|Home | About | Journals | Submit | Contact Us | Français|
We examined how US cultural involvement relates to suicide attempts among youth in the Dominican Republic.
We analyzed data from a nationally representative sample of youth attending high school in the Dominican Republic (N=8,446). Our outcome was a suicide attempt during the past year. US cultural involvement indicators included time lived in the US, number of friends who have lived in the US, English proficiency and use of US electronic media and language.
US electronic media and language, time lived in the US, and number of friends who have lived in the US had robust positive relationships to suicide attempt even when included in the same model and after controlling for demographic covariates.
Our results are consistent with previous research that has found increased risk for suicide or suicide attempts among Latino youth with greater US cultural involvement and adds to this research by finding this result in a non-immigrant Latin American sample. The results of our study also identify suicide attempts as a major public health problem among youth in the Dominican Republic.
There is growing evidence that US nativity increases risk for suicide ideation, suicide attempts, and death by suicide for Latino youth and adults. Foreign-born Latinos have lower rates of completed suicide compared with US-born generations across several national and regional cohorts.1-3 Moreover, rates for suicide ideation or attempts among foreign-born or less acculturated Latinos have been lower than their US-born counterparts.4-7
This phenomenon has been referred to by different names including the healthy immigrant effect, the Latino paradox, and the epidemiological paradox and has been found for numerous outcomes.8 Different models to explain this finding have been proposed including cultural protective factors associated with Latino culture;9,10 discrepancies in intergenerational values between immigrant parents and their US-born children;11 and selection bias related to immigration of healthier or more resilient individuals.12,13 Methodological constraints unfortunately have limited the ability to test determinants that could explain these differences. One limitation that has limited the ability to test the selection bias hypothesis has been the scarcity of comparable data from “feeder” nations of US Latino immigrant populations.
In one of the few studies using cross national data, Mexican youth in high schools near the US-Mexico border reported lower rates of suicide ideation than Mexican American youth in high schools on the US side of the border.14 In another study using a bi-national sample of Mexicans (US and Mexico), Mexican-born immigrants who arrived in the US at 12 years or younger as well as US-born Mexicans had higher rates of suicide ideation than Mexicans without a history of migration to the United States or a family member living there. Mexicans with family members living in the US and US-born Mexicans were also at higher risk for suicide attempts.15 These studies do not support the selection bias explanation for nativity differences for suicide behaviors among adults or youth of Mexican ancestry living in the US. Although the literature suggests Latinos share certain core pan-ethnic cultural values such as familismo, simpatia, and respeto,16-18 the peoples of Latin America have distinct historical, social, immigration, and cultural contexts. It is therefore prudent to test, validate, or disprove explanatory mechanisms such as immigration selection bias across different Hispanic subgroups.
One variation of the approach of using data from feeder countries is to examine how US cultural involvement may relate to risk for suicidal behavior within a non-US setting via mechanisms related to “cultural globalization”. Cultural globalization parallels the process known as economic globalization and refers to the penetration of cultural influences (e.g. US cultural influence) on the lifestyle, values, norms, and the retention of cultural heritage in youth around the world.19,20 The strength of this approach is that it examines the relationship between US cultural influence on suicidal behavior on a non-immigrant Latino population.
Given its large US-based population,21 relatively close proximity, and historical connections to the US,22,23 the Dominican Republic (DR) offers an excellent natural experiment to test if US cultural influence relates to outcomes such as suicide risk behaviors among youth. For example, there are approximately 1.3 million Dominicans living in the US21 compared to a relatively modest population of approximately 10 million Dominicans living in the DR.24 Given this ratio of US to DR Dominicans, there are several mechanisms for how cultural globalization in the DR may occur, especially as it relates to US cultural influence. The first is circular migration, which has been conceptualized and operationalized in multiple ways. We use a literal definition, leaving and then returning to a country-of-origin, once or repeatedly. Circular migration is often driven by immigrants’ economic circumstances, legal status, and US labor market demands.25 Another mechanism for the US cultural influence in the DR occurs through ties that Dominicans have with relatives, friends, or acquaintances who live in the US or who have lived in the US. The US cultural influence in the DR also occurs indirectly via the influences of electronic media such as US-based movies, television, and music.
In this report we examine how US cultural involvement indicators relate to suicide attempts among a nationally representative sample of public high school students in the DR. We focus on suicide behavior because it has been identified as a growing worldwide public health concern for youth and young adults.26,27 Moreover, suicide attempts are associated with hospitalization, future attempts, 28 and future death by suicide.29,30 Despite the concern for adolescent suicide attempts, little is known about the epidemiology of suicide behaviors in the DR. To our knowledge this is the first study to publish data on suicide attempts among DR youth using a nationally representative sample; however, in one unpublished report using data from a national sample of DR youth attending public school in 1997, as many as 7.9% of the youth reported a suicide attempt during the past year.31 This rate is on par with the 7.7% of youth that reported a suicide attempt during that same year in the United States, but lower than the 10.7% of US Hispanics that reported a suicide attempt in 1997.32 These rates for suicide behavior represent a public health problem among youth in the DR. This study will add to the literature by publishing results related to suicide attempts among DR youth using a nationally representative sample and by increasing knowledge regarding the healthy immigrant effect pertaining to suicide attempts. Based upon the robust associations between suicide behaviors and US involvement among US Latino and Mexican populations, we hypothesize that greater US cultural involvement will increase risks for suicide attempts among DR youth.
A stratified cluster design of public high schools in the DR was used for this study. The strata in this study consisted of 18 national educational regions. The primary sampling units (PSUs) or clusters were public high schools in the DR. Eighty schools were selected for a total of 8,446 youth. Schools were randomly selected from each educational region in proportion to their numbers nationally, if a region had 10% of the schools in the nation, then approximately 10% of the total schools in the sample came from that region. No region had fewer than two schools in the sample. Data were collected by the DR Department of Education using self-administered anonymous surveys in spring of 2009. An intact classroom of students in a required course was randomly selected for each grade level at each school. Participation in the study was voluntary and all students present on the day of data collection were eligible. No school refused to participate in the study. Sample weights were created using population level data from the Dominican Republic’s Department of Education. These data included the total number of current public high school students in the DR by grade level, gender, and educational region. The sample weights adjusted results to allow generalization of the results to the population of public high school students in the DR by grade level, gender, and educational region.
Our outcomes and demographic measures included items from the 2009 Youth Risk Behavior Survey,33 the Spanish version of the non-Hispanic domain of the Bidimensional Acculturation Scale (BAS),34 and a number of items designed to examine US cultural involvement, family structure, and socio-economic status. A workgroup of Dominican- and US-based translators ensured equivalence in meaning between the English and Spanish version of questions as well as understandability of survey items by DR youth.
We used four sets of indicators for US cultural involvement: (1) time lived in the US, (2) number of friends who have lived in the US, (3) English proficiency, and (4) use of US electronic media and language.
For time lived in the US, we created two categorical variables: those living in the US for less than 1 year and those living in the US for more than 1 year. The reference group was DR youth who never lived in or visited the US.
For number of best friends who ever lived in the US, we used 1 month as a minimal residence cut off. The first several responses included actual number of friends from 0 to 4. The last response was 5 or more.
A latent factor using six items taken from the BAS that asked about language comprehension was used to measure English proficiency. Examples of these items include “how well do you speak English?” and “how well do you read English?” The EFA model fit for these six items was good (CFI = .99, TLI = .98) with factor loadings ranging from .74 to .90. Cronbach’s alpha was .90. We chose a latent factor strategy rather than creating an index variable to reduce measurement bias and error.35
A second latent factor using six additional items from the BAS was used to measure use of US electronic media and language. Examples of these items include “how often do you watch television in English?” and “how often do you speak in English with your friends?” We conceptualize these items as measuring US electronic media and language because English media and language in the DR comes almost exclusively from US sources (e.g., US cable television). EFA conducted on these items for our sample supported combining the items into a single factor. The EFA model fit was good (CFI = .96, TLI = .95) with factor loadings ranging from .67 to .86; Cronbach’s alpha was .82.
Control variables were gender, age, urban residence, parental education, dual-parent household, and living in a household with a corrugated zinc roof. Gender was categorized as female or male and age was coded in years. The DR Department of Education coded schools as urban based on population density. There were multiple categories for maternal and paternal education; these were recoded into two categorical variables: (1) at least one parent who completed high school and (2) at least one parent who completed college. Our reference group for parental education was parents who did not complete high school. A dual parent household was defined as one where there was a mother or mother figure (i.e., grandmother or aunt) and a father or father figure (i.e., grandfather or uncle) residing in the household. Corrugated zinc roofs served as a proxy for poverty. Zinc roofs are seen predominantly on small inexpensive homes of improvised construction often located in high poverty areas in the DR.
Suicide attempt was measured by the YRBS item, “During the past 12 months, how many times did you actually attempt suicide?” The original response options were 0 (0), 1 (1), 2 (2 or 3), 3 ( 4 or 5), and 4 (6 or more). We recoded these options to be dichotomous: 0 for no suicide attempt and 1 for any suicide attempt during the past year.
Mplus version 5.2 was used to conduct the analyses. We used the “Type=Complex” command to account for the study’s complex survey design.36 All analyses were adjusted using sample weights to ensure generalizability to youth in the DR attending public high school by gender, grade level, and region of country.
We conducted our analysis in a stepwise fashion using logistic models. First, we estimated the unadjusted rates for suicide attempt for each of the US cultural involvement indicators using propensity scores from simple logistic models. We used these same models to estimate unadjusted odds ratio (OR) for suicide attempt for each US indicator. Next, we combined all four of our US cultural involvement indicators in a single logistic model to estimate the independent relationship of each of our indicators on suicide attempt after adjusting for each other. Our final model took into account the four US cultural involvement indicators as well as all of our control variables. To avoid experimental-wise error from multiple group comparisons, we used the Bonferroni–Holm or Holm adjustment.37 Missing data were handled using a Maximum Likelihood approach, which eliminates or reduces biases associated with missing data.38 There were no violations of the assumptions of logistic regression in any of the models.
Table 1 shows that our sample was predominantly female (57.0%) with a mean age of 16. The majority of youth lived in urban areas (67.7%), came from a two-parent household (56.1%), and never lived in the US (90.9%). Approximately half lived in an impoverished household as indicated by the presence of a corrugated zinc roof on their homes, did not have any best friends who have lived in the US, and 45.8% had parents that never completed high school. An estimated 8.7% of the population reported having made a suicide attempt during the past year.
Figure 1 illustrates the relationship between use of US electronic media and language and the propensity to attempt suicide. Since we used a latent factor to examine involvement with US electronic media and language, the mean score was 0 with a range of scores between −2.6 and 3.9. There was a significant relationship between use of US electronic media and language and the propensity to attempt suicide ranging from 6.3% for those on the lowest range of the scale to 13.3% for those on the highest range of the scale. The unadjusted OR from the bivariate logistic regression was 1.14 (95% Confidence intervals [CI] = 1.07, 1.21), for every unit increase in the latent factor use of US electronic media and language, the propensity to attempt suicide increased by a factor of 1.14. A similar bivariate relationship was found for the latent factor English proficiency (OR = 1.05; 95% CI = 1.02, 1.09). The bivariate relationship between suicide attempt and number of friends having lived in the US was also robust. The propensity to attempt suicide was 7.86% for youth with no best friends having lived in the US compared to 10.56% for those who had 5 or more friends who have lived in the US (Figure 2). The unadjusted OR was 1.07 (95% CI = 1.03, 1.11); for every additional friend having lived in the US, the propensity to attempt suicide increased by a factor of 1.07. The largest differences for the propensity to attempt suicide were found for youth who have never lived in the US (8.1%) compared to those who lived in or visited the US for less than a year (12.6%) and those who lived in the US for 1 year or longer (18.2%). The unadjusted ORs comparing youth who never lived in the US to those who lived in the US for less than a year and those that lived in the US for 1 year or longer was 1.65 (95% CI = 1.19, 2.77) and 2.54 (95% CI = 1.67, 3.87) respectively.
In the first multivariate model, use of US electronic media and language remained significantly related to suicide behavior after adjusting for all other US cultural involvement indicators. The same was true for the indicators of time lived in the US and number of friends who ever lived in the US. English proficiency was the only indicator of US cultural involvement that became non-significant in this model when adjusted for the other three indicators (OR = 0.97; 95% CI = 0.90, 1.04) (Table 2).
In the final model, we entered the four US cultural involvement variables along with the covariates gender, age, parental education, zinc roof, urban residency, and family structure. As with the previous model, the US cultural involvement variables remained significant and the English proficiency remained non-significant. There was also little to modest change in the magnitude of the OR across our three models with the exception of English proficiency. Female gender (OR = 1.57; 95% = CI 1.31, 1.88), dual parent household (OR = 0.76; 95% CI = 0.64, 0.91), and living in an urban area (OR = 0.79; 95% CI = 0.63, 0.99) were also significantly related to suicide attempt in our final model.
We found a relation between suicide attempt and US cultural involvement among a national sample of youth attending public high school in the DR. Greater number of friends who have lived in the US, time lived in the US, and use of US electronic media and language were all independently related to the propensity for a suicide attempt even when they were all in the same regression model and after controlling for gender, age, socio-economic indicators, and family structure. The increase in the propensity to attempt suicide for DR youth across these US cultural involvement indicators were not only robust but large. For example, the propensity to attempt suicide ranged from 6.3% for those on the lowest range of use of US electronic media and language to 13.3% for those on the highest range of US electronic media and language. This central finding is congruent with the lower suicide or suicide attempt rates found for first-generation or less acculturated Latinos across multiple national and regional cohorts of Latinos.1-7 These findings add to past research by using a non-US based sample of youth and examining if US cultural involvement indicators are associated with suicide attempts.
Our novel methodological framework does not support selection bias related to immigration as the sole explanatory process for the relationship between US cultural involvement indicators and suicide behavior among Latino youth. However, our findings also do not rule out selection processes related to immigration as a contributing factor for suicide behavior or other outcomes among newly arrived immigrants. Nonetheless, the results of this report are consistent with previously proposed explanatory mechanisms that relate to protective cultural factors in traditional Latino culture or intergenerational cultural values discrepancies between youth and their parents.
Durkheim wrote over a century ago about the lower rates of suicide in Catholic vs. Protestant countries and how cultural contexts that promote stronger social and familial bonds protect against suicide behavior.39 Values associated with Latino culture such as familism, respect, and affiliative obedience may lead to stronger social and familial bonds between youth and adults.40-42 Moreover, characteristics of traditional Latino culture that promote social control (e.g., parenting behaviors) may help reduce externalizing risk factors associated with suicide attempts including substance use, family conflict, and violence. This potential mechanism is consistent with one study that found that the increased risk for suicide attempts among US-born Latino adolescents was mediated by their increased use of illicit substances.7 Another study reported higher levels of risk taking-impulsivity among US-born Latino parents, which was related to the development of future alcohol dependence in their children.43 Furthermore, Latinos have been found to have greater moral objection to suicide and a greater sense of responsibility to family than non-Latinos, potential mediators that reduce the risk for suicide ideation.44
More research is needed to test how Latino cultural factors relate to suicide behaviors as well as known protective and risk factors for suicide behaviors. Future studies also are needed to examine if there are aspects of American culture that potentially lead to behavioral risk factors associated with suicide behavior. Concepts such as alienation, anomie, or risk taking-impulsivity may be promising risk factors to examine among more Americanized youth.43,45
Intergenerational discrepancies in cultural values and norms are another potential mechanism related to increased risk for youth. According to this model, the incongruence in cultural values and norms between Americanized adolescents and their more traditional Latino parents leads to weakening of family bonds, family conflict, role reversal, and adolescent behavior problems and distress. This model has been described by Phinney as intergenerational value discrepancies,11 by Szapocznik and Williams as intercultural/intergenerational conflict,46 and by Portes and Rumbaut as dissonant acculturation.47 There is evidence supporting this model of intergenerational cultural conflict as a factor associated with risk behaviors among Latino youth.48-51 Future research should test the applicability of this model to suicide behavior among Latino youth and identify the role played by shifting cultural values of both parent and child within the family context. For example, discrepant cultural beliefs about family obligations, conduct and gender norms, and social role expectations between parents and their teens may create conflict within the family environment but so may greater US cultural involvement among Latino parents.48 Methodological approaches that disentangle the relative effects of intergenerational value discrepancies and shifting cultural norms that may promote or inhibit conflict within family settings may be particularly illuminating.
The results of this study also contain noteworthy public health findings for the youth of the DR. To our knowledge, this study is the first to document in the scientific literature that suicide attempts among DR youth are a national public health problem with 8.7% of the public high school population reporting a suicide attempt during the past year. Within the US context, similar levels of suicide attempts among high school students, 6.3% in 2009,33 has been identified as a public health priority and has received private and governmental resources for prevention efforts for years.52,53 The lack of attention to or knowledge of this problem in the DR is especially concerning given its status as a developing country with fewer resources than the US. An important initial step in addressing this issue would be the creation of a national surveillance system similar to the US Youth Risk Behavior Surveillance System developed by the Centers for Disease Control and Prevention (CDC) in 1991 that can be used to draw attention to and monitor this public health problem. The World Health Organization has started promoting school-based surveillance systems in certain developing nations with their Global School Health Initiative. As of this writing, this initiative has yet to be established in the DR.54
Besides surveillance, crucial next steps include creating national health objectives and developing prevention strategies utilizing universal, selective, and indicated approaches such as those discussed in the “Reducing Suicide: A National Imperative” report,55 but that also fit within the DR context. These prevention efforts should also take into account populations with higher or lower risk for suicide attempts. Within this study female gender was associated with higher risk for suicide attempt, a finding consistent with previous research in other nations.26,56-58 Living in an urban environment and residing in a two parent household were associated with lower risk for suicide attempt. These results suggest that future prevention efforts within the DR context should take into account the elevated risk for suicide attempt for females, youth living in rural environments, and youth living in single parent households. For example, one strategy may be to create prevention programs that promote protective factors or reduce risk factors associated with suicide attempts, especially among segments of the population with elevated risk for suicide behavior such as females. Research is needed to identify what these protective or risk factors may be for these youth within the DR context.
Lastly, this study raises important questions with potential global implications for youth in multiple nations including the DR and US. Is a similar phenomenon occurring in other Latin American or other nations that send large numbers of immigrants to the US? If US cultural involvement increases risk as shown by our study, will suicide behaviors become an ever-increasing public health problem as globalization increases variety and intensity of exposures to US cultural influences in the DR and other developing nations? Moreover, what prevention efforts are needed to reduce suicide behavior among youth in non-US settings that are subject to high US-cultural influence? In moving forward with these questions, we emphasize the need to understand how US cultural involvement relates to underlying protective and risk mechanisms that create greater risk among Latino youth in US and non-US settings. Examples of mechanisms we think important to explore include those related to negative peer influences, attitudes and norms of behaviors such as suicide attempt, differential gender socialization, social bonds, social control, and family environment. We also stress the need to incorporate into and study the use of cultural values in prevention efforts for Latino youth. For example, culturally sensitive family-based approaches have shown promising results for improving bonding, reducing conflict, and preventing risk in Latino families and adolescents.59-61
Our study used self-reported measures, which may not be accurate despite previous research suggesting that such items have produced valid responses.62,63 Although youth attending public school in the DR represent a significant proportion of the overall adolescent population, results from this study may not generalize to youth who do not attend school or who attend private schools. Moreover, due to issues related to the circular migration patterns between the US and DR, a reverse selection process may be an alternative explanation for our findings. However, use of US electronic media and language was related to suicide risk independent of time lived in the US, number of friends who have lived in the US, and English proficiency. We would not expect this finding if the results were solely due to high risk youth returning from the US.
This study was innovative in its use of a national sample of DR youth to test the relationship between suicide attempt and US cultural involvement. Unlike the majority of studies that have examined this relationship using US-based samples that are subject to selection processes related to migration, this study found a robust relationship between US cultural involvement and suicide attempt in a national sample of youth living in a Latin American country. Future research is needed to replicate findings in the DR, and other nations, and to test potential mechanisms that lead to increased risk for suicide behavior such as those that suggest that US cultural involvement may erode protective factors in Latino culture or increase intergenerational conflict due to cultural value discrepancies between youth and their parents. To our knowledge our study is also the first to document that suicide attempt is a public health problem in the DR using a nationally representative sample of students.