D2

REVIEW PAPER

Daniel W. L. Lai [email protected]; [email protected]

1 Department of Applied Social Sciences, Institute of Active Ageing, The Hong Kong Polytechnic University, Kowloon, Hong Kong

2 Faculty of Social Work, University of Calgary, Calgary, AB, Canada

3 Department of International Relations, University of Sussex, Brighton, UK

© Springer Science+Business Media New York 2016

Factors Influencing Suicide Behaviours in Immigrant and Ethno-Cultural Minority Groups: A Systematic Review

Daniel W. L. Lai1,2 · Lun Li2 · Gabrielle D. Daoust3

is one of the leading causes of death among people aged 15–44, with a suicide rate of 11.5 per 100,000 people in 2009, though deaths represent only a small proportion of suicide attempts [2]. In the United States, suicide accounted for 20 % of all deaths among 15–24-year olds in 2010 [3]. The suicide rate was highest for females aged 45–54 (9 per 100,000 people in 2010) and for males aged 75 and older (36 per 100,000) [3].

Foreign-born immigrants represented 21 % of the Canadian population in 2011 [4], 13 % of the American population in 2010 [5], and 10 % of the European popu- lation in 2009 [6]. Immigrant and ethno-cultural minori- ties face particular risks and challenges associated with suicide behaviours, including suicidal thoughts, plans, and attempts, including challenges associated with immigration and adjustment processes [7, 8]. Social and psychological stressors associated with immigration and adaptation are linked to depression and other mental health challenges [9–11]. These include pre-migration trauma, loss of fam- ily and kin networks, isolation and loneliness, low social support, language and employment difficulties, financial strain, and discrimination [9, 12–15]. Challenges fac- ing immigrants and ethno-cultural minorities, including depression and anxiety, disruption of family and social ties, socio-economic disadvantage, unemployment, and stress- ful life events and loss [16–20] are risk factors for suicidal thoughts and attempts.

These factors present challenges for immigrants to Can- ada. For example, according to the 2011 National Household Survey (NHS), only 29 % of immigrants identified English or French as their mother tongue, and only 56 % reported some form of employment income [21]. Research has also revealed low sense of national, provincial, and community belonging among immigrants, with differences across gen- erations [22].

Abstract This paper reviews recent literature on factors influencing suicide behaviours, including thoughts, plans, and attempts, in immigrant and ethno-cultural minority groups, to inform a more comprehensive understanding of suicide behaviours in increasingly culturally diverse popu- lations. Thirty-three studies published between 2002 and 2013 were identified through digital databases searches and included in this review. Analysis of study findings focused on impacts of ethno-cultural identity and acculturation, other cultural and immigration influences, and family and com- munity supports on suicide behaviours. Policy, practice, and research recommendations are identified, to inform relevant suicide prevention efforts and enhance mental health sup- ports for immigrant and ethno-cultural minority populations.

Keywords Suicide · Immigrant · Ethno-cultural · Minority

Introduction

Suicide represents a significant global public health and social concern. The worldwide suicide rate was as high as 16 per 100,000 people in 2000 [1]. In Canada, suicide

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J Immigrant Minority Health (2017) 19:755–768

DOI 10.1007/s10903-016-0490-3

Published online: 17 September 2016

wellbeing of individuals, their families, and broader immi- grant communities. Immigrants in Canada face a range of psychological, social, and economic challenges that have been associated with suicide risk, and while some have been generally acknowledged in national and provincial sui- cide prevention resources, the importance of targeting sup- port to immigrant communities is rarely acknowledged or explored. This illustrates the importance of critically explor- ing the significance of factors influencing suicide behav- iours among immigrant populations, in order to encourage the consideration of these issues in national and provincial suicide responses.

The objective of this paper is to review recent literature on suicide in immigrant and ethno-cultural minority groups in their host countries in order to develop a more compre- hensive understanding of suicide issues among increas- ingly diverse populations, focusing on the determinants or influences of suicide behaviour that have been identified as significant for immigrants and ethno-cultural minorities. This review examined studies focusing on a range of coun- tries, including Western countries with similar immigration trends such as the United States and the United Kingdom, and the emerging findings can be of use in informing policy, practice, and research approaches in the Canadian context.

Mirsky et al. [51] explain that studies should differen- tiate between universal and group- or context-specific fac- tors related to suicide behaviours, and many recent reviews focus on single groups or areas, such as Han et al.’s [52] scoping review focusing on East Asians in North America. While this provides valuable research and practice knowl- edge, further study is required to better understand suicide challenges facing diverse ethno-cultural minority and immi- grant groups in different host countries, in order to better understand commonalities and differences in experiences across these different populations and regions.

Methods

Search and Screening Methods

Literature was identified through a search of digital data- bases, which began in November 2013. Peer-reviewed journal articles were identified in six databases: Abstracts in Social Gerontology, CINAHL Plus with Full Text, MED- LINE, Psychology and Behavioral Sciences Collection, Social Work Abstracts, and SocINDEX with Full Text. These databases were selected because they include content related to mental health and psychology, human behaviour, societal influences on wellbeing, and immigrant and ethno- cultural minority populations. Search limits included peer- reviewed, English-language publications between 2002 and 2013. Specific key words (suicide or suicidal or suicidality

These risks and challenges illustrate the need to better understand factors influencing suicide behaviours in immi- grant and ethno-cultural minority communities, in order to inform more responsive and effective prevention and intervention services. Some studies have reported higher suicide risk for certain immigrant and ethno-cultural minor- ity groups compared to other populations, including major- ity host country populations [23–26]. However, very little research has analyzed suicide rates in immigrant popula- tions in Canada. Existing studies report a generally low sui- cide rate (compared to native-born Canadians) of 7.9 per 100,000 [27], with rates increasing with age and differing across geographic location and generation [27–29]. Despite relatively “low” rates of suicide in immigrant populations, it is still a serious problem, with implications for the well- being of individuals, their families, and broader immigrant communities.

No national suicide prevention strategy has been developed in Canada [30], although statements on sui- cide prevention by national and provincial governmental and non-governmental bodies provide some guidance on response. While the need for greater, culturally sensitive sui- cide prevention support to immigrant communities has been emphasized by some provincial-level organisations [31], such references are missing from national governmental and non-governmental resources on suicide risk reduction and prevention, despite some references to risks associated with social exclusion (linked to ethnicity, for example), financial difficulty, family instability, and isolation and to cultural considerations in suicide prevention [32–34]. Members of immigrant communities are less likely than the general population to access mainstream mental health services [35, 36], such as suicide prevention services, due to a lack of cul- turally appropriate services, language difficulties, service costs and financial challenges, lack of information, limited service accessibility, and reliance on informal supports or medical services [9, 36–40].

Research on suicide in immigrant and minority groups, particularly in North America and Europe, has examined suicide risk factors among diverse populations, includ- ing mental health challenges, social marginalization, cul- tural beliefs, and multiple stressors [41–43]. Research has reported differences in suicide behaviours between different ethno-cultural minority groups [44–46], age groups [47], and gender groups [48–50]. Study results vary according to population and geographic area, reflecting the complexity of suicide behaviours in different ethno-cultural minority and immigrant groups.

Review Rationale and Objectives

Despite relatively “low” rates of suicide in immigrant popu- lations, it is still a serious problem, with implications for the

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(2) publication in English, (3) original study (e.g. not a review), (4) focus on immigrant or ethno-cultural minor- ity participants, and (5) socio-cultural analysis of suicidal behaviour. 56 articles were excluded, as they did not fulfill all inclusion criteria, and the remaining 33 were included in the review.

Study Concepts

Suicide behaviours include suicide ideation, or thoughts about suicide, making suicide plans or threats, and suicide attempts [53–57]. It is important to better understand fac- tors influencing this range of behaviours in order to more effectively prevent suicide thoughts, plans, and attempts, as suicide ideation and plans predict future suicide attempts [17, 58–60], and prior suicide attempts, particularly multi- ple attempts, predict later suicidal thoughts and/or attempts [61].

and immigrant or ethnicity or ethnic groups or ethnic com- munities or ethnic minority or ethnic minorities or culturally diverse population or culturally diverse groups or culture) were used to search the databases, although the structure of the query was tailored to specific database requirements.

As indicated in Fig. 1, a total of 898 journal abstracts were identified through the database searches and sub- jected to screening. Of these, 89 were identified as poten- tially relevant, based on a brief review of study titles and abstracts (studies focusing specifically on suicide risk or behaviours among immigrant or ethno-cultural minority populations). Citations were managed using a template form in Microsoft Excel. Summary data from each of the initial 89 articles were compiled, organized according to study characteristics, focus, results, and recommendations. These articles were screened to exclude those that did not meet inclusion criteria: (1) publication in a peer-reviewed journal between January 2002 and December 2013,

Records identified through database search

(n = 898)

Records screened (n = 898)

Records excluded (n = 809)

Articles assessed for eligibility (n = 89)

Articles excluded, with reasons

(n = 56)

Studies included in qualitative synthesis

(n = 33)

Fig. 1 Literature search review diagram

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fewer than 100 participants, 58 % involved 100–500 partici- pants, and 12 % involved 500 or more participants. Seventy percent of reviewed studies used convenience sampling, 15 % used purposive sampling, 12 % used random sam- pling, and 6 % used snowball sampling (some studies used more than one sampling approach), while sampling was not identified for one study. Reliance on convenience sampling may be due to the research population and sensitivity of the subject. Details on study samples, populations, methods, areas of focus, and key findings are presented in Table 1.

Data Analysis

The findings of the 33 studies retained for the review were examined in order to identify broad themes and patterns, as well as variations in the findings. In addition to examining study methodology and data collection strategies, sample age size, sampling strategy, and general area of focus, the findings of the studies were explored with respect to factors influencing suicide behaviours, prevention and intervention strategies, and emerging recommendations. First, the 33 full- text articles were reviewed in detail. In Step 2, key factors identified in the articles as influencing suicide behaviours, prevention, and intervention were then summarized and reviewed by the lead author. In Step 3, these specific influ- ences were grouped according to major themes (see Table 2 for the list of influencing factors and themes). Three major themes or categories emerged from this analysis: (1) ethno- cultural identity and acculturation, (2) other cultural and immigration influences, and (3) family and social support.

Results

Ethno-Cultural Identity and Acculturation

Ethno-cultural identity refers to identification with, and importance placed on, one’s cultural heritage and history [56, 57, 67, 68]. This includes adherence to cultural values, beliefs, norms, and practices and meaning attributed to ethno- cultural group membership, including pride, belonging, and affirmation [69–72], as well as participation in cultural activi- ties and traditions [57]. Study findings concerning the influ- ence of ethno-cultural identity on suicide behaviours among immigrants and ethno-cultural minorities were mixed. Quan- titative and qualitative studies of African American [67–69] and Latino [73] adults in the United States report that stronger ethno-cultural identity protected against suicide behaviours, including ideation and attempts, while weaker ethno-cultural identity represents a risk factor [67–69, 73]. Other studies, however, report that stronger ethno-cultural identity is posi- tively associated with suicide ideation, although not necessar- ily with plans or attempts. These include quantitative studies

Immigrants are defined as persons residing in a coun- try who were born outside of that country and who arrived through an immigration or refugee program. Ethno-cultural minorities are defined as persons, both immigrants or non- immigrants, of non-Caucasian in race or non-“white” in colour, including members of Chinese, South Asian, Black, Arab, West Asian, Filipino, Southeast Asian, Latin American, Japanese, and Korean populations (but excluding Aboriginal populations) [62]. Immigrant and ethno-cultural minority populations, including non-immigrant ethno-cultural minori- ties, were examined together due to the significant overlap between the two groups. While they are not homogenous, given different experiences and resources, immigrants and ethno-cultural minorities do face similar challenges in terms of integration, sense of belonging, and vulnerability [22], related to discrimination, health status, civic engagement, and employment [22, 63–66]. These are the factors being exam- ined in relation to suicide behaviours in the current review. In addition, most ethno-cultural minorities in Canada are immi- grants: according to the 2011 NHS, 65 % of all ethno-cultural minorities identified themselves as immigrants [4]. Many of the reviewed studies on ethno-cultural minority populations included both immigrants and non-immigrants, without dis- aggregating findings. It must be acknowledged that this rep- resents a limitation of the review. Despite shared experiences, generalizations can silence the diversity between groups.

Search Results

Thirty-three studies were included in the current review. Fifteen percent of these articles were published between 2002 and 2005, 45 % between 2006 and 2010, and 40 % between 2011 and 2013. Seventy percent of articles focused on the United States, 12 % on Canada, 15 % on European countries including the United Kingdom, France, the Neth- erlands, and Italy, and one on Israel. 33 % examined suicide attempts, 27 % examined suicidal thoughts or ideation, and 21 % referred to general suicide risk, suicidal behaviour, or “suicidality” (involving suicidal thoughts and attempts).

With respect to the methodological characteristics of the reviewed studies, 73 % of studies were quantitative studies, 24 % were qualitative studies, and one study used mixed methods. Twenty-seven percent of studies used a cross-sec- tional design, 12 % used an exploratory design, and a con- trol design and longitudinal design were each used in 6 % of studies, while the remaining studies did not specify their design. Fifty-five percent of the studies used survey-based data collection, 15 % used secondary data analysis, 27 % used in-depth interviews or focus groups, and no informa- tion was provided for two studies. Forty-five percent of studies involved adult samples, generally aged 18 and older, including 15 % with adults over age 60, and 45 % involved adolescents and youth. Thirty percent of studies involved

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J Immigrant Minority Health (2017) 19:755–768 759

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s A

cc ul

tu ra

tiv e

st re

ss a

nd

pe rc

ei ve

d di

sc ri

m in

at io

n

N o

si gn

ifi ca

nt g

ro up

d if

fe re

nc es

in a

tte m

pt s

(o ve

ra ll

ra te

: 8 %

) H

ig he

r a cc

ul tu

ra tiv

e st

re ss

fo r A

si an

s tu

- de

nt s,

m or

e di

sc ri

m in

at io

n fo

r A si

an a

nd

B la

ck s

tu de

nt s

A cc

ul tu

ra tiv

e st

re ss

a nd

d is

cr im

in at

io n

as so

ci at

ed w

ith s

ui ci

de a

tte m

pt s

13 . G

re en

fie ld

e t a

l. [5

5] Q

ua nt

ita tiv

e qu

es tio

nn ai

re Su

ic id

al N

or th

A fr

ic an

im

m ig

ra nt

a nd

N or

th

A m

er ic

an a

do le

sc en

ts

(a ge

1 2–

17 )

23 3

ad ol

es ce

nt s

C on

ve ni

en ce

s am

pl e

C an

ad a

Su ic

id e

ri sk

(i de

at io

n,

th re

at s

an d

at te

m pt

s) C

ri si

s as

se ss

m en

t a nd

d ru

g us

e

L ow

er d

ru g

us e

at ti

m e

of c

ri si

s am

on g

im m

ig ra

nt s,

w hi

ch m

ay c

on tr

ib ut

e to

lo

w er

s ui

ci de

ra te

14 . H

ir sc

h et

a l.

[2 5]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

C ro

ss -s

ec tio

na l

de si

gn w

ith c

om -

pa ri

so n

gr ou

p

B la

ck , W

hi te

, A si

an a

nd

H is

pa ni

c co

lle ge

s tu

- de

nt s

(m ea

n ag

e 19

.6 )

38 5

(6 9

% fe

m al

e) C

on ve

ni en

ce s

am pl

e U

ni te

d St

at es

Su ic

id e

id ea

tio n,

in te

nt a

nd

at te

m pt

s L

if e

st re

ss , p

ro bl

em s

ol vi

ng

an d

lo ne

lin es

s

L on

el in

es s

m od

er at

es a

ss oc

ia tio

n be

tw ee

n pr

ob le

m s

ol vi

ng a

nd s

ui ci

da l b

eh av

io ur

s fo

r a ll

gr ou

ps L

if e

st re

ss is

a m

od er

at or

fo r H

is pa

ni c

st ud

en ts

15 . H

ir sc

h et

a l.

[8 9]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

C ro

ss -s

ec tio

na l

de si

gn w

ith c

om -

pa ri

so n

gr ou

p

B la

ck , W

hi te

a nd

H is

- pa

ni c

co lle

ge s

tu de

nt s

(m ea

n ag

e 19

.6 )

37 2

(7 0

% fe

m al

e) R

an do

m s

am pl

e U

ni te

d St

at es

Su ic

id e

id ea

tio n,

th re

at s

an d

at te

m pt

s H

op e,

h op

el es

sn es

s an

d de

pr es

si on

L ow

h op

el es

sn es

s an

d ho

pe m

ed ia

te a

ss o-

ci at

io n

be tw

ee n

de pr

es si

on a

nd s

ui ci

da l

be ha

vi ou

r

16 . I

lic et

o et

a l.

[9 0]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

C ro

ss -s

ec tio

na l

de si

gn w

ith c

om -

pa ri

so n

gr ou

p

Im m

ig ra

nt s

an d

ot he

r It

al ia

ns (m

ea n

ag e

30 )

47 1

ad ul

ts C

on ve

ni en

ce s

am pl

e It

al y

Su ic

id e

ri sk

Ps yc

ho -p

at ho

lo gy

Sa m

e re

la tio

ns b

et w

ee n

su ic

id e

ri sk

a nd

ps

yc ho

pa th

ol og

y fo

r b ot

h gr

ou ps

17 . K

am ya

a nd

W hi

te

[7 7]

Q ua

lit at

iv e

fo cu

s gr

ou ps

E xp

lo ra

to ry

d es

ig n

So m

al i i

m m

ig ra

nt w

om en

an

d m

en (a

ge 1

8– 85

) 20

(7 0

% fe

m al

e) C

on ve

ni en

ce s

am pl

e U

ni te

d St

at es

C ul

tu ra

l u nd

er st

an di

ng o

f su

ic id

e D

if fe

re nt

w or

ds a

nd c

on ce

pt s

fo r d

ep re

s- si

on a

nd m

en ta

l i lln

es s

R el

ig io

n, fa

m ily

/c om

m un

ity s

ha m

e an

d st

ig m

a as

p ro

te ct

iv e

fa ct

or s

an d

(c ul

tu ra

l)

ob st

ac le

s to

d is

cu ss

in g

su ic

id e

an d

m en

ta l

he al

th 18

. K as

lo w

e t a

l. [6

9] Q

ua nt

ita tiv

e qu

es tio

nn ai

re A

fr ic

an A

m er

ic an

s ui

ci de

at

te m

pt er

s an

d no

n- at

te m

pt er

s (a

ge 1

8– 64

)

20 0

(5 0

% fe

m al

e) C

on ve

ni en

ce s

am pl

e U

ni te

d St

at es

Su ic

id e

at te

m pt

, i nt

en t a

nd

ri sk

M or

e di

st re

ss , a

gg re

ss io

n, s

ub st

an ce

us

e an

d m

al ad

ap tiv

e co

pi ng

a nd

lo w

er

re lig

io si

ty a

nd e

th ni

c id

en tit

y am

on g

at te

m pt

er s

Ta bl

e 1

(c on

tin ue

d)

1 3

J Immigrant Minority Health (2017) 19:755–768760

So ur

ce M

et ho

d Po

pu la

tio n

Sa m

pl e

C ou

nt ry

A re

a of

fo cu

s K

ey fi

nd in

gs

19 . K

en ne

dy e

t a l.

[5 6]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

C om

pa ri

so n

gr ou

p

C hi

ne se

a nd

In do

-A si

an

im m

ig ra

nt a

nd E

ur o-

pe an

u nd

er gr

ad ua

te

st ud

en ts

11 35

s tu

de nt

s C

on ve

ni en

ce s

am pl

e C

an ad

a Su

ic id

e id

ea tio

n, p

la ns

a nd

at

te m

pt s

A cc

ul tu

ra tio

n an

d ge

ne ra

tio n

Id ea

tio n,

p la

ns a

nd a

tte m

pt s

do n

ot v

ar y

by

et hn

ic g

ro up

, g en

er at

io n

or a

cc ul

tu ra

tio n

C ul

tu ra

l i de

nt ifi

ca tio

n as

so ci

at ed

w ith

s ui

- ci

da l t

ho ug

ht s

bu t n

ot p

la ns

/a tte

m pt

s 20

. K uh

lb er

g et

a l.

[8 4]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

C ro

ss -s

ec tio

na l

de si

gn

L at

in as

a do

le sc

en t

su ic

id e

at te

m pt

er s

an d

no n-

at te

m pt

er s

(a ge

11

–1 9)

22 6

gi rl

s, 2

00 p

ar en

ts Pu

rp os

iv e

an d

co nv

e- ni

en ce

s am

pl e

U ni

te d

St at

es Su

ic id

e at

te m

pt s

Fa m

ili sm

a nd

c on

fli ct

Se lf

e st

ee m

a nd

in te

rn al

- iz

in g

be ha

vi ou

rs

Fa m

ili sm

a ss

oc ia

te d

w ith

lo w

er p

ar en

t– ch

ild c

on fli

ct a

nd h

ig he

r i nt

er na

liz in

g be

ha vi

ou rs

Se lf

-e st

ee m

a nd

in te

rn al

iz in

g be

ha vi

ou rs

m

ed ia

te c

on fli

ct /s

ui ci

de re

la tio

ns hi

p 21

. M ir

an da

e t a

l. [6

1] Q

ua nt

ita tiv

e qu

es tio

nn ai

re L

on gi

tu di

na l d

es ig

n (4

–6 y

ea rs

)

W hi

te , A

fr ic

an A

m er

ic an

, H

is pa

ni c,

A si

an a

nd

ot he

r a do

le sc

en t s

ui ci

de

at te

m pt

er s

(a ge

1 2–

18 )

22 8

(6 3

% fe

m al

e) Sa

m pl

in g

no t

id en

tifi ed

U ni

te d

St at

es Su

ic id

e at

te m

pt s

an d

id ea

tio n

Ps yc

hi at

ri c

di ag

no se

s

M ul

tip le

a tte

m pt

s st

ro ng

ly p

re di

ct s

ui ci

da l-

ity a

nd d

ia gn

os es

G re

at er

m oo

d, a

nx ie

ty o

r s ub

st an

ce u

se d

is -

or de

rs fo

r m ul

tip le

th an

s in

gl e

at te

m pt

er s

22 . N

oh [8

1] Q

ua lit

at iv

e in

te rv

ie w

s A

si an

A m

er ic

an a

du lt

fe m

al e

su ic

id e

su rv

iv or

s 26

w om

en C

on ve

ni en

ce s

am pl

e U

ni te

d St

at es

Su ic

id e

th ou

gh ts

, a tte

m pt

s an

d su

rv iv

al Si

le nc

e ab

ou t t

ra um

a or

s el

f- de

st ru

ct iv

e re

pr es

en ta

tio n

of p

ai n

du e

to la

ck o

f la

ng ua

ge fo

r s ui

ci de

b ey

on d

vi ct

im ho

od

or re

co ve

ry 23

. O ’D

on ne

ll et

a l.

[2 6]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

B la

ck a

nd L

at in

o le

sb ia

ns , g

ay m

en a

nd

bi se

xu al

s (a

ge 1

8– 59

)

38 8

ad ul

ts C

on ve

ni en

ce a

nd

sn ow

ba ll

sa m

pl e

U ni

te d

St at

es Su

ic id

e at

te m

pt s

M en

ta l d

is or

de rs

a nd

s ub

- st

an ce

u se

H ig

he r s

ui ci

de a

tte m

pt ri

sk a

m on

g ra

ci al

/ et

hn ic

m in

or ity

re sp

on de

nt s

th an

W hi

te

re sp

on de

nt s

ev en

w ith

ou t d

ep re

ss io

n an

d su

bs ta

nc e

us e

24 . O

qu en

do e

t a l.

[7 3]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

C ro

ss -s

ec tio

na l

de si

gn w

ith c

om -

pa ri

so n

gr ou

p

L at

in o

an d

no n-

L at

in o

w om

en a

nd m

en w

ith

ps yc

hi at

ri c

di so

rd er

s (a

ge 1

8– 80

)

46 0

ad ul

ts C

on ve

ni en

ce s

am pl

e U

ni te

d St

at es

Su ic

id e

id ea

tio n,

a tte

m pt

s an

d in

te nt

Pr ot

ec tiv

e fa

ct or

s, re

as on

s fo

r l iv

in g

N o

si gn

ifi ca

nt g

ro up

d if

fe re

nc es

in a

tte m

pt s

an d

in te

nt L

es s

id ea

tio n

an d

le ss

le th

al a

tte m

pt s

an d

hi gh

er s

ur vi

va l/c

op in

g be

lie fs

, f am

ily

re sp

on si

bi lit

y an

d m

or al

s ui

ci de

o bj

ec -

tio ns

fo r L

at in

os 25

. O ut

la w

e t a

l. [4

2] Q

ua nt

ita tiv

e qu

es tio

nn ai

re M

ul ti-

si te

c oh

or t

de si

gn

R ac

ia l a

nd e

th ni

c m

in or

- ity

m en

w ith

H IV

w ho

ha

ve s

ex w

ith m

en (a

ge

13 –2

4)

34 2

m en

C on

ve ni

en ce

s am

pl e

U ni

te d

St at

es Su

ic id

e at

te m

pt s

R is

k be

ha vi

ou rs

a nd

e m

o- tio

na l d

is tr

es s

Se xu

al d

eb ut

b ef

or e

ag e

16 li

nk ed

to

ex ch

an ge

s ex

, d ru

g us

e, e

m ot

io na

l/p sy

- ch

ol og

ic al

p ro

bl em

s an

d su

ic id

e at

te m

pt s

26 . P

al m

er [7

8] Q

ua lit

at iv

e in

te rv

ie w

s E

th io

pi an

fo rc

ed m

ig ra

nt

w om

en a

nd m

en 10

(3 0

% fe

m al

e) Sn

ow ba

ll sa

m pl

e U

K Su

ic id

e ra

te s

R es

et tle

m en

t e xp

er ie

nc e

M en

ta l h

ea lth

a nd

tr ad

i- tio

na l h

ea lth

b el

ie fs

L ow

h el

p- se

ek in

g du

e to

c ul

tu ra

l n or

m s

an d

lo w

tr ea

tm en

t a cc

es s

R el

ig io

us a

ct iv

iti es

a s

co pi

ng m

ec ha

ni sm

s D

ir ec

t l in

k be

tw ee

n su

ic id

e an

d m

al ad

ju st

m en

t 27

. R on

[9 1]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

Im m

ig ra

nt a

nd v

et er

an

ol de

r a du

lts 76

8 ad

ul ts

C on

ve ni

en ce

s am

pl e

Is ra

el Su

ic id

al id

ea tio

n D

ep re

ss io

n an

d ho

pe le

ss ne

ss

N eg

at iv

el y

si gn

ifi ca

nt d

iff er

en ce

s in

ho

pe le

ss ne

ss , h

el pl

es sn

es s

an d

de pr

es si

on

am on

g im

m ig

ra nt

s co

m pa

re d

to v

et er

an s

28 . S

tr ee

t e t a

l. [7

0] Q

ua nt

ita tiv

e qu

es tio

nn ai

re A

fr ic

an A

m er

ic an

fe m

al e

su ic

id e

at te

m pt

er s

(a ge

18

–6 4)

82 w

om en

C on

ve ni

en ce

s am

pl e

U ni

te d

St at

es Su

ic id

e at

te m

pt s

an d

re a-

so ns

fo r l

iv in

g R

ac ia

l i de

nt ity

H ig

he r p

ri va

te re

ga rd

a ss

oc ia

te d

w ith

m or

e re

as on

s fo

r l iv

in g

R ac

ia l i

de nt

ity n

ot c

or re

la te

d w

ith re

as on

s fo

r l iv

in g

Ta bl

e 1

(c on

tin ue

d)

1 3

J Immigrant Minority Health (2017) 19:755–768 761

So ur

ce M

et ho

d Po

pu la

tio n

Sa m

pl e

C ou

nt ry

A re

a of

fo cu

s K

ey fi

nd in

gs

29 . v

an B

er ge

n et

a l.

[7 6]

Q ua

lit at

iv e

in te

rv ie

w s

So ut

h- A

si an

, T ur

ki sh

a nd

M

or oc

ca n

im m

ig ra

nt

an d

D ut

ch w

om en

(a ge

18

–4 0)

47 w

om en

C on

ve ni

en ce

s am

pl e

N et

he r-

la nd

s Su

ic id

al b

eh av

io ur

Su ic

id al

b eh

av io

ur in

flu en

ce d

by a

bi lit

y to

ac

t a ut

on om

ou sl

y fo

r s tr

at eg

ic li

fe c

ho ic

es

an d

qu es

tio ni

ng c

ul tu

ra l v

al ue

s of

s el

f- sa

cr ifi

ce a

nd p

ro te

ct io

n of

h on

ou r

30 . v

an L

ee uw

en e

t a l.

[7 1]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

Im m

ig ra

nt h

ig h

sc ho

ol

st ud

en ts

(a ge

1 5–

21 )

29 2

(4 1.

8 %

fe m

al e)

C on

ve ni

en ce

s am

pl e

Fr an

ce Su

ic id

al id

ea tio

n A

cc ul

tu ra

tio n

St re

ss fu

l l if

e ev

en ts

, d ep

re ss

io n

an d

in di

- vi

du al

is m

a re

ri sk

fa ct

or s

an d

pa re

nt al

at

ta ch

m en

t i s

a pr

ot ec

tiv e

fa ct

or fo

r b oy

s an

d gi

rl s

A ss

im ila

tio n

an d

m ar

gi na

liz at

io n

ar e

pr o-

te ct

iv e

fa ct

or s

fo r g

ir ls

o nl

y 31

. W al

ke r e

t a l.

[6 8]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

C ro

ss -s

ec tio

na l

de si

gn w

ith c

om -

pa ri

so n

gr ou

p

A fr

ic an

A m

er ic

an a

nd

E ur

op ea

n A

m er

ic an

co

lle ge

s tu

de nt

s (m

ea n

ag e

20 .9

)

45 2

(6 5

% fe

m al

e) C

on ve

ni en

ce s

am pl

e U

ni te

d St

at es

Su ic

id e

id ea

tio n

an d

de pr

es si

on A

cc ul

tu ra

tiv e

st re

ss a

nd

et hn

ic id

en tit

y

A cc

ul tu

ra tiv

e st

re ss

a nd

e th

ni c

id en

tit y

m od

er at

e lin

k be

tw ee

n de

pr es

si on

a nd

su

ic id

e id

ea tio

n fo

r A fr

ic an

A m

er ic

an b

ut

no t E

ur op

ea n

A m

er ic

an s

tu de

nt s

32 . W

in te

rr ow

d et

a l.

[5 7]

Q ua

nt ita

tiv e

qu es

tio nn

ai re

Y ok

ed c

on tr

ol d

es ig

n

M ex

ic an

–A m

er ic

an a

do -

le sc

en t g

ir ls

a nd

b oy

s (a

ge 1

4– 19

)

33 8

(5 5

% fe

m al

e) R

an do

m s

am pl

e U

ni te

d St

at es

Su ic

id e

id ea

tio n

an d

be ha

vi ou

rs Fr

ie nd

sh ip

q ua

lit y

an d

co nn

ec tio

n

Fr ie

nd sh

ip d

is co

nn ec

te dn

es s

in cr

ea se

s gi

rl s’

su

ic id

al id

ea tio

n Fr

ie nd

sh ip

p ro

bl em

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J Immigrant Minority Health (2017) 19:755–768762

stress, can increase risk of suicide behaviours, including thoughts and attempts [24, 53, 68, 74]. Qualitative studies involving diverse immigrant adults in the US [75] and Neth- erlands [76] report similar findings. However, one quantita- tive study of African American young adults [74] found that greater acculturation was associated with suicidal ideation. Gender differences can affect the impacts of ethno-cultural identity and acculturation on suicide behaviours, with quan- titative studies of Mexican–American [57] and French immigrant [71] adolescents reporting effects for girls but not boys.

Other Cultural and Immigration Influences

In addition to ethno-cultural identity and acculturation, other cultural or immigration factors influence suicide behaviours.

Cultural Beliefs and Norms

Specific cultural and religious norms and beliefs can influ- ence suicide behaviours, as both risk and protective factors.

of Mexican–American [57] and Canadian immigrant [56] adolescents and undergraduate students. Some of the stud- ies reviewed did not clearly distinguish between ethnic and national identity. This must be noted as a limitation: despite shared experiences, generalizations about ethnic and national identities can silence the diversity between groups.

Acculturation and Acculturative Stress

Processes of acculturation, involving adaptation to the dominant cultural values, beliefs, and practices of one’s country of residence, can shape ethno-cultural identity for members of immigrant and ethno-cultural minority groups. Acculturation can be affected by factors such as length of time since immigration or age at immigration. Acculturative stress or anxiety related to cultural adjustment and adapta- tion, linked to reduced family and community connections, language barriers, and discrimination, can also influence suicide behaviours [24, 53, 68].

Quantitative studies of African American, Latino, and Asian adults [68, 74] and immigrant adolescents [53] in the US report that lower acculturation, as well as acculturative

Step 1: Review of 33 full- text articles

Step 2: Identification of key factors influencing suicide behaviours, prevention, and intervention

Step 3: Group- ing of influenc- ing factors into major themes or categories

Adaptation and acculturation 1. Ethno-cultural identity and acculturation

Acculturative stress Ethnic, cultural, or racial identity or identification Cultural values, beliefs, and practices (general) Cultural beliefs or norms (related to suicide and mental

health) 2. Other cultural

and immigra- tion influencesSuicide acceptability

Stigma and shame Understandings of suicide/mental health

Religious beliefs or affiliation Immigration and settlement challenges Threat of deportation Employment Health challenges Service access or barriers

Perceived discrimination and racism Family and parental relationships 3. Family and

social supportFamily/parental support/attachments Family or parent–child conflict

Connections to peers or friends Social or community support Social/community participation Sense of community

Religious participation Social isolation

Table 2 Data analysis process

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J Immigrant Minority Health (2017) 19:755–768 763

represent risk factors. The influence of family relationships on suicide behaviours among immigrants and ethno-cultural minorities may be linked to the critical role of family and social support in adjustment, mental health, help-seeking, and wellbeing, which is described in additional research on immigrant and ethno-cultural minority groups [82, 85–87].

Community Relationships and Support

Qualitative research on African American adults [67] and diverse immigrant adults in Europe [76, 78] suggests that broader community connections and support, including from religious communities, can protect against suicide behaviours, while isolation and lack of connection and sup- port can contribute to suicide risk. Peer group connections and friendships may be particularly important in protecting against suicide behaviours such as ideation among young people, as reported in quantitative research on ethno-cul- tural minority adolescents [57].

Discussion

This review of recent literature contributes to ongoing pol- icy, practice, and research discussions on suicide risk and response for diverse populations. The significant impacts of ethno-cultural identity and acculturation, other cultural and immigration influences, and family and social support on suicide behaviours in immigrant and ethno-cultural minor- ity populations reflects the importance of addressing these issues as part of prevention and intervention efforts.

Policy and Practice Implications

In order to provide effective suicide prevention supports to immigrant and ethno-cultural minority communities, exist- ing studies emphasize the importance of providing culturally sensitive, competent, and appropriate services considering cultural norms and beliefs and addressing specific ethno- cultural risk and protective factors [24, 68–70, 77, 78, 83], as well as addressing service gaps enhancing service pro- viders’ cultural understanding through awareness-raising and training [54, 71, 77, 78]. Family, community, and peer- group relationships, which may be heavily disrupted by immigration and adjustment processes, are important factors influencing suicide behaviour for young people and adults. Recommendations for support and intervention services for immigrants and ethno-cultural minorities include support- ing family interactions and relationships (through family counselling, for example) [53, 76, 83, 84] and community level interventions [71, 75, 80], including engagement with religious communities [69, 78, 88] as well as support for social and civic engagement (e.g. volunteering).

For example, qualitative research on immigrant adults in the US [75, 77] and the UK [78] describes the negative impacts of cultural views of mental health, including silence, stigma, and shame linked to mental illness and depression, on sui- cide behaviours as well as help-seeking. Qualitative studies of immigrant women in the UK [79] and Netherlands [76] report that cultural values and beliefs about the protection of honour and family control over decisions (e.g. marriage, movement) contribute to suicide behaviours, including thoughts and attempts. At the same time, research on Latino adults in the US [73] found that cultural beliefs about fam- ily can serve as protective factors against suicide thoughts and attempts. Religious or spiritual beliefs and traditions, including beliefs about suicide also influence suicide risk. Quantitative research on African American and Latino adults in the US [68, 73, 80] reports that religious beliefs about suicide (acceptability and objections) are related to lower suicide ideation and attempts.

Immigration and Settlement Influences

Structural challenges linked to immigration and adjustment including settlement barriers and discrimination affect sui- cide behaviours. Qualitative studies of diverse immigrant adults in the US [75, 81], UK [78], and Canada [82] report that language, employment, and service barriers (e.g. lack of knowledge and mistrust of mainstream services, lack of appropriate services) and fears about immigration sta- tus contribute to suicide behaviours, including attempts, as well as limiting help seeking. Wider systems of discrimina- tion also impact suicide behaviours, including attempts, as reported by quantitative research on Asian, Black, Latino, and non-US-born White adults in the US [24, 90, 91].

Family and Social Support

Family and community relationships affect suicide behav- iours, and their influence may be particularly significant for immigrant groups, who experience changes in family and social networks as part of immigration processes, as well as for certain ethno-cultural minority groups, due to the cul- tural importance of family and community relationships.

Family Relationships and Support

The influence of family dynamics on suicide behaviours, including ideation and attempts, may be particularly sig- nificant for young people. Quantitative studies of diverse immigrant and ethno-cultural minority adolescents and young adults in the US [53, 83, 84, 89] and Europe [71, 76] report that parental attachment and support protect against suicide behaviours, while higher parent–child conflict, lower engagement and affection, and relationship disruption

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ethno-cultural minority communities, enabling the identi- fication of areas for future research. Analysis of the meth- odological characteristics of the reviewed studies revealed gaps in the existing body of research, in terms of design and populations. For example, research could explore sui- cide experiences and influences for ethno-cultural minor- ity older adults, as only five reviewed studies involved adults over age 60. Seventy-three percent of reviewed studies used quantitative methods, illustrating the need for further qualitative research on suicide, exploring sub- jective lived experiences and influences related to suicide behaviours, such as cultural and immigration challenges. This would be useful in understanding the specific ways in which influencing factors contribute to suicidal thoughts and behaviours.

Only 6 % of reviewed studies used a longitudinal design, reflecting the need for further quantitative and qualitative research examining patterns of suicidal behaviours in diverse populations over time. This could, for example, explore the changing impacts of acculturation and integration experi- ences for members of immigrant populations. The reviewed studies paid significant attention to the impacts of cultural identity and beliefs on suicide behaviours, but less atten- tion to immigration- and integration-related challenges (e.g. language, employment and service access, family and social network dynamics) and structural factors (e.g. community characteristics, policies, social and structural discrimina- tion). Given the importance of these factors for the overall wellbeing of immigrant communities, this represents a sig- nificant research gap, which ought to be addressed in future studies.

Methodological and conceptual limitations should also be noted with respect to the current review. First, the studies reviewed varied significantly in terms of population, sample size, methodological design, and area of focus limiting com- parisons of findings. However, it was possible to identify some patterns in the findings, despite this variation, reflect- ing the contribution of this review. Second, this review focuses on suicide behaviours generally, which include suicide ideation, or thoughts about suicide, suicide plans or threats, and suicide attempts. Future research might focus specifically on these different dimensions (thoughts, plans, attempts), in order to contribute to a more detailed under- standing of the links between the influencing factors identi- fied in this review and specific suicide behaviours. Third, this review focuses on factors influencing suicide behav- iours in immigrant and ethno-cultural minority populations, and does not address related issues such as prevalence of suicide behaviours (e.g. attempts) in these populations. This represents an area for further research and review, although the influence of cultural or religious barriers (e.g. stigma or shame, understanding of suicide) on disclosure of suicide behaviours should be considered.

This review found that a number of factors, such as cultural or religious beliefs, acculturation, and family or community cohesion, serve both protective and risk roles with respect to suicide thoughts and behaviours. This creates challenges in assessing suicide risk for members of immigrant popula- tions, as specific factors may enhance either vulnerability or protection for different individuals and communities. While some national governmental and non-governmental suicide prevention resources refer to the protective role of family and cultural communities [43, 44], the dual risk and protec- tive roles of factors such as family, community, and religious connections are acknowledged by very few [41]. This is of significance in the context of Canada’s increasingly diverse immigrant population, where a “one size fits all” approach that focuses on strengthening cultural community and fam- ily connections or promoting mainstream cultural integration may not necessarily reduce suicide risk.

Broader structural challenges related to immigration and adjustment, including socio-economic and service barri- ers as well as experiences of discrimination, affect suicide behaviours among immigrants and ethno-cultural minori- ties. Policy efforts, at both organizational and government levels, should address structural factors associated with economic and service barriers and discrimination, which influence suicide behaviours among diverse populations. As illustrated by recommendations included in the reviewed studies, suicide prevention or intervention efforts often focus on individual thoughts or behaviours, with less atten- tion to systemic or structural factors such as immigration and integration challenges, community characteristics, policies, and social or structural discrimination. The review findings suggest that rather than viewing suicide behaviours as individual “problems”, they should be viewed within broader community and social contexts. Previous Canadian research has identified differences in immigrant suicide rates across geographic locations [27], reflecting the need to examine contextual or environmental factors affecting suicidal behaviours.

Review findings suggest that risk factors associated with suicide behaviours are not limited to a specific stage of immigration or integration. Psychological, social, cultural, and economic risk factors exert influences at different stages of individuals’ immigration, acculturation, and integration processes, as well as across generations. While governmen- tal and non-governmental suicide prevention strategies often focus on new immigrants, viewed as particularly vulnerable [31], efforts should explicitly consider the changing impacts of immigration challenges over time and across generations.

Limitations and Recommendations

A number of limitations and gaps were identified in exist- ing research on suicide behaviours in immigrant and

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