Factors associated with the risk of suicidal behavior among adolescents transitioning to secondary school in Nairobi County, Kenya: a cross-sectional study

Introduction adolescence is a transitory stage in the lives of young people. The transition from primary to secondary school among adolescents is associated with suicidal behavior but is not well characterized in the Kenyan context. This study sought to elucidate factors associated with the risk of suicidal behavior among adolescents aged 11-18 years in transition to secondary school. Methods a cross-sectional design was employed in the study that was conducted among adolescents in 5 randomly selected secondary schools in Nairobi County. The study involved 539 students who had joined form 1 in January 2020. Data were collected using the suicide behavior questionnaire-revised (SBQ-R) in March 2020. Factors associated with suicidal behavior were assessed using a generalized linear model (GLM), using a poisson distribution with a log-link function to estimate adjusted prevalence ratios (aPR), and a significance level of p=.05. Results one-fifth (20.04%) of adolescents with a median age of 14 years were at risk of suicidal behavior. Depression (aPR=3.16, C.I {1.85, 5.41}, p=0.001) and lifetime alcohol use (aPR=1.87, C.I {1.17, 2.97}, p=0.009) were found to be significant factors for suicidal behavior. Conclusion depression and lifetime alcohol use are associated with the risk of suicidal behavior among adolescents transitioning from primary to secondary school. Interventions may need to be targeted at the pre-secondary or primary school level to prevent underage alcohol use and enhancement of social support to prevent depression in this demographic of the population.


Introduction
Adolescence is a transitory stage in life: the transition from childhood to young adulthood, physical and morphological changes, and changes in social relationships. These transitions also coincide with the transition from primary to secondary school and this is likely to place an extra mental burden on adolescents. This is associated with a variety of challenges surrounding sexuality, rapid physical growth, interpersonal relationships, autonomy, and risk-taking behaviors among other issues. These issues can also predispose adolescents to suicidal behavior [1]. Adolescents account for over 250.000 annual deaths by suicide making suicide the second most prevalent cause of adolescent mortality around the world [2]. While studies on the prevalence and correlates of suicidal behavior are few in the Kenyan context, some authors have shown that suicidal behavior accounts for one in twenty deaths among children and adolescents in Kenya [3]. Depression, history of trauma, bullying, the development of social media and the platform it provides for cyberbullying, alcohol and substance use, parental rejection, and trauma are indicated for adolescent suicidal behavior. Other factors such as food insecurity and sexual intercourse are associated with an enhanced risk of suicidal behavior, especially among adolescent girls who are the most affected [4]. Indeed, a 2016 study demonstrated that adolescent girls have a higher likelihood of displaying suicidal behaviors. However, they are also less likely than boys to complete a suicide attempt [5]. The breadth of these associated factors points to a need for a context-specific understanding of suicidal behavior. This would help to inform contextually relevant suicide prevention screening and interventions [6][7][8]. While studies into adolescent suicidal behavior have tended to focus either on continuing students or a combination of transitioning and continuing students [9,10], we postulated that assessing adolescents in the transitory period would likely yield a deeper understanding of adolescent suicidal behavior at school. This has been demonstrated elsewhere, where adolescents transitioning to high school are at an increased risk of suicidal behavior [10]. The aim was to understand whether the predisposing factors for suicidal behavior were already present by the time adolescents were joining secondary schools or not. Guided by an intention to enrich the evidence base for adolescent mental health promotion in the school setting -where the opportunity to intervene exists [11]. This study sought to elucidate the factors associated with risk of suicidal behavior among adolescents transitioning between primary and secondary schools in Nairobi County, Kenya.

Methods
Study design and setting: the study utilized a cross-sectional design. The study was carried out in 5 secondary schools in Nairobi County: 1 boy school (school A), 2 girls´ only schools (schools B and C), and 2 mixed schools (schools D and E). Of the 5, 3 were boarding schools (A, B, and C), and the rest (D and E) were day schools. Nairobi county is a cosmopolitan county in the heart of Kenya that hosts the capital city, Nairobi. It is an urban county and is the seat of political, economic, and social power in Kenya. By the time the study was being carried out (January to March 2020), there were a total of 71 public secondary schools in the county which were either mixed schools, boys-or girls-only schools. Some of the schools were day schools while others were boarding schools. The study data collection was done just before the first reported cases of coronavirus in Kenya.
Study Population: the study population comprised adolescents who had joined form 1 in the selected schools in January 2020. The selection criteria for the adolescents were that they would have to have been transitioning from primary to secondary school, would have attended the school for at least one month before data collection, and informed consent from the parents and assent from the adolescents themselves.
Sampling: the five schools were selected by simple random sampling from a pool of 71 schools. A convenience sample of 539 adolescents was recruited for the study based on meeting the study criteria. The sample size was arrived at using Fisher´s formula based on the prevalence of suicidal behavior of 27.1% [9], which gave a minimum sample size of 304. A design effect of 2 was applied to the sample size, and a total of 608 students were invited, consent and assent were received from 539 guardians and students who participated, and their data were analyzed.
Data collection: data were collected using a selfadministered questionnaire in March 2020. Quality checks during data collection ensured that there was no missing data. The questionnaire collected data on adolescent sociodemographic characteristics (gender: binary either male or female, age: binary either 11-14 years or 15-18 years, description of caregiver: 4 categories mother only, father only, both or guardian); lifetime and past 30-day alcohol, drug, and tobacco use (binary: yes or no), socioeconomic status (classified as low 0-10, middle 11-20, and high 21+ based on an additive index of household ownership of various items), romantic relationship involvement (binary: yes or no), and sexual activity (binary: yes or no). Additionally, the suicide behavior questionnaire-revised (SBQ-R) was used to assess suicidal behavior, with an overall score of 7 or higher classifying an adolescent at-risk of suicidal behavior [12,13]. These questionnaires have been validated for use either in Kenya or other African countries for use with adolescent populations [9].
Data analysis: data analysis was carried out using STATA version 14. Descriptive statistics were computed as frequency distributions of the variables of interest in the study. The factors associated with suicidal behavior were analyzed through a generalized linear model (GLM), using a poisson distribution with a log-link function, to estimate adjusted prevalence ratios (aPR). This is because, for cross-sectional surveys, prevalence ratios are recommended as a measure of risk for common outcomes >10% compared to odd ratios [14]. The basis for the inclusion of variables in the multivariable model was a relaxed p-value of 0.2 in univariable analysis, but the evaluation of statistical significance was based on p < .05.
Ethical considerations: to protect the rights of the respondents, informed consent and assent were sought before data collection -which included both the guardians and adolescents. Permission to access and conduct the study in the selected schools was obtained from the County Director of Education. Additionally, ethical approval was sought and received from the University of Eastern Africa Baraton Institutional Ethics Review Committee (Approval number B132019 and renewed as UEAB/REC/02/03/2020).

Results
Sociodemographic characteristics of the study respondents: most of the adolescents were female 60.3% (n= 325) while males constituted 39.4% (n= 214). The results indicated that 66.4% (n=358) of the adolescents were living with both parents, 2.4 % (n=13) of the participants reported to be living with a father only, 21.2% (n=114) were living with a mother only and 10.0% (n=54) were living with a guardian. The highest number of adolescents were Christians (77.9%) compared to Muslims (22.1%). In terms of socio-economic status, 40.1% (n=216) of the adolescents were from the middle socio-economic class, and 32.3% (n=174) said that they were from the high socioeconomic class. In terms of suicide behavior, 80.0% (n=431) of the adolescents, did not report suicide risk compared to 20.0% (n=108) who reported risk of suicide. The study results indicated that 36.4% (n=196) of the adolescents had depressive symptoms while 63.6% (n=343) did not have depressive symptoms. The majority of the adolescents were not in romantic relationships (82.4%, n=444), were not sexually active (87.2%, n=470), and had never used alcohol (87.8%, n=473) and tobacco (98.9%, n=522) Table 1.

Risk of suicidal behavior among adolescents transitioning to secondary school in Nairobi
County: one-fifth (n=108, 20.04%) of adolescents in this study scored 7 or higher on the SBQ-R, meaning they had a high risk for suicidal behavior.
Factors associated with risk of suicidal behavior among adolescents attending public secondary schools in Nairobi County: in univariable analysis, depression, lifetime alcohol use, and past 30-days alcohol use were found to be significant risk factors for suicidal behavior at 95% confidence. Adolescents who reported depressive symptoms were found to have a higher prevalence ratio for suicidal behavior compared to those who did not have suicidal behavior [uPR=3.28, C.I (1.93-5.59); p=0.001]. Adolescents who had a history of lifetime alcohol use were found to have a higher prevalence ratio of suicidal behavior than adolescents who did not have a history of lifetime alcohol use [uPR=2.16 C.I (1.38-3.38); p= 0.001]. Specifically, alcohol use in the last 30 days was also a significant factor in suicidal behavior. Adolescents who had used alcohol in the past 30 days had a higher prevalence ratio for suicidal behavior than those who had not used alcohol in the past 30 days [uPR=2.38 (1.04-5.42); p=0.03]. Variables that met the relaxed threshold p-value of 0.2 at the univariable level were included in the multivariable model. In multivariable analysis, depression and lifetime alcohol use were found to be significant factors for suicidal behavior. While controlling for alcohol use, adolescents who had reported depressive symptoms had a higher prevalence ratio for suicidal behavior than those who did not report depressive symptoms (aPR=3.16, C.I {1.85, 5.41}, P=0.001). It was also found that while controlling for depressive symptoms, adolescents who had a history of lifetime alcohol use were found to have a higher prevalence ratio for suicidal behavior than adolescents who did not have a history of lifetime alcohol use (aPR=1.87, C.I {1.17, 2.97}, P=0.009) Table 2.

Discussion
This study sought to elucidate the factors associated with the risk of suicidal behavior among adolescents transitioning between primary and secondary schools in Nairobi County, Kenya. This study demonstrated that lifetime alcohol use and depression are the two most important factors associated with the risk of suicidal behavior among adolescents transitioning to secondary school. These findings corroborate other similar studies which demonstrated a link between adolescent suicidal behavior and depression and alcohol use respectively [15][16][17]. Adolescent depression is the single most important predictor of suicidal behavior [16]. In terms of adolescent alcohol use, this current study agrees with another study which demonstrated that any lifetime use of alcohol results in a two-fold increase in the risk of suicidal behavior [17]. However, more work is needed to fully characterize and understand the magnitude and directionality of the association between alcohol use and suicidal behavior among adolescents [18]. Several authors have demonstrated an association between gender and suicidal behavior, either independently or moderating the effect of depression or other predictors [5,16,19]. However, contrary to other studies this study did not demonstrate any link between adolescent gender and suicidal behavior this could be accounted for since adolescents in this study were in the formative stages of their secondary school education, they are, arguably, a homogeneous group and the unique gender differences and challenges that they are likely to face throughout secondary school were yet to emerge. Adolescent sexual activity -especially early sexual debut or initiation -is another factor that previous studies have associated with suicidal ideation and behavior [20], as well as a moderate to high risk of suicidal behavior in Kenya [21]. Sexual activity was not shown as statistically significantly associated with the risk of suicidal behavior in this study.
This current study did not demonstrate a link between illicit drug use or other substance use and the risk of suicidal behavior among adolescents. Contrary to this, a 2019 study found that cannabis and other illicit drug use are predictors of suicidal behavior in older adolescents. Similarly, for bullying victimizationwhile 85.7% of adolescents had experienced some form of victimization in the two months that they had been in secondary school bullying victimization had not yet become a factor associated with suicide risk. The association of bullying victimization among adolescents with current and suicidal ideation and behavior has been demonstrated severally [22,23]. The finding that bullying victimization is not associated with suicide risk could also be explained by the fact that the victimization was still ongoing. Added to this, studies have demonstrated that the effects of victimization in adolescence are seen either in later adolescence or young adulthood [24]. The use of the cross-sectional design limits the ability to draw causal inferences in this study. However, the study findings still provide useful insights that can inform future studies on suicidal behavior among adolescents in Kenya. Our findings corroborate the findings of other studies in Africa and beyond. Therefore, our recommendations are likely applicable beyond the specific local context of our study

Conclusion
Lifetime alcohol use and depression were associated with the risk of suicidal behavior among adolescents transitioning to secondary in Nairobi County. These factors were likely pre-existing before adolescents joined secondary schools. Therefore, preventive interventions should be targeted at primary and elementary schools. In seeking to prevent the early onset of alcohol use, the government and community stakeholders should partner to enforce alcohol distribution and consumption guidelines prohibiting the sale and consumption of alcohol to underage persons. Preventing depression among pre-secondary adolescents and children could be accomplished through contextualized school and communitybased interventions to enhance social support. Additionally, while the Ministry of Health Suicide Prevention Strategy 2021-2026 is a laudable milestone, its implementation and future direction require an enhanced recognition and emphasis on adolescent suicidal behavior.