Community Ment Health J
DOI 10.1007/s10597-013-9657-8
BRIEF REPORT
Prevalence and Predictors of Suicidal Behavior Among Mongolian
High School Students
Uyanga Altangerel • Jenn-Chang Liou •
Pi-Ming Yeh
Received: 5 June 2012 / Accepted: 18 November 2013
Ó Springer Science+Business Media New York 2013
Abstract The purpose of this study was to examine the
prevalence and predictors of suicidal behavior among
Mongolian high school students. Females were more likely
to have suicidal behavior than males. No close friends,
feelings of loneliness, insomnia, self perception of under-
weight or overweight, carrying a weapon were significant
predictors of students’ suicidal behavior. Missing school
without permission, being bullied and going hungry were
also important risk factors of suicidal ideation. Families
and Schools are important environments to prevent high
students’ suicide. Improving students’ psychological well
being, quality of relationship with people, and support
resources are critical to prevent suicidal behavior.
Keywords High school students
Suicidal behavior

Mongolia
Introduction
Suicide is the third leading cause of death among 15- to
24-year olds (CDC 2007). The magnitude of this problem
increases when suicidal ideation and ‘unsuccessful’suicide
attempts are taken into account (Cheng et al. 2009). Suicide
U. Altangerel
J.-C. Liou
Department of Healthcare Administration, Asia University, 500,
Lioufeng Rd., Wufeng, Taichung 41354, Taiwan
e-mail: uyanga_and_m@yahoo.com
J.-C. Liou
e-mail: jclth@asia.edu.tw
P.-M. Yeh (&)
Department of Nursing, Missouri Western State University, 3201
North 34th Terrace, St., Joseph, MO 64506, USA
e-mail: pimingyeh@yahoo.com
is the leading cause of death among young people in Asia
and has caused significant economic losses to society.
Suicide rates in Japan, the Republic of Korea, Taiwan and
China have risen significantly in recent years and remains
at historically high levels. The full impact of the world’s
current economic crisis has been realized to be on mental
health and suicide.
It is unfortunate but the fact must be recognized that the
suicidal prevention resources are limited and underdevel-
oped. Alarmingly high rates for suicide ideation, plans, and
attempts are even higher for adolescents (Nickerson and
Slater 2009). Risk factors associated with adolescent sui-
cidal behaviour are multifactorial, complex and interrelated
(Cheng et al. 2009). Identification of factors associated
with these behavior could play an important role in the
development of school or community-based prevention and
intervention programs (Evans et al. 2005). Suicidal
behavior amongst adolescent students is a matter of great
concern due to the tragic loss of all future achievements
both personal and national and the fact that are curtailed. It
is vital to study both the prevalence and the correlates of
such behaviors (Sharma et al. 2008). The Purposes of this
study are to examine the prevalence of suicidal behavior
and to identify the risk factors for suicidal behavior in
Mongolian high school students.
Adolescents in Mongolia
Adolescents in Mongolia are not considered a distinct
group with specific needs in the population and there is no
independent and comprehensive adolescent health and
development policy. Although the government of Mongo-
lia has developed health policies and community strategies
related to child health (‘‘National Action Program on the
Child Development’’ in 2006), adolescent specific health
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studies and policies are desperately needed. There is sig-
nificant morbidity and mortality among adolescents due to
accidents, suicide, violence, pregnancy-related complica-
tions and illnesses. Many of these deaths and illnesses are
preventable (Mongolia Country Report 2010).
Demographic Factors
In the most studies gender was significantly associated with
suicidal behavior and girls were significantly more likely
than boys to report suicidal ideation (Liu and Tein 2005;
Mahfoud et al. 2011; Kim et al. 2011; Rudatsikira et al.
2007). The possible reason of gender difference of suicidal
ideation maybe is that females reported significantly lower
self-esteem, less parental support, and less delinquent
behavior than males (Sharaf et al. 2009). The emotional
problem, such as depression, is a direct effect on females’
suicidal ideation (Sharaf et al. 2009).
Psychological Factors
Multiple psychological risks differentiate between people
who think about killing themselves and those who develop
exacerbated psychopathology and attempt suicide (Borges
et al. 2008). Feeling Loneliness and without close friends
are significant factors associated with the suicidal ideation
(Rudatsikira et al. 2007; Mahfoud et al. 2011; Ruangkan-
chanasetr et al. 2005). Students feel loneliness and have no
close friend have higher tendency to have suicide ideation.
Students who reported having been bullied have higher
possibility to contemplate committing suicide and have
suicide ideation than those who had not been bullied
(Rudatsikira et al. 2007; Mahfoud et al. 2011). There is a
significant relationship between depression, hopelessness
and adolescents’ suicidal behavior, along with feelings of
worthlessness, insomnia, indecisiveness, and psychomotor
disturbance (Kim et al. 2011; Liu et al. 2005; Sharaf et al.
2009; West et al. 2010). Adolescents who feel depression,
sadness, and hopelessness have higher possibility of sui-
cidal behavior.
Overweight
Students who perceive themselves overweight are signifi-
cantly more likely to report suicidal thoughts and actions
than those who perceive themselves underweight (Wang
et al. 2010; Whetstone et al. 2007).
School and Family Factors
Poor family relationships, conflict, limited interfamily
communication and low family cohesion are greater risk of
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Community Ment Health J
a range of pathologies including suicide (Ehnvall et al.
2008; Zhang and Zhou 2011). Among the best-documented
findings from research on adolescence and their families is
the importance of adequate parental regulation involving
supervision, monitoring, rule-setting and other forms of
behavioural control (Chua 2011; Gau et al. 2008; Sfoggia
et al. 2008). After the family, the school represents the
most important social force in a young person’s life. School
attendance is related to the prevalence of several health
behaviours including violence and sexual risk behaviours
(Zhang et al. 2012). Students’ perceptions of the school
environment are associated with their health and well-
being (Nickerson and Slater 2009).
Physical Activity (PE)
Students who tend to be avoid PE class have more likely to
have a suicidal behavior than those who attend PE class
(Wang et al. 2010). The odds of suicide attempts are lower
among frequently vigorously active boys, girls, and sports
team participants (West et al. 2010).
Living Condition
Father’s occupation and poor family relationships are sig-
nificantly associated with adolescent suicidal ideation (Kim
et al. 2011; Liu et al. 2005). Pupils with working mothers
were significantly more likely to be at risk than were those
whose mothers were homemakers (Sharma et al. 2008).
Low socioeconomic status, poor relationships, and broken
families are related to students’ suicide risk (Ruangkan-
chanasetr et al. 2005).
Carrying a Weapon and Missing Class Without
Permission
Weapon-carrying is significantly associated with adoles-
cent suicide attempts (Nickerson and Slater 2009; West
et al. 2010). Suicide decreases significantly when students
report no days of missed classes or school without per-
mission (Cheng et al. 2009).
Research Framework
The Majority of the researchers classify the variables based
on theoretical models. According to other researchers
classification and all possible variables that might influence
students suicidal behavior in the Mongolian GSHS 2010
questionnaire, the authors grouped the factors into 3 blocks
including sociodemographic factors, psychological factors,
and school and family factors (Fig. 1).
Community Ment Health J

Fig. 1 Theoretical framework

Demographic Factors
Gender
Grade level
Location
Living condition

Psychological Factors Suicidal Behavior:

No friends
Feeling lonely 1. Suicidal ideation
Could not sleep 2. Suicidal plan
Having bullied
Weight description 3. Suicidal attempt

Family and School Factors

Going hungry
Missing school without
permission
Days attend to PE class
Carried a weapon

The dependent variables were: suicidal ideation, suicidal
plan, and suicidal attempt
The independent variables were: demographic factors,
psychological factors and school and family factors.
The specific research questions were
1. What was the prevalence of high school suicidal
behavior in Mongolia?
2. What were the main factors associated with suicidal
behavior according to socio-demographic factors?
3. What were the main factors associated with suicidal
behavior according to psychological factors?
4. What were the main factors associated with suicidal
behavior according to family and school factors?
Methods
Description of the Data Source: The Global School
Based Student Health Survey (GSHS)
The data resource was GSHS in Mongolia. The GSHS was
developed by the World Health Organization (WHO) in
order to provide data on health and social behaviours
among school-going adolescent students. In 2010, the
Mongolian Ministry of Health and the Public Health
Institute conducted the first nationwide GSHS in Mongolia.
The GSHS methodology was discussed and approved by
the Scientific Council Meeting of the Public Health School,
Health Science University of Mongolia and the Committee
on Ethics, under the Ministry of Health. The Mongolian
GSHS questionnaire contained 84 questions and two
anthropometric measurements (height and weight).
Sampling
The 2010 Mongolia GSHS employed a two-stage cluster
sample design to produce a representative sample of all
students in grades 7–12 aged 12–18 years old in Mongolia.
The survey was organized nationwide with financial and
technical assistance from the WHO and US CDC. The
survey was conducted in Mongolia in March 2010. The
Mongolia GSHS surveyed students in grades 7–12 in nine
districts of Ulaanbaatar and 21 aimags. The first-stage
sampling frame involved the selection of schools. All
schools in Mongolia having grades 7–12 were included in
the sampling.

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Variable Definitions
Dependent Variables: Suicidal Behavior
Suicidal behavior was measured by 3 variables-suicidal ide-
ation, suicidal plan and suicidal attempt. One example ques-
tion was ‘‘during the last year, did you ever seriously consider
attempting suicide?’’ The responses for suicidal ideation and
plan were 1 = yes, 2 = no (for the logistic regression analyze
the response 1 recoded into 1 = no, the response 2 recoded
into 2 = yes). The responses for suicidal attempt were 1 = 0
times, 2 = 1 times, 3 = 2 or 3 times, 4 = 4 or 5 times, 5 = 6
or more times. (Response 1 recoded into 1 = no, responses
range from 2 to 5 recoded into 2 = yes).
Independent Variables
The independent variables included in this analysis are
classified into 3 groups. They were demographic factors,
psychological factors, and family and school factors.
Demographic factors included gender, grade level (from
7th to 12th), location (urban and rural), and living condi-
tion (Ger in the khashaa, building in the khashaa, dormi-
tory, apartment, house, and some other places).
Psychological factors included feeling of loneliness
(from 1 = never to 5 = always), number of close friends
(1 = no, 2 = yes), couldn’t sleep (1 = no, 2 = yes),
weight description (1 = underweight, 2 = normal weight,
and 3 = overweight), and carrying a weapon (1 = no,
2 = yes).
Family and School factors included PE (1 = no,
2 = yes), missing school without permission (1 = no,
2 = yes), and hunger (1 = no, 2 = yes), being bullied
(1 = no, 2 = yes).
Statistical Analysis
The analyses were conducted using the statistic package for
the social sciences (SPSS) PC version 15.0. Descriptive
statistics (mean, SD, range, frequency, and percent) were
used to describe the study sample. Chi Square was also
used to examine the differences between two group vari-
ables. The setwise procedures for the logistic regression
analysis were used. By setwise, the authors entered the
factor groups started from the sociodemographics and then
the psychological group and finally the family and school
group. The steps for enter the factor groups were based on
theories developed by previous researchers. Theorectically,
sociodemographics should be treated as predisposing fac-
tors. Family and school variables investigated by the GSHS
may be treated as enabling factors and psychological
variables as another set of predisposing factors (according
to Green and Kreuter’s PRECEDE–PROCEED model, the
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Community Ment Health J
psychological related variables should be treated as pre-
disposing factor, because it predispioses the behavior. In a
broad definition of behavior, suicide thought, plan and
attemtp are behaviors.) Because this was a school based
survey (GSHS), we may have to stress the importance of
school and family factors since other variables studied here
are common for other target groups (from young people to
elderly for example). We used setwise procedure by
entering the variables of 3 factor groups set by set for each
of the dependent variable. Within each factor set, we used
the stepwise with forwardconditional method. Odds ratio
(OR) and 95 % CI of OR are used to indicate the associ-
ation between the predictor (dependent variable) and the
predictive (independent variables). Level of statistical
significant was set at p \ .05.
Results
Prevalence of Suicidal Ideation
Overall, 19.8 % of students reported had suicide ideation.
There were 337(15.1 %) of males and 680 (23.2 %)
females had suicidal ideation. The majority of participants
who had suicidal ideation were living in central city 288
(25.6 %) and living in apartment 274 (25.8 %). Overall
12.8 % of students reported they had made a plan for
attempting suicide. Overall 8.7 % of students had attemp-
ted suicide once or more in the 12 months preceding the
survey (Table 1).
Comparisons of the Sociodemographic Factors
with Students’ Suicidal Behavior
Among the sociodemographic factors, gender, grade level,
location and living condition were significantly associated
with suicidal ideation of the students. Female students were
1.6 times as likely (OR = 1.69; 95 % CI 1.46–1.96) to think
about suicide as males. 8th grade students were 1.4 times as
likely (OR = 1.42; 95 % CI 1.13–1.77) to think about sui-
cide as 7th grade students. Students who lived in urban areas
were 0.5 times (OR = 0.58; 95 % CI 0.50–0.67) to think
about suicide as likely as those who live in rural areas. Stu-
dents who live in apartments were 0.7 times as likely
(OR = 0.74; 95 % CI 0.53–1.05) to think about suicide as
those who live in private houses (Table 2).
Comparisons of the Psychological Factors
with Students’ Suicidal Behavior
Students who had no close friends were 2.45 times as likely
(OR = 2.45; 95 % CI 1.86–3.23) to think about suicide as
those who have 1 or more close friends. Students who felt
Community Ment Health J

Table 1 Prevalence of suicidal ideation, suicidal plan and suicidal attempt

Characteristics Suicidal ideation Suicidal plan Suicidal attempt
Total n (%) p Total n (%) p Total n (%) p

Sociodemographic
Gender
Male 2,224 337 (15.1) 0.00 2,232 245 (11.0) 0.00 2,249 159 (7.0) 0.00
Female 2,924 680 (23.2) 2,939 405 (13.8) 2,942 290 (9.8)
Grade
7th 1,335 225 (16.8) 0.00 1,340 176 (13.1) 0.32 1,344 106 (7.9) 0.04
8th 1,320 260 (19.7) 1,321 159 (12.0) 1,328 113 (8.5)
9th 890 199 (22.3) 899 130 (14.5) 907 102 (11.2)
10th 819 164 (20.0) 824 100 (12.1) 827 72 (8.7)
11th 750 167 (22.2) 756 86 (11.4) 754 56 (7.4)
Location
Central of city 1,112 288 (25.6) 0.00 1,118 152 (13.6) 0.06 1,121 101 (9.0) 0.06
Rural of city 1,199 278 (23.1) 1,205 151 (12.5) 1,207 117 (9.7)
Aimag center 812 116 (14.2) 814 78 (9.6) 818 55 (6.7)
Soum center 1,488 259 (17.4) 1,499 203 (13.5) 1,504 122 (8.1)
Rural bag 539 78 (14.4) 540 70 (13.0) 545 58 (10.6)
Living condition
Ger in the khashaa 1,673 308 (18.4) 0.00 1,688 214 (12.7) 0.34 1,693 140 (8.3) 0.56
Building in the khashaa 1,700 315 (18.5) 1,710 196 (11.7) 1,714 144 (8.4)
Dormitory 450 62 (13.4) 450 63 (14.0) 454 41 (9.0)
Apartment 1,066 274 (25.8) 1,067 144 (13.5) 1,072 95 (8.9)
House 238 49 (20.8) 239 37 (15.5) 239 28 (11.7)
Some other place 31 10 (32.2) 31 3 (9.7) 33 4 (29.0)
Psychological
Close friend
No 233 85 (36.4) 0.00 234 57 (24.3) 0.00 239 44 (18.4) 0.00
Yes 4,918 933 (19.0) 4,943 601 (12.2) 4,959 410 (8.2)
Feel loneliness
No 1,628 191 (11.7) 0.00 1,634 162 (9.9) 0.00 1,642 89 (5.4) 0.00
Yes 3,540 831 (23.4) 3,559 496 (13.9) 3,570 362 (10.1)
Couldn’t sleep
No 2,223 284 (12.3) 0.00 2,227 201 (9.0) 0.00 2,223 85 (3.8) 0.00
Yes 2,948 739 (25.0) 2,968 458 (15.4) 2,991 369 (12.3)
Weight description
Underweight 862 173 (20.0) 0.00 875 122 (14.0) 0.00 877 87 (9.9) 0.00
Normal weight 3,404 588 (17.3) 3,411 381 (11.2) 3,428 261 (7.6)
Overweight 899 263 (29.2) 904 155 (17.1) 905 107 (11.8)
Carried a weapon
No 4,841 914 (18.9) 0.00 4,862 572 (11.8) 0.00 4,869 360 (7.3) 0.00
Yes 310 106 (34.1) 315 80 (25.3) 327 94 (28.0)
School and Family
Went hungry
No 3,396 581 (17.1) 0.00 3,411 361 (10.6) 0.00 3,421 229 (6.7) 0.00
Yes 1,766 440 (25.0) 1,776 296 (16.7) 1,787 224 (12.5)
Go to PE class
No 305 77 (25.2) 0.00 311 60 (19.2) 0.00 316 54 (17.0) 0.00
Yes 4,831 937 (19.4) 4,850 593 (12.2) 4,865 397 (8.2)

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Table 1 continued
Characteristics Suicidal ideation
Total n (%) p Total
Miss school
No 3,745 659 (17.6) 0.00
Yes 1,409 357 (25.3)
Bullied
No 4,102 727 (17.7) 0.00
Yes 634 178 (28.0)
lonely were 2.3 times as likely (OR = 2.30; 95 % CI
1.94–2.73) to think about suicide as those who did not feel
lonely over the past 30 days. Students who had sleeping
problems were 2.2 times as likely (OR = 2.28; 95 % CI
1.96–2.65) to think about suicide as those who slept well
(Table 2).
Weight description was significantly associated with
suicide ideation. Students who perceived themselves as
overweight were 1.6 times as likely (OR = 1.64; 95 % CI
1.32–2.05) to think about suicide as those students of
normal weight. For those who perceived themselves as
underweight the figure was 1.9 times (OR = 1.98; 95 % CI
1.67–2.34) as those who perceived themselves of normal
weight. Students who carried a weapon were 2.2 times as
likely (OR = 2.23; 95 % CI 1.75–2.85) to think about
suicide as students who did not carried a weapon (Table 2).
Comparisons of the Family and School Factors
with Students’ Suicidal Behavior
Among family and school factors going hungry, attending
PE class, missing school without permission and having been
bullied were significantly associated with students’ suicidal
ideation. Students who felt hungry were 1.6 times as likely
(OR = 1.61; 95 % CI 1.40–1.84) to think about suicide as
students who didn’t feel hungry. Those who attended phys-
ical education class were 0.7 times as likely (OR = 0.71;
95 % CI 0.55–0.93) to think about suicide as students who
did not attend the PE class each week. Students who missed
school without permission were 1.5 times as likely
(OR = 1.58; 95 % CI 1.37–1.84) to think about suicide as
those who didn’t. Students who had been bullied were 1.8
times as likely (OR = 1.81; 95 % CI 1.49–2.19) to think
about suicide as students who hadn’t (Table 2).
Predictors of Students’ Suicidal Behavior Among
Sociodemographic Factors
Multivariate models identified eleven factors that signifi-
cantly predicted students’ suicide ideation after adjustment
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Community Ment Health J
Suicidal plan Suicidal attempt
n (%) p Total n (%) p
3,756 407 (11.0) 0.00 3,761 267 (7.0) 0.00
1,423 247 (17.3) 1,437 184 (12.8)
4,121 457 (11.0) 0.00 4,120 272 (6.6) 0.00
638 128 (20.0) 656 125 (19.0)
for gender, grade level, location and living conditions.
According to logistic multivariate models, gender signifi-
cantly predicted students’ suicidal behavior. Females were
more likely to have suicidal behavior than males. Female
students were 1.8 times as likely (AOR = 1.81; 95 % CI
1.51–2.56) to think about suicide, 1.2 times as likely
(OR = 1.29; 95 % CI 1.09–1.53) to make a suicide plan,
and 1.8 times as likely (AOR = 1.82; 95 % CI 1.31–2.46)
to attempt suicide as males. Students who lived in urban
areas were 1.5 times as likely (AOR = 1.50; 95 % CI
1.26–1.75) to think about suicide as those who lived in
rural areas. Students who live at Gers in the khashaa were
0.4 times as likely (AOR = 0.49; 95 % CI 0.30–0.80) to
attempt suicide as those who lived in private houses.
Sociodemographic factors explained 0.4 % variance of
suicidal ideation (Negelkerke R2 = 0.045), 0.04 % vari-
ance of suicidal plan (Negelkerke R2 = .004), and 0.1 %
variance of suicidal attempt (Negelkerke R2 = 0.013)
(Table 3).
Predictors of Students’ Suicidal Behavior Among
Psychological Factors
Among the psychological factors, no close friends, feelings
of loneliness, insomnia, self perception of underweight or
overweight, carrying a weapon were significant predictors
of students’ suicidal behavior. Those who had no close
friend were 2.0 times as likely (AOR = 2.05; 95 % CI
1.49–2.81) to think about suicide, 1.9 times as likely
(AOR = 1.94; 95 % CI 1.36–2.75) to make a suicidal plan,
and 1.8 times as likely (AOR = 1.82; 95 % CI 1.22–2.74)
to attempt suicide as those who had close friends. Those
who couldn’t sleep well were 1.5 times as likely
(AOR = 1.56; 95 % CI 1.31–1.87) to think about suicide,
and 1.5 times as likely (AOR = 1.53; 95 % CI 1.24–1.89)
to make a suicide plan as those who slept well. Those who
felt lonely were 0.6 times as likely (AOR = 0.63; 95 % CI
0.52–0.77) to think about suicide as those who did not feel
loneliness. Those who perceived themselves as overweight
were 1.9 times as likely (AOR = 1.98; 95 % CI 1.67–2.34)
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Table 2 Comparisons of odds ratios for suicidal behaviors among main factors
Characteristics Suicidal ideation Suicidal plan Suicidal attempt
1 1
OR 95 %CI OR 95 % CI OR1 95 % CI

Sociodemographic
Gender
Male 1.00 1.00 1.00
Female 1.69 1.46–1.96* 1.29 1.09–1.53* 1.45 1.18–1.69*
Grade
7th 1.00 1.00 1.00
8th 1.42 1.13–1.77* 0.85 0.64–1.12 1.09 0.78–1.52
9th 1.16 0.93–1.45 0.93 0.70–1.24 1.15 0.83–1.61
10th 0.99 0.78–1.25 0.75 0.56–1.01 1.57 1.12–2.22
11th 1.14 0.89–1.45 0.92 0.68–1.26 1.18 0.82–1.71
Location
Urban 0.58 0.50–0.67* 0.93 0.79–1.10 1.15 0.95–1.40
Rural 1.00 1.00 1.00
Living condition
Ger in the khashaa 1.14 0.81–1.61 1.26 0.86–1.84 0.67 0.44–1.04
Building in the khashaa 1.13 0.81–1.59 1.41 0.96–2.07 0.69 0.44–1.06
Dormitory 1.62 1.07–2.45 1.12 0.72–1.74 0.74 0.44–1.24
Apartment 0.74 0.53–1.05* 1.17 0.79–1.73 0.73 0.46–1.14
House 1.00 1.00 1.00
Some other place 0.54 0.24–1.23 1.70 0.49–5.91 1.03 0.34–3.17
Psychological
Close friend
No 0.40 0.30–0.53* 0.42 0.31–0.58* 2.50 1.77–3.52*
Yes 1.00 1.00 1.00
Feel lonely
No 1.00 1.00 1.00
Yes 2.30 1.94–2.73* 1.47 1.21–1.77* 0.50 0.39–0.64*
Couldn’t sleep
No 1.00 1.00 1.00
Yes 2.28 1.96–2.65* 1.83 1.54–2.19* 0.28 0.22–0.36*
Carried a weapon
No 1.00 1.00 1.00
Yes 2.23 1.75–2.85 2.55 1.95–3.33* 0.19 0.15–0.25*
Weight description
Normal weight 1.00 1.00 1.00
Overweight 1.64 1.32–2.05* 1.27 0.98–1.65* 0.82 0.60–1.10
Underweight 1.98 1.67–2.34* 1.64 1.34–2.01* 0.61 0.48–0.77*
Family and School
Went hungry
No 1.00 1.00 1.00
Yes 1.61 1.40–1.84* 1.68 1.43–1.99* 0.50 0.41–0.60*
Go to PE class
No 0.71 0.55–0.93* 0.58 0.43–0.78* 2.31 1.70–3.16*
Yes 1.00 1.00 1.00
Bullied
No 1.00 1.00 1.00
Yes 1.81 1.49–2.19* 2.01 1.62–2.49* 0.30 0.23–0.37*
Miss school
No 1.00 1.00 1.00
Yes 1.58 1.37–1.84* 1.72 1.45–2.05* 0.52 0.42–0.63*
1
OR Unadjusted odds ratios
CI confidence interval
* p \ 0.05

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Table 3 Multivariate odds ratios of Sociodemographic, psychological, and family and school factors
Characteristics Ideation (N = 4,548) Plan (N = 4,565) Attempt (N = 4,583)

AOR 95 %CI AOR 95 % CI AOR 95 % CI

Sociodemographic Negelkerke R2 = 0.045 Negelkerke R2 = 0.004 Negelkerke R2 = 0.013

Gender
Male 1.00 1.00 1.00
Female 1.81 1.51–2.56* 1.32 1.07–1.32* 1.82 1.31–2.46*
Grade 1.02 0.96–1.08 0.92 0.86–0.99* 0.95 0.88–1.04
Location
Urban 1.50 1.26–1.75* 1.02 0.83–1.25 1.15 0.90–1.48
Rural 1.00 1.00 1.00
Living condition
Ger in the khashaa 0.95 1.64–1.40* 0.82 0.53–1.27 0.49 0.30–0.80
Building in the khashaa 0.96 0.65–1.42 0.82 0.53–1.27 0.57 0.35–0.93
Dormitory 0.59 0.36–0.96 0.84 0.50–1.41 0.52 0.29–0.94
Apartment 1.19 0.80–1.78 0.91 0.58–1.41 0.56 0.34–0.94
House 2.72 1.08–6.89 0.71 0.19–2.65 0.44 0.09–2.17
Some other place
Psychological NegelkerkeR2 = .097 NegelkerkeR2 = .035 NegelkerkeR2 = .084
Close friend
No 2.05 1.49–2.81* 1.94 1.36–2.75* 1.82 1.22–2.74*
Yes 1.00 1.00 1.00
Feel lonely
No 1.00 1.00 1.00
Yes 0.63 0.52–0.77* 0.92 0.74–1.64 0.78 0.57–1.06
Couldn’t sleep
No 1.00 1.00 1.00
Yes 1.56 1.31–1.87* 1.53 1.24–1.89* 2.74 2.03–3.68*
Carried a weapon
No 1.00 1.00 1.00
Yes 0.49 0.36–0.67* 0.49 0.35–0.68* 0.26 0.19–0.37*
Weight description
Normal weight 1.00 1.00 1.00
Overweight 1.64 1.32–2.05* 1.27 0.98–1.65* 0.82 0.60–1.10
Underweight 1.98 1.67–2.34* 1.64 1.34–2.01* 0.61 0.48–0.77
Family and school Negelkerke R2 = .121 Negelkerke R2 = .062 Negelkerke R2 = .156
Went hungry
No 1.00 1.00 1.00
Yes 0.77 0.65–0.91* 0.72 0.60–0.88* 0.67 0.53–0.85*
Go to PE class
No 1.59 1.16–2.58* 1.55 1.10–2.59* 2.12 1.44–3.10*
Yes 1.00 1.00 1.00
Bullied
No 1.00 1.00 1.00
Yes 1.57 1.27–1.95* 1.58 1.24–2.01* 2.28 1.75–2.98*
Miss school
No 1.00 1.00 1.00
Yes 0.66 0.55–0.78* 0.60 0.49–0.74* 0.59 0.47–0.76*

Stepwise models entered by 3 independents set of sociodemographics, psychological, family and school factors
Pseudo R2—Negelkerke’s R2
AOR adjusted odds ratios were adjusted gender, grade, location and living condition
* p \ 0.05

123
Community Ment Health J

to think about suicide as those who perceived themselves (16 % in 2005, GSHS). The prevalence of suicidal plans
as of normal weight. Those who carried a weapon were 0.4 (12.8 %) was higher for Mongolian students compared
times as likely (AOR = 0.49; 95 % CI 0.36–0.67) to think with that students in China (8.1 % in 2003, GSHS), or USA
about suicide, and 0.4 times as likely (AOR = 0.49; 95 % (10.9 % in 2009, YRBS). The prevalence of suicidal
CI 0.35–0.68) to make a suicidal plan as those who did not attempt (8.7 %) was higher than students in the USA
carry a weapon. Psychological factors explained 0.9 % (6.3 % in 2009, YRBS) or Thailand (8 % in 2005, YRBS).
variance of suicidal ideation (Negelkerke R2 = 0.097),
0.3 % variance of suicidal plan (Negelkerke R2 = 0.035),
Sociodemographic Factors
and 0.8 % variance of suicidal attempt (Negelkerke
R2 = 0.084) (Table 3).
This study found gender significantly predicted students’
suicidal behavior. Female students were more likely to
Predictors of Students’ Suicidal Behavior Among
have suicidal behavior than male students. These findings
Family and School Factors
were similar with other countries studies (Kim et al. 2011;
Liu and Tein 2005; Mahfoud et al. 2011; Rudatsikira et al.
Among the family and school factors, missing school
2007). Adolescents who indicated past year suicidal idea-
without permission, being bullied and going hungry were
tion were more impulsive, lonely, irrational, and distressed
significant predictors of students’ suicidal behavior. Those
by family and peer relationships (Chan et al. 2009). The
who went hungry were 0.7 times as likely (AOR = 0.77;
interpersonal-psychological theory (Joiner 2005) hypothe-
95 % CI 0.65–0.91) to think about suicide, 0.7 times as
sizes that feeling of thwarted belongingness and burden-
likely (AOR = 0.72; 95 % CI 0.60–0.88) to make a suicide
someness lead to the desire for suicide. Gender was a
plan, and 0.6 times as likely (AOR = 0.67; 95 % CI
significant predictor of thwarted belongingness and bur-
0.53–0.85) to attempt suicide as those who did not feel
densomeness (Davidson et al. 2011). Thwarted belong-
hungry. Those who did not attend the physical education
ingness is the perception that a person is not a part of a
class were 1.5 times as likely (AOR = 1.59; 95 % CI
group, and is not significantly connected with others.
1.16–2.58) to think about suicide, and 2.1 times as likely
Burdensomeness can be described as a feeling that one is
(AOR = 2.12; 95 % CI 1.44–3.10) to attempt suicide as
an undue stress upon others and is not contributing sig-
those who did go PE class. Those who missed school
nificantly to society (Joiner 2005). Van Orden et al. (2010)
without permission were 0.6 times as likely (AOR = 0.66;
hypothesized that women were at greater risk for burden-
95 % CI 0.55–0.78) to think about suicide, 0.6 times as
someness and thwarted belongingness due to higher levels
likely (AOR = 0.60; 95 % CI 0.49–0.74) to make a sui-
of depression and greater focus on interpersonal relation-
cidal plan, and 0.5 times as likely (AOR = 0.59; 95 % CI
ships and altruism relative to men. In other words, since
0.47–0.76) to attempt suicide as those who did not do so.
these needs tend to be stronger in women, if they are
Those who were bullied were 1.5 times as likely
thwarted, women may express greater levels of the inter-
(AOR = 1.57; 95 % CI 1.27–1.95) to think about suicide,
personal risk factors for suicide (Van Orden et al. 2010).
1.5 times as likely (AOR = 1.58; 95 % CI 1.24–2.01) to
The female suicide rate decreased during the period
make s suicide plan, and 2.2 times as likely (OR = 2.28;
between 1987 and 2008, which is due to the economic
95 % CI 1.75–2.98) to attempt suicide as those who were
development over the past decades resulting in increase of
not. Family and school factors explained 12 % variance of
female social status in China, particularly in rural areas (Li
suicidal ideation (Negelkerke R2 = 0.121), 6 % variance
et al. 2012). Some studies identified grade level was sig-
of suicidal plan (Negelkerke R2 = 0.062), and 15 %
nificantly associated with suicidal behavior (Chang et al.
variance of suicidal attempt (Negelkerke R2 = 0.156)
2008; Kim et al. 2011; Liu et al. 2005). In this study grade
(Table 3).
level did not predict students’ suicidal behavior. This study
also found students living condition and location did not
predict student’s suicidal behavior.
Discussion

Prevalence of Suicidal Behavior Psychological Factors

Overall, 19.8 % of Mongolian high school students
admitted having had suicidal ideation. The prevalence of
suicidal ideation was higher than the prevalence of students
in China (17.4 %, in 2003, GSHS), Philippines (17.15 in
2003 GSHS), USA (13.8 % in 2009, YRBS), and Lebanon
This study found that students who had no close friends are
more likely to have suicidal behavior than students who
have one or more close friends. This finding was similar
with other researchers’ studies (Kim et al. 2011; Liu et al.
2005; Rudatsikira et al. 2007). This study found that

123

students who had sleeping problems were more likely to
have suicidal behavior than students who slept well. Sleep
difficulties and related problems (e.g. tiredness and night-
mares) were investigated in four studies and significant
associations with suicidal phenomena were reported in all
of them. Multivariate analysis was conducted in one study:
sleep problems made a significant additional contribution
to the variance in suicidal attempts (Evans et al. 2005).
Students who perceived themselves as underweight were
more likely to have suicidal behavior than students who
perceived themselves as of normal weight in this study.
Depression, substance use, body image, weight control
behaviors, and risky sexual behaviors were significant
predictors of adolescents’ suicidal behaviors (Kim et al.
2011). West et al. (2010) and Nickerson and Slater (2009)
found carrying a weapon was associated with student’s
suicidal behavior. Some studies indicated that feeling
loneliness was significantly associated with students’ sui-
cidal behavior (Mahfoud et al. 2011; Rudatsikira et al.
2007).
Family and School Factors
This study found the most of the school and family factors
that going hungry, not going to PE class, miss school
without permission and being bullied significantly pre-
dicted student’s suicidal behavior. This study found that
having been bullied significantly predicted students’ sui-
cidal behavior. This finding was similar to the previous
studies (Mahfoud et al. 2011; Rudatsikira et al. 2007). This
study found missing school without permission signifi-
cantly predicted students’ suicide behavior. Cheng and his
colleagues also identified that suicide decreases signifi-
cantly when students report no days of missed classes or
school without permission (Cheng et al. 2009). Poor family
relationships, conflict, limited interfamily communication
and low family cohesion are greater risk of a range of
pathologies including suicide (Zhang and Zhou 2011).
After the family, the school represents the most important
social force in a young person’s life. School attendance is
related to the prevalence of several health behaviours
including violence and sexual risk behaviours (Zhang et al.
2012). Students’ perceptions of the school environment are
associated with their health and well-being (Nickerson and
Slater 2009). Perceived high-level support from fellow
students is also related to subjective health complaints,
satisfaction with school and increased PE (Nickerson and
Slater 2009).
The majority of the factors are preventable. School and
education authorities can offer effective educational
activities to families with social support and counsellors
in suicidal behavior. Schools are emphasized as being the
best location to implement students suicide prevention
123
Community Ment Health J
programs as students spend much of their times in schools.
More importantly, schools have to identify and offer
appropriate counseling and guidance for the students at-
risk through periodical surveillance. Family interventions
can have important effects on student’s outcomes. Overall,
these findings can help guide prevention, and intervention
strategies to prevent suicidal behaviors among students in
Mongolia.
Study Limitations
Several limitations should be considered when interpreting
the findings of this study. First, it is based on students who
are attending school; therefore, the findings may not be
generalizable to students who no longer attend school.
Second, the data were self reported and may reflect biases
and misreporting. Third, we did not collect data on other
factors that may have an effect on suicidal risk. For
instance, evidence reported elevated life stress experienced
during the past year and elevated depression were common
to all suicidal ideation, suicidal plan and suicidal attempts
among adolescents (Kim et al. 2011; Liu et al. 2005).
Sadness, binge drinking, sniffing glue, hard drug use, dat-
ing violence characters, and forced sex were associated
with attempting suicide (West et al. 2010). These other
factors were not assessed largely because the secondary
data was used in this study. Anyway, using this simple
question, ‘‘yes’’ or ‘‘no’’ is a study limitation, so these
limitations could be improved in the future study.
Acknowledgments The authors would like to thank Enkhmyagmar
Dashzeveg, Researcher, Public Health Institute Mongolia, for pro-
viding the 2010 Mongolia GSHS data.
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