Background
Suicide is the second leading cause of death among adolescents worldwide (World Health Organization, 2020). The Centers for Disease Control and Prevention (2020) has reported that, during 2019, 19% of students reported seriously considered attempting suicide, 16% made a suicide plan, and 9% made a suicide attempt. Moreover, nearly 3.4 million adolescents aged 15-19 years worldwide have suicidal ideation, with half of them attempting suicide (Zalsman, 2012). The World Health Organization (2020) stated that adolescent mental health conditions account for 16 percent of the global burden of disease and injury in people aged 10 – 19 years, of which half of the mental conditions start by 14 years of age, but most cases are undetected and therefore undertreated.
The consequences of not addressing adolescent mental health conditions extend to adulthood, impairing both physical and psychological health and limiting opportunities to lead fulfilling lives as adults (World Health Organization, 2020). Despite great efforts towards suicide prevention in Thailand, the suicide rate has not decreased significantly. Adolescent suicide is the fourth highest cause of death among Thai adolescents (Kittiteerasack, 2012). In recent years, evidence indicates that 20.6% of the adolescents in central Thailand aged 12 - 19 years had suicidal ideation (Rungsang & Chaimongkol, 2017).
The causes of suicide risk behavior among Thai adolescents are complicated. However, previous research studies in Thailand reported that Thai adolescent suicide risk behavior is associated with the risk factors including adverse life events (Thanoi et al., 2010), rumination (Thanoi et al., 2010), stressful events (Rungsang & Chaimongkol, 2017), negative psychological attributes (Rungsang & Chaimongkol, 2017), resilience (Thanoi et al., 2010; Chaniang et al., 2020), and social support (Thanoi et al., 2010; Chaniang et al., 2020).
A qualitative study on attempted suicide triggers in Thai adolescents found that severe verbal criticisms, expulsion to die by a significant family member, disappointed and unwanted by boyfriend in a first serious relationship, unwanted pregnancy, and mental illness lead to intense emotions and irresistible impulses (Sukhawaha et al., 2016). Another qualitative study on the perception of adolescents, teachers, and parents towards causes and prevention of suicide in secondary school students in Chiang Mai, Northern Thailand, found that parents’ expectations, lack of skills to confront problems, feeling lonely from inadequate support, and lack of parental skills were described as the causes of students’ suicide risk behavior (Chaniang et al., 2019). On the other hand, cultivating self-esteem, parental support and caring, peer support, and supportive school environments were explained as the protective factors for adolescent suicide risk behavior (Chaniang et al., 2019).
Nakhon Phanom Province was selected for our study, located in the North-Eastern part of Thailand. The Outpatient Department, Renu Nakhon Hospital, Renu Nakhon District, Nakhon Phanom province, reported that from the years 2016 to 2021, 89 cases of adolescents had depressive symptoms and 33 cases of attempted suicide (Renu Nakhon Hospital, 2021). Therefore, a study related to suicide prevention is needed. Besides, a lack of local studies has been conducted regarding this issue, which is considered the literature gap. To our knowledge, only one quantitative study was conducted by Chaniang et al. (2020) revealed that emotional distress, rumination, and perceived negative life event were positively significantly associated with suicide risk behavior among secondary school students. In contrast, social support and resilience were negatively significantly associated with suicide risk behaviors among secondary school students (Chaniang et al., 2020). However, these results might not capture all suicide causes and prevention efforts. Thus, a qualitative study will provide new knowledge regarding this topic. Our study aimed to explore Thai secondary school students’ perceptions of suicide causes and prevention and the needs of suicide prevention.
Methods
Study Design
A qualitative descriptive design (Lambert & Lambert, 2012) was used in this study.
Setting and Participants
This study was conducted at a public school in a remote area in Nakhon Phanom Province, Thailand. This setting was selected based on the increasing number of secondary school students’ suicide risk factors, such as the number of student experiences of depressive symptoms and suicide. Purposive sampling was used to select potential secondary school students in Grade 11 based on the following inclusion criteria: (i) able to express personal thoughts and opinions on suicide-related topics, (ii) able to expressively and proficiently speak Thai, and (iii) willing to participate. The exclusion criteria of the participants were those having been diagnosed with depression or attempted suicide.
Data Collection
Data were collected using focus group discussions (FGDs) and in-depth interviews from September 2019 to March 2020. FGD guidelines were developed by the research team to explore the individual and contextually related factors causing suicide, prevention of suicide, and the need for suicide prevention in schools. FGDs were conducted with thirty-two adolescents who were studying in Grade 11. Each FGD consisted of eight adolescents per group, and each group had a moderator and a note-taker to facilitate the discussion and manage the group. These activities allowed the facilitator to participate actively and respond verbally to the topics in the FGD. In addition, the researcher used open-ended questions to encourage adolescents to think and share their ideas and experiences on suicide risk behaviors and adolescent suicide prevention. The researcher took a role as a moderator and was responsible for note-taking.
Each FGD lasted approximately 60 to 90 minutes or until repeated information was identified. The FGD process was audio-recorded. There were four main questions in FGD, namely (i) “in your opinion, what are the risk factors of adolescent suicide?”, (ii) “in your opinion, what are the protective factors for preventing adolescent suicide?”, (iii) “in your opinion, who should be involved in adolescent suicide prevention in schools, why, and how?”, and (iv) “in your opinion, what is/are characteristics of suicide prevention program in school?” The guideline contents were reviewed by three experts majoring in adolescent suicide risk behaviors and qualitative research methods.
Additionally, there were ten individual in-depth interviews conducted in a private place at a convenient time based on the participants’ preferences. The research team also developed an in-depth interview guideline, and the questions were the same as those for FGD.
Data Analysis
Data were analyzed iteratively using content analysis (Miles & Huberman, 1994). Transcripts from each group were read, and categories were reviewed several times to ensure that the concepts pertaining to the same phenomena were placed in an appropriate category. The primary author identified the categories and content throughout the data collection and analysis processes and verified by two co-authors for coding consistency, the emergence of categories, and extraction of statements to support each category and sub-category. Coding, categories, and key findings were discussed by the co-authors until consensus was reached.
Trustworthiness
The researchers used four criteria of Lincoln and Guba (1985) to establish the trustworthiness of the study. The credibility was established through triangulation and member checking, while the transferability was achieved through the thick description. Field notes were made throughout the study to achieve dependability, and the advisory team provided their expertise as auditors. Confirmability of the analysis was established by using an analysis audit trail and method triangulation that included both the individual in-depth interviews and FGDs.
Ethical Considerations
This study was approved by the Ethics Review Board of the Nakhon Phanom University, Thailand (Approval number Full-40/62 Exp.). The data collection procedures were carefully designed to protect confidentiality. All potential participants were informed verbally and in written form about the study methods, potential risks and benefits of participation, and the duration of the study. All potential participants were also informed that their participation was voluntary, and they had the right to refuse or withdraw from the study at any time without impact on them. Once they agreed, the students and their parents were asked to sign a written informed consent. Participants’ confidentiality and anonymity were guaranteed throughout the research.
Results
There were three categories: 1) causes of suicide, 2) prevention of suicide and 3) learning needs of preventing suicide (Table 1).
| Categories | Sub-categories |
|---|---|
| Causes of suicide |
|
| Prevention of suicide |
|
| Learning needs for preventing suicide |
|
Category 1: Causes of suicide
Seven sub-categories were identified as causes of suicide among secondary school students, including parents’ expectations of children’s academic achievement, bullying, family problems, teenage love, lack of stress management skills, imitation behavior on social media, and substance use behavior.
Sub-category 1.1: Parents’ expectations of children’s academic achievement
Most participants revealed that the expectations on the students’ academic achievement from parents led to increased stress, emotional tensions, and disappointment of unmet expectations. Some of the students also stated that they were unable to discover their skills and talents as they must live up to parents’ expectations that cause mental health problems, such as hopelessness, despair, and stress. Moreover, it can lead to depression as well as being a significant factor for suicidal behavior in secondary school students.
This category relates to families with most people in this study working mainly in farming since most parents are poor, they put all their hopes on their children. They have a strong desire for their children to study well, get a job and look after them in the future. It would seem some parents expect and put their children under too much pressure. Sometimes children also want to do something else apart from academic studies. Furthermore, they are pushed to achieve high scores, which could lead to increased stress and even depression. One student stated:
“If children cannot do it, they will get rebuked by their parents.” (Male student volunteers, No. 01)
A female student describes the following experience of a friend, which highlights the significance of family pressure:
“When I was in Mattayom 4 [Grade10], I had one classmate. He got poor scores on his exams and was transferred to another classroom. His father was furious. He scolded his son about the low grade and classroom transfer. In my opinion, his parents are very strict as my classmate must do what his parents wanted him to do, and he was not allowed to play outside with friends. Eventually, he ended his own life with a gun. His close friend said that his father put too much pressure on him to get a good grade and other things. Finally, he couldn’t stand it and then committed suicide.” (Female student volunteers No. 06)
Sub-category 1.2: Bullying
Most student volunteers revealed that bullying behaviors among a group of friends could be described as both physical and verbal. Bullying in school has considerably affected students’ lives and can cause negative behaviors, such as skipping classes or dropping out of class. In addition, some students stated that secondary school students who were bullied were more likely to suffer from sadness or hopelessness that might lead to a higher risk of suicidal ideation and risk behaviors. The following participants described the impact of bullying on adolescents and how it turned into thoughts of self-harm:
“Being bullied is one of the viral factors that cause adolescents to overthink and die by suicide. While I was taunted about my imperfections, for example, weight or appearance, I felt hurt and wanted to remove all these things from my body. It appears that weaklings always get bullied, extorted, and do other stuff. Consequently, I have pent-up all feelings and tried to get them off my chest by self-harm sometimes.” (Male student volunteers No. 02)
“Because I was different from others and had no friends, the bullying happened to me. The situation was getting worse day by day. I couldn’t take this and might kill myself. I was bullied excessively. Sometimes it made me feel embarrassed and got hurt. I ignored those who bullied me at first, but they kept saying bad things about me, and more than that, I was physically assaulted. It was really bad for me. I didn’t know why I should go to school if I was bullied there. I could see no way out because I had no friends. I was unhappy.” (Female student volunteers No. 09)
Sub-category 1.3: Family problems
Most students revealed that family problems, such as parental arguments, separation, financial issues, including spending less time with children, caused a lack of effective communication among family members. This leads to children not speaking to parents about their needs, potentially resulting in underprivileged children. These problems can affect students’ thoughts and emotions which may produce stress, frustration, or depression. Moreover, students may have suicidal thoughts or suicide attempts. The following students described this category:
“Whenever my parents get into a fight, I am so annoyed. Actually, they broke up once, but they keep fighting each other all the time. I saw my father hit my mother. It was me who tried to stop him and moved him off of her. Every time they fight over things, I feel extremely annoyed. I hope to finish school soon. I can’t wait to study at university and live on my own. I don’t want to come back home and face the same situation. I am tired of this thing.” (Female student volunteers No. 06)
“A parental separation is mainly caused by problems that occur in the family. This may be a reason why children often go outside and don’t want to stay home. They rely on friends more than their parents as well. One of my friends told me that when she visited cousins on her father’s side, she felt unwelcomed and got bullied. Those cousins said she was addicted to drugs and got around; unfortunately, her father believed in that accusations and hit his daughter. My friend had thoughts about dying, just only dying. She slit her wrists and could get hit by a car.” (Male student volunteers No. 08)
Some students mentioned hurtful verbal communication between parents and teens that influenced students’ thoughts and feelings, leading to suicidal ideation in students.
“My parents have no time for me. I feel like I don’t get enough love and attention from them. Besides, our family has a lot of debts. I know my parents are stressed out, and I feel it too.” (Male student volunteers No. 05)
“When my father comes home, he often starts a fight. Even I did nothing, and he was shouting at me and destroying things. So I feel really upset and question myself that why my father is doing like this; why he is not like other parents. It makes me feel stressed, and I don’t want to live like this anymore.” (Female student volunteers No. 09)
Sub-category 1.4: Teenage love
Students expressed that when teenagers were in a relationship, it was defined as an “innocent love or a puppy love.” Being in a relationship with someone could be a wonderful time. On the other hand, when it comes to a breakup, it could cause all kinds of stressful emotions and lead to thoughts of ending one’s life. Some students stated that students who faced the problem might think about suicide and make an attempt to do it. Some can cut their wrists to express feelings of sadness. The following participants described this category:
“As a teenager, our love was so innocent. But we were too young; it took a short time to break up, and it was terribly sad. So at that time, we broke up, we felt like we weren’t good enough that made it stressful, and we had thoughts of dying by suicide.” (Male student volunteers No. 04)
“When I was seeing someone, I loved her so much and felt like we had been together for years. After we both broke up, I was deeply sad and didn’t want to live anymore. Because she left me, I ended up taking my own life by hurting my wrists.” (Male student volunteers No. 08)
Sub-category 1.5: Lack of stress management skill
Most of the student volunteers described that they frequently faced issues by running away from problems or not ventilating about them. Furthermore, some of them were too afraid to talk about the problem with their parents and did not know a proper way to deal with it. Some described that they had no one to talk to and share their feelings. This problem may lead to a risk of suicidal ideation and suicide attempts. The following participants stated:
“I don’t want to talk to anyone. I prefer isolating myself from other people. Sometimes, I am afraid to talk to my friends and feel like there is no one I can ask for support. I think about committing suicide.” (Male student volunteers No. 04)
“One of my friends was in trouble, but she didn’t dare to tell a class teacher as she thought she was not that close. So, I told her to talk with a guidance counselor who could help and give her advice. However, I was not so sure if she had already told the teacher.” (Female student volunteers No. 10)
Sub-category 1.6: Imitation behavior on social media
Most of the students revealed that imitation behavior on social media influenced students to compare themselves to people they saw on social media, especially high profile’ superstars. Some of them considered those superstars as role models or spiritual anchors in their life. If those superstars had taken their own life, they would feel deeply sad for the loss of people they admired. In addition, some students stated that living an unhappy life can lead to depression and suicidal behavior. The students stated:
“Comparing ourselves to what we saw in the cyber world makes us feel depressed subconsciously. If we consume negative media content, it may influence our thoughts and actions, bringing about bad things. While being on social media, it seems that we create isolation from the actual world as we don’t speak to anyone. Thus, it makes us feel stressed.” (Female student volunteers No. 05)
“I realized that many Korean pop stars have suffered from depression because of online criticism and negative feedback. For example, I was a big fan of one band, which comprised four members. The first member, known as xxx, decided to end his life…I was shocked, but I understood that it was heartbreaking to lose someone we loved…. When losing them, their fans might feel like they lost broken parts and didn’t want to live anymore. They couldn’t be happy without people they loved. That can be the reason why some fans died by suicide. I think it is absolutely true if we lose someone so important to us and there is no one left, we may end it all.” (Female student volunteers No. 10)
Sub-category 1.7: Substance use behavior
The students indicated that substance use behavior began from cigarette smoking followed by other substances, for example, amphetamines. Some of them stated that using too many substances or the wrong way could cause significant problems such as being arrested or physical and mental health illnesses. The students expressed this:
“Cigarette smoking is a bad habit that good students don’t do. Smokers are more likely to try using other drugs. If students take drugs, they can get caught red-handed and don’t know what to do. Eventually, they might kill themselves.” (Male student volunteers No. 01)
“The use of drugs, for example, amphetamine, can cause mental health issues including anxiety, hallucination, and other problems. Some people feel frightened about things around them. Moreover, it also occurred in my village in which someone addicted to drugs and took his own life like this.” (Male student volunteers No. 04)
Category 2: Prevention of suicide
There are five main sub-categories related to the prevention of suicide for secondary school students, including peer support, parental support, school support, health professionals and significant person support, and knowing the value and believing in self (self-awareness and self-worth).
Sub-category 2.1: Peer support
Most students revealed that support from friends has an essential role in preventing suicide for adolescents because they spend most of their time with friends rather than family. Some of the students reported that friends significantly influence a students’ life, and having friends who always provide support, encouragement, counseling, and are be able to keep others’ secrets can help prevent suicide among students. The students expressed:
“From my point of view, many teenagers are addicted to their friends, and they are likely to open up to friends more than family. When they are under stress thanks to family problems or whatever, they’d rather spend time with friends. It’s fine if we have good friends. On the other hand, bad friends can bring us unhealthy or dangerous risks such as drug addiction. Sometimes I can’t talk to my parents about my problem, but I feel more comfortable talking to my friends. They listen to me, and then we share opinions on how to solve the problem.” (Male student volunteers No. 08).
“When things happen, my friends always stay by my side. They listen to my problems, try to understand me, as well as give me support and encouragement. Importantly, they keep my secrets. Besides, when I share my feelings with friends, I feel so comfortable and relieved. It looks like I get something off my chest. Also, they have a positive impact on my attitude and study outcomes. I am glad to have friends like them.” (Female student volunteers No. 09)
Sub-category 2.2: Parental support
Most students indicated that family members are essential to suicide prevention in secondary school students. Some students stated that family could help increase protective factors for their children, such as providing encouragement and support, creating a warm environment, finding solutions, and monitoring the person during the period of crisis. The students expressed this:
“When I was a kid, I dreamed of being a doctor. Since we’re growing up every day, I keep changing my mind about my future career. Currently, I want to be a deputy district chief, so I’m planning to study in the faculty of Political Science. I talked with my parents about it and asked them what they think if I decide to study in this field. They said just go for it, and they’ll support every path I choose. Besides, when I was a Mattayom 3 student, I did a lot of things to discover myself, such as playing guitar, playing sports, and so on. It was my parents who bought me the guitar. I think I am really lucky to have them.” (Male student volunteers No. 08)
“For me, family is the people who instruct, understand, and care about their children most. Parents should spend quality time with their children or participate in activities together like having meals or watching movies, including fostering a loving and comfortable environment. They can simply ask their children how their day has gone. Moreover, they have to build a positive sense of self-worth for their kids so that it will help lift them up when they are depressed.” (Female student volunteers No. 09)
Sub-category 2.3: School support
Most students informed that teachers are like second parents and school teachers play an important role in suicide prevention among students by providing counseling, monitoring behavior, and giving proper guidance to keep the students safe from suicide. Students stated:
“In my school, a guidance teacher announced all students who experienced depression or who are stressed could come to talk with her anytime. …the school teacher should pay close attention to students and report to the guidance teacher when spotting signs of depression or risk behaviors.” (Male student volunteers No. 04)
“School teachers are always supportive. Besides parents, teachers are someone with whom students can comfortably talk and share stories…. For me, I’d say teachers are my second parents because they understand me well and teach me without prejudice…teacher who teaches me concerning essential life skills such as real-world skills, interaction skills, always stays by my side, gives me support as well as makes me feel better when I am under stress…” (Male student volunteers No. 08)
Sub-category 2.4: Health professionals and significant person support
The students mentioned that support and assistance from health professionals have essential persons in protecting adolescents from suicide. Some students stated that care and encouragement from loved ones could reduce the risk of suicide in students. This is expressed by the students:
“A psychiatrist will help us manage our mental health and wellbeing.” (Male student volunteers No. 02).
“A psychologist specializes in this field. It’s like when we share problems with our parents, but it’s beyond their ability, so they take us to see the psychologist. In the worst case, a social worker can also help… moreover, for me my beloved aunty, a sister who always care and stay beside me when I am facing with the worse circumstantial in life…” (Female student volunteers No. 09)
Sub-category 2.5: Knowing the value and believing in self (self-awareness and self-worth)
Most students expressed that having self-awareness and self-worth is critical to preventing suicide among secondary school students. The students said:
“Life is important. It all depends on how we look at things and gets better if we receive support from people around us.…. some people are upset when things go wrong. However, if people figure out what they exactly want to do, they can do it well because they are passionate about it. So, I think if we have a chance to do something great in life, just go for it. One day we will succeed…we might not even think about suicide.” (Male student volunteers No. 08)
“For me, if I were a positive person, I could overcome any obstacles. Being positive can help us feel better as we will become a person who can think positively in all situations and encourage ourselves by saying “Don’t worry. It’s fine. I did a great job”, something like that. On the other hand, if we focus on negative things and ignore what others say, we might get too much stressed and end up with suicide. Therefore, we should stay positive, value ourselves, and appreciate how far we have come from where we started. Don’t let the bad things bring us down because we are the best.” (Female student volunteers No. 09)
Category 3: Learning needs of preventing suicide
Most students revealed that developing an online learning platform regarding suicide prevention and mental health promotion and prevention projects in school may help prevent future suicide.
Sub-category 3.1: Developing online learning platforms regarding suicide prevention
The students reported that developing online learning platforms for raising awareness about suicide prevention may help prevent future suicide among students. They expressed:
“It might be a good idea if we have an online support community for depression and suicide where provides useful information, shares experiences, and discusses coping skills.” (Male student volunteers No. 05)
“I think the media can be videos that provide an overview of what depression is, including causes, symptoms, treatment, and prevention. If it’s too much to handle, we should see a psychiatrist. He may prescribe medicines to treat our mental health. Another interesting idea is to set up a hotline number to allow people to get immediate support and advice from experts.” (Female student volunteers No. 10)
Sub-category 3.2: Mental health promotion and prevention projects in school
The students stated that implementing mental health promotion projects in school by giving students knowledge about suicide prevention and teaching students how to manage stress, solve a problem, and respond to bullying in school can help students reduce the risk of suicide behaviors. This is expressed by the participants:
“Educate all students, especially those at high risk, concerning depression and how to prevent ourselves access to means for suicide.” (Male student volunteers No. 01)
Furthermore, some students expressed that suicide risk behavior and prevention training designated for students, parents, and schools can also help to prevent suicide in students.
“From my point of view, schools have to organize activities such as training, workshop, or camp to raise awareness and provide insights on depression, including allowing students to think and speak out.” (Female student volunteers No. 10)
Discussion
This is the primarily qualitative study of students toward suicide prevention in secondary school students in Renu Nakhon district, Nakhon Phanom, North Eastern, Thailand. This study provides a rich description of significant causes of suicide from secondary school students’ perspectives. It is in line with Grimmond et al. (2019) stated that adolescent suicide has multiple factors related to various causes and risk factors that interact with one another.
Some of the study findings are also consistent with the study investigated by Chaniang et al. (2019), who explored perceptions of adolescents, teachers, and parents towards causes and prevention of suicide in secondary school students in Chiang Mai. However, this study found another different cause of suicide, bullying, as one of the causes of an increased level of risk factors that influence suicidal behaviors among secondary school students, which is consistent with Cooper et al. (2012) and Kim and Leventhal (2008).
Moreover, this study showed that teenage romance is a common source of stress leading to adolescent suicide, particularly when it results in the breakdown of the relationships, which is consistent with Orri et al. (2014) and Sukhawaha et al. (2016). Our study also discovered that imitation behavior on social media is the cause of secondary school student suicide and plays a significant role in preventing suicide for students. This is in line with the study conducted by Robinson et al. (2016) and Patton et al. (2014). Furthermore, our study finding was consistent with the study of Boonyamalik (2005), showing that substance use is considered one of the main factors linked to suicidal behavior among high school students.
This study also provides nurses and healthcare professionals strategies regarding suicide prevention among secondary school students in Thailand. First, most of the students mentioned that peer support is significant to an adolescent’s life, which is congruent with Pfeiffer et al. (2019). Second, parental support is essential for preventing suicide. Parents can help increase protective factors for their children, such as providing encouragement and support, which is consistent with Walls et al. (2014). Third, most students also mentioned that school teachers are like their second parents; thus, they play an important role in suicide prevention among students by providing counseling, monitoring the students’ behavior, and giving proper guidance to keep the students safe from suicide, which is consistent with Shilubane et al. (2015). Fourth, health professionals’ and significant others’ support can be particularly helpful in preventing suicide, which is in line with Holliday and Vandermause (2015). In addition, knowing the value and believing in self is a protective factor that can help and protect adolescents from the risk of behavior and suicide, which is congruent with Matel-Anderson and Bekhet (2016). Also, the findings of this study suggest the development of an online learning platform regarding secondary school students’ suicide prevention, or an app as done by a previous study for depression and suicide (Dwidiyanti et al., 2021), and conducting mental health promotion and prevention projects in schools, especially regarding warning signs of suicide, access to help, and who should receive it.
However, as this study was conducted among the secondary school students living in Renu Nakhon district, Nakhon Phanom Province, Thailand; therefore, the finding might not fully capture the cultural diversity across Thailand nor represent a larger population of adolescents.
Conclusion
This study provided information and understanding of the students’ perspectives towards causes and preventions of suicide as well as the needs for suicide prevention. The findings could be used as baseline information for health care providers, especially school nurses and mental health and psychiatric nurses, to design and develop effective programs and strategies for reducing causes and enhancing protective factors related to suicide among secondary school students.