Introduction

South Suicide is a serious public health concern worldwide, ranking as the fourth leading cause of death among 15-29 year old and the third among girls 15-19 years old [1]. WHO reported that there would be an estimated 804,000 suicide deaths worldwide in 2021. The World Health Organization defined suicidal behavior as a range of behaviors that include thinking about suicide or ideation, planning for suicide, attempting suicide, and suicide itself. Suicidal behavior can be considered to consist of ideation, attempt, and suicide. Suicide is the act of deliberately killing oneself [2]. In the Philippines, around 3.2 deaths relating to suicide were recorded per 10,000 inhabitants in 2011 [3]. The Philippine Statistical Authority (PSA) recorded 3,529 death cases due to intentional self-harm in 2020. Usually, those who commit suicide tend to be older, male, use more lethal methods, and die on the first attempt [4]. Moreover, official suicide rates are lower in the Philippines as compared with many other countries. Very likely that suicide cases were underreported due to cultural differences such as religious beliefs, stigma to the families, and lack of understanding on suicide.

The Philippines today according to the United Nations Population Fund has the largest generation of young people in our history. Thirty (30) million young people between ages of 10 to 24 account for 28 percent of Philippine population and about 19.8 million are adolescent. Said organization clearly emphasized that developing policies and investments for the future of these young people could lead the Philippines to reap the benefits of a demographic dividend-the economic growth potential that can result from shifts in a population’s age structure, mainly when the share of the working-age population is larger than the non-working-age share of the population or the dependent population. Yet, these young people are also facing different challenges and even lifethreatening risks such as suicidal behaviour. The study conducted by Refaniel, et al. through data review for suicide deaths between 1974 and 2005 obtained from Philippines Health Statistics reported that suicide rates were highest in 15-24 year-old in females and surprising suicide rates were increasing every year. Further, the identified most commonly used method for suicide was hanging, shooting, and organophosphate ingestion [5].

Suicide has a devastating and long-lasting impact on families, friends, and communities; however, suicide has no known definite cause [6]. There is no single factor that would explain why the individuals take their own life or why they hurt themselves. Suicidal behavior is a complex phenomenon influenced by several interacting factors such as personal, social, psychological, cultural, biological, and environmental [2]. Previous studies have reported several risk factors associated with suicidal behavior among young people. Psychological risk factors related to suicidal behavior were depressive moods, substance use, and history of severe psychopathology [7-12]. Moreover, with regards to personal, social, and environmental factors, suicide behavior was found to be associated with unemployment, low educational attainment, not studying, and low achievement family problems, bullying victimization, no or few friends, food insecurity, female sex, LGBTQ+ gender orientation, sleep problems, and obesity [13-16].

Existing literature showed suicidal behavior was negatively associated with religious affiliation; social support, parent-family connectedness, and positive affect [11,17-21]. However, very little research has focused on protective factors because most studies highlighted the negative or the risk factors [22-24].

This study aimed to investigate the prevalence of suicidal behavior among college students in a state university in Pampanga and examined the risk and protective factors most associated with suicidal behavior. This current study is essential to provide a picture of the size of the problem and facilitate better-informed decisions, and formulate potential etiologies and preventive actions in the state university [5,25,26].

Materials and Methods

Research design

A cross-sectional survey was utilized to determine the prevalence of suicidal behaviors and examined the association of risk and protective factors among college students in state university in Pampanga.

Study population and sample

Pampanga is located on the northwest of Manila. It has an estimate of 2.5 M population and the age group with the highest population in this province is 15 to 19 years old. The survey was conducted on college students in a state university in Pampanga during the academic year of 2021-2022. A minimum of 385 college students is required to achieve a 95% level of confidence, precision of 5% given an estimated prevalence of suicidal behaviors of 50%. All colleges were included in the sample range using a cluster sampling. A total of 443 students were voluntarily participated in the study.

Data collection procedure

An online survey was created using Jotform (https://www.jotform.com). Information about the study was placed at the beginning of the survey and was followed with an online informed consent form. Only participants who voluntarily agree to participate in the study were included in the survey. The online survey included questions on demographic characteristics of the participants such as age, gender, year level, academic status, and the seven (7) self-report standardized questionnaires. The online survey’s duration was approximately 20-25 minutes. The link to the study was distributed through the student leader per class. The link remained active for one month during the month of June 2022. The study complied with the ethical guidelines of the state university.

Instruments

Suicidal behaviour: The Suicide Behaviors Questionnaire-Revised (SBQ-R) developed Osman et al. was used to assess the suicidal behaviors of the participants. The scale consists of 4-itmes, each item tapping a different dimension of suicidality such as suicide ideation, plan, and attempt. SBQ-R is a useful measure of suicidal behavior based on empirical studies.

Symptoms of depression: Patient Health Questionnaire (PHQ-9) is a nine-item scale assessing the presence of depressive symptoms over the past two weeks.

Childhood trauma history: The Adverse Childhood Experiences (ACEs) Questionnaire is a 10-item measure used to measure childhood trauma. The questionnaire assesses 10 types of childhood trauma measured in the ACE Study.

Personal: Physical abuse, verbal abuse, sexual abuse, physical neglect, and emotional neglect. This scale has good internal validity (Cronbach’s Alpha=0.854) and predictive validity (R2=0.12, p0.001 of the SHI total score). The items are rated on a 4-point Likert scale, except for seven items. Higher scores indicate greater exposure to childhood maltreatment.

Gender identity: Gender identity was determined by single question, “What is your current gender identity?”

Family and social connectedness: The Multidimensional Scale of Perceived Social Support is a 12-item measure of perceived adequacy of social support from three sources: Family, friends, and significant other; using a 5- point Likert scale (0=strongly disagree, 5=strongly agree). MSPSS has been widely used in both clinical and non-clinical samples and easily administered using a five-point Likert-type scale. The internal consistency of the scale was good, with a Cronbach’s alpha of 0.91 with students.

Positive affect: The Positive and Negative Affect Scale (PNAS) is one of the most widely used scales to measure mood or emotion. This brief scale is comprised of 20 items, with 10 items measuring positive affect (e.g., excited, inspired) and 10 items measuring negative affect (e.g., upset, afraid).

Spirituality: The Spiritual Well Being Scale (SWBS) is a 20 item scale that measures an individual's well-being and overall life satisfaction on two dimensions: (1) religious well-being, and (2) existential well-being. Items related to religious well-being contain the word "God" and measure the degree to which one perceives and reports the well-being of his or her spiritual life in relation to God. Items related to existential well-being contain general statements that ask about life direction and satisfaction and measure the degree to which one perceives and reports how well he or she is adjusted to self, community, and surroundings.

Data analysis

The data were analysed using the Statistical Package for Social Science (SPSS v.26, IBM Corp, 2019). Frequency and percentage were used to describe the characteristics of the respondents. Multiple logistic regressions were performed to assess how well the risk and protective factors predict or explain the college students’ suicidal behavior. It also allows to test models to predict categorical outcomes withs two or more categories (non-suicide, suicide ideation, plan, and attempt). And the predictor variables can be either categorical (gender, with history and no history of adverse childhood experience) or continuous (depressive symptoms, support from significant others, support from family, support from friends, positive affect, negative affect, spiritual well-being, and age).

Results

Table 1 shows the study’s descriptive results. A total of 443 college students voluntarily participated in the study. Majority of the participants were female (65%) and third year college students (41.5%).

Table 1: Demographic profile of the participants.

According to Figure 1, most of the participants do not engage in suicidal behavior, 52.60% 28.5) of the participants reported suicidal ideation and 14% (95%, CI 11.07, 17.54) indicated they had suicidal plans (Figure 1). Moreover, 9% (95%, CI 6.7, 12.06) of the college students confessed that they would attempt to commit suicide.

Figure 1. Prevalence of suicidal behaviors among the college students.

Majority of these students who reported with suicidal behaviors were female and third year college students. Multinomial Regression Analysis was performed to assess the impact of a number of protective and risk factors on the likelihood that respondents would report that they had any suicidal behavior. Preliminary analyses were conducted to ensure no violation of the assumptions of normality, linearity, multicollinearity and homoscedasticity. The model contained ten independent variables (depressive symptoms, adverse childhood experience, support from significant others, support from family, support from friends, positive affect, negative affect, spiritual wellbeing, age, and gender). The whole model containing all predictors was statistically significant, x² (33, N=443) = 279.115, p<0.001, indicating that the model could distinguish between respondents who have suicidal behaviors and those who are not suicidal. The model explained 46.8% (Cox and Snell R square) and 51.8% (Nagelkerke R square) of the variance in types of suicidal behaviors committed by college students.

As shown in Table 2, only four independent variables made a unique statistically significant contribution to the model (depressive symptoms, adverse childhood, support from family, spiritual well-being). The strongest predictor of not committing suicide was having family support, recording an odds ratio of 2.55. The results indicated that respondents who had good social support from their families were over 2.55 times more likely to prevent themselves from attempting to commit suicide. The odds ratio of 1.040 for spiritual well-being is also shown in the table, indicating that students with good spiritual well-being would likely not attempt suicide. On the contrary, the odds ratio of .83 for depressive symptoms and the odds ratio of .42 for adverse childhood experiences were less than 1, indicating that for every one-point increase in the scores of symptoms of depression and adverse childhood experiences were .83 and .42 times more likely to have a suicide attempt.

Table 2: Demographic profiles, protective and risk factors as predicting factors of suicidal behaviors with suicidal attempt as reference group

Further, the results show an odds ratio of 1.84 for social support from the family, indicating that those students who received support from the family will be more likely to have suicide risk ideation than a suicide attempt. Times more likely to have a suicide attempt.

Discussion

College students in Pampanga were investigated for suicidal behavior such as suicide ideation and attempts and for the risk and protective factors most commonly associated with these behaviors. There were 443 college students who volunteered to participate in the study, most of whom were female and in their third year. Approximately 24% of participants reported suicidal ideation and 14% reported suicide plans. 9% of them had attempted suicide. An analysis of the model revealed statistically significant contributions from four independent variables. Family support was found to be a strong protective factor against suicide attempts. In addition, spiritual well-being prevents suicide attempts. Depression and adverse childhood experiences, however, were both found to be risk factors for suicide attempts among college students. Age and gender preferences were not found associated with suicidal behaviors.

In a recent meta-analysis by the prevalence in suicidal intention was 9.7% to 58.3% and in suicide attempts was 0.7% to 14.7% among university students. Suprisingly, suicidal ideation was relatively stable before and during the pandemic, as a previous study reported that the national rate of Sta. Maria and her colleagues in 2015 accounted for 24% of Filipino college student before the pandemic, and as shown in this study. However, suicidal attempts in the present study was relatively higher than with the National Survey of Philippine Youth in 2021, amid the COVID-19 pandemic, it was reported that 7.5% young people have attempted ending their life [27]. In the midst of the pandemic, prolonged stay at home, attendance of online classes and difficulty obtaining mental health services may increase the suicidal attempts among college students. Thus, a careful consideration of this should be given by universities when planning for future disasters that might allow students to seek assistance.

Moreover, family support may play important role in preventing suicide attempts and ideation, which led to a very high likelihood of not committing suicide. Individuals who perceived that their families supported and provided care to them during the pandemic were less likely to contemplate or attempt suicide. As previously shown in the literature, parental care was considered as protective factor for suicide among adolescents and young adults [28,29]. In fact, family problems including parental separation and conflict among the members can contribute to suicidal behavior in young people [30]. Research shows that college students are better able to cope in times of crisis if their families are providing them with appropriate assistance, especially if they remain at home for a longer period of time. However, young adults may fear being discriminated against and rejected by their families if they reveal their suicidal intentions and intentions. While the decision to attempt suicide is highly personal, receiving care from their family is important to them, since they are aware of the consequences of their actions.

In addition to the aforementioned family support associated with suicidal behaviors as protective factor, spiritual well-being has found as another significant protective factor against suicidal behavior. Students who have a subjective sense of spiritual satisfaction have a lower risk of suicidal behavior. Research conducted by Ibrahim et al., has found that spiritual wellbeing negatively correlated with suicidal ideation [31]. In alignment with this study, a meta-analysis revealed that a spiritual activity was negatively associated with suicide behaviors [32]. University students may benefit from spiritual wellbeing in managing negative emotions during difficult times [33]. There are many aspects of spirituality, including belief in a higher power, transcendence, prayer, hope, unity with nature, and connection to others. During the pandemic, Walsh suggests that transcendent values may provide meaning, purpose, harmony, and connection for individuals to cope with loss [34]. Particularly, existential spirituality appears to be the aspect of spirituality most strongly associated with suicidality [35].

Furthermore, in terms of risk factors, suicide attempts were significantly associated with depressive symptoms and adverse childhood experiences. The results showed that students who suffered from depressive symptoms were more likely to commit suicide. Depression was a common concern among college students even before the pandemic. In the midst of the pandemic, depression becomes more severe and affects the lives of many college students around the world, causing them to consider suicide [36]. The results of this study indicated that students with symptoms of depression were more likely to commit suicide. The results are consistent with the meta-analysis conducted in China in 2019, reported that a depressive symptom was significantly associated with suicidal behavior among Chinese college students [37].

Lastly, the present study extends existing knowledge by demonstrating the association of adverse childhood experiences increased the risk of suicidal behavior among college students. Adverse childhood experiences such as abuse increased the risk for suicidal behavior. A previous study conducted among Chinese college students has shown that adverse childhood experiences were associated with suicidal ideation.

Despite the significant findings of this present study, several limitations should be considered for clinical interventions in suicidal behaviors among college students in Pampanga, Philippines. First, cross-sectional data were collected at a single point in time, thus restricting the ability to monitor changes in the relationship between variables over time. The relationship between these variables must be confirmed through a longitudinal study. Also, mixed methods research is recommended to explore the in-depth the factors influencing suicidal behavior among college students. Secondly, self-reported questionnaires can lead to recall bias when data is collected. Thirdly, the study was limited to young adults in school settings and at one state university, so its findings do not represent all young adults. Using findings from this study to apply to the entire Pampanga young adult population should be done with caution.

Conclusion

An investigation was conducted to determine whether college students in Pampanga engaged in suicidal behavior, such as suicide ideation and attempted suicide. In addition, an investigation was conducted to determine the factors that benefit or hinder these behaviors. A total of 443 college students, primarily females and in their third year of studies, volunteered to participate in the study. Approximately 24% of participants reported suicidal thoughts, and 14% reported plans for suicide. Among them, 9% attempted suicide. Four independent variables, family support, spiritual well-being, depressive symptoms, and adverse childhood experiences, were statistically significant. The strength of family support was found to be a significant protective factor against suicide attempts. Moreover, spiritual well-being helps prevent suicide attempts. However, depression and adverse childhood experiences were both found to be risk factors for suicide attempts among college students. And neither gender preference nor age was significantly correlated with suicidal behavior.

Based on the findings of the present study, some recommendations are suggested: support from family and spiritual well-being can help save the lives of young people at risk of suicide, according to the findings. An intervention that integrates family support and spirituality may be more effective for young adults at risk of suicidal attempts. Additionally, treating depressive symptoms and adverse childhood experiences should also be integral to targeted mental health interventions to reduce suicidal behavior. Intervention strategies may be considered to prevent adverse childhood experiences in the Filipino family system.

Data Availability

The data that supports the findings of this study are available from the corresponding author upon reasonable request.

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Citation: Protective and Risk Factors of Suicidal Behavior among College Students in Pampanga, Philippines, Vol. 24(4) April,2023; 1-9.