Culturally contextualized suicide prevention for international students: new opportunities for research and practice

The increasing number of suicide-related thoughts and behaviors among international college students in countries like Australia and the US presents a major public health challenge. Existing prevention and intervention strategies, largely based on Western mental health paradigms and individual-level interventions, show limited effectiveness. These strategies, primarily focusing on mental health literacy, service access, and symptom reduction, are often rooted in studies of WEIRD (Western, Educated, Industrialized, Rich, and Democratic) societies, which are not representative of the diverse international student population. This lack of cultural contextualization overlooks crucial factors for effective prevention and intervention in diverse groups. This article proposes integrating culturally contextualized prevention models that blend evidence-based Western practices with the unique cultural perspectives of international students. It reviews existing evidence on international college student suicidality and culturally responsive suicide prevention, leveraging the Protective Factors Framework and the public health model of suicide prevention to identify areas for improvement along the suicide care continuum. The focus is on enhancing the effectiveness of suicide prevention efforts for this vulnerable population.

Research shows that suicidal thoughts and behaviors are common among international college students, with some studies indicating similar rates of suicidal ideation and self-harm compared to domestic students. However, international students demonstrate higher rates of suicide attempts, particularly in clinical settings. Risk factors for suicidality among international students include social isolation, loneliness, unmet personal needs, low social support, and acculturation challenges. Intrapersonal factors such as depression, anxiety, and maladaptive coping mechanisms also contribute. Contextual factors, including perceived discrimination, academic and life stress, and unmet family expectations, significantly impact suicide risk. Protective factors include high problem-focused coping, social connectedness, and strong family cohesion. Barriers to help-seeking include cultural stigma, limited mental health literacy, and inaccessible or culturally misaligned services. Culturally responsive suicide prevention approaches emphasize cultural congruence and the integration of cultural strengths to enhance effectiveness. The Protective Factors Framework, developed for American Indian and Alaskan Native populations, provides a useful lens for understanding how protective factors and mechanisms interact to promote resilience. This framework highlights the importance of cultural continuity and community engagement in suicide prevention.

The authors used an extended version of the Protective Factors Framework to analyze existing recommendations and approaches for international student suicide prevention. This framework was expanded to incorporate three key elements: 1) a well-established public health prevention framework categorizing efforts into universal, selective, and indicated interventions; 2) specification of the target groups (students, staff, or other relevant groups); and 3) identification of culturally contextualized opportunities for improvement. The authors summarized current recommendations and practices within this extended framework, presenting them in a table that outlines the approach, prevention level, target groups, protective factors, mechanisms, risk factors, current methods, and opportunities for culturally contextualized enhancements. This analysis revealed several key areas for improvement, including community involvement and empowerment, examination of mechanisms of change, and considerations for implementation and evaluation.

Analysis of existing suicide prevention recommendations for international students revealed that most focus on increasing formal support engagement, spanning universal, selective, and indicated prevention levels. Mechanisms concentrate on enhancing mental health literacy, customizing services, and overcoming structural barriers. Opportunities for improvement through culturally responsive approaches include: 1. **Community Empowerment and Ownership:** Moving from community participation to empowerment can lead to more effective gatekeeper programs, improved program acceptability and sustainability, and increased community ownership. 2. **Refining Mechanisms of Change:** Examining proposed mechanisms of change allows for refinements that acknowledge non-Western mental health perspectives, leverage cultural strengths, and integrate diverse viewpoints. For example, mental health literacy campaigns could draw upon existing cultural perspectives on mental health before trying to change them. 3. **Implementation and Evaluation:** Effective implementation requires aligning efforts with community needs, ensuring sufficient skills and resources, and engaging community leaders. Rigorous evaluation using validated measures or qualitative methods is necessary, considering cultural responsiveness in metrics and methods. Who should implement programs is an important consideration. The findings also suggest an ecological validity model is appropriate to use when developing digital mental health interventions.

The proposed extended Protective Factors Framework offers a structured approach for assessing and enhancing current suicide prevention strategies for international students. It emphasizes community empowerment, culturally aligned mechanisms of change, and culturally contextualized implementation and evaluation. This framework builds upon existing knowledge in culturally responsive suicide prevention by integrating a public health prevention framework and highlighting opportunities for strength-focused cultural adaptations. The approach represents a shift from deficit-focused models to ones that leverage cultural strengths and resources. While acknowledging the heterogeneity of the international student population and the lack of existing evidence-based programs, the framework's flexibility allows for tailoring interventions to specific cultural subgroups while addressing common challenges like acculturation stress. The shared experience of being an international student provides a foundation for interventions addressing universal challenges.

This paper provides a comprehensive framework for improving culturally responsive suicide prevention for international students. Key improvements involve fostering community empowerment, critically examining and adapting mechanisms of change to align with diverse cultural perspectives, and implementing culturally sensitive evaluation processes. Future research should focus on empirically testing culturally contextualized adaptations, conducting longitudinal studies, exploring intersectional impacts, and investigating the potential of tailored digital interventions.

The study acknowledges the complexity of addressing the diverse needs of the international student population, highlighting the challenges of creating universally applicable strategies while ensuring cultural appropriateness. The lack of existing evidence-based programs specifically for international students limits the assessment of proposed enhancements. Further research is needed to explore the framework's adaptability across different cultural subgroups and host countries.