Socioeconomic and contextual correlates of suicidal ideation among Indonesian adults: Evidence from a multilevel analysis of the 2018 National Health Survey.

Socioeconomic and contextual correlates of suicidal ideation among Indonesian adults: Evidence from a multilevel analysis of the 2018 National Health Survey - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Learn more: PMC Disclaimer | PMC Copyright Notice PLoS One . 2026 Apr 15;21(4):e0344394. doi: 10.1371/journal.pone.0344394 Search in PMC Search in PubMed View in NLM Catalog Add to search Socioeconomic and contextual correlates of suicidal ideation among Indonesian adults: Evidence from a multilevel analysis of the 2018 National Health Survey Sujarwoto Sujarwoto Sujarwoto Sujarwoto 1 Department of Public Administration, Universitas Brawijaya, Malang, East Java, Indonesia Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing Find articles by Sujarwoto Sujarwoto 1 , Penny Bee Penny Bee 2 Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, Lancashire, United Kingdom Formal analysis, Validation, Writing – review & editing Find articles by Penny Bee 2 , Helen Brooks Helen Brooks 2 Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, Lancashire, United Kingdom Formal analysis, Validation, Writing – review & editing Find articles by Helen Brooks 2 , Asri Maharani Asri Maharani 2 Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, Lancashire, United Kingdom Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing Find articles by Asri Maharani 2, * Editor: Shivanand Kattimani 3 Author information Article notes Copyright and License information 1 Department of Public Administration, Universitas Brawijaya, Malang, East Java, Indonesia 2 Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, Lancashire, United Kingdom 3 Jawaharlal Institute of Postgraduate Medical Education and Research, INDIA Competing Interests: The authors have declared that no competing interests exist. ✉ * E-mail: [email protected] Roles Sujarwoto Sujarwoto : Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing Penny Bee : Formal analysis, Validation, Writing – review & editing Helen Brooks : Formal analysis, Validation, Writing – review & editing Asri Maharani : Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing Shivanand Kattimani : Editor Received 2025 Oct 28; Accepted 2026 Feb 19; Collection date 2026. © 2026 Sujarwoto et al This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice PMCID: PMC13082633  PMID: 41984853 Abstract Suicide is a major public health concern and a leading cause of premature death, particularly in low- and middle-income countries. In Indonesia, the true burden is likely underestimated due to stigma and underreporting. Evidence on suicidal ideation, an important precursor to suicide, remains limited. This study aims to identify individual and community correlates of persistent suicidal ideation among Indonesian adults using nationally representative data. A cross-sectional analysis was conducted using data from the 2018 Indonesia National Health Survey covering adults aged 18 years and older. District-level indicators were obtained from the 2018 Village Potential Statistics and regional economic data from the National Bureau of Statistics. Multivariable and multilevel logistic regression models identified individual and contextual factors associated with suicidal ideation, accounting for individuals nested within districts. Among 636,285 adults (mean age 42.5 years; 47.4% female), 0.87% reported persistent suicidal ideation in the past month. Higher community social capital (OR = 0.94; 95% CI 0.88–1.00) and district GDP (OR = 0.91; 95% CI 0.86–0.97) were associated with lower odds, while social deprivation increased risk (OR = 1.13; 95% CI 1.06–1.21). Lower odds of suicidal ideation were observed among women (OR = 0.56), married (OR = 0.65) or widowed individuals (OR = 0.77), those with higher education attainments (OR = 0.32 for university graduates), and resident of Java (OR = 0.61). Divorce (OR = 1.28), older age (OR = 1.83 for ages 65–74), chronic illness (OR = 1.56 for heart disease), and poor self-rated health (OR = 3.38) were linked to higher risk. Strengthening community social capital and reducing social deprivation are vital to prevent suicidal ideation in Indonesia. Interventions should address socioeconomic inequalities and improve access to health and social support, especially among older adults and those with chronic illness. Promoting inclusive economic growth and community resilience may help mitigate the underlying stressors contributing to suicidal thoughts. Introduction Suicidality, encompassing suicidal thoughts, plans, and behaviours, represents a major global public health concern. It causes hundreds of thousands of deaths each year, surpassing mortality from malaria, HIV/AIDS, breast cancer, and armed conflict, and imposes profound social, emotional, and economic burdens on families and communities [ 1 , 2 ]. In recognition of its wide-ranging impact, the World Health Organization (WHO) has made suicide prevention a global priority within the Sustainable Development Goals (SDGs), its General Programme of Work, and the Live Life framework, which promotes evidence-based interventions across individual, community, and policy levels [ 2 ]. A comprehensive, coordinated prevention strategy is therefore essential to protect lives and mitigate the long-term consequences of suicidality for both individuals and society. According to WHO estimates, Indonesia experiences around 6,500 suicides each year [ 2 ]. This figure is likely an underestimate, as strong stigma surrounding mental illness and suicide discourages families from reporting deaths and leads to their classification under other causes [ 1 ]. Recent analyses suggest that suicide underreporting may reach as high as 85.9%, even when enhanced surveillance and verbal autopsy methods are used, indicating that official statistics capture only about half of all cases [ 3 ]. The highest suicide rates were recorded in Bali, the Riau Islands, Yogyakarta, Central Java, and Central Kalimantan. Men had approximately twice the suicide rate of women. Hanging and self-poisoning were the most common methods, with rural suicide rates exceeding urban rates by more than fourfold, reflecting disparities in mental health service access and social isolation in remote areas [ 3 , 4 ]. Research on suicidality, including its spectrum from suicidal thoughts to attempts and deaths, has largely focused on high-income countries, leaving major evidence gaps in low- and middle-income countries (LMICs) where social, economic, and health contexts differ substantially [ 2 , 5 ]. This study specifically examines suicidal ideation as a critical yet underexplored component of suicidality. While suicidal ideation often reflects early stages of psychological distress and constitutes a key risk factor for subsequent suicidal behaviour, the relationship between ideation and action is complex and not necessarily linear. Many individuals who experience suicidal thoughts do not progress to suicidal behaviour, and multiple psychological, social, and contextual factors may either exacerbate or buffer this trajectory. Understanding its determinants is essential for prevention efforts in resource-limited settings. Evidence from high-income contexts suggests that community social capital can protect against suicidal ideation by enhancing belonging, social support, and mutual aid [ 6 , 7 ]. Community social capital, defined as the strength of social networks, shared norms, and trust that facilitate collective action, emerged as a protective contextual factor associated with lower odds of suicidal ideation. Conversely, low social capital and social fragmentation may heighten vulnerability through isolation, diminished collective efficacy, and reduced access to help [ 8 , 9 ]. However, these associations are rarely tested in LMIC contexts, where the social meanings of connectedness and community support may differ. In Indonesia, where suicide remains highly stigmatised and frequently underreported, the complex interplay between mental health conditions, socioeconomic hardship, and community resources such as social capital has received limited empirical attention. Drawing on Durkheim’s sociological theory of suicide [ 10 ], which highlights the protective role of social integration and connectedness, social capital offers a framework for understanding how collective ties and social cohesion influence vulnerability to suicidality. Empirical research in LMICs supports this theoretical perspective: studies in China and India have shown that stronger family cohesion, community participation, and perceived social support are associated with lower suicidal ideation and attempts [ 11 – 13 ]. A large Chinese university survey found that higher social capital was associated with lower suicidal ideation among medical students, and also helped buffer the impact of uncertainty stress [ 14 ]. It is thus crucial for understanding how community-level resilience and deprivation shape vulnerability to suicidality in rapidly changing LMIC contexts. The present study aims to investigate how personal and contextual factors, including education, income, health status, community social capital, social deprivation, and district-level economic conditions, correlate with suicidal ideation among adults aged 18 years and older. The overarching research question guiding this study is: “What individual and community determinants are associated with suicidal ideation among Indonesian adults?” This study makes several novel contributions. First, it provides the first multilevel national evidence on suicidal ideation in Indonesia, integrating data from the 2018 National Health Survey (Riskesdas) and the Village Potential Statistics (PODES). Second, it expands the understanding of suicidality in LMICs by linking social and economic contexts, particularly community social capital and social deprivation, to individual mental health outcomes [ 7 , 9 ]. Finally, the study contributes policy-relevant insights for designing community-based suicide prevention strategies that strengthen social capital and reduce contextual deprivation in resource-constrained settings. Materials and methods Study design This cross-sectional analysis utilised data from the 2018 Indonesia National Health Survey (Riskesdas), a nationally representative survey conducted quinquennially [ 15 ]. Riskesdas, managed by the National Institute of Health Research and Development (NIHRD), includes health indicators such as mental health and non-communicable diseases. Ethical approval was obtained from the NIHRD prior to data collection, and informed written consent was obtained from all participants. A multistage systematic random sample technique was employed to identify 636,285 persons aged 18 and above with comprehensive suicidal ideation data [ 15 ]. Hence, the study included individuals with complete information on key variables related to suicidal ideation, socioeconomic characteristics, and community-level indicators. Cases with missing data on these variables were excluded using listwise deletion, resulting in consistent analytic samples across models. This approach ensured internal validity while maintaining comparability with the national sampling frame. Descriptive characteristics and model estimates, therefore, reflect weighted data from respondents meeting these inclusion criteria. The Riskesdas data were correlated with the 2018 Village Survey (PODES) to obtain village-level insights into community social capital and social deprivation, alongside district gross domestic product (GDP) data for 2017 from the Indonesian Bureau of Statistics [ 16 ]. Data were consolidated at the district level and linked to individual Riskesdas data, accounting for the hierarchical nature of individuals within districts. Ethics statement This study used secondary, de-identified data from the 2018 Indonesia Basic Health Survey (Riset Kesehatan Dasar, Riskesdas), which was conducted by the National Institute of Health Research and Development (NIHRD), Ministry of Health, Indonesia. The Riskesdas survey protocols were reviewed and approved by the Health Research Ethics Commission of the NIHRD (Ethical Approval No. LB.02.01/2/KE.267/2017). Written informed consent was obtained from all participants by the NIHRD at the time of data collection. The present analysis was approved by the data custodians and conducted in accordance with relevant national and institutional ethical guidelines. As this study involved secondary analysis of anonymised data, no additional ethical approval was required from the authors’ institutions. Measure of suicidal ideation Suicidal ideation was assessed using a single self-report item from the Riskesdas 2018. Respondents were asked: “During the past two weeks, have you had recurrent thoughts of hurting yourself, wanting to kill yourself, or wishing that you were dead?” Responses were coded as 1 for “yes” and 0 for “no”. The two-week recall period and emphasis on recurrent thoughts indicate that this item captures persistent suicidal ideation or death wishes, rather than transient or occasional suicidal thoughts. Single-item measures of this type are commonly used in large population-based surveys to identify individuals experiencing sustained suicidal distress, although they do not capture the full multidimensionality of suicidal ideation assessed by comprehensive clinical instruments. Individual-level covariates Individual-level variables included demographic, socioeconomic, health, and behavioural characteristics. Demographic factors comprised age, sex, and marital status. Age was grouped into seven categories (18–24, 25–34, 35–44, 45–54, 55–64, 65–74, and 75 years or older), with the 18–24 age group as the reference category. Sex was coded with males as the reference group. Marital status was classified as never married, married, divorced, or widowed. Socioeconomic characteristics included educational attainment, household expenditure, and employment status. Education was divided into seven categories, ranging from no schooling to college or university level, with higher education serving as the reference. Household expenditure was grouped into quintiles, representing relative economic standing. Employment status captured diverse labour categories, including unemployed, student, civil servant, army or police officer, private-sector employee, self-employed, farmer, fisherman, driver or household assistant, and other occupations, with unemployed individuals serving as the reference group. Health-related variables included both self-reported chronic conditions and perceived health. Respondents were asked whether they had ever been diagnosed by a health professional with conditions, including joint disease, hypertension, stroke, diabetes, heart disease, asthma, cancer, and renal failure. Self-rated health was assessed on a three-point scale: good, adequate, or poor. Health behaviours encompassed smoking and alcohol consumption. Smoking status was classified as daily smoker, occasional smoker, former smoker, or non-smoker. Alcohol consumption was grouped as none, under standard, or above standard. Finally, household and geographical characteristics were considered. Household expenditure quintiles captured relative economic position, and the island of residence distinguished between respondents living in Java and those residing in other islands of Indonesia. District-level covariates Community social capital was measured through principal component analysis of four indicators: the frequency of communal labour activities (“ gotong royong ”), the number of community-based financial institutions, the frequency of social support initiatives, and the number of community representative organisations over the past three years. This approach follows prior ecological studies linking community engagement and institutional density to mental health and suicide prevention outcomes [ 7 , 17 ]. Social deprivation was assessed using principal component analysis of crime rates and community conflicts during the same period, reflecting previous conceptualisations of area deprivation and psychosocial stressors [ 8 , 9 ]. District-level GDP data from 2017 were included as a proxy for local economic development, consistent with earlier evidence on the protective role of economic opportunity against suicidality [ 18 , 19 ]. Although GDP data precede the Riskesdas survey by one year, this temporal lag is unlikely to bias results because district-level socioeconomic indicators in Indonesia are highly stable from year to year, reflecting gradual economic and demographic change rather than abrupt shifts. The use of the most recent pre-survey GDP data, therefore, provides a valid approximation of the district economic context at the time of data collection. Statistical analysis We first mapped the geographic distribution of suicidal ideation at the district level to visualise spatial variation. Descriptive statistics were then used to summarise individual and contextual characteristics, and bivariate associations were examined using chi-squared tests for categorical variables. To identify factors associated with suicidal ideation, we employed multivariable and multilevel logistic regression models. The multilevel approach accounted for the hierarchical data structure, with individuals (Level 1) nested within districts (Level 2). Model 1 included individual-level variables (demographic, socioeconomic, behavioural, and health factors), while Model 2 additionally incorporated district-level indicators of community social capital, social deprivation, and GDP. This structure allowed estimation of both within-district and between-district effects on suicidal ideation. All analyses accounted for the complex survey design of the 2018 Indonesia National Health Survey, which involved stratification, clustering, and sampling weights. Prior to modelling, individual-level sampling weights provided within the Indonesia National Health Survey data were applied to ensure representativeness at the provincial and district levels. Survey weights were scaled to the primary sampling unit (PSU) level following Stata’s svyset procedures, enabling adjustment for unequal probabilities of selection across strata. In multilevel models, the scaled weights were incorporated at the individual level, while district-level predictors captured contextual variance. This approach ensures that estimated standard errors and confidence intervals reflect Indonesia’s multistage sampling design and hierarchical population structure. Model diagnostics included examination of multicollinearity using variance inflation factors (VIF < 2) and assessment of model fit using the intraclass correlation coefficient (ICC) and Akaike Information Criterion (AIC). Marginal effects were computed as predicted probabilities of suicidal ideation derived from the final multilevel logistic regression model. These probabilities were estimated using Stata’s margins command, holding other covariates at their mean values. This approach enables intuitive interpretation of the strength and direction of associations between district-level predictors, including social capital, social deprivation, and GDP, and the likelihood of suicidal ideation, while accounting for the nested data structure. All analyses were conducted in Stata version 18.0, with a two-tailed significance threshold of p < 0.05. Results Characteristics of participants The characteristics of all participants are presented in S1 Table . Of the 636,285 respondents, 52.6% were male and 47.4% female. Most participants (75.1%) were married, with a mean age of 42.3 years, and 27.9% had completed senior high school. Approximately 28.6% were unemployed, while 25.5% worked in agriculture. Joint problems (8.5%) and hypertension (8.8%) were the most frequently reported chronic conditions. Daily smoking was reported by 27.1%, and 2.0% described their health as suboptimal. Over half of the sample resided within the lower three quartiles of household expenditure. The mean district-level social capital score was 0.14 (range from 1.34 to 5.68), and the social deprivation index averaged 0.13 (range from 1.06 to 6.65). These standardised indices were derived using principal component analysis, with higher values indicating stronger community engagement and collective participation for social capital, and greater exposure to crime and conflict for social deprivation. The logarithmic GDP score averaged 9.43 (range from 4.99 to 10.03), representing variation in district-level economic output per capita. Together, these variables capture contextual dimensions of community cohesion, social stress, and economic capacity relevant to mental health outcomes. A total of 5,507 individuals (0.87%; 95% CI 0.84–0.89%) reported persistent suicidal ideation in the past month. Persistent suicidal thoughts were most common among married males aged 35–54 with primary education who were unemployed or employed as farmers, often reporting hypertension or asthma, belonging to economically disadvantaged households, and living outside Java ( Table 1 ). Table 1.  Characteristics of participants with persistent suicidal ideation. Variables N obs. % or mean SD Sex Male 3,418 62.1% 48.5% Female 2,089 37.9% 48.5% Marital status Never married 802 14.6% 35.3% Married 3,759 68.3% 46.6% Divorced 255 4.6% 21.0% Widowed 691 12.5% 33.1% Age (Mean) 45.52 16.26 Age group 18-24 650 11.8% 32.3% 25-34 889 16.1% 36.8% 35-44 1,135 20.6% 40.5% 45-54 1,189 21.6% 41.1% 55-64 910 16.5% 37.1% 65-74 489 8.9% 28.4% >=75 245 4.4% 20.6% Education Never go to school 668 12.1% 32.7% Less than primary school 1,211 22.0% 41.4% Primary school 1,604 29.1% 45.4% Junior high school 845 15.3% 36.0% Senior high school 982 17.8% 38.3% Diploma 77 1.4% 11.7% College/University 120 2.2% 14.6% Employment status Unemployed 2,077 37.7% 48.5% Students 137 2.5% 15.6% Civil servant/army/police officer 83 1.5% 12.2% Private worker 189 3.4% 18.2% Self-employed 571 10.4% 30.5% Farmer 1,585 28.8% 45.3% Fisherman 84 1.5% 12.3% Driver/household assistance 432 7.8% 26.9% Others 349 6.3% 24.4% Joint diseases No 4,605 83.6% 37.0% Yes 902 16.4% 37.0% Hypertension No 4,692 85.2% 35.5% Yes 815 14.8% 35.5% Stroke No 5,279 95.9% 19.9% Yes 228 4.1% 19.9% Diabetes No 5,255 95.4% 20.9% Yes 252 4.6% 20.9% Heart diseases No 5,252 95.4% 21.0% Yes 255 4.6% 21.0% Asthma No 5,160 93.7% 24.3% Yes 347 6.3% 24.3% Cancer No 5,468 99.3% 8.4% Yes 39 0.7% 8.4% Renal failure No 5,432 98.6% 11.6% Yes 75 1.4% 11.6% Smoking status Smoking every day 1,326 24.1% 42.8% Smoking not every day 305 5.5% 22.9% Ex smoker 355 6.4% 24.6% Not smoker 3,521 63.9% 48.0% Alcohol consumption Under standard 243 4.4% 20.5% More than standard 170 3.1% 17.3% No alcohol 5,094 92.5% 26.3% Self-rated health Good 2,610 47.4% 49.9% Adequate 2,065 37.5% 48.4% Poor 832 15.1% 35.8% Household expenditure 1st quartile 1,245 22.6% 41.8% 2nd 1,234 22.4% 41.7% 3rd 1,122 20.4% 40.3% 4th 1,067 19.4% 39.5% 5th 839 15.2% 35.9% Island Outer Java 4,154 75.4% 43.1% Java 1,353 24.6% 43.1% Open in a new tab Geographical distribution of suicide ideation Geographical disparities in persistent suicidal ideation are apparent among Indonesian districts ( Fig 1 ). The coastal areas of northern Papua, central and northern Sulawesi, northern and central Kalimantan, eastern Nusa Tenggara, northeastern and southeastern Sumatra, Bali, and southern West Java demonstrate the highest incidence (>4%). Fig 1.  Geographical distribution of suicidal ideation. Map redrawn by the authors using openly licensed geographic boundary data from openfreemap.org ( https://openfreemap.org/ ); the figure is distributed under the Creative Commons Attribution (CC BY 4.0) licence. Open in a new tab Multivariable logistic regression Table 2 displays the outcomes of multivariable and multilevel logistic regression analyses. The female gender exhibited lower odds of persistent suicidal thoughts in comparison to the male gender (OR = 0.560, 95% CI 0.511–0.614). In comparison to never-married persons, married and widowed individuals exhibited lower odds (OR = 0.646, 95% CI 0.584–0.715 for married; OR = 0.769, 95% CI 0.670–0.883 for widowed), but divorced individuals showed increased odds of suicidal thoughts (OR = 1.284, 95% CI 1.094–1.507). The likelihood of persistent suicidal ideation increased with age, with the highest odds observed among individuals aged 65–74 years (OR = 1.831, 95% CI 1.566–2.140). Higher education was significantly correlated with reduced suicidal ideation. Employed individuals (civil servants, private sector workers, self-employed individuals, and farmers) demonstrated a reduced likelihood of persistent suicidal ideation in comparison to jobless individuals. Chronic illness correlated with an increased likelihood of persistent suicidal thoughts. Intermittent smokers and former smokers exhibited greater probabilities than daily smokers, whereas non-smokers demonstrated reduced risks. Non-drinkers had a reduced likelihood of suicidal thoughts compared to individuals drinking below the standard limit. Individuals with poor self-rated health had markedly higher odds of suicidal ideation (OR = 10.38, 95% CI 9.50–11.33), consistent with a strong positive association between perceived ill-health and suicidal thoughts. Increased family expenditure correlated with diminished odds. Residing in Java was correlated with a reduced likelihood compared to residing in other locations. Table 2.  Multivariable and multilevel logistic regression results. Model 1 Model 2 Variables Odds ratio P-Value 95% Confidence intervals Odds ratio P-Value 95% Confidence intervals Lower Upper Lower Upper Individual-level variables Female 0.560 0.000 0.511 0.614 0.583 0.000 0.532 0.639 Marital status, reference: never married Married 0.646 0.000 0.584 0.715 0.623 0.000 0.563 0.691 Divorced 1.284 0.002 1.094 1.507 1.292 0.002 1.100 1.518 Widowed 0.769 0.000 0.670 0.883 0.754 0.000 0.656 0.866 Age group (years), reference: 18–24 25-34 0.983 0.774 0.873 1.106 1.003 0.964 0.891 1.129 35-44 0.959 0.506 0.849 1.084 0.982 0.770 0.868 1.110 45-54 0.969 0.624 0.854 1.099 1.013 0.848 0.891 1.150 55-64 1.117 0.107 0.976 1.279 1.179 0.018 1.029 1.352 65-74 1.831 0.000 1.566 2.140 1.923 0.000 1.642 2.253 >=75 1.813 0.000 1.504 2.184 1.933 0.000 1.600 2.335 Education, reference: no school Less than primary school 0.928 0.132 0.842 1.023 0.938 0.209 0.849 1.037 Primary school 0.719 0.000 0.654 0.791 0.717 0.000 0.649 0.791 Junior high school 0.587 0.000 0.525 0.656 0.597 0.000 0.533 0.670 Senior high school 0.463 0.000 0.414 0.519 0.465 0.000 0.414 0.523 Diploma 0.379 0.000 0.295 0.488 0.385 0.000 0.299 0.496 College/University 0.320 0.000 0.256 0.398 0.316 0.000 0.253 0.395 Employment status, reference, unemployed Students 0.883 0.199 0.731 1.067 0.864 0.132 0.714 1.045 Civil servant/army/police officer 0.718 0.008 0.561 0.918 0.705 0.006 0.551 0.902 Private worker 0.661 0.000 0.565 0.775 0.684 0.000 0.583 0.803 Self-employed 0.814 0.000 0.738 0.899 0.848 0.001 0.767 0.937 Farmer 0.839 0.000 0.779 0.904 0.824 0.000 0.762 0.891 Fisherman 0.971 0.799 0.773 1.219 0.876 0.260 0.695 1.103 Driver/household assistance 0.935 0.241 0.835 1.046 0.961 0.496 0.857 1.077 Others 0.893 0.057 0.795 1.003 0.874 0.027 0.777 0.985 Diagnosed with joint disease 1.443 0.000 1.337 1.558 1.448 0.000 1.339 1.565 Diagnosed with hypertension 1.049 0.270 0.964 1.141 1.052 0.241 0.967 1.145 Diagnosed with stroke 2.260 0.000 1.952 2.616 2.320 0.000 2.002 2.690 Diagnosed with diabetes 1.316 0.000 1.149 1.507 1.330 0.000 1.160 1.525 Diagnosed with heart disease 1.562 0.000 1.366 1.787 1.538 0.000 1.342 1.762 Diagnosed with asthma 1.632 0.000 1.456 1.828 1.608 0.000 1.433 1.804 Diagnosed with cancer 1.449 0.028 1.042 2.014 1.476 0.022 1.057 2.060 Diagnosed with renal failure 1.843 0.000 1.448 2.346 1.833 0.000 1.438 2.338 Smoking status, reference: everyday Not everyday 1.206 0.004 1.062 1.370 1.164 0.021 1.023 1.324 Ex smoker 1.132 0.049 1.001 1.281 1.082 0.215 0.955 1.226 Not smoker 0.699 0.000 0.635 0.770 0.714 0.000 0.647 0.786 Alcohol consumption, reference: under standard More than standard 0.987 0.898 0.809 1.205 0.886 0.244 0.722 1.086 No alcohol 0.579 0.000 0.505 0.665 0.683 0.000 0.593 0.787 Self-rated health, reference: good Adequate 2.425 0.000 2.275 2.584 2.349 0.000 2.202 2.506 Poor 3.375 0.000 9.504 11.327 3.361 0.000 8.557 10.240 Household expenditure, reference: 1 st quartile 2 nd 0.978 0.579 0.902 1.059 0.979 0.611 0.902 1.063 3 rd 0.860 0.000 0.792 0.934 0.859 0.000 0.789 0.936 4 th 0.827 0.000 0.759 0.900 0.840 0.000 0.769 0.917 5 th 0.715 0.000 0.651 0.786 0.725 0.000 0.656 0.800 Java 0.611 0.000 0.573 0.652 0.713 0.000 0.603 0.844 District-level variables Community social capital 0.935 0.050 0.875 1.000 Social deprivation 1.131 0.000 1.057 1.209 District GDP 0.909 0.002 0.856 0.966 Constant 0.039 0.000 0.032 0.049 0.065 0.000 0.037 0.115 Variance at the individual level 0.586 0.537 0.640 Variance at the district level 0.095 0.081 0.111 AIC 23,785 23,321 BIC 23,998 23,507 Open in a new tab Multilevel logistic regression The correlations at the individual level with persistent suicidal thoughts were predominantly stable. Community social capital and elevated GDP were significantly correlated with diminished odds of suicidal ideation (OR=0.935, 95% CI 0.875–1.00 for community social capital; OR=0.909, 95% CI 0.856–0.966 for district GDP), while higher levels of social deprivation were significantly associated with increased odds of suicidal ideation (OR = 1.13; 95% CI 1.057–1.209). Margins effect Fig 2 presents the predicted probabilities of persistent suicidal ideation derived from the final multilevel logistic regression model. The results demonstrate that higher levels of community social capital and district GDP were associated with a lower predicted probability of suicidal ideation, whereas increasing social deprivation corresponded to higher predicted probabilities. This pattern is consistent with the multilevel regression results, showing that higher levels of community social capital and district economic development were associated with lower odds of persistent suicidal ideation, whereas greater social deprivation was associated with higher odds. Fig 2.  Margins effect of district-level variables on suicidal ideation. Open in a new tab Discussion Hidden burden of suicidal ideation in Indonesia This national, population-based study examined the individual and community factors associated with suicidal ideation among Indonesian adults using linked survey and contextual data. The prevalence of persistent suicidal ideation was 0.87% (95% CI 0.84–0.89%), representing 5,507 individuals. By integrating data from both household and district levels, this study addressed its primary aim, to assess how socioeconomic, health, and contextual factors, including social capital, social deprivation, and local economic development, are associated with suicidal thoughts in Indonesia. The observed prevalence is lower than that reported in many low- and middle-income as well as high-income countries, such as China (3.9%) [ 20 ], South Korea (15.2%) [ 21 ], the United States (3.2%) [ 22 ], and India (11.0%) [ 23 ]. However, this comparatively low rate should be interpreted with caution due to the high likelihood of underreporting related to stigma, religious prohibition, and social desirability bias [ 1 , 3 ]. These cultural factors often lead to concealment or misclassification of suicidality as other causes of death or illness, particularly in conservative communities. Thus, the actual burden of suicidal ideation in Indonesia is likely higher than captured in national surveys. When contextualised globally, Indonesia’s prevalence suggests a lower recorded burden but a substantial hidden risk. This aligns with patterns observed across LMICs where stigma and weak mental-health surveillance systems suppress disclosure. Studies from Europe, Australia, and Canada also show considerable variation, influenced by socioeconomic inequalities and access to care [ 24 – 26 ]. Therefore, while Indonesia’s reported prevalence appears modest, it underscores the urgent need to strengthen mental-health literacy, destigmatise help-seeking, and improve surveillance accuracy. Community contexts: Social capital, deprivation, and economic opportunity We found that community social capital was significantly correlated with lower odds of persistent suicidal ideation. Evidence from high-income and Asian contexts consistently links stronger community cohesion with reduced suicide mortality and ideation rates [ 6 , 7 , 17 , 27 ]. In Indonesia, communities with higher participation in collective activities and stronger interpersonal trust may foster a sense of belonging and mutual support, thereby buffering the effects of stress and isolation as major risk factors for suicidality. Empirical evidence from Indonesia suggests that neighbourhood-level trust and collective engagement can be protective for mental health, including lower risks of depressive symptoms, particularly when community participation is experienced as supportive and reciprocal [ 28 ]. These findings resonate with Durkheim’s sociological theory of suicide [ 10 ], which emphasises the protective function of social integration and regulation in maintaining psychological stability. However, the mental health implications of community social capital are not uniformly positive. In the Indonesian context, collective practices such as gotong royong may also entail obligation and informal enforcement of village norms rather than voluntary engagement. Prior scholarship has noted that the institutionalisation of gotong royong can transform a practice of mutual aid into a compulsory form of participation, thereby introducing elements of social control and pressure [ 29 ]. Excessively rigid or coercive forms of social regulation may generate psychological strain rather than protection. As such, high levels of collective participation may simultaneously signal social integration while exposing individuals, especially those who are socially or economically marginalised, to stress or sanctions. The relationship between district-level GDP and suicidal ideation was inverse: higher GDP was associated with lower odds of persistent suicidal ideation. Economic prosperity often coincides with better access to health and social services, reduced financial stress, and enhanced community infrastructure, all of which may support mental well-being [ 18 , 19 ]. However, this relationship is unlikely to be linear; structural inequalities and uneven distribution of economic benefits can moderate these effects, even in relatively affluent districts. Future research employing longitudinal and spatial analyses could clarify causal mechanisms and identify vulnerable groups who remain at risk despite broader economic improvement. Individual vulnerabilities and gendered patterns of ideation Women had significantly lower odds of reporting persistent suicidal ideation than men. This finding contrasts with the well-established gender paradox in suicide research, whereby women typically report higher levels of suicidal ideation and attempts, while men experience higher suicide mortality [ 30 ]. It also diverges from evidence from LMICs, which generally report a higher prevalence of suicidal ideation among women than men [ 20 , 31 ]. This discrepancy warrants cautious interpretation. One plausible explanation relates to measurement: the Riskesdas item captures recurrent or persistent suicidal or death-related thoughts, and gender differences may differ for this more severe form of ideation compared with broader measures that include occasional or fleeting thoughts. In addition, gender-differential reporting bias is likely in the Indonesian context. Strong stigma surrounding suicide, combined with gendered expectations of emotional restraint, family honour, and religious norms, may discourage women from endorsing survey items that explicitly reference suicide or wishing to be dead. As a result, the observed sex difference may reflect variation in reported suicidal ideation rather than true differences in underlying risk, underscoring the need for gender-sensitive measurement approaches in future research. Unemployment, poverty, and divorce were also associated with higher odds of suicidal ideation, consistent with evidence that economic hardship and weakened social support increase psychological distress [ 5 , 32 ]. Older adults, particularly those aged 65–74 years, and individuals with chronic illnesses reported a greater likelihood of suicidal thoughts [ 33 ]. These factors often intersect and reinforce one another: unemployment can lead to poverty and relationship breakdowns, while chronic illness may restrict work ability and increase financial dependence. The interplay of social, relational, and health-related stressors underscores the importance of integrated mental-health and social-welfare systems to mitigate cumulative risk. Policy pathways for suicide prevention in resource-constrained settings This study offers several policy-relevant insights. Strengthening community social capital appears to be a promising approach to suicide prevention in resource-constrained settings. Interventions might include supporting village-level associations, faith-based or women’s groups, peer-support initiatives, and volunteering programmes that build trust and participation. However, the evidence base for community-level interventions to enhance social capital and reduce suicidality remains limited, even in high-income settings, and their effectiveness in LMIC contexts is largely untested. Future research should therefore explore how such approaches can be adapted and implemented in resource-constrained and culturally diverse communities, to identify the most effective and sustainable ways to strengthen social connectedness and reduce suicide risk. Addressing socioeconomic deprivation remains essential. Policies that expand access to education, decent employment, and social protection can reduce structural inequities that contribute to psychological distress and suicidality. Employment instability and underemployment have been consistently identified by individuals with lived experience and community stakeholders as major stressors linked to suicidal thoughts and behaviours, particularly in LMICs where social safety nets are limited [ 5 , 34 ]. These priorities echo global calls for multisectoral suicide prevention strategies that address social and economic determinants, as outlined in the WHO LIVE LIFE implementation guide and the Lancet–World Psychiatric Association Commission on Depression [ 35 , 36 ]. Strengthening job security, improving working conditions, and integrating mental health support within labour and social protection policies may therefore represent actionable and publicly supported avenues for suicide prevention. Methodological strengths and remaining limitations This study provides one of the first multilevel analyses of suicidal ideation using nationally representative data in Indonesia, integrating individual and district-level information. Its large sample and robust analytical framework enhance the reliability and policy relevance of the findings. However, several limitations must be acknowledged. The cross-sectional design precludes causal inference; associations identified here should be interpreted as correlational. Suicidal ideation was assessed using a single survey item, which may not capture the full complexity of suicidal thoughts, such as frequency, intensity, or intent [ 37 , 38 ]. Cultural differences in expressing or concealing suicidality may also affect the accuracy of assessment. Future research should use longitudinal or mixed-method designs with repeated measures of ideation and incorporate contextual qualitative data to better understand the social dynamics underlying suicidal behaviour. Another limitation concerns the measurement of suicidal ideation. The study relied on a single self-reported question to assess suicidal thoughts. The study relied on a single self-reported question to assess suicidal thoughts, referring specifically to recurrent suicidal or death-related thoughts over a two-week period. While this approach is suitable for large population-based surveys, it may not fully capture the multidimensional nature of suicidal ideation, including variation in intensity, persistence, or intent. The use of a single-item measure may therefore underestimate the overall prevalence of suicidal ideation or obscure differences across subgroups, particularly among individuals experiencing occasional or emerging suicidal thoughts. Future research should incorporate validated multi-item scales or mixed-method designs to provide a more comprehensive assessment of suicidality. Conclusion This study provides novel evidence on how community social capital, social deprivation, and economic context are associated with suicidal ideation in Indonesia, an LMIC where suicide remains highly stigmatised and underreported. While grounded in Indonesia’s socio-cultural and economic context, these findings hold broader relevance for other LMICs facing similar structural challenges. Strengthening community social capital and addressing social deprivation are associated with lower odds of suicidal ideation. Embedding such strategies within national mental-health policies, alongside efforts to reduce socioeconomic inequality, could help mitigate distress and promote mental well-being. Although causal relationships cannot be inferred, the mechanisms identified, such as the buffering role of social capital and the exacerbating effects of deprivation, mirror patterns observed globally. The Indonesian experience thus contributes valuable evidence for developing integrated, community-based suicide-prevention strategies adaptable to other resource-limited settings. Supporting information S1 Table. Characteristics of participants. (DOCX) pone.0344394.s001.docx (25.5KB, docx) Data Availability Data are available upon official request. The data set (RISKESDAS) can be accessed with approval by Director General of Health Policy Agency, Ministry of Health, Republic of Indonesia, at https://layanandata.kemkes.go.id/request . The authors had no special access privileges; others may obtain the data in the same manner. 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Psychol Assess. 2015;27(2):501–12. doi: 10.1037/pas0000053 [ DOI ] [ PubMed ] [ Google Scholar ] PLoS One. doi: 10.1371/journal.pone.0344394.r001 Decision Letter 0 Shivanand Kattimani Shivanand Kattimani Academic Editor Find articles by Shivanand Kattimani Author information Copyright and License information Roles Shivanand Kattimani : Academic Editor © 2026 Shivanand KattimaniShivanand KattimaniShivanand KattimaniShivanand Kattimani This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 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Major Issues 1. The "Frequency" Trap You report a suicidal ideation rate of 0.87%. This is incredibly low. The global average is often much higher. Look at your survey question again. You asked: "Have you frequently thought that you’d be better off dead?" The word "frequently" is a major filter. It excludes everyone who has had occasional or fleeting thoughts. You are not measuring general "suicidal ideation." You are measuring "persistent death wishes." This distinction matters. It explains why your prevalence is so low. You must be honest about this limitation. You are likely missing the vast majority of at-risk people. You should reframe your results to reflect this specific definition. 2. The Gender Paradox You found that being female reduces the risk of ideation by nearly half (OR 0.56). This contradicts the well-known "gender paradox" in suicide. Globally, women usually report more ideation and attempts than men. Men usually have higher mortality. Your data says Indonesian women think about suicide less than men. This is highly unusual. Is it a true finding? or is it a reporting bias? Women might be less likely to admit to "frequent" death wishes due to social pressure. You accept this finding too easily. You should challenge it more aggressively in your discussion. 3. The "Gotong Royong" Assumption You use communal labor (gotong royong) as a proxy for social capital. You assume this is always a positive thing. But in many Indonesian villages, this is a mandatory obligation. It can be a burden. High participation might mean "strict village rules" rather than "supportive neighbors." Does forced cooperation really protect mental health? Or does it add social pressure? You treat it as a pure positive. You should consider whether it also represents social control. This is a nuance that is missing from your interpretation. 4. Causality vs. Association This is a cross-sectional study. You cannot prove these factors cause suicidal ideation. Yet you use strong language like "determinants," "impact," and "prevent." Be careful. Poverty might cause suicidal thoughts. But suicidal thoughts might also lead to job loss and poverty. Your data cannot tell the difference. Soften your claims. Use words like "associated with" or "linked to" more consistently. Minor Issues and Language The writing is generally clear. However, there are awkward phrases and inconsistencies. "Subpar alcohol consumers" (Line 263): This is incorrect. "Subpar" means "low quality." It sounds like they are bad at drinking. You likely mean "light drinkers" or "those drinking below the standard limit." "Policeman" (Table 1): This term is dated. Use the gender-neutral "Police officer." "Escalated" (Line 255): This is too dramatic for statistics. Use "increased." Reviewer #2: The article provides well researched actionable evidence associating social determinants of health in Indonesia with risk of suicide, which carries high value for institutional public health management in the country. ********** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy ..--> Reviewer #1: Yes: Dr Nirmalya MukherjeeDr Nirmalya MukherjeeDr Nirmalya MukherjeeDr Nirmalya Mukherjee Reviewer #2: Yes: Anoopinder Singh, MBBS, MD, FAPAAnoopinder Singh, MBBS, MD, FAPAAnoopinder Singh, MBBS, MD, FAPAAnoopinder Singh, MBBS, MD, FAPA ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". 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The data set (RISKESDAS) can be accessed with approval by Director General of Health Policy Agency, Ministry of Health, Republic of Indonesia, at https://layanandata.kemkes.go.id/request . The authors had no special access privileges; others may obtain the data in the same manner. Community indicators from the 2018 Village Potential Statistics (PODES) from Statistics Indonesia (BPS) are available from Statistics Indonesia following registration ( https://ppid.bps.go.id/?mfd=0000 ). All variables used in this study are described in the article and Supporting Information.” Comments from Academic Editors #3 3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. 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There is no requirement to cite these works unless the editor has indicated otherwise. Authors’ response N/A Comments from Academic Editors #6 6. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Authors’ response We have reviewed the references and made sure there are no retracted articles. Comments from 1st Reviewer #1 Reviewer #1: This is a strong piece of work. The dataset is impressive. The multilevel analysis is the correct choice for this data. It handles the district-level nesting well. However, the results seem too "clean." They contradict global trends in ways you do not fully explain. I have four major challenges for you to consider. These points test your logic and assumptions. Addressing them will make the paper much stronger. Major Issues 1. The "Frequency" Trap You report a suicidal ideation rate of 0.87%. This is incredibly low. The global average is often much higher. Look at your survey question again. You asked: "Have you frequently thought that you’d be better off dead?" The word "frequently" is a major filter. It excludes everyone who has had occasional or fleeting thoughts. You are not measuring general "suicidal ideation." You are measuring "persistent death wishes." This distinction matters. It explains why your prevalence is so low. You must be honest about this limitation. You are likely missing the vast majority of at-risk people. You should reframe your results to reflect this specific definition. Authors’ response We thank the reviewer for this important and constructive comment. We agree that the wording and time frame of the Riskesdas item impose a substantive constraint on the definition of suicidal ideation captured in this study. The item refers to recurrent suicidal or death-related thoughts within a two-week period and therefore reflects persistent suicidal ideation, rather than occasional or transient suicidal thoughts. In response, we have revised the manuscript to (i) correct and clarify the English translation of the survey item, (ii) explicitly define the outcome as persistent suicidal ideation in the Methods and Results sections, and (iii) expand the Discussion to acknowledge that this measurement approach likely underestimates the overall population prevalence of suicidal ideation and limits comparability with studies using broader or multi-item measures. We have also revised the interpretation of our findings, accordingly, emphasising that the identified individual- and community-level associations pertain to sustained suicidal distress, which remains a critical target for public health intervention. Comments from 1st Reviewer #2 2. The Gender Paradox You found that being female reduces the risk of ideation by nearly half (OR 0.56). This contradicts the well-known "gender paradox" in suicide. Globally, women usually report more ideation and attempts than men. Men usually have higher mortality. Your data says Indonesian women think about suicide less than men. This is highly unusual. Is it a true finding? or is it a reporting bias? Women might be less likely to admit to "frequent" death wishes due to social pressure. You accept this finding too easily. You should challenge it more aggressively in your discussion. Authors’ response Thank you for the comment. We acknowledge that our finding, lower reported suicidal ideation among women, contrasts with the classic gender paradox in suicide research, as well as with much of the literature in other LMICs, which generally reports higher prevalence of suicidal ideation among women. In response, we have substantially revised the Discussion to explicitly recognise this divergence and to avoid interpreting the result as a straightforward protective effect: “Women had significantly lower odds of reporting persistent suicidal ideation than men. This finding contrasts with the well-established gender paradox in suicide research, whereby women typically report higher levels of suicidal ideation and attempts, while men experience higher suicide mortality [31]. It also diverges from evidence from LMICs which generally report a higher prevalence of suicidal ideation among women than men [23, 32]. This discrepancy warrants cautious interpretation. One plausible explanation relates to measurement: the Riskesdas item captures recurrent or persistent suicidal or death-related thoughts, and gender differences may differ for this more severe form of ideation compared with broader measures that include occasional or fleeting thoughts. In addition, gender-differential reporting bias is likely in the Indonesian context. Strong stigma surrounding suicide, combined with gendered expectations of emotional restraint, family honour, and religious norms, may discourage women from endorsing survey items that explicitly reference suicide or wishing to be dead. As a result, the observed sex difference may reflect variation in reported suicidal ideation rather than true differences in underlying risk, underscoring the need for gender-sensitive measurement approaches in future research.” Comments from 1st Reviewer #3 3. The "Gotong Royong" Assumption You use communal labor (gotong royong) as a proxy for social capital. You assume this is always a positive thing. But in many Indonesian villages, this is a mandatory obligation. It can be a burden. High participation might mean "strict village rules" rather than "supportive neighbors." Does forced cooperation really protect mental health? Or does it add social pressure? You treat it as a pure positive. You should consider whether it also represents social control. This is a nuance that is missing from your interpretation. Authors’ response Thank you for the comment. We agree that collective practices such as gotong royong should not be interpreted as uniformly beneficial and that participation may, in some contexts, reflect obligation or informal enforcement of village norms rather than voluntary mutual support. In response, we have substantially revised the Discussion to explicitly acknowledge the dual nature of community social capital in the Indonesian context: “We found that community social capital was significantly correlated with diminished odds of suicidal ideation. Evidence from high-income and Asian contexts consistently links stronger community cohesion with reduced suicide mortality and ideation rates [6, 7, 17, 27]. In Indonesia, communities with higher participation in collective activities and stronger interpersonal trust may foster a sense of belonging and mutual support, thereby buffering the effects of stress and isolation as major risk factors for suicidality. Empirical evidence from Indonesia suggests that neighbourhood-level trust and collective engagement can be protective for mental health, including lower risks of depressive symptoms, particularly when community participation is experienced as supportive and reciprocal [28]. These findi PLoS One. doi: 10.1371/journal.pone.0344394.r003 Decision Letter 1 Shivanand Kattimani Shivanand Kattimani Academic Editor Find articles by Shivanand Kattimani Author information Copyright and License information Roles Shivanand Kattimani : Academic Editor © 2026 Shivanand KattimaniShivanand KattimaniShivanand KattimaniShivanand Kattimani This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 19 Feb 2026 Socioeconomic and Contextual Correlates of Suicidal Ideation Among Indonesian Adults: Evidence from a Multilevel Analysis of the 2018 National Health Survey PONE-D-25-56524R1 Dear Dr. Maharani, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. 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If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #1: Yes Reviewer #2: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ********** Reviewer #1: This revision is much stronger. You have addressed the major conceptual concerns regarding the measurement of persistent suicidal ideation, the apparent contradiction with the gender paradox literature, the dual nature of gotong royong, and the need to avoid causal language in a cross-sectional design. The multilevel methods are appropriate, the sample is impressive, and the discussion is now nuanced and well grounded in the LMIC and Indonesian literature. The remaining issues are largely editorial: (a) clean up track-change artefacts and duplicated text in the suicidal ideation measure and limitations sections, (b) correct small inconsistencies (self-rated health OR/CI values, “correlated with” vs “linked to”, “2023” vs 2018 in the Acknowledgements, residual “policemanpolice officer” strings, double full stops), and (c) perform a final language pass to harmonise UK English spelling and split a few very long sentences. Once these minor points are resolved in a clean version, the manuscript will be ready for publication. Reviewer #2: authors have adequately addressed comments from previous round of review, and I consider this manuscript to now be acceptable for publication ********** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). 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For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy ..--> Reviewer #1: Yes: Nirmalya Mukherjee, PhDNirmalya Mukherjee, PhDNirmalya Mukherjee, PhDNirmalya Mukherjee, PhD Reviewer #2: Yes: Anoopinder Singh, MD, FAPAAnoopinder Singh, MD, FAPAAnoopinder Singh, MD, FAPAAnoopinder Singh, MD, FAPA ********** PLoS One. doi: 10.1371/journal.pone.0344394.r004 Acceptance letter Shivanand Kattimani Shivanand Kattimani Academic Editor Find articles by Shivanand Kattimani Author information Copyright and License information Roles Shivanand Kattimani : Academic Editor © 2026 Shivanand KattimaniShivanand KattimaniShivanand KattimaniShivanand Kattimani This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice PONE-D-25-56524R1 PLOS One Dear Dr. Maharani, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. 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Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Shivanand Kattimani Academic Editor PLOS One Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials S1 Table. Characteristics of participants. (DOCX) pone.0344394.s001.docx (25.5KB, docx) Data Availability Statement Data are available upon official request. The data set (RISKESDAS) can be accessed with approval by Director General of Health Policy Agency, Ministry of Health, Republic of Indonesia, at https://layanandata.kemkes.go.id/request . The authors had no special access privileges; others may obtain the data in the same manner. Community indicators from the 2018 Village Potential Statistics (PODES) from Statistics Indonesia (BPS) are available from Statistics Indonesia following registration ( https://ppid.bps.go.id/?mfd=0000 ). 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