Suicidal Behaviors in a Nationally Representative Sample of School-Going Adolescents Aged 12–17 Years in Eswatini

The burgeoning body of evidence suggests that the aggregated 12-month prevalence estimates of suicidal behaviors (ideation, planning, and attempt) are relatively higher among in-school adolescents in Africa, although country-specific data on the phenomena are still inadequate from the continent. We sought to estimate the 12-month prevalence and identify some of the correlates of suicide behaviors among school-going adolescents in Eswatini. We analyzed the nationally representative data from the 2013 Eswatini World Health Organization Global School-based Student Health Survey, using univariate, bivariate, and multivariate statistical approaches. Of the 2,513 analytical samples, 17.0% (95% confidence interval [CI]: 15.4–18.4%) reported suicidal ideation, 21.0% (95% CI: 19.3–22.6%) made a suicide plan, and 15.5% (95% CI: 14.1–16.9%) attempted suicide during the previous 12 months. The final adjusted logistic models indicated health risk behavior (i.e., marijuana use), adverse interpersonal factors within the family (e.g., intrusion of privacy by parents), and school contextual factors (e.g., bullying victimization, physical fights) to be associated with increased odds of suicidal behaviors among females. However, predominantly, school-related interpersonal factors (e.g., bullying victimization, physical fights) showed strong associations with increased odds of suicidal behaviors among males. Generally, parental monitoring, parental understanding, and social support at school were associated with reduced odds of suicidal behaviors. The multi-level nature of our findings underscores the need for multi-contextual and multi-sectoral intervention and prevention programs and policy approaches targeted at mitigating the onset of suicidal ideation and possible transition to suicidal planning, attempt, and potential death by suicide in this young population.


Introduction
Suicidal behavior is used to mean "a range of behaviors that include thinking about suicide (or ideation), planning for suicide, attempting suicide and suicide itself" (WHO, 2014, p. 12). Suicidal ideation, planning, and (history of) attempted suicide are critical risks for suicidal death among all age groups within the general population (Klonsky et al., 2016;Turecki et al., 2019;WHO, 2014). This evidence underscores suicidal ideation, planning, and attempt as important suicide research foci, towards informing intervention and prevention efforts against deaths by suicide (Hawton et al., 2012;Nock, 2012;Turecki et al., 2019;Zalsman et al., 2016).
A recent systematic review pooling evidence on self-harm among both inschool and "out-of-school" adolescents in sub-Saharan Africa has reported a 12-month median prevalence estimate of 16.5% (interquartile range [IQR] = 10.9-24.0%) from Southern sub-Saharan Africa -where Eswatini is located (Quarshie et al., 2020c). Whereas evidence from high-income countries indicates that both prevalence estimates of suicidal ideation, planning, and attempt are higher among female adolescents than males (Hawton et al., 2012;Muehlenkamp et al., 2012;Swannell et al., 2014), the research findings from sub-Saharan Africa have shown mixed gender patterns (Quarshie et al., 2020c). Some studies have found comparable estimates between males and females (Liu et al., 2018;Quarshie & Andoh-Arthur, 2020), other studies have found higher estimates among males (Peltzer & Pengpid, 2017;Shaikh et al., 2016), while some studies have reported higher estimates among females (Asante et al., 2017;McKinnon et al., 2016). Even though these gender differences may be attributable to variations in the definitions and measurements of key outcome variables, methods, contexts, sampling, and sample characteristics of available studies, the parts of sub-Saharan Africa are available (Asante et al., 2017;Peltzer & Pengpid, 2017;Pengpid & Peltzer, 2020b;Quarshie et al., 2020a;Randall et al., 2014;Rudatsikira et al., 2007;Shaikh et al., 2016;Shayo & Lawala, 2019;Wilson et al., 2012). A comprehensive analysis of the WHO-GSHS Eswatini data will, among other useful purposes, allow for comparison with the published WHO-GSHS data on suicidal behaviors from other countries in (sub-Saharan) Africa.
Thus far, while only two recent country-specific studies have drawn on separate household survey data to report the prevalence and associated factors of suicidal behaviors among adolescents in Eswatini (Berhane et al., 2020;Pengpid & Peltzer, 2020a), only one country-specific study has analyzed the 2013 Eswatini WHO-GSHS dataset on suicide ideation (12-month prevalence estimates and associated factors) (Almansour & Siziya, 2017). Notably, several recent cross-national secondary analyses of the WHO-GSHS data from Africa have included the dataset from Eswatini, without reporting the country-specific correlates of suicidal ideation, planning, and attempt (Campisi et al., 2020;Li et al., 2020;Liu et al., 2018). Therefore, the current study seeks to analyze the 2013 Eswatini WHO-GSHS data on suicidal behaviors to address the following research questions: i) What are the 12-month prevalence estimates of suicidal ideation, planning, and attempt among school-going adolescents in Eswatini, and do the estimates differ for males and females? ii) What are the personal/lifestyle-, family-, school-, and interpersonal relationship-related factors associated with suicidal behaviors among school-going adolescents in Eswatini, and do these factors differ for males and females? Considering the remit of the data analyzed in the current study, the analysis considers suicidal behaviors to be composed of suicidal ideation, planning, and attempt.

Methods
The study was reported according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria (Vandenbroucke et al., 2007).

Study design
As applied in all participating countries, the 2013 Eswatini WHO-GSHS used a cross-sectional survey design involving a structured self-report questionnaire (WHO, 2020).

Study context
Eswatini is a lower middle-income country in Southern sub-Saharan Africa with a general population of 1,093,238 people, of which about 37% are aged 15-34 years (Government of the Kingdom of Eswatini & UNFPA, 2019). Eswatini is a medium human development index country (HDI rank = 0.611) with a life expectancy at birth of 60.2 years (UNDP, 2020). The country's population is youthful, as more than 120,000 are aged 15-19 years; expected years of schooling is 11.8 (mean = 6.9) (Government of the Kingdom of Eswatini & UNFPA, 2019; UNDP, 2020). Adolescents and young people (particularly, those aged 15-24 years) in the country face many challenges, including alcohol and substance use problems, early marriage, orphanhood, teenage pregnancy, maternal mortality, a relatively high incidence of HIV, and dropping out of school (Government of the Kingdom of Eswatini & UNFPA, 2019; Ministry of Education and Training & UNICEF, 2018;Ministry of Sports Culture & Youth Affairs, 2015). For example, in 2018, the estimated net primary school enrollment was 95%, whereas secondary school net enrollment rate was 46.3% -indicating a high attrition rate in the transition from primary school to secondary school, resulting in low educational attainment (Government of the Kingdom of Eswatini & UNFPA, 2019).

Data collection
Data for this study was obtained from the 2013 Eswatini WHO-GSHS. The GSHS data are collected from a nationally representative sample of secondary school students after ethical approval and the relevant authorities grant other permissions. Students who voluntarily consent to complete the survey record their answers on a computer-scannable form distributed by trained staff during one standard class period. No individually identifiable information is collected. Additional methodological details about the 2013 Eswatini GSHS have been reported by an earlier publication (Almansour & Siziya, 2017). As shown in Fig. 1, we applied a set of inclusion and exclusion criteria to obtain an analytical sample of adolescents aged 12-17 years, the typical age range of secondary school students in Eswatini.
Overall, 3,680 students responded to the survey, but our final analytical sample included 2,513 after the data selection criteria were applied (see Fig. 1). Of the 2,513 students aged between 12 and 17 years (mean = 15.4 years, standard deviation = 1.4) who provided complete data, 1,083 (43.1%) were males and 1,430 (56.9%) were females (Fig. 1).
The survey procedure followed the Eswatini Ministry of Education and Training and the ethical requirements for recruiting students for research. The Institutional Review Board of the Country Office of WHO in Eswatini, and the Eswatini Ministry of Education and Training, approved the survey (WHO, 2020).

Measures
Demographic variables Gender (male or female) and age were demographic variables included in this study.
Outcome variables This study's outcome variables were suicide ideation, suicide plan, and suicide attempt in the past 12 months. Each of these variables was measured using a single item on the questionnaire: suicide ideation ("During the past 12 months, did you seriously consider attempting suicide?"), suicide plan ("During the past 12 months, did you make a plan about how you would attempt  Fig. 1 Flow diagram of analytic sample selection process and criteria suicide?"), suicide attempt ("During the past 12 months, how many times did you actually attempt suicide?"). See e- Table 1 in Supplementary Material for all the variables included in this study, the questions used in assessing each variable, and how responses were coded for statistical analysis.

Statistical analysis
Three statistical analyses were performed using SPSS (version 27 for windows): 1) Univariate analysis (i.e., percentages and frequencies) was performed to determine the 12-month prevalence estimates of suicidal ideation, planning, and attempt; 2) Bivariate analysis using chi-square ( 2 ) to determine the relationship between the exposure variables and each of the outcome variables; and 3) Multivariate models, one each for the outcome variables involving logistic regression, were used to determine the demographic factors and exposure variables associated with the outcome variables (suicidal ideation, planning, and attempt).
To avoid overfitting the models, the demographic and exposure variables were entered into the logistic regression models regardless of their significant bivariate associations with the outcome variables (Babyak, 2004;Sun et al., 1996). The two demographic variables were included as covariates in all three multivariate models. The logistic regression modeling results were reported as adjusted odd ratios (AOR) with their associated 95% confidence intervals (95% CI). Guided by the research questions of the study, the bivariate and multivariate analyses were stratified by gender. Missing responses were excluded from the analysis; e-Table 1 (in Supplementary Material) shows the proportion of missing data related to each variable. The statistical significance threshold was set at p < 0.05.
Data for study is publicly accessible and available on the WHO website: https:// www. who. int/ ncds/ surve illan ce/ gshs/ swazi land/ en/.
The subgroup analysis showed that while bullying victimization (AOR = 1.72, 95% CI = 1.10, 2.70; p = 0.018) was uniquely associated with increased odds of suicidal ideation among males, physical fights (AOR = 2.29, 95% CI = 1.49, 3.51; p < 0.001) emerged as a significant associate of increased odds of suicidal attempt in females. The model (Table 3) showed marijuana use as the only factor commonly associated with increased odds of suicidal attempts in both male (AOR = 3.0, 95% CI = 1.47, 6.11; p = 0.002) and female (AOR = 2.94, 95% CI = 1.01, 8.54; p = 0.048) participants. Specifically, both males and females who reported marijuana use were about three times more likely to report attempted suicide during the previous 12 months than their counterparts who reported no marijuana use.

Discussion
In this secondary analysis of the 2013 Eswatini WHO-GSHS data, we have found that approximately 1.7 out of 10 participants reported suicidal ideation, 1 out of 5 reported suicidal planning, and about 1.5 out of 10 participants attempted suicide during the previous 12 months. The prevalence estimate of suicidal ideation was higher among females than males, while the estimates of suicidal planning and attempt were comparable between females and males. Multivariate statistical modeling of the data showed the female gender to be associated with increased odds of suicidal ideation, planning, and attempt during the previous 12 months. Among females, the multivariable statistical modeling found health risk behavior (i.e., marijuana use), adverse interpersonal factors within the family (e.g., intrusion of privacy by parents), and school contextual factors (e.g., bullying victimization, physical fights) to be associated with increased odds of suicidal behaviors. However, predominantly, school-related interpersonal factors (e.g., bullying victimization, social support at school, physical fights) showed strong associations with suicidal behaviors among males.

Prevalence of suicidal behaviors
The prevalence estimates observed in the current study are relatively higher than the known recent global estimates of suicidal behaviors among school-going adolescents (Lim et al., 2019); however, continentally and regionally, the reported 12-month prevalence estimates in the current study are comparable to the pooled estimates of recent studies from Africa and sub-Saharan Africa (Biswas et al., 2020;Campisi et al., 2020;Li et al., 2020;Liu et al., 2018;Uddin et al., 2019). More interestingly, within the specific context of sub-Saharan Africa, the estimate of suicide attempt reported in the current study ( (Almansour & Siziya, 2017). Similarly, the estimates of suicidal planning and attempt in the current study are comparable to recently reported estimates based on the 2013 Eswatini WHO-GSHS dataset (Campisi et al., 2020;Li et al., 2020;Liu et al., 2018). However, the prevalence estimates by the current study are higher relative to recent estimates from household and community-based studies involving adolescents in Eswatini -which have reported suicidal behavior to be 9.0% (Pengpid & Peltzer, 2020a), 7.1% in respect of suicidal ideation, and 5.3% in respect of suicidal attempt (Berhane et al., 2020). While the differences in the prevalence estimates between the school-based and community-based studies could be due to differences in sample characteristics and measures used, the differences could also be attributed to the possibility that the school environment in Eswatini may be presenting adolescents with adverse challenges and circumstances that potentially contribute to the onset of suicidal tendencies among secondary school students (Harber, 2017;Quarshie et al., 2020c).
Furthermore, the prevalence estimates of the current study are consistent with estimates from other Southern sub-Saharan African countries, including Namibia (Peltzer & Pengpid, 2017), South Africa (James et al., 2017;Shilubane et al., 2013), and Mozambique (Pengpid & Peltzer, 2020b;Seidu et al., 2020), which suggest that comparatively more school-attending female adolescents than males report suicidal behaviors. As observed by a recent systematic review on self-harm and suicidal behaviors among young people in sub-Saharan Africa (Quarshie et al., 2020c), it stands to suggest that the prevalence estimates reported in the current study could be pointing to the possibility that the precipitating factors of suicidal behaviors among school-going adolescents in Southern sub-Saharan African countries may be similar rather than varied.

Factors associated with suicidal behaviors
The multivariable statistical modeling results align with the socio-ecological framework for the understanding of suicidal behavior among adolescents (Centers for Disease Control & Prevention, 2019; Perkins & Hartless, 2002;Pfledderer et al., 2019;Shagle & Barber, 1995;WHO, 2014). The analysis showed that the factors associated with suicidal ideation, planning, and attempt exist at multiple levels of the socio-ecological context of adolescents: individual-level factors (e.g., female gender, anxiety, loneliness, marijuana use), family environment factors (e.g., intrusion of privacy by parents, food deprivation, parental understanding), school-related factors (e.g., social support at school, bullying), and interpersonal factors (e.g., physical fights, being sexually active) are associated with suicidal behavior among school-going adolescents in Eswatini.
Specifically, the current study has shown the female gender (compared to male) to have a strong association with the odds of suicidal ideation, planning, and attempt. This evidence is consistent with previous findings from other countries in sub-Saharan Africa, including Malawi (Shaikh et al., 2016), Mozambique (Pengpid & Peltzer, 2020b;Seidu et al., 2020), Ghana (Asante et al., 2017), South Africa (Shilubane et al., 2013), and Tanzania (Shayo & Lawala, 2019). While this finding is worrying, it is not entirely surprising, considering the numerous telling psychosocial challenges that girls and women (relative to boys and men) experience in LAM-ICs generally, and specifically in sub-Saharan Africa (Petroni et al., 2015). In other words, the evidence that female adolescents -relative to males -are at elevated odds of suicidal behavior could be pointing to the high vulnerability of girls and women to rigid and unsupportive cultural norms, social and educational exclusion, discrimination, and abuse of various forms in sub-Saharan African countries and other resource-poor contexts (Kabiru, 2015;Kabiru et al., 2013). The implication is that clinical mental health support models and intervention should be supplemented with social and family interventions.
In terms of health risk behaviors associated with increased odds of suicidal behavior, marijuana use showed a strong association with suicidal ideation, planning, and attempt among females but was associated with only suicide attempts among males. On the one hand, this evidence is surprising, given that more male adolescents than females misuse marijuana; on the other hand, this evidence is to be expected considering the country-wide evidence that many school-going young people are involved in the production, transportation, and sale of marijuana in Eswatini (Ministry of Sports Culture & Youth Affairs, 2015;Mkhatshwa & Malambe, 2019), and "Swaziland has two common types of substance abuses and are regarded as socially acceptable: alcohol and marijuana…" (Youth Policy Press, 2015, p. 67). Swaziland was the former name of the present-day sub-Saharan African country, Eswatini (or the Kingdom of eSwatini) -Eswatini was adopted to replace the old name, Swaziland, effective June 1, 2018.
Notably though, compared to the male subgroup, the confidence intervals around the odds ratios of marijuana use in the female subgroup were wide, which indicates limited statistical power. This evidence would benefit from future studies that examine further the gender difference in the association between marijuana use and suicidal behavior among school-going adolescents in Eswatini. Beyond these, the current evidence of marijuana use being associated with increased odds of suicidal behavior is consistent with key findings by earlier and recent primary studies and systematic reviews (Almansour & Siziya, 2017;Borges & Loera, 2010;Carvalho et al., 2019;Gobbi et al., 2019;Tetteh et al., 2020). Evidence suggests that marijuana use has adverse health outcomes among adolescents: it impairs memory and judgement, and complicates the course of loneliness and depression, thereby elevating the risk for suicidal behaviors (Borges & Loera, 2010;Paruk & Burns, 2016;Volkow et al., 2014). Urgent concerted efforts are needed to formulate and implement regulations and control measures and policies against the unfettered access and use of marijuana (and other illicit drugs) by young people in the Eswatini (Mkhatshwa & Malambe, 2019).
The findings of the current study that intrusion of privacy by parentswithin the family context -was associated with increased odds of suicidal behavior and, in contrast, parental monitoring and parental understanding were associated with reduced odds of suicidal behavior across the overall sample, are consistent with recent evidence from Eswatini (Almansour & Siziya, 2017) and other Southern sub-Saharan African countries, including Mozambique (Pengpid & Peltzer, 2020b;Seidu et al., 2020) and South Africa (Shilubane et al., 2012). Life-course models to understanding human development have suggested that parent-adolescent connectedness, parental understanding, parental supervision and supportive monitoring, and having supportive social networks present as strong determinants of wellbeing and positive (mental) health outcomes in adolescents across contexts and cultures (Patton et al., 2016;Viner et al., 2012). Consistent with previous studies from other parts of sub-Saharan Africa (Asante et al., 2017;Koyanagi, et al., 2019aKoyanagi, et al., , 2019bQuarshie et al., 2020a;Seidu et al., 2020;Shayo & Lawala, 2019), the current study has shown that food deprivation is associated with increased odds of suicidal behavior among school-going adolescents. Evidence suggests that young people who experience hunger tend to be irritable with high emotional responsiveness and may experience increased distraction that potentially could result in suicidal behaviors (Asante et al., 2017;Koyanagi, et al., 2019aKoyanagi, et al., , 2019b. Adverse interpersonal factors and school-related problems (i.e., bullying victimization, physical fights, and truancy) showed strong associations with increased odds of suicidal behaviors in the current study; however, social support at school was associated with reduced odds of suicidal behaviors, particularly suicidal planning among males. These findings lend support to previous studies based on the WHO-GSHS data from other African countries that suggest that social adversities and adverse school-related experiences could lead to internalizing problems -including loneliness, depression, self-hate, feelings of guilt and shame -which in turn contribute to elevated risk for self-harm and suicidal tendencies among young people (Epstein et al., 2020;Koyanagi, et al., 2019aKoyanagi, et al., , 2019bPage & West, 2011;Pfledderer et al., 2019;Quarshie & Andoh-Arthur, 2020;Quarshie et al., 2015;Quarshie, , 2020aQuarshie, , 2020bQuarshie, , 2020cSiziya et al., 2007). Emerging qualitative findings from South Africa (Shilubane et al., 2012) and Ghana (Quarshie et al., 2020b(Quarshie et al., , 2020c suggest that peer social support, whether at school or within the community, contributes to effective coping, resilience, and recovery among adolescents experiencing emotional crises, thereby reducing the chances of suicidal behaviors. As recommended by a recent regional systematic review from sub-Saharan Africa (Quarshie et al. 2020c), future studies could consider exploring other social and interpersonal factors that promote mental health and "protect" school-going adolescents in Eswatini against the onset of suicidal behavior.
The key findings of the current study have implications for intervention and prevention efforts and policies. The multi-level and multi-contextual nature of the factors associated with suicidal behaviors among school-going adolescents underscores that need for multi-layered and multi-sectoral intervention and prevention programs and policy approaches. For example, while anti-bullying and anti-violence policies (Sivaraman et al., 2019) and inter-peer communication and interpersonal problem-solving programs are needed to enhance supportive school climate, social policies aimed at family poverty reduction, and supportive parenting programs are also required to improve the family environment. Schools should consider instituting help-seeking programs and mental health literacy events to improve help-seeking behaviors among students (at risk of) experiencing emotional crises, including anxiety and loneliness. Also, the evidence of the current study supports calls by the World Food Programme and other key stakeholders that the government of Eswatini must pay considerable attention to improving the Eswatini National School Feeding Programme (ENSFP) -in order to enhance the food and nutritional needs of school-going children and young people (Gandure et al., 2019). Recent evidence from Ghana suggests that school feeding programs improve educational and health outcomes among school-going young people (Awojobi, 2019).

Strengths and limitations of the study
This secondary analysis represents one of the primary efforts to use a nationally representative dataset from Eswatini to examine the prevalence and correlates of suicidal ideation, planning, and attempt among school-going adolescents in an integrated, country-specific way. However, it is imperative to cautiously adopt and interpret the evidence, as there are notable limitations to the study. Each of the outcome variables (suicidal ideation, planning, and attempt) was assessed with a single item on the questionnaire -and this might have led to imprecise categorization of the behaviors. There is evidence to suggest that single-item measures could result in misclassification and imprecise estimation of past suicidal behaviors (Hom et al., 2016;Millner et al., 2015). Thus, future studies should consider the use of contextsensitive multi-item standardized measures of adolescent suicidal behaviors. The cross-sectional design used does not readily allow for causal inference to be made: the sequence of the occurrence of the exposure and outcome variables cannot be (clearly) delineated, as they were measured at the same time; thus, the associations between the exposure and outcome variables reported should not be misconstrued to mean causation.
Notably many of the exposure variables in the WHO-GSHS were measured during the past 30 days, while the outcome variables (suicidal behaviors) were measured during the past 12 months. Even though the previous 30 days may still be part of the previous 12 months, it would have reinforced a stronger sense of equivalence if both exposure and outcome variables were measured within the same timeframe (e.g., the previous 12 months).
Another notable observation of the current study is the higher prevalence estimates of suicidal planning than suicidal ideation. Apart from being counterintuitive, this observation is inconsistent with the process model or pathway idea of suicide (Klonsky et al., 2016;Millner et al., 2017). The conventional idea is that where ideation and planning are conceptualized as distinct phenomena, the estimates of ideation are expected to be equal to or higher than suicidal planning. We suspect that the contrary observation in the current study may be pointing to the recent debate related to the definitional and conceptualization difficulty related to distinguishing suicidal ideation from planning (House et al., 2020). Besides apparent inference of terminology from the specific items on the questionnaire that measured suicidal ideation and planning, it is not clear from the source of the dataset (WHO, 2020) what specific definitions of ideation and planning were applied in the WHO-GSHS. Thus, is it possible that while some participants might have taken both concepts (ideation and planning) to mean the same thing, other participants might have seen each concept to be distinct. Future studies can avoid this by providing participants with clear, explicit definitions of the outcome variables of interest.
Considering that suicidal behaviors are stigmatized in Eswatini (Horter et al., 2019), it is also possible that some of the participants in the current study might have provided socially desirable and guarded answers to the survey questions about suicidal behaviors. Also, the survey included only students who attended school on the day of the study; absentees were excluded. Evidence suggests that students who are (at risk of) engaging in health risk behaviors and mental health problems are more likely to be truant (Bovet et al., 2006;Epstein et al., 2020). These challenges might have presented as sources of bias to our analysis. As observed recently, future WHO-GSHS should assess the sexual and gender minority status (lesbian, gay, bisexual, transgender, queer, or questioning [LGBTQ +] orientation) of the participants. Some school-going adolescents in the sub-region who identify as LGBTQ + are showing worrying vulnerability to self-harm and suicidal behaviors (Quarshie, , 2020a(Quarshie, , 2020b(Quarshie, , 2020c. Secondary school net enrolment in Eswatini is estimated to be 46.3% (Government of the Kingdom of Eswatini & UNFPA, 2019), which implies that our findings may not necessarily apply to all adolescents in the country; future studies could consider including out-of-school adolescents in the country for a relatively less biased sample. Besides the need for longitudinal studies to increase the certainty in identifying key risk and protective factors of suicidal behaviors (Franklin et al., 2017), carefully designed qualitative studies can also help explore the shared and unique personal meanings of suicidal behaviors among school-going adolescents in Eswatini (White et al., 2016).

Conclusions
Approximately 1.7 in 10 participants reported suicidal ideation, 1 in 5 reported suicidal planning, and about 1.5 out of 10 participants attempted suicide during the previous 12 months. Although the prevalence estimates of suicidal behaviors among school-going adolescents in Eswatini are compared with estimates from other sub-Saharan African countries, the multi-layered nature of the factors associated with suicidal behaviors among school-going adolescents underscores the need for multicontextual and multi-sectoral intervention and prevention programs and policy approaches targeted at mitigating the onset of suicidal ideation and possible transition to suicidal planning, attempt, and potential death by suicide in this young population.