Introduction

Suicide attempts and completed suicides are part of a process known as suicidal behavior, a complex and multifactorial phenomenon whose hegemonic causal explanation stems from psychopathology, which views these events as occurring within the course of a mental disorder¹,². According to the World Health Organization (WHO), there are 800,000 deaths by suicide each year, with the vast majority involving a mental or behavioral disorder or psychoactive substance use. The estimated rate is 11.4 deaths per 100,000 inhabitants³.

Although deaths by suicide are currently considered a public health problem, the situation with suicide attempts is even more alarming when you consider that for every person who dies by suicide, 20 others have already attempted it⁴. A previous suicide attempt is the main individual risk factor for suicide, which is defined as the deliberate act of taking one's own life. In contrast, attempted suicide refers to multiple deliberate and self-destructive behaviors initiated by an individual with the intent to cause serious harm or end their life, but that, due to some circumstances, does not result in a fatal outcome⁵.

Suicide is the second leading cause of death among youth aged 15-29 years, with suicide attempts also being more frequent in this population after traffic accidents⁵. In this sense, due to their development stage, adolescents are in the middle of a series of changes, marked by increased conflicts with their parents, distancing from home norms and values, exploration of sexuality, rupture with the usual group of friends, and mood fluctuations. These changes can contribute to engaging in risky behaviors, influenced by multiple social determinants that make suicide attempts persist into adulthood⁶. Additionally, youth is a crucial stage for achieving life autonomy as individuals transition from school to the workforce, shape their identity, and navigate dreams and aspirations in different aspects of life. Therefore, this stage is a crucial moment of change in people's lives⁶.

Hence, there is an interest in studying the social determinants of health and their influence on this phenomenon. Research from this perspective in Latin America remains limited compared to research using a risk-based approach, which has extensively examined biological, psychological, familial, and social factors associated with suicidal behavior in adolescents⁷. Furthermore, methodologically, the ecological design is the predominant design for studying the phenomenon using the model of the social determinants of health, particularly in European and Anglo-Saxon settings. This methodological trend suggests that studies following this approach probably correspond to the same design. Likewise, a Google Scholar search for systematic reviews on the phenomenon using the WHO model of social determinants of health in Latin America yielded no results.

A review of the published evidence on the relationship between social determinants of health and suicide attempts or completed suicides among adolescents and youth is considered pertinent. In this way, it is possible to contribute to an understanding of the phenomenon from a social perspective, moving beyond the psychopathological view, which often overlooks the economic, political, and social realities that adolescents and youth in Latin American countries live in. Accordingly, this research aimed to identify the structural and intermediate social determinants of health associated with suicide attempts and completed suicides among adolescents and youth in Latin America, according to published literature.

Materials and Methods

This secondary research study follows a systematic review methodology in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement⁸. The LILACS, Google Scholar, and PubMed databases were systematically consulted in November 2023. The search was restricted to studies conducted in Latin America over the past 10 years, aiming to know the state of evidence on the social determinants of health associated with suicide and suicide attempts in the region. Additionally, scientific literature published in indexed journals builds on previous knowledge, which may become outdated due to the rapid growth of research and publication.

The central theme of the studies had to focus on the social determinants of health associated with suicide attempts or completed suicides among adolescents and/or youth. The keywords "socioeconomic factors," "social determinants of health," "suicide," "suicide attempt," and "adolescent" were used and consulted in the DeCS-MeSH Health Sciences Descriptors. Search strings were constructed in Spanish, English, and Portuguese using the Boolean operators AND and OR, as follows:

- Socioeconomic Factors AND suicide OR suicide Attempted AND adolescent OR youths

- Factores Socioeconómicos AND suicidio OR intento de suicidio AND adolescente OR jóvenes

- Fatores Socioeconômicos AND Suicídio OR Tentativa de Suicídio AND Adolescente OR jovens

- Social Determinants of Health AND suicide OR suicide Attempted AND adolescent OR youths

- Determinantes Sociales de la Salud AND suicidio OR intento de suicidio AND adolescente OR jovenes

- Determinantes Sociais da Saúde AND Suicídio OR Tentativa de Suicidio AND Adolescente OR jóvenes

Inclusion and exclusion criteria. Primary ecological studies were included, provided they focused on social determinants of health associated with attempted or completed suicides among adolescents and/or youth in Latin America. Studies were excluded if full-text access was unavailable and payment was required for viewing or downloading. Additionally, gray literature was excluded as it often consists of lengthy documents and lacks peer review. Narrative reviews and opinion articles were also excluded.

Study selection. To select the studies, first, each reviewer screened article titles. If a title aligned with the research topic, the abstract was read. Studies that met the inclusion and exclusion criteria were then downloaded and stored using the Mendeley reference manager, with each reviewer maintaining a designated folder. Following the individual review process, two meetings were held, during which the three reviewers jointly examined the folders and saved articles. A folder was created for four disputed articles from the initial selection. Each article was then reassigned to two reviewers who had not previously assessed it in the initial review. Based on the established inclusion and exclusion criteria, they made the final selection decision.

Risk of bias assessment. As there are no tools for assessing bias or conducting a critical appraisal of ecological studies to our knowledge, we analyzed the biases present in the articles included in this review based on criteria described in the literature⁹,¹⁰. These criteria identify three biases which ecological studies are susceptible to: confounding bias, data quality bias, and ecological fallacy. For this purpose, Morgenstern's recommendations¹¹ were followed, as outlined below:

- Confounding bias: We checked whether the ecological variables in the included studies were treated as covariates to obtain an adjusted estimate of the effect —in this case, the outcomes of suicide attempts and completed suicides. Another possibility was that the researchers of the studies obtained standardized rates for these variables. If the ecological study involved comparing groups from multiple geographic areas, we checked whether the authors stratified the data to account for regions with less geographic variation in both exposure and rates⁹,¹⁰.

- Data quality bias: We checked whether the authors used regression models to estimate observation units that lacked data and whether cases were re-categorized¹⁰,¹¹.

- Ecological fallacy: We examined whether the authors used ecological regression rather than correlation to estimate the magnitude of the association between suicide attempts and/or completed suicides and social determinants of health. We also reviewed whether the studies used data aggregated at the smallest possible geographic units of analysis. Additionally, we examined whether the studies avoided extrapolating results to the individual level and instead focused only on conclusions that apply strictly to the population level¹¹.

Variables and data extraction. Three types of variables were extracted: a) study characteristics (authors, year of publication, country, language, study design, participants), b) social determinants associated with suicide attempts, and c) social determinants associated with completed suicide, including statistical measures (e.g., Pearson's correlation, Spearman's correlation, Odds Ratio). Data was extracted using a Microsoft Excel workbook created by the reviewers. This facilitated duplicate identification and removal while also enabling comparisons of the quality of the extracted data across studies.

Data analysis. A qualitative analysis of the data was conducted, synthesizing the general characteristics of the studies and the social determinants of health through summaries and descriptive tables.

Ethical considerations. As this study is secondary research, it complies with Colombian Law 23 of 1983 on copyright, which mandates citation of authors' names, pseudonyms, and the titles of original works used in this review.

The full dataset is freely accessible for public consultation on Mendeley Data¹².

Results

A total of 23,770 documents were identified in the initial search. After removing duplicates, 7,021 records remained, of which 6,895 were excluded for not meeting the research objectives. This left 126 records, from which 31 studies that met the research objectives were selected. Finally, 10 studies that met the inclusion criteria were included in the review (see Figure 1). All included studies followed an ecological design. Three studies were conducted in Brazil¹³-¹⁵, three in Mexico¹⁶-¹⁸, three in Colombia¹⁹-²¹, and one in Ecuador²². Additionally, 60% (6)¹⁴,¹⁷,¹⁹ of the studies were published within the last five years (Figure 1).

Figure 1
PRISMA flow diagram

Suicide attempt and completed suicide

The studies reported varying relative frequencies and rates of suicide attempts and completed suicides, depending on the population studied. Only three studies focused on attempted suicide¹⁶,¹⁸,¹⁹. Among 4,855 deaths by suicide in adolescents and youth (10-24 years), Gerstner²² reported a suicide rate of 10.5 per 100,000 in 2007 (13.4 in males and 7.7 in females); this rate had declined to 9.6 by 2012 (12.5 in males and 6.7 in females).

Among adolescents aged 10-19 years, Jaén¹³ reported a suicide rate of 2.34 per 100,000 in 2006, which increased to 2.64 per 100,000 in 2015. In the same age group, Luna¹⁶ reported a suicide attempt prevalence of 2.74%, with 1.45% of cases occurring within 12 months prior to the survey. Similarly, Rivera¹⁷ reported a lifetime suicide attempt rate of 3.9%, while it was 1.8% within the past 12 months.

Borges¹⁴ analyzed all completed suicides in Brazil between 2000 and 2011 and found a suicide rate of 10.47 in men and 2.45 in women in 2000. This rate had increased to 12.48 per 100,000 inhabitants in men and 2.42 per 100,000 inhabitants in women by 2011. The remaining studies did not report prevalence rates for attempted or completed suicide cases, as their objective was to analyze the association between social determinants and the total number of attempted and completed suicide cases recorded in government databases. These results are presented in Table 1 for further detail.

Table 1

Summary of studies included in the review

Note: r (Pearson correlation coefficient), β (beta), B (logistic regression), OR (odds ratio), R2 (R-squared), RR (relative risk), MR (odds ratio) .

Social determinants of health according to the WHO model

The WHO model of social determinants of health establishes determinants as factors or characteristics that influence individuals' health. These determinants act or interact at different organizational levels, ultimately determining the health status of a population²³.

According to the WHO model, determinants are classified as structural and intermediate. The former refers to social position and contexts that generate social stratification, including factors such as income, education, occupation, social class, gender, race/ethnicity, and macroeconomic and social policies. The latter includes the exposures and vulnerabilities faced by population groups within various social levels, such as the family, school, or workplace where individuals live and develop²⁴.

Based on the WHO model, the social determinants reported by the studies included in the review were recategorized into structural and intermediate determinants. The structural determinants associated with completed suicide among youth included being male, aged between 15-24 years, having a Gini index close to one (high inequality), having low GDP per capita¹³,¹⁸,²², and being Catholic or Evangelical¹⁴. However, the evidence may be contradictory, as two studies reported that completed suicide rates were independent of the inequality index, suggesting that no relationship exists between suicide and this determinant²⁰,²¹.

For suicide attempts, the structural determinants identified were educational backwardness, being female¹⁶, and living in a municipal capital¹⁹. Regarding intermediate determinants of suicide attempts, tobacco use, episodes of violence¹⁶,¹⁷, alcohol consumption, and depressive symptoms were identified¹⁷ (Table 2).

Table 2

Assessment of the risk of bias in the studies reviewed

Discussion

The results of this review can be interpreted in several ways. First, research on the social determinants of health in relation to suicide attempts and completed suicide is scarce in Latin America. The research that was found corresponded to ecological studies. This lack of research constitutes an opportunity for generating new knowledge. Understanding suicide attempts and completed suicide from a different perspective beyond the traditional psychopathological and biomedical approach is necessary, as this approach fails to establish a causality for the phenomenon.

Secondly, the WHO's theoretical model of social determinants of health offers a novel perspective of the problem. By shifting the focus away from individual responsibility, this model confers active participation to the cumulative impact of populations' lifestyle-related conditions that drive health inequities, ultimately determining the health status of population groups²⁵,²⁶. Although ecological studies—which dominate research on determinants— cannot establish direct causality, their strength lies in their approach to a population-level and collective explanation of the problem, far removed from the individualistic perspectives often emphasized in other research designs.

Thirdly, research adopting this theoretical stance does not go deeper into the WHO model, as it tends to analyze a few structural or intermediate determinants. In this review, the most frequently studied structural determinants include inequality index, per capita income, and sex, which have been associated with completed suicide rates¹³-¹⁹. However, the evidence is contradictory, as two studies reported no significant relationship between suicide rates and these determinants²⁰,²¹. According to Naranjo²⁷, further studies are needed to analyze the relationship between inequality and suicide in Latin America and to clarify the causal association between economic variables and deaths by suicide.

As shown in the results of this research, there are currently few studies that suggest a relationship between suicide and inequality. Brazil, Mexico, and Colombia have demonstrated interest in this problem, but research has failed to examine in depth how inequality influences suicide rates. According to Durkheim²⁸, suicide attempts and suicide rates tend to increase with economic imbalance, as social cohesion weakens, affecting individual's perceptions and cognitions, which may lead to this outcome. However, empirical evidence is needed to support this position in this region.

In other regions of the world, more empirical data on this problem exists. Chandler²⁹ analyzed suicide rates in the United Kingdom, reporting that socioeconomic inequalities lead to adverse experiences and emotions, which, in turn, lead to suicide. Curtis³⁰, in New Zealand, concluded that income inequality has contributed to the increase in suicide rates. Harper³¹, in the USA, found that economic recessions of different periods, such as those in 2000 and 2010, increased suicide mortality by 0.14 deaths per 100,000 population.

According to the studies in this review, intermediate determinants such as tobacco and alcohol use, episodes of violence, and depressive symptoms were associated with suicide attempts. Naranjo²⁷ affirms that individuals —particularly women— exposed to situations of violence, such as sexual abuse, are 12 to 20 times more likely to attempt suicide due to the emotional impact and psychological suffering caused by situations of violence on the individual³².

Several studies³³-³⁵ affirm that youth and adolescents who use tobacco and alcohol may experience depressive symptoms, increasing their risk of suicide attempts and completed suicides. A review by Hernandez⁷ found that, in adolescents, the risk of suicide increased with psychoactive substance use and the presence of depression. Given this evidence, examining how structural and intermediate determinants interact in attempted and completed suicide outcomes among adolescents and youth. This is particularly critical, as suicide prevention during this stage of life is essential to protecting their productive potential³⁶.

This article provides a synthesized overview of research on suicide and suicide attempts in Latin America from the perspective of the WHO model of social determinants of health. It also offers a different and novel perspective of causal associations between inequality, per capita income, sex, and tobacco and alcohol consumption, which are structural and intermediate determinants of the problem. These results suggest that attempted and completed suicide prevention actions should go beyond promoting healthy lifestyles for mental health and early detection of mental disorders. Political and governmental willingness is required to reduce health inequities and implement comprehensive, integrated actions that influence people's lifestyles and, consequently, their health³⁷.

At the same time, it is important to point out some limitations related to the quality of the reviewed studies. The first limitation concerns the inherent weaknesses of ecological studies, which, as observed, frequently present confounding bias. This can lead researchers to establish false associations. Therefore, it is necessary to design ecological studies that manage to control this bias by incorporating standardized outcome rates and utilizing regional stratification when comparing groups with less geographic variability³⁷.

Another bias observed in the reviewed studies is data quality bias. While this issue is beyond the researchers' control, it requires data cleaning, categorization, and tabulating data again to improve the quality of the information.

A limitation of this review is the exclusion of gray literature, which may have introduced selection bias. This bias may have reduced the likelihood of locating a broader body of research on the problem, particularly studies aligned with the theoretical model under consideration. Likewise, due to the heterogeneity in the measurement of both outcome and independent variables, conducting meta-analyses was not possible. For future reviews, analyzing more homogeneous studies that would enable quantitative synthesis is recommended, thereby strengthening the contributions to knowledge of this problem.

Conclusions

In this review, the association of social determinants with the phenomenon under study was found contradictory. Some studies reported that the higher the inequality, the higher the suicide rate, while others concluded that suicide rates do not depend on inequality level. Per capita income was another structural determinant. Some studies suggested that low GDP increases suicide rates, while others indicated that low GDP acts as a protective factor. In addition, death by suicide was higher in men, whereas suicide attempts were higher among women.

The intermediate determinants associated with suicide attempts included alcohol and tobacco use, symptoms of depression, unemployment, and a history of sexual or other forms of violence. Finally, half of the studies reviewed incurred confounding bias, indicating that these associations should be interpreted with caution.

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Notas

Autor notes

^*Correspondence: Ladini Sunanda Hernández Bellolhernandezb2@unicartagena.edu.co