Background

Suicide is the fourth leading cause of death among young people aged 15 to 29 worldwide (WHO, 2020). A meta-analysis estimated that 22.3% of college students worldwide experience suicidal ideation, and 3.2% attempt suicide in their lifetime (Mortier et al., 2018). The subgroups in this population most likely to develop the problem are young black people and those from sexual and gender minorities (Di Giacomo et al., 2018; Ministério da Saúde, 2018; Shadick et al., 2015). In Brazil, suicide rates have increased in the general population, especially among young people. The suicide rate is currently at 6.4 per 100,000 inhabitants among individuals aged 15 to 19 years and 8.19 per 100,000 in the 20 to 39 age group (Ministério da Saúde, 2021). Among college students, a national survey shows that suicidal ideation (thinking, considering, or planning suicide) increased 107.0% from 2014 to 2018 (Fonaprace, 2019). Therefore, college students with suicidal ideation constitute a highly distressed population, which justifies understanding the risk factors for suicide to support creating effective prevention strategies.

Risk factors are environmental, behavioral, or hereditary conditions that, according to epidemiological evidence, increase the probability of occurrence of an adverse health outcome (GBD, 2015 Risk Factors Collaborators, 2016). Studies show that the main risk factors for suicidal behavior in college students are psychiatric disorders, stressful events, difficulty to sleep, disconnected from other people, and feelings of hopelessness (Pereira et al., 2018; Vêncio et al., 2019; Wenjing Li et al., 2020). On the other hand, protective factors are related to: self-esteem, self-efficacy, social skills (Pereira et al., 2018), sense of hope, having reasons to live (Wenjing Li et al. 2020), practicing sports (Aragão Neto, 2019; Nomura et al., 2021), social support from family and friends (Kleiman & Liu, 2013; Pereira et al., 2018; Ribeiro & Moreira, 2018), and support and inclusion in the university (Venturini & Goulart, 2016). Although these factors are not only related to the student’s personal issues, but also to different social actors and environments they interact with, these findings are exclusively based on college students as informants. No research was found that included multiple informers, besides college students, who could unravel the various layers of suicide risk based on the perspective of who understands them best, that is, the different actors who directly (as students) or indirectly (as professionals) experience the problem.

Furthermore, most studies that involve college students have been conducted in the United States and other high-income countries. These findings, however, may not reflect the realities of groups living in developing countries. This is why it is imperative to examine risk factors in low- and middle-income countries, which have different social contexts. The literature shows that suicide risk factors are often influenced by social determinants, such as poverty, access to healthcare, and education (Wang & Wu, 2021). Due to this, a theoretical perspective that addresses the social influence on mental health becomes indispensable.

The intervention mapping (IM) approach, used in this study, proposes that every health problem be seen from a socio-ecological view at five levels: personal, interpersonal, organizational, community, and social (Kok et al., 2017). According to the socio-ecological framework (Stokols, 1992), the suicide of college students (or any other health phenomenon) can be better understood and prevented if political, economic, cultural, community, interpersonal, family, and individual determinants are considered. Then, one must examine how the social structures and networks surrounding college students interact and reinforce the effects of each level. Since it is complex to identify this problem at different levels, IM encourages using mixed methods (Eldredge et al., 2016). Studying suicide risk factors can help identify the routes that result in college students succumbing to life in developing countries, hence promoting culturally sensitive suicide prevention strategies tailored to the local reality. Thus, the overall objective of this study was to map the suicide risk factors among Brazilian university students based on multiple informers.

Method

The study followed a sequential exploratory study design (Fig. 1) (Creswell, 2010), using a mixed-method approach based on the Intervention Mapping framework (Eldredge et al., 2016). The study included an initial phase of qualitative data collection and analysis, followed by a phase of quantitative data collection and analysis. Subsequently, the results of both phases were integrated during the interpretation phase. This design was used for a clearer and more comprehensive understanding of the risk factors of college students’ suicidal ideation. The first part, qualitative, interviewed 20 university students about suicide risk factors and who had had suicidal ideation in the last 12 months. The second part, quantitative, applied a questionnaire to 22 health professionals about risk factors in university students. The third part, qualitative, interviewed 12-course coordinators about risk factors. The research process used the data analysis from one stage to support the next stage. The study was organized using the Mixed Methods Article Reporting Standards (MMARS) of the American Psychological Association – APA (Levitt et al., 2018). The study was carried out at a public university in the Northern region of Brazil, which has five campuses spread across five municipalities.

Fig. 1
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Mixed methods research design used in this study

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Participants

The study included 54 participants: 20 undergraduate students, 12 mental health professionals, and 12 course coordinators from a public university in the North of Brazil. The sample of students included in this study was defined based on a diagnosis of suicidal ideation made by healthcare professionals. Students were identified through the university’s mental health support services, which maintain records of students who seek psychological and psychiatric assistance. Healthcare professionals, including psychologists and psychiatrists, conducted initial assessments of students presenting with symptoms of depression, anxiety, and other mental health issues. The diagnosis of suicidal ideation was based on standardized clinical interviews conducted by licensed mental health professionals. These interviews were guided by established diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Key indicators for diagnosing suicidal ideation included the presence of thoughts about self-harm or suicide, reported plans or means to commit suicide, and any previous suicide attempts.

Students’ socioeconomic status was considered as part of the inclusion criteria to explore the relationship between low income and suicidal ideation. Students from low-income backgrounds were identified based on their eligibility for financial aid and other support services provided by the university. This criterion ensured that the sample included individuals who might be experiencing additional stressors related to financial instability, thereby providing a more comprehensive understanding of the risk factors for suicidal ideation. The final sample consisted of students who met the inclusion criteria of being diagnosed with suicidal ideation and belonging to a low-income background. These students had received mental health treatment within the last 12 months and had documented suicidal ideation.

The students were selected based on access to the institutional database with information about students who received financial aid from the university to undergo mental health treatment in 2020. The original sample consisted of 118 students, 50 of whom had suicidal ideation certified by a health professional, and 20 were selected for the interview. The number of students who participated followed the guidelines of Francis et al. (2010): a minimum of 10 interviews followed by three additional interviews until no new themes emerged (stopping criterion). Therefore, the minimum number of interviews suggested by the literature was doubled to ensure data saturation.

The selection of students with suicidal ideation was based on dividing their on-campus activities and time they received aid, giving preference to those who had received aid for a longer time, indicating it was a more serious case. This division was carried out by organizing the database as follows: students who presented suicidal ideation were selected. They were then classified from the longest to the shortest participation time, and then separated into 5 lists, according to the campus the student was linked to. One campus did not have students who received aid in the aforementioned year. The first 20 students who responded with the contact from each campus were interviewed (see Table 1). The following were the inclusion criteria for students: received financial benefit from the university for health treatment (medical and/or psychological consultation and purchase of medication) in 2020 and presented suicidal ideation at the start of the treatment. The students corresponded to low socioeconomic status.

Table 1 Sociodemographic and educational data of students
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The students were recruited via email, telephone call, and messaging app. They received an invitation for an individual interview via videoconference on a date and time chosen by the participant.

After interviewing the students, the researchers returned to the database and verified the health professionals who treated the 50 students with suicidal ideation in 2020. The health professionals’ email and telephone data were extracted from the student’s medical records. The health professionals were recruited via email, phone calls, and messaging apps. Those who responded to the questionnaire had the characteristics described in Table 2. Two health professionals refused to participate, citing ethical reasons. The health professionals attended 1 to 11 students (M = 1.63; SD = 2.06).

Table 2 Sociodemographic data of health professionals
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The institution had 37 undergraduate course coordinators and all of them were invited to participate. In total, 12 course coordinators (32.5%) accepted the invitation to participate with the characteristics described in Table 3.

Table 3 Sociodemographic and educational data of course coordinators
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Instruments

The interview questions were designed to deeply explore the risk factors for suicidal ideation among university students. The development process was guided by a thorough review of the literature on suicide risk factors and the theoretical framework of the Intervention Mapping approach (Eldredge et al., 2016; Kok et al., 2017). The final interview questions were open-ended to encourage detailed narratives and were structured to cover the following areas: personal history and mental health, academic and social environment, support systems, coping mechanisms, and unmet needs.

The students and course coordinators were interviewed by a researcher with ten years of experience in qualitative research and nine years of experience at the institution under study. The researcher had prior knowledge of some of the participants on one of the campuses.

The students were asked these: “What led you to seek help?” and “How was this struggle? Can you tell me the story of your suffering?” The coordinators were asked the question: “How does university life affect student mental health?” This open question was asked in order to assess whether they had perceived the suicide risk factors mentioned by the students and additional factors, without inducing responses.

The health professionals received the questionnaire with the following question: “What risk factors did you observe in the university students you looked after?” The answers related to the risk factors in the questionnaire showed a frequency above 15% in the interviews with the students (see supplementary material). Furthermore, an open question allowed the health professional to add other answers.

Procedures

The study included three data collection phases. The interviews were carried out via videoconference, and the communication was subsequently transcribed. The interviews took place in May 2021 and lasted from 17 to 50 min, with an average time of 28 min. In phase 2, an online questionnaire was applied to health professionals who had looked after the students benefiting from the aid. The questionnaire link was sent in July 2021 via email to all health professionals who looked after students benefiting from financial aid in 2020. In total, 22 health professionals (53.6%) responded to the questionnaire.

The undergraduate course coordinators were interviewed individually in phase 3. They were invited via email for an individual interview via videoconference at a date and time to be chosen by them. The interviews took place in August 2021 and lasted from 20 to 74 min, with an average time of 46 min. This phase was added because some organizational risk factors were mentioned in the interviews of the students. It was decided to interview course coordinators, who are professors in a leadership role, who assist students and direct them to other sectors. The interviews were carried out via videoconference, and the communication was later transcribed.

Data Analysis

Data analysis was carried out in three phases. Firstly, data from each public were analyzed individually by two trained coders, interviewing the students and coordinators via content analysis (Bardin, 2011) and the health professionals’ questionnaire responses via descriptive statistics. Secondly, data from each audience were individually categorized according to the 5 dimensions of the socio-ecological model: individual, interpersonal, organizational, community, and social. Thirdly, the databases of students and course coordinators were analyzed separately and subsequently grouped around large categories or meaning hubs, inductively, according to the proximity of the themes. For example, when students and course coordinators mentioned in interviews the student’s conflicts with their family, even from different points of view, this information was categorized as family conflicts.

Quantitative data were processed by identifying each risk factor in the questionnaires was tallied to determine how often the health professionals reported it. This helped to identify the most common risk factors across the sample. Simple descriptive statistics were employed to analyze the quantitative data. The quantitative data provided a numerical basis for understanding the prevalence and distribution of various risk factors. The most frequently reported risk factors were identified as key areas of concern.

The students and course coordinators interviewed, in the first phase, were analyzed considering the themes that most emerged and, then, a frequency count was carried out. Microsoft Excel software was used to create the database and count frequencies, transforming them into quantitative variables.

The first phase of data analysis involved coding the transcriptions of interviews. Two trained coders independently reviewed the data to identify meaningful segments related to suicidal ideation and its risk factors. The identified codes were grouped into broader themes using content analysis (Bardin, 2011). This process included the following steps:

  1. A.

    The students and course coordinators’ interviews were subjected to successive readings, which involved the process of floating reading (Bardin, 2011).

  2. B.

    Each coder marked sections of the text that were relevant to the research questions. Themes were labeled based on the content of the segments.

  3. C.

    Themes were examined to identify patterns and commonalities. Similar themes were clustered together to form initial codes.

  4. D.

    The codes were reviewed and refined to ensure they accurately represented the data. This involved checking the themes against the coded data extracts and the entire dataset.

  5. E.

    Each code was defined and named in a way that clearly reflected its essence.

To enhance the reliability of the content analysis, the two coders compared their coding and themes. Discrepancies were discussed and resolved through consensus. This collaborative approach ensured that the themes were comprehensive and accurately captured the data. All of the participant’s reports that corresponded to the theme investigated were counted and considered as a unit of meaning, regardless of the number of times they were mentioned in the interview. Microsoft Excel software was used to create the database and count frequencies, transforming them into quantitative variables (Fig. 2).

Fig. 2
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PRECEDE logic model of needs assessment. PRECEDE: Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation

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In the students’ interviews, a combination of inductive and deductive thematic content analysis was carried out in the second phase, considering the findings from the literature, but with an open mind so as to create new categories. The goal was to identify the codes in the participants’ responses and, subsequently, deductively validate these codes by comparing them to those that appear in similar studies (Lockman and Servaty-Seib, 2016; Pereira et al., 2018). However, in the course coordinators’ interviews, only deductive thematic analysis was carried out, because there were no similar studies identified so as to base the creation of categories on. The third phase included reading all student interviews and preparing a diagram of each student’s illness process in order to examine whether and how the risk factors were linked over time. Subsequently, all schemes were reviewed for similarities, resulting in a single Figure that illustrates this process (Fig. 3). The fourth and final phase includes the member checking procedure, systematized by Birt et al. (2016), used to evaluate qualitative data reliability. A summary of the data was sent to students and course coordinators. They were asked to read, comment and, if applicable, point out possible inconsistencies between the results and their experience regarding the phenomenon investigated. Participants were informed that reading the text could cause some discomfort and, if necessary, it provided the main researcher’s contact information. The participants did not report any data analysis inconsistencies.

Fig. 3
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Diagram of interrelationships between risk factors

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Ethical Procedures

All participants were informed about the research process and consented to participate through consent forms and an authorization form in order to use images and audio. Participants’ privacy and confidentiality were maintained using numbers to identify the interview excerpts cited in the Results section. This study was carried out in accordance with the principles of the Declaration of Helsinki. This study was approved by the Research Ethics Committee in Human and Social Sciences of the University of Brasilia (CAAE nº 42,405,021.3.0000.5540) under Resolution n° 510/2016, published by the Brazilian National Health Council. No incentives or financial compensation were offered to the participants of this study.

Results

The results of this study revealed a variety of risk factors for suicidal ideation among Brazilian university students, identified through multiple informants, including students, health professionals, and course coordinators, encompassing individual, interpersonal, organizational, community, and social levels. Figure 2 shows the integrated qualitative and quantitative results that illustrate the logical model of the problem, demonstrating a range of risk factors that contribute to the university students’ suicide risk.

Table 4 displays the rate of occurrences of the categories identified at the different socio-ecological levels according to the various informers. As shown in Table 4, the most consistently cited risk categories among the three informers were difficulty in carrying out developmental tasks for young adults (individual level), family conflicts, low social support (interpersonal level), teacher-student relationship conflicts, failed institutional support, stress generated by the overload of academic activities (organizational level) and mental suffering resulting from income inequality (social level).

Table 4 Matrix of results from multiple participants about suicide risk factors
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At an individual level, the students’ most cited category in young individuals was mental disorders. This category covers reports of generalized anxiety disorder, depressive disorder, social anxiety, bipolar disorder, self-mutilation, and alcohol abuse. This category also had the highest score among health professionals, with 81.8% reporting anxiety disorder; 63.6% depressive disorder, and 50% social anxiety.

Also at the individual level, the negative life events category covers reports of sexual abuse, parental divorce, history of mental health in the family, breaking the bond with one of the parents, and suffering childhood mistreatment. Health professionals added the answer sexual abuse when filling out the questionnaire. These events reverberate on the student’s mental health.

The psychiatrist said that I currently have major depression and generalized anxiety disorder due to childhood and adolescent trauma, which was my parents’ divorce, my mother’s absence, plus a series of things that I address in therapy. And these things really affect my resourcefulness at university, because I get very anxious, I can’t study, I don’t want to talk to anyone, I don’t want to see anyone, and I don’t even want to go to university. But I’m working on this, so it doesn’t continue like that. (…) Look, I’m not going to lie, after I started university it got worse, it’s a very difficult course. (Participant 17).

This category also appears among course coordinators. They claim that some students arrive at university sick.

(...) many are sick, many are discouraged and cannot see all the good that the environment has to offer, whether from an academic point of view or from an experience point of view. (Participant 23)

In other situations, suffering is related to other individual factors, such as difficulty in constructing meanings for stressful life events, self-demand and low self-esteem, and difficulty in carrying out developmental tasks that young adults face. In several situations, the onset of mental illness coincides with entering university, moving away from their parents’ home and city of origin, losing a network of friends, and having to meet a set of demands, not just from the university, but also from adult life, being able to manage one’s life in different spheres.

I didn’t experience pain the same way, because I was a teenager, eighteen years old and I suffered from other things like that, much not as bad. And then I entered university and I had to immediately worry about a house, I had to worry about schedules, I had to worry about my own health. If I got sick, I wouldn’t have mother, father or anyone to turn to. At the beginning of the course, my support network was very limited. It was something that made my life very difficult in the city. So, this produced a scenario that was very prone to illness. (...) And then, that moment came when I was extremely depressed, it wasn’t an overnight thing, and it was something that always happened over time. I think there are also insufficient resources to deal with so much new stuff at the same time. So, my lack of resources in light of this new scenario, the university, paralyzed me, and it happened that I was super depressed, and I experienced anxiety symptoms too. And that’s the moment when help arrived and I started going to therapy. (Participant 6)

Many course coordinators also noticed this and mentioned the student’s difficulty in managing their own lives, dependence, lack of discipline, and procrastination, as well as ineffective conflict management and, sometimes, the idealization of the university as an environment with many friends, generating frustration.

A young student creates a lot of expectations and upon arriving at university feels the pressure. He may have the necessary maturity that perhaps not. (...) They should be prepared to learn not only from a professional point of view, but also learn as a human being and be willing to live with other realities. We see that many students come from different problems. I’m not a psychologist, I don’t know how to speak the correct terms, but I imagine it’s like that. There are students who are you see are spoiled people, that they don’t have the initiative to pursue things that are basic for them to have a life in the university community, so they don’t know how to one day look for support, they depend on a teacher to explain everything. This person has that need to ask again to create a relationship. He/she will look for someone at the university who can serve as a father and a mother, a reference. And may sometimes find it, and sometimes not. (Participant 23)

The following are the categories identified at an interpersonal level: conflicts with peers, conflicts with family, and low social support. The category conflicts with peers include reports of problems with roommates or student housing, with boyfriends, and ending a romantic relationship. In the conflicts with family category, there are reports of conflicts with parents (some of them due to the young person’s sexual orientation or religious orientation), lack of support to deal with grief or to seek psychological help, as well as family members involved with drugs.

There is the issue of my sexuality, I am LGBT and my mother did not accept it. (Participant 12)

The health professionals reported this was the category with the second-highest response rate. The course coordinators also mentioned these conflicts and said that some of them could occur due to the knowledge acquired at university.

But I think this issue could increase. Due to knowledge, information. The prejudice you had about a certain subject. Then you start to have another point of view. And this creates conflict with family, relatives, society. (Participant 14)

The low social support category refers to students reporting a lack of support from colleagues, demonstrating a fragile social network and frustrated sense of belonging. In some situations, this category is related to income inequality and suffering (not feeling like you belong at university because you are from a lower social class). This category received 13.6% of responses from health professionals and was not mentioned by professors.

When I was looking for help from some “friends” to teach me, to help me, because I was already behind with my studies, no one wanted to help. (...) There was an incident with a friend I had, (...), I needed to study with him, I was persistent: can you teach me? I see that you understand the subject. Can I come to your house? He kind of said yes, not to say no. I arrived there at night to study (…). Then he kind of humiliated me, saying that I don’t study because I’m stupid (…). From then on, I started to have that in my head. (Participant 20)

The categories were identified at an organizational level: failed institutional reception, lack of physical space for leisure and rest, bullying at the university, conflicts in the teacher-student relationship, and stress generated by the overload of academic activities. The stress category produced by the overload of academic activities was most frequent among students and includes reports of insomnia, overload, lack of leisure, and competitiveness among peers. In addition to the number of subjects and school tasks, some instances of the course are more critical, such as preparing the End of Course Work. Some students need to balance work, study, and motherhood. Overload is most frequently reported by full-time university students.

The undergraduate course overload, as the course is full-time here (...) was a lot at the beginning, because we didn’t have time, you know, to rest. I also didn’t have time to rest over the weekend. There was always something from university. We are always very overwhelmed. We ignored it sometimes to have some peace and quiet. But there was always a lot to do. Always overwhelmed. (Participant 8)

Health professionals also recognize how harmful stress can be for students, so much so that this category has the third-highest response percentage among health professionals. Course coordinators also commented on the lack of leisure, the competitiveness among students, and the demands of the university.

I think it influences us. It’s too complicated. There are a lot of stories. Exhausted, you know? Tired students (...) there is always have a teacher who is a little more demanding. So we always have to balance these demands, with professors demanding content, students not being able to follow the material… So, I think the students feel powerless in relation to some professors. They can’t finish the course, go on to the next academic year, so it’s a continuous failure. (Participant 25)

At an organizational level, the teacher-student relationship conflicts category was the second highest rated among students. It includes reports of conflicts and abuse of power and lack of support and acceptance from teachers, and situations of moral harassment in some cases.

I had several difficulties with professors, in terms of humiliation. This made me very anxious, because I felt that my knowledge was not the only thing being judged. (Participant 9)

Health professionals also highlighted the conflicts in the teacher-student relationship. And course coordinators also mentioned that in some situations there is a lack of support and acceptance by professors. They cited instances of professors’ moral harassment and abuse of power. On the other hand, they mentioned violence committed by students towards professors, but they recognize these are fewer in numbers. The coordinators reported that the institution does not offer support for managing this situation.

When I arrived (...) there was this person who spoke in a hideous manner to the students in the classroom, and they didn’t reply at all. (...) At that time I felt a little like that, and I saw the students standing there silently, and they didn’t say anything, and the person terrified the students. I don’t know if that’s the case now. (Participant 31)

Because when it goes to the office of the supervisory body, I don’t know if their feedback is effective, because it wants the coordination to resolve it. But in a case like this, how do you resolve it? (...) In such cases, I think the institution does not offer much support for us, the professionals, to deal with this (...). And I kept thinking about it, (...). So, the institution does not provide support for professors, coordination, or dealing with this type of conflict. (Participant 31)

The following categories were identified at the community level: Lack of leisure in the city and Institutional violence, reported solely by students. Some university campuses are located in municipalities that offer insufficient leisure options. In other situations, students report institutional violence associated with a family conflict.

So, it really shook me that day, I took an Uber to see if it was true, I had to go to the women’s police station. I went crying. And when I got there, I was treated like a dog. Because a man who arrives at the women’s police station is the batterer, he is the aggressor. And I was treated like one of those. When the person there came to talk to me, I had no idea who this person was. I was treated the worst way possible. I was wrong because I am the son, and I have to respect the mother, and I never disrespected her. And the most incredible thing was the allegations that she put in the police report, which were all false allegations, all lies. So it was a period like that that I experienced, it was very difficult. (Participant 14)

The categories identified at the social level were: University culture portrayed in the movies is not consistent with reality, mental suffering resulting from income inequality, and learning difficulties, and the pandemic and mental suffering. The mental suffering category resulting from income inequality was rated the highest among students at a social level. It includes reports, especially from students from the most impoverished classes, related to fear of failure, anguish, low self-esteem due to low academic performance (feeling incapable in front of one’s colleagues), demanding too much from yourself because the university is a great opportunity for you and your family, experiencing mental suffering due to scarce financial resources and food insecurity, the suffering of giving up on a higher education course for financial reasons and sadness due to the parents’ precarious financial situation. And at a broader level, lack of access to mental health services in the public network and post-traumatic stress due to experiencing urban violence, such as robbery, were reported. Many young people feel that because they are the first in their family to study at university, they cannot afford to fail.

I think that being at university is a rupture, you know. I’m the first in my family to go to university, so the break from reality with a destiny that was already half-prepared for me. My father works on a farm or doing odd jobs, informal work, my mother is a housewife. (...) There was the issue of reality, that was always very strong. It is a fear of injustice that I also see in the inequality of our country. Seeing that we don’t receive the same teachings. I saw my colleagues there, light years ahead of me, and I was trying to reach that level. I still struggle a lot both to produce and to stay here. Because there really is a huge education gap. And I experienced paranoia about having to be better. But there was a lot of that, of feeling that I came from a place where education wasn’t that good and that I had to work even harder to achieve that. (...) It was this anguish of not achieving things, of being afraid of failing, of returning home, of disappointing my parents. Just at a time when I was doing something so new, achieving other things, I was afraid of not being able to handle it, and they were doing everything they could to keep me here. So if I failed it would be very intense and excruciating for me, so I always had that massive fear. (Participant 5)

Experiencing pain from income inequality was also highlighted by health professionals. They selected the options “suffering for having already given up on higher education for financial reasons” and “lack of access to health services.” They were also mentioned by course coordinators, who observed this situation.

Then I see it as if it were a cycle, there’s this work issue and there’s this financial issue too, where they can’t support themselves or those who are…. Those who are more vulnerable and who need help, more help and not just scholarships, but housing and food also feel very vulnerable, more fragile, when there is a crisis, they lose scholarship, a benefit from the university. (Participant 28)

In addition to the results presented, 8.3% of course coordinators stated that they had doubts whether university life affected the student’s mental health.

I saw in that booklet that Psychology had carried out a survey with some students. And I saw ‘some’ things there that were very new to me. (...) And when I read the Psychology booklet, even the boys who felt belittled because they were part of the university. I kept asking myself: but why? Being part of a federal university, in my view, is something prestigious and not about feeling inferior because a student studies at a private [university]. This was all new to me, I kept wondering about it. (...) But from what I saw, in the booklet they talk about the issue of grades, of work. But it’s new for me, it’s something to make someone sick. (Participant 31)

The results of this study reveal significant variations in the perceptions and experiences of students, health professionals, and program coordinators regarding the risk factors for suicidal ideation. These differences can have important implications for the interpretation and application of the findings in three aspects: perceptions of mental health issues, experiences with institutional support, and identification of risk factors.

Students often reported personal experiences with mental health issues, highlighting how these problems directly affect their academic performance and social interactions. They provided detailed narratives about their struggles with anxiety, depression, and the impact of these conditions on their daily lives. Health professionals, on the other hand, tended to focus on diagnosing and treating mental disorders. Their responses were more clinical, emphasizing the prevalence of mental health issues like anxiety and depression among students but often lacking the personal, contextual details provided by the students themselves. Course coordinators perceived mental health issues as part of broader organizational and systemic challenges. They often linked students’ mental health problems to institutional factors such as academic pressure and inadequate support systems. These variations highlight the need for a multifaceted approach to understanding and addressing mental health issues. While students provide insight into the personal and emotional impact of these problems, health professionals contribute clinical expertise, and program coordinators offer a broader organizational perspective. Integrating these views can lead to a more comprehensive understanding of the issue.

On the other hand, many students expressed dissatisfaction with the institutional support available to them. They reported feeling unsupported and overwhelmed by academic pressures, often citing specific incidents where they felt neglected or misunderstood by the university administration. Health professionals acknowledged the limitations of institutional support but were more focused on individual treatment plans. They emphasized the importance of accessible mental health services and the need for better resources to support students. Course coordinators recognized the need for improved institutional support but often pointed to systemic barriers such as funding limitations and administrative challenges. They emphasized the importance of creating a supportive academic environment and improving communication between students and faculty. Addressing the discrepancies in perceptions of institutional support requires a coordinated effort to enhance communication and collaboration between students, health professionals, and program coordinators. Universities should consider implementing comprehensive support systems that address both the individual needs of students and the broader organizational challenges identified by coordinators.

Moreover, students identified a wide range of risk factors, including personal, social, and academic challenges. They provided detailed accounts of how these factors interact and contribute to their mental health struggles. Health professionals focused on specific clinical risk factors, such as the presence of psychiatric disorders and the impact of untreated mental health issues. Their responses were often more diagnostic and less descriptive. Course coordinators highlighted organizational risk factors, such as teacher-student relationship conflicts and the stress generated by academic overload. They provided insights into how institutional policies and practices can contribute to or mitigate these risks. Understanding the varied perspectives on risk factors is crucial for developing targeted interventions. While students’ detailed accounts highlight the need for personalized support, health professionals’ diagnostic focus underscores the importance of accessible mental health services. Program coordinators’ insights into organizational risk factors suggest that institutional changes are also necessary to create a supportive academic environment.

The variations in perceptions and experiences among students, health professionals, and program coordinators emphasize the importance of a holistic approach to addressing suicidal ideation among university students. By integrating the detailed personal narratives of students, the clinical expertise of health professionals, and the organizational insights of program coordinators, universities can develop more effective, comprehensive intervention strategies. These strategies should address individual, clinical, and systemic factors to support students’ mental health and well-being effectively.

The study identified multiple risk factor categories for suicidal ideation among university students, organized across different socio-ecological levels: individual, interpersonal, organizational, community, and societal. These categories do not operate in isolation but are interconnected, influencing each other in complex ways. Mental disorders such as anxiety and depression often originate or are exacerbated by family conflicts. Students who experience family conflicts may develop or worsen their mental health conditions due to the lack of a supportive home environment. On the other hand, a lack of social support at the interpersonal level is often mirrored by institutional shortcomings. Students who do not feel welcomed or supported by the institution may struggle to find friends and build a social network, leading to a sense of isolation and increased mental distress.

The interconnections among these risk factors often result in cumulative and synergistic effects. A student experiencing academic overload, combined with low social support and unresolved family conflicts, faces a cumulative burden of stress. This can significantly increase their risk of suicidal ideation. The interaction between different levels of risk factors can amplify their impact. For example, the combined effects of low social support, academic stress, and community-level violence can create a synergistic environment where the risk of mental health issues and suicidal ideation is significantly heightened.

The integration of qualitative and quantitative data in this study provided a comprehensive understanding of the risk factors for suicidal ideation among university students. The quantitative data, derived from health professionals’ questionnaires, highlighted the most prevalent risk factors, such as mental disorders, family conflicts, and academic stress. For instance, 81.8% of health professionals reported anxiety disorders as a significant risk factor, providing a clear indication of its widespread impact. The qualitative interviews added depth to these findings by exploring how these mental disorders manifest in students’ lives. Participants shared personal stories of struggling with anxiety and depression, revealing the emotional and situational contexts behind these statistics.

In summary, there are multiple and different levels of factors that influence students’ suicidal ideation to develop. On the other hand, an analysis of the relationship between different risk factors in terms of sequencing over time demonstrates a process composed of 3 elements, illustrated in Fig. 2. Mental disorders express an illness process originating from environmental stressors and social and emotional vulnerabilities. Students’ suicidal ideation is a distal outcome influenced by previous events—such as traumatic events in childhood and adolescence—and social issues, such as social inequality and its consequences in different areas.

Discussion

The goal of the study was to evaluate suicide risk factors in university students in order to offer support for creating prevention initiatives. According to the perspective of students, health professionals, and course coordinators, university students’ suicide is multidetermined by proximal and distal risk factors. Young adults’ difficulty in carrying out developmental tasks (individual level), family conflicts, low social support (interpersonal level), teacher-student relationship conflicts, failed institutional support, stress generated by the overload of academic activities (organizational level), and suffering mental illness based on income inequality (social level) were suicide risk factors in this population, consensually pointed out by all participants.

The study identified risk factors for suicidal ideation among university students across different levels, highlighting the dynamic and interconnected nature of these factors. The interaction between risk factors can create a cumulative effect, significantly increasing suicide risk; for example, a student with a pre-existing mental health disorder facing family conflicts, academic pressure, and financial stress may experience compounded distress. Negative feedback loops, where academic pressure leads to mental health issues and affects academic performance, can create a cycle of stress and failure. Conversely, strong peer support can buffer the impact of these stressors, while a lack of support exacerbates vulnerability. Additionally, cultural norms around mental health shape how students perceive and respond to challenges, affecting their willingness to seek help.

Although it was not unanimous among informers, the findings show that mental disorders were identified as important predictors of suicidal behavior among university students, which corroborates the results of literature reviews (Graner & Cerqueira, 2019; Lima and França, 2018; Lopes, 2021; Pereira & Cardoso, 2015; Wenjing Li et al., 2020), Brazilian (Pereira et al., 2018; Vêncio et al., 2019) and international (Nomura et al., 2021; Pereira and Cardoso, 2017) empirical studies. However, by pointing this as the main cause, health professionals and students may be individualizing the problem by looking at the issue from a biomedical perspective and neglecting policy, institutional, and community factors, which is a very common lack (Golden & Earp, 2012).

Suicidal ideation can be the result of a long-term mental illness process. When not identified and appropriately treated, adverse events during childhood and adolescence represent an emotional vulnerability. Negative experiences lived in childhood have the potential to generate suffering related to sadness, loneliness, inadequacy, and existential emptiness in university students (Aguires et al., 2017). Likewise, a meta-analysis concluded that exposure to childhood harm, bullying, dating violence, and community violence are associated with a tenfold increased risk of suicide attempts and deaths (Castellví et al., 2016). Eliminating childhood exposure to interpersonal violence reduces the rate of suicide attempts by 9%. Another study concluded that the risk of suicide is present regardless of the developmental stage at which the first exposure to physical and sexual abuse occurred (Gomez et al., 2017). Moreover, a systematic review found studies with samples from the general Brazilian population that demonstrate the correlation of attempted suicide with emotional neglect and physical, emotional, and sexual abuse (Lopes, 2021). In addition, an integrative review found that a family history of mental illness was a risk factor for university students’ mental suffering (Graner & Cerqueira, 2019). Therefore, adverse events experienced in the past and not adequately treated predispose young people to developing a mental disorder during childhood or adolescence, a topic not addressed in literature reviews (Lima and França, 2018; Lopes, 2021; Wenjing Li et al., 2020).

Environmental stressors and social and emotional vulnerabilities also influence suicide. Contradictorily, it is observed that studies discuss suicide risk factors at individual and interpersonal levels, but do not extend the assessment to the young person’s organizational, community, and social context (Aragão Neto, 2019; Nomura et al., 2021; Pereira and Cardoso, 2017; Santos et al., 2018; Vasconcelos-Raposo et al.,; 2016, Vêncio et al., 2019). And the studies that do so limit the issue to social stressors, such as urban violence (Pereira et al., 2018) or traumatic life events (Wenjing Li et al., 2020), focusing on the individual’s reaction to these traumatic events and their inability to overcome them, omitting the discussion of broader social and political issues. Only one of the studies reviewed mentions university culture factors, such as competitiveness, exclusion, and lack of support (Venturini & Goulart, 2016). The studies often present risk factors in a fragmented way, without determining interrelationships between them. The study designs, which are mostly quantitative, and the approach to suicide from a biomedical perspective, considering it as the effect of an acute mental disorder, can contribute to this fragmented view. These studies also did not have multiple participants such as health professionals and professors and therefore it was not possible to compare the results.

The analysis of risk factors for student suicide needs to extend beyond the biomedical sphere, considering the challenges that are characteristic of their lives. When entering university, young people have more autonomy, since most will move out of their parents’ house. However, there is less social support due to moving out of state and separating from their family and friends. In this phase, called emerging adulthood, there is a transition between adolescence and adulthood (Arnett, 2011; Pereira et al., 2018). Previous emotional weaknesses, challenges, and lack of support, both from colleagues and the institution, can increase the challenges characteristic of this phase and produce feelings of helplessness, disconnection, and hopelessness (Wenjing Li et al., 2020), causing anxiety and depression.

In addition to pre-existing social and psychological vulnerabilities, during their university years, young people encounter stressors within the university. These include problems in the teacher-student relationship, a category mentioned by 25% of students in this study and by 16.8% of those in a national survey of university students (Fonaprace, 2019). In addition to the lack of support from the university at critical moments of their academic years, there are prejudice and interpersonal challenges related to dating and friendships. This set of factors can trigger suicidal tendencies (Drum & Denmark, 2012). The difficulty of integrating at the beginning of the course is a risk factor that deserves attention, as it can lead the student to have difficulties with group work, accessing institutional information, and receiving help, which compromises academic performance, and may contribute to the onset or worsening of anxiety disorders and depression. Friendships are important during this period, because as they gain more autonomy, young people tend to, little by little, move away from their family and strengthen ties with their peers (Peron et al., 2010). In addition to classmates, professors are valuable social actors within the university, because young people expect them to offer emotional support.

In addition to developmental issues, the findings of this study indicate that it is necessary to consider income inequality and its effects on mental health. The interviews revealed that students from lower economic strata reported feelings of low self-esteem, difficulty interacting, educational deficits, and fear of failure. Income inequality has negative effects on mental health, leading to increased incidence of depression (Deurzen et al., 2015; Patel et al., 2018). The lack of control over the living environment results in individuals experiencing a high degree of stress at the individual level, a greater feeling of collective threat, and powerlessness at the community level, in addition to processes related to exclusion and discrimination. This can lead to increased physical and mental health problems compared to more economically advantaged individuals (Whitehead et al., 2014).

Intergroup comparison, competition, discrimination, and anxiety are emphasized among the various mechanisms that operate in the relationship between income inequality and mental suffering (Deurzen et al., 2015; Patel et al., 2018). In contexts of high-income inequality, differences are more visible, and individuals from lower social classes tend to make more comparisons. Individuals tend to estimate their levels of success by comparing themselves to their peers, which can create feelings of shame, affecting self-esteem. Under conditions of greater inequality, competition for resources tends to increase, causing people to experience feelings of powerlessness, distrust, individualism, decreasing levels of optimism, and exacerbating symptoms of depression (Deurzen et al., 2015; Gordils et al., 2020, Patel et al., 2018). Furthermore, in situations where there is social comparison not only related to income but also related to race, perceived competition between racial groups promotes evading competing racial groups, feelings of anxiety, and distrust of out-group members (Gordils et al., 2020). This influence can generate a circular feedback mechanism, causing individuals from lower social classes to have less social capital, carry out more social comparison, experiencing more psychological stress, and feelings of social defeat. This culminates in depressive symptoms, which hinder productivity and, combined with less access to health services, contribute to unemployment and difficulty in treating mental disorders (Ribeiro & Moreira, 2018).

In this sense, socially vulnerable young people may experience more difficulty in dealing with the challenges of university life. They tend to experience more social comparison experiences when entering university, as they live with colleagues from different social classes. Those who have fewer subjective coping resources will be less protected when confronted with social stressors that increase depression symptoms, such as stress created by school activities, conflicts in the teacher-student relationship, interpersonal challenges related to dating, friendships, and family problems. Additionally, they may not seek a professional, since many do not have the time for treatment because they work and study (Czyz et al., 2013). Federal government data exhibit a 12% increase in suicide mortality among young black people from 2012 to 2016 (Ministério da Saúde, 2018).

In addition to pre-existing social and psychological vulnerabilities, during their university years, young people encounter stressors within the university. These include problems in the teacher-student relationship, a category mentioned by 25% of students in this study and 16.8% of those in a national survey of university students (Fonaprace, 2019). The difficulty of integrating at the beginning of the course is a risk factor that deserves attention, as it can lead the student to have difficulties with group work, accessing institutional information, and receiving help, which compromises academic performance and may contribute to the onset or worsening of anxiety disorders and depression. Friendships are essential during this period because as they gain more autonomy, young people tend to gradually move away from their families and strengthen ties with their peers (Peron et al., 2010). In addition to classmates, professors are valuable social actors within the university because young people expect them to offer emotional support.

However, experiences of violence within the university can reflect broader patterns of institutional violence. Violence and humiliation faced by university students within universities in Brazil, especially in the North region, are critical issues that profoundly affect their mental health and well-being. These students frequently report experiences of bullying, discrimination, and harassment, which can be exacerbated by specific regional and cultural factors. In the Northern region, for example, socioeconomic inequalities and the lack of adequate institutional resources to address mental health amplify these problems. Students from racial minorities, such as Indigenous and Black students, as well as those who identify as LGBTQ + , often face prejudice and exclusion from both peers and faculty (Fukutani & Sampaio, 2024; Nogueira, 2022). These acts of violence and humiliation not only undermine students’ self-esteem and academic performance but also significantly increase the risk of depression and suicidal ideation (Shadick et al., 2015; Woodford et al., 2018).

Culturally, the North region has unique characteristics that can influence the dynamics of violence and humiliation in universities. The traditional communities and strong presence of Indigenous peoples bring cultural diversity that is not always respected within the academic environment, leading to situations of discrimination and exclusion. Additionally, entrenched prejudices against minority groups, such as LGBTQ + and Afro-Brazilians, create a hostile environment that exacerbates the vulnerability of these students (Teixeira-Filho & Rondini, 2012). Hence, the evidence is consistent by highlighting the profound impact of homophobia and discrimination on mental health and suicidal behavior among LGB and transgender students, underscoring the need for targeted interventions to address these specific risk factors. This set of factors can trigger suicidal tendencies (Drum & Denmark, 2012). In the North Region, the risk of suicide in the 15 to 19 age group is higher than the national average (Ministério da Saúde, 2021).

The critique of the common biomedical approach in suicide studies highlights its limitations, as it primarily focuses on individual mental health disorders and biological factors while overlooking broader social, environmental, and contextual influences. In contrast, a socio-ecological approach offers a more comprehensive understanding by considering the interplay of factors across multiple levels, including individual, interpersonal, organizational, community, and societal. This approach situates mental health disorders within a broader context, examining how family conflicts, peer support, institutional support, community resources, and societal influences like income inequality and cultural stigma contribute to suicide risk. By understanding these interconnected factors, such as how academic pressure, family conflicts, and financial stress can compound distress, or how strong peer support and community resources can mitigate these stressors, the socio-ecological model enables the development of multifaceted interventions that address the root causes of suicidal ideation. Adopting this approach allows for a deeper, nuanced understanding of the complex factors influencing suicide risk among university students, emphasizing the need for comprehensive mental health services and supportive environments at all levels to develop effective prevention strategies.

In this study, the practical implications of the results point to initiatives at different levels, focused on students, the university community, the institution, and public policies. These initiatives focused on students should consider strengthening student assistance centers to offer life skills interventions such as self-efficacy, self-esteem, and resilience (Patel et al., 2018; Pereira et al., 2018). Postvention and welcoming measures are also recommended for students who have had someone close to them die by suicide, as this type of loss can generate feelings of guilt in those who remain.

Initiatives addressed to the university community can use the university’s material and human resources to solve the problem. Senior students and teachers can provide support to incoming students in discussion groups and tutorial programs, as listening to experiences can minimize the young person’s difficulty in dealing with adult life, especially students from lower social classes who experience more challenges (Deurzen et al., 2015). Senior students and professors can be a source of social support by using early detection and offering help to young people developing mood and anxiety disorders or at risk of suicide by referring them to mental health services (Patel et al., 2018; Pereira et al., 2018), a suicide prevention strategy known as gatekeeping (Kutcher et al., 2017). Furthermore, initiatives to prevent drug use can reach subgroups of a university’s population who are more susceptible to suicidal ideation.

Initiatives focused on the institution must focus on the teaching–learning process, teaching, and the professors’ mental health. Strengthening pedagogical and monitoring support promotes improved school performance and academic success, affecting young people’s mental health. The results indicate that social inequality causes educational deficits in young people, which increases the struggle and stress of students from lower social classes and can result in mental illness. Furthermore, the study found issues of young people with undiagnosed learning disorders who needed specialized monitoring during the course.

Investing in the professors’ training and mental health can improve the teaching–learning process and the teacher-student relationship, impacting the mental health of students. Training professors could help them understand and embrace the processes of illness during those school years. If course coordinators understood dependence, lack of discipline, and procrastination as effects of mental disorders and lack of family support, coordinators could adequately welcome students. The process of raising awareness among professors can avoid stigma and mismanagement and help reduce situations of racism, homophobia, and harassment at universities.

Initiatives directed to external environments include external social actors and organizational networks. Parents, significant others, and religious leaders can be contacted to share responsibilities to support the student. Furthermore, organizational networks, such as the “Health Promoting Universities” movement, can help to look for solutions and implement health promotion actions and institutional culture changes (World Health Organization, 2015). The movement advocates that responsibility does not only belong to the health sector, but to the entire university community, fostering an institutional culture based on care, collaboration, and collective action (World Health Organization, 2015), with the socio-ecological approach as one of the conceptual models adopted (Almeida, 2017). The Brazilian Network of Health Promoting Universities (Rebraups) was created in 2018 and currently has a membership of 20 universities (Hartmann et al., 2019; Polejack et al., 2021). Expanding the network could help strengthen interpersonal relationships and institutional processes, promoting the health of students and the university community as a whole.

Investing in public policies is relevant in order to face risk factors. Expanding student aid, especially those directed at mental health, could promote greater access to services. More broadly, it is important to reduce social inequality, directing public policies to reduce social vulnerability and gender inequalities, expand health coverage and educational opportunities, expand employment policies and equitable income distribution (Patel et al., 2018). These initiatives are urgent, especially in the northern region of Brazil, which has the lowest average family income in the country (IBGE, 2020).

Moreover, considering that 40% of the students interviewed cited that suicidal ideation was influenced by adverse events in childhood and adolescence, strengthening initiatives to protect children and adolescents should be a priority on the public agenda. Constructing and strengthening initiatives to prevent, identify, and address violence against children and adolescents early on must be addressed by public managers, especially in terms of policies related to public health, social assistance, and education. Evidence-based strategies indicate that these initiatives have the potential to influence several distal outcomes, including youth suicide (King et al., 2018).

The results of this study are useful for future studies, especially to inform quantitative research, so that data collection instruments can take into account the risk factors mentioned in this study and support the creation of programs directed at students’ mental health. In terms of research, it is suggested to utilize research designs that allow capturing risk factors beyond individual and interpersonal levels. It is critical to examine the effects of social inequalities on the suicidal behavior of Brazilian university students. Environmental issues, such as the lack of physical space for leisure and its influence on students’ mental health, which were addressed by course coordinators but were not mentioned by students, should be investigated. It also necessary to analyze the professors’ customary view that university life does not negatively affect students’ mental health, since the invisibility of the topic can generate institutional negligence.

The findings of this study must be interpreted in terms of its limitations. A sample with a bias of income and mental health was used, since students who had already sought treatment and who have proven social vulnerability were interviewed, as financial aid includes students with a per capita income of up to one and a half minimum wage. Therefore, these findings cannot be extrapolated to other Brazilian universities. In addition, data collection was carried out through videoconference, which may have restricted the depth or scope of the interviewees’ communication.

The results of this study offer support to implement suicide prevention programs for university students, pointing out behaviors and environmental conditions that should be the focus of intervention based on their relevance and changeability. The various ecological risk levels require complex actions at each level. Given the complexity beyond a program, the data indicates the need for a comprehensive mental health policy at universities. They also indicate the urgency of efforts beyond the university sphere. In summary, investing in decreasing income inequalities policies, diverse sexual orientation inclusion policies, professor’s mental health literacy training, institutional welcome policies, peer support through gatekeeper interventions, life skills interventions tailored for emerging adulthood, and mental health promotion in the early stages of life should be the target of efforts.