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A step back from the edge: empirical modeling of the role of social integration on suicide and associated deleterious health outcomes across adolescents from six middle-income countries



There is economic importance to stimulating awareness about preventing adolescent suicide and other associated deleterious mental and behavioral health outcomes, especially the long-term costs from lost productivity. However, the presence of stigma and poor healthcare reporting systems which often prevent data access have frequently limited research into these topics in low-and-middle income (LMICs) countries. The majority of existing research on these topics using LMICs data primarily focuses on prevalence rates and basic correlational associations, and is often a-theoretic. Empirically rigorous work, mostly found using data from the developed world, has primarily relegated suicide into a box of utility-maximization-based decisions. Social integration theory may be a more relevant approach for researching the mitigating factors to deleterious heath behaviors among adolescents in LMICs.


Using data from the Global School-based Student Health Survey (GSHS) of six different countries, we estimate a reduced-form, simultaneous model incorporating specialized clustering to determine the influence of social integration on five different deleterious health outcomes, including three levels of suicidal behavior.


Robust results indicate that positive parenting and social exclusion reduce and increase the likelihood of all outcomes, respectively, among both pooled and individual country samples.


Such results provide an impetus for pursuing interventions in LMICs, which focus on social-based, multi-level approaches. Such interventions could include such elements as peer-to-peer training support and awareness/promotion of mental health among parents of adolescents.

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Fig. 1

Data availability

The data is publically available online at

Code availability

STATA statistical software used for empirical analyses.


  1. 1.

    This is a standardized survey instrument created in collaboration among the WHO, United Nations’ UNICEF, UNESCO, and UNAIDS, with technical assistance from the U.S. Center for Disease Control (CDC) [79]. This survey uses a standardized scientific sample selection process, common school-based methodology, and core questionnaire modules. There are also expanded question modules and country-specific questions which form a self-administered questionnaire that 13–17-year-old students can be expected to complete in one regular class period.

  2. 2.

    This variable only captures drug use and not alcohol use. Within some of the countries used, religious prohibitions prevent the legal consumption of alcohol at any age (e.g. Bangladesh), meaning that the core module questionnaire in that country did not survey students on its consumption. Thus, to maintain consistency across the pooled samples, we chose to use drug use as a representative indicator of such risky health behaviours as drug and alcohol use.

  3. 3.

    There is evidence in literature supporting the strong predictive role that loneliness plays in the development [88,89,90] and experience [91,92,93] of mental health disorders, such as depression and anxiety. As such, experiences of loneliness, along with trouble sleeping, are two commonly measured symptoms in diagnostic survey instruments meant to capture mental health conditions [94,95,96]. These measures, thus, serve as reasonable means by which to capture overall negative mental health status.

  4. 4.

    One takes the mean survey weight value from each country, and each individual observation’s survey weight given from data is divided (i.e. weighted) by the mean weight from their respective country.


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Correspondence to Siobhan K. Yilmaz.

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Yilmaz, S.K., Bohara, A.K. A step back from the edge: empirical modeling of the role of social integration on suicide and associated deleterious health outcomes across adolescents from six middle-income countries. Soc Psychiatry Psychiatr Epidemiol 56, 793–805 (2021).

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  • Suicide
  • Multivariate probit
  • Cross-country
  • Social integration
  • Low-and-middle-income countries (LMIC)
  • Design-weighting