Suicide_EthnoCulturalGroups.pdf

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

http://crossmark.crossref.org/dialog/?doi=10.1007/s10903-016-0490-3&domain=pdf&date_stamp=2016-9-15

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 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 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 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
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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J Immigrant Minority Health (2017) 19:755–768756

(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 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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J Immigrant Minority Health (2017) 19:755–768 757

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 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

1 3

J Immigrant Minority Health (2017) 19:755–768758

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tiv

e
qu

es
tio

nn
ai

re
C

om
pa

ri
so

n
gr

ou
p

K
or

ea
n

im
m

ig
ra

nt
a

nd

A
m

er
ic

an
h

ig
h

sc
ho

ol

st
ud

en
ts

(m
ea

n
ag

e
16

.6
)

22
7

(5
6.

8
%

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
L

if
e

st
re

ss
, a

cc
ul

tu
ra

tio
n,

so

ci
al

s
up

po
rt

Fo
r i

m
m

ig
ra

nt
s

tu
de

nt
s,

d
is

tr
es

s,
p

sy
ch

o-
lo

gi
ca

l s
ym

pt
om

s
an

d
su

ic
id

al
id

ea
tio

n
as

so
ci

at
ed

w
ith

li
fe

s
tr

es
s,

la
ck

o
f p

ar
en

ta
l

su
pp

or
t a

nd
n

ot
li

vi
ng

w
ith

b
ot

h
pa

re
nt

s
9.

C
hu

ng
[7

5]
Q

ua
lit

at
iv

e
in

te
rv

ie
w

s
E

xp
lo

ra
to

ry
d

es
ig

n
C

hi
ne

se
im

m
ig

ra
nt

a
du

lt
su

ic
id

e
at

te
m

pt
er

s
31

(6
1.

3
%

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
s

Su
ic

id
e

at
te

m
pt

s
cu

lm
in

at
io

n
of

s
tr

es
so

rs
,

m
en

ta
l i

lln
es

s
an

d
lo

w
er

h
el

p-
se

ek
in

g,

co
m

po
un

de
d

by
im

m
ig

ra
tio

n
is

su
es

, c
ul

–
tu

ra
l m

ea
ni

ng
s

an
d

re
so

ur
ce

b
ar

ri
er

s
10

. D
on

ne
lly

e
t a

l.
[8

2]
Q

ua
lit

at
iv

e
in

te
rv

ie
w

s
D

es
cr

ip
tiv

e
ex

pl
or

–
at

or
y

de
si

gn

C
hi

ne
se

a
nd

S
ud

an
es

e
im

m
ig

ra
nt

w
om

en
w

ith

m
en

ta
l i

lln
es

s

10
w

om
en

Pu
rp

os
iv

e
sa

m
pl

e
C

an
ad

a
M

en
ta

l h
ea

lth
c

ar
e

ex
pe

ri
en

ce
s

C
op

in
g

Pe
rs

on
al

e
xp

er
ie

nc
e,

fe
ar

a
nd

la
ck

o
f

aw
ar

en
es

s
an

d
ap

pr
op

ri
at

e
se

rv
ic

es
li

m
it

he
lp

-s
ee

ki
ng

U
se

o
f i

nf
or

m
al

s
up

po
rt

s
an

d
se

lf
-c

ar
e

to

co
pe

w
ith

m
en

ta
l i

lln
es

se
s

Ta
bl

e
1

D
es

cr
ip

tio
n

of
re

vi
ew

ed
p

ub
lic

at
io

ns

1 3

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

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

11
. E

ls
e

et
a

l.
[5

4]
Q

ua
nt

ita
tiv

e
su

rv
ey

A
si

an
A

m
er

ic
an

a
nd

Pa

ci
fic

Is
la

nd
er

h
ig

h
sc

ho
ol

s
tu

de
nt

s

29
0

st
ud

en
ts

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
, p

la
ns

a
nd

at

te
m

pt
s

V
io

le
nc

e
(v

ic
tim

iz
at

io
n

an
d

pe
rp

et
ra

tio
n)

Fe
m

al
es

m
or

e
lik

el
y

th
an

m
al

es
to

c
on

si
de

r
an

d
at

te
m

pt
s

ui
ci

de
N

o
si

gn
ifi

ca
nt

d
if

fe
re

nc
es

in
s

ui
ci

de
in

di
ca

–
to

rs
b

y
et

hn
ic

g
ro

up
V

io
le

nc
e

as
so

ci
at

ed
w

ith
s

ui
ci

de
in

di
ca

to
rs

12
. G

om
ez

e
t a

l.
[2

4]
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
si

an
, L

at
in

o,
B

la
ck

an

d
W

hi
te

u
ni

ve
rs

ity

st
ud

en
ts

(a
ge

1
8–

25
)

96
9

(6
8

%
fe

m
al

e)
R

an
do

m
s

am
pl

e
U

ni
te

d
St

at
es

Su
ic

id
e

at
te

m
pt

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

…