The mental health of students has become an increasingly prominent issue in South Africa, with some academics suggesting suicidal behaviour has reached epidemic proportions on university campuses, and a recent survey concluding that scalable prevention interventions are urgently needed to reach the large number of youngsters who report suicidal ideation with intent.
Worldwide, suicide is the second leading cause of death among young people aged 15-29, a third of these occurring among adolescents.
There has been growing awareness globally of these high statistics, with one study of 13 984 first-year students across 19 universities in eight countries reporting 12-month prevalence estimates for suicidal ideation, plan and attempt, of 17.2%, 8.8% and 1.0%, respectively.
However, much of what is known about the epidemiology of suicidal behaviour among students comes from high-income Western countries, with comparatively little good-quality data from countries in Africa, and reliable epidemiological data are vital to plan evidence-based suicide prevention programmes and establish priorities for student mental health, especially in resource-constrained environments such as Africa.
University campuses are therefore potentially good sites for early identification and targeted interventions for young people at risk of suicidal behaviour, said the researchers of the recent survey, who added that the first onset of suicidal ideation and behaviour is typically during late adolescence when many young people transition into higher education.
In their paper, which appeared in the South African Medical Journal, the study team, a collaboration from the South African Medical Research Council (SAMRC), the universities of Stellenbosch, Cape Town and Boston College, USA, said suicidal ideation (defined by the US CDC as “thoughts of engaging in suicide-related behaviour”), is an important focus of suicide prevention, and a widely used, albeit crude, indicator of the number of people at risk of suicide.
A previous study of first-year students from two SA universities reported 12-month prevalence estimates for suicidal ideation of 40.9%, while another reported two-week prevalence estimates of 24.5%.
But none has reported accurate estimates of the proportion of SA students who have suicidal ideation and intend to act on these thoughts. It therefore remains unclear how many require immediate interventions and how best scarce financial resources should be directed to targeted prevention interventions.
The aim of this study was to establish the need prevention interventions by estimating the 30-day prevalence of suicidal ideation, frequency of ideation and self-reported intention to act on ideation in the next year among a national sample of undergraduate students (N=28 268) from 19 universities countrywide.
The team also investigated differences in these dimensions across different types of universities in SA and explored socio-demographic correlates of suicidal ideation and intent. They focused on 30-day prevalence of suicidal ideation (i.e. current suicidal ideation) given the research that this dimension of suicidality is strongly associated with transition to suicidal behaviour among adolescents, and given their aim to quantify the number of students at imminent risk of engaging in suicidal behaviour.
The data presented were collected in an SAMRC-funded National Student Mental Health Survey as part of the ongoing work of the World Health Organisation World Mental Health Surveys International College Student Initiative (WMH-ICS).
All 26 public universities in SA were invited to participate, of which 17 sent out emails inviting their undergraduate students to complete an anonymous online survey. Data were collected between April 2020 and October 2020.
The researchers assessed passive suicidal ideation (i.e. ‘did you ever in your life wish you were dead or would go to sleep and never wake up?’) and active suicidal ideation (‘did you ever have thoughts of killing yourself ?’).
Students who endorsed either of these items were then asked if these had occurred in the preceding 30 days and if so, how frequently these thoughts occurred (all or almost all of the time; most of the time; some of the time; a little of the time; none of the time), and perceived intent to act on suicidal ideation in the following 12 months (i.e. ‘in the next 12 months, what is the likelihood that you will act on those thoughts of killing yourself ?’ – very likely; somewhat likely; not very likely; not at all likely).
For the purposes of the analysis, students who indicated that they were very likely to act on their ideation were defined as having ‘high intent to act’, while those who indicated being ‘very’ or ‘somewhat’ likely to act were defined as having ‘some intent to act’.
Data were weighted within institutions using standard calibration methods to adjust for differences between survey respondents and the population on the cross-classification of gender, population group and academic year of study.
The survey was completed by 28 516 students, the overall response rate being 3.5%, ranging from a high of 10.5% at Rhodes University and a low of 0.6% at Mangosuthu University of Technology.
A total of 24.4% (SE 0.3) of students reported suicidal ideation in the preceding 30 days, with statistically significant differences across institutions (c2(3)=263.6, p<0.05) ranging from highs of 30.3% (SE 0.8) at HWIs (historically white institutions) and 29.4% (SE 1.6) at UTs (universities of technology), to a low of 21.1% (SE 0.4) (standard error) at the DLU (distance learning university).
In terms of frequency of suicidal ideation, in the total sample, 2.1% (SE 0.1) reported thinking about suicide all/almost all the time, while the proportion who thought about suicide most, some and little of the time were 4.1% (SE 0.1), 7.2% (SE 0.2) and 10.9% (SE 0.3), respectively.
Students at UTs reported the highest frequency of suicidal ideation, with 4.3% (SE 0.8) thinking about suicide all/almost all the time, and 5.4% (SE 0.6) most of the time.
At the other end of the spectrum, the frequency of suicidal ideation was lowest at the DLU, with 1.5% (SE 0.1) thinking about suicide all/almost all the time, and 3.2% (SE 0.2) most of the time.
Among students with suicidal ideation in the preceding 30 days, 33.7% (SE 3.0) reported being very likely to act on their thoughts, while 29.1% (SE 3.2), 24.2% (SE 2.7) and 13.0% (SE 2.3) reported being somewhat likely, not very likely and not at all likely to act on their ideation, respectively.
The proportion of students very likely or somewhat likely to act on their suicidal ideation was markedly higher among those who reported more frequent ideation compared with those with less frequent ideation.
Among students who reported suicidal ideation all/almost all of the time in the past 30 days, as many as 33.7% (SE 3.0) said they were very likely to act on these thoughts compared with 9.2% (SE 1.2) of those with ideation most of the time, 3.1% (SE 0.5) among those with ideation some of the time and 2.0% (SE 0.3) among those with ideation little of the time.
Similarly, the proportion of students reporting to be somewhat likely to act on their suicidal ideation was 29.1% (SE 3.2) among those with ideation all/almost all the time, 33.8% (SE 2.6) among those with ideation most of the time, but only 17.8% (SE 1.2) among those with ideation some of the time and 5.8% (SE 0.7) among those with ideation little of the time.
By comparison, among students who said they were not at all likely to act on their thoughts, only 13.0% (SE 2.3) reported ideation all/almost all the time, 21.7% (SE 1.9) most of the time, 34.6% (SE 2.0) some of the time and 59.8% (SE 1.8) among those with ideation little of the time.
Compared with males, risk of high intent was elevated among female (RR 1.9, 95% CI 1.3 – 2.7) and gender non-conforming students (RR 4.3, 95% CI 1.4 – 13.0), as well as among black students compared with white students (RR 3.6, 95% CI 1.9 – 7.1), students whose parents did not progress to secondary school compared with students whose parents had a university education (RR 1.6, 95% CI 1.0 – 2.5) and sexual minority students compared with heterosexual students (RR 1.9, 95% CI 1.3 – 2.6).
Black students with 30-day suicidal ideation were 2.7 (95% CI 1.4 – 5.1) times more likely than their white counterparts to report high intent to act on their thoughts. Similarly, students with suicidal ideation whose parents had less than secondary education were 1.5 (95% CI 1.0 – 2.1) times more likely to report high intent compared with ideators whose parents had tertiary education.
This study was the first of its kind to assess 30-day prevalence of suicidal ideation, frequency of ideation, and intent to act on ideation in the next 12 months.
In summary, almost a quarter (24.4%) reported suicidal ideation in the preceding 30 days, with as many as 6.2% thinking about suicide all or most of the time. These estimates are markedly higher than the 12-month prevalence of 9.1% for suicidal ideation among the general population reported in the SA Stress and Health Study.
There were significant variations in prevalence estimates across the different kinds of universities, with suicidal ideation being more prevalent in HWIs and UTs and lowest in the DLU.
Unsurprisingly, students with more frequent suicidal ideation reported higher intent to act on these thoughts in the following year.
This study had several limitations, including the use of non-probability sampling, a reliance on self-report measures, and the fact that nine universities in the country did not participate.
The researchers’ reliance on a convenience sample, with the relatively low and variable response rates across institutions, limits the results’ generalisability, although they had attempted to correct for this to the extent possible by weighting the data.
Data suggest that a substantial number require urgent indicated suicide prevention interventions (approximately 5.4% of undergraduates who report any intention to act on their ideation), providing sound evidence that suicide prevention should be a priority at local universities and highlighting the need for novel scalable interventions to meet this large need.
Research is needed to understand the reason for the elevated risk observed among some groups of students, most notably females, gender non-conforming, black, first-generation and sexual minority students in SA
Prevalence and correlates of 30-day suicidal ideation and intent: Results of the South African National Student Mental Health Survey
J Bantjes MJ Kessler, X Hunt, RC Kessler, DJ Stein.
Published in the SA Medical Journal on 8 March 2023
Although suicide prevention is recognised as a priority among university students in South Africa (SA), it is unclear what proportion require urgent indicated interventions and what the characteristics are of these students.
To assess the prevalence and socio-demographic correlates of 30-day suicidal ideation, frequency of ideation and self-reported intention to act on ideation in the next year among a national sample of SA university students.
Self-report cross-sectional data were collected online from students (N=28 268) at 17 universities across SA as part of the national student mental health survey. Students reported suicidal ideation in the past 30 days, frequency of ideation and intention to act on ideation in the next year. Data were weighted within institutions by gender and population group, and across the four main types of universities (historically white, historically disadvantaged, technical and distance learning) to correct for response rate discrepancies. Prevalence was estimated with these weighted in the total sample and across types of universities. Poisson regression with robust error variances was used to investigate associations of sociodemographic characteristics with ideation and intention to act on suicidal ideation. Results are reported as relative risks (RRs) with design-based 95% confidence intervals (CIs).
Thirty-day prevalence of suicidal ideation was 24.4% (standard error (SE) 0.3), with 2.1% (SE 0.1) and 4.1% (SE 0.1), respectively, reporting suicidal ideation all/almost all the time, or most of the time. A total of 1.5% (SE 0.1) of respondents reported being very likely to act on their suicidal ideation, while 3.9% (SE 0.2) were somewhat likely, 8.7% (SE 0.2) were not very likely and 85.8 (SE 0.5) either reported no suicidal ideation or that they were not at all likely to act on this ideation. Risk of suicidal ideation with high intent in the total sample was elevated among females (RR 1.9, 95% CI 1.3 – 2.7) and gender non-conforming students (RR 4.3, 95% CI 1.4 – 13.0) relative to males, black African students compared with white students (RR 3.6, 95% CI 1.9 – 7.1), students whose parents did not progress to secondary school compared with students whose parents had a university education (RR 1.6, 95% CI 1.0 – 2.5) and sexual minority students compared with heterosexual students (RR 1.9, 95% CI 1.3 – 2.6). Among students with 30-day ideation (controlling for frequency of ideation), only two of these predictors of high intent remained significant: identifying as black African (RR 2.7, 95% CI 1.4 – 5.1), and having parents with less than secondary education (RR 1.5, 95% CI 1.0 – 2.1).
Scalable suicide prevention interventions are needed to reach the large number of SA students who report suicidal ideation with intent.
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