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‘Striving to negotiate… dying to escape’: suicidal expressions among young people in Cambodia
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Suicide among young people is a global public health problem, but information on determinants and understanding of suicidal expressions are lacking in low and middle income countries (LMIC). Though school-based interventions are common in many parts of the world, evidence for efficacy is less reported, particularly from post-conflict countries.

Aim To explore suicidal expressions and their determinants with psychosocial and gender perspective in Cambodia and Nicaragua and to evaluate a school based intervention to promote mental health and prevent suicidal behavior among young people in Cambodia.

Method School students between the age of 15-19 from Cambodia and Nicaragua responded to Attitude Towards Suicide (ATTS) and Youth Self-Report (YSR) questionnaires. In addition, Life Skill Dimension Scale Adolescent Form (LSDS-AF) was used in schools in Cambodia, one experimental and the other control, to measure the impact of intervention. Six focus group discussions (FGDs), both gender-specific and mixed groups, were held to understand young people’s perception of gender, culture, religion and media and their impact on suicide among them.

Results Paper I. Revealed few gender differences in suicidal expressions, except girls reporting more attempts than boys. Girls exposed to suicide among friends and partners were likely to report own suicidal expressions and girls with internalizing syndrome were at risk for suicidal expressions.   

Paper II. Cambodian teenagers reported more mental health problems but fewer suicidal expressions as compared to Nicaragua. The determinants varied between countries.  

Paper III. Participants of FGDs mentioned “Plue Plun” male and “Kath Klei” female to describe gender difference in suicidal behavior among young people in Cambodia who found it a challenge to negotiate between traditional and modern values.

Paper IV. Suicide ambiguity in Buddhism, stigmatizing culture and double edged media were seen as suicide-provoking by the young people in Cambodia, who recommended peer-focused, school based program.

Paper V. School based Life Skills Intervention overall benefited girls. Boys with high risk behavior had shown improvement on many Life Skills dimensions, as well as in their mental health profile.

Conclusion The gender and cultural differences in suicidal expressions and their determinants among teenagers emphasize the importance of culturally sensitive and gender-specific suicide prevention programs. The influence of religion and media ought to be considered while planning intervention programs. School-based program may be a window of opportunity to promote mental health and prevent suicide among young people in Cambodia.

Place, publisher, year, edition, pages
Umeå: Umeå University , 2014. , 49 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1643
Keyword [en]
Suicidal expressions, Young people, Cambodia
National Category
Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-88195ISBN: 978-91-7601-041-9 (print)OAI: oai:DiVA.org:umu-88195DiVA: diva2:714077
Public defence
2014-05-16, Föreläsningssal A, Psykiatriska kliniken, By 23, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2014-04-25 Created: 2014-04-25 Last updated: 2014-04-25Bibliographically approved
List of papers
1. Gender difference in suicidal expressions and it's determinants among young people in Cambodia, a post-conflict country
Open this publication in new window or tab >>Gender difference in suicidal expressions and it's determinants among young people in Cambodia, a post-conflict country
2011 (English)In: BMC Psychiatry, ISSN 1471-244X, E-ISSN 1471-244X, Vol. 11, no 1, 47- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Suicide among young people is a global public health problem, but adequate information on determinants of suicidal expression is lacking in middle and low income countries. Young people in transitional economies are vulnerable to psychosocial stressors and suicidal expressions. This study explores the suicidal expressions and their determinants among high school students in Cambodia, with specific focus on gender differences.

METHODS: A sample of 320 young people, consisting of 153 boys and 167 girls between 15-18 years of age, was randomly selected from two high schools in Cambodia. Their self-reported suicidal expressions, mental health problems, life-skills dimensions, and exposure to suicidal behavior in others were measured using the Youth Self-Report (YSR), Life-Skills Development Scale (LSDS)-Adolescent Form, and Attitude Towards Suicide (ATTS) questionnaires.

RESULTS: Suicidal plans were reported more often by teenage boys than teenage girls (M=17.3%, F=5.6%, p=0.001), whereas girls reported more attempts (M=0.6%, F=7.8%, p=0.012). Young men scored significantly higher on rule-breaking behavior than young women (p=0.001), whereas young women scored higher on anxious/depression (p=0.000), withdrawn/depression (p=0.002), somatic complaints (p=0.034), social problems (p=0.006), and internalizing syndrome (p=0.000). Young men exposed to suicide had significantly higher scores for internalizing syndrome compared to those unexposed (p=0.001), while young women exposed to suicide scored significantly higher on both internalizing (p=0.001) and externalizing syndromes (p=0.012). Any type of exposure to suicidal expressions increased the risk for own suicidal expressions in both genders (OR=2.04, 95% CI=1.06-3.91); among young women, however, those exposed to suicide among friends and partners were at greater risk for the serious suicidal expressions (OR=2.79, 95% CI=1.00-7.74). Life skills dimension scores inversely correlated with externalizing syndrome in young men (p=0.026) and internalizing syndrome in young women (p=0.001).

CONCLUSIONS: The significant gender differences in suicidal expressions and their determinants in Cambodian teenagers highlight the importance of culturally appropriate and gender-specific suicide prevention programs. School-based life skills promotion may indirectly influence the determinants for suicidal expressions, particularly among young women with internalizing syndrome in Cambodia.

Place, publisher, year, edition, pages
BioMed Central, 2011
Keyword
mental-health; general-population; adolescent suicide; youth; risk; ideation; prevention; nicaragua; behaviors; children
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-41655 (URN)10.1186/1471-244X-11-47 (DOI)000289351600001 ()21418649 (PubMedID)
Available from: 2011-03-30 Created: 2011-03-30 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. ‘Plue plun’ male, ‘kath klei’ female: gender differences in suicidal behavior as expressed by young people in Cambodia
Open this publication in new window or tab >>‘Plue plun’ male, ‘kath klei’ female: gender differences in suicidal behavior as expressed by young people in Cambodia
2014 (English)In: International Journal of Culture and Mental Health, ISSN 1754-2863, E-ISSN 1754-2871, Vol. 7, no 3, 326-338 p.Article in journal (Refereed) Published
Abstract [en]

Few studies from low- and middle-income countries use qualitative methodologyto explore suicidal behavior among young people. In Cambodia, young peopleface the challenge of rapidly changing times and are vulnerable for suicidalbehavior as revealed by research in transitional economies. This study seeks togain a deeper understanding of the suicidal phenomena from a gender, psychosocialand cultural perspective. Six focus-group discussions were conductedamong boys and girls, aged 15–19 years, in two secondary schools in a suburbanarea close to Phnom Penh, the capital city. The data was analyzed using thematicanalysis approach. The participants highlighted the gender difference in suicidalbehavior by describing the suicide-prone, acting-out male as ‘plue plun’, whilesuicide-prone females were described as caught in constricted, tunneled-thinkingbehavior, expressed as ‘kath klei’. Parental attitude and family environment werealso pointed out as the chief causes of discontent and there was a strong wish onthe part of young people to find space for modern values within the traditionalfamily. The young people’s awareness of their challenges in everyday life suggeststhat school-based programs to prevent suicidal behavior ought to be gendersensitiveand peer-focused.

Place, publisher, year, edition, pages
Taylor & Francis, 2014
Keyword
young people, focus-group discussion, suicidal behaviour, Cambodia
National Category
Psychiatry Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-83539 (URN)10.1080/17542863.2013.800568 (DOI)
Available from: 2013-12-02 Created: 2013-12-02 Last updated: 2017-12-06Bibliographically approved
4. Religion, culture, media and their impact on suicide in the eyes of young people in Cambodia
Open this publication in new window or tab >>Religion, culture, media and their impact on suicide in the eyes of young people in Cambodia
(English)Manuscript (preprint) (Other academic)
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-87803 (URN)
Available from: 2014-04-10 Created: 2014-04-10 Last updated: 2015-04-29Bibliographically approved
5. Outcome of a school-based intervention to promote life-skills amongyoung people in Cambodia
Open this publication in new window or tab >>Outcome of a school-based intervention to promote life-skills amongyoung people in Cambodia
2014 (English)In: Asian Journal of Psychiatry, ISSN 1876-2018Article in journal (Refereed) In press
Abstract [en]

Background Most of the school-based interventions to prevent suicide are from high income countries and there is a need for evidence based interventions in resource-poor settings. The aim of this study is to evaluate the outcome of a school based intervention to reduce risk factors for suicide among young people in Cambodia by promoting life skills.

Method Six classes were randomly selected from two schools each, one designated as experimental and the other as control school, respectively. In experimental school 168 young people (M = 92, F = 76) received 6 sessions of life skills education and in the control school 131 students (M = 53, F = 78) received three general sessions on health. We looked at the pre-post differences on Life-Skills Development Scale Adolescent Form (LSDS-AF)- and Youth Self-Report (YSR) questionnaire to measure the effect size (ES) from the intervention after 6 months. We analyzed the data by stratifying for gender and for those who reported more severe suicidal expressions at baseline (high-risk group).

Results The girls showed improvement in Human Relationship (ES = 0.57), Health Maintenance (ES = 0.20) and the Total Life Skills Dimensions (ES = 0.24), whereas boys with high-risk behavior improved on Human Relationship (ES = 0.48), Purpose in Life (ES = 0.26) and Total Life Skills Dimensions (ES = 0.22). Effect size for YSR-syndrome scores among all individuals showed no improvement for either gender. Among high-risk individuals boys had a small to moderate effect size from intervention on Withdrawn/Depressed (ES = 0.40), Attention problems (ES = 0.46), Rule breaking behavior (ES = 0.36), Aggressive behavior (ES = 0.48) and Externalizing syndrome (ES = 0.64).

Conclusion Promoting life skills in schools may enhance the overall mental health of young people, indirectly influencing suicide, particularly among boys with high-risk behavior in Cambodia.

Keyword
Outcome; School based intervention; Life skills; Cambodia
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-88194 (URN)10.1016/j.ajp.2014.01.011 (DOI)
Available from: 2014-04-25 Created: 2014-04-25 Last updated: 2015-04-29Bibliographically approved

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