2006:10 Ma Yousuf Bhuiyan. Attitudes towards suicidal behaviour ...

Thesis/yousuf/MPH/2006 

Attitudes towards suicidal behaviour among 

adolescents in Bangladesh 

Dr. Ma Yousuf Bhuiyan 

Thesis: 20 Points 

Master’s in Public Health 

Session: 2005/2006 

Supervisor 

Gunnar Kullgren, MD, PhD 

Professor Division of psychiatry 

Head of the Dept of Clinical Sciences 

Umeå University 

SE-901 85 Umeå; Sweden 

Umea International School of Public school 

DEPARTMENT OF PUBLIC HEALTH AND CLINICAL MEDICINE 

UMEÅ UNIVERSITY, UMEÅ, SWEDEN 

1


Abstract 

BACKGROUND: The growing incidence of suicide behaviour among adolescents has 

heightened awareness for need of prevention. Suicide was the fifth most common 

cause of death overall and ranked number one among adolescents in the world. 

Attitudes towards suicide represent a keystone in understanding and preventing 

suicides 

OBJECTIVES: To adapt and validate a questionnaire ATTS regarding suicidal 

behaviour among adolescents in Bangladesh and to test its feasibility in this cultural 

setting. 

METHODS: Focus group discussions in four groups were used to culturally adapt 

ATTS to the setting in Bangladesh. In a second step, ATTS was distributed to 96 

adolescents aged 15-24 years. 

RESULTS: Among the adolescents aged 15-24 years, 5.5 percent of girls and 4.8 

percent of boys reported a suicide attempt during recent year. Many were exposed to 

suicidal behaviour among significant others: suicidal attempts, expression and 

ideation among family members, relatives and friends were 11.62%, 27.81% and 

39.58% respectively. On factor analysis, factors similar to those reported from other 

countries were obtained. Comparison of factor summary scores between boys and 

girls showed few differences and exposure to suicidal behaviour among significant 

others did not seem to have an impact on attitudes towards suicidal behaviour. 

Focus group discussions revealed several key elements in understanding suicidal 

behaviour among adolescents. 

CONCLUSIONS: The proportion of boys and girls who reported a suicide attempt 

during recent year is lower than found in some US studies but higher than figures 

reported from another developing country – Nicaragua. In this pilot study, the 

pattern of attitudes was in general similar to what has been reported from European 

and Nicaraguan studies and was not markedly influenced by gender or being exposed 

to suicidal behaviour among significant others. However, some gender differences 

found in the Nicaraguan study was not replicated in Bangladesh. Further analyses 

should be performed to identify possible misconceptions and attitudes that might 

have a negative influence in prevention of suicidal behaviour among adolescents in 

Bangladesh. 

Key words: Attitude towards suicide, suicidal behaviour, incidence, Adolescent, prevalence, 

committed suicide, exposure, permissiveness. 

2


Introduction 

Suicide is becoming a public health concern in many countries among adolescents 

(WHO, 2001). The overall suicidal rates in many countries are increased due to high 

prevalence in age group 15-24 (Nida.Z and Apolinaras.Z, 2005). Health and demographic 

surveillance data were collected from rural and semi-urban sub districts of Jessore in the 

southwest Bangladesh, by ICDDR,B during 1983-2002, and it was concluded that in 10- 

19 years old; 61/100,000 were determined to have died from suicide every year. Suicide 

was the fifth most common cause of death overall, and ranked number one among 

adolescents (ICDDR, B, 2003). 

In 1998, ESCAP has shown in their Journal that nearly about 30/100,000 of young adults 

every year have committed suicide in rural Bangladesh. 

mortality / 100,000 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Bangldesh 

China 

hong kong 

japan 

Australia 

New Zealand 

singapore 

korea 

Figure 1: Suicides mortality/ 100,000 of young adults aged 15-24 in selected countries. 

ESCAP population journal December 1998 

ICDDR,B has conducted a population base study in Matlab, and summarized that 

mortality rate by aged group 22-29 are relatively higher, nearly 50/100,000, than any 

other group. 

3


Suicide defined as a self-inflicted cause of death, can count up the number three leading 

causes of death among 15-44-year old people (WHO, 2001). Over the last several 

decades, suicidal rate among young has been increased dramatically (4 HON, 2005). In 

1996, suicide was the 3rd leading cause of death in 15 to 24 year-old, and the 4th leading 

cause in 10 to 14 year-old in USA (HON, 2005). Suicide is noticeably a serious societal 

as well as public health concern in several countries, and areas of the ESCAP region (By 

Lado T. Ruzicka, 1998). Indian subcontinent countries have high suicide mortality 

among women under 25 years of age which has been widely noted (Lado T. Ruzicka, 

1998). Suicide is related with many complex factors. More than 90% of youth suicide 

victims have at least one major psychiatric disorder, although suicidal victims among 

adolescents have lower rates of psychopathology (Gould MS et al, 2003). 

60 

50 

mortality/100,000 

40 

30 

20 


male 

female 

0 

10--19 20--29 30--39 40--49 50--59 60- 

age group 

Figure 2: mortality / 100,000 due to suicide by age and gender, source: ICDDR,B 

In September 2005, WHO, regional office for south East Asia has published, a “Suicide 

Prevention: Emerging from Darkness” .In Bangladesh part, they overviewed that an 

average of 600 suicide per month during 1972-1988, the number of suicides have been 

increased to 984 per month during 1992-1993. The total number of suicides reported to 

the Forensic Medicine Department of Dhaka Medical College indicated that committed 

4


suicides have been increased from 12 per month in 1989 to 18 per month in 1998. On an 

average, 15% of the total number of autopsies has been associated with suicides 

(Yogeeta, 2005). 

One study has been conducted by ICCRD,B in Matlab from 1980-1996 has shown that 

suicidal death is more common in adolescence, and prevalence rate is higher in female 

then male. 

suicidal m ortality of young adults aged 15-24 in 

B angladesh from 1980-1996 

m a le 

3 2 % 

fe m a le 

6 8 % 

Figure 3: suicide mortality/100,000 in Bangladesh from 1980-1996 

Source: ESCAP population journal December 1998 

In 1998, ESCAP has cited in their report that from 1980 to 1996 suicidal rate of female 

and male was 68% and 32% respectively, and prevalence almost twice in female than 

male. 

Previous study from Matlab has shown that suicidal prevalence age group between 10-29 

was higher than any other group, and prevalence rate in male and female were 63.85% 

and 82,68% respectively. 

Suicidal behavior 

It is important to distinguish between completed suicides and other suicidal behaviors; 

risk factors and risk groups differ. However, suicidal behavior remains the strongest 

single risk factor for completed suicide and it represents a logic target in suicide 

prevention. 

It seems that suicidal tendencies were quite frequent among adolescents in general 

population. Main components of suicidal behaviour or suicidal expression are suicidal 

ideation, serious plans how to commit suicide, and reported suicide attempts (Ivarsson.T 

and Gillberg.C ; 1997). Suicidal behavior in children and adolescents are, usually, a sign 

5


of mental disorder, most often depression (HON, 2005). In Nicaragua, the prevalence of 

suicidal expression was 44.8% and 47.4% in men and women respectively (Herrera et al, 

2006). Suicidal expressions were found to be associated with having friends who had 

made a suicide attempt (HON, 2005) and it appears to be an important factor to identify 

suicidal behavior. 

Suicidal thoughts are also extremely common in young people. About 16% of females 

aged 12 to 16 years reported having suicidal thoughts in the previous six months (Youth 

suicidal behavior, 2004). One Swedish study has shown that 4.3% of boys reported 

having suicidal ideation and 3.6 % were girls (Fevziye Toros et al 2004). 

The prevalence of suicidal attempts as reported in Turkey among children and 

adolescents were 1.93% (Fevziye Toros et al 2004). Dysfunctional families, absent 

fathers and lack of integration into society were some of the structuring conditions that 

lead to emotional distress. Abuse, deaths in the family, break-up with boyfriends or 

suicide among friends acted as triggering events for suicidal attempt (Herrera et al 

2006b). 

Suicidal behavior is increasingly becoming a phenomenon associated with young people, 

and a significant public health issue in Bangladesh. However, there are very few studies 

that have been carried out evaluating the impact of young attitudes towards the suicide 

and suicidal behaviors. The current study is a pilot study to prepare for a community 

based study that will be performed in a second step. 

Structure 

Suicidal behavior is a heterogeneous problem and represents a certain form of 

communication. It is often a consequence of the ‘cry for help’ as an authentic expression 

as well as an effort to find out a solution for simultaneously unbearable and unchangeable 

life situation. Attempted suicides constitute a pool from which many of the future 

suicides will be drawn, and cases for direct prevention efforts should come from this 

group of pre-suicidal individuals. Figure 4 presents some background factors and 

triggering factors for suicidal behaviour reported in the literature. 

6


Socio-economic factors 

Economics crisis 

Gender Inequity 

Social support 

Education 

Culture 

Social Security 

Family support 

Broken family 

Education of Parents 

Family members 

Step mother/ father 

Factors and process 

Behavior 

Tobacco 

Alcohol 

Gender 

Traffic-drug, culture, media 

Physical inactivity 

Isolation 

Religious 

House hold condition 

Relation of close friends 

Relation of partners 

Triggering factors 

Stress, Depression, sexual and drug abuse, violence, Mental pressure, 

Suicidal Behaviour 

Suicidal 

ideation 

Suicidal 

thoughts 

Suicidal plan 

Suicidal 

attempts 

Committed 

Suicide 

Figure 4: Suicidal process 

Socio economic characteristics 

High rates of attempted suicide occur among those of who have lower socioeconomic 

status (Holding et al 1977). Many people who commit suicide, especially men, are 

unemployed. The behaviour is more common in urban areas and also in areas of social 

deprivation and overcrowding (Skimshire, 1976) 

Gender perspective and suicidal behavior 

A comparison Swedish study has shown that female gender and young age are risk 

factors for self reported suicidal behaviors (Salander RE,1996; Moscicki E, 1994). 

7


Regarding attitudes towards suicidal behaviour, gender specific patterns have been 

identified. For example, women are less likely to hold a permissive attitude towards 

suicide (Renberg & Jacobsson, 2003). 

An important but often neglected aspect of the problem of attempted suicide concerns the 

attitudes shown by people towards the behavior. The attitudes of relatives and friends, on 

whom the behavior is liable to impinge most severely, will determine their response to 

the behavior. One study in Nicaragua has shown that women’s attitudes towards suicide 

were more oriented towards preventability (Herrera et al 2006). 

Objectives 

General Objectives 

The overall aim of the current study was to develop and to validate a questionnaire that 

will be used in future studies on suicidal behavior among adolescents in Bangladesh. 

Specific objectives 

• To adapt and further develop a questionnaire on attitudes and experience of 

suicidal behavior that has been used in other countries to fit with the cultural 

setting of Bangladesh. 

• To test the properties of the instrument in a sample of adolescents in Bangladesh 

• To get some basic information from focus group discussions to understand how 

suicidal behaviour is perceived by adolescents in Bangladesh. 

The setting 

Mirpur Thana (dhaka district) with an area of 53.58 sq km, is bounded by pallabi thana 

on the north, mohammadpur thana on the south, kafrul and Pallabi thanas on the east and 

savar upazila on the west. Main river is Turag. Mirpur area is an extended part of the 

Madhupurgarh created in the Pleistocene period. Mirpur thana was established in 1962. 

The thana consists of one union parishad, eight wards, 11 mouzas and 86 and 20 villages. 

8


Mirpur Thana (Town) area was included in keraniganj thana during the British period and 

in tejgaon thana during the Pakistan period. Many administrative and cultural 

establishments including National Zoo, National Botanical Garden, National Vagabond 

Shelter Centre are located in this thana area. National Martyr Intellectual Memorial has 

been established at the premises of the graves of martyr intellectuals. The tomb of Hazrat 

Shah Ali Bagdadi (R), a sacred place and historical relic, is located at Mirpur. Besides, 

the head offices of grameen bank, bangladesh institute of bank management, Dhaka Eye 

Hospital, National Heart Foundation, etc are located here (15) 

Study Site: Mirpur, 555,758, population, Dhaka, Bangladesh 

Population 555,758; male 56.75%, female 43.25%; Muslim 98.42%, Hindu 1.07% and 

others 0.51%. Average literacy is 59.4%; male 65.4% and female 52.2%. 

Literacy and educational institutions 

Average literacy is 59.4%; male 65.4% and female 52.2%. Educational institutions: 

college 8, high school 20, school and college 6, madrasa 16, private medical college and 

hospital 3, primary school 47, vocational training institute 3. Cultural organisations Club 

23, literary society 4, cultural centre 3, cinema hall 5, museum 1, zoo 1, botanical garden 

(15) 

9


Method 

Design 

The study was performed in three steps. Firstly, the ATTS instrument was translated into 

Bangla and re-translated into English and again translated into Bangla. 

Secondly, group of adolescents aged 15-24 years from 4 schools in the study area were 

invited as a “focus group” for discussion, where the item used in the instrument have 

been discussed. The purpose was to adapt language and expressions to fit with the 

adolescent culture in this setting. An additional purpose was to get a basis for 

understanding adolescents’ views on suicidal behaviour. For focus group discussions, 

four groups were selected from four schools with pupils aged 15 to 24 years and 10 -12 

students in each group with an equal number of boys and girls. 

Thirdly, a convenience sample of 96 adolescents aged 15-24 years from another 4 schools 

in the same study area were selected for a pilot study. In collaboration with school 

headmasters and class teacher’s, 10-12 students have been selected from each school, and 

invited to answer the questionnaire. Only age and gender were included as sociodemographic 

factors and the questionnaire study has been anonymous without any 

possibility to identify any single student. 

Instrument 

The “Attitudes Towards Suicide” (ATTS) questionnaire was developed to attempt to 

measure attitudes towards suicide in longitudinal large-scale surveys in the general 

population in Sweden in 1986 and 1996. Psychometric properties of the instrument have 

been reported in a previous paper (Renberg & Jacobsson, 2003). 

The instrument consists of three main sections: first, contact with suicidal problems 

(ideation, threats, attempted and completed suicide) among significant others; second, 

attitudes covering multidimensional attitude areas (37 items); and third, own life 

satisfaction and suicidal behaviour. 

10


The questionnaire includes some questions on suicidal behaviour as presented by Paykel 

and colleagues in a previous paper (Paykel E et al., 1974). 

In the present study, a brief version of the instrument ATTS was used; among selfreported 

suicidal behaviour only items on a suicide attempt during previous year was 

used and among attitudes only a core set of attitude items in the form of statements were 

used. Attitude statements were scored by respondents on a scale from 1= Strongly 

disagree to 5= Strongly agree. 

Mirpur thana: 

colleges 8, high 

schools 20 & 2 

university 

8 schools, 1 

collage and 1 

university 

(cluster 

4 schools for 

discussion & 4 school, 

1 college and 

university for interview 

55 girls and 41 

boys (cluster 

sampling) total 

sample 

Analysis 

All analyses were carried out by using SPSS version 13.0. Statistical analyses included 

chi-square tests were used for the comparisons of distribution. Factor analysis was 

performed by using principle component analysis with Varimax rotation. Reliability, 

internal consistency of the instrument was assessed by Cronbach’s alpha. T-tests were 

used to analyses of differences in mean score on factors and single items. Factor analysis 

was chosen as one method to allow for comparison with previous studies done with the 

ATTS instrument in Sweden and Nicaragua. 

The focus group discussions were audio/video-taped and the author (MYB) lead the 

discussions. Some attitude items in the ATTS were chosen to stimulate discussions 

among the participants. The recorded material was then analysed to identify key 

problems and experiences the participants had had related to these problems. 

Ethical consideration 

The study protocol and an accompanying letter were submitted to the headmasters of 

schools involved and the principal of college to get permission for discussion and 

interview. Counseling, if needed, was offered by help of class teacher and local 

volunteers. A brochure with information has been prepared on how to get help for 

11


suicidal problems. Screening or suicidal problems among adolescents has been widely 

used in research and is considered a safe procedure. 

Results 

From the focus group discussions 

Firstly, the ATTS questionnaire and the attitude items were presented to the adolescents 

in order to revise phrasing of statements and questions. Several comments were made. 

For example the use of the word “partner” was not a culturally acceptable concept. 

Living with someone without being married is not acceptable in Bangladesh. 

Furthermore, the expression “Suicide is a cry for help” was not fully understood by the 

adolescents. 

From the discussions several themes of importance for suicidal behaviour emerged as 

presented in Table 1. 

Table 1: Results from focus group discussions 

Problems Experiences Implications for mental health 

leading towards suicide 

Teenage love -Parents disagree to establishment -Depression 

-Unwanted pregnancy 

-Emotional distress 

Sexual violence 

Unexpected 

academic results 

Low socioeconomic 

status and 

unemployment 

-Social insecurity 

-Unwanted pregnancy 

-Isolation from family members 

and society 

-Isolation from family members 

and society 

-feeling of guilty 

-Decline in social status 

-Persistent insecurity, 

-Feeling of discrimination 

-Social instability 

-Addiction to cannabis, heroin 

-Depression 


-Addiction 

-Hopelessness 

-Stress, 

-Hopelessness 

-Addiction 


-Depression 

-Anger and hostility 

-Hopelessness 

-Cannabis psychosis 

Religious 

-Perceived injustice 

-Restriction to move freely 

and to express their opinion 

-Mental instability 


-Anger 

-Loss of autonomy 

12


a number of brother 

and sister 

-Persistent quarrel, 

-Feeling of discrimination 

-Family disharmony 


-Depression 

-Anger and hostility 

-Addiction-boys 

Dowry -Domestic violence -Shame, helplessness, 

humiliation 

-Depression 

Social isolation 

-Restricted opportunities 

-Broken social and cultural ties 

-Hopelessness, disappointment, 

and demoralization 

-Addictions 

“ Bokhate chelae” -Feeling of discrimination 

-social Insecurity 

-financial crisis 

-Helplessness, humiliation 

-Depression 

-addiction 

From the questionnaire study 

Table 2: Gender specific social demographic characteristics among responders 

Variables Gender Total 

N % 

Male 

N % 

Female 

N % 

Sex 41 (43.7) 55(56.2) 96(100) 

Age group* 

15-19 

20-24 

23(54.7) 

19(45.2) 

41(76.3) 

13(23.6) 

64(66.6) 

32(33.3) 

Total 41(100) 55(100) 96(100) 

Level of education 

9-10 years 22(52.3) 25(46.2) 47(48.9) 

11-12 years 11(26.1) 15(27.7) 25(26.0) 

>13 years 9(21.4) 14(25.9) 24(25.0) 

Total 41(100) 55(100) 96(100) 

(* Age group in sex x2=4.7602, df=1, p=.024 (95% CI), 

In table 2, social demographic characteristics of the responding group are presented. 

During the study period (January-February 2006), 96 set of questionnaire were completed 

by 96 responders. Significance gender differences were found in both age group 15-19 

years and 20-24 years. Among responders, there were more girls than boys, and their 

mean age was 18.3 years and 19.6 years, respectively. 

Figure 5: Suicidal behavior among family members, relatives and friends during 

recent year as reported by responders. 

13


Suicidal behavior among family, 

relatives and friends 

% of 

responde 

rs 

45 

40 

35 

30 

25 

20 

15 


5 

0 

Current ideation 

Suicidal expression 

Attempt 

Female 

male 

As shown in Figure 5, boys have reported that 16.6% of significant others having suicidal 

attempt which is twice as high as among girls (7.3%). Regarding suicidal expression 

among significant others, girls and boys reported 25.4% and 30.9% respectively, and in 

current ideation, boys 39.1% quite the same as girls 40.0%. 

Table 3: Obtained factors, explained variance, factor-loading and internal consistency 

(Cronbach’s alpha) for the 25 items. 

Group Factors Factors 

loading 

Explained 

Variances 

*Internal 

consiste 

ncy 

1. Permissiveness 

2. Indecisiveness 

3. Incomprehensibility 

4.Non-communication 

5. Responsibility to 

prevent 

atts37 People should have the right to commit 

suicide 

.553 

atts27 Committed suicide is one’s own business .410 

atts19 Sometimes only solution is suicide .694 

atts8 Suicide should be accepted as a solution to 

end an incurable disease 

.720 

atts25 Suicide happens without previous 

warning 

.646 

atts31 Relatives usually get no warning when a 

person is thinking about suicide 

.925 

atts26 People avoid talking about suicide .680 

atts16 One should not talk about suicide .692 

atts34 anybody can commit suicide .811 

atts22 Suicide among younger people is 

incomprehensible 

.448 

atts11 People who committed suicide are 

usually mentally ill 

.842 

atts15 People who make suicidal threats seldom 

complete suicide 

.732 

Atts36 People who talk about suicide do not 

commit suicide 

-.736 

atts12 It is a human duty to try to stop 

someone from committing suicide 

.993 

atts29 A suicide attempts is actually cry for help .776 

atts33 I am prepared to help a person in a .766 

13.1% .425 

12.0% .295 

10.0% .472 

8.7% .128 

7.1% .222 

14


6. Preventability 

7. Relation-caused 

8. Suicidal process 

(duration) 

suicidal crisis 

atts4 You can always help a person who 

has suicidal thoughts 

.541 

atts9 Once a person has made up his mind 

about committing suicide no one can stop 

.733 

him/her 

atts40 Suicide can be prevented -.605 

atts38 Most suicide attempts caused by 

inter-personal conflicts 

.563 

atts10 Many suicidal attempts are made 

because of revenge or punish someone 

.955 

atts17 Loneliness is a reason for suicide .819 

atts7 Most suicide attempts are impulsive 

actions 

.884 

atts24 Once a person has suicidal 

thoughts, they will never let them go .330 

6.3% .205 

6.0% .411 

5.0% .390 

The explained variance for all eight factors was 68.0% and overall internal consistency 

.645. 

Table 4: Mean summary scores on the 8 attitude factors as related to gender 

Factors Gender N Mean Std. Deviation t-test P 

permissiveness Male 41 9.00 4.01 

Female 55 8.61 2.73 

.58 

Indecisiveness Male 41 6.80 1.83 

Female 55 6.36 1.94 

Incomprehensibility Male 41 10.31 2.82 

Female 55 10.21 2.60 

Non-communication Male 40 5.17 2.06 

Female 55 5.89 2.05 

.26 

.85 

.09 

Responsibility to 

prevent 

Male 41 6.75 1.59 

Female 

55 7.10 1.49 

.26 

Preventability Male 40 4.85 1.91 

Female 55 4.36 1.97 

Relation-cause Male 41 6.48 1.69 

Female 55 6.89 1.71 

Suicidal process Male 41 8.78 2.23 

Female 55 9.78 1.82 

.23 

.25 

.01 

When factor scores were compared between men and women, the only factor that 

differed between genders was Suicidal process where women scored higher. 

15


Table 5: Mean summary scores on the 8 attitude factors as related to exposure with 

suicidal attempts 

Exposure to an 

attempt among 

Factors 

others N Mean Std. Deviation t-test P 

Permissiveness No 

83 8.63 3.34 

.29 

yes 13 9.69 3.19 

Indecisiveness 

Incomprehensibility 

No 

Yes 

No 

Yes 

Non-communication No 

Responsibility to 

Prevent 

Preventability 

Relation cause 

Suicidal process 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

83 6.65 1.91 

13 5.92 1.75 

83 10.24 2.77 

13 10.38 2.14 

82 5.51 2.08 

13 6.07 2.06 

83 6.93 1.57 

13 7.07 1.38 

82 4.46 2.00 

13 5.23 1.53 

83 6.66 1.74 

13 7.07 1.49 

83 9.36 2.03 

13 9.30 2.25 

.85 

.36 

.76 

.19 

.41 

.37 

.93 

Exposure to suicidal attempts among significant others has been described in table 5. The 

results seem to show that having been exposed to suicidal behaviour among significant 

other do not influence attitudes. 

Discussion 

This study is the first attempt to measure attitudes towards suicide in Bangladesh. The 

purpose of the present study was mainly to adapt the instrument to the cultural setting in 

Bangladesh and give some first impression of patterns of attitudes. Overall, the pattern 

was fairly similar to findings from Europe and Nicaragua (Rengerg & Jacobsson, 2003; 

Herrera et al. 2006). 

Suicidal behavior among adolescent in Bangladesh associated with many factors. Teen 

age love, sexual violence, unexpected academic results, unwanted pregnancy, low 

socioeconomic status and dowry are the main causes attempted suicide among adolescent 

16


in Bangladesh. Economic causes such as landlessness, pauperizations, and unemployment 

have increased the stress and tension in parents-children relations in the poor households, 

and giving rise to Emotional distress, Depression, Anger and hostility, Hopelessness and 

addiction leads adolescent attempted suicide. 

The emergence of dowry is more due to avarice and commercialization of marriage than 

the impact of traditional culture. Rising unemployment has been contributed to the 

phenomenon to demand dowry as a source of income (human rights watch, 2002). 

Prospective grooms and their families demand large sums of money or property from the 

bride’s family as a precondition to the marriage agreement. Although dowry demand is 

illegal, and this practice persists only in the rural communities. In fact, very few 

marriages in the rural areas are performed without a dowry. In most cases, the complete 

dowry is not been paid at the time of marriage. The bride’s family would like to pay part 

of the dowry before the marriage, and they promise to pay the rest as early as they can. 

When the bride’s families fail to meet the deadline, her husband or in-laws abuse her 

verbally and physically to compel her family to pay, and women feel shameless and 

depression which leads her attempted or committed suicide. 

Even though the evaluation of attitudes is more complex than the expression of 

agreement or disagreement with a set of statements, a standardized way of measuring this 

phenomenon enables useful cross-cultural comparisons (Oppenheim AN, 1992). The 

eight factorial sub-scales, altogether, seem to cover the extension of what is understood 

as attitude in its effectiveness, permissiveness and behavioral components as well as 

preventability and relation-cause factors. 

Committed Suicide, attempted suicide, and thoughts of committing suicide are, as of the 

early 2006s, substantial problems among adolescents in the Bangladesh, as it is in much 

of the world. It is the 5th leading cause of death among 15 to 19 year olds in the 

Bangladesh and the sixth leading cause of death among 10 to 14 year olds. In our study, 

we found that 5.5 percent of girls and 4.8 percent of boys report a suicide attempt suicide 

each year in the Bangladesh, which is relatively high in comparison to Nicaragua, boys 

17


and girls 2.1% and 1.5% respectively (Herrera et al, 2005). Bangladesh is considered 

high Epidemic place for committing suicide (WHO, 2004). 

In 2005, Goldstein TR et al conducted a study related with bipolar disorder and 

summarized that suicidal Attempters were probably have a lifetime history of comorbid 

substance use disorder, panic disorder, non-suicidal self-injurious behavior, family 

history of suicide attempt, and also concluded that children and adolescents with bipolar 

disorder exhibit high rates of suicidal behavior (Goldstein TR eat al,2005), In our study, 

we found that suicidal attempts, expression and ideation among family members, 

relatives and friends are 11.62%, 27.81% and 39.58% respectively. Suicidal expressions 

is significantly associated with suicidal expression among friends, and young people with 

a friend who had attempted suicide were three to six times more likely to attempts suicide 

themselves (Kirmayer LJ et al, 1996). Due to small numbers in our study, it was not 

possible to examine whether exposure to suicidal behaviour among significant others was 

associated with increased report of own suicidal behaviour. 

The impact of demographic factors on suicidal behavior among adolescent appears to be 

some importance in different studies. One study conducted in Latvia found that lower 

level of education, urban residency were identified risk factors for suicidal behaviour in 

both genders ( Rancas et al, 2003). Risk of suicidal behaviour was reported consistency 

high in young women, individuals with low level of education and lacking of stable 

relationship (Kessler R.C, et al, 2005). In our study, we were not looking for any 

association between SES and Suicidal Behaviour. We would intend to formulate it in our 

next study. 

Concerning reliability, an overall internal consistency of .645 was good for the whole 

instruments as compared with the Swedish study .60 (Renberg & Jacobsson, 2003) and 

Nicaragua .46 (Herrera et al 2005). Although, some individual factors are considerably 

low. Possible causes of these results are small number of samples, in view of the fact that 

internal consistency is increased due to the number of items on each factor (Guilford, 

1954). 

18


The factor analysis yielded 8 factors. Factor one “Permissiveness” turned out the 

strongest in our study as in the Nicaraguan study (Herrera et al. 2006). Considering the 

mean item score of the items in the factor it was almost exactly the same as in both 

countries. However, the items in factor six “Preventability” scored much higher in the 

Nicaraguan study where adolescents were more likely to consider suicide as preventable. 

In Nicaragua, girls were more likely to emphasize preventability and less likely to 

consider suicide as incomprehensible as boys. In our study, the only gender difference 

emerged on factor eight where girls more likely than boys to think that the suicidal 

process is difficult to stop. Even though these findings must be cautiously interpreted, 

they might indicate an opposite gender pattern between Nicaragua and Bangladesh. 

The present study has several limitations; sample size is too small to allow for analyses 

regarding the association between self-report suicide attempts and attitudes or exposure 

to suicidal behaviour among significant others. In this first report, we have not analysed 

level of agreement to specific items or clusters of items, which should be a natural next 

step in order to get a further understanding of adolescents’ view on suicidal behaviour. 

However, the overall aim was to test the feasibility of the ATTS in Bangladesh and 

further studies should preferably be community based with a larger sample. 

Acknowledgments 

This project was funded by department of psychiatric, clinical science, Umea University, 

Sweden. I would like to confer my earnest thanks to my illustrious supervisor, Gunnar 

Kullgren for his incisive support and invaluable guidance, extraordinary dedication in 

providing administrative and financial support for this project. I would like to give 

special thanks to Kjerstin Dahlblom and my closet friend Dr Mohammad Farhad Uddin. 

I would be grateful to Karin Johansson and Birgitta for their generous help, support, 

which give me certainty to stay in Umea. I am particularly grateful to Nils-Göran 

Lundström for his helping to get me admission in MPH program, and develop my interest 

to work on epidemiology. 

I express propound my gratitude to my wife for her extraordinary and comprehensive 

understanding and supporting for my study in Umea. I will remain forever in her debt, 

19


which give me strong promotion in this work. I will reciprocate her through my hard 

working in future. 

I am particularly grateful for the guidance in Bangladesh to Dr. A.K.M Fazlur Rahman, 

Executive director, Center for Injury Prevention and Research in Bangladesh. I would 

like to especially recognize and thank Anders Emmelin, Director of MPH program for 

administrative support for this project. Valuable help in initiating and conducting this 

study was provided by the following individuals: 

Head masters name: 

1. Hafiz uddin 

2. Mr malik 

3. Abdur razzak 

Most especially, I want to give thank the two volunteers Faisal abedin Tanim and Rajib 

who work with me to carry out field study perfectly. 

20


References 

Alem A, Kebede D, Kullgren G. 1999, The prevalence and socio-demographic correlates 

of khat chewing in Butajira, Ethiopia.. Acta Psychiatrica Scandinavica Supplementum.; 

397:84-91 

Breiman R and Thorpe P, Mortality Due to Suicide in Rural Bangladesh, Health and 

Science Bulletin Vol. 1 No. 5 December 2003.ICDDR, B 

Cynthia B. Lloyd, Facts about Adolescents from the Demography and health survey, 

statistical Tables for program Bangladesh 1996-1997, 10-14 

Fevziye Toros, Nursel Gamisz Bilgin, Tayyar Sasmaz, Resul Bugdayci, and Handan. 

2004, Suicide Attempts and Risk Factors among adolescence; Yonsei Medical Journal; 

vol 45, No 3, 367-374,. 

Goldstein TR, Birmaher B, Axelson D, Ryan ND, Strober MA, Gill MK, Valeri S, 

Chiappetta L, Leonard H, Hunt J, Bridge JA, Brent DA, Keller M. 2005; History of 

suicide attempts in pediatric bipolar disorder: factors associated with increased risk. 

Bipolar Disorder. Dec;7(6):525-35. 

Gould MS, Greenberg T, Velting DM, Shaffer D. 2003. Youth Suicide Risk and 

Preventive Interventions: A review of the past 10 years. Journal of the American 

Academy of Child and Adolescent Psychiatry. Apr; 42(4):386-405. 

Guilford, J.P.,1954, Psychometric methods, 2nd edition. New york, McGraw-hill.(9)120- 

132 

Herrera A, Dahlblom K, Dahlgren L and Kullgren G, 2006. Escape or problem solving 

Pathways to suicidal behaviour among adolescent girls in Nicaragua. Social science & 

medicine, 2006 Feb;62(4):805-14. Epub 2005 Aug 11. 

Herrera A. Caldera T, Kullgren G and Salander Renberg E. 2006, Suicidal expression 

among young people in Nicaragua- a community based study. Submitted for publication. 

Herrera A. Caldera T, Kullgren G, Pëna R and Salander Renberg E. 2005, Attitudes 

towards suicide (ATTS) among young population in Nicaragua, Submitted for 

publication. 

Holding T, 1974, The BBC Befriends series and its effects. British Journal of Psychiatry 

124, 470-2. 

HON, Mother & Child Glossary, Childhood Mental Health Suicidal Behavior, 

http://www.hon.ch/Dossier/MotherChild/child_mentalhealth/mentalhealth_suicide.html 

Human Rights Watch, Reports 2002, The Annual Report on violence against women in 

Bangladesh; http://www.hrw.org/doct=asia&c=bangla 

Internet, encyclopedia, 2005, mirpur, Dhaka. 

Ivarsson.T and Gillberg.C ; 1997, Depressive symptoms in Swedish adolescents; 

normative data using the Burleson Depression Self rating Scale ( DSRS). Journal of 

Affective Disorders. Jan; 42(1):59-68. 

21


Kirmayer LJ, Malus M, Boothroyd LJ; 1996, Suicide attempts among Inuit youth: a 

community survey of prevalence and risk factors. Acta Psychiatrica Scandinavica 

Supplementum. 1 Jul;94(1):8-17. 

Lado T. Ruzicka, 1998, Suicide in Countries and Areas of the ESCAP region, Asia- 

Pacific Journal Vol.13, No.4, December. 

Moscicki E, 1994, Gender differences in completed and attempt suicides. Annals of 

Epidemiology, 4, 1198-1200 

Nida Zemaitiene and Apolinaras Zaborskis, 2005, Suicidal tendencies and attitude 

towards freedom to choose suicide among Lithuanian schoolchildren: results from three 

cross-sectional studies in 1994, 1998, and 2002; BMC Public Health, Aug 11;5:83. 

Oppenheim AN. 1992; Questionnaire design, interviewing and attitude measurement. 

London: Printer Publishers, 303 p. 

Paykel ES, Myers JK, Lindenthal JJ, Tanner J, 1974, Suicidal feelings in the general 

population: a prevalence study, British Journal of Psychiatry. May; 124(0):460-9. 

Rancas, E., Lapins,J., Salander Renberg,E.,Jacobsson,L.,2003, Self reported suicidal and 

help seeking behaviour in the general population in Latvia. Social Psychiatry Psychiatric 

Epidemiology, 38(1), 18-26. 

Salander Renberg E & Jacobsson L , 2003, Development of a questionnaire on attitudes 

towards suicide (ATTS) and its application in a Swedish population. Suicide and Life 

Threatening Behaviour. Spring;33(1):52-64. 

Ronald C. Kessler, Patricia Berglund, Guilherme Borges, Matthew Nock, Philip S. Wang, 

2005; Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 

1990-1992 to 2001-2003 Journal of the American Medical Association. ; 293:2487-2495. 

Salander Renberg E, 2001; Self reported life awareness, death-wishes, suicidal ideation, 

suicidal plans and attempts in general population surveys in the north of Sweden 1986 

and 1996, Social Psychiatry and Psychiatric Epidemiology. 2001 Sep;36(9):429-36. 

Skrimshire, A. M, 1976, A small area analysis of self poisoning and self injury in the 

region of oxford, Journal of Biosocial Science 8, 85-112. 

UNESCO institute for statistic in Bangladesh,2005.www.uis.unesco.org 

WHO,2004,http://www.who.int/mediacentre/news/releases/2004/pr61/en/ 

World Health Organization: 2001 Background of SUPRE—Prevention of Suicide 

Behavior,.http://www.who.int/mental_health/prevention/suicide/background/ 

Youth suicidal behavior,2005; http://www.nelmh.org/ 

Yogeeta, 2005, WHO, regional office for south East Asia, Mental Health and Substance 

abuse, Suicide Prevention: Emerging from Darkness. September 8, 90-105. 

22


Appendix 

The ATTS questionnaire – abbreviated and revised version 

A. Contact with the suicide problem 

Initially there are some questions about your experiences of suicide problems in your 

closest surroundings. Please mark with a cross the appropriate alternative. (Items are 

scored never, some time, often and not applicable). 

1. Has any of the following persons (separate items for father/mother, brother/sister, 

child, partner, other relatives, friends, work-/schoolmates, others) 

a) - made a suicide attempt 

b) - expressed suicidal thoughts, plans or treats 

2. Is there at this very moment any person in your closest surrounding that you know has 

suicidal thoughts (similar alternatives, items scored no, yes and not applicable) 

3. Has any of the following persons committed suicide (similar alternatives, items scored 

no, yes and not applicable) 

B. Attitudes 

The following questions concern your opinion about suicide. Please mark 

with a cross the alternative that you find is in best accordance with your 

opinion. There are no rights or wrong answers! 

(Items are scored on the following scale: strongly agree, agree, undecided, 

disagree, strongly disagree) 

4. It is always possible to help a person having suicidal thoughts. 

5. Suicide can never be justified. 

6. Committing suicide is among the worst thing to do to ones relatives. 

7. Most suicide attempts are impulsive actions. 

8. Suicide is an acceptable means to terminate an incurable disease. 

9. Once a person has made up his/her mind about committing suicide no one can stop him/her 

10. Many suicide attempts are made because of revenge or to punish someone else. 

23


11. People who commit suicide are usually mentally ill. 

12. It is a human duty to try to stop someone from committing suicide. 

13. When a person commits suicide, it is something that he/she has considered for a long time. 

14. There is a risk of evoking suicidal thoughts in a persons mind if you ask about it. 

15. People who make suicidal threats seldom complete suicide. 

16. Suicide is a subject that one should rather not talk about. 

17. Loneliness could for me be a reason to take my life. 

18. Almost everyone has at one time or another thought about suicide. 

19. There may be situations where the only reasonable resolution is suicide. 

20. I could say that I would take my life without actually meaning to do so. 

21. Suicide can sometimes be a relief for those involved. 

22. Suicides among young people are particularly puzzling since they have everything to live for. 

23. I would consider the possibility of taking my life if I were to suffer from a severe, incurable, 

disease. 

24. A person once they have suicidal thoughts will never let them go. 

25. Suicide happens without warning. 

26. Most people avoid talking about suicide. 

27. If someone wants to commit suicide, it is his or her business and we should not interfere. 

28. It is mainly loneliness that drives people to suicide. 

29. A suicide attempt is essentially a cry for help. 

30. On the whole, I do not understand how people can take their lives. 

31. Usually relatives have no idea about what is going on when a person is thinking of suicide. 

32. A person suffering from a severe, incurable, disease expressing wishes to die should get help to 

do so. 

33. I am prepared to help a person in a suicidal crisis by making contact. 

34. Anybody can commit suicide. 

35. I can understand that people suffering from a severe, incurable, disease commit suicide. 

36. People who talk about suicide do not commit suicide. 

37. People do have the right to take their own lives. 

38. Most suicide attempts are caused by conflicts with a close person. 

39. I would like to get help to commit suicide if I were to suffer from a severe, incurable 

disease. 

40. Suicide can be prevented. 

41. Gender 

24


42. Age 

43. Education (-9 years, 10-12 years, 13 years or longer) 

44. Have you ever made an attempt to take your own life Last year and earlier in life on a yes, no 

scale, followed by number of attempts 

25

2006:10 Ma Yousuf Bhuiyan. Attitudes towards suicidal behaviour ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?