Introduction SuicidalideationandsuicideattemptamongIndonesianadolescentstudents

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I Gusti Ngurah Edi Putra

¹

/ Putu Ayu Emmy Savitri Karin

²

/ Ni Luh Putu Ariastuti

³

Suicidal ideation and suicide attempt among Indonesian adolescent students

1Center for Public Health Innovation (CPHI), Faculty of Medicine, Udayana University, Denpasar, Indonesia, E-mail:

[email protected]. https://orcid.org/0000-0002-1014-6949.

2Department of Nursing, Faculty of Medicine, Udayana University, Denpasar, Indonesia

3Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University, Denpasar, Indonesia.

https://orcid.org/0000-0002-5811-9042.

Abstract:

Suicide among young people is growing as a public health threat worldwide. With a paucity of studies on this issue in Indonesia, this study aimed to identify factors associated with suicidal behaviors (suicidal ideation and suicide attempt) among Indonesian adolescents. This was a cross-sectional study using secondary data analysis from the Global School-based Student Health Survey (GSHS) of Indonesia in 2015. The samples were 8634 school-going adolescents aged 13–18 years old. The data analysis consisted of univariate, bivariate and multivariate analysis. The chi-square (χ²) test was employed to identify proportion differences of suicidal behaviors by independent variables whereas multiple logistic regression was used to develop models for factors associated with suicidal ideation and suicide attempt. This study found that 4.75% and 2.46% reported for having suicidal ideation and suicide attempt in the last 12 months, respectively. The effects of intrapersonal factors (sex, age, loneliness, anxiety, current use of tobacco and alcohol) and interpersonal factors (physically attacked, bullying victimization, having no close friends, parental understanding and having sexual intercourse) varied by suicidal behavior and sex. Therefore, developing comprehensive approaches for prevention of mental health problems, including suicidal behaviors in the school setting is essential by asking for a collaboration of schools, parents, public health centers (PHCs), related stakeholders and non-governmental organizations (NGOs).

Keywords:adolescents, Indonesia, mental health, suicidal ideation, suicide attempt DOI:10.1515/ijamh-2019-0035

Received:February 15, 2019;Accepted:April 4, 2019

Introduction

Today suicide is growing as a public health threat in developed and developing countries [1]. Globally, the World Health Organization (WHO) reported that 804,000 people were estimated to have died due to suicide in 2012 with a suicide rate of 11.4 per 100,000 population, that varied by sex (15.0 for males and 8.0 for females) [2]. Moreover, it accounted for 1.4% of all mortality causes worldwide, of which 75% of cases occurred in low- and middle-income countries [3]. Among young people aged 10–24 years old, suicide contributed to 6% of all causes of death and was the third leading cause of death among males and the second leading cause among females [4]. Moreover, it is one of the major contributors for disability-adjusted life years lost among adolescents [5]. Suicidal behavior among adolescents potentially contributes to considerable public health problems for the future unless the efforts are made to overcome this issue as soon as possible [6], [7].

Suicidal behavior covers a range of behaviors including suicidal ideation or thinking, planning, attempting and suicide itself [2], [8]. Suicidal ideation refers to thinking about or considering self-injury or suicide [9], which can lead to severe mental health problems and plays as a risk factor for suicide attempts or completed suicide [10], [11]. Several previous studies in low- and middle-income countries showed low-to-high prevalence rates of suicidal ideation among adolescents, such as Malaysia, 7.9% [12]; Thailand, 8.8% [13]; Vietnam, 14.2%

[14]; the Philippines, 17.1% [15], and some African countries revealed high prevalence rates: Uganda, 19.6%;

Botswana, 23.1%, and Kenya, 27.9% [16] and, these prevalences significantly varied by sex in some studies.

However, limited studies attempted to assess the prevalence of suicide attempts: 18.1% in Kuwait [17], 12.9%

in Malawi [18] and 22.2% in Ghana [19]. Obviously, these findings indicate that suicide behavior is becoming a pressing public health issue among adolescents that needs appropriate interventions.

In Indonesia, to date, there is no national figure available for suicidal thinking and suicide attempts, even the rate of suicide itself is under-reported [20], and suicide data in Indonesia commonly relies on the report

I Gusti Ngurah Edi Putrais the corresponding author.

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from police offices [21]. The WHO estimated that the suicide mortality rate in Indonesia was 2.9 per 100,000 general population in 2017 [22]. Even though there is limited data for suicide, mental health problems including suicide behaviors are predicted to add the national burden of disease. The national prevalence of emotional mental problems reported by the Ministry of Health (MoH) Indonesia inRiset Kesehatan Dasar(Basic Health Research) experienced an increase from 6% in 2013 to 9.8% in 2018 [23], indicating the potential increase of suicidal behaviors. However, the estimation for suicide for specific age groups (e.g. adolescents) cannot be properly specified. Nevertheless, it is suggested that suicide among Indonesian adolescents experiences an increase year on year [24]. It is in line with a high prevalence of following mental health problems that can increase the risk of suicide behavior, identified among Indonesian adolescents from previous studies: mental emotional symptoms [25] and depression [26], [27]. In addition to this limited information, the Global School-based Student Health Survey (GSHS) of Indonesia documented suicidal behavior among adolescents. There was an increase in the prevalence of suicidal ideation in previous 12 months from 4.2% in 2007 to 5.1% in 2015 and the prevalence was higher among females, whereas the prevalence of suicide attempt was only available in 2015, at 3.8% [28], [29].

Even though suicide ideation and suicide attempt rates among adolescents in Indonesia were lower compared to other countries, its serious impacts need to be considered. Not only as regards loss of life but also as regards the long-lasting psychological trauma to family and relatives, and the economic productivity of the society as well [30]. Therefore, it is important to identify factors associated with suicidal ideation and suicide attempt among Indonesian adolescents.

Suicide behavior can be determined by two main factors, such as intrapersonal and interpersonal factors [31], [32]. According to this theory, intrapersonal factors are factors within the individual or individual characteristics that influence behavior, including knowledge, attitude and personal traits [33]. These factors also include psychological functioning that have important roles in emotion identification, emotion regulation skills and self-esteem [34]. Meanwhile, interpersonal factors are developed by the interaction process with environmental surroundings such as peers, family, etc. [33]. From previous studies, at least one of these following factors were associated with suicidal behavior (suicidal ideation and suicide attempt): intrapersonal factors: psychological factors (loneliness, anxiety), and health risk behavior (tobacco use, alcohol use); and interpersonal factors:

being physically abused at school, being bullied, having no close friends, parental understanding and having sexual intercourse [12], [13], [14], [15], [16], [17], [18], [19], [35], [36]. With a paucity of studies on this topic in Indonesia, this study aimed to identify factors associated with suicidal ideation and suicide attempt among Indonesian adolescents. In addition, this study analyzed the associated factors by sex in order to provide more insights and add to the current knowledge on this issue.

Methods

Study design and samples

This was a cross-sectional study using secondary data from the most recent of GSHS of Indonesia in 2015. This study was performed by the Public Health Research and Development Centre, Health Research and Develop- ment Board, MoH Indonesia in a collaboration with the WHO to assess the risk behavior among adolescent students aged 13–18 years old. The dataset, report, fact sheet and questionnaire of the GSHS are publicly available online [37]. The GSHS’s data collection of Indonesia was conducted in 75 junior and senior high schools which covered Sumatera and Java as the main targeted regions and other regions were also included. However, it did not include some provinces such as Bali, Maluku, North Maluku, North Borneo, Central Borneo, West Sulawesi, Gorontalo and Yogyakarta [29].

The data collection employed probability proportional to size as the sampling technique. First, schools were selected according to the proportional probability to the reported actual numbers of students. Second, the systematic random sampling was applied to select the classes and all students in the selected classes were recruited as samples. It successfully documented the data of 11,110 adolescent students, consisting of 5090 male and 6020 female students [29]. For this secondary data analysis of the GSHS, 2476 records of students were omitted due to missing value, thus, the remaining 8634 were analyzed.

Variables

There were two dependent variables in this study, namely suicidal ideation and suicide attempt. Both defini- tions of suicidal ideation and suicide attempt followed that defined by previous studies [12], [13], [16], [17], [18], [19], [30], [35], [38], [39], all of which are based on the GSHS questionnaires. Meanwhile, independent variables were adjusted with data availability and classified into two main groups: intrapersonal factors which included

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socio-demographic characteristic (age, sex); psychological factors (feeling lonely, anxious); and health risky behavior (tobacco, alcohol use), and interpersonal factors which included being physically attacked; bullying victimization; having no close friends; parental understanding; and having sexual intercourse. The measurement of dependent and independent variables was based on the GSHS as presented by Table 1.

Table 1:GSHS questions used in the analysis of factors associated with suicidal ideation and suicide attempt.

Variables Question/description Values

Suicidal ideation “Seriously considered attempting suicide during the 12 months before the survey”

1 = yes 0 = no Suicide attempt “Attempted suicide one or more times during the 12 months before

the survey”

1 = yes 0 = no

Sex “What is your sex?” 1 = male

0 = female

Age “How old are you?” 1 = > 15 years

old

0 =≤15 years old

Feeling lonely “Most of the time or always felt lonely during the 12 months before the survey”

1 = yes 0 = no Feeling anxiety “Most of the time or always were so worried about something that

they could not sleep at night during the 12 months before the survey”

1 = yes 0 = no Tobacco use “Currently smoked cigarettes on at least 1 day during the 30 days

before the survey”

1 = yes 0 = no Alcohol use “Currently drank alcohol at least one drink of alcohol on at least 1

day during the 30 days before the survey”

1 = yes 0 = no Physically attacked “Being physically attacked one or more times during the 12 months

before the survey”

1 = yes 0 = no Bullying victimization “Being bullied on one or more days during the 30 days before the

survey”

1 = yes 0 = no

Having no close friends “Did not have any close friends” 1 = yes

0 = no Parental understanding “Parents or guardians most of the time or always understood their

problems and worries during the 30 days before the survey”

1 = yes 0 = no Having sexual inter-

course

“Ever had sexual intercourse” 1 = yes 0 = no

Data analysis

Data were analyzed using univariate, bivariate and multivariate analysis. Univariate analysis aimed to describe the data distribution of dependent and independent variables. Bivariate analysis was used to identify the proportion differences of suicidal ideation and suicide attempt by independent variables where the chi-square (χ²) test was applied. In addition, binary logistic regression was used for multivariate analysis which aimed to ex- amine the impact of independent variables on dependent variables. Both bivariate and multivariate analysis was also differentiated based on sex (male and female) to find out whether the associated factors varied by sex. The results of multivariate analysis were reported as odds ratio (OR), as well as, 95% confidence interval (CI) OR and p-value to determine the significance level. For multivariate analysis, the enter method was used for model building to determine the effects by controlling all independent variables. Moreover, the results were also adjusted for sampling weight and clustering effects as the dataset has provided variables of weight, primary sampling unit and stratum.

Ethical consideration

The Indonesia-GSHS protocol was approved by the Ethics Committee of Health Research and Development Board, MoH Indonesia. Written informed consent had been obtained from each participant before data collection was conducted through a self-administered questionnaire. In addition, this survey was anonymous to reduce bias and ensure confidentiality.

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Results

Table 2 shows that out of 8634 adolescent students in this study, most of them were female (54.97%) and aged

≤15 years old (80.39%). Based on intrapersonal factors, only a few students reported that they felt lonely and anxious most of the time in 12 months preceding the survey, accounting for 5.74% and 4.10%, respectively. In addition, substance use was also documented, such as 9.21% and 3.05% of them have ever used tobacco and alcohol at least 1 day during the last month, respectively.

Table 2:Intrapersonal, interpersonal factors, suicidal ideation and suicide attempt among adolescent students in Indone- sia, 2015.

Variables n = 8634 Weighted %

Sex

Female 5003 54.97

Male 3631 45.03

Age

≤15 years old 6854 80.39

>15 years old 1780 19.61

Feeling lonely

No 8128 94.26

Yes 506 5.74

Feeling anxious

No 8277 95.10

Yes 357 4.10

Tobacco use

No 7905 90.79

Yes 729 9.21

Alcohol use

No 8370 96.95

Yes 264 3.05

Physically attacked

No 6140 70.68

Yes 2494 29.32

Bullying victimization

No 7033 81.44

Yes 1601 18.56

Having no close friends

No 8431 97.51

Yes 203 2.49

Parental understanding

No 5587 64.56

Yes 3047 35.44

Having sexual intercourse

No 8238 95.44

Yes 396 4.56

Suicidal ideation

No 8193 95.25

Yes 441 4.75

Suicide attempt

No 8420 97.54

Yes 214 2.46

Nearly one out of three students have been physically attacked during the last months (29.32%) which was in line with a high percentage of being bullied within the same period of measurement (18.56%). Less than 3% of Indonesian school-going adolescents reported for having no close friend at all and almost 5% of the students have ever had premarital sex. Based on their interpersonal communication with parents, 35.44% said that parents understood their problems most of the time. Regarding suicidal behavior (suicidal ideation and suicide attempt), 4.75% seriously considered attempting suicide and 2.46% attempted suicide at least 1 time in last 12 months.

Table 3 presents the prevalence of suicidal ideation by intrapersonal and interpersonal factors and differentiated by sex. Based on the results ofχ²test among all adolescents (males and females), the prevalence was significantly higher among females, aged >15 years old, who felt lonely or anxious, had ever used tobacco or

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alcohol, had been physically attacked or bullied, did not have any close friend, whose parents did not under- stand their problems, and who have ever had a sexual encounter. Among female samples, suicidal ideation did not vary significantly by age group and having no close friend. Meanwhile, the percentage of suicidal ideation did not differ by parental understanding among male students.

Table 3:Percentage of suicidal ideation by intrapersonal and interpersonal factors.

Variables Suicidal ideation

Total (n = 8634) Female (n = 5003) Male (n = 3631)

No Yes χ² No Yes χ² No Yes χ²

Sex

Female 94.39 5.61 17.45^a

Male 96.31 3.69

Age

≤15 years old 95.67 4.33 13.57^b 94.75 5.25 5.13 96.81 3.19 10.23^a >15 years old 93.55 6.45 92.87 7.13 94.33 5.67

Feeling lonely

No 96.06 3.94 204.16^c 95.20 4.80 87.03^c 97.10 2.90 128.13^c

Yes 82.01 17.99 82.97 17.03 80.35 19.65

Feeling anxious

No 95.95 4.05 214.05^c 95.19 4.81 151.62^c 96.87 3.13 70.29^c

Yes 79.06 20.94 74.40 25.60 84.07 15.93

Tobacco use

No 95.53 4.47 14.55^b 94.68 5.32 81.23^c 96.80 3.20 10.31^b

Yes 92.51 7.49 65.29 34.71 94.25 5.75

Alcohol use

No 95.50 4.50 37.77^c 94.56 5.44 23.56^c 96.70 3.30 27.78^c

Yes 87.33 12.67 80.14 19.86 89.34 10.66

Physically attacked

No 96.41 3.59 61.69^c 95.65 4.35 54.39^c 97.61 2.39 27.23^c

Yes 92.46 7.54 89.81 10.19 94.26 5.74

No 96.55 3.45 141.75^c 95.64 4.36 75.25^c 97.74 2.26 77.90^c

Yes 89.55 10.45 88.01 11.99 91.00 9.00

No 95.40 4.60 15.00^b 94.45 5.55 1.92 96.56 3.44 19.79^c

Yes 89.71 10.29 91.16 8.84 88.66 11.34

No 94.69 5.31 11.21^b 93.63 6.37 8.89^c 95.87 4.13 4.13

Yes 96.29 3.71 95.63 4.37 97.23 2.77

No 95.63 4.37 57.32^c 94.73 5.27 29.47^c 96.77 3.23 34.27^c

Yes 87.33 12.67 85.17 14.83 88.94 11.06

ap < 0.05;^bp < 0.01;^cp < 0.001.

According to Table 4, the percentage of suicide attempt did not vary by sex, age and parental understanding.

Both age and parental understanding remained insignificant factors when the analysis was distinguished by sex. While suicide attempt varied by smoking behavior among total and female samples, it was not significantly associated with suicide attempt among male adolescents.

Two multivariate models were developed for each dependent variable (suicidal ideation and suicide attempt). These models were constructed using the enter method which means that all independent variables are included in the model. The multivariate analysis aimed to find out the adjusted effect of each independent variable after controlling the others. Importantly, multi-collinearity testing was performed prior to multivariate analysis and no highly correlated variables (r < 0.5) were detected.

Based on Table 5, sex was a significant predictor of suicidal ideation where male students were 59% less likely to consider attempting suicide (OR = 0.41; 95% CI = 0.29–0.59). In addition, those who aged >15 years old increased the likelihood to have suicidal intention among the total and female samples, but not among male ones. Psychological factors (feeling lonely and anxious) were consistent determinants among females, males, and both sexes. For substance use, tobacco use increased the suicidal ideation by 5.53 times among female

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students, but it was not a significant predictor among males. Meanwhile, alcohol became an insignificant factor when the analysis was differentiated by sex.

Table 4:Percentage of suicide attempt by intrapersonal and interpersonal factors.

Variables Suicide attempt

No Yes χ² No Yes χ² No Yes χ²

Sex

Female 97.49 2.51 0.11

Male 97.60 2.40

Age

≤15 years old 97.47 2.53 0.79 97.41 2.59 0.56 97.54 2.46 0.24 >15 years old 97.84 2.16 97.83 2.17 97.85 2.15

Feeling lonely

No 97.88 2.12 67.18^c 97.79 2.21 26.67^c 97.98 2.02 44.58^c

Yes 92.01 7.99 93.20 6.80 89.97 10.03

Feeling anxiety

No 97.84 2.16 75.20^c 97.85 2.15 67.12^c 97.82 2.18 16.40^c

Yes 90.55 9.45 88.45 11.55 92.81 7.19

Tobacco use

No 97.75 2.25 16.00^b 97.73 2.27 110.31^c 97.80 2.20 2.45

Yes 95.45 4.55 74.45 25.55 96.79 3.21

Alcohol use

No 97.77 2.23 57.94^c 97.59 2.41 16.68^b 97.99 2.01 41.55^c

Yes 90.40 9.60 89.34 10.66 90.69 9.31

Physically attacked

No 98.20 1.80 37.01^c 98.16 1.84 33.18^c 98.25 1.75 10.28^b

Yes 95.97 4.03 95.06 4.94 96.58 3.42

No 98.14 1.86 57.18^c 98.02 1.98 28.77^c 98.31 1.69 28.63^c

Yes 94.90 5.10 94.81 5.19 94.99 5.01

No 97.97 2.03 257.33^c 97.75 2.25 71.24^c 98.24 1.76 118.98^c

Yes 80.83 19.17 84.11 15.89 78.44 21.56

No 97.37 2.63 1.85 97.24 2.76 2.07 97.52 2.48 0.22

Yes 97.85 2.15 97.90 2.10 97.78 2.22

No 97.85 2.15 72.35^c 97.66 5.27 15.50^c 98.09 1.91 60.50^c

Yes 91.06 8.94 92.95 7.05 89.66 10.34

ap < 0.05;^bp < 0.01;^cp < 0.001.

For factors under the interpersonal group, being physically attacked and bullied remained significant determinants of suicidal ideation, irrespective of sex. However, having no close friend was associated with suicidal thoughts among male students only. Interestingly, having parents who understood adolescent’s problems was related to a decreased likelihood of suicidal intention. In addition, those who had premarital sex were about 2.55 times more likely to think about suicide, and this was consistent among female, male, and both sexes.

Males were less likely to attempt suicide 1 or more times in last 12 months as presented in Table 6. How- ever, age was not a predictor for suicidal attempt, and neither was parental understanding. Feeling lonely and anxious were associated factors among total samples, but when disaggregated by sex, feeling lonely was associated with suicidal attempt among males whereas anxiety was a predictor among females. Female students who smoked cigarette were 9.21 times more likely to try committing suicide whereas it did not influence the decision among males. Meanwhile, alcohol increased the likelihood by almost three-fold among males. Being physically attacked and bullying victimization influenced suicide attempts for sex-merged samples, but those effects varied by sex. From all the interpersonal factors, having no close friend seems the most contributory factor for suicide attempt, it impacts on an increased likelihood by 8.63 and 12.57 times among female and males adolescents, respectively. Similar to suicidal thinking, the variable of premarital sex experience was a significant determinant of suicide attempt.

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Table 5:Factors associated with suicidal ideation.

Variables Suicidal ideation

OR 95% CI OR OR 95% CI OR OR 95% CI OR

Sex

Female Ref

Male 0.41 0.29–0.59^c Age

≤15 years old Ref Ref Ref

>15 years old 1.53 1.17–2.00^b 1.57 1.16–2.12^b 1.53 0.92–2.53 Feeling lonely

No Ref Ref Ref

Yes 2.69 1.84–3.92^c 2.11 1.25–3.57^b 4.37 2.36–8.11^c

Feeling anxious

No Ref Ref Ref

Yes 3.33 2.31–4.79^c 3.94 2.40–6.46^c 2.24 1.25–4.04^b

Tobacco use

No Ref Ref Ref

Yes 1.68 1.06–2.64^a 5.53 3.01–10.13^c 1.25 0.79–1.99

Alcohol use

No Ref Ref Ref

Yes 1.76 1.02–3.04^a 1.95 0.98–3.89 1.61 0.74–3.52

Physically attacked

No Ref Ref Ref

Yes 1.81 1.48–2.22^c 1.91 1.40–2.61^c 1.71 1.15–2.54^b

No Ref Ref Ref

Yes 2.36 1.83–3.05^c 2.05 1.52–2.77^c 3.01 2.08–4.35^c

No Ref Ref Ref

Yes 1.94 0.96–3.94 1.41 0.38–5.20 2.52 1.16–5.45^a

No Ref Ref Ref

Yes 0.70 0.53–0.92^a 0.69 0.48–0.99^a 0.72 0.47–1.09

No Ref Ref Ref

Yes 2.54 1.70–3.80^c 2.55 1.61–4.04^c 2.55 1.25–5.19^a

ap < 0.05;^bp < 0.01;^cp < 0.001. CI, confidence interval; OR, odds ratio.

Table 6:Factors associated with suicide attempt.

Variables Suicide attempt

OR 95% CI OR OR 95% CI OR OR 95% CI OR

Sex

Female Ref

Male 0.57 0.37–0.89^a Age

≤15 years old Ref Ref Ref

>15 years old 0.73 0.44–1.20 0.93 0.55–1.57 0.61 0.30–1.25 Feeling lonely

No Ref Ref Ref

Yes 1.86 1.13–3.07^a 1.4 0.79–2.55 2.82 1.08–7.36^a

Feeling anxious

No Ref Ref Ref

Yes 2.82 1.78–4.47^c 3.95 2.43–6.43^c 1.54 0.68–3.51

Tobacco use

No Ref Ref Ref

Yes 1.69 0.90–3.19 9.21 4.18–20.28^c 1.05 0.61–1.80

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Alcohol use

No Ref Ref Ref

Yes 2.54 1.22–5.28^a 1.70 0.55–5.27 2.86 1.25–6.53^a

Physically attacked

No Ref Ref Ref

Yes 1.75 1.27–2.41^b 2.13 1.49–3.05^c 1.40 0.81–2.42

No Ref Ref Ref

Yes 1.99 1.33–2.98^b 1.65 0.96–2.83 2.59 1.45–4.65^b

No Ref Ref Ref

Yes 10.70 6.47–17.68^c 8.63 3.40–21.92^c 12.57 6.55–24.14^c

No Ref Ref Ref

Yes 0.90 0.63–1.29 0.79 0.53–1.18 1.08 0.61–1.92

No Ref Ref Ref

Yes 2.92 1.84–4.63^c 2.05 1.04–4.05^c 3.67 2.18–6.19^c

ap < 0.05;^bp < 0.01;^cp < 0.001. CI, Confidence interval; OR, odds ratio.

Discussion

The prevalence rates of suicidal thinking and suicide attempt among Indonesian adolescent students were low at 4.75% and 2.46%, respectively, compared to previous studies in various settings [12], [13], [14], [15], [16].

However, the actual prevalence of suicidal behavior in Indonesia might be higher than what this study reported as there is a stigma attached to suicide in Indonesian society and its values as a religious country could have influenced adolescents’responses in this survey. In addition, it is important to identify factors associated with suicidal behavior among individuals where they do not only rely on intrapersonal factors, but are also tied to socio-environmental conditions (interpersonal factors).

Among Indonesian adolescents, this study found that suicidal behaviors varied by sex, where males were less likely to both consider committing suicide and attempt suicide in last 12 months. Even though some studies found no gender disparity related to suicidal behavior [13], [35], [40], [41], other studies are consistent with this finding where suicidal behavior is more prevalent among females [12], [42], [43], [44]. The higher rates of suicidal behavior among females might be due to gender roles in work and education [45]. Although gender disparity in the school environment and in labor force participation shows considerable reducing progress, females remain responsible for domestic workloads, such that they experience a double burden that can lead to additional psychosocial stressors. A previous study confirmed that women’s family roles are changing and they are also experiencing increased participation in labor force might initially contribute to higher suicide rates among females [46]. Beyond the explanation from socio-cultural perspectives, the higher rates of suicidal behaviors are also due to clinical risk factors of suicide behavior being more likely to be well-documented among females, such as depression, eating disorders, etc. [47]. Meanwhile, another socio-demographic factor, such as the older age of adolescents (>15 years old) may indirectly have contributed to increased exposure to stressors, which in turn, increases the likelihood of suicidal ideation among females and sex-merged samples, but it did not strongly affect suicide attempt.

Psychosocial distress, such as feeling lonely and anxious may play important roles in increasing the level of unbearable leading to suicidal thought and suicide attempt [42], which this finding is in concordance with other studies [12], [13], [14], [18], [19]. Interestingly, for suicide attempt predictors by sex, anxiety was a significant predictor among female students whereas loneliness was a predictor among males. Similarly, a study conducted by Ibrahim et al. found that anxiety was significantly correlated with suicidal behavior among female samples as they suffered anxiety at a higher rate [48]. Anxiety is more prevalent among females compared males due to females experiencing hormonal fluctuations throughout their lives, such as menstruation in the adolescent period or other life events (e.g. pregnancy, menopause) in their later life. These hormonal fluctuations can influence neurotransmitters, resulting in increased psychosocial stress and as the etiology of anxiety disorders [49]. Not only biological predispositions with hormonal fluctuations and anxiety sensitivity, females were also reported to have cognitive styles that are prone rumination and worry which propagate anxiety disorders [50].

Anxiety among female adolescents may potentially worsen adolescents’lives by provoking family conflicts, tenuous peer relationships and other social issues, which in turn, indirectly contributes to suicidal behaviors [48], [51].

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Meanwhile, loneliness is more likely to be reported among boys [52]. A previous study among Indone- sian adolescents confirmed that males were more likely to report loneliness than females [53]. Comparing both sexes, girls are more likely to have strong social networks due to intimacy, self-disclosure and emotional support whereas boys tend to develop large-group relationships, involving companionship, but spend less time in intimate discussion with peers [54]. Zhang et al. also found that a stronger association was identified between the quality of same-sex friendship and boys’loneliness than girls’[55]. Moreover, in the context of masculine identity in most Asian countries, males are expected to be strong emotionally. Hence, boys tend to isolate themselves and are less likely to spend time with friends when facing problems, increasing the feelings of loneliness [48], [52]. Lonely adolescents have been found to have poor social skills which restrict them from developing and maintaining friendships, in terms of both quality and quantity, as well as, less intimacy with either their friends or their parents or both [53], [56]. With low social skills, they also commonly have negative interpre- tations of their social environment or negative feelings during social interactions, leading to lower feelings of comfort, understanding, distrust and conflict [56], [57]. Therefore, loneliness might indirectly affect suicidal behaviors through its influences on the social lives of adolescents.

While some studies found that substance use (e.g. alcohol, tobacco) was not associated with suicide behaviors among sex-merged samples [19], [40], [58], this study reported that current smoking was a consistent predictor for suicidal ideation and suicide attempt among female students whereas alcohol use was a determinant for suicide attempt among males. Even though the prevalence of tobacco and alcohol use was higher among Indonesian male adolescents [59], smoking might indirectly affect suicidal behavior among females as it was found to be a coping mechanism for depression and anxiety among females [60]. Meanwhile, drinking as a coping mechanism was found to be higher among males with higher depressive symptoms [61].

Regarding interpersonal factors, the effects varied by sex and suicidal behavior. While both being physically attacked and experiencing bullying victimization were associated with suicidal thinking across the sample groups, being physically attacked had a higher effect on suicide attempt among females whereas being bullied was a noticeable predictor among males. Being a victim of being physically attacked or bullying can lead to suffering psychosocial problems such as higher anxiety or loneliness, all of which contribute to increased risk of suicide attempt [18], [62]. Interestingly, while having no close friend was not associated with suicidal ideation across samples, it was the most influential factor for suicide attempt. Having someone who is close to talk with, can provide social interaction and support and prevent someone with suicidal thoughts to commit actual suicide. Meanwhile, social isolation or being excluded from a peer group is associated with poor mental health and contributes to the increased likelihood of suicide attempt [39], [63]. Moreover, as regards parental understanding, it only affected suicide ideation, not suicide attempt.

An interesting finding was also identified in that adolescents who had sexual intercourse experience were more likely to report suicidal ideation and suicide attempt and that is similar to previous studies [13], [18], [58]. This factor might indirectly affect suicidal behavior. As the practice of engaging in protected sex among Indonesian adolescents was considerably low [64], [65], unprotected sex by adolescents can contribute to ad- verse reproductive health outcomes such as unintended pregnancy, HIV transmission, early childbearing or abortion [13], [58]. Those stressful life events can be a trigger for impulsive suicidal behaviors [66].

The findings of this study suggested recognizing suicidal behavior among Indonesian adolescents as a pressing public health issue. Even though the magnitude of suicidal tendencies among adolescents in this study was low, it potentially increases as a stigma is attached to mental health problems in Indonesian society, causing mental health sufferers to be reluctant to seek appropriate health services [20]. As we believe that the adolescent period might be the time that mental health symptoms begin to develop as risk factors for suicidal behaviors, intervention in the school setting can be used as entry point for increasing the awareness and prevention of mental health problems prior to program expansions in the wider community. In the short term, health providers can be invited as speakers to provide information related to mental health delivered routinely through student orientation, as well as, in meetings with parents aimed at developing mental health awareness. Also, the de- livery of information should also include methods on self-screening for students whilst parents can be taught how to recognize mental health problems in their children. Importantly, both will then be equipped with the necessary information on the available health services and can ask for further assistance.

For long-term programs, related stakeholders in health and education sectors should initiate developing mental health program or curriculum that can be implemented in school settings. This program should have a comprehensive approach by including collaboration from teachers, parents and health providers to create enabling environments for the prevention of mental health problems, including suicidal behaviors. Health providers can provide training for appointed teachers who will be knowledgeable about mental health issues, and its early detection and management. Hence, students can be equipped with sufficient information and skills to recognize mental health problems in a special class for mental health or at least, being part of discourse in some related subjects, such as biology or natural science, religion, etc. Teachers should persuade students to self-report if they recognize the presence of mental health symptoms in themselves. In addition, using a peer’s

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approach to identifing mental health problems in schools is promising as it is increasingly adopted in many settings [67], [68]. In addition to early detection of mental health problems, a campaign for the prevention of suicide is also important by strongly prohibiting intimidation, violence and bullying in schools.

As regards treatment, teachers can provide assistance for students with mental health problems or suicidal tendencies and also ask for parents’involvement and participation to overcome it. Students who are at risk for suicide can also be referred to public health centers (PHCs) where health professionals can provide appropriate treatment as mental health among adolescents is one of the concerns of adolescent health service program implemented by PHCs [69], and referral services can be considered under some circumstances. Furthermore, getting social support from teachers, parents and peers is essential for adolescents undergoing mental health treatment. Meanwhile, participation of non-governmental organizations (NGOs) that are interested in this issue should be taken into account as they commonly provide a hotline for asking for assistance and they can target out-of-school adolescents in the wider community. Moreover, stakeholders should campaign for mental health awareness through various media platforms to reduce the stigma and discrimination for sufferers and stimulate a positive atmosphere for the prevention of mental health problems in the community.

This study has several limitations. Being a cross-sectional study, it has a weak causal relationship among the variables in this study. The data collection on which this study is based did not accommodate all the provinces in Indonesia so that it may not represent all adolescents in Indonesia. In addition, suicide ideation and suicide attempt were measured by self-reports among adolescents that may be influenced by social desirability due to the cultural and religious values of suicide. However, data collection through self-administered and anonymous questionnaires help reduce this bias. Similar to previous studies, determination of suicidal behaviors and other psychological factors in this study might be weak as those were measured using a single-question only. A recall period of 12 months for suicidal behaviors might lead to recall bias and insensitivity in addressing the actual issues. Moreover, this study lacks understanding of how socio-environmental factors work on developing of suicidal behaviors among adolescents due to the unavailability of data on socio-cultural factors, religion and parents’characteristics in the GSHS dataset. Therefore, future studies should consider the limitations of this study.

Conclusion

The prevalence of suicidal ideation and suicide attempt among Indonesia adolescent students were low. While all intrapersonal (sex, age, loneliness, anxiety, tobacco use, alcohol use) and interpersonal factors (being physically abused, being bullied, having no close friends, parental understanding, and having sexual intercourse) were associated with suicidal ideation, only age and parental understanding did not influence suicide attempt.

Moreover, this study found that the effects of intrapersonal and interpersonal factors varied by sex. Regard- ing these findings, an approach for suicide prevention among adolescents should be integrated with schools, parents, PHCs, related stakeholders and NGOs.

Acknowledgments

The authors would like to thank the MoH Indonesia in collaboration with the WHO that conducted the GSHS and made the dataset and report available online. In addition, we would also like to thank students who par- ticipated in this study.

Conflict of Interest:The authors declared no potential conflict of interest.

Funding sources:This study did not receive any funding.

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