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When no-one notices...Studies on suicidal expressions among young people in Nicaragua:  
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Suicidal behaviour among young people is one of the major public health problems in low-income countries; it is estimated that every year 70,000 young people take their lives and maybe 40 times as many attempt suicide. Nicaragua has the highest suicide rate among young people of all Latin and Central American countries. This thesis aims at examining: (1) suicidal expressions and their determinants among school adolescents in Nicaragua, (2) cross-cultural aspects on suicidal expressions comparing Nicaragua and Cambodia, (3) pathways to suicide attempts among young men, and (4) primary health care professionals’ perceptions of suicidal behaviour and mental health problems among young people.

Method Paper I is a cross-sectional study of 368 school adolescents in Nicaragua using self-report instruments (Youth Self Report and Attitudes Towards Suicide). Paper II compares data from Paper I with corresponding data from a study of 316 adolescents in Cambodia using the same methodology. Paper III is a qualitative study based on interviews with 12 young men who have recently attempted suicide. Paper IV is a qualitative study with 12 primary health care professionals.

Results Paper I: Among adolescents, suicide ideation during recent year was reported by 22.6%, suicide plans 10.3%, and suicide attempts 6.5%. Girls were significantly more likely to report suicidal ideation. Multivariate analyses showed that anxious/depressed syndrome (YSR), somatic complaints syndrome (YSR) and exposure to attempted or completed suicide in significant others were significantly associated with their own serious suicidal expressions.

Paper II: There was no significant difference in serious suicidal expressions (plans and attempts) between countries, but milder suicidal expressions during past year were more common among Nicaraguan young people. Overall, mental health problems were more commonly reported in Cambodia, where adolescents scored significantly higher on almost all YSR-syndromes as compared to Nicaraguan adolescents, except for withdrawn/depressed syndrome among boys. The pattern of association between mental health problems and suicide plans/attempts differed between countries. In Nicaragua, all eight YSR-syndromes were significantly associated with serious suicidal expressions for both genders compared to only one syndrome among girls and two syndromes among boys in Cambodia.

Paper III: A model of the pathways leading to suicide attempts among young men was constructed based on the informants’ experiences. Structural conditions such as poverty or single-headed families, along with normative expectations within a framework of hegemonic masculinity, were all involved to create a sense of failure and an inability to cope. Subsequent increased drinking and drug abuse as well as exposure to attempted and completed suicide among friends and family acted as triggers to their own suicide attempt.

Paper IV: Primary health care professionals felt themselves that they lacked knowledge and competence when approached by young people with mental health problems. Misconceptions were common. They felt frustrated which made them either ignore signs of mental health problems or reject help-seeking young people. In practice, a common response from health care professionals was to refer the patient over to someone else, the “hot potato” strategy.

Conclusions The prevalence of serious suicidal expressions among young people in Nicaragua is within the range reported from Western high-income countries. Health care professionals need to be aware that somatic complaints as such are related to an increased risk of serious suicidal behaviour among young people, and that those who have been exposed to the attempted or completed suicide of someone close are at increased risk of serious suicidal expressions also when there are no warning signs in terms of mental distress. The cross-cultural comparison lends support to the notion that both cultural specificity and universality characterize serious suicidal expressions, as suggested by several researchers. Whereas prevalence shows less variation between cultures, associated factors might behave differently as shown in the present study, calling for different preventive approaches. The interviews with young men who had attempted suicide tell us that not only difficult socio-economic conditions but also the normative expectations on young men need to be addressed to decrease their risk of suicide. Health care professionals need to be alerted that sometimes serious mental health problems are hidden behind help-seeking for more trivial reasons. There is a necessity of a more integral approach towards mental health problems in PHC, including integral training of staff. The continued involvement of the community, family and other institutions would be essential to develop the care further.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2011. , 35 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1461
Keyword [en]
suicidal expressions, adolescents, young people, Nicaragua
National Category
Medical and Health Sciences
Research subject
Psychiatry; Public health
Identifiers
URN: urn:nbn:se:umu:diva-49750ISBN: 978-91-7459-322-8 (print)OAI: oai:DiVA.org:umu-49750DiVA: diva2:457106
Public defence
2011-12-09, Föreläsningssal A,, Psykiatriska kliniken, Byggnad 23, NUS, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2011-11-18 Created: 2011-11-16 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Suicidal expression in adolescents in Nicaragua in relation to youth self-report (YSR) syndromes and exposure to suicide
Open this publication in new window or tab >>Suicidal expression in adolescents in Nicaragua in relation to youth self-report (YSR) syndromes and exposure to suicide
2011 (English)In: Clinical Practice and Epidemiology in Mental Health, ISSN 1745-0179, E-ISSN 1745-0179, Vol. 7, 89-96 p.Article in journal (Refereed) Published
Abstract [en]

Background: Suicide and suicidal expressions among young people represent a major public health problem worldwide. Most studies are from high-income countries, and it remains unclear whether prevalence and risk factors show a similar pattern in other settings. This study aims to assess the prevalence of suicidal expressions and serious suicidal expressions (ideation, plans and attempts) among adolescents in Nicaragua, in relation to previously reported risk factors, such as exposure to suicide in significant others (parents, siblings, partners or friends) and mental health problems.

Methods: 368 adolescents aged 15-18 years were randomly selected from public secondary schools in León, Nicaragua. Data was collected using Attitude Towards Suicide (ATTS) and Youth Self-Report questionnaires (YSR). Bivariate and multivariate analyses were conducted.

Results: Suicide ideation prevalence in the past year was 22.6%, suicide plans 10.3%, and suicide attempts 6.5%. Girls were significantly more likely to report suicidal ideation. Multivariate analyses showed that anxious/depressed, somatic complaints and exposure to suicidal behavior in significant others were significantly associated with own serious suicidal expressions.

Conclusions: The prevalence of serious suicidal expressions among young people in Nicaragua is within the range reported from Western high-income countries. An attempted or completed suicide in someone close, is associated with own suicidal expressions even in the absence of increased mental distress. Furthermore, somatic complaints should alert healthcare professionals of the possibility of increased suicide risk.

Place, publisher, year, edition, pages
Bentham Open, 2011
Keyword
Suicidal expressions, youth self report, Nicaragua, school based
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-43907 (URN)10.2174/1745017901107010089 (DOI)21559237 (PubMedID)
Available from: 2011-05-16 Created: 2011-05-16 Last updated: 2017-12-11Bibliographically approved
2. Suicidal expressions among young people in Nicaragua and Cambodia: a cross-cultural study
Open this publication in new window or tab >>Suicidal expressions among young people in Nicaragua and Cambodia: a cross-cultural study
2012 (English)In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 12, 28- p.Article in journal (Refereed) Published
Abstract [en]

Background Whereas prevalence of suicidal expressions among young people is fairly similar in different countries, less is known about associated risk factors. This study compares young people in Nicaragua and Cambodia to examine if the pattern of association between mental health problems and suicidal expressions differs.

Methods 368 and 316 secondary school students, from each country respectively, participated. Self-reported suicidal expressions, exposure to suicidal behavior in significant others and mental health problems among the students were measured using Attitude Towards Suicide (ATTS) and the Youth Self-Report (YSR) questionnaires.

Results Prevalence of serious suicidal expressions (plans and attempts) during recent year, did not differ between countries. Cambodian young people scored significantly higher on all eight YSR-syndromes, except for withdrawn/depressed. In Nicaragua, all YSR-syndromes were significantly associated with serious suicidal expressions in both genders compared to Cambodia where only one syndrome showed an association in each gender; Withdrawn/depressed among girls and Somatic complaints among boys. Associations between being exposed to suicide among significant others and serious suicidal expressions also differed between Cambodia and Nicaragua.

Conclusions While the magnitude of serious suicidal expressions is similar between these structurally similar but culturally different countries, determinants behave differently. Qualitative studies are warranted to further explore cultural specific determinants for suicidal expressions among young people.

Place, publisher, year, edition, pages
London: BioMed Central, 2012
Keyword
Suicidal expressions, Adolescents, Young People Cross-cultural comparison, Nicaragua and Cambodia
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-49784 (URN)10.1186/1471-244X-12-28 (DOI)000304667800001 ()
Available from: 2011-11-18 Created: 2011-11-18 Last updated: 2017-12-08Bibliographically approved
3. I keep my problems to myself: pathways to suicide attempts in Nicaraguan young men
Open this publication in new window or tab >>I keep my problems to myself: pathways to suicide attempts in Nicaraguan young men
Show others...
2011 (English)In: Suicidology Online, ISSN 2078-5488, E-ISSN 2078-5488, Vol. 2, 17-28 p.Article in journal (Refereed) Published
Abstract [en]

This qualitative study is an attempt to understand the pathways leading to attempted suicide of young men in León, Nicaragua. Our research is based on in-depth interviews with twelve young men between the ages of 15 and 24 who had recently attempted to take their own life. The analysis is based on a grounded theory approach. The young men who participated in this study had a broadly similar background, insofar as they all came from broken families and had dropped out from school at an early age. They also all faced similar problems, such as unemployment and alcohol abuse. On this basis a model describing the pathways leading to the suicide attempts was constructed based on the informants’ experiences. In all cases the decision to attempt suicide was found to be an expression of frustration with the present conditions of life. Combined with this was the traumatic influence of a troubled childhood within an unloving, unstable family. Attention has been paid to the ambivalent and antagonistic relationships that the informants experienced within their own families from childhood onwards, and the subsequent inability to establish any meaningful relationships in later life. This study aims to increase our understanding of the complexity of suicidal behaviours in order to help develop genderspecific prevention strategies.

Keyword
Young men, Suicide attempt, Nicaragua, Qualitative approach
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-49785 (URN)
Available from: 2011-11-18 Created: 2011-11-18 Last updated: 2017-12-08Bibliographically approved
4. "...It's a shock when someone doesn't want to live". Nurses and doctors' perceptions of young people's help-seeking in primary health care in Nicaragua.
Open this publication in new window or tab >>"...It's a shock when someone doesn't want to live". Nurses and doctors' perceptions of young people's help-seeking in primary health care in Nicaragua.
(English)Manuscript (preprint) (Other academic)
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-49788 (URN)
Available from: 2011-11-18 Created: 2011-11-18 Last updated: 2015-04-29Bibliographically approved

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