Background Suicide among young people is a global public health problem, but information on determinants and understanding of suicidal expressions are lacking in low and middle income countries (LMIC). Though school-based interventions are common in many parts of the world, evidence for efficacy is less reported, particularly from post-conflict countries. Aim To explore suicidal expressions and their determinants with psychosocial and gender perspective in Cambodia and Nicaragua and to evaluate a school based intervention to promote mental health and prevent suicidal behavior among young people in Cambodia. Method School students between the age of 15-19 from Cambodia and Nicaragua responded to Attitude Towards Suicide (ATTS) and Youth Self-Report (YSR) questionnaires. In addition, Life Skill Dimension Scale Adolescent Form (LSDS-AF) was used in schools in Cambodia, one experimental and the other control, to measure the impact of intervention. Six focus group discussions (FGDs), both gender-specific and mixed groups, were held to understand young people’s perception of gender, culture, religion and media and their impact on suicide among them. Results Paper I. Revealed few gender differences in suicidal expressions, except girls reporting more attempts than boys. Girls exposed to suicide among friends and partners were likely to report own suicidal expressions and girls with internalizing syndrome were at risk for suicidal expressions.    Paper II. Cambodian teenagers reported more mental health problems but fewer suicidal expressions as compared to Nicaragua. The determinants varied between countries.   Paper III. Participants of FGDs mentioned “Plue Plun” male and “Kath Klei” female to describe gender difference in suicidal behavior among young people in Cambodia who found it a challenge to negotiate between traditional and modern values. Paper IV. Suicide ambiguity in Buddhism, stigmatizing culture and double edged media were seen as suicide-provoking by the young people in Cambodia, who recommended peer-focused, school based program. Paper V. School based Life Skills Intervention overall benefited girls. Boys with high risk behavior had shown improvement on many Life Skills dimensions, as well as in their mental health profile. Conclusion The gender and cultural differences in suicidal expressions and their determinants among teenagers emphasize the importance of culturally sensitive and gender-specific suicide prevention programs. The influence of religion and media ought to be considered while planning intervention programs. School-based program may be a window of opportunity to promote mental health and prevent suicide among young people in Cambodia.

Background Suicidal behaviour among young people is one of the major public health problems in low-income countries; it is estimated that every year 70,000 young people take their lives and maybe 40 times as many attempt suicide. Nicaragua has the highest suicide rate among young people of all Latin and Central American countries. This thesis aims at examining: (1) suicidal expressions and their determinants among school adolescents in Nicaragua, (2) cross-cultural aspects on suicidal expressions comparing Nicaragua and Cambodia, (3) pathways to suicide attempts among young men, and (4) primary health care professionals’ perceptions of suicidal behaviour and mental health problems among young people. Method Paper I is a cross-sectional study of 368 school adolescents in Nicaragua using self-report instruments (Youth Self Report and Attitudes Towards Suicide). Paper II compares data from Paper I with corresponding data from a study of 316 adolescents in Cambodia using the same methodology. Paper III is a qualitative study based on interviews with 12 young men who have recently attempted suicide. Paper IV is a qualitative study with 12 primary health care professionals. Results Paper I: Among adolescents, suicide ideation during recent year was reported by 22.6%, suicide plans 10.3%, and suicide attempts 6.5%. Girls were significantly more likely to report suicidal ideation. Multivariate analyses showed that anxious/depressed syndrome (YSR), somatic complaints syndrome (YSR) and exposure to attempted or completed suicide in significant others were significantly associated with their own serious suicidal expressions. Paper II: There was no significant difference in serious suicidal expressions (plans and attempts) between countries, but milder suicidal expressions during past year were more common among Nicaraguan young people. Overall, mental health problems were more commonly reported in Cambodia, where adolescents scored significantly higher on almost all YSR-syndromes as compared to Nicaraguan adolescents, except for withdrawn/depressed syndrome among boys. The pattern of association between mental health problems and suicide plans/attempts differed between countries. In Nicaragua, all eight YSR-syndromes were significantly associated with serious suicidal expressions for both genders compared to only one syndrome among girls and two syndromes among boys in Cambodia. Paper III: A model of the pathways leading to suicide attempts among young men was constructed based on the informants’ experiences. Structural conditions such as poverty or single-headed families, along with normative expectations within a framework of hegemonic masculinity, were all involved to create a sense of failure and an inability to cope. Subsequent increased drinking and drug abuse as well as exposure to attempted and completed suicide among friends and family acted as triggers to their own suicide attempt. Paper IV: Primary health care professionals felt themselves that they lacked knowledge and competence when approached by young people with mental health problems. Misconceptions were common. They felt frustrated which made them either ignore signs of mental health problems or reject help-seeking young people. In practice, a common response from health care professionals was to refer the patient over to someone else, the “hot potato” strategy. Conclusions The prevalence of serious suicidal expressions among young people in Nicaragua is within the range reported from Western high-income countries. Health care professionals need to be aware that somatic complaints as such are related to an increased risk of serious suicidal behaviour among young people, and that those who have been exposed to the attempted or completed suicide of someone close are at increased risk of serious suicidal expressions also when there are no warning signs in terms of mental distress. The cross-cultural comparison lends support to the notion that both cultural specificity and universality characterize serious suicidal expressions, as suggested by several researchers. Whereas prevalence shows less variation between cultures, associated factors might behave differently as shown in the present study, calling for different preventive approaches. The interviews with young men who had attempted suicide tell us that not only difficult socio-economic conditions but also the normative expectations on young men need to be addressed to decrease their risk of suicide. Health care professionals need to be alerted that sometimes serious mental health problems are hidden behind help-seeking for more trivial reasons. There is a necessity of a more integral approach towards mental health problems in PHC, including integral training of staff. The continued involvement of the community, family and other institutions would be essential to develop the care further.

In developed countries, suicidal behaviour is recognised as a significant public health problem among young people, but there are few studies from developing countries on this subject. The present thesis aims at estimating the extent of the problem and at exploring factors related to suicidal behaviour among young people in a developing country, Nicaragua, using a combined quantitative and qualitative approach. Three studies were conducted between 1999 and 2006. In the first study, all hospital admitted suicide attempt cases in the area of León were assessed over a three year period. Secondly, a qualitative study using individual in-depth interviews was conducted with eight girls aged between 12 and 19 admitted to hospital after attempting suicide. Thirdly, a study using the Attitudes Towards Suicides (ATTS) questionnaire was conducted in a community based sample of 278 young people aged 15-24 years to assess own suicidal behaviours, attitudes towards suicide as well as exposure to suicidal behaviour among significant others. The hospital surveillance showed that suicide attempt rates were highest among females in the age group 15-19 years with a female rate three times that of males (302.9 versus 98.9 per 100,000 inhabits per year). Drug intoxication and pesticides were the most commonly used methods for the attempts. A consistent seasonal variation with peaks in May-June and September-October was found in each of the three years, possibly related to exam periods in schools. Findings in the qualitative approach led to a tentative model for pathways to suicidal behaviour based on four main categories: Structuring conditions, triggering events, emotions and action taken. Dysfunctional families, lack of confidential and trustworthy contacts and interpersonal conflicts followed by emotions of shame and anger were some important components in the model. The community studies showed that suicidal expressions (life-weariness, death wishes, suicidal ideation, suicide plans and suicide attempts) were common among young people where more than 44.8% of males and 47.4% of females reported some kind of suicidal expression. Gender differences were small. Exposure to suicidal behaviour among others was associated with higher levels of self-reported suicidal behaviour. The attitude study showed that boys had less pro-preventive attitudes than girls, possibly indicating their higher risk for completed suicide. Exposure to suicidal behaviour and own suicidal behaviour showed an association with specific patterns of attitudes. The findings should be taken into consideration when planning for prevention of suicidal behaviour among young people in a developing country like Nicaragua.