OMEGA, Vol. 62(2) 169-186, 2010-2011
A QUALITATIVE STUDY OF ATTITUDES
TOWARD SUICIDE AND SUICIDE PREVENTION
AMONG PSYCHOLOGY STUDENTS IN GHANA
BIRTHE LOA KNIZEK
Norwegian University of Science and Technology, Trondheim
CHARITY SYLVIA AKOTIA
University of Ghana, Legon
Norwegian University of Science and Technology, Trondheim,
and Norwegian Institute of Public Health, Oslo
The purpose of the present study was to investigate attitudes toward suicide
and suicide prevention among psychology students in Ghana by means of
a qualitative analysis of open-ended questions about causes of suicide and
how suicide best can be prevented. The students mainly saw the causes as
intra-personal and almost all of them believed that suicide can be prevented.
The results indicated a huge impact of religion on the attitudes toward suicide
as well as some lack of distinction between their religious and professional
roles and responsibilities.
Suicidal behavior is a continuous challenge around the world and the World
Health Organization (WHO) estimates that about one million people kill them-
selves every year (2005). However, this challenge has not been taken up in all
parts of the world yet. For instance, most parts of Africa lack official suicide
? 2010, Baywood Publishing Co., Inc.
publicstatistics,thesizeof theproblemisunknown inthiscountry butestimations
done by Hjelmeland and colleagues (2008a) indicate that the problem is large
enough to necessitate suicide preventive efforts. Their estimations were based on
comparisons of experiences of suicidal behavior among students in Ghana and
Uganda with analogous experiences among students in a country with reliable
suicide statistics: Norway. These estimations are still not substantiated by proper
epidemiological studies, but we have reasons to believe that suicidal behavior
can be considered a serious public health problem in Ghana. This calls for suicide
Attitudes are important when action is to be taken. For instance, attitudes
toward suicide may affect health care workers’ will to intervene in suicidal
crises or to treat those who deliberately have harmed themselves (Bagley &
Ramsey, 1989). Research has shown that suicide is perceived negatively in
African countries (e.g., Eshun, 2003; Hjelmeland et al., 2008a; Lester & Akande,
1994; Peltzer, Cherian, & Cherian, 1998). In Ghana, suicidal behavior is
considered criminal and thus carries legal as well as social sanctions. In
some families/clans cleansing rituals are required. Eshun (2003) has shown
that Ghanaian college students have significantly more negative attitudes toward
suicide than their American counterparts and has recommended qualitative
studies in future research in order to get more detailed or informative results
(Eshun, 2006). The same trend of negative attitudes was found in a study by
Hjelmeland and colleagues (2008a), where Ghanaians saw suicide more as a
taboo compared to Ugandans and Norwegians. The difference between Ghana
and Uganda was interesting in so far as the vast majority in both countries are
very religious (Gifford, 1999), but the impact of religion on attitudes toward
suicide seems to differ in students from these two countries. Religious people
are found to be considerably more intolerant toward suicide than less religious
people (see Koenig, McCullough, & Larson, 2001, for an overview), and
to believe more in suicide prevention (Bascue, Inman, & Kahn, 1982). In
contrast to this, Hjelmeland et al. (2008a) found that the Ghanaians seemed
more reluctant than the Ugandans to help suicidal persons. We therefore
wanted to study the Ghanaian psychology students’ attitudes more in-depth.
Another reason for this is that a Mental Health Bill is under preparation in
order to improve the mental health services in Ghana (WHO, 2007). It is
likely that these future gatekeepers will be involved in this one way or the
other and may, for instance, be able to influence the construction of suicide
prevention programs. The purpose of the present study was thus to investigate
psychology students’ negative attitudes toward suicide more in-depth as well
as these attitudes’ relation with their religious/spiritual viewpoints. This was
done by qualitative analyses of the students’ responses to open-ended ques-
tions regarding the most important causes of suicide and how suicide could
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Instrument and Procedure
The Attitudes Toward Suicide questionnaire (ATTS) developed by Salander
Renberg and Jacobsson (2003) was employed in the study. This questionnaire
consists of a number of questions to be scored quantitatively on issues such as
experiences of suicidal behavior, attitudes toward suicide and suicide prevention,
and life-satisfaction. In addition, two open-ended questions are included, namely
“What is the most important cause of suicide?” and, “What do you think can be
done to prevent suicide?” The questionnaire is presented in detail by Salander
Renberg and Jacobsson (2003). In the present study we report the results of the
qualitative analyses of the open-ended questions, whereas some of the quanti-
tative findings have been reported previously (Hjelmeland et al., 2008a). In this
previous publication, qualitative studies are recommended in order to improve
the general knowledge but also to develop the ATTS into a more culture sensitive
instrument. The present study is a contribution to such an endeavor.
The questionnaire was handed out in class to psychology students at all
levels of the study. Because of a very large number of students at the first four
levels, a stratified sampling (by gender) was conducted in these classes, while all
students from the fifth level filled in the questionnaire. The data were collected in
2002. The questionnaire was in English, which is the medium of instruction in
schools in Ghana. The study was approved by the relevant ethical bodies both
in Norway and in Ghana.
The total number of participants of the study was 570: 274 women (48%),
290 men (51%), 6 nondisclosing gender (1%). The response rate was 100%.
One hundred and ninety-six (34.4 %) of the participants had responded to at least
oneof theopen-ended questions. Asoneperson cangivemorethanonestatement,
our entire data material for the qualitative analysis was 476 statements from 196
students for the question on causes and 311 statements from 190 students on the
question about prevention.
As reported in Hjelmeland et al. (2008a), 2% (N = 11) of these students had
attemptedsuicide during the last year, whereas 3% (N = 19) had attemptedsuicide
earlier in life. Ten percent (N = 53) had experienced attempted suicide and
almost 2% (N = 9) had experienced suicide in their family, while 37% (N = 192)
had experienced attempted suicide and 17% (N = 91) had experienced suicide
The analyses were first conducted by the first author (who is Danish) and a
preliminary category system was developed. Both the category system and the
ATTITUDES TOWARD SUICIDE AND PREVENTION IN GHANA/171
coding of each statement were controlled by the second author (Ghanaian) and
discussed with the first author. Based on these discussions, the category system
was modified and the statements coded according to the modified version. Both
the category system and the coding were then discussed with the third author
The choice of method for analysis was a thematic analysis (Boyatsis, 1998)
because the statements were too short and meager for a deeper interpretational
approach (they were from one word to a few sentences). The responses were
categorized in equal-leveled main categories. Subsequently, sub-categories for
eachofthesemaincategoriesweredeveloped andresultedinabranched structure.
This branched structure developed to be a hierarchical categorization system
covering all the responses and reflecting an internal logic.
RESULTS AND DISCUSSION
The Main Causes of Suicide
The analyses of the question of the most important causes for suicide resulted
in a branched structure that encompassed all the statements when the necessary
adjustments were made (see Figure 1).
Initial analysis showed that the main division was between students expressing
a general frustration (N = 46), for instance, “Frustration in life,” those stating
that they don’t know (N = 5) and those making specific suggestions (N = 424).
When following up the specific suggestions (see Figure 1), these could be cate-
gorized in three main categories, namely intra-personal, inter-personal, and extra-
personal causes. This structure has also previously been found in a study of the
general population in Norway (Hjelmeland & Knizek, 2004) as well as among
politicians in five different European countries (Knizek, Hjelmeland, Skruibis,
Fartacek, Fekete, Gailiene, etal., 2008). The vast majorityof statements(N= 326)
fell into the category “Intra-personal causes.” These categories could, in turn,
be divided into the sub-categories “perceived obstacles,” “emotions,” “personal
shortcomings,” “identity,” “existential reasons,” and “stress.” “Perceived
obstacles” were mentioned mostoften in the intra-personal category, for example,
“People commit suicide to get away from an unpleasant or difficult situation or
to avoid punishment for a misdeed”(woman, 23 years). Avoidance of punishment
and shame as a consequence of a committed crime was mentioned repeatedly.
In the case of avoidance of punishment the act can be looked at as cowardly,
of perceived obstacles mentioned are disasters and drugs, as well as painful,
incurable, disgraceful, and scary diseases. Several men also mentioned impotence
as an important cause: “When they suffer from an incurable sickness like AIDS,
impotency, depression, or schizophrenia” (man, 35 years). This list of diseases
gives an indication of what is perceived as serious enough to break all taboos and
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ATTITUDES TOWARD SUICIDE AND PREVENTION IN GHANA/ 173
Figure 1. Categories of responses to the question: What is the main cause of suicide? Number of statements in
parentheses (only the specific suggestions are included in the figure).
commit suicide, and AIDS and mental illness, although barely mentioned, as
well as impotence, makes suicide comprehensible for psychology students. Male
potency thus gets a central status, which has also been found in two studies from
Uganda; Fallersand Fallers(1960) reported impotenceasasignificantcontributor
to suicide whereas Kinyanda and colleagues (2005) more recently also observed
that impotence was a significant contributor to repetition of suicide attempts.
These findings in Ghana and Uganda seem to differ from what is found in the
Western world where this is not mentioned at all (Hjelmeland & Knizek, 2004;
Knizek et al., 2008). However, this might reflect differences in willingness to
mention this problem.
Other obstacles mentioned are financial problems as well as marital problems
and in some cases a combination of all is mentioned: “When people find life
worthless due to poverty, rejection by husband and families. Where society also
defines them as useless because they never attended school or never gave birth”
(woman, 22 years). Combinations of this kind were mentioned repeatedly and
reflected a failure of the individual to fit in and be appreciated as valuable both
to the family and to the society. This individual thus has neither the feelings of
belonging nor of human worth. Brokenheartedness was another frequently men-
tioned cause which also deals with the individual’s feeling of belonging. In
interdependent cultures like Ghana, marriages traditionally maintain and deepen
existing structures (Penn, 2008), whereas marriages on the background of love
are more common in independent societies like Scandinavia (Moxnes, 2003).
However, the problem of a broken heart could seem independent of different
ways of entering a relationship or might be a sign of a change in the personal
engagement in relationships in Ghana, maybe due to globalization.
“Emotions” were mentioned second most frequently as a cause in the intra-
personal category. Under this category, loneliness and hopelessness were fre-
quently mentioned, for instance, “When they feel there is no one to care for
them” (woman, 22 years); “When they feel all hope is gone, for example, losing
parents and sibling on top of being raped and pregnant with no one to give a
shoulder to cry on” (woman, 22 years). Again in these examples, we see the lack
of the feelings of belonging and human worth as important. Also, being depressed
and suffering was mentioned here. However, these emotions were often not
mentionedinawaythatnaturallywould point tomentalillness.Thiswasreflected
either by the wording of the statement like “People who commit suicide think
they would not gain anything extra in life if even they continue to live” (man, 22
years) or the context of the word of depression like “Stupidity; desperation;
depression, demon possession” (woman, 22 years). Their view therefore seems
to incorporate more than a clinical understanding in the category of emotions,
suicide in other parts of the world, compared to what has been found in the West
(e.g., Chan, Hung, & Yip, 2001; Phillips, Yang, Zhang, Wang, Ji, & Zhon, 2002;
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Xu, 2005; Zhang, Cowell, Zhou, & Jiang, 2004).
The “personal shortcomings” could be:
1. verygeneral,asfor example,“Becauseoffailureinlife”(woman,22 years),
or “They commit suicide because these people can hardly face life and the
struggling situations of the world, they commit suicide to escape it rather
than facing it” (woman, 22 years);
2. connected to lack of personal faith, as for example: “People who commit
suicide lack the accurate knowledge of God about life” (woman, 24 years),
or “They do not value life or do not understand the reason why they are
in this world or the purpose for which they were created” (man, 35 years);
3. about cognitive ability: “Because they have not really understood the
concept of life” (woman, 23 years), “Lack of what I will call ‘realistic
thinking’” (man, 31 years); or
4. about proper attitude: “Cowards are those who commit suicide” (woman,
22 years), or “To my best of knowledge, people who commit suicide are
cowards. They fail to face the reality of this world and feel taking their
lives will solve it” (woman, 22 years).
In short, the students think that people who kill themselves do not have what it
takes to live, either because they do not have the cognitive skills to cope with
difficult situations, because they have a wrong attitude making them vulnerable,
or because they do not get strength through an adequate religious faith. The
classification of these people as cowards also shows a general negative attitude
toward suicidal people. This is in line with a number of studies having found that
religious factors are associated with negative attitudes toward suicidal behavior
(e.g., Colucci & Martin, 2008; Domino, Cohen, & Gonzales, 1981; Domino &
Miller, 1992; Domino, Niles, & Raj, 1993). We did not differentiate between the
students’ religious affiliations based on Stark and colleagues’ (1983) statement
that religiosity seems to matter more than type of religion.
The category of “identity” encompassed responses like ego-protection, lack
of confidence, and low self-esteem. Not unexpectedly, also unbearable disgrace
and avoidance of shame and humiliation were mentioned, which is in line with
what Draguns and Tanaka-Matsumi (2003) found in interdependent societies,
where they pointed to the central status of shame. The importance of shame in an
African country was supported by the findings of Hjelmeland and colleagues
(2008a,b) in a comparative study between Uganda and Norway.
“Existential reasons” was a smaller sub-category under intra-personal causes
and referred to a meaningless or useless life and an overall sense of worthlessness
in general. As these statements were very short, it was impossible to see whether
they actually referred to lack of religious beliefs or lack of being connected to
the society under the category of emotions.
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The last and smallest category mentioned under intra-personal causes was
“stress,” especially from family members: “Pressure from family” (woman, 20
years). This indicates again the importance and impact of relationships.
When we look at the category of “Inter-personal causes” which was con-
siderably smaller than the one on intra-personal causes, we found a division
between “loss,” “lack of support,” “consequence,” and “goal-directed act.” Lack
of support was the cause most frequently mentioned, for instance: “Suicide can
be attributed most often to not engaging in intimate interpersonal relationship
as well as lack of commitment and interest in their daily lives by close friends,
associates, and relatives as well as confidants” (man, 22 years). He clearly
indicates that close relationships are a necessity and that lack of the same can
have fatal consequences. However, in this example the main weight is put on the
suicidal person because he/she does not open up and ask for support, and it could
therefore be argued that this statement should have been put in the category
The second most frequently mentioned inter-personal cause, we categorized
as “disharmonic relationships” and this category encompasses accusations and/or
injustice: “Betrayed by those they perceive to be very trustworthy” (man, 22
years), or “In most cases it is betrayal from trusted and closest somebody.
Sometimes, false accusations also can lead to suicide” (woman, 29 years). Also
being a burden to someone was mentioned, as well as unresolved conflicts
The last category is that of suicide being a goal-directed act, as in blaming/
punishment: “Some commit suicide to place guilt on others” (woman, 22 years),
or “. . . to punish the elder ones, either parents or caretakers” (man, 33 years).
This group was quite small and perceived suicide as a way of blaming somebody,
taking revenge, and make others feel guilty. Implicit in this, the suicidal person’s
lack of power is stated. However, the entire category of inter-personal causes
dealt with the relationship between people and at its core is power, which
sometimes led to suicidal behavior as a consequence of deceitful behavior and
sometimes as an act to bring others into trouble as revenge, but mainly focused
on the need of support by others and the necessity of harmonious relationships.
It is, however, thought-provoking that if we are dealing with an interdependent
societyhere, the vast majorityof causes mentionedare in the intra-personal realm.
This could either be a way of protecting the community by blaming specific
individuals, or signal a transition toward more individuality. On the other hand,
we have to take history into consideration: in the beginning of the 20th century
the African mind was commonly perceived as primitive and childish and thus
not capable of developing complex psychological problems like depression as
this presupposes a civilized, well-developed mind (Fernando, 2004; Kirmayer,
2007). When Prince (1968) made a review of 28 reports on depression among
Africans between 1895 and 1964, he noted a change around 1957, when Ghana
gained independency from its colonial masters. While under a colonial regime,
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depression should not be seen and named because Africans were not perceived
responsible, while in the era of an independent regime, depressions, in contrast,
should be seen because Africans now were perceived as responsible and aware
(Prince, 1968). The students’ emphasis on intra-individual problems thus also
might represent reminiscences or traces of their colonial history.
However, a lot of the intra-personal causes are connected to the relationship
between the individual and his/her social context, and problems in that relation-
the individual and the surroundings, pointing to problematicdynamicsin different
interrelationships. But also the clear focus on religion as the superior norm is
important and it is when you have dropped out of either the family/society or the
religious community that the individual is believed to make this fatal decision.
The “Extra-personal causes” were mentioned slightly less often than the inter-
personal causes (47/51) and fell into the categories “economic reasons,” “norms,”
“spiritual,” and “work-related.” Under economic causes the vast majority pointed
at poverty, while only one person indicated that excessive wealth could lead to
suicide. The category of norms was expressed for example by a man (27 years):
“The reasons why people take their own life are when there is normlessness
in society, too much regulating, too much social integration, and too less social
integration in society.” In other words, too many and too few norms in the society
lead to either too much pressure or too much confusion. This way of thinking
was introduced by Durkheim (1993) and it seems as if it still has a certain appeal
to the students, like for example to a man (32 years) “anomic, altruistic, and
egoistic,” who just missed the fatalistic suicide as suggested by Durkheim. Some
people also mentioned specifically work-related pressure as a possible cause for
suicide. However, four of the future psychologists also mentioned spiritual forces
as possible causes, for instance: “There are some spiritual forces behind people
committing suicide” (woman, 31 years). But also demon-possession was men-
tioned. In sum, the external causes are perceived as forces that are outside of
peoples’ control, either financially, morally, or spiritually.
Also on the question of what could be done to prevent suicide, the analyses
resulted in a branched structure covering all the statements (see Figure 2). Only
four persons stated that suicide could not be prevented, whereas four persons
answered very unspecified that it can be prevented but did not say anything about
how this could be done. The rest of the responses could be divided into three
main categories, namely efforts at the societal level, at the interpersonal level,
and at the individual level, thus following the logic from the causes. The same
categories have also been found in Europe (Hjelmeland & Knizek, 2004; Knizek
et al., 2008). With regard to causes, the vast majority (77% of those giving
specific suggestions) pointed to intra-personal problems, whereas only 23%
ATTITUDES TOWARD SUICIDE AND PREVENTION IN GHANA/ 177
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Figure 2. Categories of responses to the question: What can be done to prevent suicide? Net percentages.
pointed to causes between or outside people. However, in terms of prevention,
the opposite was the case, as 78% pointed to efforts at the societal level and only
22% to efforts at the inter-personal or individual level. A similar result has
previously been found in Europe (Knizek et al., 2008).
When we look at the societal level this category could be divided into structural
and ideological changes. On the structural side, most often an improvement of
the health services was suggested, especially with counseling and the establish-
ment of counseling centers: “Counseling facilities should be easily available and
accessible to people with suicidal tendencies” (woman, 33 years), or “In the
instance of a person having a severe, incurable disease he/she should be allowed
to commit suicide, but in all other cases counseling is advised” (man, 22 years).
But also suicide prevention campaigns were called upon by the participants.
However, sometimes the suggestions about counseling are unclear, as for
example: “People should be counseled about the meaning of life” (woman, 22
years), or “Counseling, teaching the worth of life” (woman, 21 years). Here one
can question whether the informants speak from a health-service point of view
were mentioned relatively often, and one can question whether the division
countries. Thus, the categorization might be a result of thinking from a Western
point of view, so perhaps the category should rather encompass both the religious
services as well as the health-services and be labeled “counseling/guidance.” On
the other hand, there seems to be a line between counseling and preaching, as, for
example, a 24-year-old woman wanted to prevent suicide in the following way:
“The spread of the accurate knowledge of God as regards the purpose of life and
Gods lovely will that will soon take place on his earth.” Another example is from
a 21-year-old man: “Spread the gospel that suicide will always end the person in
way forward is not through these students’ future profession, but through their
religious beliefs: “Get people born again” (man, 22 years), or “People should be
encouraged to give their lives to Christ who can provide an answer to ANY
problem” (man, 38 years), or “People who want to commit suicide should be
introduced to the God almighty. They should know with him all the things in this
world are possible, and he provides their needs not them” (woman, 22 years).
There were also 13 statements regarding the necessity of improving the social/
economic conditions. This sounds very plausible since poverty was mentioned
as one of the causes that could result in suicide. However, some statements went
in the direction that general justice and equality should be introduced in the
society, which probably is in the same direction as the improvements on the
social conditions, but they go a bit further by pointing to equality among people.
The latter thus seem to have a more political based agenda.
Only three students wanted to punish suicidal people and especially one of
them, had a rather drastic way of preventing suicide: “Kill them first” (woman, 22
ATTITUDES TOWARD SUICIDE AND PREVENTION IN GHANA/ 179
years). However, taking into account that suicide actually is a criminalized act in
Ghana, it is encouraging that so few students advocate punishment and prefer
other ways of dealing with the problem.
When we turn to the other sub-category under efforts at the societal level, ideo-
logical changes, the main part of suggestions were about education: “Education
through the mass media can help reduce it if not eliminate” (man, 28 years).
Education in school, in the media, and in the churches was indicated. The
suggestions regarding education mainly were quite unspecific, for instance, mass
education or education in childhood, but in some cases it was more specific
like, for instance, improvementof coping skills and crisis management.However,
also regarding education, the line between governmental and religious duties
seems vague: “People should be made aware of their existence on earth and who
it is that has made them and that this world in which they are in, will one day
come to an end. This life is not the end of everything. There is a better life some
where therefore, they should take the ultimate way and put their full trust in
God, the maker” (woman, 22 years). Religion and the general mentality and
responsibility seem much interwoven in the responses. Very often, there seem
not to be clearlinesbetween governmental/professional domainsand the religious
and personal beliefs and therefore the suggestions appear quite mixed.
When we turn to the efforts at both the inter-personal and individual level,
some interesting differences turn up as more than half of the suggestions in each
category were written in imperative: “People should be allowed to talk about it”
(man, 24 years), “People should be able to open up about trouble issues in their
lives” (man, 26 years), “People should accept situations and live by them the
way theyare” (woman, 24 years), or “People should be counseled and encouraged
to live” (man, 35 years). This might be a very (culture) specific way of talking
indicating that things are different than what they should or ought to be. But it
could also be an authoritarian way of thinking that places the responsibility for
a change on different agents. There is a difference in, for example, saying “there
should be education,” “the government should provide education,” and “people
should be made to understand. . . .” The question is whether the auxiliary verb
“should” has the same effect regardless of the agency (there = unspecific; the
government = specific institution; people = specific/unspecific) as the obligation
to act follows the agent. In the first case, it is just underlined that a change is
needed; in the second case it is emphasized that the responsibility belongs to
the government, whereas the most important thing in the last formulation is
that people change as an effect of education and it is more unclear who should
bring about this change. A typical example of the “should” formulations would
be that of a 21-year-old woman: “Family systems should be strengthened and
people should be encouraged to go to counseling centers to seek help as such,
the counseling centers should be easily accessible and the counselors have the
right attitude.” Here we have many indications that things must change, but
the responsibility for bringing the changes about is not defined. If we, on the other
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hand, go to one of the typical descriptive statements, the picture is different: “If
you realize somebody wants to commit suicide try to contact a professional on
that persons behalf for the necessary action to be taken” (man, 24 years). Here we
have an imaginary scene where everyone close to the suicidal person, gets the
in principle on all fellow-beings. With regard to content both groups point to
sharing, comforting and praying, and being more attentive to people as well as
being more forgiving: “We should not be too harsh on people when they do not
succeed in some areas or when they make some mistakes like getting pregnant
while young” (woman, 23 years). However, a great deal relies on the power of
prayers: “Praying for them constantly” (man, 35 years). This might indicate a
greater emphasis on their religious belief than in their future profession. It
might be important to recall that developing countries in general only have
0.34 mental health professional per 100,000 population (Vijayakumar, 2004) and
the students’ emphasis on religion thus might indicate a pragmatic approach
underlining what is in reach and not what should have been.
When we turn to the efforts at the individual level, we have the same linguistic
characteristics as at the inter-personal level that we already have discussed. The
content mainly dealt with the need for people to open up to other people so that
they can help to change attitudes toward life. Again religion is also called upon
in the efforts at the individual level as well: “Person should understand that God
many other people have problems but are believing in God for a breakthrough”
(woman, 31 years). However, the main quest was for more openness implicating
that people keep their problems for themselves too often.
This study is a qualitative analysis of open-ended questions at the end of a
questionnaire with about 60 quantitative questions. This might have influenced
both whether and how the participants responded to these questions. As the ATTS
was developed in Scandinavia and thus mirrors a Western system of thinking,
this also might have influenced both the willingness to fill in the questionnaire
as well as the way this was done. The prominent part played by religion in the
responses might be an indicator of the questionnaire’s insensitivity to factors
important for the informants. A revision of the ATTS should therefore be con-
sidered before further use in Ghana/Africa.
In order to minimize the subjective impact of the foreign researchers onto the
categorization system developed, we employed an independent coding by the
first author, a check and discussion by the native Ghanaian second author,
followed by a modification of the system and a final check and discussion with
the third author. When consensus was reached in this researcher triangulation,
the system was finalized and all data checked against the system. As some
ATTITUDES TOWARD SUICIDE AND PREVENTION IN GHANA/ 181
interpretation was necessary in order to understand and categorize a few of
the responses, it is not impossible that other teams would categorize these differ-
ently. However, by using investigator triangulation (Flick, 2007) with researchers
from different cultures, the validity of the study is strengthened. In addition, it
is important to emphasize the exploratory aim of the study. Not much is known
about these issues in Ghana and our goal was to get a broader impression than
what is possible in a limited number of in-depth interviews as well as a deeper
insight than what is possible to achieve in quantitative studies with fixed response
alternatives. On the other hand, the data we have are on a relatively large sample
for qualitative studies and thus yields a broader perspective than would have
been the case had we interviewed fewer people in-depth. Steady (2005) posed
the very important question: “How has the donor community influenced the
research agenda of Africa and distorted African realities based on preconceived
assumptions and biases?”(p. 329). By focusing in-depth on what the Ghanaian
students expressed in their own words, we try to go beyond Western biases that
cannot be avoided in quantitative studies due to pre-formulated questions and
response categories. We thus found that a strong influence of spirituality could
explain the negative attitudes toward suicide. However, we also found that the
students did not distinguish clearly between spiritual and secular counseling to
be employed in suicide prevention. Apart from direct statements, we also looked
at the specific way of employing imperatives without agent as a further indicator
for this mixture of responsibilities. In this way both the content and the form of
the statements built up the data material.
Being an exploratory, qualitative study the results cannot and should not be
generalized statistically, but they nevertheless give an indication of the partici-
pants’ reflections. The study gives us more detailed information of the meanings
psychology students attribute to suicidal behavior and the consequences this
has for their beliefs about whether and how suicide can and should be prevented.
Apparently, employment of both spiritual and secular forces is of interest, and
this needs to be investigated further by in-depth interviews.
SUMMARY AND CONCLUSIONS
The Ghanaian students’ responses regarding causes of suicide could be divided
into intra-, inter-, and extra-personal causes in a similar way that has been found
earlier in European samples (Hjelmeland & Knizek, 2004; Knizek et al., 2008).
The vast majority of responses pointed to intra-personal causes for suicidal
behavior. The students seemed to respond more from a religious perspective
than from a professional perspective. The latter also resulted in attitudes that were
not only negative, but often also condemning. This is in line with a number of
studies having found that religious factors are associated with negative attitudes
toward suicidal behavior (e.g., Colucci & Martin, 2008; Domino, Cohen, &
Gonzales, 1981; Domino & Miller, 1992; Domino, Niles, & Raj, 1993).
182/ KNIZEK, AKOTIA AND HJELMELAND
Almostallstudentsfeltthatsuicidecould beprevented and themajoritypointed
to efforts at the societal level to be made, especiallyin health-services/counseling.
However, the line between public health services and religious services seemedto
be somewhat blurred and it could be argued that the majority of students argued
for counseling/guidance as such. What was interesting was that the psychology
students had some suggestions to what should or could be done, but through their
use of language signaled someconfusion about the responsibility for these efforts.
Also, it is noteworthy that psychological professionalism seemed to be mentioned
less distinctly than their will to help from a religious viewpoint. They seemed to
the other hand, also reflect a realism concerning the lack of availability of health
care personnel in developing countries in general. The employment of spiritual
forces therefore might be a pragmatic solution to a shortcoming of the health
services. This can also be seen in light of what Mbiti (2006) pointed out, namely
that “Africans are notoriously religious, and each people has its own religious
system with a set of beliefs and practices. Religion permeates into all the depart-
ments of life so fully that it is not easy or possible always to isolate it” (p. 1).
This means that “where the individual is, there is his religion, for he is a religious
being. It is this that makes Africans so religious: religion is in their whole system
of being (Mbiti, 2006, p. 3). Therefore, it might be difficult to establish any basis
for suicide preventive efforts without taking these strong religious bonds into
consideration and thus involve religious institutions somehow.
However, Colucci and Martin (2008) and Koenig et al. (2001) have shown that
religiousness is related to negative attitudes toward suicidal behavior. Thus,
involving religious institutions in suicide prevention may also be problematic.
Negative attitudes toward suicide as such might not be a problem, but it is
important to be aware of the consequences of one’s attitudes, especiallywhen you
are working with suicidal persons (Goldney & Bottrill, 1980; Lang, Ramsey,
Tanney, & Tierney, 1989). Suicidal persons might perceive these negative atti-
tudes as a rejection, which again might affect both the content and effectiveness
of the intervention or treatment (e.g., Anderson, Standen, Nazir, & Noon, 2000;
neither seem to be clear on the distinction between public- and church-related
obligations nor to distinguish clearly between their professional and religious
skills, a focus on suicidal behavior and suicide prevention as well as on their
own role as professionals should be integrated in their education. Previous
studies have shown that educational training in suicide prevention in general
can change attitudes toward suicide (e.g., Berlim, Perizzolo, Lejderman, Fleck,
& Joiner, 2007; Samuelsson & Åsberg, 2002), but we do not know how com-
patible the education would be with their strong religious beliefs. This requires
Both the potentials as well as the possible problems of involving religious
ATTITUDES TOWARD SUICIDE AND PREVENTION IN GHANA/ 183
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Direct reprint requests to:
Birthe Loa Knizek
Department of Psychology
Norwegian University of Science and Technology
7491 Trondheim, Norway
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