The overall aim of the present paper was to examine suicidal expressions and some possible determinants in two very poor post-conflict societies from two different continents to identify differences that might reflect cultural differences. Three findings are of particular interest.
Firstly, this study shows that there is no significant difference in prevalence of serious suicidal expressions in Cambodia as compared to Nicaragua, even though milder expressions differ somewhat. Overall in both countries, prevalence of various suicidal expressions is in the lower range as compared to studies from middle or high income countries [4
Secondly, this study shows that Cambodian youth, both girls and boys, score considerably higher on almost all YSR-syndromes than Nicaraguan youth, for many syndromes with twice as high scores. Several previous studies have reported cross-cultural differences on YSR-scores but mostly to a lesser extent. For example, in a study comparing adolescents in Greece and Finland, there were higher level of anxiety and depression in Greece but the overall conclusion was that differences between these Northern and Southern regions were small [33
]. A study comparing YSR-scores from seven countries also concluded differences were small between countries [34
]. Being cross-sectional, our study cannot explain the reporting of higher mental distress by Cambodian youth compared with youth from Nicaragua. It is possible that the fairly recent period of collective trauma, experienced by the parents and grandparents of youth, may contribute to the mental health problems in Cambodia. Several studies have shown that mental health problems are common among the survivors of genocide and that mental health problems are likely to be transmitted from one generation to the next through various mechanisms [35
Thirdly, mental distress as related to suicidal expressions showed a different pattern in Cambodia and Nicaragua. Despite higher level of mental distress in Cambodia, the prevalence of serious suicidal expressions was not different between the two countries. Furthermore, almost all mental syndromes were strongly associated with serious suicidal expressions in Nicaragua but few associations were identified in Cambodia. We believe that cultural differences between these two countries with otherwise similar socio-economic conditions might play a role to prevent high level of mental distress from increasing serious suicidal expressions. Religion has been suggested to act as a protective factor, even though some studies show a mixed picture [6
] Despite the fact that the Catholic church in Nicaragua strongly condemns suicidal behavior whereas Buddhism seems to have a more tolerant view, serious suicidal expressions are as common in Nicaragua despite lower mental distress. One explanation could be that Nicaraguan culture is more secularized than Cambodia where traditional values still have a stronger influence on young people.
Fourthly, there are gender and country differences, where Nicaraguan boys exposed to suicide were almost nine times more likely to report own serious suicidal expressions while there was no significant association for Cambodian boys. Association between exposure to suicide and own suicidal expressions have been reported from many countries [1
]. For example, in Nicaragua this has been confirmed in a community based study [10
]. In most previous studies the association has been reported to be more evident among girls. For Nicaraguan boys depressive symptoms and exposure were associated with serious suicidal expressions whereas for Cambodian boys they were not.
There are various definitions on what is meant with culture and cross-cultural research [3
]. Even though this study does not take the cultural context into consideration in the analyses, we add this perspective in the interpretation of our results and we suggest that this makes it legitimate to label the study "cross-cultural".
Small sample size might have limited the results. The research instruments, ATTS and YSR, were developed in high income countries and may not measure the same constructs in the same manner in low-income countries such as Nicaragua and Cambodia. The nuances of emotions and psychological constructs are challenges to fathom particularly when the instrument is translated into different languages for cross-cultural comparison [3
]. However, both instruments have been used in diverse settings and found valid [26
]). Another important consideration is that the study deals with young people attending school and findings cannot be generalized to those outside the educational system.