Outcome of a school-based intervention to promote life-skills among young people in Cambodia

Asian Journal of Psychiatry 9 (2014) 78–84

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Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp

Outcome of a school-based intervention to promote life-skills among young people in Cambodia Bhoomikumar Jegannathan a,b,*, Kjerstin Dahlblom c, Gunnar Kullgren b a

Center for Child and Adolescent Mental Health, Chey Chumneas Hospital Takhmau, Kandal Province, Cambodia Psychiatry, Department of Clinical Sciences, University of Umea˚, 901 85 Umea˚, Sweden c Epidemiology and Global Health, Department of Public Health and Clinical Medicine, University of Umea˚, 901 87 Umea˚, Sweden b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 31 October 2013 Received in revised form 18 January 2014 Accepted 23 January 2014

Background: Most of the school-based interventions to prevent suicide are from high income countries and there is a need for evidence based interventions in resource-poor settings. The aim of this study is to evaluate the outcome of a school based intervention to reduce risk factors for suicide among young people in Cambodia by promoting life skills. Method: Six classes were randomly selected from two schools each, one designated as experimental and the other as control school, respectively. In experimental school 168 young people (M = 92, F = 76) received 6 sessions of life skills education and in the control school 131 students (M = 53, F = 78) received three general sessions on health. We looked at the pre-post differences on Life-Skills Development Scale Adolescent Form (LSDS-AF)- and Youth Self-Report (YSR) questionnaire to measure the effect size (ES) from the intervention after 6 months. We analyzed the data by stratifying for gender and for those who reported more severe suicidal expressions at baseline (high-risk group). Results: The girls showed improvement in Human Relationship (ES = 0.57), Health Maintenance (ES = 0.20) and the Total Life Skills Dimensions (ES = 0.24), whereas boys with high-risk behavior improved on Human Relationship (ES = 0.48), Purpose in Life (ES = 0.26) and Total Life Skills Dimensions (ES = 0.22). Effect size for YSR-syndrome scores among all individuals showed no improvement for either gender. Among high-risk individuals boys had a small to moderate effect size from intervention on Withdrawn/Depressed (ES = 0.40), Attention problems (ES = 0.46), Rule breaking behavior (ES = 0.36), Aggressive behavior (ES = 0.48) and Externalizing syndrome (ES = 0.64). Conclusion: Promoting life skills in schools may enhance the overall mental health of young people, indirectly influencing suicide, particularly among boys with high-risk behavior in Cambodia. ß 2014 Elsevier B.V. All rights reserved.

Keywords: Outcome School based intervention Life skills Cambodia

1. Introduction Suicide ranks as one of the leading causes of death among young people in many countries in the world and about 100,000 young people take their own lives every year (WHO, 2007). In high income countries such as United States there is 8% increase of suicide between 2000 and 2004, particularly in the middle-school aged children which is alarming (Centers for Disease Control and

Abbreviations: ASEBA, Achenbach System of Empirically Based Assessment; ATTS, Attitudes Toward Suicide; CCAMH, Center for Child and Adolescent Mental Health; LMIC, Lower and Middle Income Countries; LSDS-AF, Life Skills Development ScaleAdolescent Form; YSR, Youth Self Report. * Corresponding author at: Center for Child and Adolescent Mental Health, Chey Chumneas Hospital, Takhmau, Kandal Province, Cambodia. Tel.: +855 23 983348; fax: +855 23 216258. E-mail addresses: [email protected] (B. Jegannathan), [email protected] (K. Dahlblom), [email protected] (G. Kullgren). 1876-2018/$ – see front matter ß 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2014.01.011

Prevention, 2004). Singapore, a high income country in Asia, reports increase of suicide rate among persons between 15 and 24 years of age, similar to the Western countries (Ung, 2003). There are no reliable figures on suicide among young people from low and middle income countries (Hawton et al., 2012), especially with post-conflict background (Gosh et al., 2004). Young people in the age group of 15–24 in post conflict and transitional countries such as Cambodia are vulnerable for high-risk behaviors and suicide (Somasundaram, 2007), particularly in the background of lack of institutional structures to help young people (Patel et al., 2007a,b). A cross-cultural study comparing Nicaragua and Cambodia reported slightly higher prevalence of overall suicidal expressions in the former, but found no difference in suicidal plans and attempts among young people (Obando Medina et al., 2012). Young people in Cambodia report frequent high risk behaviors such as substance abuse, sexual abuse and early sexual experience (Ministry of Education Youth and Sports Cambodia, 2010), which are highly correlated with suicidal behavior (Dube et al., 2001). The

B. Jegannathan et al. / Asian Journal of Psychiatry 9 (2014) 78–84

decades of civil strife following the genocidal Khmer Rouge regime had led to collective trauma, with significant impact on the mental health of young people (Mollica et al., 1998). Youth risk behavior survey from Cambodia in the age group of 11–18 years revealed that 19% of them expressed suicidal thoughts and 14% made suicidal plans. Among those who had suicidal thoughts, 39.5% had attempted suicide one-time and 12.4% more than three times (Ministry of Education Youth and Sports Cambodia-Pedagogical Research Department, 2004). There is a huge service gap in low and middle-income countries (LMIC), and it is vital to implement costeffective community and school based programs to treat as well as prevent mental health problems and suicidal behavior among young people (Patel et al., 2007a,b; Vijaykumar, 2007). A study from Cambodia, highlighted the importance of taking into consideration gender difference in suicidal expressions among young people while planning school-based suicide prevention strategies (Jegannathan and Kullgren, 2011). Community and school based interventions are more relevant in LMIC countries that face chronic shortage of mental health professionals (Patel et al., 2007a,b). Schools present a promising setting to implement comprehensive mental health promotion and suicide prevention programs as majority of young people spend one-third of the day in the school campus, where they can be reached (Joiner, 2009; King, 2001). The school based suicide prevention programs are categorical or general, based on whether the intervention is specific to suicide prevention or addresses overall mental health problem, and they can be further classified as universal, selective or indicated depending on whether the whole population, specific subgroups or individuals are involved, respectively (Kalafat, 2003). The students taking part in the indicated program are likely to feel stigmatized and it is often difficult to reach sub-populations under selective program (Burns and Patton, 2000), while categorical programs alone were found to be insufficient to serve the purpose (Kalafat, 2003). Universal intervention targeting the whole population seems to be the favored approach among school mental health professionals, with various components such as awareness programs, screening, skills-training, gate-keeper training and peer-mediated programs (Portzky and van Heeringen, 2006). Hawton et al. (2012), consider school based universal programs to improve the psychological well-being and help seeking behavior of the young people, but did not find evidence for reduction of suicidal behavior. There is no conclusive evidence on the types of intervention that are most efficacious in suicide prevention in school-setting (Guo and Harstall, 2002). King (2001) underscores the importance of continuing training of school personnel and evaluation of the school based suicide prevention programs. Most of the school based mental health intervention and studies are from high income countries (Robinson et al., 2013) and there is a wide ‘research-gap’ on the outcome of school based interventions among young people in low and middle income countries. To the best of our knowledge, this is the first controlled study from a post-conflict, low income country that evaluates the outcome of universal skill-training program aimed at reducing risk factors for suicide among young people with specific focus on gender and individuals reporting serious suicidal expressions. 2. Method 2.1. Setting Cambodia has a large number of young people as 42% of the population of 14.7 million is below the age of 15 years. The GNP per capita is 1000 USD, poverty rate 19.8% and Cambodia ranks 138 in human development index (Cambodia Millennium Development Goals, 2012). There are 95 men per hundred women and the adult

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literacy rate is 74%. While the primary school net enrolment is 96% during 2008–2011, the secondary school net attendance comes down to 45% for the same period (UNICEF-Cambodia-Statistics, 2013). The revival of educational system had been a challenge, as it was dismantled during the Khmer rouge era, and is gradually being rebuilt since the 80s by the Royal Government of Cambodia (Dy, 2004). This study was conducted at Takhmau, the headquarters of Kandal Province which has approximately 58,300 inhabitants and lies 11 km south of Phnom Penh, the capital of Cambodia. The two higher secondary schools, Hunsen Srey Pheap and Hunsen Takhmau from which we collected data are government schools, with similar characteristics in terms of location, structure, the number of teachers, syllabus and socioeconomic and cultural background of students. The students in the two secondary schools are predominantly from Takhmau, a suburban area, and approximately 15–20% of the students come from nearby villages. 2.2. Instruments In this study, we used the following instruments: Attitude Toward Suicide (ATTS), Youth Self Report (YSR) and Life Skills Development Scale-Adolescent Form (LSDS-AF) which give reliable data on suicidal expressions, mental health problems and life skill dimensions, respectively. There is robust evidence that mental health problems, in particular internalizing syndromes (withdrawn depressive states, somatic complaints), are strongly associated with suicidal behavior among adolescents (Liu et al., 2005) while drug abuse, impulsivity and externalizing syndrome also correlate with suicide (Javdani et al., 2011). We used the scores of YSR syndrome and Life Skill Dimensions as outcome variables in this study instead of suicidal expressions as they are less likely to function as outcome measure due to low prevalence rates. The mental health professionals working at CCAMH translated ATTS and LSDS-AF into Khmer after adapting it to the local context through series of discussions, and field-tested them. Contextually discordant or inappropriate statements were either omitted or changed for cultural congruence; for example statement such as, ‘‘As a passenger or driver in an automobile, I always use my seat belt’’ was changed to ‘‘I always wear a helmet when I drive my motorbike’’, as young people in Cambodia drive motorbikes and not cars. 2.2.1. The ‘‘Attitudes Toward Suicide’’ (ATTS) The ATTS, a semi-structured questionnaire has three parts and the first elicits information on exposure to suicidal expressions among significant others (parents, siblings, partners, relatives, and friends). The second part explores attitudes toward suicide and probes common beliefs and misconceptions on suicide. The third part, which is the focus of this study, is about the respondent’s own suicidal expressions (meaning of life, life-weariness, death thoughts, death wishes, suicide ideation, suicide plans, and suicide attempts) during the past year. The psychometric properties of the instrument have been validated by previous studies (Renberg, 2001; Renberg and Jacobsson, 2003). 2.2.2. Youth Self Report (YSR) The YSR, a component of the Achenbach System of Empirically Based Assessment (ASEBA), provides data on a broad spectrum of emotional, behavioral problems and competencies of young people in the age group of 11–18 years. It is a self-administered, semistructured questionnaire, consisting of 112 items on emotional and behavioral profile and is scored Likert-style: 0 – not true, 1 – somewhat or sometimes true, 2 – very true or often true. The following syndrome scales are constructed based on empirical findings that comprises items that tend to occur together: Anxious/ depression, Withdrawn/depression, Somatic complaints, Social

[(Fig._1)TD$IG]

B. Jegannathan et al. / Asian Journal of Psychiatry 9 (2014) 78–84

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Random selecon of Classes

Pre intervenon assessment, over a period of 6 to 8 weeks

Intervenon, each session 60 to 90 minutes, 1 or 2 sessions per week, spread over 20 to 24 weeks

Experimental school 10th standard: 11 Classes

Control school 10th standard: 10 Classes

6 Classes selected for life skills module based intervenon

6 Classes selected for general health and hygiene sessions

YSR and LSDS Adolescent form (Male 111, Female 92)

Six specific modules of the Life Skills Educaon intervenon

YSR and LSDS Adolescent form (Male 76, Female 92)

Three sessions of general educaon on hygiene, nutrion and First Aid

Aer 25 to 30 weeks

Post-intervenon assessment

YSR and LSDS Adolescent form (Male 92, Female 76)

YSR and LSDS Adolescent form (Male 53, Female 78)

Fig. 1. Study design.

problems, Thought problems, Attention problems, Aggressive behavior and rule-breaking behavior (Achenbach, 2009). The syndrome profiles are merged to provide scores on two broad syndromes, internalizing and externalizing (Achenbach and Rescorla, 2001). The responses refer to problems faced in the past six months and it takes about 30–40 minutes to complete the questionnaire. The instrument has been translated into more than 60 languages, including Khmer (Cambodian language), and crossculturally validated in several studies (Achenbach et al., 2008). The mental health professionals and the research team working at the Center for Child and Adolescent Mental Health (CCAMH), Takhmau, Kandal province, Cambodia, discussed the Khmer version provided by ASEBA, updated and field-tested the instrument before applying it. 2.2.3. The LSDS-Adolescent Form The Life Skill Dimensions Score Adolescent Form (LSDS-AF) measures the following four life skill dimensions: Interpersonal communication/Human Relationship skills, Problem solving/Decision-making skills, Physical fitness/Health maintenance skills, and Identity development/Purpose in life skills. It is a self-administered questionnaire, scored on a Likert-type scale where the respondents mark as follows: 1 – completely agree, 2 – mostly agree, 3 – mostly disagree, or 4 – completely disagree and high score indicates better life skills, as the statements relate to negative attributes. The reliability and validity of the LSDS-AF have been established by previous studies (Darden et al., 1996; Kadish et al., 2001). The LSDS-AF that we administered has 40 items, giving scores on the following life skill dimensions: Interpersonal Communication/ Human Relationship skills 8 items; Problem solving/Decision making skills 6 items; Physical fitness/Health Maintenance skills 12 items and Identity Development/Purpose in Life 14 items. 2.3. Sample and data collection We chose the two government secondary schools, Hun Serey Pheap and Hun Sen Takhmau which are in close proximity to the

research center and designated the two schools as ‘‘experimental’’ and ‘‘control school, respectively. Six classes from within both experimental and control schools were randomly selected to be included in the study. Initially 426 students gave informed consent to take part in the study, 217 from the intervention (Hun Serey Pheap) school and 209 students from control (Hun Sen Takhmau) school. The questionnaires were administered on different occasions: on the first occasion when YSR was administered, all 426 students completed the questionnaire and subsequently when we administered LSDSAF, 55 students failed to attend for various reasons. Therefore, the responses of the 321 students who had completed all the three instruments constituted the pre-intervention dataset. At the follow-up (post-intervention assessment), we lost respondents at different stages of the study, that left us with 299 students who had completed all the three instruments, both prior to and after the intervention, which is 93.1% of the pre-intervention dataset. When we analyzed the loss to follow-up among all the 426 students invited for the project, more boys than girls were non-completers, 67.5% vs. 32.5% (X2 = 11.103; p = 0.004) and students from the control school were more likely to be non-completers, 65.5% vs. 34.5% (X2 = 19.383; p = 0.000). The overall study design is as shown in Fig. 1. 2.4. Intervention In this study, the intervention focused on enabling young people to make healthy choices, adopt healthy behavior and reduce high-risk behavior by imparting them life skills (World Health Organization, 1997, p. 80). ‘The Activity Manual for the Teachers on Health Promotion Using Life Skills Approach’ deals with the five pairs of core set of skills viz. Creative and Critical thinking, Decision making and Problem solving, Effective communication and Interpersonal relationship skills, Self-awareness and Empathy and Coping with emotions stress (Bharath and Kishore, 2010). We had chosen the following Life Skill modules for intervention, as these dealt with the factors related to suicidal behavior

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Table 1 Prevalence of suicidal expressions among young people in Cambodia. ATTS items

Boys n = 159 N

%

n

%

n

%

Meaning of Life Life-weariness Death thought Death wishes Suicide ideation Suicide plans Suicide attempts

140 37 40 23 15 27 1

88.1 23.4 25.3 14.6 9.5 17.1 0.6

140 40 41 27 20 11 9

86.4 24.8 25.6 17.0 12.3 6.8 5.6

280 77 81 50 35 38 10

87.2 24.1 25.5 15.8 10.9 11.9 3.1

a

Girls n = 162

Total n = 321

X2

p-Value

0.191 0.089 0.004 0.351 0.668 8.107 6.453

0.66 0.77 0.95 0.55 0.41 0.004 0.011a

Fisher’s exact test.

(Fergusson et al., 2000; Schilling et al., 2009): Motivation, concentration and improving memory; Problem solving skills; Peer pressure and saying ‘No’ to drugs/tobacco; Coping with stress, facing changes/problems; Self-esteem, sensation-seeking behavior; Self-Awareness, understanding depression/suicide. A core team, comprised of teachers, psychologists, a psychiatric nurse and school nurses implemented the module to promote resiliency and to reduce vulnerability to suicide among young people (Fergusson et al., 2003; Forman and Kalafat, 1998), after adequate training. The weekly intervention sessions lasted 90– 100 min and were non-pedagogic and participatory. In contrast to the six modules that contained discussions, activities and homeassignment, the students in the control schools received only three lessons on health, hygiene and nutrition. These lessons were about hand washing, micronutrient deficiency such as anemia and learning.

of Chey Chumneas Hospital administrator where CCAMH-research team is located, gave permission to conduct the research. We informed the parent-committees of both the schools about the research through the school administration. The regional research ethics committee of Umea˚ University, Sweden gave clearance for the study (Dnr:07-046 M).

2.5. Analysis

3.2. Mental health profile (YSR syndrome)

We assessed the type of suicidal expressions and categorized as high-risk individuals those who reported any of the following: death wishes, suicidal ideation, plans or attempts during the recent year. We looked at YSR-syndrome scores gender wise, as well as for the high-risk group. Among YSR items missing data was between two and five percent among seven out of all 112 variables and less than two percent for the remaining variables. We imputed with the algorithm based on median values. Among the 40 items from LSDS form missing data was between one and two percent for five variables and less than two percent for the remaining variables and there was no imputation performed. We analyzed the Life Skills Dimension score gender wise, and the effect size to assess the magnitude of improvement, and reduction on YSR-syndrome scores by looking at the difference between the pre and post intervention mean score in the experimental versus control schools, with pooled standard deviation as denominator (Volker, 2006). We analyzed further by stratifying for gender and high-risk group. Analysis was performed using SPSS version 20.

There were not many significant difference in baseline scores between experimental and control schools other than a few: Scores on Aggressive behavior (p = 0.000) and Externalizing syndrome (p = 0.004) were significantly higher in experimental than control school and scores on Somatic complaints was significantly higher in control than experimental school (p = 0.002). Baseline scores on YSR-syndromes differed between high-risk individuals and others. When analyzed gender wise, boys in the high risk group scored significantly higher than boys with less severe suicidal expressions on Aggressive behavior only (p = 0.032), whereas girls with high-risk behavior scored significantly higher on Attention problem (p = 0.006), Aggressive behavior (p = 0.013) and Externalizing syndrome (p = 0.030) than girls with less severe suicidal expressions. Among all individuals, the effect sizes from the intervention on YSR syndrome scores were below 0.2, revealing less than small or no effect (Volker, 2006). In contrast, the effect size among boys in the high-risk group revealed scores higher than 0.2 (mild to moderate effect) in the following YSR syndromes: Withdrawn/ Depressed, Attention problems, Rule breaking behavior, Aggressive behavior and Externalizing syndrome. The effect size for all YSR syndromes among girls with suicide-high-risk behavior following intervention were below 0.2, revealing less than small or no effect (Table 2).

2.6. Ethical considerations The whole class was engaged in the study and intervention and the participation was voluntary. We informed the students about the nature of the study, the purpose of the intervention and gave notebooks, pen and other materials for use during the intervention in both experimental and control schools. We assured confidentiality at every stage from the data collection, storage, analysis and the reporting and we informed the students that they could optout of the study at any time. We informed the participants about availability of free counseling service in confidential setting at the center where the research team works. We provided the contact details of the counselors to all the participants. The headmasters of the schools, the provincial educational authority and the director

3. Results 3.1. Suicidal expressions (ATTS) Boys reported significantly more suicide plans whereas the girls reported more attempts as shown in Table 1. Overall, 78 of 321 teenagers (24.3%) reported either death wish, suicidal ideations, plans or attempts, and those expressing any of these were grouped as ‘high-risk individuals’ for the purpose of this study.

3.3. Life Skills Dimension scores At baseline, school wise comparison showed no significant difference between experimental and control schools in any of the Life Skills Dimension scores other than Problem solving/Decision making score which was higher among students in control school (p = 0.006). The baseline scores for Life Skills Dimensions when stratified for high-risk group individuals showed no difference for

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Table 2 Mean pre-post difference and effect size for YSR Syndrome scores among high-risk individuals. Items

Boys (pre post difference) Experimental (n = 21) Mean

YSR syndrome scales Anxious/Depressed Withdrawn Somatic complaints Social problems Attention problems Rule-breaking behavior Aggressive behavior Internalizing Externalizing a

0.905 0.048 0.143 0.809 0.381 0.143 1.333 1.000 1.91

Girls (pre post difference) Control (n = 15)

SD

Mean

3.064 2.765 3.568 3.642 2.085 2.435 4.520 6.738 5.192

Effect size

a

Experimental (n = 22)

SD

1.333 1.133 0.200 0.467 0.533 1.400 0.600 0.000 2.000

Mean

3.697 2.642 3.321 3.777 1.884 4.239 3.562 7.663 6.856

0.13 0.40 0.09 0.09 0.46 0.36 0.48 0.14 0.64

0.909 0.000 0.500 0.773 0.455 0.136 0.364 1.409 0.227

Control (n = 20) SD

Mean

SD

2.599 2.911 4.329 3.477 2.756 2.315 3.288 7.015 4.471

0.900 0.550 0.250 0.850 0.800 0.750 0.150 1.700 0.900

3.388 1.820 2.989 3.199 2.707 2.291 3.951 6.045 5.486

Effect sizea

0.00 0.23 0.07 0.02 0.13 0.38 0.06 0.04 0.13

Cohen’s D: 0.2 = small effect, 0.5 = moderate effect, 0.8 = large effect.

Table 3 Mean pre-post difference and effect size for Life Skills Dimensions score among high-risk individuals. Life Skill Dimensions

Human relationship (Total score 32) Decision making (Total score 24) Health maintenance (Total score 48) Purpose in life (Total score 56) Total LSE core a

Boys (36)

Girls (42)

Experimental (21)

Control (15)

Mean

SD

Mean

0.952 0.191 0.667 0.714 2.524

2.559 1.749 3.773 4.027 6.653

0.286 0.286 1.429 0.786 0.071

Effect size SD 2.644 3.361 5.487 7.084 14.258

0.48 0.18 0.16 0.26 0.22

a

Experimental (22)

Control (20)

Mean

SD

Mean

0.696 0.261 0.609 0.261 1.826

3.560 2.339 3.905 5.216 8.856

0.000 0.500 0.100 0.600 1.000

Effect sizea SD 3.642 2.685 5.534 4.429 9.857

0.19 0.09 0.15 0.07 0.09

Cohen’s D: 0.2 = small effect, 0.5 = moderate effect, 0.8 = large effect.

either gender between experimental and control school. The effect size from the intervention on Life Skills Dimension score among all individuals revealed some gender differences. The girls showed mild to moderate improvement after intervention in the following dimensions: Interpersonal Communication/Human relationship dimension (ES = 0.45), Physical fitness/Health Maintenance (ES = 0.20) and Total Life Skills Dimension (ES = 0.24), while boys showed improvement only in Interpersonal Communication/ Human relationship dimension (ES = 0.36). The boys with high-risk behavior showed mild to moderate improvement in Interpersonal Communication/Human relationship dimension, Identity Development/Purpose in Life and Total Life Skills Dimension scores unlike girls in the high risk group who scored below 0.2 in all dimensions, revealing less than small or no effect (Table 3). 4. Discussion Overall, the effect sizes indicate only mild to moderate improvement in Life Skills Dimension. Among all girls, scores improved in three out of four Life Skills Dimensions whereas boys improved on only one dimension. Among high-risk individuals, boys showed improvement on three dimensions with no improvement among girls. Effect size for YSR-syndrome scores among all individuals showed no improvement for either gender. Among high-risk individuals, boys had a small to moderate effect size in five out of all ten syndromes with no improvement among girls. 4.1. Suicidal expressions The teenage boys in our study reported more suicidal plans than girls unlike in the US (Grunbaum et al., 2002) but teenage girls in Cambodia reported more suicidal attempts, which is comparable

to the findings from India (Kar, 2010). The gender difference and the relationship between suicidal expressions and mental health problem among young people in Cambodia have been previously reported (Jegannathan and Kullgren, 2011), which also comes across in the current study. The percentage of high risk individuals reporting death wishes, ideation, plan and attempts in Cambodia is similar to a study from South Africa (Shilubane et al., 2013). 4.2. Mental health profile In our study, teenage boys with high-risk behavior showed significantly higher base line scores on Aggressive behavior and girls with high-risk behavior had higher scores on Attention problem, Aggressive behavior and Externalizing syndrome in contrast to the study by Kaess et al. (2011) that reported high internalizing and externalizing problems among girls and boys, respectively. King et al. (2001) found correlation between psychosocial and mental health problems and suicidal behavior in US while several authors underscore the role of psychosocial stressors and family issues rather than mental health problem in suicide in Asian context (Chang et al., 2009; Jegannathan et al., 2013; Keshavan et al., 2013; Vijaykumar, 2005). The effect size calculation showed small or no change in the mental health profile after intervention unlike the study by Randell et al. (2001) which reports enhancement of protective factors and reduction of risk factors following ‘‘active’’ intervention vs intervention ‘‘as usual’’. In general, the participants in our study did not benefit from the intervention, however teenage boys with high-risk behavior showed improvement in many YSR syndromes unlike girls. This is similar to the finding by Page et al. (2013). Factors such as lack of social skills, deficiency in problem solving skills and low selfesteem have been found to mediate suicidal behavior among young people (Hur et al., 2011; Speckens and Hawton, 2005; Wilburn and Smith, 2005) which may explain the complexity and

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the differential outcome of intervention. Gould et al. (2003) state that ‘it is not clear which aspect of the life skills training is beneficial to whom’ and recommend additional research in this area which reflects our findings.

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5. Conclusion Promoting life skills in schools may enhance the overall mental health of young people, indirectly influencing suicide, particularly among boys with high-risk behavior in Cambodia.

4.3. Life Skills Dimension 6. Recommendations Speckens and Hawton (2005) found evidence for deficient problem solving skills among those who attempted suicide. Our study showed no difference between high-risk individuals and others as far as Life Skills Dimensions are concerned, indicating that association between life skill dimensions and suicidal behavior might differ in diverse contexts. There is often contrasting views among researchers as far as impact of schoolbased life skills intervention on suicidal behavior of young people. Ploeg et al. (1996) and Page et al. (2013) consider promoting lifeskills and mental health competency act as protective factors against suicide, while Lafromboise and Lewis (2008) report that school based intervention ‘offsets the underlying factors’ that makes the young people vulnerable for high risk behavior. In a systematic review of 43 school-based interventions, Robinson et al. (2013) found evidence for gate-keeper training and screening to be useful, whereas another team finds the outcome data of school based intervention inconsistent and recommend more research (Robinson et al., 2011). The gender difference in outcome in our study is worth attention, as overall girls show improvement while boys with high-risk behavior benefit more from intervention, which is similar to the observation of Gould et al. (2003), who suggest that skills-training approach will have an ‘‘immunization effect’’ and result in reduction of suicide risk factors. A systematic review of a school based suicide prevention program report that skills training approach imparts generic life skills such as coping, problem solving, decision making and cognitive skills targeting indirectly on suicidal behavior by increasing protective factors and concludes combination of programs may benefit (Katz et al., 2013). This is line with our study findings and conclusion. Miller et al. (2009) report selective interventions to be methodologically superior with better outcome but our study indicates a combination of intervention would be better suited to Cambodian context. World Health Organization’s Global School Health Initiative emphasizes the importance of implementing effective, evidence based programs with clear and concise modules specifically prepared for the purpose of promoting overall health and reducing risk factor for suicide among young people (Inman et al., 2011; Weisz et al., 2005), which is the key focus of our intervention and is further supported by our study. 4.4. Limitations There were some limitations in the study. A national or region wise cluster randomized approach in selecting schools for the study might have been ideal, but was not possible for several reasons. We had to choose the schools reasonably accessible to the research team, as the intervention involved multiple visits and most rural schools were inaccessible. The sessions were performed class-wise with one school as ‘‘experiment school’’ where specific life skills modules were applied and the other as ‘‘control school’’ to avoid contamination, meaning intervention in one class influencing other classes in the same school. The outcome of the study pertains to semi-urban schools in Cambodia and could not be generalized to rest of the country, which is predominantly rural. Our study looks at the outcome in school going children in Cambodia, while young people who are out of school, are often more vulnerable for high-risk behaviors and suicide (Remschmidt and Belfer, 2005).

Recruiting large enough sample and more intervention sessions may give more robust results in similar school based research. Video-documentation of the intervention sessions and feedback discussions might improve the application of life skills modules, assuring uniformity and quality of intervention. Combining different strategies such as universal and selective approaches may give opportunity to compare effectiveness of different methods in diverse contexts. In addition, gender specific intervention and focusing on high-risk individuals may lead to better results. The teachers engaged in our life skills program at the local level valued the process which indicates the possibility of scaling up the school based mental health promotion at national level, provided the educational authorities are actively involved. Conflicts of interest None for all the authors. Contributors BJ took part in the design of the study, carried out the datacollection and analysis, and drafted the manuscript. GK participated in the design of the study, performed the statistical analysis, contributed to the results section, interpretation of the data, and gave feedback on the manuscript. KD was engaged in fine-tuning the design of the study and final review of the draft. Acknowledgements We acknowledge the role of Dr. Srikala Barath, Professor of psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore in training the core group of teachers and members of the CCAMH team to implement the life skills program in schools. This study was funded by SIDA-SAREC (ref. no: SWE-2006-092). References Achenbach, T.M., 2009. The Achenbach System of Empirically Based Assessment (ASEBA): Development, Findings, Theory, and Applications. University of Vermont Research Center for Children, Youth and Families, Burlington, VT. Achenbach, T.M., Becker, A., Do¨pfner, M., Heiervang, E., Roessner, V., Steinhausen, H., Rothenberger, A., 2008. Multicultural assessment of child and adolescent psychopathology with ASEBA and SDQ instruments: research findings, applications, and future directions. Journal of Child Psychology and Psychiatry 49, 251–275. Achenbach, T.M., Rescorla, L.A., 2001. Manual for the ASEBA School-age Forms and Profiles. University of Vermont Research Center for Children, Youth and Families, Burlington, VT. Bharath, S., Kishore, K., 2010. Empowering adolescents with life skills education in schools – school mental health program: does it work? Indian Journal of Psychiatry 52 (4) 344–349. Burns, J.M., Patton, G.C., 2000. Preventive interventions for youth suicide: a risk factor-based approach. Australian and New Zealand Journal of Psychiatry 34 (3) 388–407. Cambodia Millennium Development Goals, 2012. Retrieved from http://www.undp.org/. . ./mdg/the-millennium-development-goals-report-2012/. Centers for Disease Control and Prevention, 2004. Youth suicide and attempted suicide. MMWR Morbidity Mortality Weekly Report 53, 471. Chang, S.S., Gunnell, D., Sterne, J.A., Lu, T.H., Cheng, A.T., 2009. Was the economic crisis 1997–1998 responsible for rising suicide rates in East/Southeast Asia? A time–trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and Thailand. Social Science Medicine 68 (7) 1322–1331.

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