (with insomnia and threatening experiences as RFs); (f) alcohol consumption related problems (i.e., consumption of alcohol associated with any problem with family or friends, become drunk; simply drank alcohol in the last 3 weeks, or in the last months for a week, or [greater than or equal to] 2 drinks in the last month, all of them as RFs); and (f) sex related problems (with [greater than or equal to] 1 sexual intercourse experience or sex intercourse [less than or equal to] 12 years old as RFs).

Statistical analyses

The odds ratio (OR) of presenting suicide ideation, given the presence of risk factor (RF) and protective factor (PF), was calculated with the pertaining 95% confidence interval (CI95%). All items with an OR over 1 were labeled as "RF" and those items with an OR below 1 were labeled "PF." All data was calculated by using the C Sample statistical program in the Epi-Info version 3.3.2 from CDC. A weighting factor was applied to each student record to adjust for non-responses and for the varying probabilities of selection. Differences between OR and prevalence were considered statistically significant (StatSig) if the 95% confidence intervals did not overlap.

Results

Twenty-four schools (96%) participated and 2070 (85.5%) out of the 2421 students submitted usable response sheets. The demographic information is presented in Table 1. There were 860 (41.5%) males and 1210 (58.5%) females. Most of the students, 1435 (69.3%) were 13 to 15 years old followed by 551(26.6%) who were 12 years old or less. Table 2 indicates that SI in females increases with age, a difference that reaches StatSig by comparing students 14 years and older with those 12 years or less. The same situation was found while considering the grades with a difference that was StatSig by comparing 7th to 9th grade. Among males, grade and age does not significantly modify the prevalence of SI.

Table 3 presents the OR of having SI by gender given a positive answer to selected statements (risk and protective factors [RF and PF, respectively]). RF and PF profiles for SI are influenced by gender. To begin with, male gender reduced the OR for SI in 19%; however it failed to reach StatSig (95%CI 0.61-1.07). To be older than 14 years and enrolled in grades 8 or 9 are RFs (OR 2.2 and 1.63) only among females. Perception of loneliness, fear, worrisome and alcohol related items were RFs for SI. In general, female ORs were higher than male ORs, reaching StatSig in almost all items. Thirteen out of 14 (93%) RFs in females increased the odds for SI in a range between 1.63 and 8.88. Females are more likely to consider committing suicide than males (14.6% vs. 11.7%), especially if associated with reaching senior age ([greater than or equal to] 14 years) and senior grade (8th and 9th). History of sexual intercourse, alcohol consumption without fighting and loneliness affect more females than males. SI among males is mainly associated with risk factors involving fighting associated with alcohol ingestion and problems in satisfying school's requirements.

Discussion

Suicide among adolescents is an important health and social problem. Suicide rates among adolescents aged 15 to 19 years old in some Latin-American Countries (Salvador, Cuba, Ecuador, Uruguay, Costa Rica, Argentina, Venezuela and Colombia) range from 5.45 to 14.46 per 100,000 inhabitants, figures that--on one side- are similar to those reported by Canada, USA and Germany (6.44 to 12.84) and--on the other side- surpass those reported by France, Japan, United Kingdom, and Italy (3.54 to 5.18) (4). Furthermore, 3 countries in the world reported adolescent rates for suicide higher than the adult rates; from these, 2 are Latin American countries (Chile and Venezuela) (28). This information prompts a worldwide call for action to reduce the health, social and economic burden due to suicide by means of effective community and personal health promotion programs (29). SI is a risk factor for suicide that opens the possibility for both public health measures (4, 14, 30). However, behavioral health risk factors surveillance is a relatively new concept to health care systems world wide, with few countries in the developing world adopting it in recent years (17-18, 26-27). In particular, the surveillance of SI, controversial in the past, is now been accepted as a safe and needed component of any youth suicide prevention program (31-35). Also, schools are recognized as a feasible venue to promote mental health among students (36-37). Therefore, the GSHS's module on mental health is an important step forward to filling the information gap on youth health by addressing both issues.

Our study confirms that SI is present among Venezuelan adolescents. The prevalence of SI for all participants was 13.5%; i.e., 14.6% in females and 11.7% in males. These findings are consistent with other reports. In Mexico City, Mexico, the prevalence of SI was 11.8% among female students in high school (20). In Calama, Chile, the prevalence of SI reached 14.6% when both genders were considered in students of middle school (21).

The interpretation of SI is a matter of controversy. Some authors consider that suicidal thoughts are part of the normal development process in adolescence, when young people are working on existential problems and trying to understand life, death, and the meaning of life. These authors base their assertion on surveys which show that more than half of upper-secondary school pupils report entertaining thoughts of suicide (38). Nevertheless, this assertion is challenged by other studies that establish SI as an abnormal behavior able to cause psychological problems (including suicidal behavior) later in adult life (14, 39). Either way, suicidal thoughts become abnormal in children and adolescents when realization of their suicide thoughts seems to be the only way out of their difficulties and becomes a point in which there is a serious risk for attempted suicide or suicide (4).

SI -as a RF for suicidal attempt or suicide- is multidimensional, i.e., other associations evoke or enhance the suicide thought (40). In general, we found that multiple RFs for SI are common in males and females. However, two robust conclusions are found in our study. First, females exceed males in the prevalence of SI (14.6% vs. 11.7%) (Table 2); in the number of RFs considered to reach StatSign (13 out of 14 [93%] vs. 10 out of 15 [67%]); and in the number of StatSign RFs with values greater than in males (10 [71 %] vs. 4 [28.5%], respectively) (Table 3). In addition, SI is more prevalent in females in 9th grade than both males in the 9th grade and females in the 7th grade. Furthermore, SI increases for each year of age considered (i.e., 12 <13 <14 years-old) among females. Conversely, age does not affect SI prevalence among males.

Several authors try to partially explain this abundance of SI among females compared with males. First, it is found that females have higher mean depression scores than males (19). In fact, the experience of depression and anxiety can impact more the production of SI in females than other variables such as hopelessness, negative life stress, family social climate, coping behaviors (41) and, in a questionable way, self-esteem (6). In our sample, the two RFs that affect females more compared with males are the feeling of loneliness (OR = 8.8 vs. 3.01, respectively) and history of sexual intercourse (OR = 5.58 vs. 2.73, respectively). Loneliness and history of sexual intercourse among adolescents have been strongly related with depression in females (6, 41). However, in another approach, other authors propose that these significant differences between genders may be linked to cultural issues in which females are more allowed to "verbalize," i.e., express their feelings and thoughts. Conversely, verbalization from males is perceived as a sign of weakness, which is thought to submit males to a higher level of stress and more violent forms of expression (42).

Second, SI in males is better associated with episodes of fighting in which alcohol consumption is involved as well as with a deterioration of school performance. Physical demonstration or injury-producing behaviors are especially notorious in males (43). In fact, in the only question that involved "to fight" in our study, males scored higher (OR = 12.36), the highest score in all the study compared with females (OR= 8.43). However, this ratio among females surprised us because it is the second highest OR value among females. SI among males was also associated with those who experienced feelings of sadness and hopelessness almost every day for 2 weeks or more during the past 12 months, and that had stopped doing usual student activities. But again, these feelings increased the risk for both males and females, (OR = 3.26 and OR = 2.72 respectively).

Our study failed to show StatSig in a few RF for SI. Being male was not a significant PF. Also males failed risk associations with age [greater than or equal to] 14, senior year-grade, and drinking [greater than or equal to] 2 drinks the days they drank alcohol. Among females, the only failed risk association was sexual intercourse [less than or equal to] 12 years-old (Table 3).

Finally, our study has the limitation that only adolescents from school systems were recruited; consequently, our findings may not be applicable to adolescents out from the school system. However, our data came from a cross sectional survey, that in the future will redeem substantial benefits as a base line data for a behavioral surveillance system.

Conclusions

Behavioral risk factors among adolescents are relatively new in the field of surveillance systems; therefore, we are learning how to best use our results for health promotion and disease prevention in the field of public health and the community. SI is one risk factor that needs to be explored in future studies to assess its potential as a health maker. Meanwhile, the data presented in this paper should serve as a baseline for extensive discussions on how to improve the health of adolescents in Venezuela.

Acknowledgments

This study was in part supported by the World Health Organization (WHO) obligation number HQ/03/906339 and ASCARDIO. We thank Carlos Poni for his early assistance with this manuscript. Also, we are deeply grateful to Carol Desoer for her critical review and suggestions of the final manuscript preparation.

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RICARDO GRANERO, MD * [[dagger]]; ESTEBAN PONI, MD **, CAROLIN PONI, BSPH [[double dagger]]

* ASCARDIO; [[dagger]] The Lara State Cardiovascular Program, Ministry of Health, Venezuela; ** Good Samaritan Community Hospital, Department of Pediatrics, Aguadilla, Puerto Rico; [[double dagger]] Member of the Americas' Network for Chronic Disease Surveillance (AMNET)

Address correspondence to: Esteban S. Poni, MD, 171 E., Manchester Ln., San Bernardino, CA, 92408. Tel: 909-558-7102, 909-558-1000 ext 45026 * Fax: 909-558-7950 * E-mail: este3808@hotmail.com
Table 1. Demographic characteristics of participants, The
Global School Health Survey, Lara State, Venezuela, School
period 2003-2004.

               7th grade    8th grade    9th grade    Total
               n(P%)        n(P%)        n(P%)

Gender
  Male         350 (40.7)   308 (35.8)   202 (23.5)   860
  Female       373 (30.8)   478 (39.5)   359 (29.7)   1210

Age (years)
  12 or less   455 (82.6)   93 (16.9)    3(0.5)       551
  13 to 15     268 (18.7)   675 (47.0)   492 (34.3)   1435
  16 or more   2 (2.4)      20 (23.5)    63 (74.1)    85

N and (P% = prevalence by 100 participants)

Table 2. Presence of suicidal ideation among students in 7th, 8th,
and 9th grades. The Global School Health Survey, Lara State,
Venezuela. School period 2003-2004.

                   Male              Female

                P%     IC95%      P%      IC95%

Total          11.7              14.6

Grades
  7th          12.7   8.4-16.9   11.0   8.3-13.7
  8th          11.2   8.7-13.7   15.4   11.6-19.2
  9th          10.9   8.4-13.5   18.5   14.0-22.9

Age (years)
  12 or less   9.9    3.0-16.8   7.9    5.3-10.6
  13           12.9   8.4-17.4   13.4   10.2-16.6
  14           13.2   8.6-17.7   20.5   14.7-26.4
  15 or more   11.7   6.5-16.9   20.8   13.6-27.9

P% = prevalence by 100 participants; IC95% = Interval confidence 95%

Table 3. Risk factors related to suicide ideation among students
of the 7th, 8th, and 9th grades, gender and a positive answer to
selected statements. Global School Health Survey. Lara State,
Venezuela. School period 2003-2004.

                                                        Male

                                                    OR       IC95%

Gender (PF) Male                                   0.81    0.61-1.07

Age (RF) Senior Age (Age [greater than
  or equal to] 14)                                 1.11    0.63-1.93

School Troubles (RF)
  1. During the past 12 months, you feel so sad
     or hopeless almost every day for two weeks
     or more in a row that you stopped doing
     your usual activities?                        3.26    1.83-5.79
  2. Enrolled on Senior Grade (8m or 911)          0.86    0.49-1.50

Worries (RF)
  1. During the past 12 months, you have been
     so worried about something that you could
     not sleep at night?                           3.10    1.34-7.20
  2. During the last 30 days, somebody
     threatened you in some way?                   1.88    1.24-2.85

Loneliness (RF)
  1. During the past 12 months, did you always
     or almost always feel lonely?                 3.01    1.85-4.88
  2. You have only one or no close friend?         3.69    2.37-5.76

Alcohol Use/Abuse (RF)
  1. In your life, have you experienced 3 or
     more times: a hangover, problems with
     families or friends, missed classes, or
     fought because of alcohol consumption?        12.36   5.60-27.29
  2. In your life, have you become drunken
     3 or more times?                              4.32    2.35-7.94
  3. During the last 30 days, did you drink
     alcohol between 6 and 30 days?                4.28    1.98-9.26
  4. During the last 30 days, did you drink 2
     or more drinks in each day for 6 or more
     days?                                         2.83    1.33-6.03
  5. During the last 30 days, on the days you
     drank alcohol, did you drank 2 or more
     drinks?                                       1.58    0.88-2.83

Sex Problems (RF)
  1. Have you had sexual intercourse, any time?    2.73    1.35-5.51
  2. Did you have your first sexual intercourse
     at age 12 or less?                            1.22    0.58-2.57

                                                        Female

                                                    OR       IC95%

Gender (PF) Male                                    --         --

Age (RF) Senior Age (Age [greater
  than or equal to] 14)                            2.20    1.57-3.07

School Troubles (RF)
  1. During the past 12 months, you feel so sad
     or hopeless almost every day for two weeks
     or more in a row that you stopped doing
     your usual activities?                        2.72    1.69-4.37
  2. Enrolled on Senior Grade (8m or 911)          1.63    1.10-2.42

Worries (RF)
  1. During the past 12 months, you have been
     so worried about something that you could
     not sleep at night?                           3.42    1.40-8.36
  2. During the last 30 days, somebody
     threatened you in some way?                   2.84    1.75-4.61

Loneliness (RF)
  1. During the past 12 months, did you always
     or almost always feel lonely?                 8.88    6.33-12.47
  2. You have only one or no close friend?         3.73    2.54-5.47

Alcohol Use/Abuse (RF)
  1. In your life, have you experienced 3 or
     more times: a hangover, problems with
     families or friends, missed classes, or
     fought because of alcohol consumption?        8.43    3.56-19.91
  2. In your life, have you become drunken
     3 or more times?                              5.06    2.22-11.56
  3. During the last 30 days, did you drink
     alcohol between 6 and 30 days?                5.34    2.79-10.21
  4. During the last 30 days, did you drink 2
     or more drinks in each day for 6 or more
     days?                                         5.20    2.56-10.57
  5. During the last 30 days, on the days you
     drank alcohol, did you drank 2 or more
     drinks?                                       2.43    1.82-3.25

Sex Problems (RF)
  1. Have you had sexual intercourse, any time?    5.58    3.26-9.56
  2. Did you have your first sexual intercourse
     at age 12 or less?                            0.78    0.13-4.88

OR = Odds ratio of having "Suicidal Ideation" given a positive answer
to the statement. IC95% = Interval confidence 95%.
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