SSM - Population Health 3 (2017) 427–434
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SSM - Population Health
journal homepage: www.elsevier.com/locate/ssmph
Article
The prevalence and correlates of suicidal behaviours (ideation, plan and T
attempt) among adolescents in senior high schools in Ghana
Kwaku Oppong Asantea,b,⁎, Nuworza Kugbeyc, Joseph Osafoa, Emmanuel Nii-Boye Quarshiea,d,
Jacob Owusu Sarfoe
a Department of Psychology, University of Ghana, Accra, Ghana
b Institute for Psychosocial Research in Child and Adolescent Wellbeing, Accra, Ghana
c Department of Family & Community Health, University of Health and Allied Sciences, Hohoe, Ghana
d School of Psychology, University of Leeds, Leeds, West Yorkshire, UK
e Department of Health, Physical Education and Recreation, University of Cape Coast, Cape Coast, Ghana
A R T I C L E I N F O A B S T R A C T
Keywords: Suicide is recognised as the third leading cause of death among adolescents globally. There is however limited
Suicide data on the prevalence and factors associated with suicide particularly in Ghana. To explore the prevalence and
Adolescents risk and protective factors associated with suicide in Ghana, a nationwide Global School-based Student Health
Risk and protective factors Survey data collected among senior high school adolescents in Ghana was used. The prevalence of suicidal
Ghana behaviours was 18.2%, 22.5% and 22.2% for suicidal ideation, suicidal plan and suicidal attempt respectively. In
the final analysis, anxiety increases the odds of suicidal behaviour, even after controlling for other variables.
Loneliness increases the odds of suicidal behaviour but after adjusting for other factors the odds remained for
only suicidal plan. Being bullied, physically attacked, involved in a physical fight and food insecurity remained
risk factors for suicidal behaviour (i.e. ideation, plan and attempt) after adjusting for other factors. Truancy was
found as a risk factor for both suicidal ideation and plans but such effect diminished for suicidal plan after
adjusting for other variables. Increasing number of close friends remained a risk factor for both suicidal plan and
attempt but such effect diminished for suicidal ideation after adjusting for other variables. Parental under-
standing of adolescents’ problems and worries remained a significant protective factor for all the indices of
suicidal behaviour after adjusting for other variables. Parental respect for privacy was protective of suicidal
attempt but was not significant after adjusting for other variables. Early identification and intervention for at-
risk adolescents in senior high schools, for example those experiencing different forms of physical abuse, drug
and substance use and hunger can potentially reduce the prevalence of suicide among this population in Ghana.
Introduction Hetrick &McGorry, 2007; WHO, 2014a). Since it has been estimated
that sub-Saharan Africa will have more adolescents than any other
In Sub-Saharan Africa, about 23% of the population is aged between region by the year 2050, adolescent health research and interventions,
10 and 19 years old (WHO, 2014a). Projections by the Ghana Statistical thus become key priority (WHO, 2014a).
Service (GSS) show that Ghana’s population has grown from Globally, 10–19 year olds are highly susceptible to mental health
24,658,823 (in 2010) to 28,308,301, as of December 2016 (GSS, disorders. It has been suggested that about half of adult mental health
2012, 2017). Persons aged between 10 and 24 years constitute about disorders begin in adolescence, but go undetected and untreated (WHO,
38.3% of the population. There are significant developmental changes 2014a). Suicide is recognised as the third leading cause of death among
that take place during the transition from childhood to adolescence, adolescents globally, and in Ghana, anecdotal evidence has suggested
which are accompanied by physical and psychological challenges an increase in suicide among adolescents (Citifmonline, 2012). Suicidal
(Sinha, Cnaan, & Gelles, 2007). Among these challenges is engagement ideation is a strong predictor of suicide in both the general population
in risky behaviours (e.g., having unprotected sex and substance use, as well as among adolescents (WHO, 2011). Furthermore, psychological
self-harm etc.) which increases their vulnerability to poor physical and autopsy studies show that most suicides occur on the first attempt
mental health outcomes (Glozah & Pevalin, 2016; Patel, Flisher, (Cavanagh, Carson, Sharpe, & Lawrie, 2003), highlighting the impor-
⁎ Corresponding author at: Department of Psychology, University of Ghana, P. O. Box LG 84, Legon, Accra, Ghana.
E-mail addresses: kwappong@gmail.com, koppongasante@ug.edu.gh (K. Oppong Asante).
http://dx.doi.org/10.1016/j.ssmph.2017.05.005
Received 6 February 2017; Received in revised form 4 May 2017; Accepted 5 May 2017
2352-8273/ © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license 
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
K. Oppong Asante et al. SSM - Population Health 3 (2017) 427–434
tance of identifying precursors to suicidal behaviour (such as suicidal 2008). A recent study revealed an increase in suicide reported cases
ideation) to inform suicide prevention efforts. Multiple studies have among adolescents in Ghana over a 15-year period, with more boys
demonstrated that several factors (e.g., personal/intrapersonal, inter- than girls likely to attempt and die by suicide (Quarshie et al., 2015).
personal and environmental) are associated with adolescent suicidal The same report also indicated that psychological factors, conflictual
ideation and attempts (Brent &Mann, 2006; Johnson, Krug & Potter, relationships, loss of significant other, poor school work, and socio-
2000; Portzky, Audenaert, & van Heeringen, 2005; Roberts, economic factors influence adolescent suicidal behaviours (Quarshie
Roberts & Chen, 1998). These studies have contributed to the develop- et al., 2015). Thus, generally, in Ghana, few studies have assessed the
ment of interventions aimed at suicide prevention among young adults factors that are associated with suicidal behaviours. In the context of
globally. this gap in knowledge, the purpose of this study was therefore to
There is continuous disagreement among clinicians and researchers examine the factors that are associated with suicidal ideation, plans and
on suicide-related nomenclature, terminology and definitions, particu- attempts using a national school-based survey of Ghanaian senior high
larly for nonfatal suicidal behaviours and outcomes (O’Carroll et al., school adolescents.
1996; Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007a, 2007b;
Wagner, 2009). Thus, in this study the commonly used definitions with Conceptual framework of adolescent suicide
consensus in the literature are applied. We define suicidal ideation as
“any self-reported thoughts of engaging in suicide related behaviour” The risk and protective factors model (Hawkins, Catalano, &Miller,
(O’Carroll et al., 1996, p.247); suicidal plan refers to the formulation of 1992) served as the theoretical framework that guided this study. This
a specific method by which one intends to kill oneself (Silverman et al., framework posits that within a particular population, there are factors
2007b); suicidal attempt is used to mean “intentional self-inflicted that may ameliorate the effects of psychological problems (protective
poisoning, injury or self-harm which may or may not have a fatal factors) or exacerbate the probability of developing a psychological
intent or outcome” (WHO, 2014b, p.12); and suicide is defined as “the problem (risk factors). Among school-going adolescents, several factors
act of deliberately killing oneself” (WHO, 2014b, p.12). A person may be associated with susceptibility to mental health problems
experiencing suicidal crisis typically engages in suicidal behaviours including suicide. These include personal and situational and/or social
from thinking about suicide (suicidal ideation), formulating plans for context characteristics associated with mental health. Among adoles-
suicide (suicidal plans), trying out suicidal acts (attempting suicide), to cents, pertinent socio-demographic factors related to suicidal ideation
actually killing oneself (Millner, Lee, & Nock, 2016; WHO, 2014b). and attempt may include their younger age, perceived socio-economic
Recent clinical and school-based studies involving young people show status, and alcohol and substance use. Knowledge of risk and protective
that sometimes impulsivity facilitates the transition from suicidal factors associated with suicidal ideation among school-going adoles-
thoughts to suicide in the face of negative emotions (Anestis, cents living in Ghana is needed to help develop appropriate harm-
Soberay, Gutierrez, Hernández, & Joiner, 2014; Klonsky, &May, 2010; reduction programmes for this population.
Klonsky, May, & Glenn, 2013; May, & Klonsky, 2016; Millner et al., The above mentioned studies suggest that suicidal ideation and
2016). attempts among adolescents are associated with several personal,
Compared to high income countries, studies on the prevalence and familial, societal and systemic factors which need to be addressed
determinants of adolescent suicide in low-and middle-income countries holistically in any attempt to reduce the incidence and prevalence of
(LAMICs), including many countries in sub-Saharan Africa such as suicide among adolescents. In the present study, we used the nation-
Ghana, are limited. Nevertheless, evidence from a number of studies wide Global School-based Health Survey, conducted among senior high
shows a significant increase in suicidal attempts and suicide related school students in Ghana, to explore risk and protective factors
deaths among adolescents and young adults in Africa, including Ghana associated with suicidal ideation, plans and attempts. We assessed
(McKinnon, Gariépy, Sentenac, & Elgar, 2016; Quarshie, Osafo, multiple risks and protective factors at the individual, family, peer and
Akotia & Peprah, 2015; Swahn, Palmier, Kasirye & Yao, 2012; WHO, school levels to provide a broader perspective of factors related suicidal
2014b). In a study examining adolescent suicidal behaviour among 32 behaviours in adolescents in senior high schools in Ghana. We
countries in low-and middle-income countries using the Global School- hypothesized that risk and protective factors will be uniquely asso-
based Health Survey (GSHS), selected countries within sub-Saharan ciated with suicidal ideation, plans and attempts. Specifically, we
Africa had relatively higher prevalence of suicidal behaviours among expected psychosocial variables (anxiety and loneliness), substance
school-going adolescents, compared to the selected low-and middle- use and violence related behaviours to heighten the risk of suicidal
income countries from other WHO regions (i.e., Americas, Eastern behaviours whilst parental support behaviours, and peer behaviours
Mediterranean, and South-East Asia and Western Pacific) involved in (having close friends) may be protective of suicidal behaviours.
the study (McKinnon et al., 2016). A study pooling data from Botswana,
Kenya, the Seychelles, Uganda, United Republic of Tanzania, and Methods
Zambia showed that parental involvement served as both risk and
protective factor for various mental health problems including suicidal Study design and sample
ideation, attempt and plan (Arat &Wong, 2016). On a broader societal
level, a systematic review of studies on the prevalence of child mental Data for this study was obtained from the Ghana Global School-
health problems in sub-Saharan Africa showed that low subjective based Student Health Survey (GSHS) conducted in 2012 (WHO, 2014c).
socio-economic status, poverty, or insufficient food are the most This survey was conducted through the partnership among the World
significant risk factors for poor mental health (Cortina, Sodha, Health Organization (WHO), Disease Control and Prevention (CDC),
Fazel & Ramchandani, 2012). Middle Tennessee State University and the Ghana Education Service
In Ghana, the 2010 population and housing census report by the (GES). The data was collected using a cross-sectional survey design
Ghana Statistical Service (GSS, 2012) provides some omnibus statistics among WHO countries which were interested in examining the
of death by suicide, violence, accident, and homicide. The report shows behavioral risk factors and protective factors in several domains of
18,938 deaths recorded and categorized under deaths by accident, functioning among the youth in schools. Data collection was done by
violence, homicide, or suicide within the 12 months preceding the census. the use of close-ended structured questionnaires administered to the
Additionally, the 2008 GSHS data from Ghana also showed that 14.6% students. Details of the systematic steps involved in the data collection
of the students seriously considered attempting suicide during the 12 among the students can be found on the WHO website (WHO, 2014d)
months before the survey and 15.4% of the students made plans to for further information. Participants for this study were sampled from
attempt suicide during the 12 months preceding the survey (Owusu, selected senior high schools (SHS) in all the 10 administrative regions
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K. Oppong Asante et al. SSM - Population Health 3 (2017) 427–434
of Ghana. A two-stage cluster sampling design was used to select 25 cant differences between those who reported any of the indices of
senior high schools to represent all the 10 regions of Ghana. Selection of suicidal behaviour and those who did not were entered into logistic
schools at the first stage of the sampling was based on a probability regression models at the second step. In the second step, binominal
proportional to the size of enrollment. At the second stage a random logistic regression analyses were conducted to examine the impact of
sampling technique was used to select the classes in each school. This the various risk and protective factors on suicidal behaviours (ideation,
allowed every student to have an equal chance of being selected for plan and attempt). Demographic variables (age and sex) were included
study. A numerical weighting was applied to each student record to in all logistic regression models. The results from the regression
enable generalization of results to the eligible population. A total of analyses are presented as odds ratio (OR) and 95% confidence interval
1984 students participated in the study. This sample included 1065 (CI). Statistical significance was defined as two-tailed p-value<0.05 in
(53.7%) males, 908 (45.7%) females and 11 (0.6%) were missing data. all analyses. The Statistical Package for the Social Sciences (SPSS)
The majority of the students, 1062 (53.5%) were aged 18 years or older. version 23.0 for Window (IBM SPSS, Inc., Chicago, IL, USA) was used to
Students aged 14 years and below, 15 years, 16 years and 17 years conduct data analyses. A multiple imputation method was utilized for
constitute 50 (2.5%), 180 (9.1%), 245 (12.4%) and 440 (22.3%) of the variables where the amount of missing data exceeded 5% to overcome
sample respectively. The students were relatively equally split across the weakness in analysing, or preventing any bias, or misinterpretation,
the four Senior High School grade levels. Two-thirds of those surveyed and to secure representativeness (Sterne et al., 2009). To prevent
were boarding students. estimation bias resulting from the exclusion of these subjects, missing
values were replaced with imputed values, using the multiple imputa-
Measures tion by Expectation-Maximization (EM) (Graham, 2012). The results of
the multiple imputation analysis suggested that the analysis for risks
Dependent variables and protective factors associated with suicidal behaviour (ideation,
Three main outcome measures were extracted from the data, plan and attempt) among adolescents did not demonstrate serious bias.
namely, suicidal ideation, suicidal plan and suicidal attempts. In this
study, each of these three outcome variables was measured with a Results
single self-report item or question. For example, the item, “during the
past 12 months, did you ever seriously consider attempting suicide?” was Univariate analysis
used to measure suicidal ideation while suicidal plan was measured
with the question, “during the past 12 months, did you make a plan about The prevalence of suicidal behaviours were 18.2%, 22.5% and
how you would attempt suicide?”. The responses were categorized as 22.2% for suicidal ideation, suicidal plan and suicidal attempt respec-
“yes” (1) or “no” (0). Suicidal attempt was measured with the question tively. A total of 317 (16.0%) of the participants reported feeling of
“during the past 12 months, how many times did you actually attempt anxiety during the past 12 months and 367 (18.4%) reported feelings of
suicide?” The responses for this questions were “0”, “1”, “2 or 3”, “4 or loneliness within the same time frame. About 43.8%, 37.5% and 28.2%
5”, and “6 or more times”. The responses were recoded as no attempt (0) of the participants reported to have been bullied, physically attacked
and one or more attempts (1) for analysis. and involved in a physical fight on once or more occasions respectively.
Over a third of the participants (32.1%) were truant over the past 30
Independent variables days.
A set of predictor variables including demographic characteristics of
the participants, psychological socio-environmental factors and paren- Bivariate analysis
tal involvement was used to determine their predictive effects on the
three outcome variables (suicidal ideation, suicidal plan and suicidal Bivariate findings are presented in Table 2. Age was not signifi-
attempts). The details of the questions used, the variable names and the cantly associated with any of the suicidal behaviours. With exception of
coding used for the statistical analysis are presented in Table 1. suicidal attempt, gender was associated with both suicidal ideation
(p<0.001) and suicidal plan (p<0.001). More than one in four of the
Ethical statements participants who reported feelings of loneliness and anxiety also
reported suicidal ideation, suicidal plan and suicidal attempt. Socio-
The Ghana Global School-based Student Health Survey (GSHS) environmental factors such as truancy, been bullied, physically at-
questionnaire used in the data collection in 2012 was piloted to ensure tacked, involved in a physical fight, going hungry (food insecurity) and
adequate comprehension of the survey items. The Ghana Education having close friends were independently associated with all the indices
Service’s (GES) policies on ethics regarding the use of students in survey of suicidal behaviour (i.e. ideation, plan and attempt). Parental under-
studies were adhered to in the data collection. Official written permis- standing of adolescents’ problems and worries was found to be
sions were obtained from Ghana Education Service (GES), the selected significantly associated with all the indices of suicidal behaviour (i.e.
schools, and classroom teachers. Written informed consent was ob- ideation, plan and attempt) but parental intrusion was related to only
tained from the students and parental consent was also obtained for suicidal attempt.
minors.
Multivariate analysis
Statistical analysis
The logistic regression analyses are presented in Table 3. After
Sample weights were used in all analyses so results are generalizable controlling for other factors, male were less likely to be involved in
to the population, and further to reduce bias on differing pattern of non- suicidal ideation and suicidal plan. Anxiety increases the odds of
response. All variables were re-coded on dichotomous scale in this suicidal behaviour, even after controlling for other variables. Loneliness
study as in other existing GSHS studies (e.g., Arat &Wong, 2016; Ohene increases the odds of suicidal behaviour but after adjusting for other
et al., 2015; Randall, Doku, Wilson & Peltzer, 2014). The primary factors the odds remained for only suicidal plan.
analyses were performed in two steps to determine factors most Being bullied, physically attacked, involved in a physical fight and
strongly associated with suicidal behaviours (ideation, attempt and food insecurity remained risk factors for suicidal behaviour (i.e.
plan) in adolescents. First, bivariate analyses using the Chi-square (χ2) ideation, plan and attempt) after adjusting for other factors. Truancy
test was used to examine possible relations between the independent was found as a risk factor for both suicidal ideation and suicide plan but
variables and suicidal behaviours. Variables that demonstrated signifi- such effect diminished for suicidal plan after adjusting for other
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K. Oppong Asante et al. SSM - Population Health 3 (2017) 427–434
Table 1
Independent variables derivation from survey data.
Variable Survey question Coding
Age How old are you? 11–18 years (coded categorically)
Sex What is your sex (1) Male
(0) Female
Anxiety During the past 12 months, how often have you been so worried about something that you could not sleep (1) Most of the times/always
at night? (0) Never/rarely/sometimes
Loneliness During the past 12 months, how often have you felt lonely? (1) Most of the times/always
(0) Never/rarely/sometimes
Truancy During the past 30 days, how many days did you miss classes or school without permission? (0) 0–2 times
(1) 3 or more times
Bullied During the past 30 days, how many days were you bullied? (0) 0 times
(1) 1 or more times
Attacked During the past 12 months, how many times were you physically attack? (0) 0 times
(1) 1 or more times
In a fight During the past 12 months, how many times were you in a physical fight? (0) 0 times
(1) 1 or more times
Food Insecurity During the past 30 days, how often did you go hungry because there was not enough food in your home? (1) Most of the times/always
(0) Never/rarely/sometimes
Close friends How many close friends do you have? (0) 0 friends
(1) 1 or more close friend
Smoking During the past 30 days, how many days did you smoke cigarette? (0) 0 times
(1) 1 or more times
Substance Use How old were you when you first used drugs? (0) I have never used drugs
(1) Any other response
Alcohol misuse During your life, how many times did you drink so much alcohol that you were really drunk? (0) 0 times
(1) 1 or more times
Parental homework checking During the past 30 days, how often did your parents or guardians check to see if your homework was done? (1) Most of the times/always
(0) Never/rarely/sometimes
Parental understanding During the past 30 days, how often did your parents or guardians understand your problems and worries? (1) Most of the times/always
(0) Never/rarely/sometimes
Parental knowledge of activity During the past 30 days, how often did your parents or guardians really know what you were doing you’re (1) Most of the times/always
your free time? (0)Never/rarely/sometimes
Parental intrusion of privacy During the past 30 days, how often did your parents or guardians go through your things without your (1) Most of the times/always
approval? (0)Never/rarely/sometimes
Table 2
Association of risks factors with suicidal ideation, plan and attempts among Ghanaian adolescents.
Variables Sample Suicidal Ideation Suicidal Plan Suicidal Attempt
n(%) n(%) n(%)
100% 360(18.2%) ρ 438(22.5%) ρ 438(22.2%) ρ
Demographic
Age .952 .523 .068
≤14years 50(2.5%) 9 (2.5%) 8(1.8%) 10(2.3%)
15years 180(9.1%) 29(8.1%) 35(8.0%) 30(6.8%)
16years 245(12.4%) 44(12.2%) 58(13.2%) 61(13.9%)
17years 440(22.3%) 82(22.8%) 105(24.0%) 114(26.0%)
≥18years 1062(53.7%) 196(54.4%) 232(53.0%) 223(50.9%)
Sex (Male) 1062(53.7%) 163(45.7%) .001 210(48.5%) .010 225(52.0%) .287
Psycho-social
Anxiety 317(16%) 91(25.4%) < .001 102(23.3%) < .001 101(23.1%) < .001
Loneliness 364(18.4%) 93(26.0%) < .001 111(25.6%) < .001 97(22.4%) .012
Socio-environment
Truancy 629(32.1%) 142(39.7%) .001 162(37.3%) .004 169(39.4%) < .001
Bullied 806(43.8%) 194(60.6%) < .001 226(57.5%) < .001 256(65.0%) < .001
Attacked 737(37.5%) 180(50.8%) < .001 214(49.2%) < .001 249(57.5%) < .001
In a fight 558(28.2%) 142(39.9%) < .001 164(37.6%) < .001 184(42.4%) < .001
Food insecurity 261(13.2%) 77(21.4%) < .001 93(21.3%) < .001 86(19.7%) < .001
Close friends 278(14.1%) 65(18.4%) .010 83(19.1%) < .001 76(17.6%) .010
Smoking 112(5.6%) 27(51.9%) .316 29(52.7%) .302 47(54.7%) .428
Substance Use 184(9.3%) 48(71.6%) .988 54(72.0%) .895 70(73.7%) .610
Alcohol misuse 270(13.6%) 52(47.3%) .916 64(47.8%) .739 57(45.2%) .620
Parental support issues
Parental homework checking 830(42.3%) 147(41.5%) .705 187(43.3%) .630 184(42.7%) .844
Parental understanding 867(44.6%) 131(37.0%) .010 157(36.7%) < .001 159(37.0%) < .001
Parental knowledge of activity 871(40.2%) 132(37.8%) .299 169(39.8%) .825 155(36.3%) .081
Parental intrusion of privacy 1074(54.8%) 185(52.4%) .326 232(53.7%) .489 214(49.4%) .010
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K. Oppong Asante et al. SSM - Population Health 3 (2017) 427–434
Table 3
Logistic regression for predictors of suicidal ideation, plan and attempts.
Variables Suicidal Ideation Suicidal Plan Suicidal Attempt
OR (95%CI) AOR (95%CI)a OR (95%CI) AOR (95%CI)a OR (95%CI) AOR (95%CI)a
Demographic
Age – – – – – –
≤14years 1 1 1 1 1 1
15years 0.88(0.38–1.99) 0.96(0.40–2.10) 1.29(0.55–2.98) 1.34(0.58–3.12) 0.81(0.37–1.80) 0.89(0.40–2.01)
16years 1.00(0.45–2.21) 1.02(0.46–2.27) 1.66(0.74–3.75) 1.70(0.75–3.85) 1.33(0.63–2.83) 1.38(0.64–2.97)
17years 1.05(0.49–2.25) 1.06(0.49–2.27) 1.69(0.77–3.71) 1.69(0.96–3.72) 1.42(0.69–2.92) 1.44(0.68–3.03)
≥18years 1.04(0.50–2.17) 1.02(0.48–2.15) 1.50(0.70–2.17) 1.49(0.69–3.222) 1.07(0.53–2.18) 1.06(0.52–2.20)
Sex (Male) 0.67 (0.53–84) *** 0.65(0.49–0.84)** 0.76 (0.31–94) * 0.73(0.57–0.93) * 0.89(0.72–1.10) 0.42(0.10–1.68)
Psycho-social
Anxiety 2.17(1.64–2.86)*** 1.80(1.30–2.49) *** 1.95(1.50–2.56)*** 1.52(1.11–2.08)** 1.87(1.43–2.44) *** 1.39(1.01–1.93)*
Loneliness 1.75(1.34–2.30)*** 1.36(0.99–1.87) 1.78 (1.38–2.29)*** 1.43(1.06–1.91) * 1.40(1.08–1.82) * 1.11(0.81–1.52)
Socio-environment
Truancy 1.52(1.20–1.92)*** 1.40(1.06–1.84)* 1.39(1.11–1.73) *** 1.31(1.01–1.69)* 1.52(1.22–1.90) *** 1.25(0.96–1.62)
Bullied 2.29(1.79–2.93)*** 1.68(1.38–2.20) *** 2.05(1.63–2.57) *** 1.62(1.26–2.08)*** 3.04(2.41–3.84) *** 2.14(1.65–2.77)***
Attacked 1.98(1.57–2.49)*** 1.38(1.05–1.81) * 1.89(1.52–2.34) *** 1.35(1.05–1.74)* 2.93(2.35–3.65) *** 2.14(1.64–2.76)***
In a fight 1.93(1.52–2.46)*** 1.44(1.08–1.92) 1.80(1.44–2.26) *** 1.39(1.06–1.82)* 2.34(1.87–2.93) *** 1.62(1.24–2.13)***
Food insecurity 2.15(1.60–2.89)*** 1.56(1.09–2.23)* 2.26(1.70–2.99) *** 1.61(1.15–2.46)** 1.95(1.47–2.60) *** 1.48(1.05–2.09)*
Close friends 1.49(1.10–2.02)* 1.36(0.95–1.95) 1.65 (1.24–2.20) ** 1.65(1.19–2.30)** 1.46(1.09–1.95) * 1.53(1.08–2.15)*
Smoking 0.72(0.38–1.37) 0.73(0.19–2.79) 0.71(0.38–1.36) 0.47(0.12–1.85) 0.79(0.44–1.42) 1.67(0.48–5.80)
Substance use 1.02(0.54–1.85) 2.5(0.58–10.90) 1.04(0.57–1.91) 1.88(0.47–7.61) 1.16(0.66–2.06) 1.31(0.37–4.62)
Alcohol misuse 1.02(0.67–1.55) 0.52(0.13–2.04) 1.07(0.72–1.58) 1.22(0.31–4.87) 0.90(0.61–1.35) 0.55(0.16–1.92)
Parental support issues
Parental homework checking 0.96(0.76–1.21) 1.02(0.22–4.63) 1.05(0.85–1.31) 1.85(0.46–7.50) 1.02(0.82–1.27) 3.65(0.96–13.96)
Parental understanding 0.68(0.54–0.86) *** 0.69(0.52–0.89) *** 0.66(0.53–0.83) *** 0.69(0.54–0.88)** 0.67(0.53–0.83)*** 0.67(0.52–0.88)**
Parental knowledge of activity 0.88(0.69–1.11) 0.75(0.17–3.33) 0.98(0.78–1.22) 0.95(0.23–3.90) 0.82(0.66–1.03) 0.55(0.14–2.17)
Parental intrusion of privacy 0.89(0.71–1.12) 0.26(0.10–1.02) 0.93(0.75–1.15) 0.45(0.26–1.95) 0.75(0.61–0.93) ** 0.89(0.69–1.15)
*** ρ<0.001.
** ρ<0.01.
* ρ<0.05.
a AOR adjusted for all factors which appear in table.
variables. Increasing number of close friends remained a risk factor for suicidal behaviour as found in this study and those observed in other
both suicidal plan and attempt but such effect diminished for suicidal African countries could, in part, reflect differences in the meaning of
ideation after adjusting for other variables. Parental understanding of suicidal thoughts and normative attitudes towards suicide across
adolescents’ problems and worries remained a significant protective diverse cultural, religious and economic settings
factor for all the indices of suicidal behaviour after adjusting for other (Wasserman, &Wasserman, 2009). Suicidal behaviours are highly re-
variables. Parental respect for privacy was protective of suicidal lated to context which is why critical suicidologists have suggested
attempt but was not significant after adjusting for other variables. recently that context should be given a critical consideration in the
assessment of the risks and protective factors related to suicidality
(White, Marsh, Kral, &Morris, 2015). The magnitude of suicidal idea-
Discussion
tion and suicidal plan in the present study using the 2012 Global
School-based Health survey was higher than 14.6% and 15.4% for
Despite the recent increase in adolescent suicide rates in Ghana
suicidal ideation and plan as reported in the 2008 version of the same
(Quarshie et al., 2015), sparse literature exists on the factors associated
survey in Ghana (Owusu, 2008). This increase could also be attributed
with suicidal behaviours in adolescents. This study was conducted to
to the existing economic situations in Ghana during the data collection
examine the risk and protective factors associated with suicidal
period. The year 2012 was significant in the history of Ghana as it was
behaviour among adolescents in senior high schools in Ghana. The
characterized by high rates of inflations coupled with difficult financial
prevalence of suicidal behaviours were 18.2%, 22.5% and 22.2% for
consequences for families and individuals, a situation which was found
suicidal ideation, suicidal plan and suicidal attempt respectively. In the
to increase the risk for suicidal behaviour in Ghana (Osafo, Akotia,
multivariate analyses, several factors were found to be significantly
Andoh-Arthur &Quarshie, 2015). Finally, the lower rate of suicidal
associated with suicidal ideation, plan and attempt. Being bullied,
ideation (18.2%) compared to suicidal plan (22.5%) and suicidal
physically attacked, involved in a physical fight and food insecurity,
attempt (22.2%) observed in this study may be attributable to the
having close friends were found as risk factors for suicidal behaviour
characteristic of impulsivity associated with suicidal behaviour in
whilst Parental understanding of adolescents’ problems and worries was
young people (Millner et al., 2016). Evidence from recent clinical and
protective for all suicidal behaviour.
school-based studies (e.g., Anestis et al., 2014; Klonsky, &May, 2010;
The prevalence of suicidal ideation, suicidal plan and suicidal
Klonsky et al., 2013; May, & Klonsky, 2016; Millner et al., 2016)
attempt reported among this population falls within the range of what
indicate that, compared to adults, many young people experiencing
has been reported in studies from other African countries such as Benin,
suicidal crisis attempt suicide without prior suicidal ideation or both
Uganda and Seychelles (Randall et al., 2014; Swahn et al., 2012;
suicidal ideation and plans due to adolescent impulsivity. Thus,
Wilson, Dunlavy, Viswanathan & Bovet, 2012). However, the preva-
impulsivity can be a pathway to suicidal attempt in young people
lence rates of 18.5% and 22.5% for suicidal ideation and plan
(Klonsky, &May, 2010; Millner et al., 2016).
respectively were higher compared to the prevalence rates of 7% and
Consistent with other studies, we found that compared to males,
6.3% for suicidal ideation and plan respectively in Tanzania (Dunlavy,
females were more likely to have suicidal ideation and suicidal plan
Aquah, &Wilson, 2015). The differences in the prevalence rates of
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K. Oppong Asante et al. SSM - Population Health 3 (2017) 427–434
(McKinnon et al., 2016; Sharma, Nam, Kim& Kim, 2015; Swahn et al., behaviours may contribute to suicidal behaviour through accumulative
2012). A study of suicidality in street children and adolescents in Ghana internalized behaviours such as social isolation, shame and feelings of
showed a highly significant difference between the proportion of depressions, that eventually affect their ability to deal with such
females reporting suicidal plans and attempts compared to their male stressors that are associated with physical abuse and bullying victimi-
counterparts (Oppong Asante, 2015). As argued by Blumenthal and zation (Page &West, 2011). These findings therefore underscore the
Kupfer (1990), the female preponderance of suicidal ideation and need to develop an intervention policy aimed at reducing bullying and
planning may be linked to females’ higher tendency of engaging in violent-related behaviours among school-going adolescents. It has been
both covert and overt help-seeking behaviour, plus their higher score suggested that physical violent behaviour of school teachers is a key
on affective disorders, compared to males. In low-and middle-income determinant of the overall burden of youth violence (Devries et al.,
countries, it has been observed that adolescent girls are more prone to 2015). Thus, evaluating the possible effects of how violent school
suicidal behaviour (and negative mental health outcomes, more gen- teachers’ behaviours influence suicidal behaviour is also key.
erally) notably because of rigid gender norms and discrimination Unlike other studies which have shown that having less friends was
(Petroni, Patel, & Patton, 2015; WHO, 2014e). Although rigid gender a risk factor for suicidal behaviours (Wilson et al., 2012; Swahn et al.,
norms and discrimination (e.g., unequal chore burdens, caretaking 2012), our study showed that the odds of having suicidal ideations,
responsibilities, sexual abuse and exploitation exclusion from educa- plans and attempts increase with higher number of close friends.
tion, employment, and decision making etc.) have negative effects on Friendship is a key social relationship channel for adolescents, provid-
both adolescent boys and girls, the effects are much more telling on ing motivational context for learning new social skills and receiving
girls, constraining their opportunities and aspirations (Petroni et al., feedback (Cobb, 1992). Thus, in that regard, extensive friendship
2015). network should translate into positive developmental outcomes for
Our study showed an association between suicidal behaviour adolescents. This is however not always the case since peer influence
(ideation, plan and attempts) and anxiety and loneliness. The transition and experience of friendship can also be negative and shaped bicultural
from childhood to adolescence, which is accompanied by physical and dynamics (Deegan, 2003; Toro, Urberg, & Heinze, 2004). We suspect
psychological challenges such as depression, anxiety and loneliness some underlying cultural issue in the way adolescents might have
have been linked to suicidal behaviours in other studies (McKinnon experienced suicidality in relation to friendship in this study. Cross-
et al., 2016; Swahn et al., 2012, Shilubane et al., 2014). Blum and cultural studies have shown that there are remarkable differences in
Nelson-Mmari (2004) in their study to examine the principal causes and self-construal between interdependent and independent settings
influences of morbidity and mortality among young people throughout (Markus & Kitayama, 2001). The Ghanaian cultural setting can be
the world, indicated that there are myriad of psychological and mental described as interdependent (Assimeng, 1999; Nukunya, 1992;
health problems that could lead to suicidal behaviours in young people. Wiredu & Gyekye, 1992) where life is intensely shared, social ethic
Even though 16.0% and 18.4% of the participants reported feeling valued, but shame and stigma highly avoided (Assimeng, 1999; Gyekye,
anxiety and loneliness respectively, in the multivariate analysis only 1995; 1996). Plausibly, adolescents within such cultural context may
anxiety increased the odds of suicidal behaviour, even after controlling find it difficult to endure the many social relationships that they may
for other variables. This suggests that those who follow through more have to manage when they experience challenges, leading to social
readily with the suicide are those with feelings of anxiety and not withdrawal on their part and perhaps avoidance on the part of their
necessarily those with feelings of loneliness. Unlike other studies (e.g. friends. Consequently, having large pool of friends could become
Page &West, 2011; Randall et al., 2014; Swahn et al., 2012; Wilson negative and increase the odds for distress including suicidality. It is
et al., 2012), this study did not find substance use as a risk factors for also plausible that negative peer relationship and support may be
suicidal ideations, plans and attempts. The lack of the relationship associated with heightened health risk behaviours such as suicidal
between substance use and suicidal behaviour is surprising but this behaviour, and underscore the need to emphasize the importance of
could be attributed to social desirability effect where the participants supportive relationship between peers and to develop strategies to
provided socially desirable responses to the items on substance use promote positive peer support. The only parental variable that showed
because of the strong abhorrence of adolescent drug and substance use significant association with suicidal ideation, plans and attempts in the
within the Ghanaian society (Owusu, 2008). final regression analysis was parental understanding of adolescents’
The relationship between hunger/food insecurity and suicide has problems and worries, which was protective of suicidal behaviours. In a
not been explored in literature particularly among adolescents. study on the psychosocial correlates of suicidal ideation in rural South
However, a systematic review of studies on the prevalence of child African adolescents, Shilubane and colleagues observed that adoles-
mental health problems in sub-Saharan Africa showed that low cents who felt parental love and care were less likely to think about
subjective socio-economic status, poverty, or insufficient food are the suicide or to attempt suicide (Shilubane et al., 2014). Thus, in an
most significant risk factors for poor mental health (Cortina et al., interdependent cultural setting such as Ghana, the nature of the
2012). Job loss and chronic unemployment have been found to be risk relationship with a parent may play an important role in adolescent
factors for suicidal ideations and attempts among young adults in suicidal behaviours.
Ghana (Adinkrah, 2011; Osafo et al., 2015). In the US, studies have
clearly shown that food deprivation among adolescents does not only Strengths and limitations of the study
lead to dysthymia but also thoughts of death, a desire to die and
attempted suicide (Alaimo, Olson & Frongillo, 2002; McIntyre, This is one of the first primary studies to have used a large data to
Williams, Lavorato, & Patten, 2013). In this study, perhaps adolescent’s examine adolescent suicidal behaviours and advances our knowledge of
inadequate access to food may have led to heightened emotional risks and protective factors for suicidal behaviours among senior high
responsiveness and increased irritability and distraction, leading to school adolescents in Ghana, but some limitations should be noted. The
suicidal behaviours. GSHS study provides a cross-sectional database, thus, we could not
For suicidal ideations, plans and attempts, interpersonal level risk predict causality between the various risk and protective factors and
factors that were found to be significant were being bullied, physically suicide related outcomes. A further potential limitation relates to the
attacked and being involved in a physical fight. These findings are mental health questions. Anxiety (worried), loneliness and suicidal
consistent with other studies (e.g., Randall et al., 2014; Shilubane et al., ideation were assessed each by a single question confined to the
2013; 2014; Swahn et al., 2012). The association between bullying existing GSHS data. Whereas not sufficient for diagnostic purposes
victimization and suicidal ideation is evident globally (McKinnon et al., (e.g., assessing suicidal intentions), this question format could capture
2016; WHO, 2014a). Exposure to and engagement in these adverse some predictors of clinical depression in adolescents. Finally, due to the
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K. Oppong Asante et al. SSM - Population Health 3 (2017) 427–434
GSHS, parental involvement was limited to four components, namely, Suicidal behaviour was also found to be associated with several risk and
parental bonding (parental knowledge on children’s free time), parental protective factors. Whilst anxiety, loneliness, being bullied, physically
connectedness (understanding of children’s problems), parental super- attacked, involved in a physical fight, and food insecurity were found to
vision (checking children’s homework) and parental intrusion. be risk factors for suicidal behaviour, only parental intrusion was found
Additionally, we suspect the presence of social desirability response to be protective of adolescent suicidal behaviours. Early identification
to some of the items which might also explain potentially, the lack of and intervention for at-risk street school-going adolescents, for example
relationship between substance use measures and suicidal behavior in those experiencing different forms of physical abuse, drug and sub-
this sample. Nevertheless, to the best of our knowledge, this is the first stance use and hunger, can potentially reduce the prevalence of suicidal
cross-sectional study to have used a nationally representative data to behaviours among this population in Ghana. These findings underscore
explore the risk and protective factors associated with suicidal ideation, the need to develop suicide prevention programmes that particularly
plans, and attempts, variables that hitherto have infrequently been focus on the school setting and the family environment.
studied among adolescents in Ghana. This, thus serves as a basis for
further future studies on suicidal behaviour among adolescents in Acknowledgements
Ghana.
We extend our sincere appreciation to the students, teachers, and
Implications for research and intervention Ghana Education Service for their participation and assistance in the
Global School-based Student Health Survey. We also thank the World
The findings of this study have two significant implications for Health Organization and its partners in making available the data freely
research and interventions. First, there were clear school related risk for the study.
factors accounting for suicidal behaviours among the adolescents in this
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