CHAPTER ONE

Introduction

Background to the Study

The occurrence of suicidal behaviours across the world is one of the worst public health challenges confronting humanity. Apart from the many lives that are wasted through suicide, a multitude of other lives are permanently damaged in suicide attempt. Unfortunately too, a lot of time and energy are lost every year in negative thoughts about killing oneself. According to Gvion and Apter (2013), one million persons commit suicide throughout the world and 10-20 million others engage in suicide attempt every year. Gvion and Apter projected that suicide death in the world would rise above 1.5 million by the year 2020 and the figure for attempted suicide was projected to be 10-20 times higher. They showed that the figures represented on the average one suicide every 20 seconds and one attempted suicide every one to two seconds. Wahlbeck and Makinem (2008) disclosed that 59,000 Europeans died through suicide in 2006. In the United States of America (USA) the number of suicide cases reported in the year 2007 alone was more than 34,000 (Soreff, 2013).

Suicidal behaviours are problems not only of the industrialized countries but also of the developing ones. For instance, Ogunseye (2011) indicated that Ghana recorded 21,500 cases of suicide in 2007. Nigeria, where Enugu state is located, was not among the countries that collected suicide data on routine basis. However, Ogunseye in the same report warned against the increasing rate of suicide in Nigeria. The report confirmed an alarm which was earlier on raised over the rising cases of suicidal behaviours in the country (Okafor & Okafor, 1998). Suicide reports are currently rampant in Nigeria (see Appendix A p. 151). They occurred in large numbers even among Nigerian adolescents which was extremely rare in the past. For instance, eight (18.60%) out of the 43 selected cases of suicidal behaviours reported in Nigerian media were adolescents.

The rising wave of suicidal ideation, suicide attempt and suicide among adolescents is also a global phenomenon. The frequent involvement of adolescents in suicidal behaviours in recent timeis the most shocking aspect of these tragic events (Procope-Beckles, 2007). Procope-Beckles showed that four million adolescents attempted suicide each year throughout the world. It was likely that a lot of others contemplated to engage in suicide. The adolescents in schools in Enugu state might also be involved in these kinds of behaviours.

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Behaviour has been the subject of intensive study. Behaviour was used in this study to mean the conduct of an organism in its environment. Nwachukwu (1992) defined behaviour as the way in which a person, an organism or a group responds to a specific set of conditions. Kassin (2009) described behaviour as any action or reaction that could be measured or observed-such as the blink of an eye, an increase in heart rate or the unruly violence that often erupts in a mob. According to Agbaje (2014), behaviour refers to the actions and reactions of an organism usually in relation to the environment. The limitation of behaviour to observable or measurable activities was the view of behaviorist psychologists (Dolan, 2001). However, Nwoye (2005) indicated that behaviour could also be covert.Suicidal ideation is covert behaviour while suicide and suicide attempt are overt in nature.

Suicidal ideation, attempted suicide and suicide constitute the suicidal behaviours spectrum. Vorvick (2012) defined suicidal behaviour as any act that could cause a person to die, such as taking a drug overdose or crashing a car on purpose. In the present study, suicidal behaviour means the desire of an individual to end his or her life which may or may not be translated into action.

Many scholars have defined suicidal ideation, suicide attempt and suicide in various ways. Suicidal ideation is the foundation of the suicidal behaviours continuum. It is also described as suicide thought. For instance, Robert (2008) called thoughts and plans about killing oneself suicidal ideation. Suicidal ideation refers to any self-reported thoughts of engaging in suicide related behaviour (Brown, 2014). Therefore, suicidal ideation as used in the present study means an individual’s obsession with the thoughts of how to kill him or herself. The individual who is obsessed with the idea of killing him or herself at times actually tries to do so.

When outright self-destruction is not achieved, it is described as suicide attempt. According to De Leo, Burgis, Bertolote, Kerkhof and Bille-Brahe (2006), suicide attempt is a non-fatal self-directed potentially injurious behaviour with intent on dying as a result of the behaviour. According to Clayton (2013), suicide attempt is an act of self-harm that is intended to result in death but does not. Ohio State University Medical Center (2013) viewed suicide attempt as an act focused on causing one’s own death that is unsuccessful in so doing. In suicide attempt or attempted suicide, though the effort to terminate life is deliberate, life is not lost. Alston and Anderson (1998) on their part preferred the use of non-fatal suicidal behaviour to describe suicide attempt. The idea of the use of non-fatal

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suicidal behaviour instead of suicide attempt was muted in an effort to circumvent the problem of the intention of the decedent in suicide study.

However, the use of non-fatal suicidal behaviour did not receive general acceptance. Crosby, Ortega and Melason (2011) stated that World Health Organization at the present favours the term suicide attempt instead of non-fatal suicidal behaviour in order to ensure uniformity of its definition. De Leo, Burgis, Bertolote, Kerkhof and Bille-Brahe (2006) had earlier on used the terms as synonymous and the same position was adopted in the present study. Therefore, suicide attempt was viewed in the present study as any unsuccessful action taken by an individual with intent to kill him or herself. That is to say that the individual involved in this kind of suicidal behaviour survived. Conversely, such attempt can result in death.

When the person who tries to kill him or herself eventually dies it is described as suicide. Knight (2009) perceived suicide as the act of one who causes his own death, either by positively destroying his own life, or by inflicting on himself a mortal wound or injury, or by omitting to do what was necessary to escape death, or by refusing to leave a burning house. Crosby, Ortega and Melason (2011) defined suicide as death caused by self-directed injurious behaviour with any intent to die as a result of the behaviour. Vorvick (2012) simply defined suicide as the act of taking one’s own life on purpose. The definitions showed that suicide is an intentional death and shooting, cutting, drowning, poisoning and jumping from height amongst others are usually employed to achieve the goal. From the foregoing, suicide was defined in this study as a choice death that is self-induced. This phenomenon was also termed completed suicide or fatal suicidal behaviour (Canetto, 1998). Therefore, these terms were used interchangeably in the present study. Suicide is an unacceptable behaviour.

The description of behaviour as acceptable or unacceptable is determined by the prevailing societal norms. Studies in Nigeria indicated that suicide was viewed as disordered behaviour across the nation (Nwafor, Akhnmu & Igbe, 2013). Nonetheless, this disorderedbehaviour seems to be on the increase in the country without any empirically based intervention measures aimed at reducing it.Developing well-researched intervention strategies was therefore, necessary to reduce the ugly behaviours.

The main objectiveof the present intervention strategies was to prevent suicidal behaviours from arising. Additionally, the suicide intervention was aimed to reduce illnesses and death due to suicide attempt. It would also help all those affected by suicidal acts such as fellow students, teachers and care givers (i.e., survivors) to resolve

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the negative effects of stigmatization or discrimination resulting from the disorders. Battin (1995) described suicide intervention as those procedures designed to interrupt a suicide attempt that was immediately imminent or already underway. According to Battin, suicide intervention is used to embrace all ramifications of suicide control – prevention, intervention and postvention. Consequently, in this study suicide intervention is used to mean primary prevention of suicide, secondary intervention and postvention services. In primary prevention, measures are taken to avert suicidal instincts. It included educational measures, control of means of committing suicide, social integration and mental health services. Secondary intervention on the other hand refers to measures geared towards rescuing victims of suicide attempt while postvention services mean services provided to survivors of suicide as well as those that survived suicide attempt to overcome the negative effects of shame, guilt and stigmatization or discrimination associated with suicide.

Effective suicide intervention in schools has to be well articulated and carried out with the involvement of all relevant stakeholders such as religious leaders, law enforcement agents, parents, teachers, schools’ management and in-school adolescents. Co-operative planning of intervention is important to facilitate its smooth implementation and prevent duplication of programmes of action. According to Agbaje (2014), intervention could be designed in the form of strategies.

Strategy is a plan of action directed to realize set objectives. Govah (2000) viewed strategy as method or plan to achieve some goals. Jatua (2000) defined strategy as the application of methods, plans and skills so as to achieve a desired goal. Nji (2010) asserted that without a strategy, an organization lacks a thought-out action plan to follow in order to produce its intended results. According to David (2011), strategies are the means by which long term objectives would be achieved. The author also reported that strategy is concerned with developing both a vision and mission to achieve one’s objective. Furthermore, David showed that strategy is subject to modification since the factors affecting every phenomenon were changing. Agbaje (2014) defined strategy as a carefully devised plan of action to eradicate or prevent the perpetration of violent behaviour. Likewise, in the present study, strategy was used to mean a framework of action articulated to control violent behaviours. However, the violent behaviours in this context were self-directed - suicidal behaviours. It is obvious that suicide intervention strategies required a careful planning of human and financial resources in order to promote protective behaviours and disrupt negative ones that lead to suicidal acts.

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The worst public health danger of suicidal behaviours is the horrific premature death of the victims, which in the present study were the in-school adolescents. Indeed the avoidable deaths of the future leaders of the society are regrettable. The morbidities (i.e., mental, physical & emotional injuries) associated with suicidal behaviours are also significant health problems. This is because victims of self-inflicted injuries were treated in health facilities or within the family circles at great costs. According to Gvion and Apter (2013), the costs of suicidal behaviours were not limited to mortalities and morbidities but also included their drain on public resources.

The costs of suicidal behaviours in financial terms are monumental. The Center for Mental Health Services-CMHS USA (2001) put the dollar cost of suicide in 1995 alone in the United States of America at $111.3 billion. The figure covered medical expenses, work related losses and quality of life costs. Since only a portion of the 10-20 million global cases of suicide attempts per annum were reported in USA, it means that what the world loses as a result of suicidal acts must be really outrageous. This is very serious because many countries at the present are experiencing serious economic crisis (World Bank Group, 2015). Nigeria’s economy is also hard hit by the international economic downturn which is characterized by higher borrowing costs and low prices of oil.

Nigeria’s poor economy was manifest in the deficits in her health care services which were expected to handle the cases of all those affected by suicide. The nation’s health services fell short of international standard in terms of availability and accessibility (Egbulem, 2010). The directive by Enugu state government to secondary schools within its domain to set up school health services was aimed at addressing the problems (Nnabueze, 2000). However, the school health services appeared not to be satisfying the health care needs of the in-school adolescents affected by suicide. This is so because in suicidal behaviours the victims’ problems amounted to double jeopardy. The reasons were that suicidal acts were tabooed and criminalized in Nigeria as a whole (Okafor & Okafor, 1998).

As a result, the victims were socially stigmatized. Under such circumstances they were forced to seek treatment outside the modern health clinics or even nowhere at all for fear of being discriminated against. According to Fairbairn (2007), the discrimination against suicide victims had disastrous social consequences. For instance, the victim of suicide attempt might be permanently incapacitated that he becomes a burden on the society. Moreover, the multitude of the in-school adolescent orphaned through suicide is

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added burden to the society. These orphaned adolescents and the parents of suicide victims who were made childless by suicide were likely to be exposed to social stressors. For the parents, this must be very agonizing in the location of the study because children are important measure of social class.

Another compelling consequence of suicide on survivors in Enugu state was the cultural demand of ritual cleansing of the supposedly desecrated land. Worse still, the traditional positive grief processes characterized by co-operative mourning for which the Igbos in general were known, were totally denied the survivors. In USA shared grief was also denied the survivors of suicide. For instance, Andrews (2000) reported how parents of a suicide victim who attended ‘Compassionate Friends’ meeting in the country boycotted the gathering because of the negative comments made about the suicide of their child. According to McGovern and Barry (2000), shared grief provided a buffer to emotional health of the bereaved individual. Indeed, people impacted by suicide were subjected to all sorts of ridicule to the extent that some might have engaged in suicide themselves to escape the shame, guilt or humiliation associated with the acts. Therefore, intervention measures were highly necessary to reduce the shock.

The present study was actually a response to a recommendation made by Ene (2000) for a design of suicide intervention for Nigerians generally. The adolescents were most suitable for such intervention since, according to Zenere and Lazarus (1997), intervention against social ills should start with the adolescents.

Adolescents are in a period of transition from childhood experiences to adulthood. In the present study adolescents refer to boys and girls who belong to the lifespan of 12 to 19 years of age. Adolescents are also described as teenagers. Thus these terms were used interchangeably in this study. Adolescence is marked by unique physical, psychological and social challenges that might predispose them to suicidal behaviours. For instance, the period is frequently filled with changes in body, feelings and thought. Berk (2004) posited that it is the internal stresses and the social expectations accompanying these changes that prompted moments of self-doubt and disappointment in almost all adolescents. Onohwosafe (2011) agreed that adolescence is characterized by stress, tension and worry. Many adolescents are also full of fear, uncertainty or hopelessness, and under the pressure to succeed. At the same time the young individuals were confronted with other challenges in life like family divorce or changes in friendships. Many of them at this stage move to school very far away from home.

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The in-school adolescents, therefore, constituted the subjects for the study. In-school adolescents refer to teenagers pursuing academic programme in school. They are found in primary, secondary and tertiary institutions. However, the majority of in-school adolescents in Nigeria were in secondary schools (Dangbin & Samuel, 2011). Consequently, this category of school was the locus of the present study. Olaniyan (2011) indicated that Nigeria’s educational system provided for three years of junior secondary school (JSS) for those aged 12-14 and another three years of senior secondary school (SSS) for adolescents of 15-17 years old. Consequently, in-school adolescents aged 12-17 in secondary schools were the focus of this study. They had passed through primary schools where they were likely to have acquired varieties of behaviours and attitudes that impacted on suicide. Probably, some actually had engaged in suicidal acts while others were facing the challenge of having lost a loved one through suicide. Moreover, their secondary school experiences were likely to be worsened by their teachers’ inability to provide them with the continuing desired nurturing relationship they had at home (Fawole, 2000). This shortcoming might have been occasioned by the impersonal nature of large secondary schools. Perhaps, it was caused by the staggering student teacher ratio of 40: 1 in Nigerian schools (Ani, 2007).Worse still, Olasebikan, Gabakau and Dachia (2000) revealed that essential health education that leads to behaviour modification was not receiving desired attention throughout the nation.

Suicide educationcould not have been placed on top of the country’s educational agenda. This is because Olasebikan, Gabakau and Dachia (2000) observed that many of the teachers were ill-prepared for teaching health education in the course of their training.As a matter of fact, Fawole (2000) revealed that in the sensitive areas, suicide inclusive, teachers were usually not at ease to deal with the emotions, feelings, attitudes and values of students. Consequently, the only lee way left for any in-school adolescent in such secondary schools, when faced with distressing situation might be killing oneself.

Since less attention is currently paid to the problems confronting the adolescents globally, these neglects often throw up a gamut of emotional and psychological reactions, suicidal behaviours inclusive. According to Cleary (2005), negative psychological stressors were the major cause of the increasing rate of suicide among adolescents. However, Schaefer (2007) indicated that sociologists attributed suicide to group life. It waslikely that in-school adolescents in Enugu state, who were exposed to these emotional and social stressors, indulged in suicidal acts too. Consequently, the psychological, sociological and interpersonal psychological theories of suicide were the

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anchor of this subject matter of ‘Suicidal Behaviours and Intervention Strategies for In-school Adolescents in Enugu State, Nigeria’. On the other hand, Theory of Planned Behaviour (TPB) was the model that guided the intervention strategies that were formulated.

Psychological theory of suicide dwelt on individual’s characteristics. Sigmund Freud (1856-1939)is considered as the father of the psychological theory on suicide. Freud (1957) in his work, originally published in 1917, entitled ‘ Mourning and melancholia’ propounded the theory which indicated that suicide is an internalized aggression. An important tenet of the psychological theory is that suicide results from failure to adjust to life’s stresses and strains. The psychological explanations of suicide marked the beginning of treatment of suicidal individuals instead of condemning them based on moral grounds. Thus the theory was suitable in the current study that designed intervention strategies against suicidal behaviour for in-school adolescents.

Social forces in human life have also been incriminated in the aetiology of suicide. The sociological theory on suicide was postulated in 1897 by Emile Durkheim (1858-1917), a French sociologist. His work ‘ Suicide: a study in sociology’ attributed suicide to social conditions rather than personal factors. He hypothesized that suicide rates vary inversely with the degree of social integration of the groups of which the individual formed part of. Since in-school adolescents in Enugu state exist in school communities, the sociological theory offered some explanations to some of the issues of this subject matter.

Joiner(2005) propounded the interpersonal psychological theory on suicide in an attempt to harmonize the psychological and sociological theories on suicide. According to Joiner, an individual has a desire to die when he is estranged from other people whom he feels that he has become a burden on. Nonetheless, the wish to die is not automatically translated into actual suicidal act until the person has been exposed to harsh conditions of life that neutralize the fear of death. In other words, the transition from suicide idea to attempted suicide or completed suicide could be accelerated. It could also be checked through intervention strategies like the ones designed in the present study for in-school adolescents in Enugu state.

Enugu state belongs to the Igbo society of the south eastern part of Nigeria. Record from Post Primary Schools Management Board, Enugu-PPSMB (2015) showed that the state is divided into six Education Zones with 291 secondary schools owned by Enugu state. Some of the secondary schools were exclusively for boys or girls whereas

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the majority of them were co-educational. Only insignificant number of the schools had boarding facilities. As a result, most of the in-school adolescents were attending school from either their parental homes or rented apartments in the communities where the schools were located. Privately owned secondary schools and federal government owned ones existed alongside the state owned secondary schools.

The choice of Enugu state was necessitated by findings that significant levels of suicide thought and suicide attempt existed among senior secondary school students in Enugu urban (Ene, 2000). However, the results of the study were not generalizable to the entire in-school adolescent in secondary schools owned by Enugu State Government. Thus the present study was very necessary. Moreover, it had been shown that factors known to precipitate suicidal behaviours were universal (New, 2012). As such, these variables were likely to have existed in various locations of the area of the study too. Similarly, boys and girls of different ages among the in-school adolescents in the area of the study were less likely to be insulated from the predictors of suicidal behaviours.

The rural and urban locations of the in-school adolescents together with their gender and age, therefore, were included in the study. Location was included because behaviour variance is a function of the place of residence amongst other factors. Besides, the allocation of health and other scarce resources which Briggs (2000) showed to influence behaviour is often in favour of the urban areas in the developing countries. For example, National Population Commission-NPC (2000) pointed out that the percentage of households possessing durable goods and had access to mass media in Nigeria was higher among urban than rural households. Schaefer (2007) disclosed that, even in USA, it was not uncommon for rural children to travel 90 minutes each way to school. In rural parts of Nigeria the situation was not better. As per access to secondary education, National Bureau of Statistics-NBS (2009) indicated even a wider gap between the rural and urban areas. In terms of gender, more males than females had access to these resources nationally.