Suicidal ideation in older Ghanaian women: The roles of bodily pain,functional limitation,and chronic health conditions

Abstract

Background:

Although approximately 79% of the world’s suicides occur in low- and middle-income countries (LMICs), the limited research in these regions has primarily focused on the rates of suicide attempts (SA) and ideation among men and younger members of the population.

Aim:

This study investigated the associations between bodily pain, functional limitation, chronic health conditions, and suicidal ideation among older Ghanaian women with a positive screen for depression.

Methods:

Data was obtained from the World Health Organization’s Study on global AGEing and adult health (SAGE) Ghana Wave 1, a nationally representative sample. Based on the interpersonal theory of suicide, we used logistic regression analysis to investigate the associations between the variables.

Results:

Functional limitation, bodily pain, hopelessness, and hypertension were significantly associated with a higher risk of suicidal ideation after accounting for sociodemographic and other confounding factors.

Conclusions:

Early interventions designed to decrease hopelessness, hypertension, and functional limitations may lead to reduced suicide ideation among older Ghanaian women who screen positive for depression.

Keywords

Suicidal ideation aging Ghana women health Africa physical health

Suicide is a global public health problem responsible for more than 800,000 deaths annually (World Health Organization [WHO], 2019) and is considered a complex phenomenon resulting from the interaction of individual, social, and environmental factors (WHO, 2014). The reduction of suicide mortality has been prioritized by the World Health Organization (WHO) as a global target and included as an indicator in the United Nations Sustainable Development Goals (SDGs) under target 3.4 (WHO, 2020). Notably, older adults (⩾70 years) have the highest suicide rates in nearly every region of the world (WHO, 2014). To date, existing research has been predominantly conducted within Western societies (Adinkrah, 2020), despite evidence suggesting that low- and middle-income countries (LMICs) account for 79% of suicides worldwide and will hold an estimated 80% of the older adult population by 2050 (WHO, 2018, 2019). Mental health is a challenge in any context, but this challenge is magnified in sub-Saharan Africa (SSA) due to a limited focus on non-communicable diseases (Gouda et al., 2019) and geriatric mental health (Lekoubou et al., 2014). In particular, suicide has received insufficient attention among older women dwelling in sub-Saharan Africa (SSA). A systematic focus on the health of older women in SSA is warranted due to the region’s feminization of its aging population (Apt, 2009). Women in SSA also face increased vulnerability to adverse health conditions and insufficient health care due to ageism and gender discrimination (Chrisler et al., 2016). Additionally, older adults are more likely to live in rural areas (Becker & Grewe, 1996) and are subsequently bound by financial and cultural constraints (e.g. caregiving duties, lack of access to employment) that negatively impact older women’s health (Apt, 2009).

The scarcity of suicide research in the SSA region, including Ghana, may partly be a consequence of the illegality of suicidal behavior in many areas of Africa (Adinkrah, 2020). Current law in Ghana designates attempted suicide as a crime punishable by legal penalties such as monetary fines or incarceration (Hjelmeland et al., 2014). Suicide illegality poses challenges for researchers as there are no formal reporting systems for suicide statistics (e.g. National Violent Death Reporting System in the United States; Osafo et al., 2020). Previous studies investigating suicidality in Ghana have used non-representative approaches to data collection, such as media content analysis (Quarshie et al., 2021) and qualitative interviews (Akotia et al., 2019), which provide important insights but are limited to suicidal behaviors of the target populations of these studies. The issue of suicide illegality is compounded by a cultural climate that rejects and excludes suicide attempters (Adinkrah, 2020), ultimately rendering the discussion of suicidal ideation a taboo topic and discouraging suicide research. Thus, the aim of the present study is to address this limitation in the research on suicidality in SSA by examining the relationship between bodily pain, functional limitation, and chronic health conditions.

A prominent framework that may be relevant to understanding the phenomenon of suicidal behaviors among older adults in Ghana is the interpersonal theory of suicide (IPTS; Joiner, 2005). IPTS posits that suicide is preceded by three conditions: thwarted belongingness (a perceived absence of positive and caring connections to others that causes a painful sense of not belonging), perceived burdensomeness (a self-perception that one’s death is worth more than their life to others), and an acquired capability for suicide (Joiner, 2005). Specifically, thwarted belongingness and perceived burdensomeness initiate and maintain suicidal desire, while an acquired capability for suicide produces the necessary conditions for a suicide attempt or death (Joiner, 2005; Van Orden & Conwell, 2011). Applied to older adults, IPTS has been expanded to include five key risk factors: psychiatric illness, social isolation, functional impairment, physical illness and pain, and access to lethal means (Van Orden & Conwell, 2011). Although the data collected in this study does not allow for a comprehensive test of this framework, the IPTS for late life provides a conceptual guide for understanding and interpreting the associations between physical health and suicidal ideation among older women in SSA.

In the last decade, a growing body of work has documented the connection between physical health, pain, and suicidality in older adults (Conejero et al., 2018; Fässberg et al., 2016; Racine, 2018). A systematic review (Fässberg et al., 2016) examining the relationships between physical illness, functional disability, and suicidality among older women and men (⩾65 years of age) revealed connections between physical illness, functional disability, and suicidal ideation. Specifically, poor subjective health, functional disability, and pain were independently and significantly associated with suicidal ideation. Similarly, a review by Santos et al. (2020) identified an increased risk for suicidal behavior among older men and women (⩾60 years and over) who reported higher levels of bodily pain. This review suggested that the inability to control physical suffering and the threat of losing one’s sense of independence and value may result in feelings of hopelessness, leading to a higher risk of suicidality. While such results underscore physical and mental health as crucial correlates of suicidal behaviors in older adults, these relationships have yet to be evaluated in many non-Western contexts such as Ghana.

To our knowledge, only two studies have explored the association between suicide and physical health within SSA. Adewuya et al. (2016) examined the prevalence and correlates of suicidal ideation in a representative sample of adult Nigerian men and women aged 18 to 74 years (M = 36.75, SD = 12.3), and included a brief assessment of physical disability severity. Logistic regression analyses revealed a significant positive association between moderate and severe physical disability and suicidal ideation. Similarly, Acheampong and Aziato (2018) interviewed 12 Ghanaian mothers with physical disabilities who had given birth within the last 10 years regarding their experiences with suicidal ideation, exposing a high prevalence of suicidal ideation within this population. In tandem, these studies demonstrate the limited knowledge available and the need for further investigation on the association of physical ailments on suicidal ideation within SSA.

The dearth of research on suicidal behaviors and older women’s health issues in SSA merits an in-depth, quantitative examination of the effects of chronic illnesses, bodily pain, and functional limitations on suicidal ideation using representative data. Based on the IPTS framework adapted for late life (Van Orden & Conwell, 2011), the present study uses nationally representative data from Ghana to investigate whether chronic health conditions, bodily pain, and functional limitation have significant associations with suicidal ideation among older women. We hypothesized that bodily pain, functional limitation, and the presence of chronic health conditions would be significantly positively associated with a higher risk of suicidal ideation. We tested this hypothesis while accounting for other known predictors and correlates of suicidal behavior, including self-reported depression, hopelessness, demographic characteristics, and social connectedness (Brown et al., 2000; Conwell et al., 2011; Van Orden & Conwell, 2011).

Method

Procedure and participants

The present study was conducted using Wave 1 (collected between 2007 and 2010) of the World Health Organization’s Study on global AGEing and adult health (SAGE-Ghana; Kowal et al., 2012). SAGE is a longitudinal study of aging, health, and well-being among adults in Ghana, China, India, Mexico, Russia, and South Africa. Wave 1 was nationally representative and targeted men and women 50 years and older, with a smaller sample of individuals between the ages of 18 and 49 for comparison purposes. In all six SAGE countries, a stratified multistage cluster sampling method was used to collect data from nationally representative cohorts (Naidoo, 2012). A total of 5,573 individuals 18 years and older were surveyed for SAGE-Ghana Wave 1. Of the eligible individuals, 849 participants were excluded because they were younger than 50 years old at the time of the study, identified as men (n = 2,379), or did not respond to the suicidal ideation question (n = 2,094). To respond to the suicidal ideation question, participants had to answer ‘yes’ to a set of questions that screened for depression. A final analytic sample of 251 women was used in this study.

Measures

Suicidal ideation

A question based on the World Mental Health Survey version of the Composite International Diagnostic Interview (CIDI) was used to ask participants to indicate if they experienced suicidal ideation in the last 12 months: ‘During the last 12 months, did you think of death, or wish you were dead?’ Response options were ‘Yes’ or ‘No’. Participants who responded ‘Yes’ were considered as having experienced suicidal thoughts.

Self-rated health

Participants were asked to rate their subjective overall general health using a single question: ‘In general, how would you rate your health today?’ on a 5-point Likert scale from 1 (very good) to 5 (very bad). Scores were reverse coded so that higher scores indicated better health.

Bodily pain

Participants were asked to rate their perceptions of bodily pain in the past 30 days with the following question, ‘Overall in the past 30 days, how much bodily pain did you have?’ Response options were on a 5-point Likert scale ranging from 1 (none) to 5 (extreme/cannot do). For the present study, responses were recoded into three groups based on low, moderate, and high pain levels: 1 (none and mild pains), 2 (moderate), and 3 (severe and extreme/cannot do).

Chronic health conditions

Participants were asked to self-report any chronic health conditions diagnosed in the last 12 months (i.e. hypertension [high blood pressure], asthma, chronic lung disease, diabetes [high blood sugar], stroke, heart disease, and arthritis) with the following item: ‘Have you ever been diagnosed with/told by a health care professional you have (health condition)?’ Response options were ‘Yes’ or ‘No’. To identify specific conditions related to suicidal ideation, each chronic health diagnosis was entered as a separate variable in the analyses.

Functional limitation

Functional limitation was assessed using three separate items. Participants were asked to rate their perceived level of difficulty in performing work or household activities, vigorous activities, and self-care in the past 30 days. Responses options were rated on a 5-point Likert scale from 1 (none) to 5 (extreme/cannot do). We recoded the household limitations into three groups: 1 (none and mild), 2 (moderate), and 3 (severe and extreme/cannot do). The responses to self-care limitations were recoded into two groups: 1 (none, mild, moderate, and severe) and 2 (extreme/cannot do).

Hopelessness

Participants were asked to indicate if they felt hopeless in the last 12 months with a single item, ‘Did you frequently feel hopeless – that there was no way to improve things?’ Response options were ‘Yes’ or ‘No’.

Social connectedness

This variable was measured using three items: participation in religious activities, hosting friends, and leaving the house. Participants were asked to indicate the frequency of their participation in the last 12 months. Responses were: 1 (never), 2 (1-2x per year), 3 (1-2x per month), 4 (1-2x per week), and 5 (daily). The 4 and 5 response categories were grouped together to indicate ‘high social connectedness’, while the rest indicated ‘low social connectedness’.

Depressed affect

Depressed affect was measured using the item, ‘During the last 12 months, have you had a period lasting several days when you felt sad, empty or depressed?’ Response options were ‘Yes’ or ‘No’.

Sociodemographic variables

The following sociodemographic information was included in the analyses: age, years of education, geographic location, and marital status. Age and education were self-report, continuous variables. Respondents also reported whether their region of residence was rural or urban.

Ethical considerations

SAGE was approved by the World Health Organization’s Ethical Review Committee. In addition, ethical approval was granted from the University of Ghana College of Health Sciences Research Ethics Committee. Written informed consent was obtained from all participants.

Data analytic plan

All statistical analyses were performed in IBM SPSS Statistics software Version 23.0 for Macintosh, and statistical significance was set at p < .05 for all analyses. Prior to the primary analyses, the main study variables were examined for missingness and violations of multivariate assumptions. A missing values analysis showed that 7% of the data were missing. Little’s (1988) Missing Completely at Random (MCAR) test was not significant, X² = 2542.77, DF = 2,451, p = .60, indicating data was missing completely at random. Missing values were omitted using listwise deletion because it has little impact on the validity of statistical inferences in data sets where missing data is <10% (Bennett, 2001). Descriptive analyses of the sociodemographic characteristics of the sample were conducted first. To investigate associations between bodily pain, functional limitation, chronic health conditions, and suicidal ideation, binomial logistic regression was performed with suicidal ideation as the dichotomous outcome variable. Age, years of education, marital status, and geographic location were adjusted for in the analyses. Additionally, we adjusted for self-reported health, social connectedness, and hopelessness in the analyses due to prior research identifying these variables as risk factors for suicide and suicidal ideation among older adults (Brown et al., 2000; Conwell et al., 2011; Van Orden & Conwell, 2011).

Results

Sample characteristics

Table 1 presents the characteristics of the sample of n = 251 women (ranging between 50 and 100 years; M_age = 66, SD = 11.2) with valid responses to the outcome variable, suicidal ideation. A little over 100 respondents (n = 109; 43%) reported suicidal thoughts in the last 12 months. More than half of the respondents (n = 133; 53%) lived in rural areas and the majority (n = 170; 68%) had no formal education. The majority of women were widows (n = 134; 53%), attended religious activities once or twice a week (n = 143; 57%), and stated feelings of hopelessness in the previous month (n = 185; 74%). A similar proportion of respondents indicated mild (n = 97; 39%) and moderate (n = 84; 34%) bodily pain and approximately half of the respondents (n = 122; 49%) reported moderate overall health. One hundred nine (n = 109; 43%) women indicated moderate difficulty when doing strenuous activities.

Table 1.

Characteristics of the study sample (n = 251).

Variable	Frequency (%)
Age (mean ± SD)	66.07 ± 11.22
Year of education (mean ± SD)	7.46 ± 1.95
Region of residence
Urban	118 (47)
Rural	133 (53)
Marital status
Cohabiting or married	50 (19.9)
Separated, divorced, or never married	67 (26.7)
Widowed	134 (53.4)
Religious activities
High	162 (64.5)
Low	89 (35.5)
Having friends over
High	156 (62.2)
Low	95 (37.8)
Leaving the house
High	135 (5.8)
Low	116 (46.2)
Sad, empty, and depressed
Yes	210 (83.7)
No	41 (16.3)
Hopelessness
Yes	185 (73.7)
No	66 (26.3)
Self-rated health
Very good or good	72 (28.7)
Moderate	122 (48.6)
Bad or very bad	57 (22.7)
Difficulty with vigorous activities
None	24 (9.6)
Mild	23 (9.2)
Moderate	74 (29.9)
Severe	78 (31.1)
Extreme	52 (20.7)
Difficulty with self-care
None	201 (80.1)
Mild, moderate, severe, or extreme	50 (19.9)
Difficulty with work or household activities
None or mild	60 (23.9)
Moderate	109 (43.4)
Severe or extreme/cannot do	82 (32.7)
Bodily pains
None	17 (6.8)
Mild	97 (38.6)
Moderate	84 (33.5)
Severe or extreme	53 (21.1)
Chronic health conditions
Hypertension	64 (25.5)
Asthma	20 (8)
Chronic lung disease	3 (1.2)
Diabetes	11 (4.4)
Stroke	20 (8)
Heart disease	12 (4.8)
Arthritis	102 (40.6)

Main analyses

After adjusting for sociodemographic variables, hopelessness, depressed affect, and social connectedness, suicidal ideation was predicted by four different variables with model parameters of X²(29) = 83, p < .001, Nagelkerke R² = 0.38. With respect to bodily pain, regression results (Table 2) showed that mild and moderate pains were associated with a lower risk of suicidal ideation among the older women (Odds ratio [OR] = .30; 95%CI [0.13, 1.02]; p < .05); (OR = 0.29; 95%CI = 0.11, 0.79; p < .01; respectively). With respect to functional limitation when conducting vigorous activities, women with no limitation (OR = 0.05; 95%CI [0.01, 0.38]; p < 001), mild limitation (OR = 0.10; 95%CI [0.02, 0.49]; p < .01), and severe limitation (OR = 0.36; 95%CI [0.13, 0.99]; p < .05) were significantly associated with lower risk of suicidal ideation when compared to their counterparts with extreme limitations. Additionally, hypertension was the only chronic health condition significantly associated with suicidal ideation. Women who had hypertension were 0.46 times less likely to have suicidal thoughts (OR = 0.46; 95%CI [0.21, 1.00]; p < .05). Finally, individuals who reported feeling hopeless were almost five times more likely to think about suicide (OR = 4.30; 95%CI [1.78, 10.37]; p < .001) than individuals who did not report feeling hopeless.

Table 2.

Logistic regression results of variables predicting suicidal ideation in the sample (N = 251).

Variable	B	SE	OR	95%CI
Variable	B	SE	OR	Lower	Upper
Age	−0.01	0.02	0.99	0.96	1.02
Year of education	−0.02	0.09	0.98	0.83	1.16
Region of residence^a
Urban	0.14	0.34	1.15	0.59	2.23
Marital status^b
Separated, divorced, or never	−0.27	0.37	0.76	0.15	3.79
Married	−0.29	0.45	0.75	0.31	1.81
Widowed	−0.51	0.39	0.60	0.28	1.28
Religious activities^c
High	−0.54	0.38	0.58	0.28	1.22
Having friends over^d
High	−0.17	0.43	0.84	0.36	1.97
Leaving the house^e
High	0.72	0.45	2.06	0.86	4.93
Sad, empty, and depressed^f
Yes	0.00	0.46	1.00	0.41	2.45
Hopelessness^g
Yes	1.46	0.45	4.30***	1.78	10.37
Self-rated health^h
Good and very good	−0.03	0.61	0.97	0.29	3.19
Moderate	−0.79	0.50	0.45	0.17	1.21
Difficulty with vigorous activitiesⁱ
None	2.94	1.01	0.05**	0.01	0.38
Mild	2.33	0.82	0.10**	0.02	0.49
Moderate	0.89	0.55	0.42	0.14	1.22
Severe	1.03	0.52	0.36*	0.13	0.99
Difficulty with self-care^j
None mild, moderate, and severe	0.35	0.51	0.71	0.26	1.93
Difficulty with work or household activities^k
None or mild	0.20	0.62	1.22	0.36	4.15
Moderate	−0.12	0.43	0.89	0.38	2.07
Bodily pain^l
None	0.53	0.95	0.59	0.09	3.83
Mild	1.02	0.53	0.30*	0.13	1.02
Moderate	1.25	0.51	0.29**	0.11	0.79
Chronic health conditions
Hypertension	0.79	0.40	0.46*	0.21	0.99
Asthma	−0.13	0.57	1.14	0.37	3.51
Chronic lung disease	−1.18	1.72	3.27	0.11	5.85
Diabetes	−0.88	0.96	2.42	0.37	4.75
Stroke	0.79	0.70	0.47	0.12	1.85
Heart disease	0.24	0.82	0.79	0.16	3.95
Arthritis	0.38	0.37	0.69	0.33	1.41

Note. OR = odds ratio.

Reference = rural area.

Reference = cohabiting or married.

Reference = low religious activities.

Reference = low frequency of bringing friends over.

Reference = low frequency of leaving the house.

Reference = no feelings of sadness, emptiness, and depression.

Reference = not hopeless.

Reference = bad or very bad health.

Reference = extreme difficulty.

Reference = severe or extreme difficulty.

Reference = severe or extreme pain.

p < .05. **p < .01. ***p < .001.

Discussion

The current study examined the relationship between bodily pain, functional limitation, chronic health conditions, and suicidal ideation in older Ghanaian women. Based on tenants of the interpersonal theory of suicide (Joiner, 2005), we hypothesized that greater bodily pain, more chronic health conditions, and higher functional limitation would be significantly associated with increased suicidal ideation. Overall, the results supported our hypothesis. Within a representative sample of 251 older women in Ghana, bodily pain, functional limitation, and hypertension were significantly associated with a higher likelihood of suicidal ideation, with hopelessness emerging as the most robust correlate of suicidal ideation. Generally, these results correspond with previous research indicating that physical pain, chronic health conditions, and functional limitation confer increased risk for suicidality, specifically within older adult populations (De Leo & Spathonis, 2003; Santos et al., 2020; Van Orden & Conwell, 2011).

Consistent with our hypothesis, the results of this study show that older women with mild (0.30 times) and moderate (0.29 times) bodily pain were less likely to think about pain when compared to individuals with severe bodily pain. Though previous studies from Ghana have not assessed severe or extreme bodily pain as a risk factor for suicidal ideation, these results are consistent with literature from other parts of the world indicating that individuals with higher degrees of bodily pain were more likely to contemplate suicide (Santos et al., 2020). One explanation for this association is that older women with extreme or severe bodily pain may feel powerless about their capacity to alleviate their discomfort and subsequently contemplate suicide as a solution to end the suffering caused by the pain (Sand et al., 2008; Santos et al., 2020). Additionally, in line with the IPTS adapted for late-life, habituation to pain may play a role in the acquired capability for suicide, acting as a potential catalyst for suicidal ideation to translate into suicidal behavior (Van Orden & Conwell, 2011). Furthermore, depression is highly comorbid with bodily pain and may play a mediating role between pain and suicidality (Racine, 2018; Santos et al., 2020). Thus, it is possible that increased bodily pain, perhaps in tandem with habituation and depression, may constitute a risk factor for a higher likelihood of suicidal ideation in older women in SSA. Although the current study was unable to measure suicidal behavior, the translation of suicidal ideation to suicidal behavior in older women in SSA would be an essential topic for future research.

Results from the present study revealed that older Ghanaian women with zero, mild, and severe limitations had lower risks for suicidal ideation than those with extreme limitations. Functional ability is particularly important for older individuals because it dictates independence and the onset of assisted care (Mor et al., 1994). These activities are often necessary for independent living, social interaction, and daily routine activities. Therefore, functional limitations may predict higher suicidal ideation among older women as women may perceive themselves as a burden to others as they lose personal autonomy and control (Van Orden & Conwell, 2011).

In this study, hypertension was the only significant predictor of suicidal ideation of the chronic health conditions examined. Hypertension and depression are comorbid conditions that increase the risk of suicidal behaviors among West Africans (Igwe, 2013). According to a nationally representative study on the prevalence and status of hypertension in Ghana, the prevalence rate was 61% for older women (Capistrant et al., 2019). Our results emphasize a greater need to further investigate how hypertension impacts suicidal thoughts among depressive older women in Ghana. A comprehensive understanding of this relationship may be achieved by accounting for independent predictors and confounding factors of hypertension in Ghana, such as old age, overeating, and alcohol consumption (Bosu, 2010).

While the present study focused on physical health indicators, we also accounted for known covariates of suicidal ideation among older people. Particularly, we accounted for feeling sad, depressed, and empty in addition to hopelessness. Results indicated that the risk for suicidal ideation was about five times higher among hopeless individuals than their more hopeful counterparts. This finding is in line with existing studies that have shown a higher risk of suicidal ideation associated with hopelessness (Brown et al., 2000; Szanto et al., 2002; Uncapher et al., 1998).

Limitations

This study has several limitations. First, the cross-sectional design of this study limits the ability to determine temporal or causal relationships between suicidal ideation and physical health factors. Relatedly, our focus on physical health does not account for the traditional health care in Ghana, which holistically integrates ethics, spirituality, morals, and cultural values to individuals’ physical and mental health. Second, suicidal ideation was measured as a dichotomous outcome. Although previous studies have validated the use of a single, binary measurement of suicidal ideation (Farabaugh et al., 2015), this single item does not take into account attributes of suicidal ideation such as severity, variability, or duration (Van Spijker et al., 2014). Additionally, the item used in this study asked about thoughts of death or wishing they were dead, rather than specifically asking about thoughts of suicide. Researchers have explored whether there is a clinical difference between trajectories of individuals with passive (e.g. death wishes) and active (e.g. thoughts of suicide) suicidal ideation (Szanto et al., 1996; Van Orden et al., 2015) or whether passive ideation is a normal consequence of aging (Van Orden et al., 2013). This research indicates that older adults with passive suicidal ideation do not appear normative and rarely present without additional risk factors for suicide (Van Orden et al., 2015), so it is assumed that passive suicidal ideation is indicative of risk for suicide. Third, this study did not conduct a full test of the IPTS as we did not include other factors (e.g. access to lethal means, psychiatric illness), which may increase the likelihood of suicidal ideation and behavior beyond the scope of the current study. Finally, individuals may have been less likely to disclose suicidal ideation as this data was collected in person, especially in a country that still criminalizes suicide attempts. Despite these limitations, results from our study provide significant insight into the associations between physical health and suicidal ideation among older women in Ghana.

Implications and future directions

As non-communicable diseases and geriatric disease burdens continue to emerge in SSA, our findings offer considerations for researchers and practitioners who seek to address suicide risk among aging women with potential depression in Ghana. To illuminate the pathway between physical health and suicidal ideation in this population, these findings implicate the need for further comprehensive studies. Such studies should employ systematic suicide data collection strategies, use health- and suicide-specific standardized measures, employ indigenous perspectives of health, and follow participants longitudinally to create a more detailed understanding of the link between physical health and suicidal ideation among older women in Ghana. Our findings also suggest that future studies should focus on the direct association between hopelessness and suicidal ideation.

Regarding implications for policy and practice, these findings highlight the importance of culturally responsive initiatives to address the intersection of physical health and suicidality. The heightened stigma around suicidality and policies that outlaw suicide in Ghana create a unique dynamic to engage the community in suicide prevention efforts. Policy reform to decriminalize suicide in Ghana is critical to long-term efforts of reducing suicide rates. However, initial efforts could include community and healthcare providers’ education regarding the associations between physical and mental health, with a specific focus on bodily pain, functional limitation, and hopelessness. Training these individuals, specifically on geriatric mental health, will strengthen Ghana’s capacity to monitor trends, identify mental health concerns early, and to offer effective treatments and interventions.

Conclusion

In summary, the present study demonstrated a significant positive association between self-reported hypertension, functional limitation, bodily pain, hopelessness, and suicidal ideation in older Ghanaian women with potential depression. Findings highlight the need for additional research to deepen our understanding of risk and protective factors for suicidal ideation in older women living in SSA. Importantly, this study contributes preliminary, quantitative evidence for further investigation into the connections between physical and mental health in Ghana and similar settings where suicidal behaviors among older women have received limited attention due to the taboo and illegal nature of the topic.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: SAGE was supported by the World Health Organization, the US National Institute on Aging through Interagency Agreements (OGHA 04034785; YA1323-08-CN-0020; 1-AG-1005-01) and through a research grant (R01-AG034479), and financial and in-kind support from the University of Ghana Department of Community Health.

ORCID iD

James R Muruthi

References

Acheampong

A. K.

Aziato

(2018). Suicidal ideations and coping strategies of mothers living with physical disabilities: A qualitative exploratory study in Ghana. BMC Psychiatry, 18(1), 360. https://doi.org/10.1186/s12888-018-1938-x

Adewuya

A. O.

Ola

B. A.

Coker

O. A.

Atilola

Zachariah

M. P.

Olugbile

Fasawe

Idris

(2016). Prevalence and associated factors for suicidal ideation in the Lagos State Mental Health Survey, Nigeria. BJPsych Open, 2(6), 385–389. https://doi.org/10.1192/bjpo.bp.116.004333

Adinkrah

(2020). Characteristics of elderly suicides in Ghana. OMEGA: Journal of Death and Dying, 82(1), 3–24. https://doi.org/10.1177/0030222818779527

Akotia

C. S.

Knizek

B. L.

Hjelmeland

Kinyanda

Osafo

(2019). Reasons for attempting suicide: An exploratory study in Ghana. Transcultural Psychiatry, 56(1), 233–249. https://doi.org/10.1177/1363461518802966

Apt

N. A.

(2009, October). A policy framework for health and service needs of older persons in Africa. Centre for Social Policy Studies, University of Ghana. https://www.oocities.org/csps_ghana/ageing/harare.html

Becker

C. M.

Grewe

C. D.

(1996). Cohort-specific rural-urban migration in Africa. Journal of African Economies, 5(2), 228–270. https://doi.org/10.1093/oxfordjournals.jae.a020904

Bennett

D. A.

(2001). How can I deal with missing data in my study? Australian and New Zealand Journal of Public Health, 25(5), 464–469. https://doi.org/10.1111/j.1467-842X.2001.tb00294.x

Bosu

W. K.

(2010). Epidemic of hypertension in Ghana: A systematic review. BMC Public Health, 10(418), 1–14. https://doi.org/10.1186/1471-2458-10-418

Brown

G. K.

Beck

A. T.

Steer

R. A.

Grisham

J. R.

(2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68(3), 371–377. https://doi.org/10.1037/022-006X.68.3.371

10.

Capistrant

B. D.

Charlton

Snodgrass

Kowal

(2019). Do determinants of hypertension status vary between Ghana and South Africa? Study on global ageing and adult health: Hypertension in sub-Saharan Africa. Journal of the South African Heart Association, 16(2), 108–117. https://doi.org/10.24170/16-2-3640

11.

Chrisler

J. C.

Barney

Palatino

(2016). Ageism can be hazardous to women’s health: Ageism, sexism, and stereotypes of older women in the healthcare system. Journal of Social Issues, 72(1), 86–104. https://doi.org/10.1111/josi.12157

12.

Conejero

Olié

Calati

Ducasse

Courtet

(2018). Psychological pain, depression, and suicide: Recent evidences and future directions. Current Psychiatry Reports, 20(33), 1–9. https://doi.org/10.1007/s11920-018-0893-z

13.

Conwell

Van Orden

Caine

E. D.

(2011). Suicide in older adults. Psychiatric Clinics, 34(2), 451–468. https://doi.org/10.1016/j.psc.2011.02.002

14.

De Leo

Spathonis

. (2003). Suicide and euthanasia in late life. Aging Clinical and Experimental Research, 15(2), 99–110. https://doi.org/10.1007/BF03324486

15.

Farabaugh

Nyer

Holt

Baer

Petrie

DiPierro

Nierenberg

Pedrelli

Cusin

Fava

Mischoulon

(2015). Screening for suicide risk in the college population. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 33(1), 78–94. https://doi.org/10.1007/s10942-014-0203-6

16.

Fässberg

M. M.

Cheung

Canetto

S. S.

Erlangsen

Lapierre

Lindner

Draper

Gallo

J. J.

Wong

Duberstein

Wærn

(2016). A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Aging & Mental Health, 20(2), 166–194. https://doi.org/10.1080/13607863.2015.1083945

17.

Gouda

H. N.

Charlson

Sorsdahl

Ahmadzada

Ferrari

A. J.

Erskine

Leung

Santamauro

Lund

Aminde

L. N.

Mayosi

B. M.

(2019). Burden of non-communicable diseases in sub-Saharan Africa, 1990–2017: Results from the Global Burden of Disease Study 2017. The Lancet Global Health, 7(10), e1375–e1387. https://doi.org/10.1016/S2214-109X(19)30374-2

18.

Hjelmeland

Osafo

Akotia

C. S.

Knizek

B. L.

(2014). The law criminalizing attempted suicide in Ghana: The views of clinical psychologists, emergency ward nurses, and police officers. Crisis, 35(2), 132–136. https://doi.org/10.1027/0227-5910/a000235

19.

Igwe

M. N.

Uwakwe

Ahanotu

C. A.

Onyeama

G. M.

Bakare

M. O.

Ndukuba

A. C.

(2013). Factors associated with depression and suicide among patients with diabetes mellitus and essential hypertension in a Nigerian teaching hospital. African Health Sciences, 13(1), 68–77. https://doi.org/10.4314/ahs.v13i1.10

20.

Joiner

(2005). Why people die by suicide. Harvard University Press.

21.

Kowal

Chatterji

Naidoo

Biritwum

Fan

Lopez Ridaura

Maximova

Arokiasamy

Phaswana-Mafuya

Williams

Snodgrass

J. J.

Minicuci

D’Este

Peltzer

Boerma

J. T.

, & The SAGE Collaborators. (2012). Data resource profile: The World Health Organization Study on global AGEing and adult health (SAGE). International Journal of Epidemiology, 41(6), 1639–1649. https://doi.org/10.1093/ije/dys210

22.

Lekoubou

Echouffo-Tcheugui

J. B.

Kengne

A. P.

(2014). Epidemiology of neurodegenerative diseases in sub-Saharan Africa: A systematic review. BMC Public Health, 14(653), 1–32. https://doi.org/10.1186/1471-2458-14-653

23.

Little

R. J.

(1988). A test of missing completely at random for multivariate data with missing values. Journal of the American Statistical Association, 83(404), 1198–1202. https://doi.org/10.1080/01621459.1988.10478722

24.

Mor

Wilcox

Rakowski

Hiris

(1994). Functional transitions among the elderly: Patterns, predictors, and related hospital use. American Journal of Public Health, 84(8), 1274–1280. https://doi.org/10.2105/AJPH.84.8.1274

25.

Naidoo

(2012). WHO study on global AGEing and adult health (SAGE) waves 0 and 1—Sampling information for China, Ghana, India, Mexico, Russia, and South Africa (SAGE Working Paper No. 5). World Health Organization. http://www.who.int/healthinfo/sage/SAGEWorkingPaper5_Wave1Sampling.pdf?ua=1

26.

Osafo

Asante

K. O.

Akotia

C. S.

(2020). Suicide prevention in the African region. Crisis, 41(1), S53–S71. https://doi.org/10.1027/0227-5910/a000668

27.

Quarshie

E. N. B.

Asante

K. O.

Andoh-Arthur

Asare-Doku

Navelle

P. L.

(2021). Suicide attempts and deaths in older persons in Ghana: A media surveillance approach. Current Psychology, 40(1), 292–305. https://doi.org/10.1007/s12144-018-9932-5

28.

Racine

(2018). Chronic pain and suicide risk: A comprehensive review. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 87(B), 269–280. https://doi.org/10.1016/j.pnpbp.2017.08.020

29.

Sand

Strang

Milberg

(2008). Dying cancer patients’ experiences of powerlessness and helplessness. Supportive Care in Cancer, 16(7), 853–862. https://doi.org/10.1007/s00520-007-0359-z

30.

Santos

Martins

Azevedo

L. F.

Fernandes

(2020). Pain as a risk factor for suicidal behavior in older adults: A systematic review. Archives of Gerontology and Geriatrics, 87, 104000. https://doi.org/10.1016/j.archger.2019.104000

31.

Szanto

Gildengers

Mulsant

B. H.

Brown

Alexopoulos

G. S.

Reynolds

C. F.

(2002). Identification of suicidal ideation and prevention of suicidal behaviour in the elderly. Drugs & Aging, 19(1), 11–24. https://doi.org/10.2165/00002512-200219010-00002

32.

Szanto

Reynolds

C. F.

Frank

Stack

Fasiczka

A. L.

Miller

Mulsant

B. H.

Mazumdar

Kupfer

D. J.

(1996). Suicide in elderly depressed patients: Is active vs. passive suicidal ideation a clinically valid distinction? The American Journal of Geriatric Psychiatry, 4(3), 197–207. https://doi.org/10.1097/00019442-199622430-00003

33.

Uncapher

Gallagher-Thompson

Osgood

N. J.

Bongar

(1998). Hopelessness and suicidal ideation in older adults. The Gerontologist, 38(1), 62–70. https://dx-doi-org-s.web.bisu.edu.cn/10.1093/geront/38.1.62

34.

Van Orden

Conwell

. (2011). Suicides in late life. Current Psychiatry Reports, 13(3), 234–241. https://doi.org/10.1007/s11920-011-0193-3

35.

Van Orden

K. A.

O’Riley

A. A.

Simning

Podgorski

Richardson

T. M.

Conwell

. (2015). Passive suicide ideation: An indicator of risk among older adults seeking aging services? The Gerontologist, 55(6), 972–980. https://doi.org/10.1093/geront/gnu026

36.

Van Orden

K. A.

Simning

Conwell

Skoog

Waern

. (2013). Characteristics and comorbid symptoms of older adults reporting death ideation. The American Journal of Geriatric Psychiatry, 21(8), 803–810. https://doi.org/10.1016/j.jagp.2013.01.015

37.

Van Spijker

B. A.

Batterham

P. J.

Calear

A. L.

Farrer

Christensen

Reynolds

Kerkhof

A. J

. (2014). The Suicidal Ideation Attributes Scale (SIDAS): Community-based validation study of a new scale for the measurement of suicidal ideation. Suicide and Life-Threatening Behavior, 44(4), 408–419. https://doi.org/10.1111/sltb.12084

38.

World Health Organization. (2014). Preventing suicide: A global imperative. World Health Organization. https://www.who.int/mental_health/suicide-prevention/world_report_2014/en/

39.

World Health Organization. (2018, February 5). Ageing and health. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health

40.

World Health Organization. (2019). Suicide in the world: Global health estimates. https://apps.who.int/iris/handle/10665/326948

41.

World Health Organization. (2020). Mental health: Sustainable development goals (SDGs). https://www.who.int/mental_health/suicide-prevention/SDGs/en/