Prevalence and Factors Associated With Suicide Ideation in Colombian Caribbean Adolescent Students

Abstract

The study aimed to know the prevalence of and some factors associated with suicide ideation in high school adolescents from a Colombian Caribbean city. A cross-sectional analytical study was designed with probability sampling. An expected prevalence of 50% and an alpha error of 5% were estimated. High-school students from public and private institutions were invited to participate. One thousand four hundred sixty-two adolescents participated in, they were aged between 13 and 17 years, and 33.6% of students reported suicide ideation. Suicide ideation was associated with depression risk (OR = 4.54, 95% CI 2.35–8.77), family dysfunction (OR = 4.54, 95% CI 2.35–8.77), sexual violence (OR = 1.92 CI95% 1.33–2.76) and low academic achievement (OR = 1.97, 95% CI 1.42–2.73). It is concluded that 33.6% of adolescents enrolled in secondary education reported suicide ideation and was associated with depression risk, family dysfunction, sexual abuse, and poor academic achievement.

Keywords

suicide ideation risk factors adolescent students cross-sectional studies

Suicide is an indicator of structural violence and frequently occurs in a context of social and economic disadvantage (World Health Organization [WHO], 2018). Globally, for every completed suicide, it is estimated that between 100 and 200 adolescents attempt suicide daily (McIntosh & Drapeau, 2014). In 2015, worldwide, suicide increased significantly among adolescents, it was ranked as the second cause of death in the age group between 15 to 17 years old, accounting for 6.1 of deaths (WHO, 2018).

Suicidal behaviours include the sequence of events ranging from thinking about intentionally ending one's life (suicide ideation), developing a plan to do so (planning), making a non-fatal attempt, (suicide attempt), to consummating death (suicide). Each stage is qualitatively different; however, they can be closely related and, not necessarily, they are presented sequentially (Shek & Yu, 2012).

Suicide ideation can vary according to the country's social, political, economic, and cultural conditions (Liu et al., 2018). For example, in Hong Kong, 3,328 high school students aged 10 to 18 years, found that 13.7% reported suicide ideation in the past year (Shek & Yu, 2012). In Jamaica, in 342 adolescents aged 10 to 19 years, 38% reported lifetime suicide ideation (Kukoyi et al., 2010). In Ghana, in 1,984 school adolescents aged 10 to 18 years, 18.2% were found to have reported suicide ideation in the past twelve months (Oppong-Asante et al., 2017). In the United States, 5,601 in high school students aged 12 to 14 years, 9.7% reported suicide ideation in the past year (Lear et al., 2020).

In Latin America, the prevalence of suicide ideation can vary between 7.8 and 38.0%. In Mexico, 4,759 adolescents from the city of Chiapas (M = 18.4 years), the prevalence of suicide ideation during the last week was 7.8% (García et al., 2018). In another study in the same country, in 267 Mexican adolescents between 12 and 17 years old, the prevalence of suicide ideation of 16.5% was found (Franco et al., 2020). In Colombia, in Santa Marta, in 481 adolescents in school, between 13 and 19 years old, 24.5% presented suicide ideation (Suárez-Colorado et al., 2019). In Caldas, in 179 adolescents in school-aged between 14 and 17 years, 30.2% reported suicide ideation in the last week (Gómez-Tabares et al., 2020). In the municipalities of Florida and Nariño, in 154 students, aged 11 to 19 years, from three educational institutions located in the towns, 17.5% presented suicide ideation (Villalobos-Galvis et al., 2019). In Bogotá, in 2,817 students, aged between 13 and 17 years of official institutions, the prevalence of suicide ideation of 30.5% was found in 2006; 27.9% in 2013; and 38.0% in 2018 (González-Quiñones et al., 2019).

Suicide ideation is a multidimensional and multicausal problem associated with social determinants of health. The psychological, environmental, and academic factors are related to suicide ideation, depressive symptoms, family dysfunction, sexual violence, and poor academic achievement (García et al., 2018; Pérez-Amezcua et al., 2010; Wan & Leung, 2010).

In adolescents, depressive symptoms and major depressive episodes are the main predictors of suicide ideation. In Mexico, a statistically significant association was observed between depression and suicide ideation (OR = 9.0, 95% CI 7.1–11.3) (García et al., 2018). In Colombia, depressive symptoms were found to be associated with suicide ideation (OR = 29.9, 95% CI 3.5–223.1) in eighth-grade students from schools in Bogotá (Pérez-Olmos et al., 2012). Similarly, in public schools in Mexico, significant depressive symptoms were associated with suicide ideation (OR = 5.4, 95% CI 4.5–6.4) (Pérez-Amezcua et al., 2010). In adolescents, the spectrum of depressive symptoms includes hopelessness, anhedonia, impulsiveness, irritability, and suicide ideation. Therefore, the higher the severity of depressive symptoms, the greater the probability of suicide ideation is expected (García et al., 2018; Pérez-Olmos et al., 2012).

Environmental factors are associated with suicide ideation in adolescents, including family dysfunction and sexual violence. In Mexico, in schoolchildren, low family support was associated with suicide ideation (OR = 3.4, 95% CI 1.2–9.7) (Pérez-Amezcua et al., 2010). In Colombia, it was observed in students that family dysfunction was associated with suicide ideation (OR = 2.2, 95% CI 1.4–3.4) (Paniagua et al., 2014). In adolescents, family dysfunction includes low comprehensiveness, difficulty adapting, and resolving problematic events. Also, it is related to unstable or dysfunctional emotional ties, and little support and cooperation predispose internalized and externalized problems. These problems favour suicide ideation (Shek & Yu, 2012).

On the other hand, in Chinese adolescents, sexual violence was found to be related to suicide ideation (OR = 5.8, 95% CI 4.2–8.1), in students from seventh to tenth grade (Wan & Leung, 2010). Likewise, in Mexico, a statistical relationship was found between sexual violence and suicide ideation (OR = 1.9, 95% CI 1.5–2.4) (Pérez-Amezcua et al., 2010). In adolescents, sexual violence has a more significant negative effect than other violent acts. It predisposes to the presentation of post-traumatic symptoms, such as the feeling of submission, mistrust in other people, and suicide ideation (Pengpid et al., 2018).

Problems in the academic achievement of adolescents can be associated with suicide ideation (Shek & Yu, 2012); however, few studies confirm this association in school students. Previous studies indicate that higher academic achievement was associated with a lower occurrence of self-injurious behaviours (OR = 0.8, p < 0.001) in Chinese university students (Shek & Yu, 2012). Another study, in the United States, showed that lifetime plan (β = −3.5, p = 0.014) and suicide attempt (β = −7.9, p = 0.004) was associated with lower academic achievement in first-year college students (De Luca et al., 2016). In Colombia, an association between low academic achievement and suicide attempt was reported (OR = 11.1, 95% CI 1.1–108.8) (Beitia-Cardona et al., 2019). In Mexico, low academic recognition was associated with suicide ideation (OR = 1.4, 95% CI 1.2–1.5) in public school students (Pérez-Amezcua et al., 2010). Low academic achievement is the result of the interweaving of various individual, family, economic, and school factors (Beitia-Cardona et al., 2019). Academic achievements below expectations can be configured as a stressor (Caballero-Domínguez & Suárez-Colorado, 2019). The relationship between psychological distress and suicide ideation is known (Gerstner et al., 2020).

The present study explores the relationship between suicide ideation with some psychological factors (depression risk), environmental factors (family dysfunction and sexual violence), and academic factors (performance). These findings can contribute to the understanding of suicide behaviours among school adolescents. With this, it offers a basis for the design of actions in different contexts, culturally adapted, for the reduction of suicide risk amidst school adolescents in the Colombian Caribbean Region.

This study's objective was to know the prevalence of suicide ideation and its association with some associated factors in school adolescents from a city in the Colombian Caribbean Region.

Method

Design

The present study is analytical, cross-sectional that had the approval of an ethics committee of a public higher education institution in a city in the Colombian Caribbean Region. For inclusion in the study, all parents signed informed consent, and adolescents gave voluntary consent, consistent with the Declaration of Helsinki (World Medical Association, 2008).

Participants

The population comprises 10,810 students in tenth and eleventh grade from public and private educational institutions in a city located on the Caribbean coast of Colombia. A probabilistic sample by clusters of 1,948 students, in various stages, was estimated for an expected prevalence of 50% for suicide ideation, a margin of error of 2%, a confidence level of 95%, and replacement for losses of 25%.

Instruments

Participants completed some items from the Youth Risk Behavior Survey (YOUTH) and one question for sexual violence from the Trauma Symptom Checklist. They also completed two measurement scales: the family APGAR questionnaire (APGAR) and the General Well-being Inventory (WHO, 1998).

YOUTH

The YOUTH for middle- school students is a tool of the Center for Disease Control of the United States. The questionnaire includes questions such as age, sex, educational level, socioeconomic status, perceived academic achievement, and suicide ideation at some time in life. This questionnaire has shown high reproducibility in previous studies (Brener et al., 2013).

Sexual Violence

A question was taken from the Juvenile Victimization Questionnaire that explores different experiences in youth. The instrument presents dichotomous yes or no response options (Finkelhor et al., 2005). Previously, the questionnaire was translated and adapted into Spanish spoken in the Colombian Caribbean.

APGAR

The APGAR explores adaptability, cooperation, affective development, and the family's ability to resolve through 5 items. Each item offers five response options, from never to always, that is scored from zero to four, for a total score between zero and twenty. In the present study, scores lower than 16 were considered as family dysfunction. APGAR has been adapted in Colombian adolescents (Arias & Herrera, 1994). A previous study showed adequate consistency with a Cronbach's alpha .79 (Forero et al., 2006). The scale in the present study showed Cronbach's alpha of .82.

Well-Being Index

The Well-Being Index (WBI) evaluates the general well-being indicators based on depressive symptoms and is made up of 5 items with four response alternatives ranging from never to always, that are scored from one to four, for a total score between five and twenty; lower scores indicate more depressive symptoms (WHO, 1998). In the present study, scores lower than nine were classified as depression risk. This scale in a previous study in Colombia, the WHO-5 showed adequate psychometric performance, Cronbach's alpha of .70 (Campo-Arias et al., 2015). In the present study, the WBI presented Cronbach's alpha of .82.

Analysis of Data

The frequencies and percentages of the variables were observed in the descriptive analysis. In bivariate analysis, suicide ideation was taken as the dependent variable: The variables related to psychological, environmental, and academic factors were handed as independent variables, and sociodemographic variables were considered covariates. Prevalence ratios (OR) were calculated with 95% confidence intervals (95% CI). The multivariate analysis was carried out using binary logistic regression; the variables that showed probability values of less than 25% were taken in the bivariate analysis. At the time of carrying out the different models, Greenland’s (1989) recommendations were considered. To the best model, the goodness of fit was estimated with the Hosmer-Lemeshow test (Hosmer et al., 1991), and those with 95% CI were accepted as significant associations. Data analysis was performed with the IBM-SPSS program, version 22.0.

Results

There were 1,462 adolescents between the ages of 13 and 17 (M = 14.4, SD = 0.8). Table 1 reports other sociodemographic and interesting variables.

Table 1.

Description of the student sample.

Variable	n	%
Age (year)
Between 13 and 15	425	29.1
16 or 17	1,037	70.9
Gender
Female	882	60.3
Male	580	39.7
Grade
Tenth	809	55.3
Eleventh	653	44.7
Academic achievement
Excellent or good	1,012	69.2
Fair or low	450	30.8
Family dysfunction
Yes	1,112	76.1
No	350	23.9
Depression risk
Yes	446	30.5
No	1,016	69.5

Bivariate analysis showed the history of sexual violence, family dysfunction, and depression risk were associated with suicide ideation. See Table 2. In the adjustment process for demographic variables, suicide ideation maintained a significant association with family dysfunction, depression risk, sexual violence, and poor academic achievement. More details are in Table 3.

Table 2.

Crude associations for suicide ideation.

Variable	OR	95% CI
Age 16 or 17 year	1.07	0.77–1.50
Tenth grade	1.30	0.95–1.77
Low socioeconomic status	1.21	0.88–1.67
Female gender	1.79	1.28–2.49
Fair or low academic achievement	2.35	1.73–3.19
Sexual violence	2.79	2.00–3.91
Family dysfunction	6.74	4.32–10.09
Depression risk	6.60	1.32–2.14

Table 3.

Adjusted associations for suicide ideation.

Variable	OR	95% CI
Family dysfunction	4.54	2.35–8.77
Depression risk	4.22	2.70–6.59
Fair or low academic achievement	1.97	1.42–2.73
Sexual violence	1.92	1.33–2.76

Hosmer-Lemeshow test = 7.71, df = 6, p = 0.26.

Discussion

In the present study, the suicide ideation of school-aged adolescents, in a Colombian Caribbean city, scored for 33.6%. The depression risk, family dysfunction, sexual violence, and poor academic achievement were associated with suicide ideation.

In the present study, the prevalence of ideation at some time in life was 33.6%. This finding is similar to the observed frequency of 30.5%, and it evaluated a question that explored lifetime suicide ideation in 2,817 students from different public institutions in Bogotá (González-Quiñones et al., 2019). However, the frequency is higher than the prevalence of 24%, measured with the Plutchik suicide risk scale, found in 481 students from Santa Marta, Colombia (Suárez-Colorado et al., 2019); and 13.7% at some time in life, found with the suicidal behaviour scale, in 3,328 students from Hong Kong (Shek & Yu, 2012). Furthermore, the frequency is less than 38% of suicide ideation ever in life, identified a question from the YOUTH questionnaire, reported by 342 Jamaican students (Kukoyi et al., 2010). The variability in prevalence may be due to the different periods studied, the scales used in each of the studies and the criteria for quantifying suicide ideation in adolescents, as well as the differences in the sociocultural characteristics of the participating students in each study (Liu et al., 2018; Turecki & Brent, 2016).

In the present study, the depression risk was associated with suicide ideation. The significant association is consistent with previous studies in New Zealand; in youth, it was found that the history of depression was related to suicide ideation (χ2 = 5.2, p = 0.02) (Goldman-Mellor et al., 2014). Similarly, in adolescents in Mexico a significant relation was reported (OR = 9.0, 95% CI 7.1–11.3) (García et al., 2018) and Colombian adolescents (OR = 22.9., 95% CI 3.5–223.1) (Pérez-Olmos et al., 2012) and national public schools of Mexico (OR = 5.4, 95% CI 4.5–6.4) (Pérez-Amezcua et al., 2010). The depression risk is an essential predictor for suicide ideation; in this sense, higher the severity of the symptoms of the mood spectrum is more significant the level of risk of suicide ideation (Gerstner et al., 2020).

In the present investigation, family dysfunction was associated with suicide ideation. Consistent with previous studies in Colombia, family dysfunction was related to suicide ideation in students (OR = 2.2, 95% CI 1.4–3.4) (Paniagua et al., 2014) and students from Bogotá (OR = 15.0, 95% CI 8.4–26.9) (Gonzalez-Quiñones et al., 2019). Dysfunctional, poorly resolving, and destructive family patterns could destabilize emotional development, trust, and communication between family members, and predict suicide ideation in adolescents (Cantoral-Cancino & Bentacourt-Ocampo, 2011).

Sexual violence was associated with suicide ideation in the present investigation. The finding is consistent with previous studies in China (OR = 5.8, 95% CI 4.2–8.1) (Wan & Leung, 2010) and in Mexico (OR = 1.9, 95% CI 1.5–2.4) (Pérez-Amezcua et al., 2010). In sexual violence, it represents a recognized traumatic event, the history of traumatic experiences frequently in people with suicide ideation, generally in the context of other depressive symptoms (Calvo et al., 2003).

In the present study, low academic achievement was related to suicide ideation. Similar results describe that low academic achievement was associated with suicide ideation (OR = 1.4, 95% CI 1.2–1.5) in students from public schools in Mexico (Pérez-Amezcua et al., 2010). The association can be explained by the fact that low academic achievement can be perceived as a stressor and, consequently, generate psychological difficulties, frustration, and perception of low self-efficacy, which can induce depressive symptoms, with the inclusion of suicide ideation (Oppong-Asante et al., 2017).

By way of synthesis, suicide ideation is an initial phase of suicidal behaviour and is a phenomenon related to multiple predisposing and triggers (Guadarrama-Guadarrama & Torres-González, 2018; Turecki & Brent, 2016). It is necessary to highlight the importance of family function as a protective factor for suicide ideation in adolescents (Turecki & Brent, 2016). From this perspective, the family as the central and support axis of the development of adolescents' emotional maturity is one of the primary sources for the consolidation of relationships based on the support, mutual support, and cooperation of its members (Suárez & Alcalá, 2014). The adequate family function provides adaptive models for impulse control and coping with psychological distress and, consequently, favours mental well-being and reduces suicidal behaviours (Salvo & Castro, 2013). Likewise, a good family function is a protective factor against adverse situations, such as sexual violence, which can trigger the presentation of suicide ideation (Guiliana et al., 2019).

In the same way, the school context's critical role in the psychological well-being of students must be considered. Students' interaction, parents, teachers, and peers play a determining role in the consolidation of mental resources and face the demands and difficulties of the teaching-learning process (Carvajal & Urrego, 2019). Similarly, academic achievement can be considered an indicator of psychological well-being and may suggest the presence of depressive symptoms, including suicide ideation (Carvajal & Urrego, 2019). The relationship can be bidirectional because the academic low can precipitate depressive symptoms, and in turn, the depressive symptoms deteriorate the academic achievement (Trickett & Rowe, 2012).

This study contributes to the understanding of the role of some predictive factors that help explain suicide ideation among school adolescents in the Caribbean Region of Colombia. The timely identification of these factors and the appropriate approach can help mitigate the appearance of suicide ideation and, subsequently, to prevent consummate suicide (Turecki & Brent, 2016). On the other hand, this study is an input to strengthen public policy from the particularities of the territories, channelling interdisciplinary and multidisciplinary, integrated, and comprehensive actions for the prevention of suicidal behaviour amidst school adolescents in the Caribbean Region of Colombia (Campo-Arias & Suárez-Colorado, 2019).

Suicide ideation is a complex and structural phenomenon that requires predictive factors and vulnerability conditions to be expanded, with longitudinal studies. From this perspective, this study has the limitation that multicultural and gender terms were not considered according to the evolutionary course. Furthermore, cross-sectional studies do not allow establishing a causal relationship (Shapiro, 2008).

In conclusion, 33.6% of high-school adolescents reported suicide ideation. Depression risk, family dysfunction, sexual violence, and academic achievement were associated with suicide ideation. Other variables that may be related to suicide ideation in the Colombian Caribbean need to be studied.

Footnotes

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 this article: This work was funded by the Vice-Rectory for Research of the University of Magdalena, Santa Marta, Colombia, through Resolution 0347 of 2018 (Fonciencias Call for Proposals, 2017).

ORCID iD

Adalberto Campo-Arias

Author Biographies

Carmen Cecilia Caballero-Domínguez is a psychologist and the leader of the Research Group on Health Psychology and Psychiatry of the University of Magdalena, Santa Marta, Colombia. She stands out for research in the field of mental health. Her studies highlight the importance of complex psychological phenomena such as anxiety, depression, suicidal ideation, exhaustion, and academic abandonment.

Adalberto Campo-Arias is a psychiatrist, epidemiologist, and magister in sexual and reproductive health and a member of the Research Group on Health Psychology and psychiatry of the University of Magdalena, Santa Marta, Colombia. His scientific and technical capacity is related to epidemiology in mental health and sexual health, psychometrics, and measurements in health. He also has worked on the study of sociocultural phenomena of stigma-discrimination complex, and diversity in educational and professional contexts. He has made contributions to the knowledge of mental health, sexual health, and stigma-discrimination complex.

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