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H. Hjelmeland et al.: Attitudes Toward © 2008 Suicide Crisis Hogrefe and 2008; Suicide & Vol. Huber 29(1):20–31 Prevention Publishers

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Self-Reported Suicidal Behavior and Attitudes Toward Suicide and Suicide Prevention Among Psychology Students in Ghana, Uganda, and Norway Heidi Hjelmeland1,2, Charity S. Akotia3, Vicki Owens4, Birthe L. Knizek1, Hilmar Nordvik1, Rose Schroeder5, and Eugene Kinyanda6 1

Norwegian University of Science and Technology, Trondheim, Norway, 2Norwegian Institute of Public Health, Oslo, Norway, 3University of Ghana, Legon, Accra, Ghana, 4Makerere University, Kampala, Uganda, 5Austin Community College, Austin, TX, USA, 6MRC/UVRI, Uganda Research Unit on AIDS, Entebbe, Uganda

Abstract. Self-reported suicidal behavior and attitudes toward suicide in psychology students are reported and compared in Ghana, Uganda, and Norway. Small differences only were found in own suicidal behavior. However, experience of suicidal behavior in the surroundings was more common in Uganda than in Ghana and Norway. Although differences were found between the three countries in attitudes toward suicide, which emphasizes the need for culture-sensitive research and prevention, many of the differences were not as big as expected. The most pronounced difference was that the Norwegian students were more reluctant to take a stand on these questions compared to their African counterparts. Some differences were also found between the two African countries. The implications of the results for suicide prevention in Africa are discussed. Keywords: suicidal behavior, attitudes, prevention, Africa

After many decades of intensive suicidological research it is clear that there is still a lot we don’t know about the meaning of suicidal behavior. In the article “The meaning of suicide: Implications for research,” Boldt (1988) claimed that “in order to develop valid social scientific theories of cause, suicidologists must make a paradigmatic shift from the prevailing universal, invariant definition of suicide to systematic research into culture-specific meanings of suicide.” Others have also pointed out that we need to obtain a broader view of human behavior than what has so far been provided by Western-based and ethnocentric generalization (e.g., Domino & Perrone, 1993) and that we need to be cautious in transposing research from one country to another (Leenaars & Domino, 1993). Suicide is indeed a cultural artefact in that no suicide is committed without reference to the prevailing normative standards and atCrisis 2008; Vol. 29(1):20–31 DOI 10.1027/0227-5910.29.1.20

titudes of a cultural community (Boldt, 1988). Studying attitudes toward suicide is one of several gateways in developing an understanding of the meanings of suicidal behavior in different cultures. It is also generally contended that attitudes toward suicide are important because they affect the willingness of health care staff and/or the willingness of people in general to intervene in a suicidal crisis or help those who deliberately harm themselves (e.g., Bagley & Ramsey, 1989). Moreover, attitudes affect both the content and efficiency of the intervention or treatment. Numerous cross-cultural studies have indeed shown that cultural factors do play an important role in attitudes toward suicide (e.g., Domino, Niles, & Raj, 1993–1994; Domino & Perrone, 1993; Domino & Takahashi, 1991; Domino, Lin, & Chang, 1995; Eisler, Wester, Yoshida, & Bianchi, 1999; Eskin, 1995; Leenaars & Domino, 1993). © 2008 Hogrefe & Huber Publishers

H. Hjelmeland et al.: Attitudes Toward Suicide and Suicide Prevention

In these studies, attitudes toward suicide have been compared between European, Asian and American countries. To the best of our knowledge, only a few studies of attitudes toward suicide have been undertaken in Africa. Alem, Jacobsson, Kebede, and Kullgren (1999) studied attitudes toward suicidal people (and not the phenomenon as such) in Ethiopia. Other studies have shown that attitudes toward suicide in African countries generally are negative (Lester & Akande, 1994, in Nigeria; Peltzer et al., 1998, in South Africa; Eshun, 2003, in Ghana). The present study was conducted in Ghana, Uganda, and Norway. In Ghana, suicide is a crime but since the victim is dead, no prosecution is made. Deliberate self-harm is also a crime, and thus reported to the police. After the patients are released from hospital, they are prosecuted. Culturally, suicide is strongly prohibited, and in certain subcultures those who attempt suicide need to go through some purification rites in an attempt to cleanse the victim and the family of the shame and calamity. The stigma suicide carries affects not only the individual involved but also families and even generations. There are no accurate statistics on suicidal behavior in Ghana, so nothing is known about the size of the problem. Suicide is also a crime in Uganda and it carries enormous stigma. Suicide is considered a bad omen for the clan and therefore necessitates cleansing rituals. No reliable official statistics on suicidal behavior are available in Uganda either. When considering the stigma such acts carry, it would be plausible to assume that a number of measures are taken in order to cover up the fact that someone has killed or harmed themselves deliberately in both these African countries. No official steps have been made to start suicide prevention efforts in these countries. Norway, on the other hand, has reliable statistics on suicidal behavior, and during the last 10 years has had an ongoing national suicide prevention plan initiated by the Ministry of Health and Social Affairs (Norwegian Board of Health, 1996). Suicide might still carry some stigma though. The main purpose of the present study was thus to present self-reported suicidal behavior and attitudes toward suicide and suicide prevention in psychology students in Ghana and Uganda, then to compare them with each other and with a country from the Western part of the world with reliable suicide statistics and a national suicide prevention program, namely Norway. Potential gender differences in attitudes were also investigated. Because not much is known about the prevalence of suicidal behavior in Ghana and Uganda, a comparison of suicidal acts known to students (both their own and others’) can at least give some indication of the size of the problem when we compare these figures with figures found in a country with reliable suicide statistics (Norway). Moreover, as pointed out by Eisler et al. (1999) knowledge of attitudes toward suicide in subjects not involved in suicidal behavior can provide valuable predictors of vulnerability and risk factors useful in planning of prevention programs. Thus, in Ghana and Uganda, where virtually nothing officially has been done so far to prevent suicide, the results of the present study may be useful © 2008 Hogrefe & Huber Publishers

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as a starting point in putting the issue on the agenda and initiating suicide preventive efforts. Psychology students were chosen both because they are future key personnel in treating suicidal persons and working in suicide prevention, and because they are comparable across countries with regard to age and level of education. Previous research has shown that attitudes are affected by a number of factors, for instance, experiences with suicidal behavior, own mood and knowledge (see Schmidtke & Häfner, 1989, for references). Thus, relationships between attitudes and such variables were also investigated.

Method Participants In Ghana, 570 students (274 women, 290 men, 6 nondisclosing gender) filled in the questionnaire, whereas the numbers in Uganda and Norway were 289 (170 women, 116 men, 3 nondisclosing gender) and 217 (154 women and 63 men), respectively. Students from all levels of the study were included. There was a significant difference in gender and age distribution between the three countries. The Ghanaian sample had more men (51%) than women (48%; 1% missing), while the opposite distribution was found in the other two countries (Uganda: 40% men, 59% women, 1% missing; Norway: 29% men, 71% women; χ² = 33.71, p < .001, Cramer’s V = 0.18). The gender distribution in the samples was representative of the gender distribution in the total population of the psychology students in the three countries. The Norwegian sample was slightly older, mean age 25.9 years, SD = 5.2, than the Ghanaian, mean age 25.1, SD = 6.1, which in turn was older than the Ugandan sample, mean age 24.2, SD = 6.0; F(2, 1040) = 4.31, p < .05, but the age differences were in fact quite small, although statistically significant (probably due to the relatively large sample size and thus a high statistical power).

Instrument The Attitudes Toward Suicide questionnaire (ATTS) developed by Salander Renberg and Jacobsson (2003) was employed. The ATTS contains three questions about experience of suicidal behavior, and 39 items on attitudes toward suicide and suicide prevention. Some of the items in this questionnaire were selected from the Suicide Opinion Questionnaire (Domino, Moore, Westlake, & Gibson, 1982) and others were added. Most of the items were scored on a 5-point Likert-type scale from strongly agree, with a score of 5, agree (4), undecided (3), disagree (2) to strongly disagree (1). Two of the attitude questions were scored differently; namely, a question of probability of one’s own future suicide (surely not / hope not but not sure / yes under certain circumstances / surely yes) and to what degree suicide should be prevented Crisis 2008; Vol. 29(1):20–31

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(in all cases / in all cases, but with few exceptions / in some cases yes / in some cases no / not in any case, if a person wants to commit suicide, no-one, including medical services, has the right to stop him or her). The questionnaire also assessed respondents’ own life-weariness, death wishes and suicidality (acts and ideation), using questions developed by Paykel et al. (1974) and from the European Values Study (Halman, 1993). The questions on death wishes and life-weariness were computed into two sum-variables (including 6 items each) called Life-Weariness last year (Cronbach’s α = 0.67) and Life-Weariness earlier in life (Cronbach’s α = 0.70). The questions included in these sum-variables were: (1) How often have you thought of the meaning of your life? (2) Have you ever felt that life was not worth living? (3) Have you ever thought of your own death? (4) Have you ever wished you were dead, for instance that you could go to sleep and not wake up? (5) Have you ever thought of taking your own life, even if you would not really do it? (6) Have you ever reached a point where you seriously considered taking your life, or perhaps made plans how you would go about doing it? Each of these questions was scored from often (a score of 4), through sometimes (3), hardly ever (2) to never (1). A question about the degree of happiness from the European Values Study (Halman, 1993) was included, and was to be scored from “very happy,” through “quite happy,” “not particularly happy” to “not at all happy” (scored from 4 to1). Basic demographic data were also included in the questionnaire. In their original study, Salander Renberg and Jacobsson (2003) conducted a factor analysis on the attitude questions that resulted in a ten-factor model. They acknowledged that the internal consistency for the whole instrument and of some of the factors was rather low, indicating that the instrument measures a very broad area of attitudes toward suicide. However, they questioned whether an instrument assessing different attitude domains can yield a high total internal consistency, because different attitudes toward suicide might be conflicting and instable, reflecting ambivalence toward the phenomenon. The face and construct validity of the instrument were found to be satisfactory. They suggested that future studies should investigate whether the factors found in their original study are “universal” or whether they differ between different groups.

Procedure The Norwegian data were collected as part of a European multicenter study on suicide prevention and research (Salander Renberg & Jacobsson, 2001), whereas the African data were collected in a separate study. In all three countries the data collection procedure was similar in that the questionnaires were distributed, filled in and collected again during class while someone from the research team was present to answer any questions the students might have. The participants were informed of the study both orally and in writing, and it was emphasized in both ways that participation was voluntary. Students were especially requested Crisis 2008; Vol. 29(1):20–31

to seek help from a qualified counselor if the questionnaire caused them any discomfort or if they had some related issues they would like to discuss. For this reason the name, postal address, phone number and e-mail address for those responsible for the project were written on the information sheet. None of the students in any of the countries made such contact either in class, during, or immediately after the data collection, or later. The questionnaires were only distributed to those students present in the different classes targeted. No attempt was made to send the questionnaire to those students not present in these classes. The classes chosen for data collection were either those with compulsory attendance or with a traditionally high attendance rate. Because of a very high number of students in the first four levels of psychology in Ghana, a stratified sampling (by gender) was conducted in these classes, whereas all the students in the fifth level filled in the questionnaire. No students in Ghana and Uganda refused to fill in the questionnaire, whereas two students in Norway did. There is no reason to believe that there were any systematic differences between those students attending class and those who did not on the day of the study, since the study was not announced beforehand. The data were collected during the years 2001 and 2002 in Norway and in 2002 in Ghana and Uganda. The Norwegian students filled in the Norwegian version of the questionnaire (Norwegian is very similar to Swedish), while the Ghanaian and Ugandan students filled in the English version. English is the language used in schools in both Ghana and Uganda, so the students are very familiar with it. The questionnaire went through a procedure of translation and back-translation between Swedish and English. The study was approved by two ethical committees in Norway (both the regional one assessing the Norwegian part of the study and the one responsible for research in developing countries with participation of Norwegian researchers), and by the relevant bodies at the University of Ghana, and Makerere University in Uganda.

Data Analyses Chi-square analyses were used to investigate differences between the countries on self-reported suicidal behavior and experiences of suicidal behavior from their surroundings. With regard to the attitude variables, factor analyses were initially conducted in the three countries separately and congruency coefficients calculated in order to investigate the structural equivalence of the instrument between the countries (Gorsuch, 1983, p. 285). Congruency coefficients exceeding 0.90 are considered evidence of satisfactory congruency between factors (McCrae & Costa, 1997). Furthermore, chi-square analyses, ANOVAs and correlation analyses (Pearson’s r) were conducted were relevant. The level of statistical significance was in general set at 5%, but because of the relatively high number of analyses, a Bonferroni correction of the α level was employed where © 2008 Hogrefe & Huber Publishers


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Table 1. The psychology students’ experiences with suicidal behavior Ghana

Uganda

Norway

(N = 570)

(N = 289)

(N = 217)

N

(%)

N

(%)

N

(%)

χ²

Cramer’s V

Own suicidal act(s) Last year

11

(2.0)

11

(4.0)

1

(0.5)

7.28*

Earlier in life

19

(3.4)

14

(5.0)

11

(5.1)

1.67

0.08

Suicide attempts In the family

53

(9.9)

61

(23.6)

22

(10.8)

29.58**

0.17

Among others

192

(36.6)

156

(60.9)

149

(71.6)

89.03**

0.30

9

(1.7)

20

(7.7)

3

(1.4)

23.72**

0.15

Among others 91 (17.0) *p < .05, **p < .001, df = 2, in all analyses.

142

(52.8)

105

(48.4)

135.53**

0.36

Suicide In the family

Table 2. The psychology students’ happiness, life-weariness, and death wishes Ghana M Happiness Life-weariness and death wishes last year

Uganda SD

M

Norway SD

SD

F(2, 1052)

3.32

0.61

3.02

0.64

M 3.15

0.56

22.98*

11.31

2.91

13.03

3.30

10.61

2.48

47.91*

Life-weariness and death 10.77 3.13 12.41 3.51 12.59 3.19 36.93* wishes earlier in life *p < .0001. Note. Possible range of scores on the happiness variable is 1–4, and on the life-weariness variables 6–24 (sums of 6 items).

relevant (see Results section). The strength of the differences was assessed by Cramer’s V.

Results Self-Reported Suicidal Behavior and Life-Weariness As shown in Table 1 the African students more often than the Norwegian had made at least one suicide attempt during the last year. However, the effect size of this difference was very low. There was no difference between the groups in suicide attempts earlier in life. No gender differences in own suicidal behavior were found. The Ugandan students had more often experienced both suicide and suicide attempts in their family than the Ghanaian and Norwegian students. The Norwegian students had experienced suicide attempts among others more often than the Ugandan, who in turn had experienced this more often than the Ghanaian, while the Norwegian and Ugandan more often than the Ghanaian students had experienced suicide among others. A statistically significant difference was found between all three countries on the question: “How will you estimate the probability that you sooner or later will commit suicide?” The Ghanaian students (78%) more often than the Ugandan (61%), who, in turn, more often than the Norwegian (47%), responded that they would never commit suicide, while 4% © 2008 Hogrefe & Huber Publishers

of the Ghanaian, 7% of the Ugandan and 8% of the Norwegian students said they might under certain circumstances (χ²(6) = 80.74, p < .001, Cramer’s V = 0.20). Some 0.5% of the Ghanaian students considered it to be a possibility, while none of the other groups ticked off this alternative. There was a significant difference between the countries in level of happiness among the students, with Ghanaian students being most happy and Ugandan least (Table 2). Statistically significant differences were found in both lifeweariness variables in that the Ugandan students expressed more life-weariness last year, compared to the students in the other two countries, F(2, 1052) = 43.36, p = .000, whereas the Ugandan and Norwegian students expressed more life-weariness earlier in life compared to the Ghanaian students, F(2, 1052) = 20.28, p < .001; Table 2. There was a significant negative correlation between the happiness variable and the life-weariness variable for both last year, r = –0.24, p = .000, and earlier in life, r = –0.22, p < .001, indicating internal consistency.

Attitudes Toward Suicide and Suicide Prevention Exploratory factor analyses (principal components extraction and eigenvalues exceeding one) of the data from the three countries separately resulted in 12 factors in the Norwegian sample accounting for 61.1% of the variance, and Crisis 2008; Vol. 29(1):20–31

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14 factors in both the Ghanaian and Ugandan samples, accounting for 56.5% and 58.6% of the variance respectively. At face value, the factor structure in terms of the items included in the various factors was very different between the three countries. Thus, subsequent factor analyses with the fixed number of 12 factors were conducted with the Ghanaian and Ugandan data so that congruency coefficients could be calculated. None of the congruency coefficients between any of the factors or countries exceeded the requirement of 0.90. Thus comparisons at factor level were impossible. The possible explanations and implications of this result, as well as the results of confirmatory factor analyses, have been discussed elsewhere (Hjelmeland et al., 2006). Because comparisons at factor level turned out to be impossible, some comparisons at item level were conducted. The items included were those considered to be most relevant for suicide prevention and was clustered into five groups based on their content to make it easier to follow the analyses (see Table 3 for items included in these groups): (1) principal attitude toward suicide (right to commit suicide), (2) representations of intentionality, (3) preventability, (4) tabooing, and (5) myths about suicide, reflecting the knowledge, or lack thereof, on suicide as documented in the literature (from the Western part of the world; Neuringer, 1987–88; Popenhagen & Qualley, 1998; Shneidman et al., 1994). Since the distribution on some of the items was very different between the groups (U shaped in the African countries and A-shaped in Norway), we chose to use χ² analyses instead of t-tests because that would present better information on how the students scored than just means and standard deviations. Table 3 shows the results of the comparative analyses. The effect size as measured by Cramer’s V is reported in the text where statistically significant differences were found. Statistically significant group differences were found on all of the statements reflecting a principal attitude concerning suicide as a right. The vast majority of students in all three countries (93%–95%) did not think that suicide is one’s own business and no one should interfere, so this difference was probably statistically significant only because of the large sample size, as also indicated by the low effect size (Cramer’s V = 0.11). Follow-up analyses revealed that the Norwegian differed from the African samples. Nineteen percent of the Norwegian students and 7–8% of the African agreed that people have the right to take their lives (Cramer’s V = 0.38), while 29% of the Norwegian, 50% of the Ugandan, and 60% of the Ghanaian students thought that suicide can never be justified, implicating that it cannot be a right people have (Cramer’s V = 0.31; significant differences between all three countries). The item “Suicide is the worst thing one can do to one’s relatives” was included in the group of variables implying suicide as a right because, according to Battin (1995), having a right to do something implicates not to cause others harm. Around 91% of the Ghanaian, 93% of the Ugandan, and 71% of the Norwegian students agreed with this statement (Cramer’s V = 0.29; the Norwegian students differed © 2008 Hogrefe & Huber Publishers

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significantly from the two African student groups). The item “Sometimes suicide is the only solution” also indicated that this is something people have a right to do under certain circumstances, and here the majority in all three countries disagreed (Ghana: 78%, Uganda: 69%, and Norway: 74%; Cramer’s V = 0.15). Follow-up analyses revealed statistically significant differences between all countries. The vast majority in all three countries agreed that it is a human duty to stop a person from committing suicide (Ghana and Uganda 93%, Norway 92%; Cramer’s V = 0.11). The Norwegian students were more often undecided than the African students on all but one of the variables concerning suicide as a right. Sixty-four percent of the Ghanaian, 62% of the Ugandan and 83% of the Norwegian sample regarded suicide attempt as a cry for help (Cramer’s V = 0.23; Norway differed from the two African countries). Again, a larger proportion of the Norwegian sample was undecided. Twenty-one percent of the Ghanaian, 38% of the Ugandan and 7% of the Norwegian students saw suicide attempts as acts of revenge or punishment (Cramer’s V = 0.23; the difference being statistically significant between all three countries). Ninety percent of the Norwegian and 78% and 69% of the Ugandan and Ghanaian students, respectively, did not agree that suicide should not be talked about (Cramer’s V = 0.19; statistically significant difference between all three countries). There were statistically significant differences between the groups on four of the five items concerning suicide preventability. Around 91% of the Ugandan, 84% of the Norwegian, and 80% of the Ghanaian students (significant difference between all three countries) believed that it is always possible to help a person with suicidal thoughts (Cramer’s V = 0.23). The majority in all three countries are also prepared to help a person in a suicidal crisis by contacting him/her (Cramer’s V = 0.14). The item “Most suicide attempts are impulsive” implies that it would be difficult to prevent suicide, and here the majority of both the Ghanaian (54%) and the Ugandan (63%) students agreed, while only 10% of the Norwegian students did (Cramer’s V = 0.31). Follow-up analyses indicated that there was also a statistically significant difference between the two African countries on this variable. The item “A person once having suicidal thoughts will never let them go” indicates that it would be difficult to prevent suicide. Statistically significant differences were found between all three countries (Cramer’s V = 0.29). No difference between the three countries was found on the item “Suicide can be prevented.” While 3% in all three countries were undecided, 93%–96% believed that suicide indeed can be prevented. Also regarding suicide preventability, the Norwegian students showed greater indecisiveness than the African (on three of the four variables where significant differences were found). The Ghanaian (81%) and Ugandan (77%) students more often than the Norwegian students (65%) stated that suicide should be prevented in all cases, or in all cases Crisis 2008; Vol. 29(1):20–31

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with a few exceptions (14%, 17% and 31% respectively), whereas one percent of both the Ghanaian and Ugandan and none of the Norwegian students responded that suicide should not be prevented in any case, χ²(6) = 36.35, p < .001, Cramer’s V = 0.13. Statistically significant group differences were found on all four of the knowledge/myth variables. Almost half of the students in all three countries (43% in Ghana, 48% in Uganda, and 49% in Norway) disagreed with the statement “People who talk about suicide do not commit suicide” (Cramer’s V = 0.24). Follow-up analyses showed that the Norwegian students more often were undecided and less often agreed with this statement compared to their African counterparts. Around 61% of the Norwegian, 56% of the Ghanaian and 44% of the Ugandan students did not think that suicide happens without previous warning (Cramer’s V = 0.22). The apparent difference between the two African countries was not statistically significant. About half of the African students (49% in Uganda and 52% in Ghana) and two-thirds (66%) of the Norwegian students did not believe that you might evoke suicidal thoughts in a person’s mind if you ask about it (Cramer’s V = 0.21). The vast majority of students in all three countries disagreed with the statement that once a person has made up his mind about committing suicide no one can stop him or her, but the Ghanaian students disagreed to an even larger degree than the other two groups (Cramer’s V = 0.18). The most pronounced difference on all the knowledge/myth variables was that once again the Norwegian students were undecided more often than their African counterparts.

Gender Differences in Attitudes Toward Suicidal Behavior and Prevention The gender analyses were conducted for each country separately. No gender differences were found in the knowledge/myth, preventability and tabooing variables in any of the countries. In the group of statements concerning suicide as a right, two gender differences were found. In Ghana even more women (95.2%) than men (92.0%) disagreed that suicide is one’s own business and no one should interfere, χ²(4) = 15.67, p < .01, Cramer’s V = 0.17. In Uganda women (95.2%) more often than men (76.8%) disagreed with people having a right to commit suicide, χ²(4) = 31.75, p < .001, Cramer’s V = 0.34. Gender differences were found in both statements ascribing intentionality to suicide attempts. In Ghana, more women (71.7%) than men (56.3%) agreed that a suicide attempt is a cry for help, while 11.0% of the women and 6.3% of the men were undecided (χ²(4) = 36.92, p < .001, Cramer’s V = 0.26). Also in Norway women (87.6%) more often than men (69.0%) agreed that suicide attempts are cries for help, while none of either women or men disagreed with this, χ²(2) = 11.98, p < .01, Cramer’s V = 0.24. In Norway, men (14%) more often than women (3%) Crisis 2008; Vol. 29(1):20–31

agreed that suicide attempts are made because of revenge or to punish someone, χ²(4) = 11.58, p < .05, Cramer’s V = 0.23.

Correlation Analyses Since the factor structure differed between the countries, indicating cultural differences in associations between attitude variables, the correlation analyses were conducted for each of the countries separately. In order to keep the number of analyses down to a comprehensible level, we decided to create one variable as an index of knowledge by summarizing the scores on the four knowledge/myth variables, and then reverse it so that a high score on this sum variable indicated a high level of knowledge (that is, disbelief in the myths). In addition, we let the clearest statements on suicide as a right (i.e., “People have the right to commit suicide”) and preventability of suicide (i.e., “Suicide can be prevented”) represent these groups of variables in the correlation analyses. Thus, correlation analyses (Pearson’s r) were conducted between the knowledge and attitude variables as well as between these variables and relevant background variables, namely, own suicidal behavior last year and earlier in life, suicidal behavior in the surroundings (i.e., in the family and among others), happiness and life-weariness last year and earlier in life. Due to the high number of correlation analyses (each attitude variable was correlated with 14 variables), the α level was Bonferroni corrected and set at 0.003. In Ghana the following significant correlations were found: The knowledge variable correlated negatively with tabooing (r = –0.25, p < .001) and having experienced suicide attempts among others (outside of the family; r = –0.15, p < .001). The item “People should have a right to take their own lives” correlated positively with having experienced suicide in the family (r = 0.14, p = < 001), lifeweariness last year (r = 0.15, p < .001), life-weariness earlier in life (r = 0.21, p < .001), and own suicide attempt earlier in life (r = 0.17, p < .001). The item “Suicide can be prevented” correlated negatively with having experienced suicide in the family (r = –0.19, p < .001). Happiness correlated negatively with viewing suicide attempts as cries for help, whereas life-weariness and death-wishes earlier in life correlated positively with both viewing suicide attempts a cries for help (r = 0.13, p < .01) and as revenge or punishment (r = 0.15, p < .001). With a Bonferroni correction of the α-level, only one statistically significant correlation was found in Uganda: The item “People should have a right to take their own lives” correlated positively with life-weariness and death wishes last year (r = 0.22, p < .001). In Norway the following significant correlations were found: Knowledge about the topic of suicide correlated negatively with tabooing (r = –0.24, p < .001). The item “People have the right to take their own life” correlated positively with experience of suicide among others outside © 2008 Hogrefe & Huber Publishers


the family (r = 0.15, p < .001). Seeing suicide attempts as made to revenge something or punish someone correlated positively with having experienced suicide among others (r = 0.10, p < .001). Happiness correlated positively with believing that suicide can be prevented (r = 0.23, p < .001).

Discussion Self-Reported Suicidal Behavior and Life-Weariness In terms of own suicidal behavior, the countries differed only slightly (although statistically significant) whereas the Ugandan and Norwegian students almost twice as often as the Ghanaian had experienced suicide attempts in their surroundings. The Ugandan students had experienced completed suicide more often than the Ghanaian and Norwegian students. Analyses of the happiness and life-weariness variables showed that the Ugandan psychology students seem to perceive life as harder than their Ghanaian and Norwegian counterparts. This might be reflecting less hope due to the specter of AIDS, rebel activities, and atrocities that has been going on in parts of Uganda in most of these students’ lives. In Norway the suicide rate was approximately 13/100,000 at the time of the data collection (Norwegian Bureau of Statistics, 2003) which is around the European average. Norway does not have a national registration of attempted suicide, but based on regional registrations, for instance, the Norwegian part of the WHO/EURO Multicenter Study on Suicidal Behavior (Hjelmeland & Bjerke, 1996), it is estimated that the attempted suicide rate (those medically treated) is at least ten times higher than the suicide rate. Based on the experience with suicidal behavior found among the African students compared to the Norwegian students, it would be plausible to suggest that suicidal behavior is a considerable public health problem also in the two African countries, especially in Uganda, where the suicide rate probably is higher than in Norway, while the Ghanaian suicide rate might be lower. These estimations are, of course, speculations and should be followed by epidemiological studies in these countries. Alem et al. (1999) found that their respondents in Ethiopia knew more persons who had completed suicide than had attempted suicide, which is in contrast to the known higher prevalence of attempted suicide. They explain their finding with the fact that, because of the stigma suicidal behavior carries in African countries, attempts are made to conceal suicidal acts, and it is relatively unusual for suicide attempters to be taken to hospital. Our findings are not consistent with the findings of Alem et al. in that our informants do know of more suicide attempts than they do of suicides; however, it is nowhere near the approximate 10:1 relationship that might be expected, at least in Norway. © 2008 Hogrefe & Huber Publishers

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Attitude and Knowledge Variables The lack of structural equivalence shown by the differences in factor structure might be an indication of lack of validity and/or reliability of the instrument (discussed further in Hjelmeland et al., 2006). Furthermore, comparisons at item level are by some considered to be dubious (van de Vijver & Leung, 1997). However, we still know very little about whether suicidal behavior has a different meaning in African countries compared to Western countries. Thus, we cannot dismiss the possibility that differences in factor structure, which might indicate different latent variables, is a valid finding indicating differences in meaning (Hjelmeland et al., 2006). Furthermore, we urgently need research relevant for suicide prevention in Ghana and Uganda and although it is not considered to be methodologically perfect, comparisons at item level of especially relevant items will at least give us some preliminary indications of potential cultural differences in meaning of suicidal behavior. It is also very useful to know how future gate-keepers in Ghana and Uganda respond to items like the ones included in the present study, and how they differ to some of their Western counterparts in their views on such issues. The decision to do comparisons at item level is also supported by the findings of Seidlitz et al. (1995) showing links between particular risk factors and particular attitudes demonstrating the importance of examining specific attitude items separately rather than combining them into scales. The results showed that the Norwegian students consider suicide to be a right more often than the African, but also that the Norwegian students more often seem to lack ability (or will?) to take a stand on such questions. The vast majority in all three groups, however, agreed that suicide is not one’s own business and that it is a human duty to stop someone from committing suicide. Even though the differences mainly are between the Norwegian students, on the one hand, and the African students, on the other hand, there are also some differences between the two African countries. Ugandans more often than Ghanaians think that suicide sometimes can be justified and that it sometimes can be the only solution. The Norwegian students more often than the African view suicide attempts as cries for help. Apparently the cultural context plays a role here. In Norway the current development is in the direction of increased fragmentation of social networks due to family dissolution and reconstruction. For instance, almost half of the households today consist of only one adult. The responses from the Norwegian students thus might be reflecting this weakened social network, where possibilities for a suicidal individual to communicate despair are limited. The same context sensitivity is demonstrated when the African more often than Norwegian students believe that many suicide attempts are made because of revenge or to punish someone else. In cultures where suicide affects families and clans in a different way than in the Western part of the world, the possibilities of using it as revenge or punishCrisis 2008; Vol. 29(1):20–31

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ment might also be completely different. Interestingly, there is a rather large difference between the two African countries, indicating differences also between African cultures. This underlines the danger of assuming similarity between countries from the same continent without investigating if this really is the case and demonstrates the need for further culture-specific/culture-sensitive research. Although the majority in all three countries disagreed with the statement that one should rather not talk about suicide, the topic seems to be most taboo in Ghana, followed by Uganda and then Norway. As pointed out by Phillips (2004), it is important to address such taboos before suicide prevention can truly start. It can be questioned whether this has had any effect on the responses to the questionnaire, and it might be speculated that the relatively low frequency of experience with suicidal behavior in the Ghanaian group, compared to the other two, partly can be explained by this taboo. However, the effect of social desirability is expected to be smaller in anonymous questionnaire studies than in face-to-face interviews. The majority in all three countries believes that suicide can and should be prevented. This is followed up by a belief that you can always help a suicidal person and a readiness to help by taking contact. At the same time, the majority of the Ugandan and Ghanaian students believe that most suicide attempts are impulsive, thus indicating that they might be difficult to prevent. However, this item is on suicide attempts, not on suicide, and it might be questioned whether the informants differentiate between suicide and suicide attempts. It is worth noting that there are also differences between the two African countries here in that the Ugandan students even more often than both the Ghanaian and the Norwegian believe that you can always help a suicidal person. The Ghanaian students seem a bit more reluctant to help than the Ugandan and Norwegian students. Nevertheless, these results are promising in terms of suicide prevention since suicidal behavior seems to be an even bigger problem in Uganda than in Ghana. The Norwegian students had a slightly higher level of knowledge in suicidology compared to the African students, as was to be expected since Norway has had some focus on suicide and suicide prevention during the last couple of decades, first due to a large increase in suicide rates in the 1970s and 1980s, and subsequently because a Governmental action plan for suicide prevention was launched in the 1990s (National Board of Health, 1996). However, based on both the small effect sizes of the differences and the fact that the Norwegian students to a much higher degree than the African students did not know whether to believe in the myths or not, the differences were smaller than what could be expected.

Gender Differences Few and mostly small gender differences were found in this study. The most pronounced one was found in Uganda, Crisis 2008; Vol. 29(1):20–31

where most women compared to about 75% of the men believed that people do not have the right to commit suicide. Previous research has shown mixed results in terms of gender differences in attitudes toward suicide in that some studies have found differences (e.g., Domino & Groth, 1997; Domino & Takahashi, 1991), while others have either not found or found only minor gender differences (e.g., Domino et al., 1993–1994; Domino & Su, 1994–1995; Kocmur & Dernovsek, 2003).

Relationship Between Knowledge, Attitudes and Background Variables More knowledge was associated with less tabooing in both Ghana and Norway, and also with experience of suicidal behavior in Ghana. The view that people have the right to commit suicide was associated with life-weariness and/or experience of suicidal behavior in all three countries, a finding in keeping with previous studies (e.g., Minear & Brush, 1980–1981; Stillion et al., 1986). In addition, experience of suicide was in Ghana associated with a more negative view on the possibility to prevent suicide, happiness with less, and life-weariness, with more belief in suicidal attempts as cries for help. Life-weariness was also associated with viewing suicide attempts as made in revenge or to punish someone. In Norway, happiness was associated with a more positive view on the possibility to prevent suicide. Although all the associations found were in the expected directions, they were surprisingly few and the correlation coefficients found were relatively small.

General Discussion As pointed out by Alem et al. (1999) among others, attitudes toward suicide are reflections of its social meaning in a culture, and such attitudes are generally assumed to be rather permissive in the developed part of the world, while they are considered to be more restrictive in the developing world (e.g., Lester & Akande, 1994; Eshun, 2003). Difficulties leading to suicide occur in a specific cultural and societal setting and the individuals’ possibilities of changing the circumstances are restricted by local legal and cultural practice. Accordingly, the attitudinal differences between the student groups in the present study must also be seen in light of their specific ideological environment. For example, the Norwegians are more reluctant to take a stand on both knowledge and attitude issues compared to the Africans. In a society like Norway’s, where suicide has been on the agenda to a larger degree than in, for example, Ghanaian and Ugandan societies, such insecurity might reflect a transitional state between prejudice and more knowledge-based attitudes. However, it might also just reflect lack of knowledge among the students and if this indecisiveness persists into their professional ca© 2008 Hogrefe & Huber Publishers


reers, this might have damaging effects on the ability of these future psychologists to prevent suicide in their clients. Based on previous research on the relationship between attitudes toward suicide and suicidal behavior, it is premature to claim that some attitudes are wrong and others are right in terms of their effectiveness to prevent suicide (Salander Renberg & Jacobsson, 2003). What we do know, however, is that it is of vital importance for therapists to be conscious of their own attitudes and the effect such attitudes have on the relationship with their clients. Although Maine et al. (2001) found that only knowledge, not attitudes, were important, we believe that even if they may not be directly important in intervention or treatment, they are important indirectly as they might affect people’s interest in acquiring knowledge (Lang et al., 1989), and also people’s receptivity to different kinds of knowledge. We also believe that attitudes have an impact on therapists’ ability or will to talk to suicidal clients and influence the way that suicidality is talked about. Domino and Takahashi (1991) pointed out that cultural differences influence the willingness to share personal information on such a sensitive topic as suicide, and that this might result in a higher incidence of the “undecided” response alternative. Since this topic was expected to be more taboo in the two African countries, as was supported to some degree in our study, we would have expected to find that the African students ticked the undecided alternative more often than the Norwegians. The finding that this was more often the case for the Norwegian students, and also to a much higher degree compared to the African students, was therefore surprising and is difficult to explain. It can be speculated that religion might have had an effect on this. We would assume that religion plays a much larger part in the lives of Ugandans and Ghanaians compared to Norwegians in general since Norway in many ways is a more secular country. Based on their faith and their religious values, it therefore might be easier for the Africans to take a stand on questions regarding life or death. Moreover, the greater emphasis on religion in the two African countries might also explain the difference in viewing suicide as a right, in that tolerance of suicide has been found to be negatively associated with religiousness (Neeleman et al., 1997). Because religion might be more important in the African students’ life compared to the Norwegians’, religion can be considered as a confounding variable in this study. However, as pointed out by Domino et al. (1993–1994) such differences do reflect the real world and controlling for religion would have resulted in nonrepresentative samples. Besides, Bagley and Ramsey (1989) have found the influence of religious affiliation on attitudes toward suicidal behavior to be weak.

Methodological Considerations In addition to the methodological issues discussed elsewhere in this paper, one other important question in crosscultural studies like this is whether the respondents in coun© 2008 Hogrefe & Huber Publishers

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tries with such different cultures understand the questions in the same way, or even define suicide attempt and suicide in an equal manner. Attitudes toward suicide appear to be quite complex and, perhaps more than other phenomena, reflect both individual and cultural dynamics. However, Domino and Takahashi (1991) have emphasized that although cross-cultural comparisons might be influenced by quite a substantial number of variables and thereby be limited in their generalizability, they still provide a window into an important area of human concern, and thus help us to develop our understanding of the meanings of suicidal behavior.

Implications for Suicide Prevention Some implications for suicide prevention should be mentioned. It is clear that the attitudes toward suicide and suicide prevention found in this study in general give grounds for optimism regarding initiation of suicide preventive efforts in Ghana and Uganda. No doubt, both the African countries have a young generation of upcoming psychologists who do not reflect the generally held negative and condemning attitudes to the same degree as often seen in the general population, and who see both the value and possibility of preventing suicidal behavior. We would also assume that mere participation in this study might have some suicide preventive power in itself, as it made the respondents reflect upon a topic that they might not have thought much about previously, and thus will be more alert to problems of suicidality in their surroundings. This view is supported by the findings of Jenner and Niesing (2000), as well as a number of the comments made on the back page of our questionnaire (where the participants were encouraged to give their comments to the study), and orally as the questionnaires were handed in. Eisler et al. (1999) pointed out that knowledge and attitudes toward suicide in subjects not involved in suicidal behavior gives valuable information on meanings assigned to suicide in a culture and the results of the present study indeed indicate that the phenomenon of suicide is assigned different meanings in different cultures. For instance, in Norway the general impression of indecisiveness might point to an understanding of suicide as such a complex phenomenon that it is almost impossible to take a clear stand on the various aspects connected to it. In those able to take a stand, a tendency toward viewing suicide as a matter of personal rights and/or as a cry for help from an individual under unbearable circumstances is evident. In Ghana and Uganda, on the other hand, suicide is viewed more as a joint matter with less choice for the individual and huge consequences for the family, even though the Ugandan students seem a bit more permissive than the Ghanaian. This is also the case for the representation of intentionality, where the suicidal act more often is viewed in terms of influencing others. This leaves us with a general meaning of suicide as more of a private matter in Norway compared to the two Crisis 2008; Vol. 29(1):20–31

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African countries where it is perceived more as a joint matter for the family/clan, reflecting the different family structures in general in these countries, where the extended family is more common in Africa than in Norway. Some countries in the Western part of the world, as Norway, have had national suicide prevention plans for some time now, and it might be tempting to just “export” these plans to developing countries. However, in line with previous authors underlining the dangers of transposing research from one country to another (e.g., Boldt, 1988; Domino & Perrone, 1993; Leenaars & Domino, 1993), the findings of the present study emphasize the need for suicide prevention efforts to be culture-sensitive and culture-specific. This has also been underlined by Phillips (2004) and Vijayakumar et al. (2004, 2005) who pointed to the fact that there are large differences in both risk and protective factors associated with suicidal behavior between developed and developing countries. Moreover, since priorities of preventive efforts and strategies in developing countries to a large degree is ruled by donor money (S. Ndyanabangi, Ministry of Health, Uganda, personal communication, 2003), this might in some quarters create a backlash against “imported” programs. When planning suicide prevention programs in developing countries, it is also important to keep in mind that, for instance, Africa in general has only 0.34 mental health professional per 100,000 population (Vijayakumar, 2004). The results of this study, however, gives grounds for optimism regarding the possibilities for developing and initiating suicide preventive efforts in Ghana and Uganda, although parallel with that, more research is, of course, needed. We propose qualitative studies in order to develop our understanding of the meaning(s) of suicidal behavior in these two countries further. The results of such studies will also contribute to develop the ATTS into a more culture sensitive instrument.

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Vijayakumar, L. (2004) Suicide prevention: The urgent need in developing countries. World Psychiatry, 3, 158–159. Vijayakumar, L., John, S., Pirkis, J., & Whiteford, H. (2005). Suicide in developing countries (2). Risk factors. Crisis, 26, 112–119.

About the authors Heidi Hjelmeland is Professor of Health Science at the Department of Social Work and Health Science, Norwegian University of Science and Technology in Trondheim, Norway, as well as a researcher at the Division of Mental Health at the Norwegian Institute of Public Health, Oslo, Norway. Her current research focuses on cultural and communicative/intentional aspects of suicidal behavior. Charity S. Akotia is Senior Lecturer at the Department of Psychology, University of Ghana, Legon, Accra, Ghana. Her current research focuses on community psychology and suicidal behavior. Vicki Owens is Lecturer at the Department of Mental Health and Community Psychology, Makerere University, Kampala, Uganda. Her current research interests are development of values and counseling training. Birthe L. Knizek is Associate Professor at the Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway. Her current research focuses on various aspects of suicidal behavior as well as the use of qualitative methods in cultural studies. Hilmar Nordvik is Professor of Personality Psychology at the Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway. His research interests lie in personality traits, vocational psychology, and psychometric methodology. Rose Schroeder is Counseling Psychologist and Professor at Austin Community College, Austin, Texas, USA. Her research interest is stress among black women. Eugene Kinyanda is a consultant psychiatrist currently working as Research Manager with the Medical Research Council/Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda. His current research focuses on suicidality in the high risk groups of HIV/AIDS and war traumatized populations.

Heidi Hjelmeland Department of Social Work and Health Science Norwegian University of Science and Technology N-7491 Trondheim Norway E-mail [email protected]

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