Risk and protective factors in triethnic adolescent suicide attempts

Nursing Critique

Comparison of the Effect of Risk and Protective Factors on Suicide Attempts in a Group of Triethnic Adolescents Divided According to Race, Gender and Age.

This is an critique on a research paper about self-reported suicide attempts in a triethnic group of adolescents. 2 references are given.

The purpose of the following paper is to evaluate and critique a study performed on a group of students pertaining to adolescent suicide. This study attempts to examine the multiple factors affecting recent suicide attempts in adolescents from three different ethnic backgrounds. The resilience model is used to describe and analyze the relationships between these variables categorized according to sex, age and race. A group of 10,059 school children from the 7th, 9th, and 11th grade in Connecticut were surveyed in 1996 and data from the African-American, Hispanic Latino and American Caucasian respondents was analyzed using bi -- and multivariate methods. [Rew, et al., 2001] The study attempted to determine the degree to which each factor had affected the tendency to attempt suicide in this group of subjects. It was found that the tendency to attempt suicide was highest in Hispanic females and least in American Caucasian males. [Rew et al., 2001] The risk factors were identified as a history of previous suicide/attempt in family or friends, physical or sexual abuse and stress or depression while protective variables included social connectedness and spiritual support. [Rew et al., 2001] That significant relationships were found between many of these variables and attempted suicide indicates the validity of applying the resilience model to such behavior and the need for more detailed studies so as to format viable intervention techniques.

Introduction

Adolescent suicide is a major sociological dilemma and one that is growing with time. Past research shows that suicide is amongst the top three causes of death in 15- to 24-year-olds and that this trend is multiplying rapidly in the younger age group. [Rew et al., 2001] Females have been shown to be more prone to attempt suicide and some ethnic minority groups seem to be more affected than others. Not only is this behavior a source of grief to the loved ones but its increasing pattern have also made it an important social, and medical issue. Previous studies have shown that both external and internal factors have a significant effect on the statistics relating to suicide. Data has been collected to show that physical and sexual abuses have a significant relationship to an increase in suicide attempts.[Rew et al., 2001] Feelings of depression, hopelessness and inadequacy are also associated factors to adolescent suicide. It has been seen however that even if these factors are present suicide attempts can be avoided by the influence of social values, religious influences, and peer support or social activities.

This study is an attempt to use this previously gathered information and apply it to ethnic and gender differences. It compares the degree of influence exerted by these variables on adolescent behavior in terms of attempted suicide depending on race and sex. This not only gives insight into patterns in different strata of society but also lays the foundation for further study and perhaps formulation of mechanisms to intervene.

One of the frustrating issues about suicidal behavior is that it is largely preventable given timely intervention and adequate treatment. If the groups more likely to attempt suicide are identified then preventing suicide is made that much easier. It is especially important for medical personnel such as nurses to understand and be able to help apply the principles extracted from this study. These are the people likely to come in contact with adolescents who have been abused, or are under stress. To be able to pick up the signals, or clinical signs particular to adolescents vulnerable to thoughts of suicide and by keeping a high index of suspicion, nurses should be able to provide initial support or facilitate intervention by experts that can deal with this disturbing behavior, such as psychologists.

Purpose

This study was designed to determine the percentage of attempted suicides in adolescents divided according to ethnicity and gender, and to compare the differences in frequency amongst them. Also investigated is the influence of previously identified risk and protective factors on these attempts and to what extent each variable was significant in the different groups.

Problem Statement

This study is an attempt to describe the influence of stress, physical and sexual abuse and history of suicide attempts in family and friends plus protective factors such as religion and social connectedness on frequency of suicide attempts by adolescents from three different ethnic minorities by analyzing data collected from anonymous self-administered surveys using the Cronbach alpha method to form culturally sensitive intervention methods that can be applied practically to reduce suicide attempts.

Theoretical / Conceptual Framework

The analysis of the data collected from this study was based on the formula that attempted suicide amongst adolescents was a result of multiple factors. These included risk factors, protective mechanisms, and sociocultural contextual factors such family dynamics, background, race, other suicides etc.. [Rew et al., 2001]Combined this information formed the Resilience Model which helps identify what intervention can be done to prevent suicide and in which form it would be most beneficial.

Assumptions

The Cronbach's alpha was used as an index of reliability.. [Rew et al., 2001]Using this method it was assumed that certain items (questions) on the survey were actually a measure of a particular factor stated on the Resilience model. Data pertaining to variables affecting attempted suicide was extracted from a survey designed to identify general health needs, health risk behavior and protective mechanisms. Since the attempt was to isolate causes that encourage or prevent suicidal behavior through evaluating an individual's mental and emotional health status extracting information from a non-specific survey is not an unreliable method.

Limitations

The study was confined to adolescents from the Caucasian, Black American and Hispanic Latino backgrounds. These of course are the major ethnic groups in America though Asians are also not far behind. However subsets in these categories also need to be delineated as certain variables such as depression have been found to be more pronounced in Puerto Ricans as compared to Mexican or Cuban Americans. [Oquendo MA, 2001] Thus even the Hispanic Latino category is a generalization. The research was also limited in that it was in the form of a self reported survey obtained from just one area and though the aim was to target all strata of the population how well that was achieved by studying only public schools is yet to be decided. Also the reliability of such variables as stress, depression, family dynamics, and social activities was weak according to the scale indicators.

The source of information was general health status determining survey, not one formulated to extract data on suicidal behavior. There was only one specific question pertaining to suicide," have you attempted to kill yourself in the past 12 months?" This is perhaps too limited. It precludes those individuals who may have attempted it before that period, and those who may have tried just inflicting harm to themselves, or had suicidal thoughts. Thus it ignores the potential cases of attempted suicide.

Hypothesis

The Resilience Model is a reliable means of evaluating the effects of the interaction between sociocontextual factors, risky behavior and protective mechanisms on attempted suicides in adolescents from different ethnic backgrounds. Using the logistic regression method to compare variables means of intervention that are culturally sensitive and that focus on protective mechanisms such as religion, and social activities can be employed.

Definition of Terms

The ability of some adolescents to thrive despite adverse conditions and others to attempt self-harmful behavior as a measure of resilience. Conceptually this was defined as an interaction between risk factors such as physical and sexual abuse, depression, history of suicide attempts in the family or social circle and protective mechanisms such as spiritual and social values. Combined with internal factors such as depression and stress all these factors form a youth resilience model that defines the concept on which suicide preventative strategy could be based.

This concept can be further defined using reliability factors such as Cronbach's alpha and logistical regression to measure the validity and exact extent to which these variables affect suicide attempts. Using these methods to measure reliability and validity of the results an operational definition can be given to the resilience concept.

Research Design

This study was a secondary analysis of previously collected data in the form of a self-administered survey encompassing 10,059 students in public schools across Connecticut. The questions on the survey had been obtained from previous research and from another health survey conducted in Minnesota. [Rew et al., 2001] The items were designed to evaluate adolescent health needs and identify risky behavior and protective mechanisms. This design was at risk of validity due to possible ambiguity of the items, interaction of the variables, inadequate operationalization of the factors involved, and due to the fact that the subjects were self-selected.

Setting

The survey was taken in more than 50 public schools across five geographic service delivery areas of Connecticut in1996. [Rew et al., 2001] The setting encompassed five socioeconomic strata but was limited in geography to one state only and thus also the social environment is limited. The study variables can thus be externally affected.

Population and Sample

The population surveyed was 7th, 9th, and 11th grade public school students belonging to Caucasian, Black American, and Hispanic Latino minorities only. Individuals were chosen by stratified random sampling, which is a method by which subjects are chosen from different sub-groups of a certain population at random. This particular sample was adequate in size consisting of over 10,000 students. Both girls and boys were included, and the population as a whole supposedly consisted of an average group of adolescents in America. However many ethnic minorities were missed and if percentages per population are being considered this could be a significant exclusion and lead to sample bias. The language used in the survey may have influenced the response and the sensitive nature of the questions may have led to a lack of response both factors causing the sample to be biased.

Since the study was to compare adolescent suicide rates in different ethnic groups thus the stratified sample method had the advantage of testing American adolescents yet categorizing them according to race and gender. Thus both the adolescent population and sub-population are assessed at the same time for the effect of the resilience model variables on their attempts at suicide.

This was a survey that retained the anonymity of the subjects and there was no compulsion to answer all the questions as seen by the fact that some data is incomplete for e.g. In questions of physical and sexual abuse. The subjects were randomly chosen and not specifically isolated for certain characteristics that may have been personally embarrassing such as choosing students suspected of; having behavior disturbances, abusive backgrounds, or groups with a higher tendency towards suicide such as gays and lesbians. This protected their right to privacy.

All data was analyzed using the same techniques and the test questions were uniform for all students, formulated at a basic 6th grade level so they would not be misunderstood by any and even translated versions available in Spanish.

Data Collection Methods

The survey was self administered, cross-sectional (attempted once only), multi-variate and conducted on students in classrooms of various public schools in Connecticut in 1996. [Rew et al., 2001] It consisted of questions to evaluate the health status and risk and protective factors related to adolescents. It was a good way of collecting a large amount of information, serious and often personal by retaining anonymity and simplicity. It is made vulnerable however by the possibility of non-response due to inability to answer from lack of comprehension, or unwillingness to respond.

Data collection Instruments

The survey was composed of 225 questions formulated by a statewide advisory body to assess adolescent health needs and risk and protective factors.. [Rew et al., 2001] The questions also attempted to assess the influence of various factors related to the resilience concept on attempted suicide rates. Different variables were measured by previously identified items on the survey and assigned operational significance and analyzed according to subscale reliability using the Cronbach alph method. Keeping the survey in simple, 6th grade level English, providing Spanish translations, and asking questions that could obtain sensitive information indirectly helped reduce the chances of error due to no response, and as the results for the logistic regression of the variables shows support for the resilience method. Logistic regression allows flexibility, prediction of probability for each case, and forming discrete predictions from variables that may be discrete, continuous, dichotomous or mixed. It was thus an ideal method of analysis for this particular study.

Data Analysis

The information gathered was presented in the form of text and also in tables. The questions of percentage of attempted suicides and their comparison in different ethnic backgrounds and gender were answered using both. The variables involved and the interaction and influence of each on the attempted suicide rate and each other was also described and evaluated using tables and reliability factors.

Conclusions were formed on the basis of each piece of data described.

Discussion of Findings

Some of the findings of this study reinforced previous research but other figures gave new insight into future approaches to the problem of attempted suicide. It was found that female had the highest rate of suicide attempts, the same as previous studies but also was discovered that it was the Hispanic Latino girls that were at greatest risk.. [Rew et al., 2001] This could be sample bias but there was a significant disparity in the results so as to make further investigation necessary. The large percentage of sexual abuse in this group is also a possible influential factor that needs to be explored.

The lowest attempted suicide rates in Caucasian males and the significantly disparate figures for Black American males in this study and previous ones are also highlighted.. [Rew et al., 2001].

Examination of variable statistical significance showed that the correlations between risk and protective factors supported the resilience model but that this was mostly due to the large sample size and not strong relationships. The discussion also emphasizes the fact that all previous research on the effects of connectedness, religion, social support as protective mechanisms was further collaborated with the results of the survey. Sexual and physical abuse, depression, attempted suicides amongst family or friends were proven once again to be significant risk factors. The study identifies the groups at risk in the adolescent population and advocates the use of this data to form interventional approaches that would target the encouragement of religious and social activity along with early detection of stress and depression in these youngsters to provide mental health care. [Rew et al., 2001] It summarizes the results of the study, explains the weak points and limitations, while advising further research into new data.

Conclusion

The conclusion identifies the ethnic-gender group found to be most at risk through the analysis of the data. Also a possible influencing variable, sexual abuse, is determined. The conclusion does not give any comparisons of the data from other ethnic-gender groups. It is simple and advises culturally sensitive interventions to reduce attempted suicides.

Implications

The conclusion that girls are more at risk of attempting suicide than boys, that Hispanic Latino females are especially so, and that most attempted suicide of both genders involve a history of sexual or physical abuse will help serve as guidelines for medical parishioners especially nurses. This then is the population that needs to be targeted with a high degree of suspicion. If cases which seem that the injuries may be due to abuse or self inflicted are encountered, nurses must be aware of the potential dangers, who to ask for expert opinions and what methods to apply so as to intervene beneficially without scaring or antagonizing the subject. Mental health referrals should not be the exception but the rule.

Nurses should be taught the signs to look out for, low confidence, depression, anger, recurrent and suspicious episodes of injury. Research into the best possible approach so as to provide help and avoid suicide needs to be done. The approaches as we can see need to be sensitive to culture, gender and even on a personal level.

Recommendation

The study has recommended further investigation into the new discovery of the highest attempted suicides amongst adolescent Hispanic Latino females. Since this has not been noticed before new studies will help decide whether this conclusion was due to research design error or is a genuine fact. Also is the need for culturally sensitive interventions due to the apparent significant influence of family history of suicides and sexual abuse on suicide attempts. Most of the other conclusions drawn were similar to previous research implying the probable reliability of the method.

Other Considerations

For the most part the study has used simple easy to comprehend language, limiting technical jargon to a minimum. The format or rather the presentation of information is slightly haphazard, many details being repeated in different places. There is less discussion about the interrelationships of the different variables. Citations are appropriate and properly cited.