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. Author manuscript; available in PMC: 2021 Apr 1.
Published in final edited form as: Psychol Health Med. 2019 Nov 7;25(4):446–456. doi: 10.1080/13548506.2019.1687921

Experiences of Stigma and Suicidal Behaviors among Rural-to-urban Migrants: The Mechanistic Roles of Depression and Substance Use

Chengbo Zeng a,b,*, Xiaoming Li a,b, Xueying Yang a,b, Hongfei Du c,d, Danhua Lin e
PMCID: PMC7166174  NIHMSID: NIHMS1541778  PMID: 31697204

Abstract

Previous studies have documented the adverse effect of stigma on suicidal behaviors. Existing studies also indicated that depression and substance use were positively related to suicidal behaviors. However, data regarding the mechanism among these concepts are still limited. Therefore, this study aims to examine the relationship between experiences of stigma and suicidal behaviors as well as the mechanisms of how experiences of stigma affect suicidal behaviors through depression and substance use among migrant workers in China. A sample of 641 young rural-to-urban migrants was recruited through a venue-based sampling approach in Beijing, China. Participants were assessed on their sociodemographic characteristics, suicidal behaviors, experiences of stigma, depression, and substance use in their urban communities. The sum score of how often migrants had suicide ideation or suicidal attempt in the past six months was used as the indicators of suicidal behaviors. Path analysis was used to examine the relationship between experiences of stigma and suicidal behaviors as well as the mechanistic roles of depression and substance use. Among the participants, average score of suicidal behaviors in the last six months was 2.3 (±1.1). After adjusting for monthly income and health status, the final model showed an adequate goodness of fit. While the direct path from experiences of stigma to suicidal behaviors was not statistically significant (β=.01, p=.81), the indirect paths between these two concepts were statistically significant. Experiences of stigma were positively associated with both depression and substance use, which in turn were positively related to suicidal behaviors (Depression: Delta z=4.82, p<.01; Substance use: Delta z=9.02, p<.01). The chain effect from experiences of stigma, depression, substance use to suicidal behaviors was also statistically significant (Delta z=5.16, p<.01). To prevent and reduce suicidal behaviors among migrant workers, targeted interventions focusing on reducing experiences of stigma and improving mental and behavioral health are needed.

Keywords: Suicidal behaviors, Stigma, Depression, Substance use, Migrants, China

Introduction

The relationship between experiences of stigma and suicidal behaviors (i.e., suicidal ideation and suicide attempt) has been documented in the literature from both western and Chinese contexts. Stigma is defined as a social undesirable attribute or mark which is used to separate a group of individuals from the mainstream population (Goffman, 1963; Stafford & Scott, 1986). In Canada, HIV positive gay and bisexual men who experienced HIV related stigma (e.g., social exclusion, sexual rejection, verbal abuse, and physical abuse) were more likely to reported suicidal ideation and attempts (Ferlatte, Salway, Oliffe, & Trussler, 2017). In China, people living with HIV (PLWH) who had high levels of perceived and internalized stigma reported high risks of suicidal behaviors (Zeng et al., 2018). While most of existing studies were conducted among PLWH, data regarding the mechanisms of how experiences of stigma affect suicidal behaviors are still limited among other populations at risk of suicide, such as rural-to-urban migrant workers (Kuang & Liu, 2012).

China has witnessed a large number of internal migration from rural areas to urban centers, and these rural-to-urban migrants reported high risks of suicide (Dai et al., 2015; Zhang, 2001). For instance, compared to non-migratory rural residents, rural-to-urban migrants were more likely to have suicidal behaviors (Dai et al., 2015). Migrating to urban areas without urban household registration for better lives and economic opportunities, migrants experienced a variety of stressors that stemmed from poor employment and living conditions, social inequity, and discrimination (Chen et al., 2012; Li, Stanton, Fang, & Lin, 2006; Lin et al., 2011; Wong, Li, & Song, 2007; Yang et al., 2012). These stressors may increase the prevalence of mental health problems and suicide among rural-to-urban migrants.

Among the aforementioned factors, experiences of stigma is closely associated with suicidal behaviors among migrant workers. Leaving their hometowns and working in the urban centers, rural-to-urban migrants are often characterized as low-educated, incapable, and ill-mannered (Chen et al., 2011; Roberts, 2001). These characteristics may increase the stigma against rural-to-urban migrants. In addition, the dual household registration system (urban vs. rural) causes inequalities in social status between rural and urban residents (Kuang & Liu, 2012). This divide of socioeconomic status may further exacerbate the stigma against rural-to-urban migrants. Experiences of stigma, as a chronic stress, may increase the risk of suicidal behaviors through mental and behavioral health problems.

Experiences of stigma may affect suicidal behaviors through depression. Stigma plays a critical and direct role on depression (Hong et al., 2010; Lee, Kochman, & Sikkema, 2002). For instance, a cross-sectional study among female sex workers (FSWs) in Guangxi, China reported that perceived stigma was significantly associated with FSWs’ depression (Hong et al., 2010). One of the most detrimental consequences of depression is the increased likelihood of committing suicide. Using structural equation modeling, Zeng et al (2018) found that perceived and internalized stigma was positively associated with depression, which in turn was positively associated suicidal behaviors among PLWH. Depression could partially explain the relationship between perceived and internalized stigma and suicidal behaviors.

Experiences of stigma may also affect suicidal behaviors through substance use. Suffering from a variety of migration-related stress (e.g., stigma, acculturation stress, poor living and working conditions) when working and living in urban centers, rural-to-urban migrants are more likely to use substances to seek pleasure or cope with stressors than non-migrants (Canfield, Worrell, & Gilvarry, 2017; Chen, Stanton, Li, Fang, & Lin, 2008; Cooper, Weller, Fox, & Cooper, 2005). Previous studies have indicated that substance use was positively associated with depression and suicide (Goodman & Huang, 2002; Schneider, 2009). For instance, adolescents of low socioeconomic status were more likely to report elevated depressive symptoms, which in turn was positively associated with cigarette and cocaine use behaviors (Goodman & Huang, 2002). Existing study also found that between 19% and 63% of all suicides suffered from substance use (Schneider, 2009). However, few studies investigated whether depression and substance use exacerbated the relationship between experience of stigma and suicidal behaviors among rural-to-urban migrants.

To address the knowledge gaps, the current study aims to examine the relationship between experiences of stigma and suicidal behaviors as well as the mechanism of how experiences of stigma affect suicidal behaviors among migrant workers. We hypothesized that: a) experiences of stigma was positively associated with suicidal behaviors; b) both depression and substance use could mediate the relationship between experiences of stigma and suicidal behaviors; and c) the chain effect from experiences of stigma, depression, substance use to suicidal behaviors was statistically significant. The hypothesized model is shown in Figure 1.

Figure 1.

Figure 1.

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Hypothesized Model

Method

Data source and study sample

Data in the current study were derived from the baseline survey of a theory-based HIV behavioral intervention study implemented in Beijing, China from 2011 to 2012 (Li et al., 2014). The intervention study aimed at increasing condom use and reducing HIV risk among young rural-to-urban migrants.

The sampling and recruitment procedures were described in details elsewhere (Li et al., 2014). Briefly, the venue-based sampling approach was employed, and young rural-to-urban migrants were recruited from their workplaces (e.g., shops, offices, factories), migrant settlements, streets, and job markets. The inclusion criteria were migrants: a) ≤30 years of age; b) without a permanent Beijing household registration; c) having been in Beijing for at least 3 months; d) being unmarried or if married, not living with their spouses in Beijing; and e) sexually active (e.g., had one or more sexual partners in Beijing). Exclusion criteria included unwillingness to provide informed written consent or unwillingness to be randomized to either of the experimental conditions. Initially, 660 rural-to-urban migrants were recruited but 19 of them were excluded from the program evaluation because they self-reported an age >30 years on the survey, although they were identified as ≤30 during the initial screening (Li et al., 2014), resulting in a sample of 641 young migrants in the study.

The questionnaire was administered one-on-one or to small groups in private settings in the community. Interviewers began with a description of the purpose of the assessment and assurance of confidentiality and followed by a brief instruction on how to provide the answers on the questionnaire. The interviewers provided assistance during the survey when needed. Upon completion, all participants received a small gift equivalent to 2 U.S. dollars as a token of appreciation for their participation. The current study protocol was approved by the Institutional Review Boards at both Wayne State University in the United States and Beijing Normal University in China.

Measures

Socio-demographic characteristics

Participants provided information on socio-demographic characteristics including age, gender, ethnicity (Han or non-Han), marital status (unmarried, unmarried but living together, married, and divorced/widowed/separated), years of being migrant workers in Beijing, years of education, monthly income in Chinese currency Yuan (CNY), frequency of home visit (at least once every six month, once a year, once every two years, once every three or more years, and never), and health status (very good, good, fair, poor, and very poor).

Suicidal behaviors

Participants were asked how often they had ever seriously considered committing suicide (suicidal ideation) and/or how often they had ever attempted suicide (suicide attempt) in the past six months (1=never, 2=occasional, 3=at least once every month, 4=at least once every week, 5=almost every day). The sum of responses to these 2 items was used as a composite score, with a higher score indicating more frequent suicidal behaviors in the past six months.

Depression

Depression was measured using the Chinese version of the Center for Epidemiological Studies Depression Scale (CES-D). The CES-D is a 20-item scale that measures various depressive symptoms (e.g., “bothered by things that don’t usually bother me”, “did not feel like eating”). Participants were asked the frequencies they experienced each of the symptom during the last week. Items were scored from 0 (rarely or none=less than one day) to 3 (most or all of the time=five to seven days). The total score ranged from 0 to 60 with a higher score indicating a greater level of depression. The CES-D scale has been widely used with adequate validity and reliability in the Chinese populations (Zhang & Norvilitis, 2002). The Cronbach alpha of the scale for the current study sample was .90.

Substance use

Substance use was assessed with an 8-item scale on the use of eight types of substance including tobacco, alcohol, ecstasy, ketamine, methamphetamine, other types of drug (e.g., heroin), drug injection, and needle sharing during drug injection. Participants reported how often they have used each type of the substances in the past six months (1=never, 2=occasional, 3=at least once every month, 4=at least once every week, 5=almost every day). The total score of these 8 items was used as a composite score, with a higher score indicating more substance use in the past six months.

Experiences of stigma

Experiences of stigma were assessed with a 20-item scale which has been validated among Chinese migrants (Lin et al., 2011). This scale measures discriminatory acts or unfair treatment experienced or perceived by participants during work and life. The sample item included “When I look for a job, I do not have the same opportunity as others” and “If something got lost, people will first suspect me”. Items were scored from 1 (never happened) to 4 (frequently happened). The total score ranged from 20 to 80 with a higher score indicating a greater level of stigma. Internal consistency estimate (Cronbach alpha) for this scale was .94.

Statistical analysis

First, descriptive statistics were reported on sociodemographic characteristics (e.g., age, gender), suicidal behaviors, depression, substance use, and experiences of stigma. Mean and standard deviation (SD) were used to describe continuous variables (e.g., age, years of being migrant workers in Beijing), and frequencies and percentages were used to describe categorical variables (e.g., gender, health status). In the current study, missing values were handled using multiple imputations for all variables except the dependent variable (i.e., suicidal behaviors).

Second, bivariate analyses were performed to examine the relationships of suicidal behaviors with sociodemographic characteristics. Spearman correlation analyses were used to examine the relationships between continuous variables and suicidal behaviors, Wilcoxon rank-sum tests for the relationships between categorical variables and suicidal behaviors. Spearman correlation analyses were performed to examine the associations among experiences of stigma, depression, substance use, and suicidal behaviors.

Third, after adjusting for covariates with p-values less than .10 in bivariate analyses, path analysis was used to examine the hypothesized model. The mediating effects of depression and substance use on the relationship between experiences of stigma and suicidal behaviors were examined using Delta z method (Muthen & Muthen, 2017).

Multiple indices were used to evaluate goodness of fit of path model in the current study. These indices included χ2/df, Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR). χ2/df < 3, CFI>0.95, RMSEA≤0.06, and SRMR≤0.08 indicate a good model fit (Wang & Wang, 2012). All of the analyses were conducted using SAS software version 9.4 (SAS Institute, Inc., Cary, NC, US).

Results

Descriptive statistics

Among the 641 participants, table 1 shows participants’ sociodemographic characteristics. The average age of the participants was 24.1 (SD=3.3) years ranging from 17 to 30 years. More than half of the individuals were male (58.7%, 376/641) or unmarried (60.4%, 387/641). The average years of being migrant workers in Beijing and education were 3.6 (SD=2.5) and 10.1 (SD=2.5), respectively. About two-thirds (61.2%, 392/641) of the participants visited their hometown once a year. More than two-thirds (77.9%, 499/641) of the migrants reported being in good health status. The mean score of suicidal behaviors was 2.3 (SD=1.1) out of a possible maximum score of 10. The mean scores of depression, substance use, and experiences of stigma were 14.8 (SD=7.1) out of 60, 10.7 (SD=4.4) out of a possible maximum of 40, and 30.7 (SD=10.2) out of 80, respectively.

Table 1.

Descriptive statistics and bivariate analyses among young rural-to-urban migrants

Variables Total (%) Suicidal behaviors
 p value
Mean r
N (%) 641 (100.0) 2.3 (1.1) -
Age (Mean, SD) 24.1 (3.3) −.01 .72a
Gender (%) .14b
 Male 376 (58.7) 2.3 (1.2)
 Female 265 (41.3) 2.3 (1.0)
Ethnicity (%) .48b
 Han 615 (95.9) 2.3 (1.1)
 Non-Han 26 (4.1) 2.2 (.8)
Marital status (%) .35b
 Unmarried 387 (60.4) 2.2 (1.1)
 Unmarried but living together 47 (7.3) 2.1 (0.6)
 Married 205 (32.0) 2.4 (1.3)
 Divorced, widowed, or separated 2 (.3) 2.0 (.0)
Years of being migrant workers in Beijing (Mean, SD) 3.6 (2.5) −.01 .74a
Years of education (Mean, SD) 10.1 (2.5) .01 .89a
Mean monthly income in CNY (Mean, SD) 2423.5 (1185.8) .09 .02a
Frequency of home visit (%) .28b
 At least once every 6 mo. 159 (24.8) 2.2 (.9)
 Once a year 392 (61.2) 2.4 (1.3)
 Less than once a year 90 (14.0) 2.1 (.5)
Health status (%) .09b
 Very good 264 (41.2) 2.3 (1.2)
 Good 235 (36.7) 2.3 (1.2)
 Fair 123 (19.1) 2.1 (.8)
 Poor or very poor 19 (3.0) 2.2 (.9)
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Note:

a:

Spearman correlation analysis

b:

Wilcoxon rank-sum test.

Bivariate and correlation analyses

Table 1 also shows the bivariate analyses of suicidal behaviors. Monthly income was positively associated with suicidal behaviors (correlation coefficient=.09, p=.02). As shown in Table 2, suicidal behaviors were also significantly associated with experiences of stigma (correlation coefficient=.33, p<.01), depression (correlation coefficient=.36, p<.01), and substance use (correlation coefficient=.39, p<.01).

Table 2.

Correlation Matrix

1. 2. 3. 4.
1.Suicidal behaviors 1.00
2.Stigma .33*** 1.00
3.Depression .36*** .33*** 1.00
4.Substance use .39*** .34*** .18*** 1.00
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Note:

***:

p<.001

Path analysis

After adjusting for covariates (i.e., monthly income and health status) with p value less than .10 in the bivariate analyses, the final model showed a good model fit (χ2/df =2.98, CFI=.99, SRMR=.03, RMSEA=0.06). Path model analysis revealed that experiences of stigma were positively associated with depression (β=.28, p<.01) and substance use (β=.39, p<.01) but was not significantly related to suicidal behaviors (β=.01, p=.81). Both depression (β=.22, p<.01) and substance use (β=.77, p<.01) were positively associated with suicidal behaviors. Depression was also positively associated with substance use (β=.35, p<.01). Path coefficients are shown in Table 3.

Table 3.

Path Coefficients

Paths β Std.β 95% C.I. S.E. p-value
Stigma----»Depression .28 .41 .23~.33 .03 <.01
Stigma----»Substance use .39 .36 .31~.47 .04 <.01
Depression----»Substance use .35 .22 .23~.46 .06 <.01
Depression----»Suicidal behaviors .22 .14 .14~.30 .22 <.01
Substance use----»Suicidal behaviors .77 .75 .71~.82 .03 <.01
Stigma----»Suicidal behaviors .01 .01 −.05~.07 .03 .81
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Mediation analysis

Results of mediation analysis (Table 4) showed that the indirect paths from experiences of stigma to suicidal behaviors through depression and substance use were statistically significant. Experiences of stigma were positively associated with both depression and substance use, which in turn were positively related to suicidal behaviors (Depression: Delta z=4.82, p<.01; Substance use: Delta z=9.02, p<.01). The chain effect from experiences of stigma, depression, substance use to suicidal behaviors was also statistically significant (Delta z=5.16, p<.01). Figure 2 shows the final path model.

Table 4.

Mediation Analysis

Effects β Std.β 95% C.I. S.E. p-value
Total effect .44 .40 .36~.52 .04 <.01
Indirect effect .43 .39 .36~.50 .03 <.01
 Path1 .06 - .04~.09 .01 <.01
 Path2 .30 - .23~.36 .03 <.01
 Path3 .08 - .05~.10 .02 <.01
Direct effect .01 .01 −.05~.07 .03 .81
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Note:

***:

p<.001

Path1: Stigma----»Depression----»Suicidal behaviors

Path2: Stigma----»Substance use----»Suicidal behaviors

Path3: Stigma----»Depression----»Substance use----»Suicidal behaviors.

Figure 2. Final Path Model.

Figure 2.

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Note: Monthly income and health status were adjusted as covariates in the final model.

Discussion

This study aims to examine the association between experiences of stigma and suicidal behaviors as well as the mechanistic roles of depression and substance use among rural-to-urban migrants. Path model analysis revealed the significant indirect paths from experiences of stigma to suicidal behaviors and non-significant direct path between these two concepts. Experiences of stigma could affect suicidal behaviors through both depression and substance use. The current study also suggested a significant chain effect from experiences of stigma, depression, substance use, to suicidal behaviors. To the best of our knowledge, this is one of the first studies to examine the mechanism of how experiences of stigma affect suicidal behaviors among young rural-to-urban migrant workers.

Experiences of stigma was not directly associated with suicidal behaviors but could affect suicidal behaviors through depression. This finding was partially inconsistent with previous study, which found that perceived and internalized stigma was directly and indirectly associated with suicidal behaviors among PLWH (Zeng et al., 2018). The most likely reason for such an inconsistence may be the different types of stigma (e.g., HIV vs. migration) in these studies. While the stigma against HIV may lead directly to suicidal behaviors among PLWH, migrant workers may experience stigma that will lead to suicidal behaviors through depression.

Experiences of stigma could also result in suicidal behaviors through substance use. Moving to urban areas with limited job skills and social capital, rural-to-urban migrants are at risk for migration-related stress (i.e., stigma, acculturation stress, poor living and working conditions) (Chen et al., 2008; Conway, Vickers, Ward, & Rahe, 1981; Khlat, Sermet, & Le Pape, 2004). The lack of local household registration will also increase migrants’ stress, which may further lead to elevated levels of substance use as a maladaptive coping strategy (Chen et al., 2008; Conway et al., 1981; Elder et al., 2000). High levels of substance use or substance use disorders may put migrant workers at risk for suicide (Schneider, 2009). In addition, the significant chain effect from experiences of stigma, depression, substance use to suicidal behaviors among migrant workers indicated that stigma, as a chronic stress, could affect suicidal behaviors through mental and behavioral problems sequentially. Mental health problem (i.e., depression) played an important role in the relationship between experiences of stigma and behavioral problems (i.e., substance use, suicidal behaviors).

To prevent and reduce suicidal behaviors among rural-to-urban migrants, targeted interventions to reduce stigma and improve migrants’ mental health are needed. At societal level, structural efforts should be made to reduce stigma against rural-to-urban migrant workers. Migrant workers have made a significant contribution on China’s urban development and economic growth in the past decades, but these contributions are not fully recognized by society (Li et al., 2007; Wang, Li, Stanton, & Fang, 2010). Instead, this population is often stigmatized by the urban residents and restricted from better occupational opportunities because of the dual household registration systems (i.e., urban vs. rural) in China (Li et al., 2007). Therefore, future public education among urban residents to improve their recognition about the contribution that migrant workers have made towards the socioeconomic development in urban areas may help to reduce stigma against rural-to-urban migrants (Li et al., 2007). In addition, policy reform should be made to either demolish the “dual” household registration system in China or allow migrants to obtain the local household registration while in urban areas and receive the same benefits available to urban residents (Brune & Bossert, 2009; Wang et al., 2010). These structural efforts may reduce the stigma against migrants and their migration-related stress. At an individual level, resilience intervention approach could help rural-to-urban migrants cope with stigma, manage their stress, and improve their mental and behavioral health using adaptive strategies (Wang et al., 2010).

The current study has several limitations. First, the causal relationships cannot be warranted with the cross-sectional data. Second, all measures were self-reported and subject to self-reported bias (e.g., recall bias, social desirability bias). The levels of substance use and suicidal behaviors might be underestimated in the current study due to the sensitive nature of these questions. Finally, the participants were recruited from one urban district in Beijing and might not be representative of other migrant populations in China. Therefore, caution should be given when generalizing the results from this study to migrant populations elsewhere.

Despite these limitations, the current study found that experiences of stigma was positively associated with suicidal behaviors through depression and substance use. The findings in this study suggested the importance of structural interventions, such as household registration policy reform and public education, in reducing system or social level stigma against migrants. In addition, findings from path model analysis suggested that resilience intervention approach aiming to empower migrants and cultivate adaptive coping strategies might be helpful for improving the mental and behavioral health of migrants. All of the aforementioned efforts are needed in preventing and reducing suicidal behaviors among rural-to-urban migrant workers in China and resource-poor settings.

Acknowledgements

The authors wish to thank all participants who gave of their time for the current study, and the reviewers for their helpful comments.

Funding

This study was supported by the National Institute of Health (NIH) Research Grant R01NR10498 by the National Institute of Nursing Research and National Institute of Mental Health.

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