Factors influencing suicidal ideation and self-harm among undergraduate students in a Nigerian private university

Suicide and self-harm have been documented as the main cause of death among young adults. Nigeria as well as other low-income countries is reported to have a higher prevalence rate of suicidal ideation and self-harm as compared to high-income countries. The aim of this study was to evaluate the factors that influence self-harm and suicidal ideation among university undergraduates. Four hundred fifty students consented to participate in this study where 61.3% were female with mean age of 20.02 + 1.88 years. More than 46% (208) had moderate social support while 80.4% had a high self-esteem and 72.7% low environmental factor scores. There was an association between self-esteem (p=0.001), social support (p<0.001), and self-harm but no association between social support and suicide ideation (p=0.199) as well as between gender and self-harm (p=0.118). There was some form of influence from self-esteem, social support, and environmental factors on self-harm and suicidal ideation. Interventions tailored towards these factors in order to improve mental health outcomes among undergraduates are needed.


Background
One major public health issue that has become rampant throughout the world and is increasing the burden of health care is suicidal behavior (suicidal ideation and deliberate self-harm) among young people [1]. Estimation from the World Health Organization (WHO) reported that each year, more than 700,000 people die from suicide and for every suicide there are many more people who attempt suicide [2]. Suicide is a tragedy that has a lasting impact on families, communities, and even nations. Suicide occurs at any age and was the fourth biggest cause of death worldwide for people aged 15 to 29 in 2019 [2]. However, in Africa, suicide is the 2nd leading cause of death among people aged 15-29 years [3].
Suicide is a primary cause of death among school undergraduates globally [4]. Suicide rates among school undergraduates vary widely among countries ranging from 5% to about 31% [5][6][7]. Low-income countries including Nigeria have a higher prevalence rate of suicidal ideation and self-harm as compared to high income countries [5,6,8]. School undergraduates have biopsychosocial problems which could explain the high prevalence in African countries [9]. In Nigeria, a study reported a prevalence rate of 20% for suicide ideation and 12% of self-harm among young people [10]. Risky behaviors such as suicidal ideation and self-harm enhance students vulnerability to poor physical and mental outcomes [3,9]. A study reported that those adolescents who follow through more readily with suicide are those with feelings of anxiety [8]. Also gender disparities, poor academic performance, and social economic factors are associated with suicidality and self-harm among school undergraduates [10,11]. In some low-income countries, girls are at higher risk of suicidal behaviors notably because of rigid gender norms and discrimination. Also, female undergraduates are generally much more likely than males to experience suicidal ideation, while males complete suicide more than females [12]. Similarly, suicidal behavior is associated with certain factors which could be genetic, psychiatric, environmental, psychological, social, and cultural factors [1]. In addition, physical, sexual, and emotional abuses have also been related to suicidal ideation and attempt in adolescents [13]. According to Miller et al. (2013), it was reported that suicidal behaviors also comes together with other health risk behaviors such as tobacco smoking, aggressive behaviors, illicit drug use, alcohol use, and experience of sexual intercourse, anger, shock, and depression [13].
Deaths by suicide have received little or no recognition with most cases mistakenly labeled as an accident or another cause of death. Also, due to its sensitive nature and associated stigma around it, suicide is occasionally not acknowledged or reported [14]. Suicidal attempts in form of self-harm are significantly more common than actual suicide and are thought to occur between 10 and 20 times more frequently. About 3 out of every 1000 adults worldwide report trying to commit suicide each year, according to estimates. A lifelong attempt at suicide is made by about 2.5% of the population [15,16].
In African countries including Nigeria, few studies have been carried out on suicidal ideation and self-harm [8,10,17]. This could be attributed to poor surveillance and socio-cultural factors associated with suicide as well as the stigma that it carries [7]. Also, suicide attempts are perceived as criminal offence rather than a mental health problem [18]. This study is meant to evaluate the various factors that influence self-harm and suicidal ideation among Afe Babalola undergraduates.

Research design
This research employed a cross-sectional descriptive research design.

Study area
The study was conducted in Afe Babalola University, Ekiti. Ado-Ekiti, Nigeria. Ado-Ekiti is a city in Southwest with a population of over 424,340 [19]. The university operates a collegiate system and has six major colleges. They include College of Medicine and Health Sciences, College of Sciences, College of Pharmacy, College Of Law, and College of Social and Management Sciences.

Study population
The target population was Afe Babalola University undergraduate students estimated to be 8900 students in total grouped into different colleges and courses of study.

Inclusion criteria and exclusion criteria
Undergraduates of Afe Babalola University who gave consent to participate in this study were included while students who did not give consent or were not available as at the time of administration of questionnaires were excluded.

0.05
n= 384 respondents 10% of the calculated sample size was added. The minimum sample size for the study was 450 respondents.

Sampling technique
The multi-stage sampling technique was used for this study.
Stage 1: Out of the 6 colleges. Four colleges were chosen using simple random sampling technique. These were College of Medical and Health Sciences, College of SMS, College of Sciences, and College of Engineering. Stage 2: From the 4 colleges selected, 2 departments were selected using simple random sampling, making a total number of 8 selected departments. The departments selected were Nursing, Public Health, Computer Science, Geology, International Relations and Diplomacy (IRD), Accounting, Electrical Electronics, and Mechanical. Proportionate allocation was used here (Table 1). Stage 3: Simple random sampling was used to select the students in each department.

Data collection instrument
The instrument used for data collection in this study was a 51-item semi-structured questionnaire that was developed after a thorough literature search. The questionnaire had 4 sections. Section A comprised of 18 items aimed at assessing the socio-demographic characteristics and health behavior of the participants. The variables assessed included age, gender, ethnicity, religion, college, hostel, level of study, living situation at home, number of roommates, frequency of alcohol use, tobacco smoking, and physical activity. Section B assessed the reinforcing factors influencing self-harm and suicidal ideation. This section was made up of 14 Likert scale questions categorized into 2 sub-sections. The first sub-section assessed social support while the second measured self-esteem of the study participants. Social support was assessed using six Likert questions and was measured using a 4-point rating scale of Never (N), Rarely (R), Occasionally (OCC), Always (A) where Never (N) was represented as 1, Rarely (R) as 2, Occasionally (OCC) as 3, and Always (A) as 4. Social support was categorized into poor (6)(7)(8)(9)(10)(11)(12)(13)(14), moderate (15)(16)(17)(18)(19), and strong support (20-24). Self-esteem was measured using eight Likert questions measured on a 4-point rating scale of Strongly Agree (SA), Agree (A), Disagree (D), and Strongly Disagree (SD). The scale was represented as Strongly Agree (SA) as 1, Agree (A) as 2, Disagree (D) as 3, and Strongly Disagree (SD) as 4. Selfesteem was categorized into low (<50% of total score) and high (>50% of total score). Section C evaluated the enabling (environmental) factors that can influence selfharm and suicidal ideation in the participants. This section comprised of six Likert questions and was measured using a 4-point rating scale of Strongly Agree (SA), Agree (A), Disagree (D), and Strongly Disagree (SD). The scale was represented as Strongly Agree (SA) as 1, Agree (A) as 2, Disagree (D) as 3, and Strongly Disagree (SD) as 4. The environmental factors was categorized into low (<50% of total score) and high (>50% of total score). Sections D assessed the pattern of suicidal ideation and self-harm among the study participants. This section consisted of thirteen dichotomous yes or no questions.

Reliability and validity of research instrument
The instrument was constructed under the guidance and inspection of the supervisor together with lecturers of the Department of Public Health, College of Medicine and Health Sciences. The research instrument was checked for validity using face validity by lecturers of the Department of Public Health, College of Medicine and Health Sciences, Afe Babalola University, who assessed the instrument for its intellectual content and extent to which the research instrument covered the concepts relating to the prevalence of factors influencing suicidal ideation and self-harm. Cronbach alpha test was conducted to test for the reliability of the instrument. A pretest was first conducted for internal consistency of the instrument using 10% of the total projected sample size which was excluded from the main analysis.

Data collection
The instrument used in this study was a semi-structured, self-administered questionnaire which was distributed to each randomly selected student. The questionnaire took about 10 min to complete.

Data analysis
Data obtained from completed instrument was computed and analyzed using Statistical Package for Social Science (SPSS) version 25. Computed data were subjected to descriptive statistics (i.e., means, standard deviation) for numerical variables while association between the categorical variables was carried out using Pearson's chi-square test. Self-harm and suicidal ideation were coded as independent variables while demographics, environmental factors, self-esteem, and social support were coded as dependent variables during the cross tab analysis. Also information obtained was summarized and presented in tables.

Ethical consideration
This study obtained ethical approval from Afe Babalola University Research and Ethics Committee (ABUAD-REC). All selected participants used for this study were informed that their participation is voluntary, and inform consent was sought from all participants prior to their participation. Confidentiality of participants was maintained as no personal identifying information was collected on the questionnaire. This study was carried out in accordance with the latest version of the Declaration of Helsinki.

Demographics and health behavior of study participants
A total of four hundred fifty students consented to participate in this study and the mean age of the participants was 20.02 + 1.88 years (range 17-27 years). Two hundred and seventy-six were female while less than 8% (34) were Hausa. More than 89% (403) were Christians and two hundred and eighty people lived with both parents. Less than 30% (130) reported that a member of their family had attempted suicide before while more than 85% (385) documented that none of their siblings had thought of suicide (Table 2). One-hundred and eighty students (40%) stated that they take alcohol and less than 25% reported they take it monthly. More than 26% (119) reported that they smoke cigarette and 10% admitted that they smoke twice weekly (Table 3).

Reinforcing factors for self-harm and suicidal ideation
The reinforcing factors for self-harm and suicidal ideation were assessed in this study and the factors were For social support, fourteen percent (63) admitted that they do not have any special person with whom they can share their joys and sorrows while less than 27% (120) stated that they rarely talk about their problems with their family. One hundred ninety-nine participants (44.2%) reported that occasionally have friends with whom they can share joys and sorrows. Overall, more than 46% (208) had moderate social support while less than 25% (112) had poor social support (Table 4). For the participants' self-esteem, a total of one hundred and fifty-two (33.8%) students agreed that they felt that they are persons of worth and on an equal plane with others while more than 33% (150) strongly agreed that they certainly feel useless at times. Majority (362, 80.4%) had a high self-esteem (Table 5).

Enabling (environmental) factors that influence self-harm and suicidal ideation
In this study, less than 27% (121) strongly disagreed that they had a family member who engaged in self-harm while more than 45% (204) stated that their parents believed that suicidal ideations are demonic. Two hundred eleven students (46.9%) stated the counseling unit in school are too judgmental and do not understand them while majority (285, 63.3%) of the students reported that academic workload stresses them out and the school is not considerate of their situation. Most (72.7%, 327) had a low environmental factor score ( Table 6).

Patterns of suicidal ideation and self-harm
The patterns of suicidal ideation and self-harm was also assessed in this study, and it was reported that less than   (Table 7). Three hundred forty-eight students (77%) admitted to have thought of killing themselves in the last 6 months and 85% (383) stated to have performed actions on the thoughts. The actions reported by the students were cutting of skin, drug overdose, and use of chemically poisonous substances.

Influence of predisposing, enabling, and reinforcing factors towards suicidal ideation and self-harm
In this study, there was no association between gender and self-harm (X 2 =2.437; p=0.118) as well as with suicide ideation (X 2 =0.350; p=0.554), but there was an association between self-esteem and self-harm (X 2 =11.189; p=0.001) as well as suicide ideation (X 2 =6.450; p=0.011).

Demographics, self-harm, and suicidal ideation among study participants
Suicide and self-harm have been documented as the main cause of death in both men and women, particularly between the age of 15 and 35 years, and it happens at a higher incidence in this age group than in any other [20]. The population used for this study was of mean age 20  years which is quite close to findings in a study by Johnson and colleagues [21] where the mean age was 19.78 years This population is important because suicide ideation and self-harm may have long-term consequences, including sadness, depression, and morbidity.
This study showed that a higher proportion of males did self-harm and had suicide ideation than females similar to studies carried out by Neeleman et al. (2004) [22] and Johnson et al. (2021) [21] that reported that selfharm and suicidal tendencies develops faster in males than females. This is contrary to a study from Li and colleagues where the female gender is significantly associated with suicidal ideation [23]. This could be due to the fact that women are more emotionally expressive than men. There was more alcohol use reported among the students than tobacco smoking. This is consistent with  studies in Nigeria where unhealthy alcohol consumption was estimated to be between 40 and 50% among adolescents and young adults aged 15 years and above [24,25]. Furthermore, according to a number of studies, drinking alcohol is being reported as the main dangerous behavior among students and young adults in general [26][27][28]. Alcohol dependence, aggression, self-harm, and suicidal ideation have also been substantially correlated with harmful alcohol use among young adults [29][30][31]. Harmful alcohol use can impair functioning and can also raise dropout rates and cause adolescents to perform poorly in school [32][33][34]. Similarly, a strong association has been reported between cigarette smoking and suicide-related behaviors characterized as ideation, plans, attempts, and suicide-related death [35][36][37]. These associations have been shown to have positive dose-response relationships [38,39]. There is a need for intervention in form of awareness and other prevention strategies against alcohol use and smoking targeted towards young adults in tertiary institutions.

Social support, self-harm, and suicide ideation
Social support is the functional (practical, emotional support) and structural (social network, network outside the family, household size) component of support generated from social networks [40]. In this study, there were more participants with moderate support and poor social support than strong social support and interestingly, a large proportion of participants with strong social support did not carry out self-harm or suicidal ideation. This is in tandem with a study by Chioqueta and Stiles [41] that reported that social support is linked to a lower risk of suicidal ideation. There was also an association between social support and self-harm. Adequate social support is vital as it has been shown to control personal stress responses and prevent anxiety or depression [42] and affect help-seeking behavior in individuals [43].

Self-esteem, self-harm, and suicide ideation
During adolescence and adulthood, self-esteem is said to have a substantial impact on crucial life outcomes such as health and social results. Higher self-esteem is linked to favorable outcomes such as stronger social relationships, a sense of well-being, favorable peer evaluations, academic accomplishment, and good coping abilities [44]. Low self-esteem on the other hand has been linked with depression, substance misuse, antisocial behavior, and suicide [45,46]. Majority of the participants in this study had good self-esteem, but some students still had low self-esteem. According to Aryana [47], high self-esteem is linked with good academic performance but low self-esteem is linked with poorer outcomes among school students. Screening for poor self-esteem in adolescents could be a useful technique for identifying young adults who are at risk of anxiety, depression, or suicide.

Living situation at home, environmental factors, and self-harm
Relationship between children and their parents can have a substantial impact on children's social communication and mental health [48]. Numerous researches have demonstrated the importance of family relationships in self-harm behavior in adolescents [49,50]. In this study, a lesser proportion of the study participants that lived with both parents did self-harm and suicidal ideation compared to those living with a single parent. This is in line with a study by Moore et al. (2006) [51] where it was reported that children of single parents have a higher tendency of depression, aggression, loneliness, and other mental health-related problems than children with both parents. Similarly, parental strategies as well as parental attachment to their children have been as an important determining factor of self-harm and/or suicidal behavior in children [52]. Parental attention and emotional participation, as well as parenting methods, have a big role in determining the overall mental wellbeing and communication in the family throughout adolescence and the early phase of adult life. This study also showed that participants with higher environmental factor score had a higher selfharm tendency. This goes in line with a study by John et al. [53] where there was a significant association between environment risk factors (such as poor social support, parental care, child abuse, and drug abuse) and self-harm tendencies. Similarly, Cassels and colleagues stated that self-injury is associated with poor family functioning, an important environmental factor [54]. Children from households with negative environmental factors (such as sexual or physical abuse, neglect, parental loss, or significant family turmoil) are more likely to self-harm or consider suicide than those not exposed to these environmental factors [55,56]. This study was not without limitations which included the fact that this study was carried out in one university, and this should be considered in the generalizability of the study findings. However, this study provides information that can serve as a building block for further studies.

Conclusions
There was some form of influence from self-esteem, social support, and environmental factors on self-harm and suicidal ideation. There is need for proper intervention channeled towards these factors to improve outcomes.