Abstract
During the last decade New Zealand has had one of the highest rates of youth suicide among developed Organization for Economic Co-operation and Development (OECD) countries [1]. As a consequence there has been extensive political, policy and public concern about youth suicide, and the issue has received wide, and repeated, media coverage.
Given this widespread discussion and media reporting, it might be expected that young New Zealanders who have grown up during the last decade would be relatively well informed about suicide, particularly when this issue has been regarded as the major youth health issue of their time. To date, however, no studies have examined young New Zealanders' knowledge about suicide.
In turn, knowledge about suicide might be expected to shape attitudes about suicide. While the extent to which attitudes are related to actual behaviours is complex and a matter of extensive, as yet unresolved, debate [2–4], the attitudes that young people develop about suicide may influence their suicidal thinking and suicidal behaviour.
Despite recent interest in youth suicide issues, relatively few studies have examined these issues, and it appears that only one study has examined the attitudes that young New Zealanders hold about suicide. This study compared attitudes toward suicide between young university students in New Zealand and the US, and found that young New Zealanders were less likely to regard suicidal behaviour as serious or as impulsive, and were more likely to consider that an individual had the right to take his or her own life [5]. However, this study was conducted prior to recent concerns about youth suicide. Attitudes vary over time, and it is useful to examine current attitudes about suicide in the population of young people for whom youth suicide was the major youth issue of concern during their adolescence and young adulthood.
Further, given increased rates of suicide during this time, more young people may have experienced the suicide attempt or death of a friend or family member, or may have personally thought about suicide or made a suicide attempt. The extent, and direction, in which personal experience and exposure to suicidal behaviour influence attitudes to suicide has been examined in relatively few studies, and some of these studies have produced conflicting findings. For example, Brent and colleagues have suggested that experiencing the effects that a suicide death has on family members may make adolescents less likely to consider suicide [6]. However, it may be that some vulnerable young people with histories of suicidal ideation and/or suicide attempt, who are exposed to the effects of suicide in this way, may be more attracted to suicidal behaviour.
Research about attitudes toward suicide has tended to suggest gender differences, with young women appearing more empathic, approving and accepting of suicide than young men [7], [8]. There are clear gender differences in youth suicidal behaviour in New Zealand, with young men approximately four times more likely to die by suicide, and young women more likely to make nonfatal suicide attempts [9]. The extent to which these gender differences in suicidal behaviour either reflect or shape attitudes toward suicide have not been well explored.
In addition to gender differences, some studies have found that attitudes toward suicide vary with age, with younger people generally holding more tolerant, accepting attitudes toward suicide than their parents [10]. It is not clear whether these more liberal attitudes reflect the emergence of a more general youth culture, with young people who have attitudes and values different from those of adults [11] or whether they arise from young people having more experience with, or exposure to, suicide than their parents.
Against this background, this study reports on knowledge and attitudes to suicide among a birth cohort of over 1000 young people studied at age 25. The aims of this study were to use this cohort to provide data about the following issues: Young people's knowledge about suicide, and the sources of that knowledge. The attitudes that young New Zealanders hold about suicide. The extent to which young people's attitudes about suicide are influenced by personal suicidal behaviour, and/or by experience of family suicidal behaviour.
Method
Participants
The data described in this paper were gathered during the course of the Christchurch Health and Development Study (CHDS). The CHDS is a longitudinal study of an unselected birth cohort of 1265 children (635 male, 630 female) born in the Christchurch (New Zealand) urban region during a 4-month period in mid-1977. This cohort has been studied at 4 months, 1 year, annual intervals to 16 years, and at 18, 21 and 25 years. An overview of the study design and methodology has been given previously [12], [13]. The following measures were used in the present analysis.
Knowledge about suicide
At assessment at age 25 cohort members were interviewed on a structured research interview that lasted 1–2 h and examined various aspects of the individual's life history, mental health and psychosocial adjustment since the previous assessment. As part of this assessment, young people were questioned about their knowledge of suicide. Specifically, in a multichoice question format they were asked three questions relating to: (i) the number of youth (15–24 years) suicide deaths in New Zealand each year; (ii) the single most common method of youth suicide in New Zealand; and (iii) the proportion of all suicides in New Zealand accounted for by youth (15–24 years) suicides. In addition, participants were asked about the sources of their information about suicide.
Attitudes toward suicide
As part of their assessment at 25 years, participants were also asked about their attitudes toward suicide. For each of a total of 10 statements about suicide, participants were asked to indicate the extent to which they agreed or disagreed with the statement using a four-point Likert scale (agree strongly/agree/disagree/disagree strongly). These statements were taken from the Suicide Opinion Questionnaire [14]. For the purposes of this analysis, the responses ‘agree strongly’ and ‘agree’, and ‘disagree strongly’ and ‘disagree’ were aggregated to give a dichotomised score of ‘agree’ and ‘disagree’.
Individual factors
Suicidal ideation and suicide attempt
At age 15, cohort members were asked if they had ever thought of taking their own lives by suicide. As part of assessments at 16, 18, 21 and 25 years, participants were asked to indicate whether they had thought about taking their lives by suicide, during each year since the previous assessment.
If a respondent reported having suicidal thoughts at any time, they were asked a further series of questions about the nature, reasons and frequency of these thoughts. All cohort members who reported having suicidal thoughts were also asked if they had made a suicide attempt during the same interval.
On the basis of this information it was possible to create, for each cohort member, a description of their lifetime history of suicidal ideation and suicide attempt to the age of 25 years. For the purposes of this analysis, those participants who reported at any of the assessments that they had seriously considered suicide or made a plan for suicide, were classified as having a lifetime history of suicidal ideation. Those participants who reported, at any of the assessments, that they had made at least one suicide attempt were classified as having a lifetime history of suicide attempt.
Family history of suicide or suicide attempt
As part of the assessment at age 25, participants were asked about the history of suicide and non-fatal suicide attempt in their first and second degree family members. For the purposes of this analysis those participants with a family history of suicide or suicide attempt in first or second degree relatives were classified as having a family history of suicide or suicide attempt.
Educational achievement
At age 25 participants were questioned about their secondary school and tertiary educational attainment, including secondary school examination success, grade levels completed, age of school leaving and tertiary education including degrees and diplomas completed. For the purposes of this analysis, this information was used to construct a dichotomous measure of educational achievement in which cohort members who had left school by age 18 without achieving at least one pass grade in School Certificate examinations were classified as having left school without qualifications, and all other cohort members were classified as having secondary school or tertiary educational qualifications.
Sample size and sample bias
The analyses in this paper are based upon 1003 cohort members who were assessed at age 25. This sample represented 79.3% of the initial cohort of 1265 participants. Sample losses were accounted for by migration from New Zealand (49%), refusal (38%), death (12%) and inability to trace (1%). In addition, for the analysis of attitudes to suicide, data were available for only 987 respondents as a result of missing data on some items.
Comparison of the sample available for analysis with the remaining surviving members of the cohort on measures of socio-demographic characteristics assessed at the point of birth suggested that there were slight but statistically significant (p <0.05) tendencies for the analysis sample to under-represent individuals from disadvantaged family backgrounds (low parental education, low socioeconomic status, single parent family). To examine whether these slight selection biases might influence study findings, the data were re-analyzed using the data weighting methods described by Carlin et al. [15]. These analyses produced essentially identical conclusions to those reported here.
Results
Knowledge about suicide
Table 1 shows the distribution of responses to each of three questions examining knowledge about youth suicide. Less than a third (28.7%) of respondents were able to identify the annual number of youth suicides in New Zealand, with a quarter (25.5%) believing that the number of youth suicides was at least 10× higher than the actual number. Just under a third (29.3%) knew that hanging was the most common method of youth suicide. The majority of young people (68.5%) believed that youth (15–24 years) deaths accounted for 50% or more of all suicides in New Zealand. (In fact, youth deaths account for 25% of all suicides.) In general the findings indicate that respondents showed a clear tendency to overestimate both the number of youth suicide deaths in New Zealand and the fraction of all suicides that are youth suicides.
Knowledge about suicide amongst 25-years-olds
It is possible that gender and/or educational attainment might influence knowledge about suicide. These issues were examined, for each item, by comparing responses by gender and by level of educational achievement. This analysis showed that young men were more likely to correctly report the most common method of suicide than young women (33.0% vs. 25.8%; p < 0.05). In addition, there were slight but statistically significant (p < 0.05) tendencies for young women and those who left school with qualifications to be more likely to overreport the percentage of suicides accounted for by youth.
Sources of knowledge about suicide
The analysis examining knowledge about suicide was supplemented by inquiring about the sources from which the participants acquired information about suicide. This questioning revealed that the most common source was the media: 76.9% of young people reported obtaining information about suicide from newspapers and magazines, 80.4% gained such information from radio and television news and 67.2% from television documentaries. Less common sources of information included family (with 21.6% of respondents reporting that they obtained information from this source), friends (41.6%), secondary school courses (23.2%), university courses (10.7%) and films and videos (30.7%).
Attitudes to suicide
Table 2 shows the proportion of the total sample who agreed with a series of statements about suicide. These statements represented 10 propositions either supportive of, or opposed to, suicidal behaviours. Young people tended to have mixed attitudes about suicide issues. A majority of young people displayed liberal attitudes to some items, favouring euthanasia under certain circumstances (82%), were able to understand why, under some circumstances, people take their own lives (72.5%), and were believing that suicide is an option when life becomes too difficult (51%). Forty percent considered that suicide was justifiable under certain circumstances. However, they also showed conservative attitudes with one-third believing that suicide was a sin, and two-thirds believing that those who wanted to commit suicide should be stopped from doing so at all costs. Ninety percent felt that things could never be bad enough for suicide.
Attitudes towards suicide amongst 25-year-olds (n = 987)
The items in Table 2 were subjected to factor analysis, which showed that all items loaded on a single common factor which appeared to reflect the extent to which the individual held liberal or conservative attitudes towards suicide. To represent individual scores on this continuum the items in Table 2 were summed by scoring positive responses to items iii, iv, vi, vii, and x as ‘1’, and negative responses to items i, ii, v, xii, and ix as ‘1’;. This gave a score which could theoretically range from 0 (extremely conservative) to 10 (extremely liberal).
Table 3 shows associations between this attitude score and a series of factors which might be expected to influence attitudes toward suicide, including gender, personal suicidal behaviour, experience of suicidal behaviour in family members and knowledge about suicide (assessed on the basis of the number of correct responses to the items in Table 1). There were no significant gender differences (p > 0.80), suggesting that young men and women were equally liberal/conservative about suicide. Young people with a family history of suicide or suicide attempt (p < 0.001) tended to hold more liberal attitudes toward suicide. Similarly, those individuals with a personal history of suicidal ideation (p < 0.0001) or suicide attempt (p < 0.0001) tended to have more liberal attitudes than those without such history. Young people's knowledge about suicide (as measured by the number of questions answered correctly) was not related to their attitudes toward suicide (p > 0.90).
Factors associated with conservative/liberal attitudes towards suicide
Discussion
This study has examined knowledge and attitudes to suicidal behaviour in a birth cohort of New Zealand-born young adults. The major findings to emerge from this analysis were that this population seriously overestimated the prevalence of suicidal behaviours in young people with a quarter believing that the number of youth suicides in New Zealand was more than 10× higher than, in fact, is the case. Similarly, members of this cohort tended to overestimate the proportion of suicides in New Zealand accounted for by youth suicides with two-thirds believing that 50% or more of all suicides in New Zealand were youth suicides. The major source from which young people obtained information about suicide was the media with over 80% of this cohort reporting that they gained information about suicide from newspapers and magazines, radio and television news reports and television documentaries.
It is likely that the tendency for this cohort to overestimate the prevalence of youth suicide and their strong reliance on the media as the primary source of information are closely linked. In particular, during the last decade the New Zealand media has displayed a strong interest in the issue of youth suicide as a result of official statistics which have indicated that New Zealand has one of the highest rates of youth suicide among a series of OECD countries. Thus, during the last 10 years, when this cohort was aged 15 through 24 years, media stories about suicide often emphasized New Zealand's high rate of youth suicide, and suicide among other age groups, particularly adults and older adults, was virtually ignored as an issue. The legacy of this history of reporting appears to have been the development of a generation of young people who believe that youth suicide in New Zealand is far more prevalent than, in fact, it is. One of the potential risks of this overestimation of youth suicide by young people is that it may result in suicide becoming ‘normalized’, that is, as being viewed by young people as a common and prevalent response among youth as a means of addressing life difficulties. The findings from this study suggest that there is a clear need for more balanced media reporting which conveys more accurately to young people that youth suicide in New Zealand is, in fact, an uncommon event.
The findings that young people in New Zealand do not have accurate knowledge about suicide are similar to the results of the limited number of studies that have examined this issue in other countries [16]. More generally, these findings are consistent with a growing number of studies which report poor public knowledge and understanding about a range of mental health matters [17], [18] and suggest the need for improved public education about these matters. To date, media coverage of suicide has generally been limited to reporting particular events and annual statistics. The findings from the present study, however, suggest that the media are in a powerful position to play a leading role in educating and informing the public about a range of mental health issues, including suicide. There is now a wealth of very good information about suicide on the websites of international suicide research and prevention centres and relevant government departments. A challenge for media and public health professionals is how to develop a partnership to best disseminate this information in efforts to improve public knowledge about these issues.
Responses to questions examining the attitudes that young New Zealanders hold toward suicide suggested a spectrum of opinion ranging along a continuum from conservative to liberal. However, it is notable that the majority of young people in this cohort held the view that, in certain circumstances, suicide was justifiable, and the majority were supportive of euthanasia. At the same time many also believed that those who wanted to take their own lives should, at all costs, be prevented from doing so. Further, the cohort also tended to hold the opinion that no matter how bad things may seem, they were never bad enough for suicide. Overall, while supporting an individual's right to die in some circumstances, young people tended to see suicide as an action so abhorrent as to justify intervention to prevent it.
The apparent inconsistencies in young people's attitudes, justifying suicide in some situations, while, on the other hand, believing that society has a right to intervene to prevent suicides, likely reflect the complexity of suicidal issues, encompassing as they do euthanasia, right to die arguments, assisted suicide, rational suicide and personal choice. It is probable that all people, regardless of age, tend to hold similarly pluralistic views about the range of suicide issues.
We found that attitudes to suicide did not vary with gender but that those individuals with a family history of suicide, and those with a personal history of suicidal ideation or suicide attempt, tended to hold more liberal attitudes. These findings suggest that an individual's attitudes to suicide are, to some extent, shaped by personal experience and, to some extent, may shape personal suicidal behaviours and responses.
During the last decade, New Zealand's high youth suicide rates have led to some speculation that young New Zealanders might have more liberal and lenient attitudes toward suicide than their overseas counterparts, with such views contributing to the high suicide rates. While the present study is not able to provide comment on this issue since it does not compare young New Zealanders' attitudes with those of young people in other countries, it might be interesting to include such comparisons in future studies.
Footnotes
Acknowledgements
This research was funded by grants from the Health Research Council of New Zealand, the National Child Health Research Foundation, the Canterbury Medical Research Foundation, the New Zealand Lottery Grants Board and was supported by the Canterbury Area Health Board and Healthlink South.