ORIGINAL ARTICLE
Suicide Ideation and Acceptability Among Females Aged 15 to 34 Years in Rural China Jie Zhang, PhD*Þ and Long Sun, MPH*
Abstract: The suicide rate of females is very close to that of males in China, in contrast to Western societies, in which the rates of male suicide outnumber those of females by three to four times. This study investigated the prevalence of suicidal ideation and prosuicide attitude (acceptability) among females of childbearing age. With the Chinese version of the Scale for Suicide Ideation and the General Social Survey questionnaire, we examined the demographic and psychological risk factors of suicide among Chinese rural young females aged 15 to 34 years. Logistic regression analysis was performed to explore the factors related to suicidal ideation and suicide acceptability. The prevalence rates of suicidal ideation and suicide acceptability among the sampled females are 22.5% and 3.8%, respectively. Education, depression, social support, hopelessness, and negative life events were significantly associated with suicidal ideation. Ethnicity, education, abortion, and depression were significantly associated with suicide acceptability. There is statistical difference between suicide ideation and acceptability. The results indicate that mental disorder remains a major risk factor of suicidal ideation. Sociodemographic and psychological characteristics are associated with suicide acceptability. Key Words: Suicidal ideation, suicide acceptability, females, rural China, cross-sectional study. (J Nerv Ment Dis 2014;202: 161Y166)
I
n the past 2 decades, suicide rates have steadily decreased in China (Hvistendahl, 2012; Zhang et al., 2011), but suicide still remains the fifth cause of death of the Chinese populations and the first cause of death among the population aged 15 to 34 years in China (Ministry of Health [MOH], 2011; World Health Organization, 2005). The data from the China Ministry of Health Vital Registration system shows that in 2010, suicide rate is 10.01 per 100,000 people in rural areas and 6.86 per 100,000 people in urban areas (MOH, 2011). China accounts for an estimated 22% of global suicides, or roughly 200,000 deaths every year (Hvistendahl, 2012). Compared with Western countries, suicide in China demonstrates three unique characteristics: a) the female suicide rates are approximately the same as in the males; b) the rural suicide rates are almost double those in the urban rates; and c) there exist two peaks in the curve of suicide rates among different ages, the 15- to 34-year-olds and the 60- to 84-year-olds (Phillips et al., 2002a; Qin et al., 2001). The sex difference was found in many studies from different cultures, which showed that females had a higher incidence of suicidal ideation and suicide attempt but lower suicide rates than male in the world (He and Lester, 2001; Schaffer et al., 2000; Takusari et al., 2011).
*Shandong University School of Public Health Center for Suicide Prevention Research, Jinan, China; and †Department of Sociology, State University of New York College at Buffalo, Buffalo, NY. Long Sun is a PhD candidate at Shandong University School of Public Health Center for Suicide Prevention Research. Send reprint requests to Jie Zhang, PhD, Department of Sociology, State University of New York College at Buffalo, 1300 Elmwood Ave, Buffalo, NY 14222. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0161 DOI: 10.1097/NMD.0000000000000104
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However, in China, the sex pattern was reversed, with more females, especially rural young females, killing themselves by suicide. Thus, suicide has been an important public health issue, and rural young females have formed a high-risk population of suicide in China (Phillips et al., 2002b). Suicidal ideation has been found to be an important predictor of suicide death (De Leo et al., 2005; Kessler et al., 2005). Thus, study on suicidal ideation can be an important approach in the suicide prevention among Chinese rural females. In the past few decades, many researchers have tried to measure the ideation of suicide among Chinese populations. Using the instrument developed by Kessler et al. (2005), Lee et al. (2007a) reported that the lifetime prevalence estimates of suicidal ideation, plans, and attempts in China were 3.1%, 0.9%, and 1.0%, respectively. Another study among Chinese college students showed that the lifetime prevalence of suicidal ideation, plan, and attempt was 45.1%, 6.8%, and 1.9%, respectively (Zhao et al., 2012). Zhang and Zhou (2011) observed that the lifetime prevalence of ideation, plans, and attempts among the informants of suicide was 18.1%, 4.1%, and 1.7%. Dai et al. (2011) conducted a study on the suicidal ideation and attempts among rural Chinese aged 16 to 34 years, and the results showed that lifetime and 1-year prevalence of suicidal ideation were 18.8% and 5.2%, respectively. Positive correlation between suicide acceptability and suicidality has been demonstrated in many studies (Joe et al., 2007; Li and Phillips, 2010). Because suicide acceptability was defined as prosuicide attitudes in some studies, we collected the articles about suicide acceptability and prosuicide attitude. In a case-control study, Zhang and Jia (2010) estimated the extent to which suicide death affected attitudes (acceptability) toward suicide among family members of suicides. Japanese researchers also investigated the knowledge and attitude toward suicide among medical students in Japan (Sato et al., 2006). In Hong Kong, researchers investigated the attitudes toward life and death among Chinese adolescents (Wong, 2004). In addition, many researchers found that suicide acceptability was correlated with suicide planning and marital status (Cutright and Fernquist, 2004; Joe et al., 2007). Further, researchers in Hong Kong developed a Hong Kong version of the Chinese Attitude Toward Suicide Questionnaire, which can be used to assess attitudes toward suicide (Lee et al., 2007a). Although numerous studies have been performed on suicidal ideation and suicide acceptability, few have specifically focused on females aged 15 to 34 years, a high-risk group for suicide in China. In this study, we examined the current situation of suicidal ideation and suicide acceptability among such a rural population in China.
METHODS Participants and Survey Procedure A total of 1039 rural females were recruited from two towns in Xinle City (in the North of China) in the spring of 2011. Respondents meeting the following criteria were included in the sample: a) female, b) living in a rural area, and c) aged 15 to 34 years. All subjects were convened to the Maternal and Child Care Service
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Centre to fill out the questionnaire, which lasted a mean of 1 hour. The participants who could not read completed the questionnaire under the guidance of interviewers. All interviewers were trained on the interview procedures for a minimum of 1 day by the research group. Personal and demographic characteristics and psychosocial functioning (approximately 300 questions) were included in the interview.
Measures Suicidal Ideation Suicidal ideation was assessed by the Chinese version of the Scale for Suicide Ideation (SSI), which contained 19 items (Beck et al., 1997, 1999, 1985). If the subject endorsed any 1 of the first 5 items, then the next 14 items should be answered. If none of the first five items were positive, the subjects should skip the whole SSI scale and go to the next section of the questionnaire (Zhang and Brown, 2007). The final total score of the 19 items was dichotomized to 0 and 1. The score is 0 if the total is 0 (the ‘‘not applicable’’ response was also coded as 0), and the score is 1 if the total score is 1 or greater than 1.
Suicide Acceptability Suicide acceptability was evaluated by the four items on acceptability toward suicide in the General Social Survey (GSS) study (Davis and Smith, 1972Y1993). These items were ‘‘Can he/she commit suicide if they got some incurable diseases?’’ ‘‘Can he/she commit suicide if they lost lots of money?’’ ‘‘Can he/she commit suicide if they were tired of living?’’ and ‘‘Can he/she commit suicide if they dishonored his/her family?’’ The answer options were yes (1) and no (0). The total score of the four suicide acceptability items was dichotomized into two groups, with 0 if the total score equals 0 and 1 if the total score is 1 or greater (Zhang and Jia, 2007).
Sociodemographic Characteristics The demographic information from the questionnaire is limited to females aged 15 to 34 years in China. Nationality was measured by Han (1) and others (0). Education was evaluated by five choices: 1, no education or lower than elementary school; 2, middle school; 3, high or vocational school; 4, college or university; and 5, graduate school or higher. Education was recoded to 1, junior high or lower; 2, senior high or vocational school; and 3, college or higher. Marital status was assessed by six options: 1, single; 2, married and living together; 3, married but separated; 4, widower; 5, divorced; and 6, others. Because there is none of other marital status and few females were separated, widowed, or divorced, we coded the marital status variable to 0, never married, and 1, ever married. Religious identity was assessed by the following choices: 1, Daoist; 2, Islamic; 3, Protestant; 4, Catholic; 5, Buddhist; 6, others; and 7, atheist. This variable on religion was then coded into 0, no religion (atheist), and 1, has a religion. Political affiliation was measured by 1, Communist Party member; 2, Communist League member; 3, Communist Party membership applicant; 4, other party member; and 5, no party affiliation. This variable was recoded into 0, not a Communist Party member, and 1, Communist Party member. Whether the subject lived alone was assessed by 1, yes, and 0, no. Whether the subject has a family suicide history was assessed by 1, yes, and 0, no. Whether the subject has a male baby was measured by the number of her male babies, which we dichotomized into two groups, with 0 if the number is 0 and 1 if the number is 1 or more. Whether the subject is an only child was measured by the total number of her brothers and sisters, which we dichotomized into two groups, with 0 if the number is 0 and 1 if the number is 1 or more. Whether the subject has a history of abortion was measured by the number of her abortions, which 162
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we dichotomized into two groups, with 0 if the number is 0 and 1 if the number is 1 or more. Occupation was measured by 1, farmer; 2, businessman; 3, national staff; 4, student; 5, worker; 6, rural physician; 7, teacher; 8, housewife; 9, unemployed; and 10, others. It was recoded to 1, farmer; 2, nonfarmer; and 3, unemployed. To assess the subjects’ social support level, we used the 12-item Duke Social Support Index scale (DSSI). The scale measures multiple dimensions of social support and has been used extensively in cross-sectional and longitudinal studies of aging (Koenig et al., 1993). It is a self-report scale and contains family support, support of friends, and other support. The answer can be chosen from five answers: 1, strongly disagree; 2, disagree; 3, not sure; 4, agree; and 5, strongly agree. The Chinese version of the DSSI has been validated with a number of Chinese samples and proved to be an excellent measure of social support in general Chinese populations (Jia and Zhang, 2012; Landerman et al., 1989). Life events were measured by the Interview for Recent Life Events. It has 64 items, and for each of them, respondents answer whether the events occurred in the past 1 year: 1, yes; 2, no. We count the number of negative life events as the variable of negative life events (Zhang and Ma, 2012). Whether the subject had a physical disease was assessed by 1, yes, and 0, no. Whether the subject had a mental disease was assessed by 1, yes, and 0, no.
Mental and Physical Health Status All the psychopathological and social behavioral scales have been validated in Chinese populations, as follows. We used the Center for Epidemiologic StudiesYDepression Scale (CES-D) to assess the respondents’ depression level (Radloff, 1977). The CES-D is a self-report scale, and it covers affective, cognitive, behavioral, and somatic symptoms associated with depression. The CES-D was originally developed for assessing depression symptoms and was specifically designed for research use in the general and nonclinical populations. It has 20 items, and for each of them, respondents rate their own feeling for the number of days in the past 1 week: 1, less than one day; 2, one to two days; 3, three to four days; and 4, five to seven days. The Chinese version of the CES-D has been validated with a number of Chinese samples and proved to be an excellent measure of depression in general Chinese populations (Zhang and Norvilitis, 2002; Zhang et al., 2012). The Spielberger Trait-Anxiety Scale was used to measure the subjects’ anxiety level. The Trait-Anxiety Scale, which includes 20 items, is half of Spielberger’s State-Trait Anxiety Inventory Form (STAI; Spielberger, 1983). The State-Anxiety Scale, the second half of the inventory, also has 20 items. The STAI clearly differentiates between the temporary condition of ‘‘state anxiety’’ and the more general and long-standing quality of ‘‘trait anxiety.’’ In responding to the Trait-Anxiety Scale, subjects rate the frequency of the feelings on these 4-point scales: 1, never; 2, sometimes; 3, often; and 4, always. The Chinese version of the scale has been validated in a Chinese sample and proved to be an excellent measure of trait anxiety in Chinese culture (Zhang and Gao, 2012). Self-esteem was estimated by the Rosenberg Self Esteem Scale (RSES), created by Rosenberg (1965). The scale ranges from 10 to 40, with 40 being the highest score (each item ranges from a score of 1 to 4). Higher score indicates higher level of self-esteem. In responding to the scale, the subjects chose from these 4-point scales: 1, strongly disagree; 2, disagree; 3, agree; and 4, strongly agree. The Chinese version of the RSES has been validated with a number of Chinese samples and proved to be an excellent measure of selfesteem in general Chinese populations (Lee and Lee, 2000; Zhang et al., 2010). We used the Beck Hopelessness Scale (BHS) developed by Beck (1978) to evaluate hopelessness. It is a self-report scale that * 2014 Lippincott Williams & Wilkins
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measures three major aspects of hopelessness: feelings about the future, loss of motivation, and expectations. This BHS questionnaire consists of 20 questions examining the respondents’ attitude. The answer can be chosen from five answers: 1, strongly agree; 2, agree; 3, not sure; 4, disagree; and 5, strongly disagree. The Chinese version of the BHS has been validated with a number of Chinese samples and proved to be an excellent measure of hopelessness in general Chinese populations (Cheung et al., 2006).
Suicide Ideation and Acceptability
Statistical Analysis The Statistical Package for the Social Sciences for Windows (version 16.0) was used for data analysis. t-Tests were used to compare the difference on continuous variables across groups, whereas the chi-square test was used for categorical variables. Logistic regression analysis was performed to examine the factors related to suicidal ideation and suicide acceptability. All of the factors were chosen as the independent variables. The thesis brings the unordered
TABLE 1. Demographic Characteristics of Suicidal Ideation and Suicide Acceptability (N = 1039) Suicidal Ideation
n (%) Age, mean (SD) Ethnicity Han (1) Others (0) Education Junior high or lower (1) Senior high or vocational school (2) College or higher (3) Political affiliation Party or League member (1) No affiliation (0) Marital status Never married (0) Ever married (1) Live alone Yes (1) No (0) Physical disease Yes (1) No (0) Family suicide history Yes (1) No (0) Only child Yes (1) No (0) At least 1 male baby Yes (1) No (0) Abortion Yes (1) No (0) Religious belief Yes (1) No (0) Occupation Farmer (1) Nonfarmer (2) Unemployed (3) Social support (total score), mean (SD) Life events (total score), mean (SD)
Total, n (%)
Yes, n (%)
1039 (100) 24.94 (4.68)
234 (22.5) 24.96 (4.87)
1005 (96.8) 33 (3.2)
No, n (%)
Suicide Acceptability Yes, n (%)
No, n (%)
775 (77.5) 24.98 (4.74)
40 (3.8) 23.50 (5.28)
999 (96.2) 25.03 (4.73)*
222 (94.9) 12 (5.1)
783 (97.3) 22 (2.7)
35 (87.5) 5 (12.5)
970 (97.1)* 29 (2.9)
586 (56.5) 297 (28.6) 155 (14.9)
139 (59.4) 73 (31.2) 22 (9.4)
448 (55.7)* 224 (27.8) 133 (16.5)
19 (47.5) 19 (47.5) 2 (5.0)
568 (56.9)* 278 (27.8) 153 (15.3)
488 (47.0) 551 (53.0)
107 (45.7) 127 (54.3)
381 (47.3) 424 (52.7)
24 (60.0) 16 (40.0)
464 (46.4) 535 (53.6)
287 (27.6) 751 (72.4)
69 (29.5) 165 (70.5)
218 (27.1) 587 (72.9)
15 (37.5) 25 (62.5)
272 (27.2) 727 (72.8)
48 (4.6) 990 (95.4)
8 (3.4) 226 (96.6)
40 (5.0) 765 (95.0)
1 (2.5) 39 (97.5)
47 (4.7) 952 (95.3)
10 (1.0) 1029 (99.0)
3 (1.3) 231 (98.7)
7 (0.9) 798 (99.1)
2 (5.0) 38 (95.0)
8 (0.8)* 991 (99.2)
13 (1.3) 1025 (98.7)
6 (2.6) 228 (97.4)
7 (0.9)* 798 (99.1)
2 (5.0) 38 (95.0)
11 (1.1)* 988 (98.9)
10 (1.0) 1029 (99.0)
3 (1.3) 231 (98.7)
7 (0.9) 798 (99.1)
0 (0.0) 40 (100.0)
10 (1.0) 989 (99.0)
482 (46.4) 557 (53.6)
106 (45.3) 128 (54.7)
376 (46.7) 429 (53.3)
16 (40.0) 24 (60.0)
466 (46.6) 533 (53.4)
145 (14.0) 893 (86.0)
36 (15.4) 198 (84.6)
109 (13.5) 696 (86.5)
11 (27.5) 29 (72.5)
134 (13.4)* 865 (86.6)
142 (13.7) 896 (86.3)
42 (17.9) 192 (82.1)
101 (12.5)* 704 (87.5)
7 (17.5) 33 (82.5)
135 (13.5) 863 (86.5)
176 (16.9) 349 (33.6) 514 (49.5) 48.69 (6.40) 4.44 (5.63)
39 (16.7) 78 (33.3) 117 (50.0) 49.31 (6.19) 6.10 (7.06)
137 (17.0) 271 (33.7) 397 (49.3) 46.53 (6.64)*** 3.97 (5.05)***
5 (12.5) 8 (20.0) 27 (67.5) 45.78 (6.04) 6.55 (7.42)
171 (17.1) 341 (34.1) 487 (48.7) 48.80 (6.39)** 4.36 (5.54)**
*p G 0.05. **p G 01. ***p G 0.001.
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categorical variable (such as occupation) as dummy variables into the regression analysis model. All tests were two tailed, and a p-value of less than 0.05 was considered statistically significant.
RESULTS Participation Demographic characteristics of the sample are presented in the second row of Table 1. A total of 1039 respondents answered the question regarding suicide intent (with 31 missing cases). The response rate was 97.1%.
Distribution and Single-Factor Analysis of Suicide Ideation and Suicide Acceptability Table 1 presents the social distribution and single-factor analysis of suicide ideation and acceptability, and Table 2 presents the psychological distribution and single-factor analysis of suicide ideation and acceptability. The prevalence of suicidal ideation among females aged 15 to 34 years in rural China was 22.5%, and 3.8% of the subjects considered suicide acceptable. Education, family suicide history, religious belief, depression, social support, anxiety, selfesteem, hopelessness, and life events demonstrated significant difference by suicide ideation ( p G 0.05). There was significant variation in age, ethnicity, education, physical disease, family suicide history, abortion, depression, social support, anxiety, self-esteem, hopelessness, and life events by suicide acceptability ( p G 0.05).
Logistic Regression Analysis The logistic regression analyses of suicidal ideation and suicide acceptability are shown in Table 3. The variable of occupation was in this model as a dummy variable. Education (p = 0.048), depression ( p = 0.001), social support ( p = 0.014), negative life events ( p = 0.008), and hopelessness ( p = 0.014) were significantly associated with suicide ideation. Ethnicity ( p = 0.017), education ( p = 0.036), abortion ( p = 0.018), and depression ( p = 0.048) showed significant association with suicide acceptability.
The Difference Between Suicide Ideation and Suicide Acceptability We did the chi-square test between suicide ideation and suicide acceptability, and the result shows that there is statistical difference between them (W2 = 21.426, p G 0.001).
DISCUSSION In our sample, we found that the prevalence rate of suicide ideation and acceptability in Chinese females of childbearing age was 22.5% and 3.8%, respectively. Depression, social support, hopelessness, and life events were significantly associated with suicidal
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ideation. Ethnicity, education, abortion, and depression were significantly associated with suicide acceptability. The suicide ideation is close to the rates reported by previous studies in China. A study in Sichuan (South of China) found that the prevalence of suicidal ideation among rural Chinese females aged 16 to 34 years is 21.85% (Dai et al., 2011), and a study in Shandong (East of China) reported that the prevalence of suicidal ideation among rural girls of China is 22.0% (Liu et al., 2005). However, in other countries, the prevalence of suicide ideation ranged from 3.8% to 23.1% (Abell et al., 2012; De Leo et al., 2005; Huang et al., 2012; Kessler et al., 2005; Kuo et al., 2001). In comparison with the above-mentioned data, the prevalence of female suicide ideation in China was at the higher end. We found in this study that the suicide acceptability rate among the sampled Chinese females of childbearing age was 3.8%. In contrast to other countries, the rate resulting from the same measures of the GSS is higher than that found in our Chinese sample (Blosnich and Bossarte, 2013; Stack, 1998, 2000). The reason why the rate of suicide acceptability was so low might be that suicide is a negative event in China, and the suicides might be discriminated against by the fellow villagers. Therefore, there are more people in China than in other societies who see suicide as less acceptable. The logistic regression analysis shows that factors associated with suicidal ideation included depression, social support, hopelessness, and life events. In our study, we found that mental health was mainly associated with suicidal ideation in Chinese females of childbearing age. In many earlier studies, those factors had been demonstrated as the influential factor of suicide ideation (Cheung et al., 2006; Gong et al., 2011; Vasiliadis et al., 2013; Wang et al., 2009), which was consistent with our findings. It is also found that ethnicity, education, abortion, and depression have an impact on suicide acceptability, which is in line with the findings in many other studies in which sociodemographic characteristics were found to be associated with suicide acceptability (Chiles and Strosahl, 1995; Eskin, 2004; Jing et al., 2008; Lee et al., 2007b). The finding that religion is not a protective factor against suicidal ideation or suicide acceptability is in contrast to a large study based in the West (Stack and Kposowa, 2011). Because religious population is of a small percentage in modern China, this finding might be anticipated. Durkheim (1951) found, for example, that where Catholics were a minority of the population in some European nations and cities, they actually had a higher rate of suicide than Protestants. According to the moral community view of Durkheim, religion best protects against suicide when a whole population is of one faith. In China, most of the population has no religion. In that context, most of the population is atheist and is less apt to reinforce the beliefs of the religious minority. The relative lack of support from
TABLE 2. Psychological Characteristics of Suicidal Ideation and Suicide Acceptability (N = 1039) Suicidal Ideation Total, n (%)
n (%) Depression (total score), mean (SD) Anxiety (total score), mean (SD) Self-esteem (total score), mean (SD) Hopelessness (total score), mean (SD)
1039 30.78 41.75 30.37 40.31
(100) (8.55) (6.76) (3.53) (10.54)
Yes, n (%)
234 34.19 44.33 29.11 44.60
(22.5) (8.97) (6.17) (3.46) (9.69)
No, n (%)
775 29.79 41.08 30.73 39.06
(77.5) (8.16)*** (6.69)*** (3.47)*** (10.45)***
Suicide Acceptability Yes, n (%)
40 (3.8) 37.95 (10.40) 46.55 (7.96) 28.18 (3.80) 47.72 (11.56)
No, n (%)
999 30.49 41.62 30.45 40.01
(96.2) (8.35)*** (6.59)*** (3.49)*** (10.39)***
***p G 0.001.
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Suicide Ideation and Acceptability
TABLE 3. Logistic Regression Analysis of Correlates of Suicidal Ideation and Suicide Acceptability in Chinese Rural Females (N = 1039) Dependent Variables Independent Variables
Age Ethnicity (reference, others) Education Junior high or lower Senior high school College or higher Occupation Farmer Nonfarmer Unemployed Political affiliation (reference, no affiliation) Live alone (reference, no) Physical disease (reference, no) Mental disease (reference, no) Marital status (reference, never married) Family suicide history (reference, no) Only child (reference, no) At least 1 male baby (reference, no) Abortion (reference, no) Religious belief (reference, no) Depression Social support Anxiety Self-esteem Hopelessness Life events
2
Suicidal ideation OR (95% CI) R = 0.142
Suicide Acceptability OR (95% CI) R2 = 0.229
0.974 (0.932Y1.019) 1.196 (0.493Y2.902)
1.043 (0.938Y1.161) 7.686 (1.427Y41.402)*
1.858 (1.044Y3.306)* 1.860 (1.054Y3.284)* Reference
2.737 (0.540Y13.874) 5.008 (1.074Y23.365)* Reference
0.984 (0.631Y1.534) 1.015 (0.716Y1.440) Reference 0.904 (0.629Y1.299) 1.667 (0.708Y3.923) 1.963 (0.378Y10.190) 0.687 (0.088Y5.348) 0.654 (0.391Y1.094) 0.540 (0.143Y2.031) 0.906 (0.185Y4.443) 1.052 (0.719Y1.537) 1.080 (0.684Y1.705) 0.782 (0.483Y1.266) 1.034 (1.014Y1.054)** 0.966 (0.939Y0.993)* 1.007 (0.974Y1.042) 0.985 (0.927Y1.047) 1.023 (1.004Y1.043)* 1.036 (1.009Y1.064)**
0.578 (0.201Y1.665) 0.446 (0.188Y1.055) Reference 0.581 (0.258Y1.308) 1.441 (0.169Y12.263) 0.375 (0.046Y3.068) 1.353*108 (0.000) 0.736 (0.226Y2.396) 0.361 (0.044Y2.983) 0.000 (0.000) 1.086 (0.462Y2.554) 0.382 (0.157Y0.928)* 2.143 (0.541Y8.491) 1.045 (1.003Y1.089)* 0.990 (0.933Y1.050) 1.043 (0.967Y1.124) 1.005 (0.879Y1.149) 1.033 (0.989Y1.079) 0.998 (0.946Y1.054)
Only odds ratio (OR) and 95% confidence interval (CI) of variables retained in the final regression models were presented in the table. *p G 0.05. **p G 0.01.
a moral community weakens the influence of religion on the small religious group (Eskin, 2004; Neeleman et al., 1998; Stack and Kposowa, 2011). The correlation between suicide ideation and acceptability was demonstrated in our study, although we cannot establish that suicide acceptability causes suicide ideation because of the lack of time sequence of the data. Some studies have demonstrated that suicide acceptability predicts suicide ideation, suicide plans, and even suicide rates (Joe et al., 2007; Stack and Kposowa, 2011). There were several limitations that should be addressed when interpreting these results. First, as a cross-sectional study, we could not infer any causal relationship on the basis of the results. Second, all of the data were self-reported and thus may have some biases, such as shared method variance problems. Third, our sample was limited to one province, and the generalization of the findings has to be done cautiously. Finally, the suicide acceptability was measured by the four items in the GSS, and the reliability and the validity of the scale deserve further tests in Chinese societies. Despite these limitations, the study can still contribute to our understanding about the prevalence and risk factors of suicidal ideation and suicide acceptability in rural Chinese females aged 15 to 34 years, a high-risk group for suicide in China. This study also provided the baseline data regarding the suicides of rural females in Hebei Province. Through such studies, programs that can effectively * 2014 Lippincott Williams & Wilkins
reduce the morbidity and the mortality associated with suicide could be developed and tested. DISCLOSURES This research was supported by the US NIMH: R01 MH68560. The authors declare no conflict of interest.
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Cheung YB, Law CK, Chan B, Liu KY, Yip PSF (2006) Suicidal ideation and suicidal attempts in a population-based study of Chinese people: Risk attributable to hopelessness, depression, and social factors. J Affect Disord. 90:193Y199. Chiles J, Strosahl K (1995) The suicide patient: Principles of assessment, treatment, and case management. Washington, DC: American Psychiatric Press. Cutright P, Fernquist RM (2004) Marital status integration, psychological wellbeing, and suicide acceptability as predictors of marital status differentials in suicide rates. Soc Sci Res. 24:570Y590. Dai J, Chiu HF, Conner KR, Chan SS, Hou ZJ, Yu X, Caine ED (2011) Suicidal ideation and attempts among rural Chinese aged 16Y34 yearsVSociodemographic correlates in the context of a transforming China. J Affect Disord. 130:438Y446. Davis JA, Smith TW (1972Y1993) General Social Surveys, 1972-1993. Chicago: National Opinion Research Center. De Leo D, Cerin E, Spathonis K, Burgis S (2005) Lifetime risk of suicide ideation and attempts in an Australian community: Prevalence, suicidal process, and help-seeking behaviour. J Affect Disord. 86:215Y224. Durkheim E (1951) Suicide: A study in sociology. New York: Free Press. Original work published in 1897. Eskin M (2004) The effects of religious versus secular education on suicide ideation and suicidal attitudes in adolescents in Turkey. Soc Psychiatry Psychiatr Epidemiol. 39:536Y542. Gong Y, Zhang L, Wang Z, Liang Y (2011) Pathway analysis of risk factors for severe suicidal ideation: A survey in rural China. Can J Public Health. 102: 472Y475. He Z-X, Lester D (2001) Sex differences in suicidal ideation in a community sample from China. Crisis. 22:132Y134. Huang H, Faisal-Cury A, Chan Y-F, Tabb K, Katon W, Menezes PR (2012) Suicidal ideation during pregnancy: Prevalence and associated factors among lowincome women in Sao Paulo, Brazil. Arch Womens Ment Health. 15:135Y138. Hvistendahl M (2012) Making sense of a senseless act. Science. 338:1025Y1027. Jia C-X, Zhang J (2012) Psychometric characteristics of the Duke Social Support Index in a young rural Chinese population. Death Stud. 36:858Y869. Jing C, Wang S, Yang G, Zhao L, Li D, Kuang Q, Wang Q (2008) Attitudes towards suicide among undergraduates and its influencing factors. Chin J Public Health. 24:913Y915. Joe S, Romer D, Jamieson PE (2007) Suicide acceptability is related to suicide planning in U.S. adolescents and young adults. Suicide Life Threat Behav. 37:165Y178. Kessler RC, Berglund P, Borges G, Nock M, Wang PS (2005) Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990Y1992 to 2001Y2003. JAMA. 293:2487Y2495. Koenig HG, Westlund RE, George LK, Hughes DC, Blazer DG, Hybels C (1993) Abbreviating the Duke Social Support Index for use in chronically ill elderly individuals. Psychosomatics. 34:61Y69. Kuo WH, Gallo JJ, Tien AY (2001) Incidence of suicide ideation and attempts in adults: The 13-year follow-up of a community sample in Baltimore, Maryland. Psychol Med. 31:1181Y1191. Landerman R, George LK, Campbell RT, Blazer DG (1989) Alternative models of the stress buffering hypothesis. Am J Community Psychol. 17:625Y642. Lee S, Fung SC, Tsang A, Liu ZR, Huang YQ, He YL, Zhang MY, Shen YC, Nock MK, Kessler RC (2007a) Lifetime prevalence of suicide ideation, plan, and attempt in metropolitan China. Acta Psychiatr Scand. 116:429Y437. Lee S, Lee AM (2000) Disordered eating in three communities of China: A comparative study of female high school students in Hong Kong, Shenzhen, and rural Hunan. Int J Eat Disord. 27:317Y327. Lee S, Tsang A, Li X, Phillips MR, Kleinman AM (2007b) Attitudes toward suicide among Chinese people in Hong Kong. Suicide Life Threat Behav. 37:565Y575. Li X, Phillips MR (2010) The acceptability of suicide among rural residents, urban residents, and college students from three locations in China: A crosssectional survey. Crisis. 31:183Y193. Liu X, Tein J-Y, Zhao Z, Sandler IN (2005) Suicidality and correlates among rural adolescents of China. J Adolesc Health. 37:443Y451. Ministry of Health (2011) Chinese health statistics yearbook 2011. Beijing, China: Ministry of Health of the People’s Republic of China. Neeleman J, Wessely S, Lewis G (1998) Suicide acceptability in African- and white Americans: The role of religion. J Nerv Ment Dis. 186:12Y16.
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Phillips MR, Li X, Zhang Y (2002a) Suicide rates in China, 1995-99. Lancet. 359:835Y840. Phillips MR, Yang G, Zhang Y, Wang L, Ji H, Zhou M (2002b) Risk factors for suicide in China: A national case-control psychological autopsy study. Lancet. 360:1728Y1736. Qin P, Mortensen PB (2001) Specific characteristics of suicide in China. Acta Psychiatr Scand. 103:117Y121. Radloff LS (1977) The CES-D Scale: A self-report depression scale for research in the general population. Appl Psychol Meas. 1:385Y401. Rosenberg M (1965) Society and the adolescent self-image. Princeton, NJ: Princeton University Press. Sato R, Kawanishi C, Yamada T, Hasegawa H, Ikeda H, Kato D, Furuno T, Kishida I, Hirayasu Y (2006) Knowledge and attitude towards suicide among medical students in Japan: Preliminary study. Psychiatry Clin Neurosci. 60: 558Y562. Schaffer A, Levitt AJ, Bagby RM, Kennedy SH, Levitan RD, Joffe RT (2000) Suicidal ideation in major depression: Sex differences and impact of comorbid anxiety. Can J Psychiatry. 45:822Y826. Spielberger CD (1983) Manual for the State-Trait Anxiety Inventory (Form Y). Palo Alto, CA: Consulting Psychologists Press Inc. Stack S (1998) Heavy metal, religiosity, and suicide acceptability. Suicide Life Threat Behav. 28:388Y394. Stack S (2000) Blues fans and suicide acceptability. Death Stud. 24:223Y231. Stack S, Kposowa AJ (2011) Religion and suicide acceptability: A cross-national analysis. J Sci Study Relig. 50:289Y306. Takusari E, Suzuki M, Nakamura H, Otsuka K (2011) Mental health, suicidal ideation, and related factors among workers from medium-sized business establishments in northern Japan: Comparative study of sex differences. Ind Health. 49:452Y463. Vasiliadis H-M, Gagne´ S, Jozwiak N, Pre´ville M (2013) Gender differences in health service use for mental health reasons in community dwelling older adults with suicidal ideation. Int Psychogeriatr. 25:374Y381. Wang J, Deng XJ, Wang JJ, Wang XW, Xu L (2009) Substance use, sexual behaviours, and suicidal ideation and attempts among adolescents: Findings from the 2004 Guangzhou Youth Risk Behaviour Survey. Public Health. 123: 116Y121. Wong WS (2004) Attitudes toward life and death among Chinese adolescents: The Chinese version of the Multi-Attitude Suicide Tendency Scale. Death Stud. 28:91Y110. World Health Organization (2005) The world health report. Geneva, Switzerland: World Health Organization. Zhang J, Brown GK (2007) Psychometric properties of the Scale for Suicide Ideation in China. Arch Suicide Res. 11:203Y210. Zhang J, Gao Q (2012) Validation of the Trait Anxiety Scale for State-Trait Anxiety Inventory in suicide victims and living controls of Chinese rural youths. Arch Suicide Res. 16:85Y94. Zhang J, Jia C (2010) Attitudes toward suicide: The effect of suicide death in the family. Omega (Westport). 60:365Y382. Zhang J, Jia CX (2007) Validating a short version of the Suicide Intent Scale in China. Omega (Westport). 55:255Y265. Zhang J, Jing J, Wu X, Sun W, Wang C (2011) A sociological analysis of the decline in the suicide rate in China. Soc Sci China. 2011:97Y113. Zhang J, Ma Z (2012) Patterns of life events preceding the suicide in rural young Chinese: A case control study. J Affect Disord. 140:161Y167. Zhang J, Norvilitis JM (2002) Measuring Chinese psychological well-being with Western developed instruments. J Pers Assess. 79:492Y511. Zhang J, Sun W, Kong Y, Wang C (2012) Reliability and validity of the Center for Epidemiological Studies Depression Scale in 2 special adult samples from rural China. Compr Psychiatry. 53:1243Y1251. Zhang J, Wang Y, Liu S (2010) Perfectionism and depression among college students. Innovation. 2010:111Y115. Zhang J, Zhou L (2011) Suicidal ideation, plans, and attempts among rural young Chinese: The effect of suicide death by a family member or friend. Community Ment Health J. 47:506Y512. Zhao J, Yang X, Xiao R,Zhang X, Aguilera D, Zhao J (2012) Belief system, meaningfulness, and psychopathology associated with suicidality among Chinese college students: A cross-sectional survey. BMC Public Health. 12:668Y678.
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Suicide Ideation and Acceptability Among Females Aged 15 to 34 Years in Rural China Jie Zhang, PhD*Þ and Long Sun, MPH*
Abstract: The suicide rate of females is very close to that of males in China, in contrast to Western societies, in which the rates of male suicide outnumber those of females by three to four times. This study investigated the prevalence of suicidal ideation and prosuicide attitude (acceptability) among females of childbearing age. With the Chinese version of the Scale for Suicide Ideation and the General Social Survey questionnaire, we examined the demographic and psychological risk factors of suicide among Chinese rural young females aged 15 to 34 years. Logistic regression analysis was performed to explore the factors related to suicidal ideation and suicide acceptability. The prevalence rates of suicidal ideation and suicide acceptability among the sampled females are 22.5% and 3.8%, respectively. Education, depression, social support, hopelessness, and negative life events were significantly associated with suicidal ideation. Ethnicity, education, abortion, and depression were significantly associated with suicide acceptability. There is statistical difference between suicide ideation and acceptability. The results indicate that mental disorder remains a major risk factor of suicidal ideation. Sociodemographic and psychological characteristics are associated with suicide acceptability. Key Words: Suicidal ideation, suicide acceptability, females, rural China, cross-sectional study. (J Nerv Ment Dis 2014;202: 161Y166)
I
n the past 2 decades, suicide rates have steadily decreased in China (Hvistendahl, 2012; Zhang et al., 2011), but suicide still remains the fifth cause of death of the Chinese populations and the first cause of death among the population aged 15 to 34 years in China (Ministry of Health [MOH], 2011; World Health Organization, 2005). The data from the China Ministry of Health Vital Registration system shows that in 2010, suicide rate is 10.01 per 100,000 people in rural areas and 6.86 per 100,000 people in urban areas (MOH, 2011). China accounts for an estimated 22% of global suicides, or roughly 200,000 deaths every year (Hvistendahl, 2012). Compared with Western countries, suicide in China demonstrates three unique characteristics: a) the female suicide rates are approximately the same as in the males; b) the rural suicide rates are almost double those in the urban rates; and c) there exist two peaks in the curve of suicide rates among different ages, the 15- to 34-year-olds and the 60- to 84-year-olds (Phillips et al., 2002a; Qin et al., 2001). The sex difference was found in many studies from different cultures, which showed that females had a higher incidence of suicidal ideation and suicide attempt but lower suicide rates than male in the world (He and Lester, 2001; Schaffer et al., 2000; Takusari et al., 2011).
*Shandong University School of Public Health Center for Suicide Prevention Research, Jinan, China; and †Department of Sociology, State University of New York College at Buffalo, Buffalo, NY. Long Sun is a PhD candidate at Shandong University School of Public Health Center for Suicide Prevention Research. Send reprint requests to Jie Zhang, PhD, Department of Sociology, State University of New York College at Buffalo, 1300 Elmwood Ave, Buffalo, NY 14222. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20202Y0161 DOI: 10.1097/NMD.0000000000000104
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However, in China, the sex pattern was reversed, with more females, especially rural young females, killing themselves by suicide. Thus, suicide has been an important public health issue, and rural young females have formed a high-risk population of suicide in China (Phillips et al., 2002b). Suicidal ideation has been found to be an important predictor of suicide death (De Leo et al., 2005; Kessler et al., 2005). Thus, study on suicidal ideation can be an important approach in the suicide prevention among Chinese rural females. In the past few decades, many researchers have tried to measure the ideation of suicide among Chinese populations. Using the instrument developed by Kessler et al. (2005), Lee et al. (2007a) reported that the lifetime prevalence estimates of suicidal ideation, plans, and attempts in China were 3.1%, 0.9%, and 1.0%, respectively. Another study among Chinese college students showed that the lifetime prevalence of suicidal ideation, plan, and attempt was 45.1%, 6.8%, and 1.9%, respectively (Zhao et al., 2012). Zhang and Zhou (2011) observed that the lifetime prevalence of ideation, plans, and attempts among the informants of suicide was 18.1%, 4.1%, and 1.7%. Dai et al. (2011) conducted a study on the suicidal ideation and attempts among rural Chinese aged 16 to 34 years, and the results showed that lifetime and 1-year prevalence of suicidal ideation were 18.8% and 5.2%, respectively. Positive correlation between suicide acceptability and suicidality has been demonstrated in many studies (Joe et al., 2007; Li and Phillips, 2010). Because suicide acceptability was defined as prosuicide attitudes in some studies, we collected the articles about suicide acceptability and prosuicide attitude. In a case-control study, Zhang and Jia (2010) estimated the extent to which suicide death affected attitudes (acceptability) toward suicide among family members of suicides. Japanese researchers also investigated the knowledge and attitude toward suicide among medical students in Japan (Sato et al., 2006). In Hong Kong, researchers investigated the attitudes toward life and death among Chinese adolescents (Wong, 2004). In addition, many researchers found that suicide acceptability was correlated with suicide planning and marital status (Cutright and Fernquist, 2004; Joe et al., 2007). Further, researchers in Hong Kong developed a Hong Kong version of the Chinese Attitude Toward Suicide Questionnaire, which can be used to assess attitudes toward suicide (Lee et al., 2007a). Although numerous studies have been performed on suicidal ideation and suicide acceptability, few have specifically focused on females aged 15 to 34 years, a high-risk group for suicide in China. In this study, we examined the current situation of suicidal ideation and suicide acceptability among such a rural population in China.
METHODS Participants and Survey Procedure A total of 1039 rural females were recruited from two towns in Xinle City (in the North of China) in the spring of 2011. Respondents meeting the following criteria were included in the sample: a) female, b) living in a rural area, and c) aged 15 to 34 years. All subjects were convened to the Maternal and Child Care Service
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Centre to fill out the questionnaire, which lasted a mean of 1 hour. The participants who could not read completed the questionnaire under the guidance of interviewers. All interviewers were trained on the interview procedures for a minimum of 1 day by the research group. Personal and demographic characteristics and psychosocial functioning (approximately 300 questions) were included in the interview.
Measures Suicidal Ideation Suicidal ideation was assessed by the Chinese version of the Scale for Suicide Ideation (SSI), which contained 19 items (Beck et al., 1997, 1999, 1985). If the subject endorsed any 1 of the first 5 items, then the next 14 items should be answered. If none of the first five items were positive, the subjects should skip the whole SSI scale and go to the next section of the questionnaire (Zhang and Brown, 2007). The final total score of the 19 items was dichotomized to 0 and 1. The score is 0 if the total is 0 (the ‘‘not applicable’’ response was also coded as 0), and the score is 1 if the total score is 1 or greater than 1.
Suicide Acceptability Suicide acceptability was evaluated by the four items on acceptability toward suicide in the General Social Survey (GSS) study (Davis and Smith, 1972Y1993). These items were ‘‘Can he/she commit suicide if they got some incurable diseases?’’ ‘‘Can he/she commit suicide if they lost lots of money?’’ ‘‘Can he/she commit suicide if they were tired of living?’’ and ‘‘Can he/she commit suicide if they dishonored his/her family?’’ The answer options were yes (1) and no (0). The total score of the four suicide acceptability items was dichotomized into two groups, with 0 if the total score equals 0 and 1 if the total score is 1 or greater (Zhang and Jia, 2007).
Sociodemographic Characteristics The demographic information from the questionnaire is limited to females aged 15 to 34 years in China. Nationality was measured by Han (1) and others (0). Education was evaluated by five choices: 1, no education or lower than elementary school; 2, middle school; 3, high or vocational school; 4, college or university; and 5, graduate school or higher. Education was recoded to 1, junior high or lower; 2, senior high or vocational school; and 3, college or higher. Marital status was assessed by six options: 1, single; 2, married and living together; 3, married but separated; 4, widower; 5, divorced; and 6, others. Because there is none of other marital status and few females were separated, widowed, or divorced, we coded the marital status variable to 0, never married, and 1, ever married. Religious identity was assessed by the following choices: 1, Daoist; 2, Islamic; 3, Protestant; 4, Catholic; 5, Buddhist; 6, others; and 7, atheist. This variable on religion was then coded into 0, no religion (atheist), and 1, has a religion. Political affiliation was measured by 1, Communist Party member; 2, Communist League member; 3, Communist Party membership applicant; 4, other party member; and 5, no party affiliation. This variable was recoded into 0, not a Communist Party member, and 1, Communist Party member. Whether the subject lived alone was assessed by 1, yes, and 0, no. Whether the subject has a family suicide history was assessed by 1, yes, and 0, no. Whether the subject has a male baby was measured by the number of her male babies, which we dichotomized into two groups, with 0 if the number is 0 and 1 if the number is 1 or more. Whether the subject is an only child was measured by the total number of her brothers and sisters, which we dichotomized into two groups, with 0 if the number is 0 and 1 if the number is 1 or more. Whether the subject has a history of abortion was measured by the number of her abortions, which 162
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we dichotomized into two groups, with 0 if the number is 0 and 1 if the number is 1 or more. Occupation was measured by 1, farmer; 2, businessman; 3, national staff; 4, student; 5, worker; 6, rural physician; 7, teacher; 8, housewife; 9, unemployed; and 10, others. It was recoded to 1, farmer; 2, nonfarmer; and 3, unemployed. To assess the subjects’ social support level, we used the 12-item Duke Social Support Index scale (DSSI). The scale measures multiple dimensions of social support and has been used extensively in cross-sectional and longitudinal studies of aging (Koenig et al., 1993). It is a self-report scale and contains family support, support of friends, and other support. The answer can be chosen from five answers: 1, strongly disagree; 2, disagree; 3, not sure; 4, agree; and 5, strongly agree. The Chinese version of the DSSI has been validated with a number of Chinese samples and proved to be an excellent measure of social support in general Chinese populations (Jia and Zhang, 2012; Landerman et al., 1989). Life events were measured by the Interview for Recent Life Events. It has 64 items, and for each of them, respondents answer whether the events occurred in the past 1 year: 1, yes; 2, no. We count the number of negative life events as the variable of negative life events (Zhang and Ma, 2012). Whether the subject had a physical disease was assessed by 1, yes, and 0, no. Whether the subject had a mental disease was assessed by 1, yes, and 0, no.
Mental and Physical Health Status All the psychopathological and social behavioral scales have been validated in Chinese populations, as follows. We used the Center for Epidemiologic StudiesYDepression Scale (CES-D) to assess the respondents’ depression level (Radloff, 1977). The CES-D is a self-report scale, and it covers affective, cognitive, behavioral, and somatic symptoms associated with depression. The CES-D was originally developed for assessing depression symptoms and was specifically designed for research use in the general and nonclinical populations. It has 20 items, and for each of them, respondents rate their own feeling for the number of days in the past 1 week: 1, less than one day; 2, one to two days; 3, three to four days; and 4, five to seven days. The Chinese version of the CES-D has been validated with a number of Chinese samples and proved to be an excellent measure of depression in general Chinese populations (Zhang and Norvilitis, 2002; Zhang et al., 2012). The Spielberger Trait-Anxiety Scale was used to measure the subjects’ anxiety level. The Trait-Anxiety Scale, which includes 20 items, is half of Spielberger’s State-Trait Anxiety Inventory Form (STAI; Spielberger, 1983). The State-Anxiety Scale, the second half of the inventory, also has 20 items. The STAI clearly differentiates between the temporary condition of ‘‘state anxiety’’ and the more general and long-standing quality of ‘‘trait anxiety.’’ In responding to the Trait-Anxiety Scale, subjects rate the frequency of the feelings on these 4-point scales: 1, never; 2, sometimes; 3, often; and 4, always. The Chinese version of the scale has been validated in a Chinese sample and proved to be an excellent measure of trait anxiety in Chinese culture (Zhang and Gao, 2012). Self-esteem was estimated by the Rosenberg Self Esteem Scale (RSES), created by Rosenberg (1965). The scale ranges from 10 to 40, with 40 being the highest score (each item ranges from a score of 1 to 4). Higher score indicates higher level of self-esteem. In responding to the scale, the subjects chose from these 4-point scales: 1, strongly disagree; 2, disagree; 3, agree; and 4, strongly agree. The Chinese version of the RSES has been validated with a number of Chinese samples and proved to be an excellent measure of selfesteem in general Chinese populations (Lee and Lee, 2000; Zhang et al., 2010). We used the Beck Hopelessness Scale (BHS) developed by Beck (1978) to evaluate hopelessness. It is a self-report scale that * 2014 Lippincott Williams & Wilkins
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measures three major aspects of hopelessness: feelings about the future, loss of motivation, and expectations. This BHS questionnaire consists of 20 questions examining the respondents’ attitude. The answer can be chosen from five answers: 1, strongly agree; 2, agree; 3, not sure; 4, disagree; and 5, strongly disagree. The Chinese version of the BHS has been validated with a number of Chinese samples and proved to be an excellent measure of hopelessness in general Chinese populations (Cheung et al., 2006).
Suicide Ideation and Acceptability
Statistical Analysis The Statistical Package for the Social Sciences for Windows (version 16.0) was used for data analysis. t-Tests were used to compare the difference on continuous variables across groups, whereas the chi-square test was used for categorical variables. Logistic regression analysis was performed to examine the factors related to suicidal ideation and suicide acceptability. All of the factors were chosen as the independent variables. The thesis brings the unordered
TABLE 1. Demographic Characteristics of Suicidal Ideation and Suicide Acceptability (N = 1039) Suicidal Ideation
n (%) Age, mean (SD) Ethnicity Han (1) Others (0) Education Junior high or lower (1) Senior high or vocational school (2) College or higher (3) Political affiliation Party or League member (1) No affiliation (0) Marital status Never married (0) Ever married (1) Live alone Yes (1) No (0) Physical disease Yes (1) No (0) Family suicide history Yes (1) No (0) Only child Yes (1) No (0) At least 1 male baby Yes (1) No (0) Abortion Yes (1) No (0) Religious belief Yes (1) No (0) Occupation Farmer (1) Nonfarmer (2) Unemployed (3) Social support (total score), mean (SD) Life events (total score), mean (SD)
Total, n (%)
Yes, n (%)
1039 (100) 24.94 (4.68)
234 (22.5) 24.96 (4.87)
1005 (96.8) 33 (3.2)
No, n (%)
Suicide Acceptability Yes, n (%)
No, n (%)
775 (77.5) 24.98 (4.74)
40 (3.8) 23.50 (5.28)
999 (96.2) 25.03 (4.73)*
222 (94.9) 12 (5.1)
783 (97.3) 22 (2.7)
35 (87.5) 5 (12.5)
970 (97.1)* 29 (2.9)
586 (56.5) 297 (28.6) 155 (14.9)
139 (59.4) 73 (31.2) 22 (9.4)
448 (55.7)* 224 (27.8) 133 (16.5)
19 (47.5) 19 (47.5) 2 (5.0)
568 (56.9)* 278 (27.8) 153 (15.3)
488 (47.0) 551 (53.0)
107 (45.7) 127 (54.3)
381 (47.3) 424 (52.7)
24 (60.0) 16 (40.0)
464 (46.4) 535 (53.6)
287 (27.6) 751 (72.4)
69 (29.5) 165 (70.5)
218 (27.1) 587 (72.9)
15 (37.5) 25 (62.5)
272 (27.2) 727 (72.8)
48 (4.6) 990 (95.4)
8 (3.4) 226 (96.6)
40 (5.0) 765 (95.0)
1 (2.5) 39 (97.5)
47 (4.7) 952 (95.3)
10 (1.0) 1029 (99.0)
3 (1.3) 231 (98.7)
7 (0.9) 798 (99.1)
2 (5.0) 38 (95.0)
8 (0.8)* 991 (99.2)
13 (1.3) 1025 (98.7)
6 (2.6) 228 (97.4)
7 (0.9)* 798 (99.1)
2 (5.0) 38 (95.0)
11 (1.1)* 988 (98.9)
10 (1.0) 1029 (99.0)
3 (1.3) 231 (98.7)
7 (0.9) 798 (99.1)
0 (0.0) 40 (100.0)
10 (1.0) 989 (99.0)
482 (46.4) 557 (53.6)
106 (45.3) 128 (54.7)
376 (46.7) 429 (53.3)
16 (40.0) 24 (60.0)
466 (46.6) 533 (53.4)
145 (14.0) 893 (86.0)
36 (15.4) 198 (84.6)
109 (13.5) 696 (86.5)
11 (27.5) 29 (72.5)
134 (13.4)* 865 (86.6)
142 (13.7) 896 (86.3)
42 (17.9) 192 (82.1)
101 (12.5)* 704 (87.5)
7 (17.5) 33 (82.5)
135 (13.5) 863 (86.5)
176 (16.9) 349 (33.6) 514 (49.5) 48.69 (6.40) 4.44 (5.63)
39 (16.7) 78 (33.3) 117 (50.0) 49.31 (6.19) 6.10 (7.06)
137 (17.0) 271 (33.7) 397 (49.3) 46.53 (6.64)*** 3.97 (5.05)***
5 (12.5) 8 (20.0) 27 (67.5) 45.78 (6.04) 6.55 (7.42)
171 (17.1) 341 (34.1) 487 (48.7) 48.80 (6.39)** 4.36 (5.54)**
*p G 0.05. **p G 01. ***p G 0.001.
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categorical variable (such as occupation) as dummy variables into the regression analysis model. All tests were two tailed, and a p-value of less than 0.05 was considered statistically significant.
RESULTS Participation Demographic characteristics of the sample are presented in the second row of Table 1. A total of 1039 respondents answered the question regarding suicide intent (with 31 missing cases). The response rate was 97.1%.
Distribution and Single-Factor Analysis of Suicide Ideation and Suicide Acceptability Table 1 presents the social distribution and single-factor analysis of suicide ideation and acceptability, and Table 2 presents the psychological distribution and single-factor analysis of suicide ideation and acceptability. The prevalence of suicidal ideation among females aged 15 to 34 years in rural China was 22.5%, and 3.8% of the subjects considered suicide acceptable. Education, family suicide history, religious belief, depression, social support, anxiety, selfesteem, hopelessness, and life events demonstrated significant difference by suicide ideation ( p G 0.05). There was significant variation in age, ethnicity, education, physical disease, family suicide history, abortion, depression, social support, anxiety, self-esteem, hopelessness, and life events by suicide acceptability ( p G 0.05).
Logistic Regression Analysis The logistic regression analyses of suicidal ideation and suicide acceptability are shown in Table 3. The variable of occupation was in this model as a dummy variable. Education (p = 0.048), depression ( p = 0.001), social support ( p = 0.014), negative life events ( p = 0.008), and hopelessness ( p = 0.014) were significantly associated with suicide ideation. Ethnicity ( p = 0.017), education ( p = 0.036), abortion ( p = 0.018), and depression ( p = 0.048) showed significant association with suicide acceptability.
The Difference Between Suicide Ideation and Suicide Acceptability We did the chi-square test between suicide ideation and suicide acceptability, and the result shows that there is statistical difference between them (W2 = 21.426, p G 0.001).
DISCUSSION In our sample, we found that the prevalence rate of suicide ideation and acceptability in Chinese females of childbearing age was 22.5% and 3.8%, respectively. Depression, social support, hopelessness, and life events were significantly associated with suicidal
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ideation. Ethnicity, education, abortion, and depression were significantly associated with suicide acceptability. The suicide ideation is close to the rates reported by previous studies in China. A study in Sichuan (South of China) found that the prevalence of suicidal ideation among rural Chinese females aged 16 to 34 years is 21.85% (Dai et al., 2011), and a study in Shandong (East of China) reported that the prevalence of suicidal ideation among rural girls of China is 22.0% (Liu et al., 2005). However, in other countries, the prevalence of suicide ideation ranged from 3.8% to 23.1% (Abell et al., 2012; De Leo et al., 2005; Huang et al., 2012; Kessler et al., 2005; Kuo et al., 2001). In comparison with the above-mentioned data, the prevalence of female suicide ideation in China was at the higher end. We found in this study that the suicide acceptability rate among the sampled Chinese females of childbearing age was 3.8%. In contrast to other countries, the rate resulting from the same measures of the GSS is higher than that found in our Chinese sample (Blosnich and Bossarte, 2013; Stack, 1998, 2000). The reason why the rate of suicide acceptability was so low might be that suicide is a negative event in China, and the suicides might be discriminated against by the fellow villagers. Therefore, there are more people in China than in other societies who see suicide as less acceptable. The logistic regression analysis shows that factors associated with suicidal ideation included depression, social support, hopelessness, and life events. In our study, we found that mental health was mainly associated with suicidal ideation in Chinese females of childbearing age. In many earlier studies, those factors had been demonstrated as the influential factor of suicide ideation (Cheung et al., 2006; Gong et al., 2011; Vasiliadis et al., 2013; Wang et al., 2009), which was consistent with our findings. It is also found that ethnicity, education, abortion, and depression have an impact on suicide acceptability, which is in line with the findings in many other studies in which sociodemographic characteristics were found to be associated with suicide acceptability (Chiles and Strosahl, 1995; Eskin, 2004; Jing et al., 2008; Lee et al., 2007b). The finding that religion is not a protective factor against suicidal ideation or suicide acceptability is in contrast to a large study based in the West (Stack and Kposowa, 2011). Because religious population is of a small percentage in modern China, this finding might be anticipated. Durkheim (1951) found, for example, that where Catholics were a minority of the population in some European nations and cities, they actually had a higher rate of suicide than Protestants. According to the moral community view of Durkheim, religion best protects against suicide when a whole population is of one faith. In China, most of the population has no religion. In that context, most of the population is atheist and is less apt to reinforce the beliefs of the religious minority. The relative lack of support from
TABLE 2. Psychological Characteristics of Suicidal Ideation and Suicide Acceptability (N = 1039) Suicidal Ideation Total, n (%)
n (%) Depression (total score), mean (SD) Anxiety (total score), mean (SD) Self-esteem (total score), mean (SD) Hopelessness (total score), mean (SD)
1039 30.78 41.75 30.37 40.31
(100) (8.55) (6.76) (3.53) (10.54)
Yes, n (%)
234 34.19 44.33 29.11 44.60
(22.5) (8.97) (6.17) (3.46) (9.69)
No, n (%)
775 29.79 41.08 30.73 39.06
(77.5) (8.16)*** (6.69)*** (3.47)*** (10.45)***
Suicide Acceptability Yes, n (%)
40 (3.8) 37.95 (10.40) 46.55 (7.96) 28.18 (3.80) 47.72 (11.56)
No, n (%)
999 30.49 41.62 30.45 40.01
(96.2) (8.35)*** (6.59)*** (3.49)*** (10.39)***
***p G 0.001.
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Suicide Ideation and Acceptability
TABLE 3. Logistic Regression Analysis of Correlates of Suicidal Ideation and Suicide Acceptability in Chinese Rural Females (N = 1039) Dependent Variables Independent Variables
Age Ethnicity (reference, others) Education Junior high or lower Senior high school College or higher Occupation Farmer Nonfarmer Unemployed Political affiliation (reference, no affiliation) Live alone (reference, no) Physical disease (reference, no) Mental disease (reference, no) Marital status (reference, never married) Family suicide history (reference, no) Only child (reference, no) At least 1 male baby (reference, no) Abortion (reference, no) Religious belief (reference, no) Depression Social support Anxiety Self-esteem Hopelessness Life events
2
Suicidal ideation OR (95% CI) R = 0.142
Suicide Acceptability OR (95% CI) R2 = 0.229
0.974 (0.932Y1.019) 1.196 (0.493Y2.902)
1.043 (0.938Y1.161) 7.686 (1.427Y41.402)*
1.858 (1.044Y3.306)* 1.860 (1.054Y3.284)* Reference
2.737 (0.540Y13.874) 5.008 (1.074Y23.365)* Reference
0.984 (0.631Y1.534) 1.015 (0.716Y1.440) Reference 0.904 (0.629Y1.299) 1.667 (0.708Y3.923) 1.963 (0.378Y10.190) 0.687 (0.088Y5.348) 0.654 (0.391Y1.094) 0.540 (0.143Y2.031) 0.906 (0.185Y4.443) 1.052 (0.719Y1.537) 1.080 (0.684Y1.705) 0.782 (0.483Y1.266) 1.034 (1.014Y1.054)** 0.966 (0.939Y0.993)* 1.007 (0.974Y1.042) 0.985 (0.927Y1.047) 1.023 (1.004Y1.043)* 1.036 (1.009Y1.064)**
0.578 (0.201Y1.665) 0.446 (0.188Y1.055) Reference 0.581 (0.258Y1.308) 1.441 (0.169Y12.263) 0.375 (0.046Y3.068) 1.353*108 (0.000) 0.736 (0.226Y2.396) 0.361 (0.044Y2.983) 0.000 (0.000) 1.086 (0.462Y2.554) 0.382 (0.157Y0.928)* 2.143 (0.541Y8.491) 1.045 (1.003Y1.089)* 0.990 (0.933Y1.050) 1.043 (0.967Y1.124) 1.005 (0.879Y1.149) 1.033 (0.989Y1.079) 0.998 (0.946Y1.054)
Only odds ratio (OR) and 95% confidence interval (CI) of variables retained in the final regression models were presented in the table. *p G 0.05. **p G 0.01.
a moral community weakens the influence of religion on the small religious group (Eskin, 2004; Neeleman et al., 1998; Stack and Kposowa, 2011). The correlation between suicide ideation and acceptability was demonstrated in our study, although we cannot establish that suicide acceptability causes suicide ideation because of the lack of time sequence of the data. Some studies have demonstrated that suicide acceptability predicts suicide ideation, suicide plans, and even suicide rates (Joe et al., 2007; Stack and Kposowa, 2011). There were several limitations that should be addressed when interpreting these results. First, as a cross-sectional study, we could not infer any causal relationship on the basis of the results. Second, all of the data were self-reported and thus may have some biases, such as shared method variance problems. Third, our sample was limited to one province, and the generalization of the findings has to be done cautiously. Finally, the suicide acceptability was measured by the four items in the GSS, and the reliability and the validity of the scale deserve further tests in Chinese societies. Despite these limitations, the study can still contribute to our understanding about the prevalence and risk factors of suicidal ideation and suicide acceptability in rural Chinese females aged 15 to 34 years, a high-risk group for suicide in China. This study also provided the baseline data regarding the suicides of rural females in Hebei Province. Through such studies, programs that can effectively * 2014 Lippincott Williams & Wilkins
reduce the morbidity and the mortality associated with suicide could be developed and tested. DISCLOSURES This research was supported by the US NIMH: R01 MH68560. The authors declare no conflict of interest.
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