International Journal of Psychiatry in Clinical Practice

ISSN: 1365-1501 (Print) 1471-1788 (Online) Journal homepage: http://www.tandfonline.com/loi/ijpc20

Suicidal ideation and associated factors among

students aged 13–15 years in Association of
Southeast Asian Nations (ASEAN) member states,
2007–2013

Karl Peltzer & Supa Pengpid

To cite this article: Karl Peltzer & Supa Pengpid (2017): Suicidal ideation and associated
factors among students aged 13–15 years in Association of Southeast Asian Nations (ASEAN)
member states, 2007–2013, International Journal of Psychiatry in Clinical Practice, DOI:
10.1080/13651501.2017.1301486

To link to this article: http://dx.doi.org/10.1080/13651501.2017.1301486

Published online: 20 Mar 2017.

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INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE, 2017
http://dx.doi.org/10.1080/13651501.2017.1301486

ORIGINAL ARTICLE

Suicidal ideation and associated factors among students aged 13–15 years in
Association of Southeast Asian Nations (ASEAN) member states, 2007–2013
Karl Peltzera,b,c and Supa Pengpida,b
a
ASEAN Institute for Health Development, Mahidol University, Nakhon Pathom, Thailand; bDepartment of Research Innovation and
Development, University of Limpopo, Turfloop Campus, Sovenga, South Africa; cHIV/AIDS/STIs and TB (HAST), Human Sciences Research
Council, Pretoria, South Africa

ABSTRACT ARTICLE HISTORY

Objective: The aim of this study was to assess suicidal ideation and associated factors in school-going Received 1 December 2016
adolescents in the Association of Southeast Asian Nations (ASEAN) member states. Revised 1 February 2017
Methods: The analysis included 30,284 school children aged 13–15 years from seven ASEAN countries Accepted 16 February 2017
that participated in the cross-sectional global school-based student health survey (GSHS) between 2007
and 2013. KEYWORDS
Results: The overall prevalence of suicidal ideation in the past 12 months across seven ASEAN countries Suicidal ideation;
was 12.3%, significantly higher in girls (15.1%) than boys (9.3%). Among seven ASEAN countries with the demographic; factors;
highest prevalence of suicidal ideation was in the Philippines (17.0%) and Vietnam (16.9%) and the lowest psychological; stress;
in Myanmar (1.1%) and Indonesia (4.2%). In multivariable logistic regression analysis, female gender, older social environment;
age (14 or 15 years), living in a lower middle income country, having no friends, loneliness, bullying vic- Southeast Asia
timisation, having been in a physical fight in the past 12 months, lack of parental or guardian support,
tobacco use and having a history of ever got drunk were associated with suicidal ideation.
Conclusions: Different rates of suicidal ideation were observed in ASEAN member states. Several risk
factors for suicidal ideation were identified which can help guide preventive efforts.

Introduction Young people in transitional ASEAN economies are vulnerable

to psychosocial stressors and suicidal behaviour (Jegannathan &
Globally, suicide is a leading cause of death among adolescents
Kullgren 2011). Previous studies among adolescents in Asia and
(Wasserman et al. 2005). Although suicide among young people is
globally have found socio-demographic factors, psychosocial dis-
a global public health problem, adequate information on determi-
nants of suicidal behaviour, including suicidal ideation, is lacking tress and social-environmental factors to be associated with sui-
in several Association of Southeast Asian Nations (ASEAN) member cidal ideation, as reviewed in Peltzer and Pengpid (2012). Socio-
states (Jegannathan & Kullgren 2011). Suicidal ideation is risk fac- demographic factors associated with suicidal ideation may include
tor for suicide (Tran Thi Thanh et al. 2006; Sharma et al. 2015). female gender (e.g. Page & West 2011; Chan et al. 2013; Ahmad
Therefore, it is important for suicide prevention among adoles- et al. 2014), male gender (e.g. Jegannathan & Kullgren 2011), older
cents to identify and improve the prediction of suicide risk age (e.g. Page & West 2011) or higher grade (e.g. Page et al.
(Hawton et al. 2012). 2011), and lower socioeconomic status, food insecurity or hunger
Only a few studies, in particular national representative ones, (Ke & Ford-Jones 2015; Lee & Choi 2015). Psychosocial distress or
on adolescent suicidal ideation have been conducted in ASEAN poor mental health, including no close friends, loneliness, depres-
member states. In two national population-based surveys among sion, inadequate sleep, anxiety and stress were found in a number
adolescents in Vietnam, the prevalence of suicidal behaviours was of studies to be associated with adolescent suicidal ideation (Chen
5.3% in the 2003–2004 survey and 12.2% in the 2009–2010 survey et al. 2005; Rudatsikira et al. 2007; Cheng et al. 2009; Mahfoud
(Le et al. 2012). Based on the analysis of the global school-based et al. 2011; Page & West 2011; Page et al. 2011; Le et al. 2012;
student health survey (GSHS), the prevalence of suicidal ideation Peltzer & Pengpid 2012; Wilson et al. 2012; Ahmad et al. 2014; Lee
was 4.8% in 2007 in Indonesia (Lie & Liou, 2012), 7.9% in 2012 in & Choi 2015; Sharma et al. 2015). Additionally, psychosocial dis-
Malaysia (Ahmad et al. 2014), 0.7% in 2007 in Myanmar (Page tresses such as being bullied (Mahfoud et al. 2011; Wilson et al.
et al. 2013), 17.1% in 2003 (Page et al. 2011), 17.8% in 2007 (Lie & 2012; Phuong et al. 2013; Ahmad et al. 2014), being attacked
Liou 2012), and 12.0% in 2011 in the Philippines (Peltzer & (Sharma et al. 2015) and in a physical fight (Chen et al. 2005;
Pengpid 2015) and 8.8% in 2008 in Thailand (Peltzer & Pengpid Page & West 2011; Page et al. 2011; Sharma et al. 2015) increased
2012). In local school surveys among adolescents the prevalence the odds of suicidal ideation among adolescents. Further, social-
of suicidal ideation was 8.6% of boys and 13.3% in girls in environmental factors associated with suicidal ideation, included a
Cambodia (Medina et al. 2012), 7.0% in Malaysia (Chen et al. lack of parental support (Cheng et al. 2009; Mahfoud et al. 2011;
2005), 6.1% in Thailand (Muehlankamp et al. 2005) and 26.3% in Le et al. 2012; Peltzer & Pengpid 2012), lack of peer support
Vietnam (Nguyen et al. 2013). (Cheng et al. 2009), and substance use, such as tobacco use

CONTACT Karl Peltzer karl.pel@mahidol.ac.th ASEAN Institute for Health Development, Mahidol University, 25/25 Phutthamonthon 4 Rd., Salaya,
Phutthamonthon, Nakhon Pathom 73170, Thailand
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 K. PELTZER AND S. PENGPID

(Juan et al. 2010; Innamorati et al. 2011; Page & West 2011; Page was used to collect data to represent all students in grades 6,
et al. 2011; Wilson et al. 2012; Kim et al. 2014; Lee & Choi 2015), 7, 8, 9 and 10 in each country (CDC 2015). At the first stage
alcohol use or got drunk (Mahfoud et al. 2011; Page & West 2011; of sampling, schools were selected with probability proportional
Page et al. 2011; Le et al. 2012; Peltzer & Pengpid 2012; Wilson to their reported enrolment size. In the second stage, classes
et al. 2012; Kim et al. 2014; Lee & Choi 2015; Sharma et al. 2015) in the selected schools were randomly selected and all stu-
and illicit drug use (Mahfoud et al. 2011; Sharma et al. 2015). dents in selected classes were eligible to participate irrespect-
Additional social-environmental factors associated with suicidal ive of their actual ages (CDC 2015). Students self-completed
ideation, included truancy (Chen et al. 2005), physical inactivity the questionnaires to record their responses to each question
(Page et al. 2011; Kim et al. 2014), sedentary leisure time behav- on a computer scannable answer sheet (CDC 2015). Consistent
iour (Page et al. 2011) and overweight or obesity (Juan et al. with the GSHS study protocol, in each participating country,
2010). the GSHS was approved by appropriate national government
Limited information is available about the relationship agencies (conforming to the provisions of the Declaration of
between socio-demographic factors, psychosocial distress, social- Helsinki, as revised in Edinburgh 2000), and informed consent
environmental factors and suicidal ideation among adolescents was obtained from the students, parents and/or school officials
across ASEAN countries. Therefore, the aim of this study was to (CDC 2015).
examine the relationship between suicidal ideation frequency and
associated factors among school children in ASEAN countries, in a Measures
pooled analysis and also comparing individual countries.
The study variables used were from the GSHS (CDC 2015) are
described in Table 1. Suicidal ideation was assessed with the ques-
Methods tion, ‘During the past 12 months, did you ever seriously consider
Description of survey and study population attempting suicide?’ Body weight and height were recorded by
self-report, and obesity was classified as children with BMI figures
This study involved secondary analysis of existing data from the referring to an adult BMI of
30.0 kg/m2 using international age-
GSHS from seven ASEAN countries (Cambodia, Indonesia, and gender-specific criteria (Cole et al. 2000). Inadequate physical
Malaysia, Myanmar, Philippines, Thailand and Vietnam). All ASEAN activity was defined as obtaining <60 min of physical activity per
countries from which GSHS datasets were publicly available were day on at least 5 d/week (Guthold et al. 2010; Prochaska et al.
included in the analysis. Details and data of the GSHS can be 2001). ‘Sedentary’ leisure time behaviour was defined as spending
accessed online (CDC 2015). A two-stage cluster sample design 3 or more hours per day sitting (Guthold et al. 2010).

Table 1. Variable description.

Variables Question Response options
Suicidal ideation ‘During the past 12 months, did you ever seriously consider 1 ¼ yes, 2 ¼ no
attempting suicide?’
Hunger ‘During the past 30 days, how often did you go hungry 1 ¼ never to 5 ¼ always (coded 1–3 ¼ 0 and 4–5 ¼ 1)
because there was not enough food in your home?’
Psychosocial distress indicators
Close friends ‘How many close friends do you have?’ 1 ¼ 0 to 4 ¼ 3 or more (coded 1 ¼ 1 and 2–5 ¼ 0)
Lonely ‘During the past 12 months, how often have you felt lonely?’ 1 ¼ never to 5 ¼ always (coded 1–3 ¼ 0 and 4–5 ¼ 1)
Bullied ‘During the past 30 days, on how many days were you 1 ¼ 0 d to 7 ¼ all 30 d (coded 1 ¼ 0 and 2–7 ¼ 1)
bullied?’
Physically attacked ‘During the past 12 months, how many times were you phys- 1 ¼ 0 to 8 ¼ 12 or more times (coded 1 ¼ 0 and
ically attacked?’ 4–5 ¼ 1)
In a physical fight ‘During the past 12 months, how many times were you in a 1 ¼ 0 to 8 ¼ 12 or more times (coded 1–3 ¼ 0 and
physical fight?’ 2–8 ¼ 1)
Social-environmental factors
Parental or guardian supervision ‘During the past 30 days, how often did your parents or 1 ¼ never to 5 ¼ always (coded 1–3 ¼ 0 and 4–5 ¼ 1)
guardians check to see if your homework was done?’
Parental or guardian connectedness ‘During the past 30 days, how often did your parents or 1 ¼ never to 5 ¼ always (coded 1–3 ¼ 0 and 4–5 ¼ 1)
guardians understand your problems and worries?’
Parental or guardian bonding ‘During the past 30 days, how often did your parents or 1 ¼ never to 5 ¼ always (coded 1–3 ¼ 0 and 4–5 ¼ 1)
guardians really know what you were doing with your free
time?’
Peer support ‘During the past 30 days, how often were most of the stu- 1 ¼ never to 5 ¼ always (coded 1–3 ¼ 0 and 4–5 ¼ 1)
dents in your school kind and helpful?’
Current smoking cigarettes ‘During the past 30 days, on how many days did you smoke 1 ¼ 0 d to 7 ¼ all 30 d (coded as 1 ¼ 0 and 2–7 ¼ 1)
cigarettes?’
Current other tobacco use ‘During the past 30 days, on how many days did you use any 1 ¼ 0 days to 7 ¼ all 30 d (coded as 1 ¼ 0 and
other form of tobacco, such as chewing tobacco leaves?’ 2–7 ¼ 1)
Ever got drunk ‘During your life, how many times did you drink so much 1 ¼ 0 to 4 ¼ 10 or more times (coded 1 ¼ 0 and
alcohol that you were really drunk?’ 2–4 ¼ 1)
Truancy ‘During the past 30 days, on how many days did you miss 1 ¼ 0 d to 5 ¼ 10 or more days (coded 1 ¼ 0 and
classes or school without permission?’ 2–5 ¼ 1)
Physical activity ‘During the past 7 days, on how many days were you physic- 0 ¼ 0 d to 8 ¼ 7 d (coded 0–4 ¼ 1 and 5–7 ¼ 0)
ally active for a total of at least 60 minutes per day?’
Sedentary leisure time behaviour ‘How much time do you spend during a typical or usual day 1 ¼ less than 1 h/d … 3 ¼ 3 to 4 h/d … 6 ¼ 8 or more
sitting and watching television, playing computer games, hours a day (coded as 1–2 ¼ 0 and 3–6 ¼ 1)
talking with friends, or playing cards?’
Height ‘How tall are you without your shoes on?’
Weight ‘How much do you weigh without your shoes on?’
 INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 3

Data analysis Prevalence of suicidal ideation

The overall prevalence of suicidal ideation in the past 12 months
Data analysis was conducted using STATA software version 13.0
across seven ASEAN countries was 12.3%, significantly higher in
(Stata Corporation, College Station, TX). This software provides
girls (15.1%) than boys (9.3%) (p < .001). Among seven ASEAN
robust standard errors that account for the sampling design, i.e.
countries with the highest prevalence of suicidal ideation was in
cluster sampling owing to the sampling of school classes. In order
the Philippines (17.0%) and Vietnam (16.9%) and the lowest in
to compare study samples across countries each country sample
Myanmar (1.1%) and Indonesia (4.2%). Although in all countries
was restricted to the age group 13–15 years, younger and older
except for Thailand, the prevalence of suicidal ideation was higher
participants were excluded from the analyses. Associations
in girls than in boys, this was only significant in Malaysia,
between socio-demographics, psychosocial distress indicators,
Philippines and Vietnam (see Table 3).
social-environmental factors and suicidal ideation among school
Table 4 gives the descriptive statistics of the independent
children were evaluated calculating odds ratios (OR). Multivariable
variables.
logistic regression was used for the evaluation of the impact of
explanatory variable for suicidal ideation (binary dependent vari-
Associations with suicidal ideation. Multivariable logistic regres-
able) for all participants, and for boys and girls separately. In the
sion analysis, female gender, older age (14 or 15 years), living in a
analysis, weighted percentages are reported. Missing data were
lower middle income country, having no friends, loneliness, bully-
excluded by listwise deletion of cases with missing values. The
ing victimisation, having been in a physical fight in the past
reported sample size refers to the sample that was asked the tar-
12 months, lack of parental or guardian support, tobacco use and
get question. The two-sided 95% confidence intervals are
having a history of ever got drunk were associated with suicidal
reported. The p value less or equal to 5% is used to indicate stat-
ideation. Compared with girls, among boys having no close
istical significance. Both the reported 95% confidence intervals
friends and school attendance (no truancy) and compared with
and the p value are adjusted for the multi-stage stratified cluster
boys, among girls older age and coming from a low or lower mid-
sample design of the study.
dle income country were associated with suicidal ideation
(see Table 5).
Further, separate logistic regression models were fitted for
Results each study country (see Table 6), which are pretty similar to the
overall models. While most individual countries showed an
Sample characteristics
increase of suicidal ideation with age, as in the pooled analysis,
The total sample included 30,284 school children aged 13–15 the prevalence of suicidal ideation decreased with age in Vietnam.
years from seven ASEAN countries. The sample size in individual Moreover, in the pooled sample no association was found
countries ranged from 1734 in Cambodia to 16,095 in Malaysia, between attacked, sedentary leisure time behaviour and suicidal
14,750 (48.5%) were boys and 15,430 (51.5%) were girls, and the ideation, while significant associations were found between hav-
overall mean age 14.1 years (SD ¼ 0.8) (see Table 2). ing been attacked and suicidal ideation in Malaysia and Myanmar,

Table 2. Details of participating country samples included in the analyses (age 13–15 years only) (N ¼ 30284).
Country Overall Sample
Study country Study year income levela response rate (13–15 years) Male Age in years
% N % M (SD)
Cambodia 2013 LMI 85 1734 49.1 14.1 (0.8)
Indonesia 2007 LMI 93 2867 49.5 13.9 (0.7)
Malaysia 2012 UMI 89 16,095 49.5 14.0 (0.8)
Myanmar 2007 LMI 95 1983 50.0 13.9 (0.8)
Philippines 2011 LMI 82 3640 48.3 14.1 (0.8)
Thailand 2008 UMI 93 2223 49.2 13.9 (0.8)
Vietnam 2013 LMI 96 1742 46.6 14.5 (0.5)
All – – – 30,284 48.5 14.1 (0.8)
LMI: lower middle income; UMI: upper middle income; NA: not available
a
The World Bank (2016).

Table 3. Descriptive data of suicidal ideation by country and sex in school-going adolescents aged 13–15 years.
Suicidal ideation
All Boys Girls
Country % (95% CI) OR (95% CI) % (95% CI) % (95% CI)
Cambodia 6.4 (5.6–7.2) 1 (Reference) 5.5 (4.2–7.2) 7.3 (6.1–8.7)
Indonesia 4.2 (3.1–5.7) 0.71 (0.47–1.10) 3.5 (2.3–5.4) 4.9 (3.8–6.5)
Malaysia 7.9 (7.3–8.6) 1.46 (1.10–1.92)a 6.6 (5.9–7.5) 9.2 (8.4–10.0)
Myanmar 1.1 (0.8–1.7) 0.13 (0.07–0.25)b 1.1 (0.7–1.8) 1.2 (0.7–1.9)
Philippines 17.0 (15.1–19.1) 3.36 (2.49–4.54)b 12.0 (10.5–13.7) 21.8 (18.7–25.2)
Thailand 8.8 (7.7–10.1) 1.61 (1.18–2.20)b 9.9 (8.5–11.6) 7.7 (5.9–10.0)
Vietnam 16.9 (15.0–19.0) 2.81 (2.01–3.94)b 12.2 (10.0–14.8) 21.1 (18.4–24.0)
All 12.3 (11.4–13.3) – 9.3 (8.4–10.2) 15.1 (13.8–16.6)
CI: confidence interval; OR: odds ratio
a
p < .01.
b
p < .001.
4 K. PELTZER AND S. PENGPID

Table 4. Descriptive statistics of independent variables and by suicidal ideation.

Total sample
Suicidal ideation
All Boys Girls
Variable N (%) N (%) N (%) N (%)
Socio-demographics
Gender
Female 15,490 (51.9) 1405 (12.2) – –
Male 14,750 (48.5) 912 (8.1) – –
Age in years
13 9130 (25.8) 570 (7.7) 279 (7.7) 288 (7.6)
14 10,972 (39.2) 876 (10.0) 324 (7.9) 549 (12.0)
15 10,182 (34.9) 879 (12.4) 309 (8.6) 568 (15.9)
Hunger
Never 12,658 (43.1) 792 (8.6) 304 (7.0) 488 (10.0)
Rarely 7876 (25.3) 645 (12.0) 255 (9.4) 388 (14.4)
Sometimes/mostly/always 9663 (31.6) 881 (11.1) 350 (8.6) 526 (13.6)
Country income
Upper middle income 11,966 (39.5) 1288 (8.2) 573 (8.3) 710 (8.0)
Lower middle income 18,318 (60.5) 1037 (10.8) 339 (8.0) 695 (13.4)
Psychosocial distress
No close friends 957 (3.2) 156 (20.2) 91 (21.0) 65 (19.2)
Loneliness 2396 (9.7) 554 (26.9) 188 (21.8) 363 (30.4)
Bullied 7648 (35.6) 990 (14.4) 382 (10.4) 602 (18.3)
Attacked 8804 (31.4) 1314 (13.0) 463 (9.8) 528 (17.8)
In physical fight 8659 (30.1) 1045 (14.7) 503 (11.2) 537 (21.0)
Social-environmental factors
Parental/guardian support index
0 11,177 (39.9) 1220 (15.4) 456 (11.5) 759 (19.3)
1 7929 (26.8) 563 (8.4) 239 (7.1) 322 (9.7)
2–3 9034 (33.3) 406 (5.9) 163 (4.8) 242 (6.8)
Peer support (mostly/always) 12,024 (40.4) 740 (7.8) 243 (6.1) 495 (9.1)
Current tobacco use 2661 (8.8) 354 (18.8) 225 (13.9) 128 (38.3)
Ever got drunk 1914 (10.7) 373 (21.9) 181 (16.4) 191 (30.6)
Truancy 7255 (24.8) 760 (13.4) 301 (9.1) 455 (19.0)
Physical activity <60 min/d on at least 5 d/week 23,590 (80.4) 1866 (10.6) 685 (8.1) 1174 (12.2)
Sitting (
3 h/d) 10,896 (33.0) 1002 (12.1) 362 (8.5) 636 (15.1)
BMI overweight or obesity 4823 (9.9) 362 (10.7) 154 (9.0) 208 (12.7)

and between sedentary leisure time behaviour and suicidal idea- ASEAN member states. Looking at individual ASEAN states, the
tion in Malaysia. preponderance of suicidal ideation among girls was only signifi-
cant in Malaysia, Philippines and Vietnam while for the other
countries it was not significantly different. Even in Thailand the
Discussion
prevalence of suicidal ideation was higher (although not signifi-
The overall prevalence of suicidal ideation in the past 12 months cantly) in boys than in girls. In a previous study among school
across seven ASEAN countries was 12.3%, which seem lower than adolescents in Vietnam male gender was also positively associated
in other mostly developing countries (>15%) (Page & West 2011; with suicidal ideation (Jegannathan & Kullgren 2011), sex-/gender-
Page et al. 2013; Randall et al. 2014; Sharma et al. 2015) and defined social expectations and norms have been thought to
mostly developed countries (>19%) (Evans et al. 2005). The study influence suicidal behaviour (Rhodes et al. 2014). This study found,
found a large country variation of suicidal ideation, with the high- in agreement with several previous studies (Page & West 2011;
est prevalence in the Philippines (17.0%) and Vietnam (16.9%) and Page et al. 2011) that older age was associated with adolescent
the lowest in Myanmar (1.1%) and Indonesia (4.2%). These large suicidal ideation. Contrary to some previous studies (Ke & Ford-
country differences are difficult to understand. It is possible that Jones 2015; Lee & Choi 2015), this study did not find an associ-
social and cultural factors play a role in explaining these differen- ation between lower socioeconomic status, food insecurity or hun-
ces. It appears that, for example, in largely Buddhist countries ger and suicidal ideation. However, girls living in low or lower
(Cambodia, Myanmar and Thailand) and Muslim countries middle income ASEAN countries had an increased odds of suicidal
(Indonesia and Malaysia) suicidal ideation rates were lower than in ideation than girls in upper middle income ASEAN countries.
a mainly Christian (Catholic) country (Philippines) and mainly Regarding psychosocial distress, this study found a strong asso-
none, unaffiliated religion country (Vietnam) (Central Intelligence ciation between loneliness and suicidal ideation, and in addition,
Agency 2015). Moreover, the country-specific estimates of adoles- among boys, having no close friends with suicidal ideation. The
cent suicide ideation (Myanmar the lowest and the Philippines the association between psychosocial distress indicators and suicidal
highest) did not correlate at all with national estimates of suicide ideation have been consistently confirmed in various studies (e.g.
deaths (with Myanmar the highest and the Philippines the lowest) (Chen et al. 2005; Rudatsikira et al. 2007; Cheng et al. 2009;
among ASEAN countries (WHO 2014). Clearly, more research is Mahfoud et al. 2011; Page & West 2011; Page et al. 2011; Le et al.
needed to understand cross-country differences in suicidal idea- 2012; Lee & Choi 2015; Peltzer & Pengpid 2012; Wilson et al. 2012;
tion in ASEAN member states. Ahmad et al. 2014; Sharma et al. 2015). The relationship found in
Further, the study found, in agreement with some studies this study between suicidal ideation and feeling lonely and having
(Page & West 2011; Ahmad et al. 2014) that the prevalence of sui- no close friends may refer to social isolation which will need
cidal ideation was higher in girls than boys across the seven to be addressed in suicide prevention (Page & West 2011).
 INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 5

Table 5. Associations between socio-demographic factors, psychosocial distress, social-environmental factors and suicidal ideation prevalence
in school-going adolescents from seven ASEAN countries.
All Boys Girls
Variable AOR (95% CI) AOR (95% CI) AOR (95% CI)
Socio-demographics
Gender
Female 1 (Reference) – –
Male 0.43 (0.35–0.52)c – –
Age in years
13 1 (Reference) 1 (Reference) 1 (Reference)
14 1.48 (1.22–1.81)c 1.08 (0.74–1.59) 1.74 (1.38–2.20)c
15 1.64 (1.29–2.10)c 1.01 (0.67–1.52) 2.13 (1.50–3.01)c
Hunger
Never 1 (Reference) 1 (Reference) 1 (Reference)
Rarely 1.01 (0.81–1.26) 1.00 (0.68–1.45) (0.77–1.31)
Sometimes/mostly/always 1.01 (0.84–1.22) 1. (0.67–1.34) 1.05 (0.82–1.35)
Country income
Upper middle income 1 (Reference) 1 (Reference) 1 (Reference)
Lower middle income 1.52 (1.27–1.82)c 1.04 (0.78–1.38) 1.94 (1.52–2.47)c
Psychosocial distress
No close friends (base ¼ yes) 1.65 (1.10–2.46)a 2.27 (1.38–3.73)c 1.23 (0.67–2.26)
Loneliness (base ¼ no) 3.19 (2.47–4.11)c 3.61 (2.42–5.38)c 2.99 (2.19–4.07)c
Bullied (base ¼ no) 1.46 (1.21–1.76)c 1.40 (1.00–1.97)a 1.47 (1.17–1.85)c
Attacked (base ¼ no) 1.13 (0.93–1.38) 1.11 (0.79–1.58) 1.17 (0.92–1.48)
In physical fight (base ¼ no) 1.47 (1.24–1.75)c 1.58 (1.17–2.13)b 1.39 (1.05–1.84)a
Social-environmental factors
Parental/guardian support index
0 1.00 1 (Reference) 1 (Reference)
1 0.55 (0.45–0.68)c 0.64 (0.46–0.90)c 0.50 (0.38–0.67)c
2–3 0.47 (0.36–0.62)c 0.51 (0.36–0.77)c 0.45 (0.34–0.60)c
Peer support (mostly/always) (base ¼ never to sometimes) 0.89 (0.73–1.09) 1.13 (0.82–1.56) 0.80 (0.63–1.03)
Current tobacco use (base ¼ no) 1.65 (1.23–2.22)c 1.51 (1.04–2.20)a 2.14 (1.35–3.39)c
Ever got drunk (base ¼ no) 2.09 (1.41–2.66)c 2.09 (1.41–3.09)c 2.08 (1.50–2.87)c
Truancy (base ¼ no) 0.97 (0.78–1.20) 0.67 (0.48–0.94)a 1.19 (0.92–1.54)
Physical activity <60 min/d on at least 5 d/week (base ¼5–7 d) 1.05 (0.86–1.28) 1.04 (0.78–1.37) 1.12 (0.81–1.54)
Sitting (
3 h/d) (base ¼ less than 3 h) 1.13 (0.94–1.36) 0.98 (0.71–1.36) 1.22 (0.98–1.52)
BMI overweight or obesity (base ¼ no) 1.07 (0.80–1.43) 0.87 (0.56–1.35) 1.21 (0.85–1.71)
UOR: unadjusted odds ratio; AOR: adjusted odds ratio; CI: confidence interval
a
p < .05.
b
p < .01.
c
p < .001.

Other psychosocial distress indicators, including being bullied and problem behaviours, which may need to be addressed in a com-
having been in a physical fight, have also been found associated bined way in interventions. The finding that several problem
with suicidal ideation. This result has also been confirmed in sev- behaviours, including loneliness, having no close friends, bullying
eral studies (Chen et al. 2005; Mahfoud et al. 2011; Page & West victimisation, having been in a physical fight, tobacco use and
2011; Page et al. 2011; Wilson et al. 2012; Phuong et al. 2013; having been drunk, were associated with suicidal ideation may
Ahmad et al. 2014; Sharma et al. 2015). Having been attacked was indicate that suicide prevention should target these problem
in this study, except for in Malaysia, not found to be associated behaviours among adolescents in ASEAN countries.
with suicidal ideation in the pooled analysis, as found in a study
among adolescents in urban Peru (Sharma et al. 2015).
In terms of social-environmental factors associated with suicidal Study strength and limitations
ideation, this study found, in agreement with several studies The strength of the use of GSHS was standardised methods and
(Cheng et al. 2009; Mahfoud et al. 2011; Le et al. 2012; Peltzer & questionnaires were used across study countries. The study survey
Pengpid 2012), a strong association between lack of parental or was limited to 13–15 year-old school-going youth and cross-sec-
guardian support and suicidal ideation. Lack of peer support was tional and therefore no causal inferences can be made. Further,
not found to be related to suicidal ideation, as found in a previ- the GSHS is based on self-reports of behaviour, including mental
ous study (Cheng et al. 2009). Consistent with a number of studies health risks and body weight and height, and could lead to bias
(Juan et al. 2010; Innamorati et al. 2011; Mahfoud et al. 2011; in reporting. Since the time span for the data collection in the dif-
Page & West 2011; Page et al. 2011; Le et al. 2012; Peltzer & ferent study countries varied from 2007 to 2013, results from
Pengpid 2012; Wilson et al. 2012; Kim et al. 2014; Lee & Choi cross-country comparisons might have been biased due to period
2015; Sharma et al. 2015) this study found an association between effect. Further, this study used various time frames to collect data
substance use (tobacco use and ever got drunk) and suicidal idea- on dependent and independent variables, i.e. 12-month suicidal
tion. Physical inactivity, sedentary leisure time behaviour and over- ideation, 30-d bullying, 7-d physical activity. Therefore, significant
weight or obese were not correlated with suicidal ideation in this links between suicidal ideation and risk factors with different time
study, unlike in some previous studies (Juan et al. 2010; Page frames might be misleading. Finally, the study did not assess
et al. 2011; Kim et al. 2014 ). The correlation between substance depression, which is a common psychological risk factor for sui-
use and other risk behaviours such as in a physical fight and bul- cidal ideation, yet loneliness was assessed which can be consid-
lying and suicidal ideation may be referring to a cluster of ered a proxy of depression.
 6

Table 6. Associations between socio-demographic factors, psychosocial distress, social-environmental factors and suicidal ideation prevalence in school-going adolescents from seven ASEAN countries.
Cambodia Indonesia Malaysia Myanmar
Variable AOR (95% CI) AOR (95% CI) AOR (95% CI) AOR (95% CI)b Philippines Thailand Vietnam
K. PELTZER AND S. PENGPID

Socio-demographics
Gender
Female 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Male 0.52 (0.27–1.00) 0.37 (0.21–0.64) 0.50 (0.40–0.61) 0.67 (0.14–3.28) 0.31 (0.21–0.46) 0.90 (0.46–1.75) 0.49 (0.34–0.72)
Age in years
13 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
14 1.31 (0.70–2.47) 2.02 (0.97–4.22) 1.18 (0.92–1.49) 0.50 (0.08–3.32) 1.60 (1.13–2.27) 0.98 (0.64–1.51) 0.24 (0.09–0.64)
15 1.66 (0.66–4.19) 2.32 (1.02–5.27) 1.21 (0.92–1.58) 0.52 (0.07–3.81) 1.82 (1.35–2.46) 0.54 (0.28–1.02) 0.24 (0.07–0.83)
Hunger
Never 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
Rarely 0.74 (0.22–2.50) 0.63 (0.28–1.42) (0.76–1.18) 1.46 (0.29–7.40) 0.79 (0.55–1.14) 0.87 (0.50–1.51) 1.34 (0.81–2.23)
Sometimes/mostly/always 0.73 (0.37–1.46) 0.59 (0.33–1.07) 1.10 (0.87–1.41) 1.62 (0.57–4.65) 0.91 (0.73–1.14) 0.85 (0.50–1.45) 1.53 (0.96–2.43)
Psychosocial distress
No close friends (base ¼ yes) 2.31 (0.87–6.18) 3.16 (0.52–19.34) 1.67 (1.09–2.58) 2.36 (0.61–9.07) 1.35 (0.73–2.48) 1.30 (0.48–3.55) 1.38 (0.57–3.35)
Loneliness (base ¼ no) 3.36 (0.94–12.00) 1.89 (0.65–5.51) 3.40 (2.63–4.40) 4.10 (0.38–44.16) 3.06 (1.99–4.70) 3.67 (1.75–7.72) 3.44 (2.08–5.68)
Bullied (base ¼ no) 2.15 (1.12–4.16) 3.00 (1.40–6.46) 2.09 (1.65–2.64) 1.70 (0.25–11.49) 1.58 (1.22–2.04) 1.60 (0.93–2.75) 1.33 (0.82–2.15)
Attacked (base ¼ no) 1.15 (0.52–2.53) 0.82 (0.52–1.27) 1.61 (1.28–2.02) 5.51 (1.25–24.24) 1.18 (0.88–1.60) 1.33 (0.70–2.49) 1.00 (0.62–1.61)
In physical fight (base ¼ no) 2.06 (0.99–4.29) 1.71 (0.89–3.28) 1.48 (1.18–1.86) 0.49 (0.03–8.26) 1.37 (1.03–1.81) 1.55 (0.99–2.42) 1.44 (0.94–2.19)
Social-environmental factors–
Parental/guardian support index
a
0 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference)
1 0.68 (0.36–1.29) 0.81 (0.65–1.02) 2.31 (0.40–13.81) 0.56 (0.38–0.84) 0.88 (0.50–1.54) 0.44 (0.30–0.64)
2–3 0.71 (0.38–1.31) 0.61 (0.47–0.80) 0.49 (0.09–2.62) 0.60 (0.34–1.04) 0.43 (0.19–1.15) 0.48 (0.31–0.75)
a
Peer support (mostly/always) 0.68 (0.36–1.29) 0.90 (0.74–1.10) 1.61 (0.49–5.28) 0.83 (0.63–1.09) 0.81 (0.49–1.33) 0.96 (0.60–1.54)
(base ¼ never to sometimes)
Current tobacco use (base ¼ no) 7.82 (2.50–24.52) 1.74 (0.70–4.51) 1.31 (0.97–1.76) 1.03 (0.08–12.69) 1.94 (1.27–2.96) 2.37 (0.99–5.69) 2.33 (1.08–5.02)
Ever got drunk (base ¼ no) 0.99 (0.34–2.89) 2.05 (0.84–4.99) 1.90 (1.40–2.59) 0.95 (0.05–17.81) 1.45 (1.01–2.06) 1.72 (1.06–2.79) 2.02 (1.07–3.79)
a
Truancy (base ¼ no) 1.16 (0.61–2.23) 1.17 (0.94–1.45) 1.52 (0.22–10.44) 1.03 (0.72–1.47) 0.87 (0.48–1.58) 1.10 (0.70–1.82)
Physical activity <60 min/d on at 0.75 (0.23–2.45) 0.72 (0.31–1.64) 0.92 (0.76–1.12) 1.38 (0.28–5.56) 0.86 (0.58–1.26) 1.42 (0.80–2.52) 1.13 (0.77–1.65)
least 5 d/week (base ¼5–7 days)
Sitting (
3 h/d) (base ¼ less than 3 h) 1.95 (0.83–4.57) 0.94 (0.51–1.74) 1.37 (1.15–1.62) 2.03 (0.17–24.65) 1.13 (0.82–1.56) 0.94 (0.56–1.57) 1.13 (0.77–1.65)
BMI overweight or obesity 1.05 (0.27–4.11) 1.17 (0.47–2.92) 1.17 (0.94–1.45) 1.21 (0.85–1.71) 0.82 (0.45–1.51) 0.79 (0.55–1.14) 1.26 (0.62–2.55)
(base ¼ no)
UOR: unadjusted odds ratio; AOR: adjusted odds ratio; CI: confidence interval
a
Not assessed in Cambodia sample.
b
Low sample size of suicidal ideation (N ¼ 30, 1.1%); bold letters show significant associations.
 INTERNATIONAL JOURNAL OF PSYCHIATRY IN CLINICAL PRACTICE 7

Conclusions Evans E, Hawton K, Rodham K, Deeks J. 2005. The prevalence of

suicidal phenomena in adolescents: a systematic review of
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psychosocial distress, which can help in guiding health promotion Physical activity and sedetnary behavior among schoolchildren:
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 A high prevalence of suicidal ideation in the past 12 Hawton K, Saunders KE, O'Connor RC. 2012. Self-harm and suicide
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15.1% in girls and 9.3% in boys. Innamorati M, De Leo D, Rihmer Z, Serafini G, Brugnoli R, Lester D,
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Philippines (17.0%) and Vietnam (16.9%). cidal ideation in school-aged children 12–15 years old: impact
 Risk factors for suicidal ideation include: female gender, of cultural differences. J Addict Dis. 30:359–367.
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