Impact of perceived social support on suicidal ideation among students at Ain Shams University

Background Suicide is a significant public health issue that has long-term impacts on individuals, families, and communities. Perceived social support can reduce the frequency of suicidal ideation (SI), which is an important precursor to later attempted and completed suicide. The present study aimed to measure the prevalence of SI and perceived social support among students at Ain Shams University, compare SI and perceived social support among medical and non-medical students, and identify the factors affecting SI. Methods A cross-sectional study was conducted among 745 students recruited from two medical and two non-medical faculties at Ain Shams University. The data was gathered through a self-administered questionnaire, including socio-demographic characteristics, family relationships, daily habits, the Suicidal Ideation Scale (SIS), and the Oslo Social Support Scale (OSSS-3).


Background
Suicidal ideations (SI) are suicidal thoughts or ideas that encompass a variety of contemplations, aspirations, and obsessions with suicide and death [1].Suicide is a significant public health issue with long-term consequences for people, families, and communities [2].Among individuals aged 15 to 29, suicide is the fourth most common cause of death.Around (77%) of suicides worldwide take place in low-and middle-income nations, where poor access to services, poverty, and stigma around mental health are listed as obstacles to receiving care [3].Every 40 s, a suicide case occurs around the world [4].
In Egypt, the number of suicides has significantly increased over the past few years [5].In 2022, 7881 people committed suicide, while Egypt witnessed 3022 suicides in 2019 [6].Egypt has a suicide rate of around 0.5 per 100,000 people, compared to around 9.0, globally [7].This large difference can be attributed to flaws in the surveillance system or religious customs of the country that encourage under-reporting implications [5].
A variety of risk factors can lead to SI like relationship problems, trauma, substance use, stress at work or education, a physical health problem, or financial obstacles.Additionally, having a mental health condition like anxiety, bipolar disorder, post-traumatic stress disorder, or depression can also have an impact [8].Furthermore, females attempt suicide more often than males, but males are successful about three to four times more often than females [9][10][11][12].
The prevalence of SI varies among different countries.In the USA, the prevalence of SI was (9.7 to 58.3%) among university students and attempted suicide was (0.7 to 14.7%) according to a meta-analysis in 2018 [13].Among Chilean adolescents, 65.6% of them reported that they had SI and 18.4% had attempted suicide [11].In Bangladesh, the prevalence of SI was 61.1% [14].In Ethiopia, the prevalence of SI, plans, and attempts among campus students was 58.3%, 37.3%, and 4.4%, respectively [12].In Muslim-majority countries, a meta-analysis revealed that the pooled lifetime prevalence of SI was 21.9%, suicide plans were 6.4%, and suicide attempts were 6.6%.South-East Asia had the highest lifetime prevalence of SI (46.2%), but the Eastern Mediterranean Region had the highest 12-month prevalence (16.8%) [15].
Regarding the prevalence of SI in Egypt, 25% of university students in Zagazig had a significant risk for suicidal behaviors.Being in the first years of practical faculties and having no friends are significantly correlated with suicidal behaviors [9].The quality of life had a statistically significant negative correlation with suicidal behaviors.Youths' perspectives about suicidal behaviors (pressure/ escaping tool, seeking help/ending pain, and attentiongrabbing behavior) are also risk factors [9].Furthermore, SI was higher among students in the preclinical medical years when compared with students in clinical training and among students who live far from their families [16].
Suicides can be prevented with prompt, evidencebased, and often inexpensive interventions [3].There are a number of activities that can be implemented at individual levels to prevent suicide such as; supporting social and emotional learning programs, teaching parenting skills to strengthen family relationships, and teaching stress management [2].Perceived social support can reduce the incidence of SI and increase personal self-esteem [10,[17][18][19].Low perceived social support and stressful life events were significantly associated with suicide attempts [20].Research by Abdu et al. in Ethiopia found that students with poor social support, a family history of suicide attempts, lifetime alcohol use, rural residency, and less regular religious practice had an increased likelihood of developing SI [12].Shenouda and Basha in 2014 showed that perceived stress is a significant predictor of SI for females among university students in Egypt, whereas perceived stress and social support are significant predictors of SI for males [21].
Previous research revealed that there is no evidence of iatrogenic consequences resulting from suicide screening and screening in high schools is a secure element of youth suicide prevention efforts [22,23].Furthermore, asking an at-risk population about SI is not associated with subsequent increases in its occurrence [24].
In international comparisons, medical students had a higher rate of SI and attempt because they experienced higher levels of stress due to poor sleep, mental issues, and challenges in their study courses [25].Because university students are the backbone of our society, it is important to safeguard them against suicide and other preventable causes of illness and mortality.The present study was the first one to identify the association between SI and perceived social support among students in Egypt.Therefore, the present study aimed to measure the prevalence of suicidal ideation (SI) and perceived social support among students at Ain Shams University, compare SI and perceived social support among medical and nonmedical students, and identify the factors affecting SI.

Type of study and setting
A cross-sectional study was conducted at Ain Shams University.

Target population
The current study involved students recruited from 4 faculties: 2 medical faculties (faculty of medicine and faculty of nursing) and 2 non-medical faculties (faculty of engineering and faculty of commerce) at Ain Shams University (Supplementary Table S1).
Inclusion criteria were Egyptian students at the abovementioned faculties of Ain Shams University aged 17-32 years old.

Sample size and type
Using the epi info program for sample size calculation using the following assumptions: prevalence of suicidal risk behavior among university students was 25% (Abozaid et al., 2022), 97% confidence interval (CI), 5% margin of error, a non-response rate of 5%, and design effect = 2.A sample size of at least 745 participants will be needed.Regarding the sample type, a convenience non-random sample was conducted.

Data collection tool
A self-administered questionnaire was used to collect data.It consisted of the following sections: -Socio-demographic characteristics included age, gender, and monthly family income.-Daily habits such as smoking, drinking alcohol or substance abuse, practicing exercise, and sleeping hours.-Family and social issues included information about satisfaction with parents' and friends' relationships.-Suicidal Ideation Scale (SIS): It consisted of a 10-item scale.It is a 5-point Likert-type scale that is based on how the respondent felt or acted over the preceding year and is rated from 1 (never or none of the time) to 5 (always or a great many times).The overall score ranged from 10 to 50.SIS was created as a brief tool to measure the severity of suicidal behavior among the general population.It was intended to show the range of SI, from covert thoughts to more overt or intense ideation and actual suicide.SIS questions are divided into two groups: group 1 measures suicide desire (ongoing thoughts) and consists of 4 questions "5, 6, 7, 8", and group 2 measures resolved plans and preparation (intense thought, plans, and attempt suicide) and consists of 6 questions "1, 2, 3, 4, 9, 10".Among college students, a score of ≥ 15 is the starter score of minimum SI, while a total score of ≥ 36 is considered serious SI [26][27][28].Based on these cutoff values, our participants were categorized into 3 categories: those who scored < 15 were labeled as low risk of SI, those who scored from 15 to 35 were labeled as moderate risk of SI, and those who scored ≥ 36 were labeled as serious or high risk of SI. -The Oslo Social Support Scale (OSSS-3): A 3-item self-reported scale measuring one's perception of social support is used.It comprises three questions with a focus on the availability of practical assistance that inquires about the number of close confidants, the perception of other people's care, and the relationship with neighbors, with a focus on the accessibility of getting practical help.The sum score varied from 3 to 14, with high values indicating strong levels of social support and low values indicating poor levels.Three broad types of social support are determined by the OSSS-3 sum score: 3 to 8 have poor social support, 9 to 11 have moderate support, and while 12 to 14 have strong support [29].

Pilot study
To assess the questionnaire's clarity and feasibility, a pilot study involving 10% of the sample was carried out.
Based on the pilot study's findings, some questions were modified, and the findings were not included in the study results.

Validity and reliability of the study scales
-SIS: Previous research has demonstrated that SIS exhibits a high degree of internal consistency (Cronbach Alpha = 0.86 and 0.91, respectively) [26,27].Evidence from earlier studies showed that SIS is more easily understood by students and is capable of detecting early to serious SI by examining the convergent validity and known-group validity [27,30].
Regarding our data, assessment of the reliability of the SIS resulted in Cronbach's α = 0.91, and interterm correlations ranged from 0.35 to 0.73.-Validity evaluation is done by an expert panel, which consists of three experts: two public health experts and one psychiatry expert to evaluate the relevance, feasibility, and comprehensiveness of the tool.The investigators used a back-to-back translation for the development of the Arabic version of the questionnaire to ensure the validity of the Arabic version.-OSSS-3: Regarding our data, assessment of the reliability of the OSSS-3 results in Cronbach's α = 0.7, and interterm correlations ranged from 0.25 to 0.53.

Statistical analysis
Data were collected, checked, coded, and entered PC.Data were analyzed using the Statistical Package for Social Sciences (SPSS version 25).Descriptive analyses were performed as numbers and percentages for all qualitative data, mean, and SD for quantitative data.Bivariate analyses were performed using the chi-square test for categorical variables, and the Student's t test for quantitative data.Pearson correlation was used to assess the correlation between SIS and OSSS-3 scores, and relationships were illustrated using scatter plots.
Ordinal logistic regression was used to identify significant predictors of the severity of SI among participants, and ten variables were selected as predictors for the degree of SI.The selection of variables was done after reviewing the literature and identifying all factors that were proven to be related to our outcome.P value < 0.05 was considered significant.

Results
The present study involved 745 students at Ain Shams University: 418 (56.1%) medical students and 327 (43.9%) non-medical ones.The mean age was significantly higher among non-medical students (20.5 ± 1.3) than medical ones (19.8 ± 1.3).Males were significantly higher among non-medical students (52%) compared to medical ones (34%).Regarding cigarette smoking, it was significantly higher among non-medical than medical ones (11.6% versus 3.8%).Lifetime drug and alcohol use were significantly higher among non-medical students (1.5% and 5.2%, respectively).On the other hand, satisfaction with family's and friends' relationships was significantly higher among medical than non-medical (Table 1).
Regarding the 10 items of SIS, non-medical students were significantly higher in reporting the "Always" option in comparison with the medical ones (Supplementary Table S2).
OSIO Social Support Scale (OSSS-3) was statistically higher among medical students where (48.9%) of non-medical students reported poor social support versus (43.3%) among medical ones, and only (7.1%) of non-medical students reported strong social support versus (15.1%) among medical ones (Table 3).Medical and non-medical students did not differ statistically in terms of the number of close people in case of great personal problems, but (18.2%) of medical students reported a lot of interest and concern expressed by people versus only (13.1%) among non-medical students, which was statistically significant.Moreover, (14.2%) of medical students showed that getting practical help from neighbors in case of need was very easy versus (7.4%) among non-medical, which was statistically significant (Supplementary Table S3).

Discussion
Suicide is the fourth-leading cause of death among individuals aged 15 to 29 [3].The global goal is to reduce suicide rates worldwide by one-third by 2030 [7].Concerning Egyptian society, it has recently witnessed an  escalation in the suicide rate, especially among youth [5].Therefore, the present study was conducted to investigate the suicide phenomenon among students at Ain Shams University.
The current study revealed that 50.9% and 4.7% of the participants had moderate-and high-risk SI, respectively.The prevalence of SI varies among different countries.It was the highest among Chilean adolescents as 65.6% of them reported that they had SI [11] followed by students in Bangladesh, where the prevalence of SI was 61.1% [14], and in Ethiopia, where the prevalence of SI among campus students was 58.3% [12].Moreover, in Muslim-majority countries, the prevalence of SI was 21.9%, suicide plans were 6.4%, and suicide attempts were 6.6% [15].
In addition, the Suicidal Ideation Scale (SIS) was statistically higher among non-medical students (19.89 ± 8.58) versus among medical ones (16.60 ± 7.56).Moderate and high SI risks were significantly higher among non-medical students (59.3% and 6.4%, respectively) versus among medical ones (44.3% and 3.3%).This study was inconsistent with a study in Pakistan, where medical students had high levels of SI compared to non-medical students [31].This discrepancy can be attributed to different academic curriculums and populations.
There was a moderate negative significant correlation between SIS and perceived social support measured by OSSS-3 among whole participants (r = − 0.409), medical students (r = − 0.416), and non-medical students (r = − 0.381).The results were comparable to a study in Zagazig showing that SI had a statistically significant negative correlation (r = − 0.415) with the quality-oflife score, which included the social relationship as a domain [9].
As for the factors affecting severity of SI among the participants, ordinal logistic regression revealed that non-medical education (OR = 1.74, 95% CI 1.25-2.Regarding the age of participants, the current study demonstrated that the age of participants was not a significant predictor for the severity of SI, which agreed with Abdelaziz et al. in 2022 about SI among youth at Suez Canal University [32] and another study at Zagazig University [9].As for gender, previous studies revealed that SI is higher among females than males [9,10,31].This can be explained by the assumption that females are dependent and indecisive and that they ruminate to release their tension [9].But the present study revealed that gender is not a predictor for the severity of SI, which is consistent with other studies conducted in Egypt [21,32] and a study that was conducted in Bangladesh [14].This discrepancy may be attributed to different study populations.
As regards regular exercise, SIS in the current study was not affected by the presence of regular exercise which agreed with other studies [9,14].
Concerning the type of education, it was expected that SI would be higher among medical students than non-medical ones due to more academic pressure and long years of study in practical faculties compared to other non-medical ones, like a study in Pakistan showing that medical students had more academic stress and a higher level of SI compared to non-medical students [31].But surprisingly, the present study revealed that SI was higher among non-medical students.This finding can be explained by what Zagazig University students said in focus group discussions that a graduate of theoretical colleges holds the stressor of not having a future or a well-paying job, which is a widespread perception of the great majority of Egyptian families [9].Therefore, nonmedical students were significantly higher in reporting the "Always" option in the 10 items of SIS compared with the medical ones.
Furthermore, cigarette smoking was significantly higher among non-medical students than medical ones (11.6% versus 3.8%, respectively), and it was a significant predictor for the severity of SI.Smokers in Nepal were somewhat more likely than non-smokers to report SI (OR = 1.12) [33].Besides, Waters et al. in 2021 proved that daily smokers had the highest level of SI [34].
For sleeping hours per day, the current study revealed that sleeping was not associated with SI.The results disagreed with other studies that showed that short sleep duration was associated with SI in undergraduate students [35,36].
Family income was not associated with SI, and this study was consistent with Abozaid et al. who revealed that socioeconomic status did not affect SI [9] and agrees with Mamun et al. in Bangladesh [14].
According to satisfaction with friends' and family's relationships, the present study showed that dissatisfaction and neutral satisfaction regarding friends and family were significant positive predictors of the severity of SI among participants.These findings were consistent with another study, which revealed that having

Table 4 Ordinal logistic regression for the association between the degree of suicidal ideation and different variables
The dependent variable is the degree of suicidal ideation, no f observation = 745, *p value < 0.05, AOR adjusted odds ratio.Model chi-square (χ 2 ) = 210.6,p value < 0.001.Chi-square goodness of fit = 947.no friends was significantly correlated with suicidal behaviors [9].This is explained by the fact that as young people spend more time with their peers throughout this stage of life, friends become a more vital source of social support [9].Moreover, poor family relationships and improper parenting styles in China were associated with SI, which demonstrates the importance of considering the family environment when examining SI among university students, and it can help predict and prevent suicides among them [37].
Concerning perceived social support, OSSS-3 was statistically higher among medical students, where 48.9% of non-medical students reported poor social support versus 43.3% among medical ones, and only 7.1% of nonmedical students reported strong social support versus 15.1% among medical ones.These findings agreed with various studies.In Germany, middle or high social support was associated with a lower probability of reporting SI (OR = 0.42, 95% CI = 0.34-0.52)[10].In Indonesia, perceived social support was a significant predictor of decreased SI [18].Furthermore, in Ethiopia, students who had poor social support were significantly associated with suicidality [12].

Limitations
Because the study participants were recruited from different faculties in a single university and our sample was a convenient one, the current study cannot be generalized to Egyptian students.The presence of psychiatric disorders such as depression and anxiety, which have been linked to suicide, was not examined in this study.Additionally, because the study was cross-sectional, it was unable to examine the causal association between the factors.Since the data was collected using self-administered questionnaires, the study also exhibits information bias.

Conclusion and recommendations
Since SI is a serious issue among Ain Shams University students, screening is required as a secure element of initiatives to prevent youth suicide.As poor perceived social support was a significant predictor of SI severity, teaching parenting strategies to enhance family relationships and coping with stressful situations through lectures and media must be intensified.

Fig. 1
Fig. 1 Correlation between OSIO-3 and SIS; A Among the total sample, B among medical students, and C among non-medical students * Sig p-value Hussein and Yousef Middle East Current Psychiatry (2024) 31:1

Table 1
Socio-demographic characteristics of the studied participants (N = 745) * Sig p value, test of sig chi-square # Chi-square for trend & Independent sample t test

Table 2
Suicidal ideation scores (SIS) among the studied group (N = 745) * Sig.p value, test of sig chi-square # Chi-square for trend & Independent sample t test

Table 3
OSIO-3 social support scale scores, and prevalence of perceived social support among the studied group (N = 745) * Sig.p value # Chi-square for trend & Independent sample t test