Background
Suicide is a major global health problem, however, low- and middle-income countries account for a greater proportion of cases [
1]. Attempted suicide is defined as a self-initiated sequence of behaviors by an individual who, at the time of initiation, expected that the set of actions would lead to his or her own death [
2]. According to the report of the World Health Organization (WHO), the worldwide number of suicide cases in 2019 was 703,000, representing 9 deaths per 100,000 people [
3]. Also, the age-standardized suicide rate for all ages (per 100,000) in Iran has been reported as 5.5 [
3]. The results of a study showed that the average annual mortality rate in Kermanshah province during an 11 years period was 15.77 per 100,000, and hanging (48.1%) and self-immolation (47.8%) were common methods of suicide in men and women, respectively [
4]. Another study showed that Kermanshah province has the second highest suicide rate in Iran after its neighboring province of Ilam [
5]. We conducted this study on women because studies have shown that suicide attempt in Kermanshah province is significantly higher in women than in men [
6,
7].
To investigate suicide attempt, special attention should be paid to the two terms of risk factors and protective factors [
1]. Risk factors are those that show whether a person, a community or a population is particularly vulnerable to suicide [
8]. There is a consensus that suicidal behavior is not a single-caused behavior, and there is agreement that this behavior clearly results from a complex interaction of many different factors [
9]. Accordingly, many theories and models have been presented to explain suicidal behaviors. For example, interpersonal theory of suicide posits that mental pain and communication difficulties (marked by thwarted belongingness and perceived burdensomeness) are factors that work together to motivate a person to engage in suicidal behavior [
10]. A broad wider model; the integrated motivational– volitional (IMV) model of suicidal behavior postulates that suicide attempt is the result of the interaction and effects of multiple risk factors at three levels: pre motivational phase includes diathesis, environment, and life event, motivational phase includes psychosocial factors that cause suicidal thoughts and intent, and volitional phase contains risk factors that transit suicidal ideation/intent to action [
11]. The cultural theory and model of suicide also believes that many cultural factors are involved as risk factors in suicidal behaviors [
12]. In the case of Iran, factors such as marital discord, love and strong emotional tendencies, educational failures, traditional Iranian patriarchal culture, economic constraints, and work problems are introduced as predisposing factors of suicidal behaviors [
13‐
15].
As the subject of our study, there are protective factors that protect people from the risk of suicide. While many interventions focus on reducing suicidal risk factors, it is equally important to strengthen factors that increase resilience and connectedness and protect individuals against suicidal behaviors [
1]. Rodgers (2011), identifies four main factors protecting against suicide attempts: mental health care, connectedness, problem-solving skills, and contact with health care providers [
16]. Meaning in life is introduced a protective factor against suicidal tendencies through the creation of protective responses such as optimism, planning for the future, life satisfaction, and assertiveness in dealing with problematic situations [
17]. The results of a cross-national study confirmed that social support is a significant protective factor against suicide in men and women [
18]. Especially, women who receive a high level of social support from the family are less likely to attempt suicide than those with low social support [
19]. The results of a comparative study in Iran showed that intrinsic religiousness, support from friends, and problem-focused coping strategies were significant protective factors against suicide attempts [
20]. Feeling hopeful, feeling happy, and ringing for a general chat were also significant protective factors against suicidal behaviors in help-seekers [
21].
Some documents have suggested that in preventive interventions to reduce suicidal behaviors, it is better to emphasize strategies that promote protective factors against suicide in people [
8,
22,
23]. Given that suicide attempt is a global public health problem that is highly dependent on cultural, social, and psychological contexts in different parts of the world, achieving a correct understanding of factors related to suicide attempt, especially protective factors, requires qualitative studies [
24]. Therefore, the present study was conducted to identify protective factors against suicide attempt in women of Kermanshah, a region in western Iran.
Discussion
In this study, the results showed that both individual and social factors have a protective role against suicide attempt. Protective factors are one of the most important factors both in preventing the formation of suicidal ideation and in people who have suicidal ideation or plan to attempt suicide. While many interventions are performed to reduce risk factors for suicide prevention, it is equally important to consider and reinforce the factors that protect individuals from suicidal behaviors [
16]. In the present study, based on interviews and participants' opinions, we extracted five individual protective factors against suicide attempt, including problem-solving skills or coping strategies, reasons for living, resilience, religious beliefs, and fear of death. We also identified two social protective factors against suicide, including social support and effective communication.
There are limited studies that have comprehensively examined protective factors against suicide. Most of the studies have investigated some protective factors in different populations in a single or multi-subject manner, and less have focused on the classification of individual and social protective factors. Also, the conceptualization of protective factors through theories and models has rarely happened. In one of these works, IMV model has introduced individual and social protective factors including reasons for living, attainable positive future thinking, adaptive goal pursuit, belongingness and connectedness as motivational moderators [
11]. A theory driven network analysis also concluded that optimism, resilience and goal re-engagement were protective factors against suicide ideation [
28]. In this study, we tried to present a clearer picture of these issues by categorizing protective factors in the form of individual factors and social factors, which are discussed below.
Positive coping strategies protect people against suicide. Emotional stability, optimism about the future, and developed self-identity help a person cope with life's problems. Good self-esteem, self-efficacy, problem-solving skills, and help seeking skill in critical situations can mitigate the impact of stressors on suicidal behaviors [
1]. In the strain theory of suicide, a defect in positive coping skills is introduced as a source of strain, leading translate the suicidal ideation to suicide attempt [
29]. Zhang and Li (2013), found that women who attempted suicide had lower scores of coping and problem-solving skills [
30]. Jobes et al. (2015), believe that by using the right problem-solving skills and problem-oriented coping strategies, individuals can moderate the trigger role of stressors and prevent impulsive suicidal behaviors [
31]. According to the three-step theory of suicide and suicide strain theory, hopelessness is one of the predisposing factors for suicidal ideation [
29,
32]. On the other hand, some type of coping strategies are tools that protect people against despair and suicidal behaviors [
29]. It should be mentioned that not all coping strategies necessarily protect people against suicide. For example, Liang et al. showed that among coping strategies, self-distraction, substance abuse, behavioral disengagement, venting, and self-blame had a positive relationship with suicidality [
33]. Another study has also showed that an excessive avoidable coping is likely to lead to suicidal behaviors [
34].
Reasons for living such as hope for the future, having and nurturing children, and enjoying the positive aspects of life were individual protective factors against suicide attempt in this study. Prospective studies have shown that people who have fewer reasons to live are at greater risk for suicidal behaviors [
30,
35]. As suggested by the IMV model, the reasons for living and wish to live in the motivational phase of the model can weaken the relationship between defeat and entrapment with suicidal ideation and intent [
11]. Another study suggested that having reasons to live can protect people from suicidal behavior by weakening the relationship between depression and suicidal ideation [
36]). Consistent with some studies [
37,
38], we found that having a young child at home as a reason for living can be protective against suicidal behaviors. It seems that despite the inequalities and discrimination against women in the traditional society of Iran, some reasons for continuing life such as having a small child, keeping the family, and hoping for a better future temporarily protect women from suicide attempts in the present study.
Resilience was reported as an important personal protective factor against suicide attempt by women in this study. Resilience is a dynamic process that allows an individual to adapt to and overcome stress [
39]. According to Johnson et al. (2010), resilience can weaken the process of suicidal ideation during the stressful life events [
40]. Similar to the results of our study, a study in Iranian Kurdish women showed that resilience is one of the protective factors against suicidal ideation [
41]. The buffer hypothesis suggests that for people who are at risk of suicidal behavior, resilience acts as a buffer and weakens or eliminates suicidal behavior [
42]. Review studies have shown that improving resilience is one of the most key interventions to prevent or reduce suicidal behaviors [
39,
43]. One of the ways of impacting resilience on reducing suicidal behaviors can be through reducing impulsivity [
44]. In support of this opinion, Ram et al. (2019) found that in attempted suicide, cognitive flexibility and resilience are interrelated positively and inversely associated with impulsivity [
45].
In the present study, several participants cited the role of religion as a protective factor against suicide attempts. Religion is likely to have a protective effect in a variety of ways such as valuing the right to life, and promoting social bonds, which may reduce the risk of mental disorders such as depression and antisocial behaviors [
46]. In the Holy Qur'an, in Surah 4, verses 29 and 30, suicide is explicitly forbidden and the eternal punishment for suicide is burning in hell. Probably one of the reasons for the lower suicide rate in Muslims is that Islam is stricter about the sin of suicide than other religions [
47]. In addition, due to the fact that suicide is forbidden in Islam, it is still considered a crime in many Islamic countries [
48]. However, the social stigma of suicide in Muslim countries and the possibility of underreporting suicide rates should not be ignored [
49]. Taking all considerations into account, this topic can be used in suicide prevention interventions in Islamic countries.
In the present study, some women mentioned the fear of death as a protective factor against attempting suicide. Despite the importance of the topic, not many studies have been conducted to examine the relationship between fear of death and suicide attempts, but the few available evidences have not reported contradictions about this relationship. The simultaneous presence of suicidal ideation and reduced fear of death creates a situation in which the suicidal tendency becomes active and turns into suicide attempt [
10]. Britton and colleagues (2008), showed that patients who reported higher levels of fear of dying by suicide were less likely to experience suicidal thoughts [
50]. A study has shown that the fear of death acts as a protective shield against suicidal behaviors [
51]. The interpersonal theory of suicide suggests that the ability to overcome the fear of death and suicidal desire are prerequisites for attempting suicide [
10].
In the present study, based on the content analysis, we recognized two social protective factors against suicide attempts, including social support and effective communication. Studies have shown that social support has an effective role in controlling or reducing suicidality [
52]. Khezeli et al. (2019) showed that peer and family support reduces suicidal ideation, while family conflicts increase suicidal ideation and attempt in women [
53]. Meadows et al. similarly showed that women who receive more family support are less likely to attempt suicide [
19]. A study by Ariapooran and Khezeli in Kermanshah (2018), also showed that perceived social support in women was inversely related to suicidal ideation [
41]. Some models and theories of suicide have provided justifications regarding the role of social support in modulating suicidal behaviors. In the Cry of pain model (CoP), "no rescue" as the third component of the model directly refers to the level of social support (or loneliness) and is an important factor in explaining suicidal and self-harming behaviors [
54,
55]. The Schematic Appraisals Model of Suicide (SAMS) also suggests that perceived social support influences suicidal ideation through appraisals of defeat and entrapment [
56]).
There is evidence that the intrapersonal and interpersonal quality communication can protect people from suicidal behaviors [
57]. According to WHO in 2014, the risk of suicidal behaviors increases when people have severe communication conflict or disagreement. On the contrary, the continuation of intimate communication can increase people's self-esteem and act as a protective factor against suicide [
1]. Positive and effective communication helps to deal with stress, reduce hopelessness and depression in the face of painful life events and increase people's resilience by increasing intimate relationships [
58]. One type of effective communication is suicide communication, in which people share their suicidal thoughts or intentions with others. The results of a study have shown that communication with suicide is associated with a lower chance of suicide attempt in people [
59]. Khezeli et al. (2019), in Iranian Kurdish women showed that the score of suicidal ideation was higher in those who had decreased effective communication [
53]. Regarding the classification of social protective factors, it may seem that these two subcategories overlap. In this study and by analyzing the data, we found out that people viewed the tangible or perceived support they received from others as one of the protective factors against suicide attempts. However, there were also cases where support from others was not provided at first, but people actively sought a verbal or face-to-face communication. This may overlap slightly with social support, and this subcategory can also be defined as help-seeking behaviors. However, the research team concluded that effective self-initiated communication in this study can be classified separately from social support.
This was a qualitative study with a content analysis approach that was conducted on a sample of Kurdish women in Kermanshah, western Iran. The limitation of this study due to the nature of qualitative studies is that the generalization of the results cannot be considered with certainty. However, this study provided a good insight into the protective factors against suicide in a sample of Iranian Kurdish women. The strength of this study was the conduct of interviews in Kurdish language by the female interviewer to gain a deeper understanding of the subject and to communicate appropriately with the interviewees. Another strength of this study is conducting in-depth interviews and immersing the researcher in the data by reviewing them several times, which led to extracting, reporting and classifying the concepts hidden in women's experiences.
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