Nursing research critique methodology and practice

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.

Review of Literature

Suicide is a growing problem amongst the adolescents in modern society. All social strata and backgrounds are effected but not equally implying that many environmental factors must be at the root of this menace. Various studies have been conducted to explore the issue of suicide especially in adolescents and teenagers. Correlated factors that affect this behavior have been studied and various risk factors identified. These include depression, stress, anxiety, and hopelessness. Past or ongoing physical and sexual abuse have been determined to be major factors in causing suicide attempts in all gender and ethnic groups.. [Rew et al., 2001]Other influences are drug and alcohol abuse, and accessibility of lethal weapons and chemicals.

Protective mechanisms such as social and family support, parental expectations, social activities, spiritual influences all counter the effects of the risk factors. It is the interaction of risk and protective factors that ultimately determines what action a child will take. The Youth Resilience Model is a concept which explains and clarifies the factors involved in making the child vulnerable to suicidal thoughts and where and what kind of intervention can be done to prevent these thoughts from being put into action.[. [Rew et al., 2001]

It has been found that young girls are more at risk to attempt suicide as compared to boys. In both groups the presence of sexual abuse was a frequent common factor.. [Rew et al., 2001]Though data is available for different races no actual comparison has been done on the variability produced due to ethnic background. Some data shows that suicide attempts are most common in Caucasian females as compared to least prevalent in Black males. This study however concludes that it is Hispanic girls that have the highest rate of attempted suicide while male Caucasians the lowest.. [Rew et al., 2001]

If culturally sensitive programs are to be designed, aimed at the ethnic groups more at risk, then suicide statistics will have to be studied in context of ethnicity as well. To prevent adolescent suicide, the target population for intervention methods needs to be identified. Awareness needs to be propagated throughout the professional sector, including teachers, nurses, and physicians that come into contact and have the requisite skills for handling at risk adolescents. Recognition of emotional and mental distress in such individuals and awareness and use of referral options to mental health services when suspected cases are encountered is a must.

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.