Response rate

The high response rate of 95.6% (n = 2534 out of 2652 participants) was not unique to this study. Similar rates have been consistently found in Kenyan studies, particularly those involving school-going children.^{Reference Ndetei, Khasakhala, Mutiso, Ongecha-Owuor and Kokonya18,Reference Ndetei, Khasakhala, Mutiso, Ongecha-Owuor and Kokonya19} There are several explanations, including our approach of explaining the nature of the study to schools and communities to achieve buy-in, and the willingness to participate in an activity that has the potential to improve mental health – specifically, the mental health of students – and in turn improve academic performance.

Prevalence of thoughts, plans and attempts

The overall prevalence of 26.8% suicidal thoughts was well above rates reported for Western countries but within the range reported for other African countries, as referenced earlier in this paper. The disparity in prevalence between these regions could be due to socioeconomic factors.^{Reference Ndetei, Mutiso, Weisz, Okoth, Musyimi and Muia1} African countries often face greater economic instability, poverty and lack of access to basic resources such as healthcare, education and employment opportunities, which can contribute to higher levels of stress and hopelessness, increasing vulnerability to suicide. Furthermore, mental health services and resources are often limited in these countries, and the stigma surrounding mental illness may also prevent individuals from seeking help or accessing appropriate care even where services are available.^{Reference Ndetei, Mutiso, Maraj, Anderson, Musyimi and McKenzie20,Reference Mutiso, Pike, Musyimi, Rebello, Tele and Gitonga21}

However, the prevalence rates of 14.9% for plans and 15.7% for attempts were above those reported in the literature, as indicated earlier. These may reflect the prevailing situation, given the timing of the study with respect to events including the COVID-19 pandemic; media reports of war in Europe; an election year in Kenya, with threats of violence associated with past elections; and the consequences of climate change, presenting in Kenya with unusual extremes of temperature, droughts (failure of crops, death of livestock) often alternating with deadly floods.²² Even those students who did not have personal experience with these factors would have seen many reports in the media, potentially leading to vicarious trauma. In addition, the sample included students in the final year of high school, facing high-stakes exams and thus pressure to excel. Not all suicidal attempts were associated with thoughts and plans. This poses a challenge in predicting suicidal attempts, and there is thus a need for reliance on other associations of suicide attempts, as well as simple screening of mental health in schools.²³

Methods in suicidal plans and attempts

Methods were similar for plans and attempts, and they appeared to reflect availability and ease of access; this suggests that an important step toward preventing suicide may be to limit access to those methods. Our study found taking chemicals and poisons to be the leading method reported in plans and attempts in the Kenyan context, a finding similar to that of the WHO report referenced earlier. This finding is not surprising, because in Kenya these chemicals are widely available in homes and at agro-vet outlets for the control of vermin at homesteads and farms, and as herbicides and pesticides for agricultural activities such as the farming of tea, coffee and other crops and of livestock. These are major sources of income for families and the country. There is, therefore, a need for alternatives that are less injurious to human beings, coupled with regulations on availability and access and appropriate secure storage at home. This should be amplified by an awareness campaign targeting communities and families, especially those who use such poisons and chemicals for the economic activities specified above. The same general principles should be applied in relation to drug overdose (the third most common method), especially in relation to regulated access and availability, for prescribed drugs in particular, as well as involving caregivers at home in the oversight and safe custody of prescribed drugs at home. It is noteworthy that participants with a drug overdose suicide plan had two times greater odds of suicide attempt, reflecting easy access to these drugs.

It may be especially challenging to prevent suicides by hanging or cutting because of the wide range of options available at home and outside home. Raising caregiver awareness is paramount. To some extent, jumping from heights (buildings, bridges, etc.) can be mitigated by installing barriers on parapets, windows and other areas where people are likely to jump. It was noteworthy that in our study, having a jumping plan was a significant predictor of suicide attempts but in a negative direction; that is, participants with a jumping suicide plan had lower odds of attempting suicide than those who did not have a suicide plan. Worrisome, though, is the fact that methods traditionally associated with settings outside Kenya – cutting oneself, for example – are beginning to enter the scene in Kenya.

The fact that the students we surveyed had survived their attempts and could thus tell their stories may be a reflection of the mild severity of the attempts or the low lethality of the methods used. Overall, the findings suggest that exerting control over students’ environment at home, school and community may go a long way towards preventing youth suicide, and public and family awareness of methods could contribute to the prevention of suicide.

Mitigating the association of suicidal attempts with thoughts and plans

First, our findings suggest very strongly the need to take suicidal thoughts and plans seriously and on their own merit. This is because those with suicidal thoughts have an increased prevalence of plans, and those with plans have an increased prevalence of attempts (with the caveat that this was a cross-sectional population study, and we had no information on sequential or different staring points for a given individual). Second, our findings suggest that focusing only on thoughts and/or plans as necessary precursors of attempts may be inadequate, as nearly one-third of attempts appeared to be unanticipated on the basis of thoughts and plans.

Sociodemographic and environmental factors associated with suicidal attempts

We emphasise sociodemographic factors and other environmental factors because these are key to potential entry points for interventions; in particular, environmental factors that are amenable to manipulation as part of mitigation, for example, the availability of chemical and poisons, and the need for caregivers to be aware of various methods and hotspots in the community and at home. To this end, our findings confirm literature reports, including our own earlier findings,^{Reference Ndetei, Mutiso, Weisz, Okoth, Musyimi and Muia1} that older age (here reflected by increasing seniority of high school students) and urban rather than rural areas are associated with suicidality. Female gender and age are independently associated with suicidal attempts. In the Kenyan context, an important finding is that form 4 students, the most senior students in high school, are particularly vulnerable to suicide attempts. This final year is the most stressful as the students prepare for their National Examination, which will affect their future educational and career opportunities, i.e. whether or not they will qualify to continue their education by gaining admission to colleges and universities. Our study provides more information on environmental factors related to available methods; these environmental factors could be manipulated to mitigate suicidal attempts and suicide.

In summary, suicidal thoughts, plans and attempts are prevalent in Kenyan high school students. There are multiple methods with different frequencies of use, with taking chemicals and poisons being the leading method reported in plans and attempts. There are different starting points before suicidal attempts. Although the most common and well-documented starting point is from suicidal thoughts to plans to attempts, there are other starting points to attempts that do not include thoughts and plans. These other starting points may not lend themselves to detection at clinical and community levels except to the extent that various other associations can be identified, in particular, sociodemographic characteristics and environmental factors related to the availability of certain methods. There is, therefore, a need for reliance on the other various associations of suicide attempts. Being a senior-level student and going to a school in an urban area were associated with increased suicide attempts, whereas being in the final year of high school and female gender were independently associated with suicide attempts.

Strengths and limitations of the study

This was a cross-sectional study; thus, no causalities were drawn. Neither could we determine the different starting points for a given individual. As we used a self-report survey, there was a likelihood of social desirability bias, where participants might have responded to questions in a way that they perceived to be socially acceptable or desirable, rather than providing honest or accurate answers. Although this study was conducted in groups meeting in classrooms, with students filling out the questionnaire at their own pace, the students were given the option not to answer any question they did not want to answer. We only worked with the responses that the students were willing to provide, so it is possible that our findings would have been different in some respects if we had had all the information that some students chose not to provide. This study may not represent Kenyan high school students generally, as it was conducted in only three counties, which do not fully account for sociocultural differences across Kenya. In addition, the very sad fact that only those whose suicide attempts were unsuccessful could participate in the study meant that we were not able to assess associations of lethal suicide attempts. The focus of this study was on the prevalence of thoughts, plans and attempts, methods and modifiable environmental factors. It did not explore the mental health aspects. A major strength is the high response rate, as discussed above.

Recommendations

To understand the sequential progression from thoughts to plans to attempts we recommend a prospective study using mixed methods, i.e. qualitative and quantitative.