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Qualitative content analysis of suicidal ideation in Korean college students
Collegian (2011) 18, 87—92
available at www.sciencedirect.com
Qualitative content analysis of suicidal ideation in Korean college students Kae-Hwa Jo, PhD, RN a, Gyeong Ju An, PhD, RN b,∗, Ki-Cheul Sohn, MD c a
Department of Nursing, School of Nursing, Catholic University of Daegu, Republic of Korea Department of Nursing, Cheongju University, Daesung-ro, Sangdang-gu, Cheongju 360-764, Republic of Korea c School of Medicine, Catholic University of Daegu, Republic of Korea b
Received 16 February 2010; received in revised form 9 October 2010; accepted 11 November 2010
KEYWORDS Suicidal ideation; College student; Qualitative content analysis; Korea
Summary The suicide rate for ages 15—24 increased recently in South Korea. The purpose of this study was to understand the suicidal ideation using the qualitative content analysis in South Korean college students. The data were collected with non-structured open questions in 134 college students and were analyzed with qualitative content analysis. The collected materials were classified 2 categories, 6 themes, and 21 theme clusters. Two categories are emerged: (1) facilitators of suicidal ideation, and (2) inhibitors of suicidal ideation. This study identified that the facilitators of suicidal ideation are physical, psychological and societal concerns, and suggested that the inhibitors of suicidal ideation are influenced by religious and cultural context. These results presented that Buddhism and Confucianism had influence on reasons to not attempting suicide behavior as the inhibitor of suicidal ideation. In conclusion, cultural context should be considered to develop strategies for the suicide prevention in South Korean college student. © 2010 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction In recent years, suicide has become a serious mental health problem in Korea. South Korea’s overall suicide rate more than doubled from 11.8 per 100,000 people in 1995 to 26.0 per 100,000 in 2008; it is the highest suicide rate among Organization for Economic Cooperation and Development (OECD) countries (Statistics Korea, 2008). Among
people aged 15—24 years, suicide is becoming a serious phenomenon in Korea, affecting 16.0 per 100,000 people, compared with 10.0 per 100,000 people in the United States. During the past 10 years, suicide has become the leading cause of death among young adults in Korea (Korean National Statistical Office, 2006). A recent study showed that 8.1% of college students had seriously considered suicide in Korea (Seogang University Counseling Center, 2008).
Background ∗
Corresponding author. Tel.: +82 43 229 8992; fax: +82 43 229 7988. E-mail addresses: [email protected], [email protected] (G.J. An).
The young adult stage is a period of transition and adjustment. All young adults experience socioeconomic changes as they enter independent life, employment, military service,
1322-7696/$ — see front matter © 2010 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.colegn.2010.11.001
88 and marriage (Min, 2005). However, many college students experience frustration due to the pressure of competition for good grades and failure to find work. As a result, they can become disappointed, pressured, and, finally, suicidal (Wu, Su, & Chen, 2009). Suicidal ideation means thinking about suicide without actually making plans to commit suicide (Crow, Eisenberg, Story, & Neumark-Sztainer, 2008). Numerous correlates of suicidal ideation during adolescence have been identified. These include family history of suicide (Brent & Mann, 2005), substance use disorders, early childhood maltreatment (Bridge, Goldstein, & Brent, 2006), and psychiatric disorders (Fergusson, Beautrais, & Horwood, 2003). Suicidal ideation appears prior to an actual suicide attempt, so to understand why students who did not attempt suicide while experiencing suicidal ideation should be helpful in developing suicide prevention strategies. There are many studies about both the prevalence and the predictors of suicide. In one previous study, depression indirectly predicted suicidal ideation, but other unknown variables predicting suicidal ideation may exist (Ha & An, 2008). According to Gutierrez, Rodriguez, & Garcia (2001), there are racial differences in suicide risk factors among white, black, and Hispanic young adults. Therefore, suicide research should take into account the context and importance of culture. However, most studies have been quantitative in nature, so it has been difficult to hear the living voices of those who have had personal experiences with suicidal ideation. Qualitative research methods are valuable in tracking unique events, illuminating the experience, and allowing interpretation of suicidal ideation. This study investigated how the participants faced and overcame their experiences with suicidal ideation.
K.-H. Jo et al.
Sampling For this study, 134 participants were selected from an advertisement attached to the bulletin board of ‘‘D university.’’ The inclusion criteria of the participants were the following: - Those who had experienced suicidal ideation within three years. - Those who had never attempted suicide. The each participant who saw the advertisement visited student counseling center in the university and received an ‘‘informed consent’’ form and questionnaire with an envelope for returning their private materials. They took the envelope home, and then those who agreed to participate in the study filled out the informed consent form and questionnaire. After completing the materials, the participants returned them to a collection box in the sealed envelopes.
Content analysis
Design
Qualitative content analysis is a method of managing and interpreting narrative material and, thus, has been associated with coding and classifying processes used in some types of qualitative research (Miles & Huberman, 1994). Content analysis was useful for this study because it is an unobtrusive method of analysis that can easily accommodate large amounts of data (Shuyler & Knight, 2003). The participants wrote in response to the open question, ‘‘Could you explain the situation when you had the suicidal ideation?’’ Researchers analyzed the materials by reading them and looking for themes and patterns. The authors of this study independently determined what categories spontaneously emerged from the data and then compared and contrasted all of the categories until agreeing on a final list. The authors then returned to the raw data and independently coded each response. Cohen’s kappa values are used for estimating inter-coder reliability used in qualitative content analysis. Resulting Cohen’s kappa values of .92 can be regarded as satisfactory (Strijbos, Martens, Prins, & Jochems, 2006). First, a coding scheme was developed using an inductive approach. Second, 10 materials were coded independently by two researchers, and inter-coder reliability was calculated using an on-line calculator (accessible at http://cosmion.net/jeroen/software/kappa/). The qualitative content analysis process was conducted according to the following steps:
This study was conducted using an exploratory design with qualitative data collected from March until June 2007. In this study, the participants who had an experience of suicidal ideation but not suicide attempt answered. Participants wrote about the situation that had provoked suicidal ideation in them. Students made honest and direct statements about suicidal ideation when they answered the open question; ‘‘Could you explain the situation when you had the suicidal ideation?’’ The participants freely described when they provoked suicidal ideation and what kind of thoughts inhibited the suicide attempts. Researchers reviewed and summarized the submitted materials.
(1) The units of analysis were defined as the words, ‘‘life,’’ ‘‘death,’’ and ‘‘suicide.’’ (2) The units were arranged in categories inductively using raw data. All statements were divided by themes and categories. (3) After the sample was coded, the coding consistency was checked by inter-coder agreement. (4) After sufficient consistency was achieved, coding was applied to all text, including the explanatory statement derived from the analysis. (5) All discrepancies were discussed until a final inter-rater agreement of 100% was reached.
Aim of the study The aim of this study was to explore the thoughts of students who had experienced suicidal ideation but had not attempted suicide, and to identify specific themes of suicidal ideation among college students in South Korea.
Method
Suicidal ideation in Korean students
Ethical consideration Ethical approval was granted by the institutional review board of the university. An information sheet explaining the purpose of the study was provided to the participants. The participants were informed that their confidentiality would be maintained and that they could withdraw from the study at any time. Materials were submitted anonymously. Because some of the participants could be at high risk for suicide, all participants were provided a list of telephone numbers of social network services after submitting their materials.
Results A total of 134 students consented to participate in this study. These participants’ ages ranged from 18 to 28 years (male 55, female 79). This study uncovered new perspectives on suicide, which has become a significant issue in Korean society, through content analysis of materials written by college students. Statements about suicidal ideation in the materials provided by 134 participants were divided into six themes in two categories: Facilitators of suicidal ideation and inhibitors of suicidal ideation.
Facilitators of suicidal ideation There are many facilitators of suicidal ideation, such as physical, psychological, and societal concerns. Regarding physical concerns, students wrote statements like the following: ‘‘If it is so hard to endure the pain, selecting suicide could be one way to finish the pain’’ and ‘‘I would think of suicide because of unsatisfied appearance as I need to have a plastic surgery.’’ Among the psychological concerns, participants expressed ideas such as ‘‘Suicide could be extreme way to escape from reality,’’ ‘‘I usually thinks the results in pessimistic view and there’s no one who I can talk with,’’ ‘‘There is hope nowhere,’’ ‘‘I broke my heart,’’ and ‘‘There is nothing I can do.’’ Regarding societal concerns, students wrote, ‘‘Suicide would be the best way if it raises my financial difficulty,’’ ‘‘My family is suffering from me,’’ ‘‘I was distressed by scholastic performance,’’ ‘‘It is responsibility of the society to commit suicide because of unemployment,’’ ‘‘I was discarded by my parent,’’ and ‘‘I have a problem to be socialized with others.’’ Some statements seemed to glorify suicide: ‘‘I would like to follow a celebrity’s suicide’’ and ‘‘Suicide in the flower of life is beautiful.’’ Among the facilitators of suicidal ideation, there are many influential factors in the area of societal concerns.
Inhibitors of suicidal ideation Reasons given for not attempting suicide included religious beliefs, individual beliefs, and relational beliefs. Regarding the transmigration of souls, participants provided statements such as ‘‘Nobody wants to be born again as such a worm,’’ and ‘‘Life after death could be more painful than this life.’’ Regarding filial piety, students wrote, ‘‘Suicide is the worst choice and make one’s parents in miserable
89 despair,’’ ‘‘Suicide is rude to one’s family and ancestors,’’ and ‘‘Suicide is such a thing to cut the lineage which was succeeded by parents.’’ They also wrote statements endowing the meaning of ‘‘survivorship,’’ like ‘‘Everyone should live their live happily because there is no more chance to live again,’’ ‘‘Every cloud has a silver lining,’’ ‘‘If the sky falls, we shall catch larks,’’ ‘‘As long as there is life, there is hope,’’ ‘‘I decided to think positively,’’ ‘‘Let me set the problem aside and ventilate my emotion,’’ ‘‘I changed my life pattern,’’ and ‘‘If I were you, I would live my life until I dead because suicide means the defeat to oneself.’’ Regarding self-dignity, there were statements such as ‘‘The person who has high self-esteem does not commit suicide,’’ ‘‘There is no life same as I,’’ and ‘‘We all are the image of God.’’ Some students wrote about the meaning of life: ‘‘I found the real meaning of life despite of bad situation’’ and ‘‘It was the true life to make an effort in desperate circumstance.’’ Statements such as the following referred to relational beliefs: ‘‘I received help of the organizational program,’’ ‘‘Counseling in suicide prevention center was helpful to prevent suicide,’’ ‘‘I was supported emotionally by internet community,’’ ‘‘It was helpful to receive support of family and friends,’’ and ‘‘organizational financial support prevented my suicide.’’
Discussion These participants expressed various suicide risk factors, including physical, psychological, and societal concerns. In this study, pain was identified as a physical concern that can facilitate suicidal ideation. This finding is consistent with a prior study that pain conditions are associated with an increased risk for suicidal ideation (Braden & Sullivan, 2008). Another theme cluster among physical concerns was ‘‘appearance complex.’’ According to previous studies, BMI (body mass index) and body dissatisfaction did not predict suicidal ideation (Crow et al., 2008). However, body image has been identified as an important indicator of suicidal ideation in Korea (Kim, 2009). Jung (1999) also showed that adolescent groups at high risk for suicide show some stress caused by their appearance. College students are in a complex transition process that includes physical change, social and political recognition, identity definition, and relationships with family and friends. This is reflected in Yu’s, 2003 research that reviewed the relationship between suicide and family environment. Family disorganization and a parentless family (Piquet & Wagner, 2003), loss of love (Beautrais, 2003), insufficient social and emotional support (Pfeffer, 1981), excessively distressed life styles (Beautrais, 2003), financial difficulty, and a lonely life (Qin & Mortensen, 2003) all correspond to the participants’ statements. In general, young adults’ attitude towards suicide is receptive (Jarvis & Boldt, 1982). Young people today are exposed to mass media such as TV, movies, and internet content that sometimes glorify suicide. For them, suicide is a way to escape from uncomfortable realities (Min, 2005). Korean students must study hard, and failure to get into a good school is considered shameful for students and their families (Park & Kim, 2009). Park found that suicidal ideation was significantly correlated with academic stress
90 and depression. Stress about employment is another facilitator for suicidal ideation in this study, in accordance with Min’s (2005) study that unemployment is a risk factor for suicide in college students. Pressure for success, competition, and disharmony between social and academic demands are also complex factors (Ha & An, 2008). Even though suicidal ideation could be an important predictor of suicide, it does not necessarily cause or lead to a suicide attempt. It is believed that thoughts of suicide and strong internal restraints against it occur simultaneously (Braden & Sullivan, 2008) (see Table 1). According to the ‘‘escape’’ theory of suicide, the person who commits suicide chooses suicide to escape from him/herself after six phases: the gap between expectation and reality, internal rationalization for the gap, negative evaluation of oneself, negative affection, cognitive ruin, and decreased restraint for suicide (Baumeister, 1990). In this theory, decreased restraint for suicide is an important factor leading to suicide. ‘‘Cognitive ruin’’ means the process of thinking that rejects constructional and integrated thought and becomes a way to escape from painful self-recognition and negative affection. Baumeister (1990) argues that the gap between expectation and reality causes stress and, eventually, leads to the impulse of suicide. Sohn (2007) also mentioned that suicide was related to depression more than impulse and that the risk of a suicide attempt increased with thoughts of suicide without impulse; thus, some people perceive suicide to be the last method for escape from pain and despair after consideration and emotional conflict. In this study, culture emerged as a suicidal-protective factor. Culture was defined as self-identity and communityidentity, community norms, and behavioral practices that affect how an individual engages in behavior linked to lifeor-death outcomes. In the past, suicide by burning was a ‘‘democratic’’ way for college students to demonstrate resistance against political and social problems, and this became a creature of the era in Korea (Nam, 1997). Ethnocultural differences are prevalent in adolescent suicidal behaviors (Roberts, Chen, & Roberts, 1997). However, Abdel-Khalek and Lester (2002) insist that there were no significant differences between the suicidal ideation rates in Kuwait and American undergraduates. More research is clearly needed to explore the differences in ethnocultural factors. The majority of college students in this study stated that their social system influences suicidal ideation. Thus, it is necessary to reflect both personal and social perspectives in developing suicide prevention programs. Indeed, it is urgent to establish intervention to prevent suicide among college students. Those who intend to commit suicide usually do not take actions to decrease their stress and blame, restrain themselves, or oppose this problem (Horesh et al., 1996). In Korean society, filial piety makes a person think of suicide negatively because dying earlier than one’s parents is considered a kind of crime. Filial piety, which is called ‘hyo’’ in Korean, is defined as supporting and serving one’s parents, and is a basic responsibility for a person. In Asia, since B.C. 2500, the culture of filial piety was established by Confucius. In Confucian ideals, filial piety is one of the virtues to be held above all else. The country that has flourished and inherited the filial piety until now as a culture is Korea (Glass, Chen, Hwang, Ono, & Nahapetyan, 2010).
K.-H. Jo et al. Many believe that a person who commits suicide will be born again as an animal or worm by transmigration of souls or reincarnation. Reincarnation is believed to occur when the soul or spirit, after the death of the body, comes back to the earth in a newborn body. This phenomenon is also known as transmigration of the souls. Each soul passes from one body to another in a continuous cycle of births and deaths, their condition in each existence being determined by their actions in previous births. Therefore, some Korean Buddhists believe that suicide make them rebirth as an animal (Shin, Cho, & Kim, 2005). Many moral systems dominant in traditional Korean culture prohibit or look unfavorably upon suicide, including Buddhism and Confucianism. Buddhism emphasizes the ‘‘Wheel of Life’’ (birth—death—rebirth), and Confucianism contains moral/ethical considerations. This should be considered a religious factor because religious coping style is important in developing suicide intervention programs (Spann, Molock, Barksdale, Matlin, & Puri, 2006). An active belief in life after death was mentioned as a coping strategy. These students overwhelmingly identified the need for coping strategies when confronting suicidal thoughts. Teaching various coping strategies can increase students’ resilience and should be an integral part of an end-of- life curriculum. Kim and Jung (1991) found that 60.9% of adolescents agree that everyone has to live, even though they are ‘‘worthless’’ people. This supports the statements, ‘‘Every cloud has a silver lining’’ and ‘‘If the sky falls, we shall catch larks’’ in this study. The proverbs express the opinion that life is important, and one has to have courage for one’s life. Meanwhile, Shin (1995) suggests that self-dignity and social support are needed for decreasing depression in college students, and Park and Kwon (2006) suggest that self-dignity, vocational identity, and communication with parents increase students’ life satisfaction. Therefore, it is necessary to make some effort to increase satisfaction and decrease depression by enhancing students’ self-dignity. In this study, programmatic assistance and counseling, emotional support of family and an internet community, and financial assistance worked to prevent suicide attempts. This implies that more community and on-line programs should be developed for young people. This study revealed that facilitators of suicidal ideation among college students are similar to those found in other countries. However, in Korean traditional culture, filial piety, the idea of the transmigration of souls, and incarnation beliefs influence the inhibition of suicide. This is in accordance with the findings of Gencoz, Vatan, Walker, & Lester (2007), that religion influences suicide, but in Korean society, traditional culture has a particularly strong influence. To summarize this study’s analysis and evaluation of suicidal inhibitors, it is clear that suicide prevention programs should incorporate cultural factors. According to Kao and Lusk (1997), there are some special factors to be considered for such education in Oriental culture because the recognition of death is largely affected by culture, and the death education programs of Western culture cannot be directly applied to Oriental culture. Therefore, it is necessary to have appropriate death education exploring the issue of
Suicidal ideation in Korean students Table 1
91
Qualitative content analysis of suicidal ideation.
Categories
Themes
Theme clusters
Facilitators of suicidal ideation
Physical concerns Psychological concerns Societal concerns
Pain, appearance complex Pessimistic view, worthlessness Interpersonal conflict, financial burden, study burden, unemployment, suicide of celebrity
Inhibitors of suicidal ideation
Religious belief
Filial piety, transmigration of soul, life after death, succeed of lineage, image of god Survivorship, self-dignity, meaning of life Support of family, support of on-line community, help of organization
Individual belief Relational belief
suicide included in any Korean undergraduate curriculum. These findings provide useful information for developing culturally appropriate suicide intervention for Korean youth. This study may have limitations that should be considered in interpreting and generalizing its findings due to unique culture and location. Nonetheless, it can be the basis for more consideration of cultural context in coping with suicidal ideation.
Conclusion In conclusion, this study identifies the facilitators of suicidal ideation as physical, psychological, and societal concerns and suggests that the inhibitors of suicidal ideation are influenced by religious and cultural contexts such as Buddhism and Confucianism. In the future, suicide prevention programs for college students should be developed based on the unique cultural background of South Korea.
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Gencoz, F., Vatan, S., Walker, R. L., & Lester, D. (2007). Hopelessness and suicidality in Turkish and American respondents. Omega, 55(4), 311—319. Glass, A. P., Chen, L. K., Hwang, E., Ono, Y., & Nahapetyan, L. (2010). A cross-cultural comparison of hospice development in Japan, South Korea, and Taiwan. Journal of Cross-Cultural Gerontology, 25(1), 1—19. Gutierrez, P. M, Rodriguez, P. J., & Garcia, P. (2001). Suicide risk factors for young adults: testing a model across ethnicities. Death Studies, 25(4), 319—340. Ha, J. H., & An, S. H. (2008). The verification of a structural relationship model of suicidal ideation to stress, coping styles, perfectionism, depression, and impulsivity. Korean Journal of Counseling and Psychotherapy, 20, 1149—1171. Horesh, N, Rolnick, T., Lancu, I., Dannon, P., Lepkifker, E., Apter, A., & Kotler, M. (1996). Coping styles and suicide risk. Acta Psychiatrica Scandinavica, 93(6), 489—493. Jarvis, G. K., & Boldt, M. (1982). Death styles among Canada’s Indians. Social Science and Medicine, 16(14), 1345—1352. Jung, C. S. (1999). Study on the adolescent‘s suicidal risk, stress and coping. Unpublished master’s thesis, Cheonan: Dankook University. Kao, S. F., & Lusk, B. (1997). Attitudes of Asian and American graduate nursing students towards death and dying. International Journal of Nursing Studies, 34(6), 438—443. Kim, C. K., & Jung, S. K. (1991). A relational study on attitudes toward death between life satisfaction and values of juveniles. Journal of Korean Social Health Education, 8(2), 61—73. Kim, D. S. (2009). Body image dissatisfaction as an important contributor to suicidal ideation in Korean adolescents: gender difference and mediation of parent and peer relationships. Journal of Psychosomatic Research, 66(4), 297—303. Korean National Statistical Office. (2006). The statistics compiled from causes of death, accessed at http://www.nso.go.kr. Miles, M. B., & Huberman, M. A. (1994). Qualitative data analysis. New York: Sage. Min, Y. K. (2005). Evaluation on suicidal risk factors and suicidal thought of college students. Journal of Student Guidance, 31, 31—52. Nam, M. (1997). Adolescent’s suicide. Journal of Korean Medicine Association, 40(10), 1282—1287. Park, H. S., & Kwon, B. S. (2006). Satisfaction with life and it’s predictors of college students. Journal of Korean Academy Psychiatric and Mental Health Nursing, 15(1), 48—56. Park, Y. S., & Kim, U. C. (2009). Factors influencing happiness among Korean adolescents: With specific focus on the influence of Psychological, relational and financial resources and academic achievement. Korean Journal of Psychology, 15(3), 399—429. Piquet, M. L, & Wagner, B. M. (2003). Coping responses of adolescent suicide attempters and their relation to suicidal ideation across
92 a 2-year follow-up: A preliminary study. Suicide Life and Threat Behavior, 33(3), 288—301. Pfeffer, C. R. (1981). Suicidal behavior of children: A review with implications for research and practice. American Journal of Psychiatry, 138(2), 154—159. Roberts, R. E., Chen, Y. R., & Roberts, C. R. (1997). Ethnocultural differences in prevalence of adolescent suicidal behaviors. Suicide Life and Threat Behavior, 27(2), 208—217. Qin, P., & Mortensen, P. B. (2003). The impact of parental status on the risk of completed suicide. Archive of General Psychiatry, 60(8), 797—802. Shin, K. R., Cho, M. O., & Kim, J. S. (2005). The meaning of death as experienced by elderly women of a Korean clan. Qualitative Health Research, 15(1), 5—18. Shin, H. O. (1995). Stress, social support and maladjustment of adolescents. Journal of Korean Association of Child Studies, 16(1), 89—98. Shuyler, K. S, & Knight, K. M. (2003). What are patients seeking when they turn to the internet? Qualitative content analysis of questions asked by visitors to an orthopaedics Web site. Journal of Medicine Internet Research, 5(4), e24.
K.-H. Jo et al. Seogang University Counseling Center. (2008). Report on student’s life. Seoul: Seogang University Press. Sohn, J. N. (2007). Discriminating power of suicidal ideation by life stress, coping strategy and depression in college students. Journal of Korean Psychiatric and Mental Health Nursing, 16(3), 267—275. Spann, M., Molock, S. D., Barksdale, C., Matlin, S., & Puri, R. (2006). Suicide and African American teenagers: risk factors and coping mechanisms. Suicide Life and Threat Behavior, 36(5), 553—568. Statistics Korea. (2008). The statistics compiled from report about OECD countries, accessed at http://www.kostat.go.kr. Strijbos, J. W., Martens, R. L., Prins, F. J., & Jochems, W. M. G. (2006). Content analysis: What are they talking about? Computers and Education, 46, 29—48. Wu, Y. W., Su, Y. J., & Chen, C. K. (2009). Clinical characteristics, precipitating stressors, and correlates of lethality among suicide attempters. Chang Gung Medical Journal, 32, 543—552. Yu, S. H. (2003). Domestic countermeasure of suicide. Soongsil University Society of Science Collection Paper, 6, 69—80.
available at www.sciencedirect.com
Qualitative content analysis of suicidal ideation in Korean college students Kae-Hwa Jo, PhD, RN a, Gyeong Ju An, PhD, RN b,∗, Ki-Cheul Sohn, MD c a
Department of Nursing, School of Nursing, Catholic University of Daegu, Republic of Korea Department of Nursing, Cheongju University, Daesung-ro, Sangdang-gu, Cheongju 360-764, Republic of Korea c School of Medicine, Catholic University of Daegu, Republic of Korea b
Received 16 February 2010; received in revised form 9 October 2010; accepted 11 November 2010
KEYWORDS Suicidal ideation; College student; Qualitative content analysis; Korea
Summary The suicide rate for ages 15—24 increased recently in South Korea. The purpose of this study was to understand the suicidal ideation using the qualitative content analysis in South Korean college students. The data were collected with non-structured open questions in 134 college students and were analyzed with qualitative content analysis. The collected materials were classified 2 categories, 6 themes, and 21 theme clusters. Two categories are emerged: (1) facilitators of suicidal ideation, and (2) inhibitors of suicidal ideation. This study identified that the facilitators of suicidal ideation are physical, psychological and societal concerns, and suggested that the inhibitors of suicidal ideation are influenced by religious and cultural context. These results presented that Buddhism and Confucianism had influence on reasons to not attempting suicide behavior as the inhibitor of suicidal ideation. In conclusion, cultural context should be considered to develop strategies for the suicide prevention in South Korean college student. © 2010 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Introduction In recent years, suicide has become a serious mental health problem in Korea. South Korea’s overall suicide rate more than doubled from 11.8 per 100,000 people in 1995 to 26.0 per 100,000 in 2008; it is the highest suicide rate among Organization for Economic Cooperation and Development (OECD) countries (Statistics Korea, 2008). Among
people aged 15—24 years, suicide is becoming a serious phenomenon in Korea, affecting 16.0 per 100,000 people, compared with 10.0 per 100,000 people in the United States. During the past 10 years, suicide has become the leading cause of death among young adults in Korea (Korean National Statistical Office, 2006). A recent study showed that 8.1% of college students had seriously considered suicide in Korea (Seogang University Counseling Center, 2008).
Background ∗
Corresponding author. Tel.: +82 43 229 8992; fax: +82 43 229 7988. E-mail addresses: [email protected], [email protected] (G.J. An).
The young adult stage is a period of transition and adjustment. All young adults experience socioeconomic changes as they enter independent life, employment, military service,
1322-7696/$ — see front matter © 2010 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
doi:10.1016/j.colegn.2010.11.001
88 and marriage (Min, 2005). However, many college students experience frustration due to the pressure of competition for good grades and failure to find work. As a result, they can become disappointed, pressured, and, finally, suicidal (Wu, Su, & Chen, 2009). Suicidal ideation means thinking about suicide without actually making plans to commit suicide (Crow, Eisenberg, Story, & Neumark-Sztainer, 2008). Numerous correlates of suicidal ideation during adolescence have been identified. These include family history of suicide (Brent & Mann, 2005), substance use disorders, early childhood maltreatment (Bridge, Goldstein, & Brent, 2006), and psychiatric disorders (Fergusson, Beautrais, & Horwood, 2003). Suicidal ideation appears prior to an actual suicide attempt, so to understand why students who did not attempt suicide while experiencing suicidal ideation should be helpful in developing suicide prevention strategies. There are many studies about both the prevalence and the predictors of suicide. In one previous study, depression indirectly predicted suicidal ideation, but other unknown variables predicting suicidal ideation may exist (Ha & An, 2008). According to Gutierrez, Rodriguez, & Garcia (2001), there are racial differences in suicide risk factors among white, black, and Hispanic young adults. Therefore, suicide research should take into account the context and importance of culture. However, most studies have been quantitative in nature, so it has been difficult to hear the living voices of those who have had personal experiences with suicidal ideation. Qualitative research methods are valuable in tracking unique events, illuminating the experience, and allowing interpretation of suicidal ideation. This study investigated how the participants faced and overcame their experiences with suicidal ideation.
K.-H. Jo et al.
Sampling For this study, 134 participants were selected from an advertisement attached to the bulletin board of ‘‘D university.’’ The inclusion criteria of the participants were the following: - Those who had experienced suicidal ideation within three years. - Those who had never attempted suicide. The each participant who saw the advertisement visited student counseling center in the university and received an ‘‘informed consent’’ form and questionnaire with an envelope for returning their private materials. They took the envelope home, and then those who agreed to participate in the study filled out the informed consent form and questionnaire. After completing the materials, the participants returned them to a collection box in the sealed envelopes.
Content analysis
Design
Qualitative content analysis is a method of managing and interpreting narrative material and, thus, has been associated with coding and classifying processes used in some types of qualitative research (Miles & Huberman, 1994). Content analysis was useful for this study because it is an unobtrusive method of analysis that can easily accommodate large amounts of data (Shuyler & Knight, 2003). The participants wrote in response to the open question, ‘‘Could you explain the situation when you had the suicidal ideation?’’ Researchers analyzed the materials by reading them and looking for themes and patterns. The authors of this study independently determined what categories spontaneously emerged from the data and then compared and contrasted all of the categories until agreeing on a final list. The authors then returned to the raw data and independently coded each response. Cohen’s kappa values are used for estimating inter-coder reliability used in qualitative content analysis. Resulting Cohen’s kappa values of .92 can be regarded as satisfactory (Strijbos, Martens, Prins, & Jochems, 2006). First, a coding scheme was developed using an inductive approach. Second, 10 materials were coded independently by two researchers, and inter-coder reliability was calculated using an on-line calculator (accessible at http://cosmion.net/jeroen/software/kappa/). The qualitative content analysis process was conducted according to the following steps:
This study was conducted using an exploratory design with qualitative data collected from March until June 2007. In this study, the participants who had an experience of suicidal ideation but not suicide attempt answered. Participants wrote about the situation that had provoked suicidal ideation in them. Students made honest and direct statements about suicidal ideation when they answered the open question; ‘‘Could you explain the situation when you had the suicidal ideation?’’ The participants freely described when they provoked suicidal ideation and what kind of thoughts inhibited the suicide attempts. Researchers reviewed and summarized the submitted materials.
(1) The units of analysis were defined as the words, ‘‘life,’’ ‘‘death,’’ and ‘‘suicide.’’ (2) The units were arranged in categories inductively using raw data. All statements were divided by themes and categories. (3) After the sample was coded, the coding consistency was checked by inter-coder agreement. (4) After sufficient consistency was achieved, coding was applied to all text, including the explanatory statement derived from the analysis. (5) All discrepancies were discussed until a final inter-rater agreement of 100% was reached.
Aim of the study The aim of this study was to explore the thoughts of students who had experienced suicidal ideation but had not attempted suicide, and to identify specific themes of suicidal ideation among college students in South Korea.
Method
Suicidal ideation in Korean students
Ethical consideration Ethical approval was granted by the institutional review board of the university. An information sheet explaining the purpose of the study was provided to the participants. The participants were informed that their confidentiality would be maintained and that they could withdraw from the study at any time. Materials were submitted anonymously. Because some of the participants could be at high risk for suicide, all participants were provided a list of telephone numbers of social network services after submitting their materials.
Results A total of 134 students consented to participate in this study. These participants’ ages ranged from 18 to 28 years (male 55, female 79). This study uncovered new perspectives on suicide, which has become a significant issue in Korean society, through content analysis of materials written by college students. Statements about suicidal ideation in the materials provided by 134 participants were divided into six themes in two categories: Facilitators of suicidal ideation and inhibitors of suicidal ideation.
Facilitators of suicidal ideation There are many facilitators of suicidal ideation, such as physical, psychological, and societal concerns. Regarding physical concerns, students wrote statements like the following: ‘‘If it is so hard to endure the pain, selecting suicide could be one way to finish the pain’’ and ‘‘I would think of suicide because of unsatisfied appearance as I need to have a plastic surgery.’’ Among the psychological concerns, participants expressed ideas such as ‘‘Suicide could be extreme way to escape from reality,’’ ‘‘I usually thinks the results in pessimistic view and there’s no one who I can talk with,’’ ‘‘There is hope nowhere,’’ ‘‘I broke my heart,’’ and ‘‘There is nothing I can do.’’ Regarding societal concerns, students wrote, ‘‘Suicide would be the best way if it raises my financial difficulty,’’ ‘‘My family is suffering from me,’’ ‘‘I was distressed by scholastic performance,’’ ‘‘It is responsibility of the society to commit suicide because of unemployment,’’ ‘‘I was discarded by my parent,’’ and ‘‘I have a problem to be socialized with others.’’ Some statements seemed to glorify suicide: ‘‘I would like to follow a celebrity’s suicide’’ and ‘‘Suicide in the flower of life is beautiful.’’ Among the facilitators of suicidal ideation, there are many influential factors in the area of societal concerns.
Inhibitors of suicidal ideation Reasons given for not attempting suicide included religious beliefs, individual beliefs, and relational beliefs. Regarding the transmigration of souls, participants provided statements such as ‘‘Nobody wants to be born again as such a worm,’’ and ‘‘Life after death could be more painful than this life.’’ Regarding filial piety, students wrote, ‘‘Suicide is the worst choice and make one’s parents in miserable
89 despair,’’ ‘‘Suicide is rude to one’s family and ancestors,’’ and ‘‘Suicide is such a thing to cut the lineage which was succeeded by parents.’’ They also wrote statements endowing the meaning of ‘‘survivorship,’’ like ‘‘Everyone should live their live happily because there is no more chance to live again,’’ ‘‘Every cloud has a silver lining,’’ ‘‘If the sky falls, we shall catch larks,’’ ‘‘As long as there is life, there is hope,’’ ‘‘I decided to think positively,’’ ‘‘Let me set the problem aside and ventilate my emotion,’’ ‘‘I changed my life pattern,’’ and ‘‘If I were you, I would live my life until I dead because suicide means the defeat to oneself.’’ Regarding self-dignity, there were statements such as ‘‘The person who has high self-esteem does not commit suicide,’’ ‘‘There is no life same as I,’’ and ‘‘We all are the image of God.’’ Some students wrote about the meaning of life: ‘‘I found the real meaning of life despite of bad situation’’ and ‘‘It was the true life to make an effort in desperate circumstance.’’ Statements such as the following referred to relational beliefs: ‘‘I received help of the organizational program,’’ ‘‘Counseling in suicide prevention center was helpful to prevent suicide,’’ ‘‘I was supported emotionally by internet community,’’ ‘‘It was helpful to receive support of family and friends,’’ and ‘‘organizational financial support prevented my suicide.’’
Discussion These participants expressed various suicide risk factors, including physical, psychological, and societal concerns. In this study, pain was identified as a physical concern that can facilitate suicidal ideation. This finding is consistent with a prior study that pain conditions are associated with an increased risk for suicidal ideation (Braden & Sullivan, 2008). Another theme cluster among physical concerns was ‘‘appearance complex.’’ According to previous studies, BMI (body mass index) and body dissatisfaction did not predict suicidal ideation (Crow et al., 2008). However, body image has been identified as an important indicator of suicidal ideation in Korea (Kim, 2009). Jung (1999) also showed that adolescent groups at high risk for suicide show some stress caused by their appearance. College students are in a complex transition process that includes physical change, social and political recognition, identity definition, and relationships with family and friends. This is reflected in Yu’s, 2003 research that reviewed the relationship between suicide and family environment. Family disorganization and a parentless family (Piquet & Wagner, 2003), loss of love (Beautrais, 2003), insufficient social and emotional support (Pfeffer, 1981), excessively distressed life styles (Beautrais, 2003), financial difficulty, and a lonely life (Qin & Mortensen, 2003) all correspond to the participants’ statements. In general, young adults’ attitude towards suicide is receptive (Jarvis & Boldt, 1982). Young people today are exposed to mass media such as TV, movies, and internet content that sometimes glorify suicide. For them, suicide is a way to escape from uncomfortable realities (Min, 2005). Korean students must study hard, and failure to get into a good school is considered shameful for students and their families (Park & Kim, 2009). Park found that suicidal ideation was significantly correlated with academic stress
90 and depression. Stress about employment is another facilitator for suicidal ideation in this study, in accordance with Min’s (2005) study that unemployment is a risk factor for suicide in college students. Pressure for success, competition, and disharmony between social and academic demands are also complex factors (Ha & An, 2008). Even though suicidal ideation could be an important predictor of suicide, it does not necessarily cause or lead to a suicide attempt. It is believed that thoughts of suicide and strong internal restraints against it occur simultaneously (Braden & Sullivan, 2008) (see Table 1). According to the ‘‘escape’’ theory of suicide, the person who commits suicide chooses suicide to escape from him/herself after six phases: the gap between expectation and reality, internal rationalization for the gap, negative evaluation of oneself, negative affection, cognitive ruin, and decreased restraint for suicide (Baumeister, 1990). In this theory, decreased restraint for suicide is an important factor leading to suicide. ‘‘Cognitive ruin’’ means the process of thinking that rejects constructional and integrated thought and becomes a way to escape from painful self-recognition and negative affection. Baumeister (1990) argues that the gap between expectation and reality causes stress and, eventually, leads to the impulse of suicide. Sohn (2007) also mentioned that suicide was related to depression more than impulse and that the risk of a suicide attempt increased with thoughts of suicide without impulse; thus, some people perceive suicide to be the last method for escape from pain and despair after consideration and emotional conflict. In this study, culture emerged as a suicidal-protective factor. Culture was defined as self-identity and communityidentity, community norms, and behavioral practices that affect how an individual engages in behavior linked to lifeor-death outcomes. In the past, suicide by burning was a ‘‘democratic’’ way for college students to demonstrate resistance against political and social problems, and this became a creature of the era in Korea (Nam, 1997). Ethnocultural differences are prevalent in adolescent suicidal behaviors (Roberts, Chen, & Roberts, 1997). However, Abdel-Khalek and Lester (2002) insist that there were no significant differences between the suicidal ideation rates in Kuwait and American undergraduates. More research is clearly needed to explore the differences in ethnocultural factors. The majority of college students in this study stated that their social system influences suicidal ideation. Thus, it is necessary to reflect both personal and social perspectives in developing suicide prevention programs. Indeed, it is urgent to establish intervention to prevent suicide among college students. Those who intend to commit suicide usually do not take actions to decrease their stress and blame, restrain themselves, or oppose this problem (Horesh et al., 1996). In Korean society, filial piety makes a person think of suicide negatively because dying earlier than one’s parents is considered a kind of crime. Filial piety, which is called ‘hyo’’ in Korean, is defined as supporting and serving one’s parents, and is a basic responsibility for a person. In Asia, since B.C. 2500, the culture of filial piety was established by Confucius. In Confucian ideals, filial piety is one of the virtues to be held above all else. The country that has flourished and inherited the filial piety until now as a culture is Korea (Glass, Chen, Hwang, Ono, & Nahapetyan, 2010).
K.-H. Jo et al. Many believe that a person who commits suicide will be born again as an animal or worm by transmigration of souls or reincarnation. Reincarnation is believed to occur when the soul or spirit, after the death of the body, comes back to the earth in a newborn body. This phenomenon is also known as transmigration of the souls. Each soul passes from one body to another in a continuous cycle of births and deaths, their condition in each existence being determined by their actions in previous births. Therefore, some Korean Buddhists believe that suicide make them rebirth as an animal (Shin, Cho, & Kim, 2005). Many moral systems dominant in traditional Korean culture prohibit or look unfavorably upon suicide, including Buddhism and Confucianism. Buddhism emphasizes the ‘‘Wheel of Life’’ (birth—death—rebirth), and Confucianism contains moral/ethical considerations. This should be considered a religious factor because religious coping style is important in developing suicide intervention programs (Spann, Molock, Barksdale, Matlin, & Puri, 2006). An active belief in life after death was mentioned as a coping strategy. These students overwhelmingly identified the need for coping strategies when confronting suicidal thoughts. Teaching various coping strategies can increase students’ resilience and should be an integral part of an end-of- life curriculum. Kim and Jung (1991) found that 60.9% of adolescents agree that everyone has to live, even though they are ‘‘worthless’’ people. This supports the statements, ‘‘Every cloud has a silver lining’’ and ‘‘If the sky falls, we shall catch larks’’ in this study. The proverbs express the opinion that life is important, and one has to have courage for one’s life. Meanwhile, Shin (1995) suggests that self-dignity and social support are needed for decreasing depression in college students, and Park and Kwon (2006) suggest that self-dignity, vocational identity, and communication with parents increase students’ life satisfaction. Therefore, it is necessary to make some effort to increase satisfaction and decrease depression by enhancing students’ self-dignity. In this study, programmatic assistance and counseling, emotional support of family and an internet community, and financial assistance worked to prevent suicide attempts. This implies that more community and on-line programs should be developed for young people. This study revealed that facilitators of suicidal ideation among college students are similar to those found in other countries. However, in Korean traditional culture, filial piety, the idea of the transmigration of souls, and incarnation beliefs influence the inhibition of suicide. This is in accordance with the findings of Gencoz, Vatan, Walker, & Lester (2007), that religion influences suicide, but in Korean society, traditional culture has a particularly strong influence. To summarize this study’s analysis and evaluation of suicidal inhibitors, it is clear that suicide prevention programs should incorporate cultural factors. According to Kao and Lusk (1997), there are some special factors to be considered for such education in Oriental culture because the recognition of death is largely affected by culture, and the death education programs of Western culture cannot be directly applied to Oriental culture. Therefore, it is necessary to have appropriate death education exploring the issue of
Suicidal ideation in Korean students Table 1
91
Qualitative content analysis of suicidal ideation.
Categories
Themes
Theme clusters
Facilitators of suicidal ideation
Physical concerns Psychological concerns Societal concerns
Pain, appearance complex Pessimistic view, worthlessness Interpersonal conflict, financial burden, study burden, unemployment, suicide of celebrity
Inhibitors of suicidal ideation
Religious belief
Filial piety, transmigration of soul, life after death, succeed of lineage, image of god Survivorship, self-dignity, meaning of life Support of family, support of on-line community, help of organization
Individual belief Relational belief
suicide included in any Korean undergraduate curriculum. These findings provide useful information for developing culturally appropriate suicide intervention for Korean youth. This study may have limitations that should be considered in interpreting and generalizing its findings due to unique culture and location. Nonetheless, it can be the basis for more consideration of cultural context in coping with suicidal ideation.
Conclusion In conclusion, this study identifies the facilitators of suicidal ideation as physical, psychological, and societal concerns and suggests that the inhibitors of suicidal ideation are influenced by religious and cultural contexts such as Buddhism and Confucianism. In the future, suicide prevention programs for college students should be developed based on the unique cultural background of South Korea.
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