Thesis/yousuf/MPH/2006
Attitudes towards suicidal behaviour among
adolescents in Bangladesh
Dr. Ma Yousuf Bhuiyan
Thesis: 20 Points
Master’s in Public Health
Session: 2005/2006
Supervisor
Gunnar Kullgren, MD, PhD
Professor Division of psychiatry
Head of the Dept of Clinical Sciences
Umeå University
SE-901 85 Umeå; Sweden
Umea International School of Public school
DEPARTMENT OF PUBLIC HEALTH AND CLINICAL MEDICINE
UMEÅ UNIVERSITY, UMEÅ, SWEDEN
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Thesis/yousuf/MPH/2006
Abstract
BACKGROUND: The growing incidence of suicide behaviour among adolescents has
heightened awareness for need of prevention. Suicide was the fifth most common
cause of death overall and ranked number one among adolescents in the world.
Attitudes towards suicide represent a keystone in understanding and preventing
suicides
OBJECTIVES: To adapt and validate a questionnaire ATTS regarding suicidal
behaviour among adolescents in Bangladesh and to test its feasibility in this cultural
setting.
METHODS: Focus group discussions in four groups were used to culturally adapt
ATTS to the setting in Bangladesh. In a second step, ATTS was distributed to 96
adolescents aged 15-24 years.
RESULTS: Among the adolescents aged 15-24 years, 5.5 percent of girls and 4.8
percent of boys reported a suicide attempt during recent year. Many were exposed to
suicidal behaviour among significant others: suicidal attempts, expression and
ideation among family members, relatives and friends were 11.62%, 27.81% and
39.58% respectively. On factor analysis, factors similar to those reported from other
countries were obtained. Comparison of factor summary scores between boys and
girls showed few differences and exposure to suicidal behaviour among significant
others did not seem to have an impact on attitudes towards suicidal behaviour.
Focus group discussions revealed several key elements in understanding suicidal
behaviour among adolescents.
CONCLUSIONS: The proportion of boys and girls who reported a suicide attempt
during recent year is lower than found in some US studies but higher than figures
reported from another developing country – Nicaragua. In this pilot study, the
pattern of attitudes was in general similar to what has been reported from European
and Nicaraguan studies and was not markedly influenced by gender or being exposed
to suicidal behaviour among significant others. However, some gender differences
found in the Nicaraguan study was not replicated in Bangladesh. Further analyses
should be performed to identify possible misconceptions and attitudes that might
have a negative influence in prevention of suicidal behaviour among adolescents in
Bangladesh.
Key words: Attitude towards suicide, suicidal behaviour, incidence, Adolescent, prevalence,
committed suicide, exposure, permissiveness.
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Thesis/yousuf/MPH/2006
Introduction
Suicide is becoming a public health concern in many countries among adolescents
(WHO, 2001). The overall suicidal rates in many countries are increased due to high
prevalence in age group 15-24 (Nida.Z and Apolinaras.Z, 2005). Health and demographic
surveillance data were collected from rural and semi-urban sub districts of Jessore in the
southwest Bangladesh, by ICDDR,B during 1983-2002, and it was concluded that in 1019 years old; 61/100,000 were determined to have died from suicide every year. Suicide
was the fifth most common cause of death overall, and ranked number one among
adolescents (ICDDR, B, 2003).
In 1998, ESCAP has shown in their Journal that nearly about 30/100,000 of young adults
80
70
60
50
40
30
20
10
0
Ba
ng
ld
es
h
C
hi
n
ho
ng a
ko
ng
ja
pa
n
Au
st
N
ew ralia
Ze
al
an
si
d
ng
ap
or
e
ko
re
a
mortality / 100,000
every year have committed suicide in rural Bangladesh.
Figure 1: Suicides mortality/ 100,000 of young adults aged 15-24 in selected countries.
ESCAP population journal December 1998
ICDDR,B has conducted a population base study in Matlab, and summarized that
mortality rate by aged group 22-29 are relatively higher, nearly 50/100,000, than any
other group.
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Thesis/yousuf/MPH/2006
Suicide defined as a self-inflicted cause of death, can count up the number three leading
causes of death among 15-44-year old people (WHO, 2001). Over the last several
decades, suicidal rate among young has been increased dramatically (4 HON, 2005). In
1996, suicide was the 3rd leading cause of death in 15 to 24 year-old, and the 4th leading
cause in 10 to 14 year-old in USA (HON, 2005). Suicide is noticeably a serious societal
as well as public health concern in several countries, and areas of the ESCAP region (By
Lado T. Ruzicka, 1998). Indian subcontinent countries have high suicide mortality
among women under 25 years of age which has been widely noted (Lado T. Ruzicka,
1998). Suicide is related with many complex factors. More than 90% of youth suicide
victims have at least one major psychiatric disorder, although suicidal victims among
adolescents have lower rates of psychopathology (Gould MS et al, 2003).
60
mortality/100,000
50
40
male
30
female
20
10
0
10--19 20--29 30--39 40--49 50--59
60-
age group
Figure 2: mortality / 100,000 due to suicide by age and gender, source: ICDDR,B
In September 2005, WHO, regional office for south East Asia has published, a “Suicide
Prevention: Emerging from Darkness” .In Bangladesh part, they overviewed that an
average of 600 suicide per month during 1972-1988, the number of suicides have been
increased to 984 per month during 1992-1993. The total number of suicides reported to
the Forensic Medicine Department of Dhaka Medical College indicated that committed
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Thesis/yousuf/MPH/2006
suicides have been increased from 12 per month in 1989 to 18 per month in 1998. On an
average, 15% of the total number of autopsies has been associated with suicides
(Yogeeta, 2005).
One study has been conducted by ICCRD,B in Matlab from 1980-1996 has shown that
suicidal death is more common in adolescence, and prevalence rate is higher in female
then male.
s u ic id a l m o r t a lit y o f y o u n g a d u lt s a g e d
B a n g la d e s h f r o m 1 9 8 0 -1 9 9 6
1 5 - 2 4 in
m a le
3 2 %
f e m a le
6 8 %
Figure 3: suicide mortality/100,000 in Bangladesh from 1980-1996
Source: ESCAP population journal December 1998
In 1998, ESCAP has cited in their report that from 1980 to 1996 suicidal rate of female
and male was 68% and 32% respectively, and prevalence almost twice in female than
male.
Previous study from Matlab has shown that suicidal prevalence age group between 10-29
was higher than any other group, and prevalence rate in male and female were 63.85%
and 82,68% respectively.
Suicidal behavior
It is important to distinguish between completed suicides and other suicidal behaviors;
risk factors and risk groups differ. However, suicidal behavior remains the strongest
single risk factor for completed suicide and it represents a logic target in suicide
prevention.
It seems that suicidal tendencies were quite frequent among adolescents in general
population. Main components of suicidal behaviour or suicidal expression are suicidal
ideation, serious plans how to commit suicide, and reported suicide attempts (Ivarsson.T
and Gillberg.C ; 1997). Suicidal behavior in children and adolescents are, usually, a sign
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Thesis/yousuf/MPH/2006
of mental disorder, most often depression (HON, 2005). In Nicaragua, the prevalence of
suicidal expression was 44.8% and 47.4% in men and women respectively (Herrera et al,
2006). Suicidal expressions were found to be associated with having friends who had
made a suicide attempt (HON, 2005) and it appears to be an important factor to identify
suicidal behavior.
Suicidal thoughts are also extremely common in young people. About 16% of females
aged 12 to 16 years reported having suicidal thoughts in the previous six months (Youth
suicidal behavior, 2004). One Swedish study has shown that 4.3% of boys reported
having suicidal ideation and 3.6 % were girls (Fevziye Toros et al 2004).
The prevalence of suicidal attempts as reported in Turkey among children and
adolescents were 1.93% (Fevziye Toros et al 2004). Dysfunctional families, absent
fathers and lack of integration into society were some of the structuring conditions that
lead to emotional distress. Abuse, deaths in the family, break-up with boyfriends or
suicide among friends acted as triggering events for suicidal attempt (Herrera et al
2006b).
Suicidal behavior is increasingly becoming a phenomenon associated with young people,
and a significant public health issue in Bangladesh. However, there are very few studies
that have been carried out evaluating the impact of young attitudes towards the suicide
and suicidal behaviors. The current study is a pilot study to prepare for a community
based study that will be performed in a second step.
Structure
Suicidal behavior is a heterogeneous problem and represents a certain form of
communication. It is often a consequence of the ‘cry for help’ as an authentic expression
as well as an effort to find out a solution for simultaneously unbearable and unchangeable
life situation. Attempted suicides constitute a pool from which many of the future
suicides will be drawn, and cases for direct prevention efforts should come from this
group of pre-suicidal individuals. Figure 4 presents some background factors and
triggering factors for suicidal behaviour reported in the literature.
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Thesis/yousuf/MPH/2006
Factors and process
Socio-economic factors
Behavior
Economics crisis
Gender Inequity
Social support
Education
Culture
Social Security
Tobacco
Alcohol
Gender
Traffic-drug, culture, media
Physical inactivity
Isolation
Family support
Broken family
Education of Parents
Family members
Step mother/ father
Religious
House hold condition
Relation of close friends
Relation of partners
Triggering factors
Stress, Depression, sexual and drug abuse, violence, Mental pressure,
Suicidal Behaviour
Suicidal
ideation
Suicidal
thoughts
Suicidal plan
Suicidal
attempts
Committed
Suicide
Figure 4: Suicidal process
Socio economic characteristics
High rates of attempted suicide occur among those of who have lower socioeconomic
status (Holding et al 1977). Many people who commit suicide, especially men, are
unemployed. The behaviour is more common in urban areas and also in areas of social
deprivation and overcrowding (Skimshire, 1976)
Gender perspective and suicidal behavior
A comparison Swedish study has shown that female gender and young age are risk
factors for self reported suicidal behaviors
7
(Salander RE,1996; Moscicki E, 1994).
Thesis/yousuf/MPH/2006
Regarding attitudes towards suicidal behaviour, gender specific patterns have been
identified. For example, women are less likely to hold a permissive attitude towards
suicide (Renberg & Jacobsson, 2003).
An important but often neglected aspect of the problem of attempted suicide concerns the
attitudes shown by people towards the behavior. The attitudes of relatives and friends, on
whom the behavior is liable to impinge most severely, will determine their response to
the behavior. One study in Nicaragua has shown that women’s attitudes towards suicide
were more oriented towards preventability (Herrera et al 2006).
Objectives
General Objectives
The overall aim of the current study was to develop and to validate a questionnaire that
will be used in future studies on suicidal behavior among adolescents in Bangladesh.
Specific objectives
•
To adapt and further develop a questionnaire on attitudes and experience of
suicidal behavior that has been used in other countries to fit with the cultural
setting of Bangladesh.
•
To test the properties of the instrument in a sample of adolescents in Bangladesh
•
To get some basic information from focus group discussions to understand how
suicidal behaviour is perceived by adolescents in Bangladesh.
The setting
Mirpur Thana (dhaka district) with an area of 53.58 sq km, is bounded by pallabi thana
on the north, mohammadpur thana on the south, kafrul and Pallabi thanas on the east and
savar upazila on the west. Main river is Turag. Mirpur area is an extended part of the
Madhupurgarh created in the Pleistocene period. Mirpur thana was established in 1962.
The thana consists of one union parishad, eight wards, 11 mouzas and 86 and 20 villages.
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Thesis/yousuf/MPH/2006
Mirpur Thana (Town) area was included in keraniganj thana during the British period and
in tejgaon thana during the Pakistan period. Many administrative and cultural
establishments including National Zoo, National Botanical Garden, National Vagabond
Shelter Centre are located in this thana area. National Martyr Intellectual Memorial has
been established at the premises of the graves of martyr intellectuals. The tomb of Hazrat
Shah Ali Bagdadi (R), a sacred place and historical relic, is located at Mirpur. Besides,
the head offices of grameen bank, bangladesh institute of bank management, Dhaka Eye
Hospital, National Heart Foundation, etc are located here (15)
Study Site: Mirpur, 555,758, population, Dhaka, Bangladesh
Population 555,758; male 56.75%, female 43.25%; Muslim 98.42%, Hindu 1.07% and
others 0.51%. Average literacy is 59.4%; male 65.4% and female 52.2%.
Literacy and educational institutions
Average literacy is 59.4%; male 65.4% and female 52.2%. Educational institutions:
college 8, high school 20, school and college 6, madrasa 16, private medical college and
hospital 3, primary school 47, vocational training institute 3. Cultural organisations Club
23, literary society 4, cultural centre 3, cinema hall 5, museum 1, zoo 1, botanical garden
(15)
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Thesis/yousuf/MPH/2006
Method
Design
The study was performed in three steps. Firstly, the ATTS instrument was translated into
Bangla and re-translated into English and again translated into Bangla.
Secondly, group of adolescents aged 15-24 years from 4 schools in the study area were
invited as a “focus group” for discussion, where the item used in the instrument have
been discussed. The purpose was to adapt language and expressions to fit with the
adolescent culture in this setting. An additional purpose was to get a basis for
understanding adolescents’ views on suicidal behaviour. For focus group discussions,
four groups were selected from four schools with pupils aged 15 to 24 years and 10 -12
students in each group with an equal number of boys and girls.
Thirdly, a convenience sample of 96 adolescents aged 15-24 years from another 4 schools
in the same study area were selected for a pilot study. In collaboration with school
headmasters and class teacher’s, 10-12 students have been selected from each school, and
invited to answer the questionnaire. Only age and gender were included as sociodemographic factors and the questionnaire study has been anonymous without any
possibility to identify any single student.
Instrument
The “Attitudes Towards Suicide” (ATTS) questionnaire was developed to attempt to
measure attitudes towards suicide in longitudinal large-scale surveys in the general
population in Sweden in 1986 and 1996. Psychometric properties of the instrument have
been reported in a previous paper (Renberg & Jacobsson, 2003).
The instrument consists of three main sections: first, contact with suicidal problems
(ideation, threats, attempted and completed suicide) among significant others; second,
attitudes covering multidimensional attitude areas (37 items); and third, own life
satisfaction and suicidal behaviour.
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Thesis/yousuf/MPH/2006
The questionnaire includes some questions on suicidal behaviour as presented by Paykel
and colleagues in a previous paper (Paykel E et al., 1974).
In the present study, a brief version of the instrument ATTS was used; among selfreported suicidal behaviour only items on a suicide attempt during previous year was
used and among attitudes only a core set of attitude items in the form of statements were
used. Attitude statements were scored by respondents on a scale from 1= Strongly
disagree to 5= Strongly agree.
Mirpur thana:
colleges 8, high
schools 20 & 2
university
8 schools, 1
collage and 1
university
(cluster
4 schools for
discussion & 4 school,
1 college and
university for interview
55 girls and 41
boys (cluster
sampling) total
sample
Analysis
All analyses were carried out by using SPSS version 13.0. Statistical analyses included
chi-square tests were used for the comparisons of distribution. Factor analysis was
performed by using principle component analysis with Varimax rotation. Reliability,
internal consistency of the instrument was assessed by Cronbach’s alpha. T-tests were
used to analyses of differences in mean score on factors and single items. Factor analysis
was chosen as one method to allow for comparison with previous studies done with the
ATTS instrument in Sweden and Nicaragua.
The focus group discussions were audio/video-taped and the author (MYB) lead the
discussions. Some attitude items in the ATTS were chosen to stimulate discussions
among the participants. The recorded material was then analysed to identify key
problems and experiences the participants had had related to these problems.
Ethical consideration
The study protocol and an accompanying letter were submitted to the headmasters of
schools involved and the principal of college to get permission for discussion and
interview. Counseling, if needed, was offered by help of class teacher and local
volunteers. A brochure with information has been prepared on how to get help for
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Thesis/yousuf/MPH/2006
suicidal problems. Screening or suicidal problems among adolescents has been widely
used in research and is considered a safe procedure.
Results
From the focus group discussions
Firstly, the ATTS questionnaire and the attitude items were presented to the adolescents
in order to revise phrasing of statements and questions. Several comments were made.
For example the use of the word “partner” was not a culturally acceptable concept.
Living with someone without being married is not acceptable in Bangladesh.
Furthermore, the expression “Suicide is a cry for help” was not fully understood by the
adolescents.
From the discussions several themes of importance for suicidal behaviour emerged as
presented in Table 1.
Table 1: Results from focus group discussions
Problems
Teenage love
-Parents disagree to establishment
-Unwanted pregnancy
Implications for mental health
leading towards suicide
-Depression
-Emotional distress
Sexual violence
-Social insecurity
-Unwanted pregnancy
-Isolation from family members
and society
-Depression
-Emotional distress
-Addiction
-Hopelessness
Unexpected
academic results
-Isolation from family members
and society
-feeling of guilty
-Decline in social status
-Persistent insecurity,
-Feeling of discrimination
-Social instability
-Addiction to cannabis, heroin
-Stress,
-Hopelessness
-Addiction
-Emotional distress
-Depression
-Anger and hostility
-Hopelessness
-Cannabis psychosis
Low socioeconomic
status and
unemployment
Religious
12
Experiences
-Perceived injustice
-Restriction to move freely
and to express their opinion
-Mental instability
-Emotional distress
-Anger
-Loss of autonomy
Thesis/yousuf/MPH/2006
a number of brother
and sister
-Persistent quarrel,
-Feeling of discrimination
-Family disharmony
Dowry
-Domestic violence
-Shame, helplessness,
humiliation
-Depression
Social isolation
-Restricted opportunities
-Broken social and cultural ties
-Hopelessness, disappointment,
and demoralization
-Addictions
“ Bokhate chelae”
-Feeling of discrimination
-social Insecurity
-financial crisis
-Helplessness, humiliation
-Depression
-addiction
-Emotional distress
-Depression
-Anger and hostility
-Addiction-boys
From the questionnaire study
Table 2: Gender specific social demographic characteristics among responders
Variables
Sex
Age group*
15-19
20-24
Total
Level of education
9-10 years
11-12 years
>13 years
Total
Gender
Total
N %
Male
N %
41 (43.7)
Female
N %
55(56.2)
96(100)
23(54.7)
19(45.2)
41(100)
41(76.3)
13(23.6)
55(100)
64(66.6)
32(33.3)
96(100)
22(52.3)
11(26.1)
9(21.4)
41(100)
25(46.2)
15(27.7)
14(25.9)
55(100)
47(48.9)
25(26.0)
24(25.0)
96(100)
(* Age group in sex x2=4.7602, df=1, p=.024 (95% CI),
In table 2, social demographic characteristics of the responding group are presented.
During the study period (January-February 2006), 96 set of questionnaire were completed
by 96 responders. Significance gender differences were found in both age group 15-19
years and 20-24 years. Among responders, there were more girls than boys, and their
mean age was 18.3 years and 19.6 years, respectively.
Figure 5: Suicidal behavior among family members, relatives and friends during
recent year as reported by responders.
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Thesis/yousuf/MPH/2006
C
u
rr
en
t
id
ea
tio
n
% of
re sponde
rs
Female
A
tt
em
p
t
45
40
35
30
25
20
15
10
5
0
S
u
ic
id
a
le
x
p
re
s
si
on
Suicidal behavior among family,
relatives and friends
male
As shown in Figure 5, boys have reported that 16.6% of significant others having suicidal
attempt which is twice as high as among girls (7.3%). Regarding suicidal expression
among significant others, girls and boys reported 25.4% and 30.9% respectively, and in
current ideation, boys 39.1% quite the same as girls 40.0%.
Table 3: Obtained factors, explained variance, factor-loading and internal consistency
(Cronbach’s alpha) for the 25 items.
Group
1. Permissiveness
2. Indecisiveness
3. Incomprehensibility
4.Non-communication
5. Responsibility to
prevent
14
Factors
atts37 People should have the right to commit
suicide
atts27 Committed suicide is one’s own business
atts19 Sometimes only solution is suicide
atts8 Suicide should be accepted as a solution to
end an incurable disease
atts25 Suicide happens without previous
warning
atts31 Relatives usually get no warning when a
person is thinking about suicide
atts26 People avoid talking about suicide
atts16 One should not talk about suicide
atts34 anybody can commit suicide
atts22 Suicide among younger people is
incomprehensible
atts11 People who committed suicide are
usually mentally ill
atts15 People who make suicidal threats seldom
complete suicide
Atts36 People who talk about suicide do not
commit suicide
atts12 It is a human duty to try to stop
someone from committing suicide
atts29 A suicide attempts is actually cry for help
atts33 I am prepared to help a person in a
Factors
loading
.553
Explained
Variances
*Internal
consiste
ncy
13.1%
.425
12.0%
.295
10.0%
.472
8.7%
.128
7.1%
.222
.410
.694
.720
.646
.925
.680
.692
.811
.448
.842
.732
-.736
.993
.776
.766
Thesis/yousuf/MPH/2006
6. Preventability
7. Relation-caused
8. Suicidal process
(duration)
suicidal crisis
atts4 You can always help a person who
has suicidal thoughts
atts9 Once a person has made up his mind
about committing suicide no one can stop
him/her
atts40 Suicide can be prevented
.541
6.3%
.205
6.0%
.411
5.0%
.390
.733
-.605
atts38 Most suicide attempts caused by
inter-personal conflicts
atts10 Many suicidal attempts are made
because of revenge or punish someone
atts17 Loneliness is a reason for suicide
.563
.955
.819
atts7 Most suicide attempts are impulsive
actions
atts24 Once a person has suicidal
thoughts, they will never let them go
.884
.330
The explained variance for all eight factors was 68.0% and overall internal consistency
.645.
Table 4: Mean summary scores on the 8 attitude factors as related to gender
Factors
permissiveness
Indecisiveness
Gender
Male
N
Mean
Std. Deviation
41
9.00
4.01
Female
55
8.61
2.73
Male
41
6.80
1.83
Female
55
6.36
1.94
41
10.31
2.82
55
10.21
2.60
Incomprehensibility Male
Female
Non-communication Male
.58
.26
.85
40
5.17
2.06
Female
55
5.89
2.05
Responsibility to
prevent
Male
41
6.75
1.59
55
7.10
1.49
Preventability
Male
40
4.85
1.91
Female
55
4.36
1.97
Male
41
6.48
1.69
Female
55
6.89
1.71
Male
41
8.78
2.23
Female
55
9.78
1.82
Relation-cause
Suicidal process
Female
t-test P
.09
.26
.23
.25
.01
When factor scores were compared between men and women, the only factor that
differed between genders was Suicidal process where women scored higher.
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Thesis/yousuf/MPH/2006
Table 5: Mean summary scores on the 8 attitude factors as related to exposure with
suicidal attempts
Factors
Permissiveness
Indecisiveness
Incomprehensibility
Non-communication
Responsibility to
Prevent
Preventability
Relation cause
Suicidal process
Exposure to an
attempt among
others
No
N
Mean
Std. Deviation
t-test P
83
8.63
3.34
.29
yes
13
9.69
3.19
No
83
6.65
1.91
Yes
13
5.92
1.75
No
83
10.24
2.77
Yes
13
10.38
2.14
No
82
5.51
2.08
Yes
13
6.07
2.06
83
6.93
1.57
Yes
13
7.07
1.38
No
82
4.46
2.00
Yes
13
5.23
1.53
No
83
6.66
1.74
Yes
13
7.07
1.49
No
83
9.36
2.03
Yes
13
9.30
2.25
.85
.36
.76
No
.19
.41
.37
.93
Exposure to suicidal attempts among significant others has been described in table 5. The
results seem to show that having been exposed to suicidal behaviour among significant
other do not influence attitudes.
Discussion
This study is the first attempt to measure attitudes towards suicide in Bangladesh. The
purpose of the present study was mainly to adapt the instrument to the cultural setting in
Bangladesh and give some first impression of patterns of attitudes. Overall, the pattern
was fairly similar to findings from Europe and Nicaragua (Rengerg & Jacobsson, 2003;
Herrera et al. 2006).
Suicidal behavior among adolescent in Bangladesh associated with many factors. Teen
age love, sexual violence, unexpected academic results, unwanted pregnancy, low
socioeconomic status and dowry are the main causes attempted suicide among adolescent
16
Thesis/yousuf/MPH/2006
in Bangladesh. Economic causes such as landlessness, pauperizations, and unemployment
have increased the stress and tension in parents-children relations in the poor households,
and giving rise to Emotional distress, Depression, Anger and hostility, Hopelessness and
addiction leads adolescent attempted suicide.
The emergence of dowry is more due to avarice and commercialization of marriage than
the impact of traditional culture. Rising unemployment has been contributed to the
phenomenon to demand dowry as a source of income (human rights watch, 2002).
Prospective grooms and their families demand large sums of money or property from the
bride’s family as a precondition to the marriage agreement. Although dowry demand is
illegal, and this practice persists only in the rural communities. In fact, very few
marriages in the rural areas are performed without a dowry. In most cases, the complete
dowry is not been paid at the time of marriage. The bride’s family would like to pay part
of the dowry before the marriage, and they promise to pay the rest as early as they can.
When the bride’s families fail to meet the deadline, her husband or in-laws abuse her
verbally and physically to compel her family to pay, and women feel shameless and
depression which leads her attempted or committed suicide.
Even though the evaluation of attitudes is more complex than the expression of
agreement or disagreement with a set of statements, a standardized way of measuring this
phenomenon enables useful cross-cultural comparisons (Oppenheim AN, 1992). The
eight factorial sub-scales, altogether, seem to cover the extension of what is understood
as attitude in its effectiveness, permissiveness and behavioral components as well as
preventability and relation-cause factors.
Committed Suicide, attempted suicide, and thoughts of committing suicide are, as of the
early 2006s, substantial problems among adolescents in the Bangladesh, as it is in much
of the world. It is the 5th leading cause of death among 15 to 19 year olds in the
Bangladesh and the sixth leading cause of death among 10 to 14 year olds. In our study,
we found that 5.5 percent of girls and 4.8 percent of boys report a suicide attempt suicide
each year in the Bangladesh, which is relatively high in comparison to Nicaragua, boys
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Thesis/yousuf/MPH/2006
and girls 2.1% and 1.5% respectively (Herrera et al, 2005). Bangladesh is considered
high Epidemic place for committing suicide (WHO, 2004).
In 2005, Goldstein TR et al conducted a study related with bipolar disorder and
summarized that suicidal Attempters were probably have a lifetime history of comorbid
substance use disorder, panic disorder, non-suicidal self-injurious behavior, family
history of suicide attempt, and also concluded that children and adolescents with bipolar
disorder exhibit high rates of suicidal behavior (Goldstein TR eat al,2005), In our study,
we found that suicidal attempts, expression and ideation among family members,
relatives and friends are 11.62%, 27.81% and 39.58% respectively. Suicidal expressions
is significantly associated with suicidal expression among friends, and young people with
a friend who had attempted suicide were three to six times more likely to attempts suicide
themselves (Kirmayer LJ et al, 1996). Due to small numbers in our study, it was not
possible to examine whether exposure to suicidal behaviour among significant others was
associated with increased report of own suicidal behaviour.
The impact of demographic factors on suicidal behavior among adolescent appears to be
some importance in different studies. One study conducted in Latvia found that lower
level of education, urban residency were identified risk factors for suicidal behaviour in
both genders ( Rancas et al, 2003). Risk of suicidal behaviour was reported consistency
high in young women, individuals with low level of education and lacking of stable
relationship (Kessler R.C, et al, 2005). In our study, we were not looking for any
association between SES and Suicidal Behaviour. We would intend to formulate it in our
next study.
Concerning reliability, an overall internal consistency of .645 was good for the whole
instruments as compared with the Swedish study .60 (Renberg & Jacobsson, 2003) and
Nicaragua .46 (Herrera et al 2005). Although, some individual factors are considerably
low. Possible causes of these results are small number of samples, in view of the fact that
internal consistency is increased due to the number of items on each factor (Guilford,
1954).
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The factor analysis yielded 8 factors. Factor one “Permissiveness” turned out the
strongest in our study as in the Nicaraguan study (Herrera et al. 2006). Considering the
mean item score of the items in the factor it was almost exactly the same as in both
countries. However, the items in factor six “Preventability” scored much higher in the
Nicaraguan study where adolescents were more likely to consider suicide as preventable.
In Nicaragua, girls were more likely to emphasize preventability and less likely to
consider suicide as incomprehensible as boys. In our study, the only gender difference
emerged on factor eight where girls more likely than boys to think that the suicidal
process is difficult to stop. Even though these findings must be cautiously interpreted,
they might indicate an opposite gender pattern between Nicaragua and Bangladesh.
The present study has several limitations; sample size is too small to allow for analyses
regarding the association between self-report suicide attempts and attitudes or exposure
to suicidal behaviour among significant others. In this first report, we have not analysed
level of agreement to specific items or clusters of items, which should be a natural next
step in order to get a further understanding of adolescents’ view on suicidal behaviour.
However, the overall aim was to test the feasibility of the ATTS in Bangladesh and
further studies should preferably be community based with a larger sample.
Acknowledgments
This project was funded by department of psychiatric, clinical science, Umea University,
Sweden. I would like to confer my earnest thanks to my illustrious supervisor, Gunnar
Kullgren for his incisive support and invaluable guidance, extraordinary dedication in
providing administrative and financial support for this project. I would like to give
special thanks to Kjerstin Dahlblom and my closet friend Dr Mohammad Farhad Uddin.
I would be grateful to Karin Johansson and Birgitta for their generous help, support,
which give me certainty to stay in Umea. I am particularly grateful to Nils-Göran
Lundström for his helping to get me admission in MPH program, and develop my interest
to work on epidemiology.
I express propound my gratitude to my wife for her extraordinary and comprehensive
understanding and supporting for my study in Umea. I will remain forever in her debt,
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Thesis/yousuf/MPH/2006
which give me strong promotion in this work. I will reciprocate her through my hard
working in future.
I am particularly grateful for the guidance in Bangladesh to Dr. A.K.M Fazlur Rahman,
Executive director, Center for Injury Prevention and Research in Bangladesh. I would
like to especially recognize and thank Anders Emmelin, Director of MPH program for
administrative support for this project. Valuable help in initiating and conducting this
study was provided by the following individuals:
Head masters name:
1. Hafiz uddin
2. Mr malik
3. Abdur razzak
Most especially, I want to give thank the two volunteers Faisal abedin Tanim and Rajib
who work with me to carry out field study perfectly.
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Thesis/yousuf/MPH/2006
References
Alem A, Kebede D, Kullgren G. 1999, The prevalence and socio-demographic correlates
of khat chewing in Butajira, Ethiopia.. Acta Psychiatrica Scandinavica Supplementum.;
397:84-91
Breiman R and Thorpe P, Mortality Due to Suicide in Rural Bangladesh, Health and
Science Bulletin Vol. 1 No. 5 December 2003.ICDDR, B
Cynthia B. Lloyd, Facts about Adolescents from the Demography and health survey,
statistical Tables for program Bangladesh 1996-1997, 10-14
Fevziye Toros, Nursel Gamisz Bilgin, Tayyar Sasmaz, Resul Bugdayci, and Handan.
2004, Suicide Attempts and Risk Factors among adolescence; Yonsei Medical Journal;
vol 45, No 3, 367-374,.
Goldstein TR, Birmaher B, Axelson D, Ryan ND, Strober MA, Gill MK, Valeri S,
Chiappetta L, Leonard H, Hunt J, Bridge JA, Brent DA, Keller M. 2005; History of
suicide attempts in pediatric bipolar disorder: factors associated with increased risk.
Bipolar Disorder. Dec;7(6):525-35.
Gould MS, Greenberg T, Velting DM, Shaffer D. 2003. Youth Suicide Risk and
Preventive Interventions: A review of the past 10 years. Journal of the American
Academy of Child and Adolescent Psychiatry. Apr; 42(4):386-405.
Guilford, J.P.,1954, Psychometric methods, 2nd edition. New york, McGraw-hill.(9)120132
Herrera A, Dahlblom K, Dahlgren L and Kullgren G, 2006. Escape or problem solving?
Pathways to suicidal behaviour among adolescent girls in Nicaragua. Social science &
medicine, 2006 Feb;62(4):805-14. Epub 2005 Aug 11.
Herrera A. Caldera T, Kullgren G and Salander Renberg E. 2006, Suicidal expression
among young people in Nicaragua- a community based study. Submitted for publication.
Herrera A. Caldera T, Kullgren G, Pëna R and Salander Renberg E. 2005, Attitudes
towards suicide (ATTS) among young population in Nicaragua, Submitted for
publication.
Holding T, 1974, The BBC Befriends series and its effects. British Journal of Psychiatry
124, 470-2.
HON, Mother & Child Glossary, Childhood Mental Health Suicidal Behavior,
http://www.hon.ch/Dossier/MotherChild/child_mentalhealth/mentalhealth_suicide.html
Human Rights Watch, Reports 2002, The Annual Report on violence against women in
Bangladesh; http://www.hrw.org/doc?t=asia&c=bangla
Internet, encyclopedia, 2005, mirpur, Dhaka.
Ivarsson.T and Gillberg.C ; 1997, Depressive symptoms in Swedish adolescents;
normative data using the Burleson Depression Self rating Scale ( DSRS). Journal of
Affective Disorders. Jan; 42(1):59-68.
21
Thesis/yousuf/MPH/2006
Kirmayer LJ, Malus M, Boothroyd LJ; 1996, Suicide attempts among Inuit youth: a
community survey of prevalence and risk factors. Acta Psychiatrica Scandinavica
Supplementum. 1 Jul;94(1):8-17.
Lado T. Ruzicka, 1998, Suicide in Countries and Areas of the ESCAP region, AsiaPacific Journal Vol.13, No.4, December.
Moscicki E, 1994, Gender differences in completed and attempt suicides. Annals of
Epidemiology, 4, 1198-1200
Nida Zemaitiene and Apolinaras Zaborskis, 2005, Suicidal tendencies and attitude
towards freedom to choose suicide among Lithuanian schoolchildren: results from three
cross-sectional studies in 1994, 1998, and 2002; BMC Public Health, Aug 11;5:83.
Oppenheim AN. 1992; Questionnaire design, interviewing and attitude measurement.
London: Printer Publishers, 303 p.
Paykel ES, Myers JK, Lindenthal JJ, Tanner J, 1974, Suicidal feelings in the general
population: a prevalence study, British Journal of Psychiatry. May; 124(0):460-9.
Rancas, E., Lapins,J., Salander Renberg,E.,Jacobsson,L.,2003, Self reported suicidal and
help seeking behaviour in the general population in Latvia. Social Psychiatry Psychiatric
Epidemiology, 38(1), 18-26.
Salander Renberg E & Jacobsson L , 2003, Development of a questionnaire on attitudes
towards suicide (ATTS) and its application in a Swedish population. Suicide and Life
Threatening Behaviour. Spring;33(1):52-64.
Ronald C. Kessler, Patricia Berglund, Guilherme Borges, Matthew Nock, Philip S. Wang,
2005; Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States,
1990-1992 to 2001-2003 Journal of the American Medical Association. ; 293:2487-2495.
Salander Renberg E, 2001; Self reported life awareness, death-wishes, suicidal ideation,
suicidal plans and attempts in general population surveys in the north of Sweden 1986
and 1996, Social Psychiatry and Psychiatric Epidemiology. 2001 Sep;36(9):429-36.
Skrimshire, A. M, 1976, A small area analysis of self poisoning and self injury in the
region of oxford, Journal of Biosocial Science 8, 85-112.
UNESCO institute for statistic in Bangladesh,2005.www.uis.unesco.org
WHO,2004,http://www.who.int/mediacentre/news/releases/2004/pr61/en/
World Health Organization: 2001 Background of SUPRE—Prevention of Suicide
Behavior,.http://www.who.int/mental_health/prevention/suicide/background/
Youth suicidal behavior,2005; http://www.nelmh.org/
Yogeeta, 2005, WHO, regional office for south East Asia, Mental Health and Substance
abuse, Suicide Prevention: Emerging from Darkness. September 8, 90-105.
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Appendix
The ATTS questionnaire – abbreviated and revised version
A. Contact with the suicide problem
Initially there are some questions about your experiences of suicide problems in your
closest surroundings. Please mark with a cross the appropriate alternative. (Items are
scored never, some time, often and not applicable).
1. Has any of the following persons (separate items for father/mother, brother/sister,
child, partner, other relatives, friends, work-/schoolmates, others)
a) - made a suicide attempt
b) - expressed suicidal thoughts, plans or treats
2. Is there at this very moment any person in your closest surrounding that you know has
suicidal thoughts? (similar alternatives, items scored no, yes and not applicable)
3. Has any of the following persons committed suicide? (similar alternatives, items scored
no, yes and not applicable)
B. Attitudes
The following questions concern your opinion about suicide. Please mark
with a cross the alternative that you find is in best accordance with your
opinion. There are no rights or wrong answers!
(Items are scored on the following scale: strongly agree, agree, undecided,
disagree, strongly disagree)
4. It is always possible to help a person having suicidal thoughts.
5. Suicide can never be justified.
6. Committing suicide is among the worst thing to do to ones relatives.
7. Most suicide attempts are impulsive actions.
8. Suicide is an acceptable means to terminate an incurable disease.
9. Once a person has made up his/her mind about committing suicide no one can stop him/her
10. Many suicide attempts are made because of revenge or to punish someone else.
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11. People who commit suicide are usually mentally ill.
12. It is a human duty to try to stop someone from committing suicide.
13. When a person commits suicide, it is something that he/she has considered for a long time.
14. There is a risk of evoking suicidal thoughts in a persons mind if you ask about it.
15. People who make suicidal threats seldom complete suicide.
16. Suicide is a subject that one should rather not talk about.
17. Loneliness could for me be a reason to take my life.
18. Almost everyone has at one time or another thought about suicide.
19. There may be situations where the only reasonable resolution is suicide.
20. I could say that I would take my life without actually meaning to do so.
21. Suicide can sometimes be a relief for those involved.
22. Suicides among young people are particularly puzzling since they have everything to live for.
23. I would consider the possibility of taking my life if I were to suffer from a severe, incurable,
disease.
24. A person once they have suicidal thoughts will never let them go.
25. Suicide happens without warning.
26. Most people avoid talking about suicide.
27. If someone wants to commit suicide, it is his or her business and we should not interfere.
28. It is mainly loneliness that drives people to suicide.
29. A suicide attempt is essentially a cry for help.
30. On the whole, I do not understand how people can take their lives.
31. Usually relatives have no idea about what is going on when a person is thinking of suicide.
32. A person suffering from a severe, incurable, disease expressing wishes to die should get help to
do so.
33. I am prepared to help a person in a suicidal crisis by making contact.
34. Anybody can commit suicide.
35. I can understand that people suffering from a severe, incurable, disease commit suicide.
36. People who talk about suicide do not commit suicide.
37. People do have the right to take their own lives.
38. Most suicide attempts are caused by conflicts with a close person.
39. I would like to get help to commit suicide if I were to suffer from a severe, incurable
disease.
40. Suicide can be prevented.
41. Gender
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42. Age
43. Education (-9 years, 10-12 years, 13 years or longer)
44. Have you ever made an attempt to take your own life? Last year and earlier in life on a yes, no
scale, followed by number of attempts
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