Suicidal Behaviors Among Adolescents in ; Is Bullying a Key Player?

MGH301: Epidemiology and biostatistics with special reference to social epidemiology Introduction

Suicide is a public health problem worldwide, and one of the leading causes of death among adolescents (Zaborkis, Ilionsky & Heinz, 2018, WHO 2018a). Lithuania has the highest mortality rate in the world, 31.9 per 100 000 population compared to a region average of 15.4, and high rate of suicide among adolescents (WHO 2018b). Another public health concern in Lithuania is the high levels of bullying among adolescents (Strukcinskiene, Andersson, & Janson, 2011). Bullying can be both physically and mentally and lead to both physical and mental health issues (Hertz, Donato, & Wright, 2013; Rivers 2013). Bullying can occur both in a specific environment and on the internet and social media anonymously (Zaborkis, Ilionsky, Tesler & Heinz, 2018; Mark et al., 2013). Research has shown a significant association between bullying and suicidality (Hertz, Donato, & Wright, 2013; Rivers 2013) Previous research on suicide in Lithuania (and Eastern Europe) has focused the role of the Soviet Union and the structural changes in post-Soviet countries (Minagawa, 2012), and on socioeconomic factors related to the recession in 2008 (Stankunas, Lindert, Avery, & Sorensen, 2013), as well as the role of the family (Zaborkis et al., 2018; Mark et al, 2013). To date no research has focused solely on the association between bullying and suicidality in Lithuania. This study will contribute to filling this gap and add to the body of research on suicide in Lithuania. For the purpose of this study the main outcome is suicide ideation as it is a significant precursor of suicide (Mark et al, 2013).

Aim The aim of this study is to investigate the association between ideation among adolescents in Lithuania.

Research Questions 1. Is there an association between bullying and suicide ideation in Lithuania? 2. What is the prevalence of suicide ideation and bullying and are there variations in rural and urban schools?

Theory The suicide trend has been steadily high in Lithuania, meaning that the societal rate of suicide in Lithuania is predictable. Therefore, it can be argued that there must be factors within the Lithuanian society that contribute to the high suicide rates. The study by Zaborskis, Sirvyte, & Zemaitiene (2016) which focused on family relations found that adolescents with weak family functioning had higher odds of suicide ideation compared to adolescents with an intact family structure. This would point to the fact that the social context affects the individual’s risk of suicide ideation. Using Durkheim’s theory on suicide and social integration with bullying as a factor of isolation and alienation, the social context of the individual is incorporated into our research. According to Muller and Abrutyn (2016) Durkheim’s theory on suicide is based on the idea that an individual’s well-being is shaped by the structure of the social relations surrounding that individual. Further, that an individual who does not feel a sense of belonging is more vulnerable to suicide, compared to individuals who feel integrated into a social group. Social integration takes two forms, attachment- an individual’s sense of belongingness and/or regulation- in which individuals are affected by the values, beliefs and norms of the society they live in (Berkman, Kawachi, Glymour, 2014). Bullying can affect an individual’s bond to society through (dis)attachment and is a way of isolating an individual from the surrounding and thus separating them from the group.

Method

Study Design/data collection A mixed study method of a sequential explanatory design strategy will be carried out and divided in 3 phases. Phase 1 is a pilot stage in which we will have a Focus-group-discussion (FGD) with key informants like psychiatrists, social workers and school nurses selected by an advertisement. The purpose of the FGD is to develop the questionnaire. Further, we will conduct a pilot questionnaire with 20 adolescents to validate our instrument. The discussion questions will be semi-structured with open-ended questions. Some possible questions in the FGD could be what are the triggering factors of suicide ideation in adolescents? How does school bullying affect the health of adolescents? etc. In phase 2, quantitative data will be collected through a cross-sectional study on suicide ideation in high school students. This will enable us to get a snapshot of the prevalence of as well as to investigate if there is an association between suicide ideation and school bullying. 20 Public high schools;10 each from rural and urban in Lithuania will be selected in order to get a variety of representations from students residing in both rural and urban settings. The questionnaire for this study will be translated into Lithuanian and divided into 5 parts which measure suicidality, school bullying, demographic characteristics, family characteristics and social networks. This questionnaire should take about 30 minutes to complete (Appendix 1 ). Consent forms will be given to qualified students (any student in one of the selected schools who is between 15-19 years old, mentally fit to answer survey questions and resides within the locality of his/her school is qualified to participate), who will then send it home to be signed by a parent or guardian. The questionnaires will be distributed to students by teachers in the classroom who will return them to the research team after being filled and sealed by the participants anonymously inside the classroom. All teachers will be enlightened by the research team about the selection criteria and instructions. Also, students can choose to participate and the whole survey is confidential. In phase 3, 2 FGDs will be carried out with professionals of the same profession as from phase one. This qualitative research will allow us to investigate how bullying plays a role in the social integration and how bullying can affect the interactions within schools, friend groups and social networks which has been shown to be of importance for adolescent’s health and well-being (Bearman & Moody, 2004). This FGDs will include 10 participants each but ends when saturation is reached. The qualitative results will further interpret and explain the findings from phase 2. The whole study period from data collection, analysis of the results and report writing will span from January to August 2018 (Appendix 2).

Variables: Suicidal ideation is the outcome variable, and school bullying is the main predictor variable. Our covariates will be demographic characteristics, family characteristics, and social network (Appendix 2).

Sample size calculation and Data Analysis The population of adolescents (15-19 years old) in Lithuania is 144.287 (United Nation Statistic Division, 2018). The power of this study is 80% with a significance level 5% and margin of error 2.5%, so our sample size with this calculation is about 1513 of adolescents. SPSS will be used to analyze the data. The appropriate statistical test is multiple logistic regression and prevalence ratio will be calculated to find a significant association between the suicide ideation and bullying and also adjust for other covariates.

Ethical Considerations Sensitive topics like suicide require a great deal of ethical considerations and caution. In our case the study begins with contacting the institutional bioethics committee in Lithuania and asking for their approval for the study (Strukcinskiene et al., 2011). With that being said, we are planning to proceed and follow the set of guidelines that the ethics committee has required us to do. These guidelines include confidentiality, informed consent, the responsibility to do a risk assessment which means whether to intervene in cases of imminent risk or not, and so forth. Also, if study participants feel the need of counselling, they will find a phone number on the questionnaire to contact professionals.

Strengths, Limitations and Biases One of the good assets in our study is the ability to use mixed methods in order for us to investigate the topic in a more explicit way. Also, by validating our instrument and measurements, we are conducting a pilot study in phase 1 of the research. Besides that, we are having a data collection process that obtains data from both students and school professionals which is in fact a good improvement to earlier studies done in the past (Rivers & Noret, 2013). Nevertheless, there happens to be several limitations in terms of biases. We expect biases in form of recall biases due to data collection method and social desirability bias, due to the nature of the topic. These are expected to arise as they appear in any cross-sectional study (Zaborskis, 2016). Another important limitation is suicidal ideation stemming from factors other than bullying, because we are unable to observe every confounding factor that may affect the results due to limited resources that we have access in to. Further research on adolescents and suicide in Lithuania needs to extend to the macro level of Lithuanian societies and incorporate Durkheim’s regulation aspect to see how societies are regulated, politically, socially, economically, culturally and religiously and how that affects both bullying and suicide. Appendix 1

Variables Definitions Questionnaire Range values

Suicidal Thought of committing Consider to attempt 0 = No Ideation suicide suicide within a year 1 = Yes

Bullying one or more students tease, Have you been bullied 0 = No; 1 = Yes threaten, spread rumors in the past months? 0 = ‘never; 1 = about, hit, shove, or hurt ‘once or twice’ ; another student over and How often have you 2 = ‘two or three over again (Sampasa- been bullied? in a month’ Kanyinga et. al. 2014) 3 = ‘once a week’ 4 = ‘more than once in a week) Family 1.Family Affluence, using . Does your family own . 0 = no; 1 = Characteristics Family Affluence Scale with a car or another vehicle? yes, one; 2 = 6 questions to illustrate the yes, two socioeconomic status of . Do you have your own family bedroom? . 0 = no, 1= yes

. How many computers does your family own? . 0 = none, 1 = (including tablets, laptop one, 2 = two, 3 = except smartphones and more than two. game consoles)

. How many times did you and family out of . 0 = never, 1 = Lithuania for holiday once, 2 = twice, last year? 3 = more than twice. . How many bathrooms (room with a bath/shower or both) are . 0= none, 1 = at your home? one, 2 = two, 3 =

more than two. . Does your family have

a dishwasher?

. 0 = No, 1= Yes 2.Family Structure . Respondents are given . Living in a checklist of adults intact family = (father, stepfather, both father and mother, stepmother, mother are etc.) checke

. Living in non- intact family = living only with one of father or mother

3.Parent-Child . how easy it is to talk . 0 = don’t have Communication with their father, this person, 1 = stepfather, mother, or very easy, 2 = stepmother about things easy, 3 = that bother them difficult, 4 = very difficult

Social Friendship . Do you have close 0=no Network friends in school or 1=yes outside? . Are you part of a friendship group?

Appendix 2

Month Task

January- February 1. Ethical clearance, recruitment and training of research team, Pilot phase (FGDs and questionnaire validity) March-April 1. Recruitment of participants for the cross-sectional study (phase 2) 2. Enlighten teachers about the selection criteria and survey instructions 3. Survey data collection

May 1. Phase 2 Data Analysis

June-August 1. Phase 3 2. Write report and discuss the overall results obtained Reference list

Bearman, P. S., & Moody, J. (2004). Suicide and friendships among american adolescents. American Journal of Public Health, 94(1), 89-95. Retrieved from https://search-proquest- com.ezproxy.ub.gu.se/docview/215092649?accountid=11162

Berkman, L., Kawachi, I. & Glymour, M. (2014). Social epidemiology. Oxford: Oxford University Press.

Hertz, M. F., Donato, I., & Wright, J. (2013). Bullying and Suicide: A Public Health Approach. Journal of Adolescent Health, 53(1), S1-S3. Retrieved from: https://doi.org/10.1016/j.jadohealth.2013.05.002

Mark, L., Samm, A., Tooding, L., Sisask, M., Aasvee, K., Zaborskis, A., Värnik, A. (2013). Suicidal ideation, risk factors, and communication with parents: An HBSC study on school children in estonia, lithuania, and luxembourg. Crisis: The Journal of Crisis Intervention and , 34(1),3-12. doi: http://dx.doi.org.ezproxy.ub.gu.se/10.1027/0227-5910/a000153

Minagawa, Y. (2012). The Social Consequences of Postcommunist Structural Change: An Analysis of Suicide Trends in Eastern Europe. Social Forces, 91(3), 1035-1056. doi: https://doi-org.ezproxy.ub.gu.se/10.1093/sf/sos172

Muller, A. S. & Abrutyn, S. (2016) Adolescents under Pressure: A New Durkheimian Framework for Understanding Adolescent Suicide in a Cohesive Community American Sociological Review Vol 81, Issue 5, pp. 877 – 899. doi: https://doi- org.ezproxy.ub.gu.se/10.1177/0003122416663464

Rivers, I., Noret, N. (2013). Potential Suicide Ideation and Its Association With Observing Bullying at School, Journal of Adolescent Health, 53(1), S32-S36. doi: https://doi.org/10.1016/j.jadohealth.2012.10.279.

Sampasa-Kanyinga, H., Roumeliotis, P., & Xu, H. (2014). Associations between Cyberbullying and School Bullying Victimization and Suicidal Ideation, Plans and Attempts among Canadian Schoolchildren. PLoS ONE, 9(7). doi: https://doi.org/10.1371/journal.pone.0102145

Stankunas, M., Linder, J., Avery, M., Sorensen, R. (2013). Suicide, recession, and unemployment. The Lancet, 381(9868), 721. dio:https://doi.org/10.1016/S0140- 6736(13)60572-3

Strukcinskiene, B., Andersson, R., & Janson, S. (2011). Suicide mortality trends in young people aged 15 to 19 years in Lithuania. Acta Paediatrica, 100(11), 1476-1480. doi:https://doi-org.ezproxy.ub.gu.se/10.1111/j.1651-2227.2011.02347.x

United Nation Statistics Division. (2018). UNdata a world of information: Population aged 15-19, both sexes combined in Lithuania. Retrieved from: http://data.un.org/Data.aspx?d=PopDiv&f=variableID%3A1056#PopDiv

WHO. (2018a, August 24). Suicide. Retrieved from http://www.who.int/news-room/fact- sheets/detail/suicide

WHO. (2018b, April 5). Suicide mortality rate. Retrieved from http://apps.who.int/gho/data/node.sdg.3-4-viz-2?lang=en

Zaborskis, A., Ilionsky, G., Tesler, R., & Heinz, A. (2018). The Association Between Cyberbullying, School Bullying, and Suicidality Among Adolescents: Findings from the cross-national study HBSC in israel, lithuania, and luxembourg. Crisis:The Journal of Crisis Intervention and Suicide Prevention, 1-15. doi: http://dx.doi.org.ezproxy.ub.gu.se/10.1027/0227-5910/a000536

Zaborskis, A., Sirvyte, D., & Zemaitiene, N. (2016). Prevalence and familial predictors of suicidal behaviour among adolescents in Lithuania: A cross-sectional survey 2014. BMC Public Health, 16(1). http://doi.org/10.1186/s12889-016-3211-x