Suicidal ideation, attempts and help-seeking behaviors among adolescent girls in, Southwest Ethiopia: a community-based cross-sectional study

Adolescence is a crucial transitional phase between childhood and adulthood, marked by significant growth and change, second only to infancy [1]. Approximately 85% of adolescents globally reside in low- and middle-income countries [2]. In Sub-Saharan Africa, adolescents make up 20–30% of the population, with several countries experiencing a larger and growing adolescent demographic compared to other regions of the world [3, 4]. In Ethiopia, roughly one in four individuals is an adolescent [5].

During this stage, there is a marked change in biological, cognitive, and social experiences, especially among females, including significant increases in the occurrence of emotional and physiological responses to interpersonal stress that results in suicidal thoughts and behaviors among adolescent girls [6]. During this period, girls adopt additional gender-specific roles, and as they navigate individuation and exploration, their options may become limited, which might culminate in suicide. Notably, there is a sharp rise in suicidal thoughts and actions among teenage girls 7. Suicidal ideation is any self-reported desire to harm oneself that is not accompanied by any preparatory behavior. Suicidal planning means formulating a specific, feasible, and intentional method to carry out the action. This often involves steps taken to acquire the means or set the timing. The suicidal attempt is a nonfatal outcome that is instigated and perpetrated by the person in question and culminates in self-harm [8, 9].

A recent study reported that suicidal thoughts and behaviors rise dramatically during this developmental stage [10]. Globally, suicide accounts for approximately 6% of all adolescent deaths [11] and 70% of global violent deaths in women [12]. It is the second leading cause of death among female adolescents [13]. Nearly, 800,000 adolescents die by suicide each year, with over 79% occurring in LMICs [14]. Studies report, girls are more likely than boys to attempt suicide and report suicidal ideation [15]. Approximately 53% of American adolescents experience suicidal thoughts [16]. A study done in U.S.A, 22% of adolescent girls report suicidal ideation, 9.3% attempt suicide annually [17]. Another cross-sectional study in Turkey indicated that 13.2% of adolescent girls have attempted suicide [18]. The prevalence of suicidal attempts and ideation among adolescent girls in the community ranged from 13% to 21% [19]. However, compared to high-income countries relatively little is known about the epidemiology of adolescent suicide and suicidal behaviors in LMICs.

Adolescent suicidality is a significant mental health issue, with suicide rates increasing despite prevention efforts especially LMICs [20]. Many adolescents who experience suicidal thoughts or behaviors face barriers to accessing mental health services, and these barriers discourage help-seeking behavior; only about 28% receive professional help [21]. According to WHO data, only 10% of adolescents who attempt suicide seek professional help [22]. Research suggests that fewer than half of adolescents who died by suicide received prior mental health care [23]. A study in Taiwan found that among adolescents with a lifetime history of suicidal behavior, 5.5% sought psychiatric services and 5.0% sought help from mental health workers. For those with suicidal behavior in the past week, 17.4% sought psychiatric services, while none approached mental health workers [24]. A study conducted in America shows that 55% of individuals who commit suicide had no primary care contact, and 68% had no contact with mental health services [25]. Adolescent suicide help-seeking in Low- and Middle-Income Countries (LMICs) is critically low due to a complex interplay of systemic and cultural barriers. These include insufficient mental health resources, widespread under-diagnosis and under-treatment, and a lack of awareness regarding available psychiatric care. Culturally, help-seeking is aggressively hindered by pervasive stigma, deeply rooted cultural taboos surrounding suicide, poor mental health literacy, and the fear of negative outcomes [26, 27]. Even with accessible psychiatric services and universal health coverage, stigma and lack of information may explain low help-seeking rates [26]. Clarifying the roles of mental health care provision and help-seeking is therefore essential for suicide prevention. Despite high suicide rates in Ethiopia, many people do not seek professional help for suicide, and no evidence exists on suicidal behaviors and help-seeking among adolescent girls. This study addresses suicidal concerns and help-seeking behaviors in this population.

Adolescent mental health is significantly impacted by suicide, with emotional, physical, and financial consequences. Adolescent girls are more susceptible to anxiety, mood swings, and internalizing disorders, leading to depression and other mental health issues [28]. Survivors may experience trauma, leading to long-term negative effects on their well-being [29]. The impact extends beyond individuals, affecting friends, family, coworkers, and the community [30, 31]. Despite different studies done in Ethiopia on suicide in various populations, adolescent females have received less attention in Ethiopian studies, making understanding suicidal ideation and attempt patterns, and their help-seeking behaviors is crucial for distributing health resources, designing policies, and implementing effective treatment and preventive interventions.

Suicide is a serious and preventable public health issue, with timely and low-cost intervention [32]. Different biological, psychological, and social factors affect adolescent girls’ suicidal ideation and attempts. Among these factors are experiences of bullying [33], sexual, emotional, and physical abuse [34]. In addition, childhood physical and sexual abuse appears to be risk factors for future suicide attempts [35]. Other important risk factors includes family situation, interpersonal conflict, disturbed functioning in social roles, hopelessness, substance use, and mental disorders [36, 37].

Despite, adolescent girls are at higher risk for suicidal behavior, and low rates of help-seeking for suicide particularly in vulnerable populations such as adolescent girls in LMICs, less attention is given regarding suicidality and helpseeking behaviour among adolescent girls in Ethiopia. Therefore, this study was designed to address this gap by assessing the magnitude and risk factors of suicidal plan, ideation, attempts, and help-seeking behaviors among adolescent girls in Southwest Ethiopia. The results will have important clinical and policy implications, providing policymakers, planners, and health professionals with valuable insights to design strategies for preventing suicidal behaviors, and promoting their help-sought among adolescent girls. The findings of this study will also contribute to future research in this field.

Generally, higher estimates of suicidal ideation, planning, and attempts have been reported among adolescent girls [28], alongside low rates of help seeking behaviors for suicidality particularly in LMICs. So, in the current study, the magnitude of suicide ideation and attempts and their possible association with various factors, and their help-seeking behaviors were assessed among adolescent girls in Ethiopia for the first time. The findings of this study showed that the prevalence of past 12-month suicidal ideation among adolescent girls was 25.3% (95% CI: 23.5%−28.4%). The current study is consistent with studies done in Peru (26.3%) [49], and Liberia (27.0%) [50]. However, this finding is higher than previous studies done in the U.S. (22%) [17], and Myanmar (18.5%) [42]. Possible reasons for these differences between countries include differences in socioeconomic status, sociocultural conditions, and differences in availability of mental health facilities and health professionals, leading to differences in early detection and treatment [51]. For example, in Ethiopia, adolescent girls’ life opportunities are significantly limited by gender inequalities, cultural norms, and expectations of early marriage, domestic duties, and child-rearing, all of which contribute to suicidal thoughts. In contrast, adolescent girls in the U.S. have more legal rights and educational opportunities, so they are less stressed about fundamental survival and freedom, focusing more on performance and social dynamics, which can be protective against suicidal ideation [52].

The prevalence of suicidal attempts among adolescent girls in this study was 16.1% (95% CI: 13.5%−19.2%), which is in line with previous studies done in the Americas (18.6%) [53], and Samoa (17.4%) [54]. However, the proportion of suicidal attempts in this study was higher than in previous studies done in the U.S. (9.3%) [55], and Turkey (13.2%) [56]. The possible explanation for this discrepancy might be due to sociocultural factors, level of mental health awareness, attitudes towards mental illness, and study settings. For example, in Ethiopia, mental health issues are heavily stigmatized and are often viewed as a spiritual weakness or curse. This makes girls suffer in silence, as speaking out would bring shame to the family, leading to hopelessness and suicidal attempts as the only perceived escape. In contrast, the U.S. and Turkey have a much greater societal awareness and open discussion regarding to mental health [55].The other possible reasons accounting for the variations in study findings could be the differences in the measurement of suicidal behaviors as well as differences in time. For example, the above studies used the Global School-based Health Survey (GSHS), while the current study used CIDI to assess suicidal ideation and suicide attempts. On the other hand, the prevalence of suicidal attempts was lower than what was reported in Guatemala (20.2%) [57], Liberia (33.4%) [50], and Mongolia (31.3%) [58]. The discrepancy may stem from the sensitive nature of suicide; participants from various sociocultural backgrounds may be reluctant to discuss topics deemed socially unacceptable, influencing the results. Additionally, sociocultural stigma and taboos might deter individuals from reporting suicidal behaviors, thereby affecting the prevalence data [52].

In the current study, we discovered that participants who had experienced gender-based violence were 3.7 times more likely to have suicidal thoughts than those who had not. The findings are consistent with other research conducted in USA [59], Cambodia [60], Ghana [61], and Tanzania [62]. This could be because GBV has a number of implications for adolescent females, including social discrimination and stigmatization, physical handicap, school and employment absenteeism, and adolescent girls’ declining economic reliance, which leads to suicide [63]. GBV experiences and the fear of such abuse might impede gender equity for adolescent women by devaluing them and limiting their education, employment, and mobility owing to safety concerns, potentially leading to suicide [64]. Furthermore, experiencing GBV throughout adolescence has been connected to negative health and social outcomes, such as mental health problems, school dropout, substance abuse, hazardous sexual behaviors, and injury, with long-term consequences for future health and well-being, including suicide [61, 63]. GBV can lead young women on a path toward future violence and sexual risk behavior [62]. These findings indicate that designing an intervention strategy, stronger community engagement and develop treatment modalities to diminish the effects and, consequences of GBV among adolescent girls are crucial.

The current study also showed that participants who had anxiety symptoms were two times more likely to have suicidal ideation than adolescent girls who had no anxiety symptoms. This is similar to studies conducted in Taiwanese and Vietnamese [65, 66]. The possible explanation is that adolescent girls with anxiety symptoms face excessive worry that causes apprehensive expectations, restlessness, muscle tension, irritability, difficulty in falling asleep, and stress that results in suicidal behavior [65]. Moreover, anxiety symptoms become overwhelming, or experiencing distress in adolescent girls may lead to suicide as a coping strategy for emotional problems/overwhelming situations [66]. This result indicates an approach to anxiety to minimize suicidal ideation is necessary.

This study also revealed that adolescent girls who were food insecure were 1.73 times more likely to have suicidal ideation as compared to their counterparts. This is consistent with evidence from previous studies done in Ghana and Liberia [50, 61]. This could be Adolescent girls who go hungry may face heightened distraction, irritability, and increased emotional sensitivity, potentially leading to suicidal tendencies [61].

Adolescent girls with PMDD are approximately 3.54 times more likely to experience suicidal ideation than those without PMDD, as supported by studies from the USA, South Korea, and Germany [67‐69]. These girls report a range of cognitive, psychological, and somatic symptoms, including heightened stress, depression, anxiety, mood swings, irritability, abdominal bloating, social withdrawal, and poor concentration, all of which contribute to an increased risk of suicidal thoughts and behaviors [67]. Consequently, adolescent girls with PMDD should be regarded as a high-risk group for suicidality, representing a significant risk factor for both the onset and exacerbation of suicidal behavior each month [69]. Therefore, timely identification and treatment of their symptoms are crucial for reducing suicidal behaviors.

Regarding the risk factors of suicide attempts, participants who had depression were three times more likely to have suicidal attempts as compared to non-depressed ones. The finding was consistent with other studies done in Vietnamese, English, Thailand, and Nigeria [66, 70, 71]. This is due to decreased serotonin levels in the brains of depressed individuals are associated with an increased risk of suicide attempts [72]. Adolescent girls with depression often exhibit symptoms such as hopelessness, helplessness, and isolation core features of demoralization, which can lead to suicidal attempts [73]. Moreover, adolescent girls with depressive symptoms may have a loss of interest in activities, negative self-perception, a tendency to experience the world as hostile and demanding, and a future expectation of suffering and failure, eventually leading to suicide attempts [72]. Therefore, giving mental health services in the community for depressed individuals is a crucial means to reduce suicidal ideation.

The odds of having suicidal attempts were about 4.6 times more likely among adolescent girls who had experienced gender-based violence than among participants who had not experienced gender-based violence. This result was in line with studies done in the USA [59], Cambodia [60], Peru [49], Ghana [61], Brazil [74], Malaysia [36], and Benin [75]. The associations may stem from GBV during this period, which has significant mental health implications for adolescent girls. These consequences include depression, anxiety, post-traumatic stress disorder (PTSD), substance abuse, chronic inflammation, and low self-esteem that lead to suicide [36, 59]. Thus, working on reducing the consequences and interventions that address the issue of GBV against adolescent girls is important to reduce suicidal attempts.

The odds of having suicidal attempts among participants who had a family history of suicide were two times higher as compared with the referent groups. Studies from Brazil [76], Tanzania [77], and Ethiopia [78] supported this. This may be due to the families and genetic linkage of suicide, as evidence reported [70, 76]. Another possible justification could be that family mental health issues present risk factors in offspring that elevate suicidal behaviors [79]. Furthermore, family members who have attempted suicide and victims are at a significantly increased risk of suicidal behavior on the anniversary [80].

Another associated factor with suicidal attempts was having a social phobia, which is 1.8 times more likely to have suicidal attempts than those who did not. This is consistent with a previous study conducted in the USA [81]. The reason could be that social anxiety is often associated with shyness, frustration, behavioral inhibition, overanxious disorder, school refusal, feelings of hopelessness, isolation, stigma, and low self-esteem that increase suicidal attempts [82]. This often leads to a chronic, unremitting course, leads to substantial impairments in vocational, and social functioning, substance use disorders, depression, and mental disorders increase suicide risk [81, 82]. This finding suggests that expanding mental health services in the community and addressing SP among adolescent girls are very important to preventing suicidal attempts.

This study explores suicide and help-seeking behaviors among adolescent girls in Ethiopia. However, it has limitations. Firstly, the cross-sectional study design makes it difficult to establish cause-effect relationships between the outcome and explanatory variables. Secondly, the study did not assess the factors that influence help-seeking behaviors among adolescent girls. Finally, the magnitude of the problem may be underestimated due to the sensitive nature of topics like sexual violence and suicide, which can lead to social desirability bias. To mitigate this bias, female interviewers were also used and trained to be trauma-informed when asking sensitive questions for data collectors.

The study indicated that one in four adolescent girls had experienced suicidal ideation, one in six had attempted suicide, and help-seeking behaviors for suicidality were low. Being experienced gender-based violence, having anxiety symptoms, being food insecure, and having premenstrual dysphoric disorder were statistically significant predictors of suicidal ideation. The current study also revealed that suicidal attempts were higher among adolescent girls having depressive symptoms, having experienced gender-based violence, having a family history of suicide, and having social phobia. Since suicide needs urgent action, all concerned stakeholders should give better intervention. We recommend the Ministry of Health expand and implement mental health services in the community by designing universal, multi-level, collaborative, targeted intervention efforts especially by giving training and supporting front line primary care health staffs towards the assessment, diagnosis and management of common mental disorders, suicide prevention and encouraging help-seeking behaviors are crucial.