A qualitative study of perceptions of risk and protective factors for suicide among Bhutanese refugees

Abstract

Over 100,000 ethnically Nepalese, “Lhotshampa,” people experienced systematic oppression, disenfranchisement, and violence during the latter part of the 20^th century. The Lhotshampa people were forced to flee their homes in southern Bhutan and enter refugee camps in Nepal for over 20 years. As of this writing, most Bhutanese refugees have been resettled in other countries (primarily the United States, Canada, and Australia). As the two remaining Nepalese refugee camps prepare to close, a growing suicide crisis is developing among many Bhutanese refugees. Bhutanese refugees resettled in the United States are dying by suicide at approximately twice the rate of the general U.S. population. It is crucial to examine, qualitatively, the nature of both risk and protective factors from the perspective of Bhutanese refugees, themselves. Our study included 15 Bhutanese refugees (8 men, 7 women) recruited from a community sample as part of a parent project examining culturally responsive suicide risk assessment. Mean age across both genders was 38.4 years (range of 22–55 years). Participants in our study were asked open-ended questions about suicide risk and prevention. We conducted a thematic analysis, synthesized risk and protective themes, and applied a socio-ecological framework to the data. We found risk themes included psychological distress and vulnerability, substance use, social and familial discord, interpersonal violence, isolation, and postmigration stressors. Protective themes included low levels of substance use, de-stigmatization of mental health concerns, strong social connections, reduced postmigration stressors, increased access to mental health care, and strong awareness within the host community of migration-related challenges.

Background

Bhutanese refugees resettled in the United States are dying by suicide at a rate (24.4/100,000; Ao et al., 2012) approximately twice that of the general U.S. population (14.2/100,000; National Center for Health Statistics, 2020). Beginning in the 1970’s ethnically Nepalese individuals (i.e., Lhotshampa) who had been living in southern Nepal since the late 19^th century began facing a series of restrictive and discriminatory government sponsored legislation and persecution. In 1990, the Hindu, Nepali-speaking citizens of Southern Bhutan were forced to leave the country and flee to refugee camps in Nepal, because of the Bhutanese government’s ethnic cleansing policies, which favored the Buddhist ethnic Bhutanese. Severe physical and psychological torture techniques, including imprisonment, beatings, and rape were used as a method of systematic forced eviction. Over 134,000 Bhutanese citizens, approximately 20% of Bhutan’s total population, fled to refugee camps in eastern Nepal. They lived in a series of camps in Southern Nepal for over two decades. In 2008, after failed negotiations to repatriate Bhutanese refugees, refugees began resettlement into third countries (Gulf Coast Jewish Family & Community Services: Refugee Services, 2015; Hutt, 2005; Worldwide Refugee Admissions Processing System, 2018). Since that resettlement, a major suicide epidemic has emerged within this population leading to a significant public health crisis. A small body of literature has examined suicide prevention research within this population (Adhikari et al., 2015; Ao et al., 2012; Benson et al., 2012; Brown et al., 2019; Ellis et al., 2015; Hagaman et al., 2016; Meyerhoff et al., 2018). The majority of these studies included epidemiological reports to characterize the crisis as well as quantitative studies that evaluated explanatory models of suicide risk within this population (e.g., Ellis et al., 2015; Meyerhoff & Rohan, 2020). In contrast, qualitative data on suicide in resettled Bhutanese refugees have been sparse. To the authors’ knowledge, only two studies examined qualitative data as a component of their analysis (Brown et al., 2019; Hagaman et al., 2016), and only one study systematically examined qualitative data about suicide among Bhutanese refugees in order to directly inform a model of suicide (Brown et al., 2019).

Brown and colleagues (2019) conducted a series of focus groups with Bhutanese refugees resettled on the east coast of the United States. Their work resulted in a qualitative report that applied a telescoping social-ecological model to Joiner’s (2005) Interpersonal Psychological Theory of Suicide (IPTS) within the resettled Bhutanese refugees (Ellis et al., 2015). Brown and colleagues (2019) went beyond individual-level risk factors to consider the myriad interlocking and overlapping societal, communal, and familial risk and protective factors informing suicide risk. They argued that extant models of suicide were forged largely out of western European concepts and may not be entirely appropriate for use within non-western European populations, including this one.

Specific cultural influences are critical to consider when modeling suicide in non-western populations in order to better understand these risk and protective factors, and to develop more culturally relevant suicide prevention interventions (e.g., Chu and colleagues’ Cultural Model of Suicide [Chu et al., 2010] and our prior work integrating Joiner’s IPTS and Chu’s Cultural Model of Suicide [Meyerhoff et al., 2018]). To fully achieve this aim, additional qualitative studies examining the nature of these risk and protective factors are necessary. Brown et al.’s (2019) work specifically explored the perceived themes, precipitants, and impacts of suicide-related deaths within the Bhutanese refugee community. They elucidated systemic and cultural factors and themes and placed them in an interlocking social-ecological model that revealed potential intervention targets as identified from the perspective of community members. Their work highlights the utility of applying culturally-informed explanatory models of suicide. Qualitative research, such as that conducted by Brown et al. (2019), facilitates a more complete understanding of the suicide epidemic within the Bhutanese refugee community from the perspectives of Bhutanese refugees, themselves.

Our qualitative exploration builds upon Brown et al. (2019) by exploring specific factors that contribute to the suicide crisis among Bhutanese refugees within the individual, familial, communal, and societal levels as perceived by community members themselves. In addition to presenting community member perspectives on risk factors contributing to suicide, our work extends that of Brown et al. (2019) by eliciting – from community members themselves – acceptable perceived pragmatic solutions to address the crisis. We conducted individual interviews with a sample of 15 Bhutanese refugees, asking them what factors they believe contribute to the suicide crisis among Bhutanese refugees and what changes they believe might help reduce the suicide-related deaths in their community. In this work, we synthesize these themes and make recommendations that will improve precision, relevance, and efficacy of preventive interventions within this population.

Methods

Design

This qualitative study was conducted as part of a project examining culturally responsive proximal risk factors for suicide among Bhutanese refugees resettled in the United States (Meyerhoff & Rohan, 2020). Our study presents a qualitative analysis of the risk and protective factors for suicidal behavior in this population, based on interviews with the participants. All study procedures were reviewed and approved by the University of Vermont’s Institutional Review Board.

Participants

In partnership with cultural consultants, refugee agencies, and service providers, the study team recruited a general community sample of Bhutanese refugees to participate in this study. Recruitment procedures included direct advertising, word of mouth, agency referrals, and snowball sampling techniques in which early participants were given flyers upon completion of the study procedures to distribute to other interested individuals. Referring agencies or community service providers introduced eligible participants to the study, and if potential participants expressed interest, providers referred them to the P.I. for follow-up. Referring agency staff was trained on inclusion/exclusion criteria and provided with a set recruitment script. Interested parties were scheduled for an in-person study visit as part of a larger 60-person project that explored culturally responsive suicide assessment among Bhutanese refugees (described in Meyerhoff & Rohan, 2020). These study visits lasted approximately two hours and consisted of structured interviews and questionnaires administered via an interpreter, in which the interviewer asked follow-up questions when necessary (these data are reported in Meyerhoff & Rohan, 2020). As part of the study procedures, 15 of the 60 participants in the larger project, provided qualitative data by responding to two open-ended semi-structured interview questions. Following study procedures, all participants received information about suicide prevention, strategies for identifying when individuals are at-risk, community mental health resources, and a brief overview of strategies for reducing acute distress. All participants were compensated for their participation with a $20 gift card for a local retailer.

Fifteen community-dwelling adult Bhutanese refugees responded to open-ended queries regarding their perspectives on (1) the factors that contributed to, and (2) possible preventative measures for the reduction of, suicide deaths among at-risk Bhutanese refugees. To be included in this study, participants were required to hold refugee status from Bhutan, be between the ages of 18 and 65, and have the ability to provide informed consent to all study procedures in either English or Nepali. Participants’ age and gender distribution reflected the reported age and gender distribution of the resettled Bhutanese refugee community in the greater Burlington, Vermont, area. Participants provided informed consent and completed in-depth individual in-person interviews (detailed in Meyerhoff & Rohan, 2020) as part of the parent project. Because most participants did not communicate using English, a trained Nepali-speaking interpreter was present at all interviews and interpreted participant responses. Participants all received some supportive services through local refugee organizations.

Procedures

We provide details about this study in accordance with the consolidated criteria for reporting qualitative research (COREQ) standards for reporting qualitative studies (Tong et al., 2007). The first author (JM)¹ conducted all study interviews at a community center that provides support services to resettled refugees, new Americans, and asylum seekers. To assess perceived contributing factors for suicide risk, participants were asked, “Why do you think suicide is such a large problem in the Bhutanese refugee community? Specifically, what factors do you believe contribute to death by suicide among some refugees from Bhutan?” To assess perceived factors that might be protective against suicidal behaviors within the Bhutanese refugee community, participants were asked, “What are possible suicide prevention measures that can be taken to reduce suicide deaths among Bhutanese refugees who might be at risk?” These prompts were translated into Nepali by a trained Nepali- and English-speaking interpreter present during each interview. The lead author then recorded detailed field notes and summaries of participants’ responses to open-ended questions. Though audio recordings and transcripts would have been a preferable data format, these were unavailable to the investigator during the course of the study. As a result, raw data from these responses are in the format of investigator field notes. Audio recordings and full transcripts should be used in future research with this population.

Data Analysis

Qualitative data were analyzed using a deductive Rapid Assessment Process (Beebe, 2014), an iterative team-based approach that allows researchers to more quickly understand community perspectives when conducting time-limited qualitative research. The Rapid Assessment Process used in this study involved the summaries of participant responses rather than the use of direct quotes or transcripts for analysis due to the raw data format (i.e., investigator field notes) and the unavailability of audio recordings or transcripts. Summary statements were coded into identified themes using iterative thematic analysis. Themes were first created deductively, drawing from prior research literature on risk and protective factors of suicide for forcibly displaced Asian populations, generally, and Bhutanese refugees, specifically (e.g., Adhikari et al., 2015; Benson et al., 2012; Brown et al., 2019; Ellis et al., 2015; Hagaman et al., 2016; Meyerhoff et al., 2018). Initial derived themes are presented in Table 1. We then applied an inductive approach to collaboratively revise themes and clarify theme definitions after initial reviews of the data. Each of three coders (JM, PI, LAM) independently completed all three cycles of coding. Following each round of coding, all three coders met to discuss and review discrepant codes, revise codes as necessary, or reach consensus on initially discrepant codes. Following the third and final round of coding, coders achieved good inter-rater reliability and reached consensus, Fleiss’ Kappa value = .75. At the time of this study, coders were PhD students in clinical psychology (JM and PI) and a Bhutanese clinical psychologist (LAM). All coders were familiar with the interview protocol and the Bhutanese refugee population. Analyses occurred at the statement level, and each statement from a participant was analyzed as a complete unit. For example, if a participant made a statement about language barriers followed by a separate sentence about substance use, these were treated as two separate statements and were coded separately. Multiple codes were applied to summary statements as needed. Exemplar summary statements were selected to illustrate each of the identified themes in this manuscript. All data was managed using Microsoft Excel and analyses were conducted using R v3.5+. Summary statements included in this report are italicized.

Table 1:

Initial derived themes used for first round of coding

	Theme
Risk Factors	Isolation/Thwarted Belongingness
	Social/Familial Discord
	Interpersonal Violence
	Perceived Burdensomeness
	Perspective on Political Conflict
	Religious/Cultural Beliefs
	Postmigration Stressors (linguistic, immigration status, etc.)
	Lack of Access to Services/Host Community Resources
	Psychological Distress/Vulnerabilities
	Stigma of Mental Health Issues
	Other
Protective Interventions	Community Cohesion/Social Connection
	Cultural Acceptance/Host Community Integration
	Reduction of Postmigration Stressors
	Cultural/Religious Practice or Beliefs
	Perceived Contributions to Community/Family
	Understanding/Acceptance of Psychological Factors (i.e., Psychological Mindedness)
	Other

Results

Participants

Our sample included 8 (53.3%) men and 7 (46.7%) women. Mean age across both genders was 38.4 years (range of 22–55 years). A majority of participants were married (86.7%; 13/15), one (6.7%) participant was single, and one (6.7%) was separated from their partner. Four (26.7%) participants never attended school, 4 (26.7%) completed primary school, 3 (20%) completed secondary school, 3 (20%) completed some university/post-secondary education, and one (6.7%) completed graduate school. Slightly fewer than half of participants (46.7%; 7/15) reported being able to read English. Participants spent a mean of 21.4 years (SD=4.2) in Nepalese refugee camps and arrived in the U.S. a mean of 4.8 (SD=2.6) years prior to the study (min.=1.4 years, max.=9.4 years). Just under half (46.7%; 7/15) of participants personally knew someone who died by suicide, and 4 (26.7%) participants knew someone who survived at least one suicide attempt.

Risk Themes

A number of important themes about risk were derived from in-person interview data and participant summary statements. Participants’ responses to the question, “Why do you think suicide is such a large problem in the Bhutanese refugee community? Specifically, what factors do you believe contribute to death by suicide among some refugees from Bhutan?” fell into eight themes. The most common risk factor endorsed by participants was “postmigration stressors,” which was reported by 10 participants. This was followed by “isolation/thwarted belongingness,” endorsed by six participants, and “social/familial discord,” endorsed by five participants. “Psychological distress and vulnerability” was reported by four participants. “Interpersonal violence,” “substance use problems,” and “perceived burdensomeness” were each noted by three participants. The “other” code was derived from the statements of six participants. Fleiss’ Kappa for each code is reported in Table 2.

Table 2:

Final consensus themes, frequencies, and interrater agreement.

	Theme	Frequency	Fleiss’ Kappa
Risk Factors	Isolation/Thwarted Belongingness	9	0.90
	Social/Familial Discord	9	0.85
	Interpersonal Violence	4	0.76
	Perceived Burdensomeness	3	0.59
	Postmigration Stressors	21	0.85
	Psychological Distress/Vulnerabilities	6	0.64
	Substance Use Problems	4	1.00
	Other	7	0.58
Protective Interventions	Community Cohesion/Social Connections	5	0.92
	Increased Community Awareness of Refugee-related Issues	1	1.00
	Increased Access to Mental Health Assessment and Treatment	8	0.86
	Reduction of Postmigration Stressors	3	0.84
	Low Substance Use	1	1.00
	De-stigmatization/Psychoeducation About Mental Health Issues	4	0.89
	Other	6	0.50
	Unknown	4	0.88

Note: Frequency = frequency of code applied among 3 raters in a single coding cycle

Individual-level factors.

Psychological Distress and Vulnerability

In our sample, several participants highlighted the role that psychological vulnerability and distress played in contributing to the suicide epidemic within the Bhutanese refugee community. P2 highlighted a social comparison effect, People who came here early have made good life. People who came more recently see these well-established people and think there must be something wrong with them.

Substance Use

Our sample highlighted that, within the Bhutanese refugee community, alcohol and other substances can serve as a risk multiplier. Specifically, several participants noted that substance use exacerbated existing problems that some resettled Bhutanese refugees faced. P1 stated, Drugs were a contributor of risk. P12 noted that, Consuming alcohol [contributes risk]. Importantly, P6 highlighted the role of alcohol as a multiplier of risk, Depression, for a variety of reasons [contributes risk]. Sometimes it becomes worse with alcohol use.

Family/Relational-level factors.

Social and Familial Discord

Participants in our sample reported familial conflict or disconnection as a contributor to suicide risk. Discord included major contentions within a family (e.g., no longer speaking or in contact with family members, divorce, or separation from partners or spouses). For example, (P1) suggested that, maybe there isn’t understanding between husband and wife. (P12), echoed this concern, Sometimes conflict between husband and wife. Meanwhile (P9) noted, Maybe because of family dispute. Other participants simply noted, Family relationships (P6), or Family conflict (P7).

Interpersonal Violence

Of the identified themes in participant responses, interpersonal violence was minimally reported, but believed to be a major contributor to suicide risk. We coded participant responses as interpersonal violence if they contained abuse, neglect, or acts of violence perpetrated by one person against another. Examples included: (P1) Women are being tortured by husbands who use more alcohol or drugs. Some participants cited traumatic experiences in the refugee camps, such as, (P3) Trauma in Bhutan-they sometimes came to peoples’ houses, raped women and girls and killed kids in front of their families. Among participants, these experiences were believed to be contributors to suicide risk. High levels of stigma are attached to being a survivor or victim of domestic and sexual abuse, and as a result, these issues may be under-reported contributors of suicide risk.

Community-level factors.

Isolation/Thwarted Belongingness

Isolation and thwarted belongingness emerged as key contributors to suicide risk among Bhutanese refugees according to community members participating in our study. Participants reported that feelings of isolation and disconnection from family members and community members also contributed risk, especially among resettled Bhutanese refugees who have a history of living in communities surrounded by others with a similar socio-cultural orientation. One participant (P1) noted, Because we don’t have our own Nepali community around us. If we have a Nepali housing community that would help. Another (P3) stated that, when in the U.S., people feel they lost their community, country, families, etc. Similarly, (P5) reported that, Separation from family may cause stress.

Societal-level factors.

Postmigration Stressors

Participants frequently noted stressors such as difficulties with language, employment, discrimination, transportation, financial stressors, and other logistics of navigating life in a host country. For example, one participant noted, (P7) Difficulties adapting to new changes. Another participant detailed the challenge of not being able to converse in the language of the host country, (P11) Not being able to speak in English. Relatedly, educational difficulties were mentioned by one participant, (P8) Uneducated. Financial and employment concerns were frequently endorsed by participants, (P9) Unable to work or earn income to pay rent, get good food, or buy good clothes; and (P4) People are unable to work at the level at which they are trained. You have engineers working as custodians and manufacturing. Participants also reported believing that limited and difficult to access resources were additional risk factors, (P15) People who are new to America die by suicide because lack of resources and lack of access to help.

Participants in our sample also noted a variety of acculturation stressors. For example, P11 reported, Not knowing about systems in U.S. or how things work in the U.S. Relatedly, the authors concluded that tensions and conflict between family members as a direct result of an acculturation gap (i.e., differences among family members in the speed with which they each adjust to a new culture or cultural identity) also merited a thematic code of postmigration stressor. This determination was made on the advisement of the author (LAM), a Bhutanese psychologist, with personal, lived experience.

Other

The “other” code was applied to statements that did not fall into any of the aforementioned 7 categories. Primarily, this designation was reserved for statements from participants noting that they did not know why some individuals died by suicide. For example, P10 who simply noted, I don’t know, and P13 who reported, I don’t know – I have seen people do it [attempt suicide] without any reason. Other participants reported specific reasons that did not fall into any clear category such as P14 who stated that they, Could not get good sleep.

Protective Factors

Participants responded to the question “What are possible suicide prevention measures that can be taken to reduce suicide deaths among Bhutanese refugees who might be at risk?” with statements that fell into nine themes (inclusive of an “I don’t know” theme). Six participants responded to the above prompt with a response that fell into the “increased access to mental health assessment and treatment” theme. This was followed by, “community cohesion/social connections,” which was reported by 4 participants. Three participants provided answers that fell into the “de-stigmatization of/psychoeducation about mental health issues” theme, and two participants made statements that fell into the “reduction of postmigration stressors” theme. One participant made a statement that was categorized as “increased community awareness of refugee-related issues,” and a separate participant responded with a statement that fell into the “low substance use” theme. Five participants’ answers fell into the “other” category. Four participants reported that they didn’t know and subsequently these responses fell into a separate “I don’t know” theme. Fleiss’ Kappa for each code is reported in Table 2.

Individual-level factors.

Low Substance Use

Low substance use was viewed as a protective factor for suicide risk. P12 reported that one protective factor for resettled Bhutanese refugees may be, Refraining from alcohol. This sentiment was echoed by others who noted that substance use as an especially significant multiplier of risk.

Family/Relational-level factors.

Importantly, none of the protective themes identified by Bhutanese refugee community members was best or exclusively captured by the familial/relational level of a social-ecological model.

Community-level factors.

De-stigmatization of Mental Health

Community members reported themes that suggest that de-stigmatizing mental health-related issues and disseminating psychoeducation throughout the community would be a productive prevention effort. P6 noted that talking with struggling refugee community members might be the first step towards supporting a person’s mental health needs, [having a] conversation. If we suspect a family has family relation problems, financial problems, or alcohol problems, that might help. Similarly, P7 recognized that it is crucial for community members to better understand suicide prevention efforts and evidence-based principles that might be protective. Specifically, P7 stated that, Awareness about suicide prevention and education about warning signs would be helpful.

Community Cohesion and Social Connection

Many participants in our sample identified the central role that connections to others played in supporting the refugee population’s mental health needs and reducing suicide. Particularly salient exemplar statements included P2, More community gatherings would be beneficial and protective. P5 also echoed this sentiment, noting a need for, lots of cultural get together programs. P5 also provided a specific idea for how to achieve this goal, Community groups once per week would allow for connection with others. Related to this, two participants considered the importance of community proximity and the benefit added by being physically near other Bhutanese refugee community members. P3 explained, They are in need of a cohesive Nepali community where they can work and live in close proximity. P9 also offered, If these high-risk people have same-language speaking relatives around them, that might help.

Societal-level factors.

Reduction of Postmigration Stressors

Consistent with the theme of postmigration stressors as a significant contributor to suicide risk, a number of participants highlighted the reduction of these stressors as likely being protective. For example, P8 noted the importance of providing growth infrastructure to reduce the language barriers that many resettled Bhutanese refugees encounter. Specifically, they noted the need for, Education workshops/job training and language classes.

Increased Access to Mental Health Assessment and Treatment

Many refugees in our sample reported that having increased access to mental health care would allow for preventive interventions and reduce the mental health burden within the resettled refugee community. One participant summarized the issue concisely, (P3) Here, most of our Bhutanese community is in need of mental health treatment. Another expanded that one way to increase access is to increase both culturally-informed care and outreach by community liaisons, (P1) If we had Nepali or other counselors who could give counseling to at risk families [that would be helpful]. One participant (P2) noted that, Better screening would be helpful. Two other participants echoed this sentiment, (P11) reported that, Not knowing who wants to die is a crucial barrier that could be addressed through improved screening. Moreover, P9 noted that, If we know someone is at high risk, we should alert helping agencies about these people. This comment builds on the notion that helping agencies could conduct outreach and screening in a way that does not require refugees to initiate care but allows the collective refugee community to care for members by indirect means.

Increased Community Awareness of Refugee-related Issues

Host community awareness of refugee-specific difficulties and community norms and practices was cited as a preventive measure that could lead to reductions in suicide. Specifically, one participant (P2) explained that one way to improve the refugee community’s mental health burden would be to provide, Better education for outreach workers about non-educated refugees and camp conditions. P2 highlights the need for community members in provider roles to be sensitive to the specific histories, needs, and lived experiences of their refugee constituents.

Other

Finally, the “other” category was primarily applied to responses that were uninterpretable without additional context, for example, P4 Strength from our heart.

Unknown

Four participants were at a loss for ideas about what solutions or interventions could be developed to slow the suicide epidemic within the resettled Bhutanese refugee community.

Discussion

To effectively address a major public health crisis, such as the suicide epidemic among Bhutanese refugees, it is imperative that the perspectives and views of affected community members be heard and understood. This ensures that both public and private entities can support affected communities by leveraging community members’ expertise and initiating appropriate collaborative intervention development. Brown and colleagues (2019) outline a relevant conceptual framework for understanding suicide among Bhutanese refugees as an ecological systems problem that is influenced by stressors at different environmental levels: individual, familial, community, and societal levels. Brown and colleagues framework adapts Bronfenbrenner’s ecological systems theory (Bronfenbrenner, 1992), which provides a robust model of overlapping environments in which an individual is affected, influenced, and must relate to each inter-related system (e.g., their family; school or community; and nation, culture, or government, etc.). According to ecological systems theory, the development of a child is influenced by many levels of the social environment. At the family level, for example, caregivers’ ability to meet their child’s physical and emotional needs and to respond to their child in a responsive, effective, safe, and consistent manner profoundly effects the child’s development. Trauma at any of the levels, for example, at the national level (i.e., war, ethnic cleansing), can influence the other levels (e.g., family and caregivers’ ability to satisfy the child’s physical and emotional needs). Conversely, intervention at any level can positively impact all other levels of the child’s social environment. Brown and colleagues’ (2019) adaptation of the Bronfenbrenner model to the problem of suicide among resettled Bhutanese refugees emphasizes that risk factors for, and protective factors against, suicide come from different but related contextual and environmental levels. Brown et al.’s (2019) conceptual framework suggests that a comprehensive intervention that successfully interrupts and prevents future suicide deaths among Bhutanese refugees cannot be developed in isolation, but must be integrated and delivered at every level of the socio-ecological context. Our results offer insights for the development of interventions that can be deployed at the level of the individual, the family, the community, and the society to reduce suicide among Bhutanese refugees and prevent future suicide-related deaths.

Socio-ecological Levels

Individual

Individual characteristics, according to the socio-ecological framework, include factors that are inherent to a particular person, for example, genetic predispositions, personality, worldview, and experience, among other inherent traits. All individual characteristics and predispositions are embodied and, thus, become the medium through which a person interacts with their world and accumulates knowledge and experience. This can impact psychological wellbeing and individual vulnerability to distress, which is a major contributing factor to suicide (Bell et al., 2015; Tanji et al., 2018) and is associated with suicidal ideation among Bhutanese refugees (Ao et al., 2016). For Nepali-speaking populations – such as Bhutanese refugees – elements of psychological health lay at the intersection of the mind and the body: heart-mind (man), brain-mind (dimag), social status (ijjat), body (jiu), and spirit (sato; for additional detail, the interested reader is referred to Kohrt & Harper, 2008). Bhutanese refugees believe that disruptions in any of these elements of the self can result in imbalance in the others and lead to emotional suffering, a psychological vulnerability for suicide.

Study participants identified several risk and protective factors that impact individual Bhutanese refugees and require interventions at the level of the individual. Specifically, participants identified psychological distress and vulnerability, as well as substance use as two individual level risk factors for suicide among Bhutanese refugees. This aligns with prior research from epidemiological reports that have linked the prolonged displacement experienced by Bhutanese refugees with various mental health issues, including depression, anxiety, and PTSD (Ao et al., 2012). The experience of torture may be an added layer of trauma that increases vulnerability to suicide. As compared to non-tortured Bhutanese refugees living in camps in Nepal, those who experienced torture had higher likelihood of reporting PTSD, somatoform and pain disorders, and dissociative disorders (Van Ommeren et al., 2001). Psychological problems are also prevalent among Bhutanese refugees resettled in the United States. In more recent work, Betancourt and colleagues (2015) found the most commonly cited emotional problems included loneliness, depression, and lasting feelings of fear (Betancourt et al., 2015). As such, the psychological vulnerabilities highlighted by our participants as contributors to suicide risk are in line with other research studies on Bhutanese refugees in the United States. Additionally, participants in our study noted substance use as a risk factor for suicide and expressed how it can magnify the negative consequences of psychological problems. While often underreported, some studies have shown elevated rates of substance use among resettled Bhutanese refugees. A study of alcohol consumption among Bhutanese refugees in Nepal revealed a prevalence of hazardous drinking similar to that of Western populations (Luitel et al., 2013). Additionally, the use of alcohol and other addictive substances have been linked to badmaas, loosely translated as conduct problems, among Bhutanese refugees (Betancourt et al., 2015).

Bhutanese refugees in the present study expressed that addressing mental health concerns and substance misuse were important steps for mitigating suicide risk in their community, and these data speak to the need for culturally-tailored interventions aimed at targeting these individual-level risk factors. Culturally competent individual psychological counseling has been shown to be effective for reducing psychological distress and vulnerability among refugee populations (e.g., Fondacaro & Harder, 2014). Treatment models that integrate cultural brokers or bi-cultural interpreters and focus on helping patients identify and cope with their emotions using healthy coping skills, such as identifying safe and trusting people they can reach out to when in crisis, can be highly effective for Bhutanese refugees. Previous trials of treatments, such as trauma systems therapy for refugees (TST-R; Benson et al., 2018) and dialectical behavior therapy (Ramaiya et al., 2017), have demonstrated efficacy for Nepali-speaking populations. Another crucial individual-level intervention is to increase the cultural and language accessibility of substance use counseling groups. This can be achieved by having interpreters present at community substance use support groups and working with community members to identify acceptable ways of developing culturally-tailored support groups targeted specifically to Bhutanese refugee community members.

Family

Risk and protective factors for suicide can be assessed within familial and social relationships, which are central to the lives of resettled Bhutanese refugees. The resettlement process can be positive for many refugees, but is also a highly stressful process that is known to have a lasting negative impact, especially within family units. Previous work within a resettled Bhutanese refugee sample identified that resettlement was associated with family-related anxiety and depressive symptom elevations (Vonnahme et al., 2015). Resettlement stress, including financial difficulties, may contribute to caregivers who are less able to meet their family’s physical and emotional needs, less attuned to family members who are in distress, and more likely to experience discord with their partner. Previous work has also shown that different rates of acculturation within a family unit generates tension and cultural discord within a household and family unit as different family members relate differently to host communities (e.g., Berry et al., 2006; Birman, 2006; Lau et al., 2005; Rasmi et al., 2015). Brown and colleagues (2019) reported that shifting family structures, such as faster acculturation among younger generations and role reversals between parents and children, were perceived to be risk factors for suicide as they significantly increase inter-family tension. Bhutanese refugees in our study highlighted that internal conflict, tension, or disconnection within a family unit was a significant stressor that was perceived as life threatening and insidious. Our data suggests that familial and social discord can be a potent contributor to suicide risk. This finding echoes previous findings that family and social conflict plays a central role in the development of suicide-related risk among Bhutanese refugees (Ellis et al., 2015). Furthermore, this finding is consistent with the Cultural Model of Suicide, whereby social discord is considered to be a contributor of risk for suicide, especially among cultural minorities (Chu et al., 2010).

Our data indicates that interpersonal violence within families is a major contributor of risk for suicide. Many Bhutanese refugees exist within a patriarchal culture that suppresses women’s worth relative to that of men, resulting in gender-based domestic violence (Donini, 2008). Interpersonal violence among Bhutanese refugees was studied within the refugee camp systems (Schininà et al., 2011) and is common among many refugee and immigrant communities (e.g., Keygnaert et al., 2012; Rees & Pease, 2007; Stamatel & Zhang, 2018; Vu et al., 2014). However, interpersonal violence has largely been understudied and under-reported among resettled Bhutanese refugees.

These data point to specific interventions that can target risk factors at the familial level. For example, care environments (e.g., medical, psychological, social work) can target the family level of the socio-ecological structure of Bhutanese refugees by treating them as care allies, to help implement care recommendations or behavioral change strategies, while simultaneously providing a strong foundation of emotional support (Shannon, 2014). Importantly, providers must still maintain confidentiality standards appropriate to their profession and should seek consent to include family members in interventions that are – in western cultures – traditionally targeted only towards individuals. For example, including family members in psychological treatments may foster a sense of safety within the family unit to improve communication and sensitivity to signs of distress. Additional family-level interventions that may be beneficial to psychological health include trauma-informed interventions that focus on helping families create a trauma narrative about resilience and strength, such as the Trauma Systems Therapy for Refugees (TST-R; Benson et al., 2018). To reduce acculturative and intergenerational tension, it may be important to consider family therapy focused on improving communication, building empathy, and, if appropriate, parenting skills. Additionally, it can be beneficial to provide refugee families and providers of health and wellness services with useful and accessible evidence-based psychoeducational and socio-cultural information, such as that hosted by Bridging Refugee Youth and Children’s Services (BRYCS). This service maintains a multi-language web-portal specifically designed for refugee families and providers to improve health, wellness, and navigate life following resettlement (“Refugee Portal,” n.d.). Increasing family awareness of the negative impact of domestic violence on children and partners and offering culturally-appropriate communication, counseling, and safety resources to all family members empowers abused family members to access safety resources. Such resources should include access to those that collaboratively work with family members who are perpetrators of violence to end domestic abuse in the home, and create a safe living environment.

Community

Our sample heavily cited isolation and feelings of thwarted belongingness as the most prominent risk factors for suicide within the resettled Bhutanese refugee community. Bhutanese refugees predominantly practice Hinduism (Schininà et al., 2011). A central belief of Hinduism is that the spirit is reincarnated many times, and, in each life, the spirit traverses a hierarchy of incarnation based on behaviors, deeds, and misdeeds in previous incarnations (Fowler, 1997). This belief system is tied to the caste system, a deeply rooted socio-religious organizing structure positing that caste is essentially unchangeable, determined by birth, and partially the result of merit from past lives (reviewed in Acharya, 2008; Fowler, 1997). Subsequently, the caste system discourages intermingling of castes and may be a contributor to within-community discrimination and isolation. Both isolation and thwarted belongingness are risk factors known to be associated with suicidal ideation among Bhutanese refugee community members (Ellis et al., 2015; Meyerhoff & Rohan, 2020). Isolation requires community level interventions to increase feelings of inclusiveness and community integration. Importantly, participants identified increasing community cohesion as an important preventive step that, if executed properly, could lead to reductions in suicide deaths within the Bhutanese refugee community.

Numerous community level interventions are indicated based on this data. Due to the highly heterogeneous nature of resettlement communities, community intervention campaigns must be tailored to individual communities. One example of a community-level intervention program includes Mental Health First Aid (MHFA) training, which was developed to help lay-leaders identify, intervene, and refer individuals who are experiencing general psychological distress and are nearing a crisis state. MHFA has been helpful within the Bhutanese refugee community (Subedi et al., 2015) and can increase community mental health literacy and awareness of signs and symptoms of mental health crises. In addition to broad gatekeeper trainings such as MHFA, bi-cultural community liaisons and lay leaders should complete culturally-informed suicide-specific trainings, which can improve community leaders’ skill and confidence for discussing and identifying suicide-specific risk (Teo et al., 2016), especially in cultural minority groups. However, such mass-audience training program do not yet exist and need to be developed for use within the Bhutanese refugee community by bi-cultural community members in collaboration with mental health professionals and researchers.

Stigma around discussing mental health problems, especially suicide, was identified in our sample as a community level contributor of suicide risk. This echoes previous findings that mental health and suicide often go undiscussed within the Bhutanese refugee community due to their intense stigma (Adhikari et al., 2015; Ao et al., 2012). De-stigmatization of mental health symptoms and help-seeking for suicidal desires or thoughts is a crucial community-level target. Within the Bhutanese refugee community, mental health symptoms are heavily stigmatized. Therefore, community-level interventions must directly target mental health stigma by framing symptoms as normal responses to difficult life events. De-stigmatization efforts can be delivered in a variety of mediums depending on the needs and nature of the community of interest. Prior community intervention efforts have included communal events such as film screenings, community dialogues, educational panels, community gatherings, and cultural events (Nazzal et al., 2014). Community-based de-stigmatization efforts, especially community gatherings and investment in community centers and meeting spaces can also increase community cohesion, which is a crucial protective factor for psychological wellbeing among Bhutanese refugees (Chase & Sapkota, 2017; Gerber et al., 2017).

Society

Societal structures and norms of host countries serve as the larger environmental context within which resettled refugees must navigate. Results from this study highlight societal-level risk factors for suicide, such as postmigration stress. Postmigration stressors, including language barriers, reduced access to care or services, minority stress, acculturation gaps within families, and discrimination, make the transition to a new home country or community particularly difficult. Postmigration stressors have been shown to be a major contributor to stress and poor psychological functioning among new immigrants, refugees, and asylum seekers regardless of voluntary or forced migration status (Bentley et al., 2012; Chen et al., 2017; Laban et al., 2005; Sangalang et al., 2019; Teodorescu et al., 2012) and are known to be specific risk factors for psychological distress and suicidal thoughts and behaviors among the resettled Bhutanese refugee population (Adhikari et al., 2015; Ao et al., 2012; Ellis et al., 2015; Meyerhoff et al., 2018). A recent study of host community perceptions of refugee resettlement offers insight into the sometimes hostile socio-political environment that can exacerbate postmigration stressors (Bose, 2018). Although many individuals within host communities are highly supportive of refugee resettlement, resettled refugees often must navigate significantly hostile host communities long after arriving in the U.S., thereby adding stress to the other psychological and logistic challenges of the transition period.

Our participants reported that actively working to reduce postmigration stressors, improving access to care, and increasing societal awareness of the challenges facing refugees upon resettlement were each key intervention targets. Societal-level interventions typically require government or non-governmental organizational support and can be challenging to implement due to cost or weak political will. However, increasing access to care is a key area of focus for societal-level interventions (Langlois et al., 2016). Geographic access to public goods and services, such as transportation, can make a substantial impact on the magnitude of the barriers faced by many resettled refugees. For example, in many small city resettlement sites like Burlington, Vermont, resettled refugees are often geographically concentrated and have difficulty accessing publicly funded transportation (Bose, 2013), limiting access to financial, medical, or psychological services and employment opportunities. This can have the unfortunate effect of isolating refugee communities and exacerbating postmigration stressors. Advocacy organizations can work in collaboration with transit organizations to increase transit service in regions where refugees are concentrated, providing a bridge to improve access to necessary care, services, and opportunities.

In addition to increased physical access to care and services, institutions and service providers must increase their language and cultural accessibility. When a host society becomes more aware of the challenges faced by refugees, it must also increase the sensitivity and efficacy of care delivered. For example, trauma-informed care has highlighted the need for providers to be sensitive to the specific needs of torture survivors. One psychological service provider adopted a culturally-informed model of psychotherapy designed specifically to serve area refugees (Fondacaro & Harder, 2014). Their model incorporated trauma-informed care, social work, legal, and interpreter services at every level of interaction with refugee patients to comprehensively address patients’ needs. Moreover, in some states, tens to hundreds of refugee service providers and stakeholders regularly meet to coordinate their services at the organization level. The Refugee Immigrant Service Provider Network (RISP-NET) has since been successfully implemented in other states across the United States (RISP-NET, n.d.). Coordination efforts help minimize care-gaps for refugees without placing the burden of identifying and advocating for solutions to such care gaps on refugees themselves. Moreover, implementing early school-based interventions for refugee children and families can also reduce postmigration stressors for children and families and increase opportunities for younger generations of refugees. Implementing guidance and career counseling earlier than for U.S. born children may help families and children meet application and course requirements necessary for post-secondary educational programs, such as 4-year universities or vocational schools. Implementing college counseling earlier and more actively for refugee children or children of refugees can help overcome structural knowledge gaps for families that do not have generational knowledge about the process of applying for and securing a post-secondary education.

Limitation and Future Directions

There are a number of important limitations to this qualitative study. Because this qualitative study was conducted as part of a larger project to develop more culturally-responsive methods for assessing suicide risk among Bhutanese refugees, sampling from within participants of the larger study may have introduced unanticipated bias. Participants in the present study were recruited based on convenience and feasibility, which also may have unintentionally introduced bias into our results. Importantly, with respect to interrater reliability, some Fleiss’ Kappa values fell within the moderate range, this was primarily the case for the “Other” themes, reflecting the heterogeneity of this theme. Additionally, while we achieved good data saturation, our sample size remains small, and future work should solicit responses from a broader and larger sample. Our study used field notes rather than direct quotes to develop summary statements. Future work should rely on audio recorded and transcribed conversations between interviewer and participant.

This study highlights the factors that Bhutanese refugees perceive as contributing to the suicide epidemic within their community as well as pragmatic preventive efforts that community members believe will slow or reduce the suicide rate. Each of the identified risk factors and prevention solutions addresses one or more socio-ecological contextual levels that can be further developed and integrated to inform future policy and intervention development across the socio-ecological spectrum. Future qualitative research is necessary to refine specific interventions that must be developed in collaboration with Bhutanese refugee community members. Future group elicitation workshops should be conducted with multiple samples of Bhutanese refugees across resettlement sites to better understand the full spectrum of risk and protective factors as they relate to suicide. Moreover, these elicitation workshops should be facilitated by bi-cultural and bi-lingual researchers to increase rapport with participants and reduce barriers to participation. Qualitative work, such as this, is crucial to develop interventions that are sustainable and effective within a minority community like the resettled Bhutanese refugee community.

Public Health Significance Statement.

In order to effectively address a major public health crisis such as the suicide epidemic among Bhutanese refugees, it is imperative that the perspectives and views of affected community members be incorporated into preventive interventions. Qualitative data highlights Bhutanese refugee community members perspectives on contributors to suicide risk and preventive interventions that protect against suicide.