Attitudes Toward Suicide Among Chinese People in Hong Kong

Suicide and Life-Threatening Behavior 37(5) October 2007
© 2007 The American Association of Suicidology
Attitudes Toward Suicide Among Chinese
People in Hong Kong
Sing Lee, MB BS, FRCPsych, Adley Tsang, BSSc, Xian-yun Li, BMed, MPH,
Michael Robert Phillips, MD, MA, MPH, and Arthur Kleinman, MD, MA
Since suicide in Chinese people exhibits certain distinctive characteristics,
it is important to develop indigenous measures to assess Chinese attitudes toward
suicide that may be used to inform suicide reduction programs. Combining qualitative
and quantitative methods, we developed a Hong Kong version of the Chinese
Attitude toward Suicide Questionnaire (CASQ-HK) which assesses attitudes
toward suicide, suicidal inclination under 12 hypothetical scenarios, and prior suicidal
experience. A convenience sample of 1,226 people completed the self-report
questionnaire. In keeping with Chinese tradition, respondents revealed both tolerant
and condemning attitudes that varied with their sociodemographic characteristics.
Generally, they were not strongly inclined to consider suicide in the presence
of difficult scenarios. Female gender, older age, and the presence of suicidal ideation
were associated with more contemplation of suicide.
Research on suicide in Chinese society has data was not available until about a decade
attracted increased interest for several rea- ago (Lee & Kleinman, 2005). Second, consons.
First, suicide in China was previously a trary to the contemporary medical depiction
forbidden topic of research so that reliable of suicide as being due to treatable mental
diseases, suicide has long been endorsed in
Chinese society. In a scholarly analysis of sui-
Sing Lee is Professor, Department of Psy- cide in pre-modern China, Lin (1990) even
chiatry; Adley Tsang is with the Hong Kong
Mood Disorders Center at The Chinese University
of Hong Kong in Shatin, Hong Kong; Xian-
yun Li is with the Beijing Suicide Research and
Prevention Center, and Michael Robert Phil-
described suicide to be “a hallmark of Chinese
culture.” For example, suicide was connected
with the changing of dynasties, wars,
corrupt emperors, women’s defense of chaslips
is Executive Director, Beijing Suicide Re- tity, and the seeking of ghostly vengeance
search and Prevention Center at the Beijing Hui
Long Guan Hospital; and Arthur Kleinman is
the Esther and Sidney Rabb Professor of Anthropology,
Department of Anthropology, at Harvard
University.
upon the living (Hsieh & Spence, 1981; Wolf,
1975). Third, despite the high value Chinese
people place on social cohesion and the de-
monstrably low rates of depression and alco-
This research was supported by grant holism in Chinese communities (Shen et al.,
#CUHK4380/00H from the Research Grant
Council of Hong Kong and the Hong Kong
Mood Disorders Center of The Chinese University
of Hong Kong.
We also thank Lydia Chan and Alice Chiu
2006), the rate of suicide in China is definitely
high by global standard (Phillips, Li, &
Zhang, 2002). Likewise, although there has
been a noticeable recovery from economic
for their help with this study. recession, the suicide rate in Hong Kong has
Address correspondence to Professor Sing
Lee, Director, Hong Kong Mood Disorders Center,
7A, Block E, Staff Quarters, Prince of Wales
Hospital, Shatin, NT, Hong Kong; E-mail: singlee
@cuhk.edu.hk
steadily increased from 10.6/100,000 during
1981–1994 to 18.6/100,000 in 2003 ( Judi-
ciary of the Hong Kong Special Administration
Region of the People’s Republic of
491
565

566 Attitudes Toward Suicide in Hong Kong
China [HKSAR], 2004; Census and Statistics Chinese subjects (Phillips, 2004). This ver-
Department of HKSAR, 2004).
sion of the CASQ was then adapted for the
Published research on suicide and at- present study after another round of nine fotempted
suicide in Hong Kong has focused cus groups conducted among Chinese sub-
on the analysis of trends, methods of suicide, jects in Hong Kong.
risk factors, and its association with mental With written informed consent, nine
disorders (Centre for Suicide Research and focus groups with a total of 82 participants
Prevention, 2005). The findings of these stud- (41 males and 41 females) were conducted in
ies are usually derived from a quantitative Hong Kong in a quiet group room of a
analysis of clinical or population data and university department from April 13 to June
provide an informative epidemiological pro- 7, 2002. Six of the groups consisted of people
file of suicide. Nonetheless, they have limited of different age categories (namely, 15–19,
explanatory power with regard to the cultural 20–26, 27–38, 39–50, 51–65 and 66 years or
meanings of suicide among Chinese people above, respectively). The other three groups
(Hsieh & Spence, 1981; Lee & Kleinman, were composed of suicide attempters, health-
2005; Wolf, 1975).
care professionals, and policy-related per-
Cultural meanings are linked to social sonnel.
attitudes. Since individuals draw upon cul- During the focus groups, we used
tural representations of suicide when they open-ended questions to probe participants’
contemplate, attempt, or commit suicide, perception of such issues as what suicide was,
studying public attitudes toward suicide may why it happened, how common it was, what
help us elucidate the causes and patterns of kind of people it affected, how it influenced
suicide in a community (Lee & Kleinman, others, and what could be done to prevent it.
2005). Attitudinal research may also shed We then presented 13 scenarios of fatal and
light on theories of suicide in general. To nonfatal suicides to the participants. The sce-
date, no systematic study of Chinese attitudes narios were about problems arising from love
toward suicide has been carried out in Hong relationships, chronic psychiatric illness, in-
Kong or mainland China. Thus, the authors law oppression, domestic violence, haunting
(from Hong Kong, Beijing, and Boston, MA, by ghosts, nonfilial children, repeated failures
respectively) carried out a collaborative proj- in a college entry examination, parental disect
that combined qualitative and quantita- approval of marriage, business failure, alcotive
methods to assess attitudes toward suihol/gambling, unexplained depression, tercide
in several communities in China minal cancer, and impulsive wrist-slashing
including Hong Kong. The present paper re- related to loss of face. Each focus group
ports the findings from Hong Kong. lasted 2 hours. The sessions were taperecorded,
transcribed, and analyzed using the QSR
Nvivo text analysis software. From the main
themes the investigators derived by listening
METHOD to the tapes, the text analysis created nine
Instrument
primary nodes for content organization.
These included a general impression about
suicide in society, personal attitudes toward
The Chinese Attitude Toward Suicide suicide, methods used, reasons for suicide,
Questionnaire (CASQ) was generated on the perception of impulsivity, acceptance of sui-
basis of text analysis (using QSR Nvivo softcide, and the consequence and prevention of
ware) of 101 focus groups and 18 in-depth suicide. Subbranches of the content were ininterviews
conducted by the mainland aucluded in each node and the number of octhors
(LX, MP). It was revised after two sub- currences was counted for each subbranch.
sequent pilot tests of the preliminary scales Additional questions were derived from each
in approximately 2,000 randomly selected subbranch that occurred frequently.
492

Lee et al. 567
The revised version of the Chinese At- nese University of Hong Kong to their
titude Toward Suicide Questionnaire–Hong friends and relatives. Informed consent was
Kong (CASQ–HK, available upon request) obtained from the participants and confiden-
consists of 98 items. It was pilot-tested with tiality and anonymity were assured. A total of
96 individuals of varied sociodemographic 746 and 480 questionnaires were collected,
background in August 2004. Further revi- respectively. The overall response rate was
sions were then made so that the items would 81.7%. Statistical analysis was carried out
convey their intended meanings effectively.
The final version of the CASQ-HK consists
of three parts. Part A is composed of 73
with SPSS 13.0 for Windows.
statements about attitudes toward suicide on
a 5-point Likert scale (1-greatly agree, 2-
RESULTS
agree, 3-neutral, 4-disagree, 5-greatly disagree).
Part B includes 12 statements about
Sociodemographic Characteristics
12 difficult scenarios. Respondents were The demographic distribution of re-
asked on a 5-point Likert scale (5–definitely spondents is shown in Table 1. The mean age
consider, 4–very likely to consider, 3–probably of males was 36.3 years (SD = 15.2) and for
consider, 2–probably not consider, and 1–definitely females, 31.8 years (SD = 13.9). There were
not consider) their likelihood of considering more males than females and most respon-
suicide in those scenarios. Part C was composed
of 13 items about sociodemographics
dents reported no religious affiliation.
and the presence of serious suicidal ideation,
previous suicidal attempt, and having known
Reliability and Factor Analysis
someone who attempted or committed sui- The Cronbach’s alpha of the CASQcide
previously. Approval for the study was HK is 0.852. Part A of the CASQ-HK was
obtained from the research ethics committee factor analyzed using the principal axis facof
The Chinese University of Hong Kong. toring method with varimax rotation. A nine-
Owing to the sensitivity of the topic, several factor model, which together explained 36.1%
hotlines for help-seeking were provided at of the total variance, emerged as the most in-
the end of the questionnaire. terpretable and could be considered an ade-
Although we renamed the CASQ-HK quate representation of the data provided by
as an instrument that examined attitudes to- the sample of respondents. In Table 2 the
ward life and death, our attempts to approach items with loadings of more than 0.35 on any
several organizations for data collection, such of the factors are displayed. The nine factors
as schools, corporations, and old age homes, pertained to negative appraisal, stigma, sui-
were uniformly refused. According to the ad- cidal spectrum, fatalism, social change, sup-
ministrators of those institutions, they were port, contagiousness, sympathy, and function.
concerned that their study could evoke sui- Sixteen items (available from the authors
cidal ideas among their students, staff, or inmates
that they did not know how to handle.
Survey Participants
upon request) did not load on any factors.
Variation of Attitudes Toward Suicide
Items on each of the nine factors were
We eventually recruited a convenience scored from 1 to 5, with a higher score indisample
that was composed of Chinese people cating stronger disagreement. Items with op-
born and living in Hong Kong. One thouposite meanings were reversely scored. These
sand questionnaires were distributed to staff scores were tested using two-tailed t tests and
members of a medium-sized trading com- ANOVA at the significance level of 0.05 to
pany. Another 500 questionnaires were dis- compare differences across demographic sub-
tributed by nine student helpers of The Chi- groups (Table 3). Although males showed a
493

568 Attitudes Toward Suicide in Hong Kong
TABLE 1 Endorsement of Suicide Under Difficult
Sociodemographic Profile of Respondents
Life Scenarios
Sociodemographic characteristics n % The likelihood of respondents considering
suicide under hypothetical difficult life
Gender
Male
Female
Age (years)
15–25
26–50
51–75
Marital Status
Single
667
530
503
410
229
636
55.7
44.3
44
35.9
20.1
52.7
scenarios is shown in Table 4. There were six
scenarios with mean scores higher than 2
(probably not consider suicide). In descending
order of the mean score, they were, namely,
“being terminally ill,” “having a chronic psychiatric
illness,” “being severely depressed,”
“being a burden to others and feeling hopeless
about the future,” “being heavily in-
Married 570 47.3 debted because of gambling,” and “not hav-
Education ing anyone to provide financial or emotional
Primary or below 166 14.0 support in old age.” The six mean scores of
Middle School 233 19.7 the same six scenarios were also significantly
High School
Tertiary or Above
Religion
Christianity
Buddhism or Taoism
Others
None
Employment
254
529
192
217
12
805
21.5
44.8
15.7
17.7
1.0
65.7
lower than 3 (probably consider suicide). This
suggests that respondents’ general inclination
toward suicide in the hypothetical scenarios
is not strong. Multivariate logistic regression
on how sociodemographic variables relate to
consideration of suicide in hypothetical scenarios
shows that females (OR = 1.4) were
Working 736 62.1 significantly more likely than males to con-
Nonworking 40 3.3 sider suicide. Older respondents (51–75 years)
Students 410 34.6 were more likely to consider suicide (OR =
Occupation
Professional
Administrative
Skilled
Nonskilled
Personal monthly income
Less than US$641
US$641–US$1,282
US$1,283 or above
134
190
112
600
576
396
250
12.9
18.3
10.8
57.9
47.1
32.4
20.5
2.3) than the youngest age group (below 25
years). Respondents who had suicidal ideation
(OR=2.3) were also more likely to consider
suicide.
The likelihood of considering suicide
in hypothetical scenarios was compared to
respondents’ report of suicide ideation and
attempt. Among the respondents who reported
that they would be “very likely to consider”
or would “definitely consider” suicide
less negative appraisal of suicide than fe-
males, they showed less sympathy toward suicidal
people and less agreement that suicide
had instrumental functions such as revenge.
They were also less likely to differentiate sui-
cide attempt from completed suicide. Nega-
tive appraisal and fatalistic view of suicide decreased
with age. Respondents who were
in at least one hypothetical scenario, a substantial
proportion had thought of suicide
(20.8%) or had attempted suicide before
(3.3%). Those who did not consider suicide
seriously in the hypothetical scenarios were
less likely to report suicidal thought (4.7%)
or suicide attempt (1.3%).
married, less educated, working, or believers
in Buddhism or Taoism were less negative
DISCUSSION
and fatalistic about suicide. More educated
respondents and more skilled workers were
Diversity of Attitudes Toward Suicide
more likely to disagree that suicide is related The biased sampling notwithstanding,
to social change.
the present study revealed a diversity of atti-
494

Lee et al. 569
TABLE 2
Factor Analysis of Attitudes Toward Suicide
Overall (36.1% of variance, alpha = 0.852) Loadings
Factor 1 (Negative Appraisal: Negative appraisal of suicide)
6.2% of variance, alpha = 0.394
47. Suicide is a stupid act. 0.675
10. Suicide is a totally irresponsible act. 0.628
65. Suicide is an extremely timid act. 0.624
36. Suicide can be a respectable act.* 0.587
41. The suicide has a very selfish personality. 0.552
7. Suicide can sometimes be a responsible act.* 0.535
24. Suicide is a rational act.* 0.511
52. Suicide deserves sympathy from others.* 0.456
15. Suicide can sometimes be a courageous act.* 0.44
27. Suicide reflects a person’s low self-esteem. 0.418
12. Suicide is frustrating to others. 0.365
18. Suicide is a betrayal to friends and families.
17. Under most circumstances, we should not stop terminally ill people from committing
0.406
suicide.* 0.363
Factor 2 (Stigma: Stigmatization of suicide) 5.8% of variance, alpha=0.735
58. Most people are afraid to develop relationships with those who have suicidal acts. 0.689
5. Most people would avoid a person who attempted suicide. 0.637
38. Most people would avoid the family of the suicide. 0.589
46. People who had suicidal acts are disliked by others. 0.583
49. Family members of the suicide live with shame for the rest of their lives. 0.564
62. Suicide is carried out by primitive people. 0.432
35. The major intention of the suicide is to influence others. 0.388
50. Once someone has decided to commit suicide, it is difficult to change his/her mind. 0.385
21. People who attempt or commit suicide are impulsive. 0.37
44. Everyone dislikes the act of suicide. 0.366
Factor 3 (Suicidal Spectrum) 4.5% of variance, alpha = 0.693
32. Attempted and completed suicides share the same causes. 0.634
53. Attempted and completed suicides have similar intentions. 0.645
11. Attempted and completed suicides have similar personalities. 0.624
61. Attempted and completed suicides have similar intention to die. 0.539
16. Attempted and completed suicides suffer from similar levels of psychological stress. 0.522
13. The suicide adapts to daily life poorly. 0.417
68. Attempted and completed suicides can both achieve their goals via suicide. 0.352
Factor 4 (Fatalism: Fatalism towards suicide) 4.2% of variance, alpha = 0.566
33. Suicide cannot be prevented. 0.666
9. The causes of suicide are beyond the control of people who commit suicide. 0.454
6. Suicide happens without previous warning. 0.613
39. Mental health promotion cannot reduce suicide.
Factor 5 (Social change: Acknowledging the relationship between social change
0.443
and suicide) 3.8% of variance, alpha = 0.623
59. Long-term negative events represent the major cause of suicide. 0.538
34. A person commits suicide because he/she cannot solve his/her own problems. 0.502
37. There has been a steep rise in suicide following the Asian economic crisis. 0.487
73. Negative equity is the major cause of male suicide in Hong Kong. 0.486
72. Terrible spousal relationships easily lead to homicide followed by suicide. 0.422
60. The close connection between suicide and societal change is unalterable. 0.383
31. Unexpected life events constitute the major cause of suicide. 0.362
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570 Attitudes Toward Suicide in Hong Kong
TABLE 2
Continued
Overall (36.1% of variance, alpha = 0.852) Loadings
Factor 6 (Support: Support toward suicidal people) 3.3% of variance, alpha = 0.604
69. Most people are willing to offer psychological support to friends who want to attempt
or commit suicide.
70. Most people are willing to offer material support to friends who want to attempt or
0.579
commit suicide. 0.576
64. Most people care about those who had suicidal attempts. 0.558
51. People can solve problems that may lead to suicide through personal effort.
28. The suicide should have been able to change the psychological and personality factors
0.405
that led to suicide. 0.399
66. Strengthening mental health services can reduce suicide. 0.365
Factor 7 (Contagiousness: Contagiousness of suicide) 3.2% of variance, alpha = 0.511
56. Suicide by celebrities leads to imitation by members of the general public. 0.605
67. The media coverage of suicide news causes more people to attempt or complete suicide. 0.597
71. Group suicide is becoming more common in Hong Kong.
3. Suicide leads to huge economic loss to society.0.441
0.515
Factor 8 (Sympathy: Sympathy towards suicide) 2.7% of variance, alpha = 0.334
43. Suicide is not self-sought. 0.471
22. Most people are sympathetic toward the person who had suicidal acts. 0.470
63. Suicide is not under voluntary control. 0.412
Factor 9 (Function: Function of suicide) 2.4% of variance, alpha = 0.308
54. Sometimes a person may commit suicide for the welfare of another person.
40. People with interpersonal problems attempt or commit suicide primarily for the pur-
0.460
pose of making threats or retaliating against others. 0.498
26. A person has the right to euthanasia as long as he/she chooses it. 0.352
Note. 16 items that did not load on any factors were not listed.
*Scored in reverse direction.
tudes toward suicide among different socio- tudes toward suicide to a manageable number
demographic groups of Chinese people in of perspectives, our respondents, like subjects
Hong Kong. These findings are congruous in our focus groups, still exhibited several atwith
Chinese historical sources that suggest titudinal dimensions that could be intrinsi-
that there is no master theory that adequately cally contradictory. Thus, while four factors
explains how Chinese people perceive sui- pertained to social and interpersonal aspects
cide. Rather, suicide might be endorsed and/ of suicide (suicidal spectrum, social change,
or condemned by particular individuals un- contagiousness, and sympathy), the remainder
a variety of life situations. On the one ing five (negative appraisal, stigma, fatalism,
hand, suicide can be a means of avoiding un- support, and function) were about whether
bearable situations as well as a partially sanc- suicide was right or wrong, or should be met
tioned strategy for dealing with a variety of with sympathy or disapproval. These mani-
social, political, economic, and moral adver- festly dissimilar perspectives attest to the
sities. On the other hand, suicide was to be moral complexity of suicide and cast doubt
avoided and the dead person was in some on sweeping statements about whether Chi-
texts not to be mourned for (Hsieh & Spence, nese culture is for or against suicide (Lin,
1981; Lee & Kleinman, 2005; Lin, 1990; 1990).
Wolf, 1975).
Elderly suicide is one example of Chi-
Although factor analysis reduces atti- nese people’s attitudinal complexity toward
496

Lee et al. 571
TABLE 3
Variation of Factor Score (1: greatly agree—5: greatly disagree) Across Sociodemographic Characteristics
Factors
Negative Suicidal Fatal- Social Sup- Conta- Sym- Funcappraisal
Stigma spectrum ism change port giousness pathy tion
Gender
Male 2.96 2.62 3.02 2.93 3.25 3.24 2.95 2.81 3.05
Female 2.91 2.58 2.91 2.89 3.24 3.25 2.97 2.77 2.95
t(1) 2.56* 1.93 4.33* 1.77 0.24 0.21 0.74 1.98* 4.67*
Age (years)
15–25 2.90 2.60 2.96 2.82 3.26 3.27 2.96 2.79 3.00
26–50 2.95 2.61 2.94 2.96 3.24 3.26 2.97 2.79 3.02
51–75 3.00 2.62 3.04 3.01 3.23 3.33 2.95 2.82 3.00
F(2) 8.77* 0.37 4.16* 25.67* 0.88 2.55 0.22 0.72 0.41
Marital Status
Single 2.91 2.60 2.96 2.86 3.26 3.25 2.97 2.79 3.01
Married 2.97 2.61 2.99 2.97 3.22 3.30 2.95 2.80 3.00
t(1) 3.56* 0.64 1.11 5.05* 1.92 2.27* 0.59 0.54 0.80
Education
Primary or below 2.99 2.66 3.01 3.03 3.19 3.31 3.02 2.81 2.98
Middle School 2.97 2.62 2.99 2.96 3.22 3.26 2.93 2.84 3.02
High School 2.95 2.58 2.97 2.95 3.25 3.25 2.93 2.78 3.03
Tertiary or above 2.89 2.59 2.96 2.83 3.27 3.28 2.97 2.78 3.00
F(3) 6.28* 2.02 0.65 17.59* 2.88* 1.20 2.25 1.34 0.77
Religion
Christianity 2.94 2.61 2.97 2.86 3.28 3.30 3.03 2.80 3.00
Buddhism or Taois 2.99 2.61 2.98 3.01 3.23 3.31 2.99 2.84 3.02
Others 2.99 2.62 3.10 2.88 3.17 3.34 2.97 2.68 3.05
None 2.92 2.60 2.97 2.90 3.24 3.26 2.93 2.79 3.00
F(3) 3.56* 0.11 0.32 6.09* 0.82 1.50 3.17* 1.36 0.23
Employment
Working 2.97 2.61 2.99 2.96 3.24 3.30 2.96 2.80 3.01
Unemployed 2.89 2.71 2.86 2.99 3.19 3.05 3.00 2.81 3.01
Students 2.89 2.59 2.87 2.81 3.26 3.27 2.97 2.79 3.00
F(2) 9.01* 1.86 1.78 22.19* 0.83 9.32* 0.15 0.07 0.34
Occupation
Professional 2.94 2.60 3.04 2.88 3.34 3.34 3.03 2.77 3.08
Administrative 2.97 2.58 3.03 2.96 3.29 3.28 2.93 2.79 3.03
Skilled 2.95 2.62 2.86 2.99 3.22 3.30 3.06 2.77 2.98
Nonskilled 2.92 2.93 2.95 2.88 3.20 3.27 2.92 2.79 2.99
F(3) 1.44 0.28 4.92* 4.20* 6.78* 1.29 5.91* 0.13 3.00*
Personal monthly income
Less than US$641 2.91 2.61 2.97 2.85 3.25 3.25 2.96 2.80 3.01
US$641–US$1,282 2.97 2.60 2.97 2.98 3.22 3.31 2.93 2.79 2.98
US$1,283 or above 2.94 2.89 2.99 2.92 3.27 3.28 2.99 2.78 3.04
F(2) 5.10* 0.41 0.21 13.98* 1.67 2.79 1.26 0.25 1.94
*p < 0.05
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572 Attitudes Toward Suicide in Hong Kong
TABLE 4
Endorsement of Suicide Under Difficult Life Scenarios
Life Scenarios Mean Score SD
Being terminally ill 2.61* 1.10
Having a chronic psychiatric illness 2.53* 1.12
Being severely depressed 2.50* 1.14
Being a burden to others and feeling hopeless about the future 2.36* 1.11
Being heavily indebted because of gambling 2.22* 1.11
Not having anyone to provide financial or emotional support in old age 2.22* 1.08
Having been raped 2.10 1.09
Being addicted to drugs 1.96 1.02
Being sentenced to imprisonment 1.88 0.94
Having a business failure 1.86 0.95
Being criminally charged 1.81 0.95
Frequently abused or beaten up by spouse 1.75 0.94
Note. Each of the 12 items was measured on a 5-point Likert scale as follows: 5 = definitely
consider, 4 = very likely to consider, 3 = probably consider, 2 = probably not consider, and 1 = definitely not
consider.
*refers to mean score significantly higher than 2 (probably not consider) (p < 0.05)
suicide. Filial piety in the Confucian tradi- more sympathetic toward suicidal people
tion has often been cited as a Chinese virtue when compared to male respondents. They
that protects the elderly from adversities, yet were also more likely to make a distinction
the rates of suicide among the elderly are between suicide and attempted suicide. This
consistently very high among Chinese com- combination of attitudes appears to protect
munities in Hong Kong, China, Taiwan, and them against suicide but, in the presence of
Singapore (Lee & Kleinman, 2005). Such a impulsivity, may also make them more likely
paradox indicates the need to take a multi- to attempt suicide under circumstances of
attitudinal approach to understanding the el- perceived hopelessness (Goldsmith, Pellmar,
derly vulnerability to suicide. The present Kleinman, & Bunney, 2002). Conversely, by
study provides at least two clues to this vul- making a smaller distinction between suicide
nerability. First, terminal and chronic dis- and attempted suicide and demonstrating less
eases were the most commonly endorsed ra- sympathy toward suicidal people, male retionales
for suicide out of the twelve difficult spondents might be less likely to expect res-
scenarios presented to our respondents (Ta- cue or seek help, and more likely to make a
ble 4). Second, older respondents were more lethal attempt. This may help explain the
fatalistic toward suicide and more likely to higher ratio of suicide/attempted suicide
consider suicide under the hypothesized sce- among male than female individuals in both
narios. This indicates a clinical need for help- Chinese and Western communities (Lee &
ing professionals to be especially sensitive to Kleinman, 2005). The clinical implication of
the vulnerability to suicide of Chinese elderly this finding may be that proactive approaches
with chronic diseases.
are required for helping suicidal males. Pop-
Attitudinal variability may stem from ular measures such as hotline counseling may
the fact that a given person holds a contradic- not be effective.
tory mixture of attitudes that interact among
themselves under particular scenarios. In the
Cross-Cultural Comparison
present study, female respondents exhibited a Different methodologies employed premore
negative appraisal of suicide and were clude a valid comparison between the find-
498

Lee et al. 573
ings of our study and those reported in the ceived limited public and policy attention in
West. Nonetheless, it is instructive to draw Hong Kong. This echoed our focus group
comparisons on certain items of general in- findings, which showed that the professional
terest. Thus, we compared five items of the viewpoint of suicide being due to treatable
CASQ-HK about the myths and prevention mental disorders such as depression or hav-
of suicide with comparable items drawn from ing biological causes was conspicuous by its
a Norwegian survey (Table 5; Hjelmeland & absence (except in the group consisting of
Knizek, 2004). The results suggest that both healthcare professionals). It was also shown
Chinese and Norwegian respondents were by the finding that only 23.9% of responneutral
about the statement “People who talk dents endorsed the item “People who at-
about suicide do not commit suicide,” but tempted or committed suicide very often had
Norwegians showed a stronger agreement to mental illnesses.” How this difference may
“There is a risk to evoke suicidal thoughts relate to lower rates of suicide in Norway
in a person’s mind if you ask about it.” Our (11.1/100,000 in 2003) than in Hong Kong
respondents also demonstrated more agree- (18.6/100,000 in 2003) is worth examining in
ment to “Suicide happens without previous the future (Census and Statistics Department
warning” and less agreement with “Suicide of HKSAR, 2004; Judiciary of HKSAR, 2004;
can be prevented.” Both Chinese and Nor- Statistics Norway, 2004).
wegian respondents somewhat disagreed with A study in Sweden examined public at-
“Once someone has decided to commit suititudes toward suicide in 1986 and 1996 in
cide, it is difficult to change his/her mind.” the context of a multifactor model (Renberg
Overall speaking, our respondents exhibited & Jacobsson, 2003). This suggested that at an
a more pessimistic attitude than Norwegians individual level, a permissive attitude toward
toward the prevention of suicide. This is not suicide was associated with affirmative re-
surprising because suicide prevention has re- sponses to questions about one’s own suicidal
TABLE 5
Comparison of Response Distribution About the Myths and Prevention of Suicide with the Study
by Hjelmeland and Knizek (2004)
Strongly In doubt/ Strongly
agree Agree Middle Disagree Disagree
Nw Hk Nw Hk Nw Hk Nw Hk Nw Hk
(%) (%) (%) (%) (%) (%) (%) (%) (%) (%)
People who talk about suicide do not
commit suicide
There is a risk to evoke suicidal
thoughts in a person’s mind if one
1.9 3.2 27.4 33.6 52.9 34.3 12.8 26.5 5.1 2.4
asks about it.
Suicide happens without previous
1.9 1.5 7.4 7.8 44.1 19.6 34.3 55.3 12.3 15.5
warning.
Once a person has made up his/her
mind about suicide, nobody can
3.9 4.9 25.3 30.4 32.7 14.7 32.3 41.2 5.8 7.7
stop him/her. 3.9 1.7 15.0 15.3 29.3 21.3 38.1 52.1 13.6 8.4
Suicide can be prevented 36.7 5.3 45.8 32.1 16.3 16.8 0.7 38.8 0.5 6.4
Hk (Hong Kong): findings from this study
Nw (Norway): findings shown in the study by Hjelmeland and Knizek (2004)
499

574 Attitudes Toward Suicide in Hong Kong
behavior. This tallied with our finding that tudinal complexity of suicide may navigate
respondents who were classified under hypo- different forms of prevention efforts to more
thetical scenarios as being high risk had more
suicidal ideation, made previous suicide at-
realistic goals.
tempts, and demonstrated a more positive
appraisal of suicide than their respective
Limitations and Future Research
comparison groups. The present study has several limitations
that suggest the need for further re-
Implications for Suicide Prevention search. First, the findings from a convenience
sample clearly cannot be generalized to the
Phillips, Liu, and Zhang (1999) sug- general population in Hong Kong or other
gested five interacting factors that collec- Chinese communities. The low variance extively
determined suicide rates in a commuplained by the identified factors could, for exnity.
These included cultural attitudes toward ample, be due to sampling bias toward pro-
suicide in addition to the prevalence of social ductive members of society (namely, employees
and mental health problems, convenience of and students). Future studies should encommethods
of suicide, and comprehensiveness pass a general population sample that in-
of suicide prevention services. While intu- cludes socially disadvantaged people who
itively plausible, these five factors are not eas- may be more prone to endorse suicide. Secily
modifiable, especially by clinicians. In the ond, attitudes do not necessarily translate
case of Hong Kong, there is little popula- into behavior in accordance with the multition-based
public health policy that addresses factor model of suicide (Manstead, 1996). At-
the treatment gap of mental disorders, not to titudes must interact among themselves and
speak of their prevention. Widely believed to with non-attitudinal factors in their ultimate
be gatekeepers, primary care practitioners are impact on behavior. As such, our findings
inadequately trained to manage common should be interpreted cautiously. Third, the
mental disorders (Lee, Tsang, & Kwok, CASQ-HK was lengthy and, because of our
2007). The most common methods of suicide failure to secure consent from the partici-
in Hong Kong—jumping from height and pants for a second round of distribution, its
charcoal burning (Centre for Suicide test-retest reliability was not established.
Research and Prevention, 2005)—are hardly Shortening it will allow larger samples of
controllable. Moreover, suicide prevention people to be examined and a more stringent
efforts are not only limited in quantity but assessment of its psychometric properties. Fi-
also have adopted methods (e.g., hotline nally, we believe that attitudinal surveys fail
counseling by volunteers and advice to jour- to uncover the layers of privacy and equivonalists
on appropriate ways of reporting sui- cality that typically envelop suicide. They
cide) that are of questionable usefulness. In should be complemented by ethnographic
regards to the findings of the present study, research that elucidates the complex interac-
we are still uncertain about how attitudes and tions of attitudes and behaviors in specific
contextual factors act in concert to evoke sui- contexts and how large-scale socioeconomic
cide, and how attitudinal data can be inte- transformations in Chinese society shape the
grated into health interventions to reduce inter-subjective meanings of suicide (Lee &
suicide. Nonetheless, acknowledging the atti- Kleinman, 2005).
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