Socio-environmental, psychological and digital determinants of suicidal ideation and behavior among Tunisian adolescents: a cross-sectional study

Background

Suicide is recognized by the World Health Organization as the fourth leading cause of death among individuals aged 15–29 years worldwide in 2021[1]. Suicidal ideation and behavior in adolescents result from a complex interplay of psychological vulnerabilities, socio-environmental exposures and, increasingly, digital influences. Established risk factors include depressive symptomatology, social isolation and exposure to interpersonal violence. A better understanding of these interacting factors is essential to inform evidence-based prevention strategies. The aim of this study was to identify the socio-environmental, psychological and digital factors associated with suicidal ideation or behavior among Tunisian adolescents.

Methods

A cross-sectional study was conducted in November 2023 among students enrolled in the 9th year of education across two middle schools in Tunis, Tunisia. Eligible participants were aged 15 years or older, present on the day of the survey and provided informed consent. Data were collected through a self-administered, paper-based Arabic-language questionnaire exploring four domains: suicidal ideation and behavior (including self-injury), psychological factors (sadness and despair, anhedonia, loneliness, impulsivity, expressive ability), socio-environmental factors (family and friends relationship dissatisfaction, witnessing moral, verbal, or physical violence, being a victim of any form of violence, sexual harassment, bullying) and digital factors (average daily screen time, social media checking frequency, fear of missing out and life neglect related to social media use). Associations were assessed using univariate analysis followed by multivariate logistic regression to identify independently associated factors.

Results

A total of 203 students were included, with a female predominance (sex ratio M/F= 0.7). One-third of the sample (33%) reported suicidal ideation or behavior. On univariate analysis, female was found to be a significant risk factor (p=0.047). Among digital determinants, the fear of missing out was the only factor who showed a significant association (p= 0.046). Many Socio-environmental factors emerged as significant ones. Sexual harassment, bullying and family dissatisfaction were all highly significant (p< 0.001), while exposure to moral, verbal or physical violence was also significantly associated (p= 0.034). Among psychological variables, sadness and despair (p< 0.001), loneliness (p< 0.001), anhedonia (p= 0.002) and expressive disability (p= 0.013) were significantly associated with suicidal ideation or behavior. On multivariate logistic regression, sexual harassment emerged as the strongest independent predictor (OR= 5.41; p= 0.003), followed by sadness and despair (OR= 3.63; p= 0.002) and loneliness (OR= 3.21; p= 0.005).

Conclusions

These finding identified a critical prevalence of suicidal ideation and attempts among Tunisian adolescents. This study concludes that sexual harassment represents the most severe and corrosive independent risk factor. At the core of these manifestations lies a psychological triad of sadness, despair and loneliness. Consequently,these results underscore the urgent need for targeted prevention strategies, including the implementation of school-based safety protocols and systematic psychological screening and preventing programs and actions. Such measures are vital to mitigate modifiable environmental and emotional risk factors within this vulnerable population.

References

World Health Organization, 2021. Suicide worldwide in 2021. Available from: https://iris.who.int/server/api/core/bitstreams/769d0a45-b50a-4b17-ba40-259bef44d9dd/content. [Accessed: 4 May 2026].