Suicide is a complex phenomenon; therefore, it should be approached in light of sociocultural perspectives and the general attitude toward suicide. This study aimed to extract factors from the Attitude Toward Suicide Scale (ATTS) and investigate the relationship between attitudes toward suicide and suicidal behavior (i.e., suicidal idea, plan, and attempt) by using a representative sample of Korean adults.
Three thousand Koreans aged 19 to 75 years were surveyed cross-sectionally in 2013 and 2018. The data collected were subjected to exploratory factor analysis. Extracted attitude factors were compared using a suicidal behavior continuum. Univariate and multivariate logistic models were constructed to compare the association between attitude factors and suicidal behaviors.
Among the participants, 477 (15.9%) experienced suicidal idea only, 85 (2.8%) had a suicidal plan without attempt, and 58 (1.9%) attempted suicide. Four meaningful factors were extracted from the factor analysis: “permissiveness,” “unjustified behavior,” “preventability/readiness to help,” and “loneliness.” “Permissiveness,” “unjustified behavior,” and “loneliness” factors showed significant trends across the suicidal behavior continuum. Permissive attitude toward suicide increased the odds of suicidal idea, suicidal plan, and suicide attempt (adjusted odds ratio [aOR]=1.49, 95% confidence interval [CI]=1.25–1.79; aOR=2.79, 95% CI=1.84–4.25; aOR=2.67, 95% CI=1.65–4.33), while attitude toward suicide as unjustified behavior decreased the odds of suicidal ideation and attempt (aOR=0.79, 95% CI=0.67–0.94; aOR=0.64, 95% CI=0.42–0.99).
A significant association was found between attitude toward suicide and suicidal behaviors. Attitude toward suicide is a modifiable factor that can be used to develop prevention policies.
Suicide is a major public health concern worldwide. According to the Organization for Economic Cooperation and Development (OECD) report in 2017, the average suicide rate of OECD countries was 12.1 per 100,000 [
Suicide is not a momentary reaction but a complex phenomenon that starts from a suicidal idea with many factors accumulating in stages [
To clarify the complex intertwined relationship between public perspective on suicide and suicidal behavior and measure the attitude toward suicide, a valid and reliable instrument is needed along with a representative sample. Many previous studies tried to validate the Attitude Toward Suicide Scale (ATTS), developed by Renberg and Jacobsson [
To date, no study has confirmed the association between attitude toward suicide and suicidal behaviors in a large representative sample. The aim of this study was to extract valid attitude factors using the ATTS in a large representative sample from the Korean population and to explore whether those factors of ATTS are related to suicidal behaviors.
The current study used data from the Korean National Suicide Survey, a cross-sectional national representative survey conducted once every 5 years by the Ministry of Health and Welfare of South Korea [
Interviewers must complete survey-related education based on a consistent survey guideline and maintain quality control through continuous contact with supervisors. They were able to contact the research supervisors if any questions arose during the survey process. All statistical sampling and weighting procedures for the survey were the same for both 2013 and 2018 to achieve comparability.
The 2013 and 2018 surveys were approved by the Kangwon National University Hospital’s Institutional Review Board (approval number: KNUH-2013-06-007-001) and Seoul National University Hospital’s Institutional Review Board (approval number: H-1810-062-979), respectively.
To examine participants’ attitudes toward suicide, the ATTS first developed and validated by Renberg [
In addition to the ATTS responses, socio-demographic factors including age, sex, marital status, urbanicity, education level, income, employment, and religion were investigated. Subjective happiness and physical health status, history of suicide exposure, attitude on the suicide shown on the media, and agreement on suicide prevention and on current suicide prevention management programs were comprehensively investigated.
In order to minimize the resistance of the respondent, questions about happiness and physical/mental health status, which can be answered more easily, were placed in the beginning, followed by questions on suicidal behaviors, asked in the order of suicidal ideation, suicide plan, and attempt. All questions were structured with clear guidelines. A more detailed explanation of the survey process can be found in the Statistical information report of Korea National Suicide Survey (KNSS) [
Group comparisons of sociodemographic characteristics among participants with and without suicidal behaviors (i.e., ideation, plan, and attempt) were carried out using the χ2 test. Cronbach’s α was used to assess the internal reliability of ATTS. Items of communality score under 0.4 and items that increase α when removed were discarded. Exploratory factor analysis was performed to extract factors using the principal factor method with a varimax rotation. Items with loadings <0.4 and those with loadings >0.4 for two or more factors were discarded. For each factor, Cronbach’s α was calculated. Item scores were averaged to obtain subscale attitude factor scores. Items with negative loadings were scored in reverse order when averaged.
One-way analysis of variance was performed to compare the attitude factor scores among the suicidal continuum groups. The Bonferroni method was used for multiple comparisons. Trend analysis using Jonckheere-Terpstra test was performed to examine whether a factor score had an increasing or decreasing trend with statistical significance across the suicidal continuum.
Logistic regression analyses were performed to identify the association between each attitude factor’s score and the suicidal behavior (i.e. ideation, plan, and attempt). Odd ratios (ORs) and 95% confidence intervals (95% CIs) of each suicidal behavior group were calculated with no suicidal idea group as the reference group. Age, sex, marital status, education, income, and religion were adjusted in the multivariate model. All data analyses were performed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA).
Sociodemographic characteristics of the participants are presented in
The average scores and standard deviation for each ATTS item are shown in
The group comparisons of mean attitude factors are depicted in
The univariate and multivariate models are depicted in
The main objective of this study was to extract meaningful factors from the ATTS to investigate the relationship between attitude scales and suicidal behavior. Among nine factors, “permissiveness”, “unjustified behavior”, “preventability/readiness to help”, and “loneliness” factors were found to be meaningful. There were significant group differences and meaningful trends of factors along the suicidal behavior continuum of idea-planattempt. Furthermore, those factors showed a strong association with suicidal behaviors when the analysis models were adjusted for confounders.
The lifetime prevalence rates of suicidal idea, plan, and attempt found in the current study were similar to those in previous studies in South Korea; however, the proportion of people who attempted suicide (1.9%) found in our study seemed to be lower than the estimated numbers in previous studies (2.4%–3.2%) [
The overall factor structure of the study yielded similar results as those of previous studies; nine factors were comparable with Renberg’s study [
The results of the current study are consistent with those of previous studies, implying an association between permissive attitude toward suicide and suicidal behaviors in various study populations [
There are only a few studies [
The main strength of this study was that it not only extracted meaningful factors from the ATTS but also investigated its association with suicidal behavior simultaneously with a sufficiently large sample. This was the first study to show increasing/ decreasing trends of attitude scores along the suicidal continuum and analyze the comprehensive association between attitudes toward suicide and suicidality.
In conclusion, our study determined the factor structure of ATTS and investigated the relationship between attitude factors and suicidal behaviors. We extracted four meaningful factors from the data and were able to investigate the association between these factors and groups along the suicidal continuum. Permissive attitude toward suicide increased the odds of suicidal behaviors, whereas negative attitude toward suicide decreased the odds. Attitude toward suicide is one of the few modifiable factors in suicide prevention. By investigating the relationship between suicidal behavior and attitude toward suicide, tailored prevention policies that target specific attitudes to suicide can be developed.
The online-only Data Supplement is available with this article at
Mean and standard deviation (SD) of each item of Attitude Toward Suicide Scale
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
The authors have no potential conflicts of interest to disclose.
Conceptualization: Min Ji Kim, Hyunju Lee. Data curation: Minseok Hong. Formal analysis: Min Ji Kim. Funding acquisition: Jong-Ik Park, Yong Min Ahn. Investigation: Min Ji Kim, Hyunju Lee. Methodology: Min Ji Kim, Hyunju Lee. Software: Yong Min Ahn. Supervision: Sang Jin Rhee, Jong-Ik Park, Yong Min Ahn. Writing—original draft: Min Ji Kim. Writing—review & editing: Daun Shin, Sang Jin Rhee.
This research was supported by a grant from the Korea Ministry of Health & Welfare, Republic of Korea.
The authors would like to appreciate professor Ellinor Salander Renberg of Umeå University for providing the original text and advice on the Attitude Toward Suicide Scale. We also thank the staff of Hankook Research who were in charge of the survey’s field practice and the participants of the study.
Sociodemographic factors among no suicidal idea group, suicidal idea only, suicidal plan, and suicidal attempt group
No suicidal idea (N=2,380) (79.3%) | Suicide behavior (N=620) (20.7%) |
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---|---|---|---|---|---|
Suicidal idea only (N=477) (15.9%) | Suicidal plan (N=85) (2.8%) | Suicide attempt (N=58) (1.9%) | p-value | ||
Sex | 0.430 | ||||
Male | 1,151 (48.4) | 216 (45.3) | 38 (44.7) | 24 (41.4) | |
Female | 1,229 (51.6) | 261 (54.7) | 47 (55.3) | 34 (58.6) | |
Age (yr) | 0.375 | ||||
19–29 | 410 (17.2) | 77 (16.1) | 12 (14.1) | 11 (19.0) | |
30–39 | 471 (19.8) | 86 (18.0) | 19 (22.4) | 9 (15.5) | |
40–49 | 516 (21.7) | 101 (21.2) | 21 (24.7) | 15 (25.9) | |
50–59 | 472 (19.8) | 109 (22.9) | 15 (17.6) | 18 (31.0) | |
≥60 | 511 (21.5) | 104 (21.8) | 18 (21.2) | 5 (8.6) | |
Marital status | <0.001 | ||||
Married | 524 (22.0) | 109 (22.9) | 18 (21.2) | 14 (24.1) | |
Unmarried | 1,705 (71.6) | 318 (66.7) | 52 (61.2) | 31 (53.4) | |
Divorced/Deceased | 151 (6.3) | 50 (10.5) | 15 (17.6) | 13 (22.4) | |
Education level (yr) | 0.047 | ||||
≤9 | 400 (16.8) | 99 (20.8) | 13 (15.3) | 12 (20.7) | |
10–12 | 988 (41.5) | 207 (43.4) | 44 (51.8) | 28 (48.3) | |
≥13 | 992 (41.7) | 171 (35.8) | 28 (32.9) | 18 (31.0) | |
Monthly income (million KW) |
0.010 | ||||
<200 | 472 (19.8) | 123 (25.8) | 19 (22.4) | 21 (36.2) | |
200–399 | 1,082 (45.5) | 197 (41.3) | 37 (43.5) | 22 (37.9) | |
≥400 | 824 (34.7) | 157 (32.9) | 29 (34.1) | 15 (25.9) | |
Urbanicity | 0.917 | ||||
Urban | 1,914 (80.4) | 389 (81.6) | 69 (81.2) | 48 (82.8) | |
Rural | 466 (19.6) | 88 (18.4) | 16 (18.8) | 10 (17.2) | |
Employment | 0.917 | ||||
Employed | 1,030 (43.3) | 201 (42.1) | 36 (42.4) | 27 (46.6) | |
Unemployed | 1,350 (56.7) | 276 (57.9) | 49 (57.6) | 31 (53.4) | |
Religion | 0.006 | ||||
Yes | 1,064 (44.7) | 245 (51.4) | 45 (52.9) | 34 (58.6) | |
No | 1,316 (55.3) | 232 (48.6) | 40 (47.1) | 24 (41.4) | |
Year | 0.113 | ||||
2013 | 1,165 (48.9) | 258 (54.1) | 43 (50.6) | 34 (58.6) | |
2018 | 1,215 (51.1) | 219 (45.9) | 42 (49.4) | 24 (41.4) |
Values are presented as N (%) unless otherwise indicated.
two cases were missing for income data.
$1=1,100 KW (Korean Won)
Factor structure of Attitudes Toward Suicide Scale’s 29 items
Factor | Explained variance (%) | Factor loadings | Cronbach’s α |
---|---|---|---|
Factor 1. Permissiveness | 10.47 | 0.733 | |
18. Suicide a relief | 0.676 | ||
16. Situations where suicide is the only solution | 0.611 | ||
20. Consider suicide if incurable disease–myself. | 0.608 | ||
36. Get help to commit suicide if incurable disease–myself | 0.607 | ||
17. Could express suicide wish without meaning it-myself | 0.552 | ||
32. Suicide understandable if incurable disease–people | 0.508 | ||
29. Give help to commit suicide if incurable disease–people | 0.460 | ||
5. Suicide acceptable means to end incurable disease | 0.456 | ||
Factor 2. Unjustified behavior | 7.27 | 0.593 | |
2. Suicide can never be justified | 0.728 | ||
3. Suicide among the worst thing to do to relatives | 0.712 | ||
19. Suicides among younger people particularly puzzling | 0.526 | ||
9. Duty to restrain a suicidal act | 0.472 | ||
Factor 3. Call for help | 5.51 | 0.266 | |
26. Suicides basically signal for help | 0.651 | ||
24. Suicide one’s own business |
0.555 | ||
13. Should or would rather not talk about suicide |
0.431 | ||
Factor 4. Preventability/Readiness to help | 5.40 | 0.473 | |
30. Prepared to help a suicidal person-myself | 0.736 | ||
1. Can always help | 0.720 | ||
37. Suicide can be prevented. | 0.422 | ||
Factor 5. Loneliness | 5.32 | 0.496 | |
25. Loneliness that drives people to suicide | 0.777 | ||
14. Loneliness can be a reason for suicide | 0.640 | ||
Factor 6. Reasons for suicide | 5.21 | 0.365 | |
7. Attempts due to revenge and punishment | 0.597 | ||
4. Attempts are impulsive actions | 0.573 | ||
35. Attempts due to interpersonal conflicts | 0.528 | ||
Factor 7. Incomprehensibility | 4.54 | 0.326 | |
22. Suicide happens without warning | 0.736 | ||
28. Relatives have no idea about what is going on | 0.622 | ||
27. Could express suicide wish without meaning it-myself | 0.440 | ||
Factor 8. Unreliable | 4.33 | 0.289 | |
12. Communication not serious | 0.692 | ||
33. People who make threats seldom complete suicide | 0.593 | ||
Factor 9. Nonreversible | 3.88 | - | |
6. Suicide decision can’t be reversed. | 0.840 | ||
Total | 51.94 |
The English expression for each Attitudes Toward Suicide Scale (ATTS) item is the same as the expression in Renberg et al. [
reversely scored item
Group comparisons of factors and trend analysis along suicidal continuum
No suicidal idea (Mean [SD]) | Suicidal behavior (Mean [SD]) |
Trend |
Group comparison |
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---|---|---|---|---|---|---|---|---|---|
Suicidal idea only | Suicidal plan | Suicide attempt | J-T statistic | p-value | F | p-value | Post-hoc |
||
Permissiveness | 2.76 (0.61) | 2.93 (0.61) | 3.09 (0.59) | 3.19 (0.70) | 7.824 | <0.001 | 25.322 | <0.001 | a<b<d |
Unjustified behavior | 4.01 (0.62) | 3.91 (0.65) | 3.89 (0.80) | 3.85 (0.77) | -3.004 | 0.003 | 5.016 | 0.002 | a<c, a>b |
Preventability/Readiness to help | 3.54 (0.65) | 3.56 (0.65) | 3.44 (0.64) | 3.67 (0.74) | 0.052 | 0.959 | 1.571 | 0.194 | - |
Loneliness | 3.26 (0.87) | 3.38 (0.85) | 3.35 (0.82) | 3.70 (0.82) | 4.155 | <0.001 | 7.491 | <0.001 | a<b<d |
a, b, c, and d refer to no suicidal idea, suicidal idea only, suicidal plan, and suicidal attempt, respectively.
SD, standard deviation; J-T, Jonckheere-Terpstra
Association between factor scores among no suicidal idea, suicidal idea only, suicidal plan, and suicidal attempt groups
Univariate model |
Multivariate model |
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---|---|---|---|---|---|---|---|---|---|---|---|---|
Suicidal idea only |
Suicidal plan |
Suicide attempt |
Suicidal idea only |
Suicidal plan |
Suicide attempt |
|||||||
OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | aOR (95% CI) | p-value | aOR (95% CI) | p-value | aOR (95% CI) | p-value | |
Permissiveness | 1.60 (1.35–1.89) | <0.001 | 2.60 (1.18–3.79) | <0.001 | 3.42 (2.17–5.38) | <0.001 | 1.49 (1.25–1.79) | <0.001 | 2.79 (1.84–4.25) | <0.001 | 2.67 (1.65–4.33) | <0.001 |
Unjustified behavior | 0.78 (0.67–0.91) | 0.001 | 0.75 (0.54–1.03) | 0.079 | 0.68 (0.46–1.00) | 0.055 | 0.79 (0.67–0.94) | 0.006 | 0.93 (0.65–1.33) | 0.689 | 0.64 (0.42–0.99) | 0.043 |
Preventability/Readiness to help | 1.30 (1.11–1.52) | 0.001 | 0.78 (0.57–1.09) | 0.147 | 1.37 (0.91–2.07) | 0.137 | 1.11 (0.94–1.30) | 0.220 | 0.78 (0.55–1.12) | 0.179 | 1.38 (0.88–2.17) | 0.166 |
Loneliness | 1.19 (1.06–1.33) | 0.004 | 1.14 (0.89–1.47) | 0.307 | 1.93 (1.37–2.71) | <0.001 | 1.08 (0.95–1.22) | 0.259 | 0.91 (0.68–1.21) | 0.501 | 1.50 (1.03–2.20) | 0.036 |
Reference=no suicidal idea.
multivariate model was adjusted for age, sex, marital status, education, income, and religion.
OR, odds ratio; aOR, adjusted odds ratio; CI, confidence interval