Abstract
Background:
The aim of the investigation was to evaluate past 12-month suicidal behaviour (PSB) among adults in Cabo Verde.
Methods:
Data from 4,563 adults (mean age 41.4 years) that participated in the 2020 Cabo Verde STEPS survey were analysed.
Results:
Results indicate that the proportion of PSB (attempt 0.6%, plan 1.5% and ideation 3.3%) was 3.7% (2.4% men/5.0% women). In adjusted logistic regression analysis, younger age, female sex, unemployed, widowed or divorced, alcohol family problem, heart attack, angina or stroke, current smokeless tobacco use and low fruit/vegetable intake were associated with PSB.
Conclusion:
Almost 4% of participants had PSB and several associated factors were identified that can guide public health interventions.
Introduction
Globally, it is estimated that with 20 suicide attempts come one death, and of every 100 deaths one is suicide (World Health Organization, 2022). In the Africa region, the suicide rate (11.2/100,000 population) is the highest in the world, compared to 9.0/100,000 globally (World Health Organization Regional Office for Africa, 2022). To inform suicide prevention activities, representative country data are indicated on the prevalence of past 12-month suicidal behaviour (PSB; Joe et al., 2008). However, there is scanty data on PSB in African island nations, such as Cabo Verde. The age-standardised suicide rate was 15.2/100,000 in 2019 in Cabo Verde (WHO, 2020a). Suicide mortality increased from 1.5% in 2012 to 2.3% in 2016 in Cabo Verde (World Health Organization Cabo Verde, 2022).
Cabo Verde is a small island lower middle income country in Africa; the total population is 603,901 with expariates outnumbering the resident population, 71% are Creole (Mulatto), 28% African and 1% European, 68.0% live in urban areas, 86.8% are literate, life expectancy (at birth) was 74.0 years and youth (15–24 years) unemployment rate was estimated at 34.3% in 2021 (The World Factbook, 2023).
In other African island countries, the age-standardised suicide rate was 7.73/100,000 in 2019 in the Seychelles (WHO, 2020b), 7.3 in Mauritius in 2016, 6.9 in Madagascar in 2016 and 3.1 in São Tomé and Príncipe in 2016 (WHO, 2019). On the island of Mayotte, one suicide attempt for 2,504 inhabitants has been reported, while in France the ratio was 1:375 (Charbonnier et al., 2008), and a high prevalence of suicide attempts (335/100,000/year) was found on the island of Reunion (Duval et al., 1997). In countries on the African mainland, the prevalence of PSB in Malawi was 7.9% (Pengpid & Peltzer, 2021b), 8.5% in Zambia (Pengpid & Peltzer, 2021c) and 10.1% in Eswatini (Pengpid & Peltzer, 2020). Based on data from the World Mental Health Survey in low- and middle-income countries (LMICs), the proportion PSB was 0.4% attempts, 0.7% plans and 2.1% suicidal ideation (Borges et al., 2010).
In Cabo Verde, the total number of mental health professionals was 13.82 per 100,000 population (WHO, 2020a). In a population survey in Ethiopia, 26% of the sample sought treatment after a suicide attempt (Jordans et al., 2018), and among those with PSB in middle-income countries 28% received treatment (Bruffaerts et al., 2011). Factors that can increase the risk of SB include psychosocial distress, such as mental health and substance use problems (WHO, 2023), problematic life events (Sorsdahl et al., 2011; WHO, 2023), including unemployment (Scott et al., 2010; Scottish Government Social Research, 2008) and exposure to suicide (Lee et al., 2013). Chronic diseases [diabetes, cardiovascular disease (Elamoshy et al., 2018; Moazzami et al., 2018; Scott et al., 2010), hypercholesterolemia (Cheah et al., 2018), overweight or obesity (Henriksen et al., 2014) and low systolic blood pressure (Joung & Cho, 2018)] and lifestyle factors [physical inactivity, sedentary behaviour (An et al., 2015; Uddin et al., 2020) and substance use (Breet et al., 2018; Goldstone et al., 2020)] can increase the risk of SB. In addition, sociodemographic factors, such as younger age, female sex, family history of suicide (Dendup et al., 2020; Pengpid & Peltzer, 2021a; WHO, 2023) and lower socioeconomic status (Scottish Government Social Research, 2008) are associated with SB.
Sociodemographic factors, chronic diseases, psychosocial distress, lifestyle and socioeconomic factors have been hypothesised to increase the odds of PSB in Cabo Verde. The aim of the investigation was to evaluate PSB among adults in Cabo Verde.
Methods
Secondary data from the STEPS cross-sectional survey in Cabo Verde in 2020 were analysed (Ministério da Saúde, República De Cabo Verde, 2021). A three-stage probabilistic sampling process (district, household and individual) was carried out to randomly select one individual per household from the target population, 18 to 69 years old in 2020. Exclusion criteria included if individuals were unable to respond to the interview. The response rate for interview and physical measurement was 63.5% and for biochemical measures 56.5% (Ministério da Saúde, República De Cabo Verde, 2021).
Following the three-STEPS protocol: (1) questionnaire administration, (2) blood pressure (BP) through the sphygmomanometer (OMRON®), and anthropometric measurements using a digital scale (Seca®) and a conventional stadiometer (Seca®) and (3) blood glucose and blood lipids using the CardioChek PA@system (Ministério da Saúde, República De Cabo Verde, 2021).
The National Ethics Committee for Health Research and the Data Protection Commission (CNEPS) approved the study and written informed consent was obtained from all participants.
Assessment components
Questions related to suicide included PSB (attempt, plan and ideation)
‘In the past 12 months have you seriously considered a suicide attempt? (Yes/No)’ ‘In the past 12 months, have you made a plan for how you would attempt suicide? (Yes/No)’ ‘In the past 12 months, have you made a suicide attempt? (Yes/No)’.
Further, questions were asked about suicide methods, and treatment for PSB (Ministério da Saúde, República De Cabo Verde, 2021).
Low systolic blood pressure (<100 mmHg) measured by two of three last readings in survey.
Body mass index (BMI): ‘obesity (⩾30.0 kg/m2), overweight (25.0–29.9 kg/m2) and underweight (<18.5 kg/m2)’ (WHO, 2017).
Diabetes: ‘fasting plasma glucose: ⩾7.0 mmol/L or ⩾126 mg/dL, and/or currently taking insulin or oral hypoglycemic drugs’ (WHO, 2017).
Total elevated cholesterol: ‘⩾200 mg/dL; ⩾5.18 mmol/L’ (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001).
Self-reported history of heart attack, angina or a stroke, current smokeless tobacco consumption, fruit/vegetable consumption (grouped into 0–<2, 2–<4 and 4 or more standard servings per day), current smoking, low physical activity (defined as ‘<600 metabolic equivalent of task [MET]-minutes/week’) according to the ‘Global Physical Activity Questionnaire’ (Armstrong & Bull, 2006), sedentary behaviour (⩾8 hours/day; van der Ploeg et al., 2012; ‘How much time do you usually spend sitting or reclining on a typical day? Hours/minutes’) and hazardous alcohol use (⩾7 in women and ⩾14 in men standard drinks in the past week; ‘During each of the past 7 days, how many standard drinks did you have each day?’; US Preventive Services Task Force, 2004).
Psychosocial distress (family member suicide death or attempt, and family problems due to alcohol use (Ministério da Saúde, República De Cabo Verde, 2021). Questions included ‘Has anyone in your close family (mother, father, brother, sister or children) ever attempted suicide? (Yes/No)’ ‘Has anyone in your close family (mother, father, brother, sister or children) ever died from suicide? (Yes/No)’ ‘During the past 12 months, have you had family problems or problems with your partner due to someone else’s drinking?’ (categorised as 1=yes and 0=no)
Sociodemographic data
Sex (female, male), age (grouped into 18–31, 32–45 and 46–69 years), education (grouped into 0–4, 5–8 and 9 or more years), adult members of the household (0–1, 2 or 3 or more), interview language (Portuguese, Crioulo), work status (grouped into employed, unemployed, homemaker and other), marital status (married, cohabiting, single and widowed/divorced/separated) and geolocality (rural and urban; Ministério da Saúde, República De Cabo Verde, 2021).
Data analysis
Chi-square statistics were used to assess differences in proportions of PSB. Unadjusted and adjusted (with variables significant in unadjusted analysis) logistic regression was applied to estimate associations with PSB. p<.05 was accepted as significant, and missing values were discarded. Statistical analyses were performed with STATA software version 15.0, considering the complex study design.
Results
Participants
The total sample was 4,563 adults (mean age = 41.4 years, SD = 13.9 years, 18–69 years), and about half (48.8%) were women, 53.1% had nine or more years of education, 54.6% were single, 57.3% were employed, 78.7% were Crioulo speakers and 65.6% resided in urban areas. The prevalence alcohol problems in the family was 8.3%, and almost 1 in 10 (9.0%) had a family member that had committed a suicide attempt and 7.8% had died from suicide. Of all participants, 1.9% had low systolic blood pressure (<100 mmHg), 5.2% had diabetes, 3.5% had cardiovascular disease, 14.0% had raised total cholesterol, 9.6% were current smokers, 3.6% used currently smokeless tobacco, 5.5% engaged in hazardous alcohol use, 68.6% consumed less than four servings of fruits/vegetables a day, 36.6% had low physical activity and 12.1% engaged in sedentary behaviour (see Tables 1 and 2).
Sample by sociodemographic and psychosocial distress and suicidal behaviour characteristics among adults in Capo Verde in 2020.
Suicidal ideation (3.3%) and/or suicide plan (1.5%) and/or suicide attempt (0.6%); bp-values were calculated by Chi-square statistics; % are weighted.
Sample by physical factors and risk behaviours and suicidal behaviour characteristics among adults in Capo Verde in 2020.
Suicidal ideation (3.3%) and/or suicide plan (1.5%) and/or suicide attempt (0.6%); bp-values were calculated by Chi-square statistics; % are weighted.
Suicidal behaviour characteristics
The proportion of PSB (attempt 0.6%, plan 1.5% and ideation 3.3%) was 3.7% (2.4% men/5.0% women, p<0.001). Those who reported PSB were females, younger, unemployed, single, widowed or divorced and had alcohol family problems (see Table 1). Furthermore, those who were more likely reporting PSB had a history of heart attack, angina or stroke, were currently using smokeless tobacco, and ate fewer or no fruit and vegetables (see Table 2).
The main suicide methods applied included overdose of medication (36.8%), sharp instrument (13.2%), pesticide poisoning (13.2%), overdose of other substances (7.9%) and others (mainly jump from heights/cliff; 28.9%).
Medical out-patient and in-patient treatment after the last suicide attempt was sought by 35.0% and 22.4% of the participants, respectively, and 22.4% had sought professional help after suicidal ideation.
Associations with PSB
In adjusted logistic regression analysis, relative to participants aged 46 to 69 years, younger age, 18 to 31 years (AOR: 3.15, 95% CI [1.65, 6.02]) and 32 to 45 years (AOR: 3.17, 95% CI [1.64, 6.09]), females sex (AOR: 2.60, 95% CI [1.65, 6.09]), unemployed (AOR: 1.91, 95% CI [1.14, 3.21]), widowed or divorced (AOR: 2.72, 95% CI [1.22, 4.09]), alcohol family problem (AOR: 3.59, 95% CI [1.95, 6.59]), heart attack, angina or stroke (AOR: 2.85, 95% CI [1.20, 6.79]), current smokeless tobacco use (AOR: 3.36, 95% CI [1.12, 10.09]) and inadequate (<2 servings) fruit/vegetable intake (AOR: 2.08, 95% CI [1.06, 4.08]) were associated with PSB (see Table 3).
Associations with suicidal behaviour (ideation, plan and/or attempt) in the past year.
Note. COR = crude odds ratio; AOR = adjusted odds ratio.
Adjusted for all variables in the table.
p < .001. **p < .01. *p < .05.
Discussion
In this nationally representative sample of people aged 18 to 69 years in Cabo Verde, the prevalence of PSB (3.7%; 0.6% attempt, 1.5% plans and 3.3% ideation) in this survey was higher than in the LIMCs study (0.4% attempt, 0.7% plan and 2.1% ideation; Borges et al., 2010), but lower than in Zambia (10.1%; 1.1% attempt, 3.6% plan and 7.8% ideation; Pengpid & Peltzer, 2021c), Eswatini (10.1%; 2.1% attempt, 5.4% plan and 9.3% ideation; Pengpid & Peltzer, 2020) and Malawi (7.9%; 0.4% attempt, 3.9% plan and 7.2% ideation; Pengpid & Peltzer, 2021b). The suicide rate in Cabo Verde in 2019 (15.2 per 100,000; WHO, 2020a) was higher than in other African island nations 7.73 per 100,000 in 2019 in Seychelles (WHO, 2020b), 7.3 in Mauritius in 2016, 6.9 in Madagascar in 2016 and 3.1 in São Tomé and Príncipe in 2016 and in LMICs (11.4/100 000; WHO, 2019).
The survey showed that younger age, female sex, unemployed, widowed or divorced, alcohol family problem, having a cardiovascular incident (heart attack, stroke or angina), current use of smokeless tobacco and inadequate fruit/vegetable intake increased the odds of PSB. Consistent with some research (Dendup et al., 2020; Pengpid & Peltzer, 2021a; WHO, 2023), women had a higher rate of PSB than men. Women may suffer more likely from depression than men, which make women more vulnerable to SB than men (Ministério da Saúde, República De Cabo Verde, 2021). Furthermore, younger individuals were significantly more likely to engage in SB than older ones, which is in agreement with previous research (Dendup et al., 2020; Pengpid & Peltzer, 2021c; WHO, 2023). Although some previous studies (Scottish Government Social Research, 2008) found an association between lower socioeconomic status and PSB, we did not find significant differences. As previously found (Claveria, 2022; Scottish Government Social Research, 2008), being unemployed was positively associated with PSB. A high unemployment rate among young people 34.3% in 2021 in Cabo Verde has been reported (The World Factbook, 2023). Economic uncertainty and unemployment have been found to increase the odds of suicide (Claveria, 2022).
According to previous research (Bachmann, 2018; Moazzami et al., 2018), having a history of heart attack, angina or stroke increased the odds of PSB. Patients with cardiovascular disease may be more susceptible to PSB due to disability (Bachmann, 2018). In a South Korean study, low systolic blood pressure was associated with PSB (Joung & Cho, 2018), while we did not find a significant association. Unlike some previous studies (Cheah et al., 2018; Elamoshy et al., 2018; Uddin et al., 2020), our study did not show associations between obesity, diabetes, low physical activity, elevated total cholesterol, sedentary behaviour and PSB. However, having insufficient fruit/vegetable intake increased the odds of PSB in this study. In a study among older adults in Japan, a high intake of vegetables, fruits, etc. decreased the risk of suicide (Nanri et al., 2013). The potential benefits of fruit/vegetable consumption on mental health have been described (Głąbska et al., 2020).
Consistent with previous research (Breet et al., 2018; Goldstone et al., 2020; Pengpid & Peltzer, 2021c; Sorsdahl et al., 2011), we found that psychosocial distress (alcohol family problems, widowed or divorced, but not family history of suicide attempt or death) and substance use (current smokeless tobacco use, but not hazardous alcohol use) increased the odds of SB. Yet, in this study a high proportion reported suicide (7.8%) and attempted suicide (9.0%) of a family member, calling for self-help initiatives for suicide survivors and bereaved relatives (Bachmann, 2018; De Leo et al., 2013).
Major suicide methods included overdose of medication, sharp instrument and pesticide poisoning, which is consistent with global suicide methods in LMICs (WHO, 2023), except for 'hanging on a rope', which does not seem to be commonly used in Cabo Verde. Having knowledge of suicide methods may help in developing interventions targeting access restrictions to means of suicide (WHO, 2023). Of the respondents who had attempted suicide, 35.0% had medical care, which is higher than in Ethiopia (26%; Jordans et al., 2018) and among those with PSB in middle-income countries (28%; Bruffaerts et al., 2011). The access to treatment for mental distress and PSB can be improved by integrating mental health into primary mental health care (Claveria, 2022), which is still suboptimal in Cabo Verde; there were 2.55 visits per 100,000 population in the last year to an outpatient mental health facility (WHO, 2020a).
Social psychiatric approaches to suicide prevention may include: access to quality treatment for mental distress and PSB need to be scaled-up by integrating mental health into primary health care; implementation of the Mental Health Gap Action Programme (mhGAP) in primary health care networks; early intervention and active case management for people with mental disorders, including community-level case investigation; crisis intervention in collaboration with various agencies to people who are at immediate risk of suicide; social welfare services should be offered to unemployed individuals at risk of suicide; awareness and stigma reduction programmes should be accelerated; access to methods of committing suicide, such as pesticide poisoning, should be regulated by the government; proactive psychosocial strategies by psychosocial support centres (CAPS) targeting females, younger age groups, widowed or divorced individuals and those with a cardiovascular disorder, should be implemented with government support; increase health promotion efforts to reduce health risk behaviours, especially alcohol problems, smokeless tobacco use and inadequate fruit/vegetable consumption may help preventing suicidal behaviour (Jordans et al., 2018; Kim et al., 2019; World Health Organization Cabo Verde, 2022).
Study limitations and strengths
The study used standardised methods and nationally representative samples. However, we cannot draw causative inferences due to the cross-sectional nature of the study design. Biochemical analysis was only conducted on a sub-sample (60%) in the 2020 Cabo Verde STEPS surveys, and some of the variables were incomplete, such as household income and others such as mental disorders, for example, depression, were not included in the survey, and therefore could not be included in the analysis.
Conclusions
Almost 4% of the participants had PSB. Several risk factors of PSB were found, including younger age, females sex, unemployed, widowed or divorced, alcohol family problem, heart attack, stroke or angina, current smokeless tobacco use and low fruit/vegetable intake, which can guide public health interventions to prevent PSB in Cabo Verde.
All authors fulfil the criteria for authorship. SP and KP conceived and designed the research, performed statistical analysis, drafted the manuscript and made critical revision of the manuscript for key intellectual content. All authors read and approved the final version of the manuscript and have agreed to the authorship and order of authorship for this manuscript.
Footnotes
Acknowledgements
This paper uses data from the Cabo Verde 2020 STEPS survey, implemented by the Ministry of Health with the support of the World Health Organization.
Availability of data and materials
The data are available at the World Health Organization NCD Microdata Repository at https://extranet.who.int/ncdsmicrodata/index.php/catalog#_r=&collection=&country=38&dtype=&from=1999&page=1&ps=&sid=&sk=&sort_by=nation&sort_order=&to=2020&topic=&view=s&vk=
Ethical approval and consent to participate
The National Ethics Committee for Health Research and the Data Protection Commission (CNEPS) approved the study, and written informed consent was obtained from all participants.
Consent for publication
Not applicable.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
