Sarfo et al. Middle East Current Psychiatry (2023) 30:68 Middle East Current https://doi.org/10.1186/s43045-023-00343-z Psychiatry RESEARCH Open Access Suicidal behaviours among school-going adolescents in samoa: a secondary analysis of prevalence, protective, and risk factors Jacob Owusu Sarfo1* , Newton Isaac Gbordzoe2, Dean Attigah2, Timothy Pritchard Debrah3, Crescens Osei Bonsu Ofori4 and Paul Obeng1 Abstract Background Suicide has become a major threat to achieving Sustainable Development Goals three and four, especially for school-going adolescents worldwide. As part of efforts to prevent suicide, population-based studies regarding the prevalence and variables that predict suicidal behaviours are required to inform decisions. Despite this realisation, Samoa lacks empirical data on suicidal behaviours among adolescents. We conducted a secondary analysis of the 2017 Global School-based Student Health Survey to examine the prevalence of suicidal behaviours (idea, plan, and attempt) of school-going adolescents in Samoa. Results The prevalence of suicidal ideation, plan, and attempt was 24.1%, 23.8%, and 21.8%, respectively. Also, we found that having understanding parents was an important protective factor against all three suicidal behaviours among Samoan in-school adolescents. Suicidal ideation was predicted by cigarette smoking, having someone who smokes in adolescents’ presence, bullying, loneliness, and worrying about things they could not study. Also, cigarette smoking, bullying, having multiple sexual partners, and worrying increased the risk of having suicidal plans. Again, adolescents’ suicidal attempt was predicted by adolescent truancy, alcohol use, cigarette smoking, being bullied, hav- ing close friends, loneliness, and worry. Conclusions Rather than focusing on the school setting alone, suicide prevention interventions in Samoa should foster interdisciplinary collaborations to help reduce suicide. Keywords Adolescents, Suicidal behaviours, Prevalence, Predictors, Samoa Introduction consistently increases over time [2]. This rate is particu- Suicide accounts for over 700,000 global deaths, almost larly of concern for adolescents due to the vast years of 80% in low- and middle-income countries [48]. Among potential life lost. Among people aged 15 to 29  years, suicide cases recorded annually, adolescent suicide suicide ranks as the fourth most common cause of death [48]. Suicidal behaviours usually involve suicidal ideation, planning, and attempt. Adolescent suicide has been iden- *Correspondence: tified as a serious public health problem in all economies. Jacob Owusu Sarfo In 2020, suicide was the cause of 45,979 fatalities in the jacob.sarfo@ucc.edu.gh 1 Department of Health, Physical Education and Recreation, University USA [7]. of Cape Coast, Cape Coast, Ghana Recent statistics indicate suicide was the second-lead- 2 School of Public Health, University of Ghana, Legon, Ghana 3 ing cause of death in 2020 for people aged 10 to 24 [3]. In Department of Nursing, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana 2017, there were over 1000 suicides among young people 4 Department of Psychology, University of Ghana, Legon, Ghana aged 15 to 19 in the European Union, with boys making © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. Sarfo et al. Middle East Current Psychiatry (2023) 30:68 Page 2 of 11 up most of these deaths. Despite the comparatively low study aims to investigate the occurrence and associated absolute number of adolescent suicides, this age group’s factors of suicidal behaviours among school-going ado- leading cause of death is suicide [24]. Adolescents in low- lescents in Samoa using the most current version of the income and middle-income nations, particularly in Africa GSHS data. and the Western Pacific, and girls aged 15 to 17 are more likely to have suicidal behaviours [44]. In countries like Conceptual framework of adolescent suicide Mozambique, the prevalence of suicidal behaviours was We conceptualised adolescent suicidal behaviours to as follows; ideation (17.7%), plan (19.6%), and attempt be made up of suicidal ideation, plan, and attempt. Our (18.5%) [38]. The prevalence of suicidal behaviours was conceptual framework is based on the risk and protec- also high in Ghana, with a prevalence of ideation (18.2%), tive factors model [12] and literature on correlates of plan (22.5%), and attempt (22.2%) [26]. adolescent suicidal behaviours [4, 13, 26, 36–38]. This According to data from the 2016 State of the World framework proposes that within a specific population, Children (SOWC), adolescents in Samoa make up 22% there are factors that can either decrease (protective fac- of the total population, which is a much larger percent- tors) or increase (risk factors) the likelihood of an ado- age than the 13% regional average for East Asia and the lescent exhibiting any suicidal behaviour [4, 13, 18, 26, Pacific [45]. For the past 20 years, suicide-specific death 27, 36–38]. These explanatory variables included ado- among Samoans has consistently exceeded the world lescent sociodemographic characteristics such as sex, average. While the world average of suicidal deaths as age, and grade. Also, the other factors include personal of 2019 was 9.49 per 100,000 people, that of Samoa was like adolescent truancy at school and hunger, drugs and 12.6 per 100,000, with marked gender differences of 6.7 substance use, and psychosocial characteristics of adoles- per 100,000 for females against 18 per 100,000 for males cents in Samoa. (World Bank, 2022). Adolescents in Samoa have par- In our study, the sex of the participants and their ticularly been identified as a high-risk group for suicidal parental characteristics were conceptualised as protec- behaviours, with the most recent data showing that the tive factors. We also considered personal factors like suicide rate among adolescents aged 15–19 is 18.13 sui- truancy and hunger, drugs and substance use, and other cides per 100,000, also with sex variations of 22.13 per psychosocial factors like bullying and loneliness as risk 100,000 for males and 13.17 per 100,000 for females. factors. These correlates have often provided mixed find- Additionally, the 15–24 years age group were the second ings in similar studies in settings like Bangladesh [22], highest contributor to suicidal deaths in Samoa. Brunei Darussalam [40], Ghana [26], Guatemala [29, 30], Similarly, earlier studies have identified specific pre- Indonesia [22], Indonesia [35], Iran [50], Mozambique dictors associated with an increased risk of suicidal [38], and Tonga [32]. behaviours in low- and middle-income countries. These predictors included food insecurity, bullying, loneliness, Method anxiety, cigarette smoking, and alcohol use [21]. This Design finding is consistent with existing studies but for gender Using 2017 GSHS data, we examined suicide and its cor- disparities in predictors. For example, a survey from 90 relates among school-aged adolescents in Samoa. The countries indicates that being bullied continued to be a WHO repository contains these secondary open data. A key problem for girls,however, having no friends, being self-administered questionnaire was used in the GSHS to bullied, and being physically injured remained signifi- obtain data on young people’s physical, social, and men- cant predictors of suicide attempts in boys [6]. Hunger tal health habits. The GSHS was developed with WHO, and bullying were significant predictors for ideation and Samoa’s Ministry of Health (MoH), and the Centres for attempt, respectively, while the physical attack was asso- Disease Control and Prevention (CDC). A cross-sec- ciated with suicidal ideation, plan and attempt [38]. tional study methodology was used to collect data from Progress towards achieving Sustainable Development WHO member countries interested in reducing teen Goal (SDG) 3.4.2 of reducing the suicide mortality rate suicide. In Samoa, data was collected from school-aged requires that the issue of suicide is tackled. In Samoa, the teenagers aged 13 to 17. previous studies on the prevalence of suicide behaviours among school-going adolescents are alarmingly high [44]. Sampling Many researchers [6, 9, 18, 22] have relied on the Global In the 2017 Samoa GSHS, a two-stage cluster sample School-based Student Health Survey (GSHS) to under- design was used to obtain data representing all students stand the suicidal behaviours of adolescents. The findings between 13 and 17 years. Schools in Samoa were chosen of previous studies [1, 21] are based on older versions of with a probability proportionate to enrollment size in the the GSHS and may not reflect current happenings. This first stage. Classes were randomly selected in the second S arfo et al. Middle East Current Psychiatry (2023) 30:68 Page 3 of 11 round, and all students in those classes could participate. with the corresponding adjusted odds ratio (AOR) at a The overall response rate was 59%, with 94% from the 95% confidence interval (CI) (p0.05). institution and 63% from the students. Results Background characteristics of adolescents in Samoa Variables The outcome variables in this study were “Suicide idea- The prevalence of suicide behaviours in Samoa was 24.1% tion, plan, and attempt” among the students. The study ideation, 23.8% plan and 21.8% attempt (see Fig. 1). Sig- measured each of the suicide behaviours during the past nificantly, truant participants experienced suicidal idea- 12  months (suicide ideation, suicide plan, and suicide tion (9.9%), plan (1.0%), and attempted suicide (10.3%). attempt) with a single self-report item or question. The Also, amphetamine use significantly influenced suicidal responses to these questions were categorised as “yes” (1) ideation (2.3%), plan (2.6%), and attempt (3.1%). Mari- or “no” (0). juana use, alcohol consumption and cigarette smoking We also classified the explanatory variables as sociode- were significantly associated with suicide ideation (3.2%, mographic (sex, age, and grade), personal (school tru- 4.9%, and 5.1%), plan (3.6%, 5.1%, and 5.4%), and attempt ancy, hunger), drugs and substance use (adolescent use (3.7%, 5.6%, and 5.2%), respectively. Moreover, partici- of amphetamine, marijuana smoking, alcohol), and psy- pants who got drunk after consuming too much alco- chosocial (physical attacks, and bullying victimisation). hol reported suicidal ideation (4.0%), plan (4.3%), and Except for sociodemographic (sex: 1 = male, 0 = female; attempted suicide (4.0%). Also, participants who were age: 1 = 12–14, 0 = 15–17; and grade: 0 = grades 1–3, physically attacked, engaged in a physical fight, seriously 1 = grades 4–6), all other explanatory variables were cat- injured, and those who were bullied significantly expe- egorised as “yes” (1) or “no” (0). rienced suicidal ideation (6.4%, 1.3%, 13.8% and 11.9%), plan (6.1%, 12.0%, 12.5%, and 11.7%), and attempted sui- cide (6.4%, 11.5%, 12.8% and 11.6%) respectively. Ado- Data analysis lescents who mostly felt lonely, people smoked in their We employed the sample weighting technique at the presence, and those who worried about what they could school, student, and also for sex within grade levels to not study significantly experienced suicidal ideation prevent bias on various nonresponse tendencies and (4.0%, 18.5%, 2.7%), plan (3.7%, 17.8%, 4.3%) and suicide make the findings a reflection of school-going teenag- attempt (4.2%, 16.6%, 4.4%) respectively. Also, partici- ers in Samoa. We assessed the final model’s goodness of pants who had multiple sexual partners and those with fit, and the results indicated no evidence of a lack of fit understanding parents significantly had suicidal ideation with our model’s capacity to predict suicidal behaviours. (3.6%, 4.6%), plan (3.9%, 5.1%), and attempt (3.9%, 4.5%), We also performed bivariate analysis using Pearson chi- respectively. Further, participants whose parents checked square to measure the relationships between variables. on whether they had done their assignment and those The covariates that showed a significant correlation whose parents knew what they do with their free time (p0.05) were then incorporated into a binomial logistic significantly experienced suicidal thoughts (10.3%, 6.4%), regression model. The results of the study were provided plan (10.6%, 6.4%), and attempted suicide (9.3%, 5.2%) Fig. 1 Prevalence of suicide behaviours (suicide thoughts, plan, and attempt) among school-going adolescents in Samoa Sarfo et al. Middle East Current Psychiatry (2023) 30:68 Page 4 of 11 respectively. However, participants who did not have Multivariate analysis close friends and those who had parents/guardians who Table  2 shows the logistic regression for predictors of use any form of tobacco significantly influenced only sui- suicide behaviours (ideation, plan, and attempt. Adjust- cide plans (3.0%, 8.0%) and attempts (3.1%, 7.6%), respec- ing for the results, compared to non-truant participants, tively (see Table 1). truant participants were more likely to attempt suicide (AOR = 1.34, 95%CI = 1.038–1.736). Also, participants who use alcohol are more likely to attempt than those Bivariate analysis who do not use alcohol (AOR = 1.34, 95%CI = 1.038– Table  2 shows the chi-square analysis of the relation- 1.736). Again, compared to those who do not smoke ship between outcome and explanatory variables. Per- cigarettes, those who smoke cigarettes were more likely sonal factor like truancy was significantly associated to have suicidal thoughts (AOR = 1.83, 95%CI = 1.281– with suicidal ideation (p < 0.006), plan (p < 0.002), and 2.602), plan (AOR = 2.12, 95%CI = 1.494–3.020), and attempt (p < 0.001). Also, using drugs or substances sig- attempt (AOR = 1.74, 95%CI = 1.205–2.506). Also, bul- nificantly predicted suicide behaviours. For instance, lied victims were more likely to have suicidal ideation amphetamines use was significantly associated with (AOR = 1.66, 95%CI = 1.298–2.111), plan (AOR = 1.75, suicide ideation (p < 0.004), suicide plan (p < 0.001) and 95%CI = 1.369–2.236), and attempt (AOR = 1.91, suicide attempt (p < 0.001). Also, marijuana use was sig- 95%CI = 1.476–2.467) than those who were not bullied. nificantly associated with suicide ideation (p < 0.001), Compared to those who do not have understanding plan (p < 0.001), and attempt (p < 0.001). Further alco- parents, those with understanding parents were less likely hol use was significantly associated with suicide idea- to have suicide ideas (AOR = 0.58, 95%CI = 0.429–0.782), tion (p < 0.001), plan (p < 0.001), and attempt (p < 0.001). plan (AOR = 0.70, 95%CI = 0.520–0.934), and attempt Also, smoking cigarettes was significantly associated suicide (AOR = .  68, 95%CI = 0.495–0.929). Having mul- with suicide ideation (p < 0.001), plan (p < 0.001), and tiple partners predicted only suicide plans (AOR = 1.51, attempt (p < 0.001). Again, related psychosocial factors 95%CI = 1.016–2.243), while not having close friends pre- were significantly associated with suicidal behaviours. dicted only suicide attempts (AOR = 1.75, 95%CI = 1.186– For instance, experiencing a physical attack was signifi- 2.582). Loneliness increased the odds of having suicide cantly associated with suicide ideation (p < 0.001), suicide ideas (AOR = 1.60, 95%CI = 1.125–2.286) and suicide plan (p < 0.001), and attempt (p < 0.001). Also, the physi- attempts (AOR = 1.88, 95%CI = 1.303–2.720). Also, worry cal fight was associated with suicide ideation (p < 0.001), about things participants could not study increased the plan (p < 0.001), and attempt (p < 0.001). Experiencing odds of experiencing suicidal thoughts (AOR = 1.95, serious injuries and bully were significantly associated 95%CI = 1.375–2.754), plan (AOR = 1.91, 95%CI = 1.190– with suicide ideation (p < 0.000, p < 0.001), plan (p < 0.002, 2.409), and attempt (AOR = 1.89, 95%CI = 0.311–2.723) p < 0.001), and attempt (p < 0.001, p < 0.001), respectively. (see Table 2). Furthermore, loneliness and worrying about things an adolescent could not study were significantly associated with suicide ideation (p < 0.001, p < 0.001), plan (p < 0.001, Discussion p < 0.001), and attempt (p < 0.001, p < 0.001), respectively. Given the public health significance of suicide preven- Further, having multiple sexual partners and people tion among adolescents to meet SDGs 3 and 4, our smoking in an adolescent’s presence were significantly study examined the prevalence and factors that predict associated with suicide ideation (p < 0.001, p < 0.000), plan suicidal behaviours among school-going adolescents in (p < 0.000, p < 0.002), and attempt (p < 0.000, p < 0.003) Samoa using data set from the 2017 GSHS. Among this respectively. Again, having parents/guardians who check population, the prevalence of suicidal ideation, plan, if adolescents have done their homework and having an and attempt was 24.1%, 23.8%, and 21.8%, respectively. understanding of parents were significantly associated The prevalence of suicidal ideation among Samoan ado- with suicide ideation (p < 0.002, p < 0.001), plan (p < 0.030, lescents is relatively higher compared to GSHS findings p < 0.004), and attempt (p < 0.004, p < 0.005) respectively. of studies from countries such as Ghana [26], Iran [50], Also, having parents/guardians who knew what chil- and Indonesia [35]. Also, the prevalence of suicidal plan dren do in their free time was significantly associated among this study’s population is higher compared with with suicide ideation (p < 0.010), plan (p < 0.019), and evidence from Bangladesh and Indonesia [22], Mozam- attempt (p < 0.000). Again, having close friends (p < 0.003, bique [38], and Brunei Darussalam [40]. Again, the prev- p < 0.001) and parental/guardian use of tobacco (p < 0.011, alence of suicidal attempts among our study population p < 0.002) were significantly associated with only suicidal is higher than those reported in Saint Vincent and the plans and attempts, respectively (see Table 1). Grenadines (SVATG) [37], Tonga [32] and Guatemala S arfo et al. Middle East Current Psychiatry (2023) 30:68 Page 5 of 11 Table 1 Association of independent factors with suicidal behaviours (ideation, plan, and attempts) among participants Variable Suicide ideation (1779) Suicidal plan (N = 1779) Suicidal attempt (N = 1779) Yes No Chi-square (χ2) Yes No Chi-square (χ2) Yes No Chi-square (χ2) Demographic Sex Male 165(9.3%) 494(27.8%) .488 147(8.3%) 512(28.8%) 1.25 145(8.2%) 514(28.9%) .02 Female 264(14.8%) 856(48.1%) 276(15.5%) 844(47.4%) 243(13.7%) 877(49.3%) Age (years) 13–15 216(12.1%) 744(41.8%) 2.97 232(13.0%) 728(40.9%) .17 207(11.6%) 753(42.3%) .075 ≥ 16 213(12.0%) 606(34.1%) 191(10.7%) 628(35.3%) 181(10.2%) 638(35.9%) Grade Grade 1–3 222(12.5%) 744(41.8%) 1.48 231(13.0%) 735(41.3%) .02 207(11.6%) 759(42.7%) .180 Grade 4–6 207(11.6%) 606(34.1%) 192(10.8%) 621(34.9%) 181(10.2%) 632(35.5%) Personal Truancy Yes 177(9.9%) 457(25.7%) 7.79** 178(10.0%) 456(25.6%) 10.04** 184(10.3%) 450(25.3%) 30.05*** No 252(14.2%) 893(50.2%) 245(13.8%) 900(50.6%) 204(11.5%) 941(52.9%) Hunger Yes 48(2.7%) 162(9.1%) .206 47(2.6%) 163(9.2%) .26 43(2.4%) 167(9.4%) .248 No 381(21.4%) 1188(66.8%) 376(21.1%) 1193(67.1%) 345(19.4%) 1224(68.8%) Substance and drugs Uses amphetamine/methamphetamines Yes 41(2.3%) 76(4.3%) 8.17** 46(2.6%) 71(4.0%) 16.69*** 56(3.1%) 61(3.4%) 49.85*** No 388(21.8%) 1274(71.6%) 377(21.2%) 1285(72.2%) 332(18.7%) 1330(74.8%) Uses marijuana Yes 57(3.2%) 83(4.7%) 22.88*** 64(3.6%) 76(4.3%) 40.35*** 66(3.7%) 74(4.2%) 57.19*** No 372(20.9%) 1267(71.2%) 359(20.2%) 1280(72.0%) 322(18.1%) 1317(74.0%) Drinks alcohol Yes 87(4.9%) 147(8.3%) 25.13*** 91(5.1%) 143(8.0%) 33.95*** 100(5.6%) 134(7.5%) 69.18*** No 342(19.2%) 1203(67.6%) 332(18.7%) 1213(68.2%) 288(16.2%) 1257(70.7%) Drunk after consuming alcohol Yes 71(4.0%) 115(6.5%) 22.43*** 76(4.3%) 110(6.2%) 33.45*** 71(4.0%) 115(6.5%) 32.61*** No 358(20.1%) 1235(69.4%) 347(19.5%) 1246(70.0%) 317(17.8%) 1276(71.7%) Smoke cigarettes Yes 91(5.1%) 115(6.5%) 51.23*** 96(5.4%) 110(6.2%) 66.97*** 92(5.2%) 114(6.4%) 71.33*** No 338(19.0%) 1235(69.4%) 327(18.4%) 1246(70.0%) 296(16.6%) 1277(71.8%) Psychosocial Physically attacked Yes 113(6.4%) 216(12.1%) 23.09*** 109(6.1%) 220(12.4%) 19.48*** 114(6.4%) 215(12.1%) 39.03*** No 316(17.8%) 1134(63.7%) 314(17.7%) 1136(63.9%) 274(15.4%) 1176(66.1%) Physical fight Yes 231(13.0%) 537(30.2%) 26.26*** 214(12.0%) 554(31.1%) 12.46*** 205(11.5%) 563(31.6%) 18.89*** No 198(11.1%) 813(45.7%) 209(11.7%) 802(45.1%) 183(10.3%) 828(46.5%) Seriously injured Yes 245(13.8%) 571(32.1%) 28.77*** 222(12.5%) 594(33.4%) 9.78** 228(12.8%) 588(33.1%) 33.23*** No 184(10.3%) 779(43.8%) 201(11.3%) 762(42.8%) 160(9.0%) 803(45.1%) Bullied Yes 211(11.9%) 416(23.4%) 48.132*** 208(11.7%) 419(23.6%) 47.17*** 207(11.6%) 420(23.6%) 71.28*** No 218(12.3%) 934(52.5%) 215(12.1%) 937(52.7%) 181(10.2%) 971(54.6%) Sarfo et al. Middle East Current Psychiatry (2023) 30:68 Page 6 of 11 Table 1 (continued) Variable Suicide ideation (1779) Suicidal plan (N = 1779) Suicidal attempt (N = 1779) Yes No Chi-square (χ2) Yes No Chi-square (χ2) Yes No Chi-square (χ2) Loneliness Yes 72(4.0%) 106(6.0%) 28.84*** 66(3.7%) 112(6.3%) 19.31*** 74(4.2%) 104(5.8%) 45.30*** No 357(20.1%) 1244(69.9%) 357(20.1%) 1244(69.9%) 314(17.7%) 1287(72.3%) Worry Yes 81(4.6%) 104(5.8%) 43.65*** 76(4.3%) 109(6.1%) 34.11*** 79(4.4%) 106(6.0%) 52.85*** No 348(19.6%) 1246(70.0%) 347(19.5%) 1247(70.1%) 309(17.4%) 1285(72.2%) Close friends Yes 48(2.7%) 116(6.5%) 2.62 53(3.0%) 111(6.2%) 7.27** 56(3.1%) 108(6.1%) 16.12*** No 381(21.4%) 1234(69.4%) 370(20.8%) 1245(70.0%) 332(18.7%) 1283(72.1%) Parental/guardian use of tobacco Yes 140(7.9%) 369(20.7%) 4.48 142(8.0%) 367(20.6%) 6.68* 136(7.6%) 373(21.0%) 10.08** No 289(16.2%) 981(55.1%) 281(15.8%) 989(55.6%) 252(14.2%) 1018(57.2%) People smoked in adolescent’s presence Yes 330(18.5%) 903(50.8%) 15.41*** 317(17.8%) 916(51.5%) 8.28** 295(16.6%) 938(52.7%) 10.54** No 99(5.6%) 447(25.1%) 106(6.0%) 440(24.7%) 93(5.2%) 453(25.5%) Multiple sexual partners Yes 64(3.6%) 101(5.7%) 21.40*** 69(3.9%) 96(5.4%) 32.66*** 69(3.9%) 96(5.4%) 42.69*** No 365(20.5%) 1249(70.2%) 354(19.9%) 1260(70.8%) 319(17.9%) 1295(72.8%) Parents/guardians check if homework is done Yes 183(10.3%) 690(38.8%) 9.31** 188(10.6%) 685(38.5%) 4.76* 165(9.3%) 708(39.8%) 8.51** No 246(13.8%) 660(37.1%) 235(13.2%) 671(37.7%) 223(12.5%) 683(38.4%) Understanding parents Yes 81(4.6%) 399(22.4%) 18.83*** 91(5.1%) 389(21.9%) 8.42** 80(4.5%) 400(22.5%) 10.19** No 348(19.6%) 951(53.5%) 332(18.7%) 967(54.4%) 308(17.3%) 991(55.7%) Parents/guardians know what adolescent Yes 113(6.4%) 445(25.0%) 6.63* 113(6.4%) 445(25.0%) 5.58* 93(5.2%) 465(26.1%) 12.61*** does with their free time No 316(17.8%) 905(50.9%) 310(17.4%) 911(51.2%) 295(16.6%) 926(52.1%) Note: ∗p < 0.05, ∗∗p < 0.01, ∗∗∗p < 0.001 Sarfo et al. Middle East Current Psychiatry (2023) 30:68 Page 7 of 11 Table 2 Predictors of suicide behaviours (ideation, plan, and attempt) among adolescents in Samoa Variable Suicidal ideation Suicidal plan Suicidal attempt AOR (95%CI) AOR (95%CI) AOR (95%CI) Personal Truancy 1.08(.842–1.377) 1.120(.875–1.433) 1.34(1.038–1.736) * Substance and drugs Uses amphetamine/methamphetamines .63(.373–1.077) .671(.397–1.135) 1.10(.654–1.854) Uses Marijuana 1.26(.781–2.033) 1.55(.966–2.488) 1.43(.877–2.328) Drinks alcohol 1.16(.791–1.703) 1.20(.816–1.752) 1.89(1.286–2.781) ** Drunk after consuming alcohol 1.12(.738–1.684) 1.20(.797–1.804) .823(.534–1.269) Smoke cigarettes 1.83(1.281–2.602) ** 2.12(1.494–3.020) *** 1.74(1.205–2.506) ** Psychosocial Physically attacked 1.13(.841–1.522) 1.138(.844–1.535) 1.21(.891–1.651) Physical fight 1.24(.972–1.587) 1.056(.824–1.354) 1.03(.789–1.336) Serious injury 1.23(.964–1.580) .933(.727–1.199) 1.21(.928–1.572) Bullied 1.66(1.298–2.111) *** 1.75(1.369–2.236) *** 1.91(1.476–2.467) *** People smoked in adolescent’s presence 1.34(1.025–1.745) * 1.20(.918–1.558) 1.25(.943–1.663) Parents/guardians’ use of tobacco – 1.18(.917–1.520) 1.21(.928–1.582) Parents/guardians check if homework is done .87(.681–1.108) .99(.776–1.264) .94(.724–1.216) Understanding parents .58(.429–.782) *** .697(.520–.934) * .68(.495–.929) * Parents/guardians’ know what adolescent does with .95(.726–1.249) .907(.691–1.190) .77(.576–1.036) their free time Multiple sexual partners 1.36(.914–2.030) 1.509(1.016–2.243) * 1.39(.922–2.094) Close friends – 1.43(.977–2.085) 1.75(1.186–2.582) ** Loneliness 1.60(1.125–2.286) ** 1.40(.973–2.007) 1.88(1.303–2.720) ** Worried 1.95(1.375–2.754) *** 1.694(1.190–2.409) ** 1.89(.311–2.723) ** Constant .022*** .006*** .001*** Note: ∗p < 0.05, ∗∗p < 0.01, ∗∗∗p < 0.001 [29, 30]. Interestingly, these studies conducted in WHO appreciate life’s beauty and disengage from suicidal risk member countries also utilised data sets from GSHS, behaviours. which provided a neutral ground for comparing preva- After adjusting for other predictor variables, we found lence rates. The relatively higher prevalence of suicidal that adolescents who were truant in school were at higher behaviours among adolescents in Samoa signifies the risk of attempting suicide. This finding corroborates evi- problematic nature of suicide among the population. dence from SVATG [37], Nepal [27], Tonga [32], and Suicide prevention interventions should be prioritised five Southeast Asian countries (Indonesia, Laos, Philip- in Samoan schools to help combat this canker among pines, Thailand, and Timor-Leste) [31], which predicted a school-going adolescents. strong association between truancy and adolescents’ sui- Aside from measuring the prevalence of suicidal behav- cidal behaviours. From our perspective, the link between iours among Samoan in-school adolescents, our results truancy and suicidal attempt can be explained on the observed that understanding parents was the only sig- basis that most adolescents who are truant from school nificant protective factor conceptualised in our study. may fall victim to externalising behaviours (substance Similar to our study finding, parents who are considerate, use, physical attack, bullying, and fight victimisation) and understanding, and supportive of adolescents have been high internalising behaviours [29, 30] which may predis- reported to be an important protective factor against sui- pose them to suicidal attempt. Rather than focusing on cidal behaviours in several studies [23, 36]. This finding the school setting alone, truancy prevention interven- implies that parents have a major role to play in reduc- tions in Samoa should foster interdisciplinary collabora- ing suicide risk among adolescents. Since adolescence is tion between stakeholders and policymakers. a period of transitioning into adulthood, parental sup- Among our study population, the use of alcohol was port and guidance expressed through understanding found as a significant risk factor for a suicidal attempt. adolescents’ problems and needs will help adolescents Also, smoking cigarettes increases the odds of ideating, Sarfo et al. Middle East Current Psychiatry (2023) 30:68 Page 8 of 11 planning, and attempting suicide. Again, having people develop a keen interest in school-going adolescents’ who smoke in adolescents’ presence increases their risk friendships and help them make meaningful choices of ideating suicide. The predictive link between substance regarding the company they keep. use (alcohol use and cigarette smoking) and suicidal The psychosocial state of being lonely increased the behaviours has been substantiated by the findings of sev- possibility of ideating and planning suicide among our eral studies [8, 10, 19, 39]. Given that alcohol is a seda- study population. Our finding is supported by some pre- tive and stimulant [14], we suggested that alcohol use vious studies [11, 28]. Similarly, our study confirmed the might impair adolescents’ decision-making, driving their results of previous studies in which the state of worrying impulsivity toward suicide. Schools in Samoa need to was a significant predictor of suicidal behaviours [20, 37]. pay particular attention to substance-use risk assessment interventions to identify students at risk of substance use and those already using them to inform policies and Conclusion interventions for suicide prevention. Using data from the 2017 GSHS, the study discovered We also found that school-going adolescents in Samoa that suicide conduct was highly common among Samoan who were bullied were highly predisposed to ideating, school-aged teenagers. We found that teenagers with planning, and attempting suicide than their peers who understanding parents protected against suicide activ- were not bully-victimised. Findings of several previous ity in the research population after controlling for other studies have validated the predictive association between characteristics linked with suicidal behaviour (idea, bullying of any form and the suicidal behaviours of ado- plan, and attempt). Furthermore, multiple risk variables lescents [15, 17, 41, 49]. Adolescents who do not have predicted the chance of some or all suicidal behaviours well-adaptive mechanisms against the psychosocially among the individuals in our study. Cigarette smoking, devastating consequences of bullying, suicide ideation, having someone who smokes in the company of teenag- plan, or attempt may be seen as an option. This finding ers, bullying, loneliness, and worrying about topics an may partly explain this observed outcome among ado- adolescent could not study, for example, all predicted lescents in Samoa. Multi-collaborative efforts between suicidal thoughts. Cigarette smoking, bullying, having Samoan school administrations, policymakers, parents several sexual partners, and worrying all raised the like- and teachers will significantly prevent bullying among lihood of suicide ideation. In contrast, suicidal attempts school-going adolescents on- and off-campus. were predicted by truancy, alcohol use, cigarette smok- In line with previous studies which found multiple ing, bullying, having close friends, loneliness, and worry- sexual relationships as a significant risk factor for sui- ing about things an adolescent could not study. cidal behaviours [33, 43], our study found that having If this incidence of suicidal conduct continues, Samoa multiple sexual partners increased Samoan school-going may be unable to ensure healthy lives for these school- adolescents’ odds for suicidal plans. This finding can be age teens by 2030, create opportunities for lifelong learn- explained from the perspective of intimate partner vio- ing, or provide inclusive and equitable quality education. lence mainly occurring among adolescents, possibly pre- Government, school administration, parents, and other disposing them to suicidal behaviours. Adolescents in stakeholders must adopt policies and programmes to Samoa must be educated on the risks and negative conse- assist and influence teens’ conduct at school and home. quences of practising multiple sexual relationships. Samoa would also benefit from proactive initiatives to Contrary to our study findings which found having minimise the prevalence of suicidal behaviour in order to close friends as a predictive factor of suicidal attempts reach several SDG objectives, specifically SDGs 3.5 and among school-going adolescents in Samoa, Seidu et  al. 4.1. Students must have access to services to assist with [38] found having close friends as a protective factor. their psychosocial and mental health needs. The study findings of Campisi et al. [6],and Pengpid and Peltzer [31] also contradict ours, as they reported hav- Strengths and limitation ing no close friends instead increased the risk of suicide. Our study examines adolescent suicide behaviours in However, our study finding corroborates Oppong Asante Samoa using a national dataset that covers all in-school et al. [26] and Sarfo et al. [37]. Close friends significantly adolescents. Since our sample is very representative, influence their negative or positive peers. In the case we can learn more about the factors that make it more of school-going adolescents in Samoa, it could be that likely for these Samoan adolescents to engage in suicidal their close friends might have been engaged in suicide behaviours. Notwithstanding these strengths, our study risk behaviours or may be ideating, planning or attempt- is limited in several aspects. As a secondary data study, ing suicide, which increased their vulnerability to sui- we were restricted to using only explanatory variables cidal behaviours. Parents and teachers in Samoa should included in the WHO’s GSHS questionnaire. S arfo et al. Middle East Current Psychiatry (2023) 30:68 Page 9 of 11 Furthermore, because the GSHS is a cross-sectional hence, community-based programs should educate par- database, we could not account for causal relationships ents on how their parenting practices affect adolescent between the various risk variables and suicidal conduct. suicidal behaviour. Again, utilising a single dichotomised question to evalu- Initiatives to prevent suicidal behaviour should focus ate mental health categories such as suicidal behaviour, heavily on adolescents’ use of drugs and other sub- concern, loneliness, and parental traits may not cap- stances. The use of amphetamine, marijuana, tobacco, ture all elements of the variables. A question style like alcohol, cigarettes and other drugs has been associated this may not effectively offer a meaningful estimate of with various suicide behaviours. Additionally, research- all essential clinical symptoms for diagnostic reasons. ers have found a connection between student drug and Despite these limitations, our study provides important substance use and subpar academic results [5]. Eliminat- findings that would inform research, policy, and adoles- ing student substance use would improve both academic cent-focused interventions in Samoa. These constraints performance and aggressiveness levels. According to must also govern the interpretation and application of Botvin and Griffin [5], the educational system or envi- our study’s findings. ronment could not be disregarded in efforts to prevent teenage drug and alcohol use. By providing chances for skill development in areas like music, athletics, and other Implications for research and intervention activities that stimulate teenagers’ interests and act as We measured the prevalence and correlates of suicidal an alternative to drug use. More significantly, teach- behaviours among adolescents in the island country of ers should give children the tools to increase their self- Samoa. We wanted to look for protective characteristics esteem and confidence to resist peer pressure and media and risk factors that make people more prone to suicide. messages. This section highlighted a few prospective research initi- atives and tactics for preventing suicide behaviours. First, Abbreviations school administrators and teachers in Samoa must obtain AOR Adjusted odds ratio suicide literacy training on recognising early warning sig- CDC Centers for Disease Control and Prevention nals among their adolescent students. Training school CI Confidence interval GSHS G lobal School-based Student Health Survey staff to act as gatekeepers is a major concern for effec- MoE Ministry of Education tive school-based suicide prevention programmes [34]. MoH Ministry of Health This will increase their competence and confidence in SVATG Saint Vincent and the Grenadines SDG Sustainable Development Goal identifying early warning signs, assessing the risk of sui- WHO World Health Organization cide, and linking these troubled adolescents to school- based resources [42, 46]. This intervention would include Acknowledgements We thank the WHO, CDC, and the Samoan MoH for making the data available. appointing some school staff members as mental health We sincerely thank the Centre for Behaviour and Wellness Advocacy, Ghana, points of contact or contact points and training them on for their expert review and writing support. the essential skills for recognising learners who are vul- Authors’ contributions nerable to suicide [26]. Conceptualisation: JOS, methodology, data curation, data analysis: JOS and The relevance of the family and social connections PO; writing—original draft preparation, writing: JOS, NIG, DA, TPD, COBO, and in suicidality is reflected in the fact that parental-asso- PO; writing—review and editing: all authors; writing—supervision: JOS. All authors read and agreed to the final version of the manuscript for publication. ciated risk variables were strongly related to suicidal behaviours among students in the current study. As Funding a result, the family’s role in preventing youth suicide None. might be contradictory depending on whether it is Availability of data and materials protective or risky [16]. In the past decade, it has been We used data from the GSHS database. WHO and the CDC support this open discovered that connection offers a conceptual frame- data, which is freely available at: https:// extra net.w ho. int/n cdsm icrod ata/ index. php/c atal og/ 773/ study-d escri ption. work for pursuing a public health prevention agenda in the area of teenage suicide behaviours, where parents’ Declarations awareness of adolescents in distress requesting help and encouraging them to seek care becomes crucial. Ethics approval and consent to participate According to Whitlock et al. [47], an important preven- The study received the necessary authorisation from Samoa’s MoH and the Ministry of Education (MoE) Institutional Review Board before the researchers tion goal is community-based initiatives that educate commenced the data collection. The study strictly adhered to the ethical poli- parents about adolescent distress and how to relate to cies set by Samoa’s MoH and MoE. Entry permission protocols were followed and assist their children [25]. Again, parenting prac- to obtain authorisation from the MoH, and the heads of the individual schools included in the study. Informed consent, parental consent, and child assent tices have a major impact on teenage suicide behaviour; were obtained from teenagers under the age of 18 using both verbal and Sarfo et al. Middle East Current Psychiatry (2023) 30:68 Page 10 of 11 written agreements. The data can be accessed at the WHO website: https:// 17. John A, Glendenning AC, Marchant A, Montgomery P, Stewart A, Wood extra net. who.i nt/n cdsm icroda ta/ index.p hp/c atal og/ 773/ study-d escr iption. S, Hawton K. (2018). Self-harm, suicidal behaviours, and cyberbully- ing in children and young people: systematic review. J Med Internet Consent for publication Res 2018;20(4):E129. Https://Www.Jmir.Org/2018/4/E129, 20(4), e9044. Not applicable. 10.2196/JMIR.9044. 18. 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