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With refugees, migrants and people from culturally and linguistically diverse backgrounds more at risk of death by suicide, more funding and better record keeping is needed for suicide registries.
Sadly, studies show that new migrants, refugees, and people from some culturally and linguistically diverse (CALD) backgrounds are at higher risk of death by suicide in Australia than people in the general population (here and here). This is particularly concerning as individuals from CALD communities are less likely to access mental health services (here and here).
We do not currently know what factors directly or indirectly influence suicidality among CALD communities. Potential factors might include level of English proficiency (and its impact on the person’s ability to navigate the health care system), visa status, religious identity, cultural attitudes towards mental ill health, and connectedness to communities.
For background, the Coroners Court in each state and territory is responsible for investigating suspected deaths by suicide (here). Several jurisdictions have established their respective suicide surveillance systems to collect and report timely data and information on suspected and confirmed deaths by suicide.
Suicide registers are currently operational in New South Wales, Victoria, Queensland, South Australia, Tasmania and the Australian Capital Territory.
Our recent research
In our recent research, we initially set out to address this gap using data from the Victorian Suicide Register (VSR) — a detailed repository of information on suicides occurring in Victoria, Australia. Information recorded in the VSR includes the deceased’s sociodemographic characteristics, physical and mental health history, contact with health and other services, evidence of life stressors experienced, and the circumstances of the fatal incident.
Of relevance to our study, the VSR has a field to capture information on the deceased’s country of birth and a field to indicate evidence of possible cultural and/or linguistic diversity (ie, each suicide is coded as having either evidence of CALD identity or no evidence of CALD identity). If there is evidence of CALD identity, coders record the nature of the evidence in free text so that it can be reviewed and analysed.
However, when we examined the available information recorded about cultural and linguistic diversity in the VSR, we found that it was highly variable in scope and detail. For example, some cases had information about the deceased’s first language, when they migrated to Australia, and English proficiency; other cases had not much more than a mention the person had been born in another country. This lack of consistent information about the elements of people’s CALD identity rendered problematic any attempt to understand what aspects of CALD identity and experience might contribute to vulnerability to suicide.
Therefore, we changed our focus from analysing the links between CALD identity and suicide risk to the more fundamental task of understanding what information is available relating to CALD identity in the VSR. We used an existing set of CALD indicators to develop a framework describing evidence of CALD identity and applied this to all suicides that occurred in 2016 and which had been flagged in the VSR as having evidence of CALD identity. We piloted this framework on 2016 data where 652 suicides were recorded in the VSR. Of these, 126 (19.3%) suicides were flagged in the VSR as showing evidence of being of CALD background. After some checks, the final set of CALD cases for this pilot study consisted of 111 suicide cases (17% of all 2016 cases).
What our research found:
- Broadly, the age and sex of decedents coded as CALD reflected the general cohort of suicide deaths in Victoria in 2016; most were male and the median age was 48 years.
- Country of birth was by far the most frequent CALD indicator for which information was recorded for decedents in the VSR; almost 80% of decedents were born overseas. Of the 111 total cases, country of birth was known for 108. Eighty-five of these 108 individuals (97.3%) were born overseas and the most frequent regions of birth were southern Asia (n = 13, 12%), followed by south-eastern European (n = 11, 10%) and Chinese Asia (n = 9, 8%).
- The year of arrival was known for approximately 75% of these individuals.
- There was much less information about citizenship, residency or visa status, preferred language, English language proficiency, religious affiliation and mother and father’s country of birth.
Insights from our research provide considerations for future practice in documenting and understanding suicide across CALD communities. Specifically, the study highlighted the importance of having a formal framework for capturing information about CALD identity and of reviewing how this framework operates in practice to ensure that systematic, meaningful and usable information is being collected.
This is particularly crucial in settings such as suicide, where it is not possible to gather information directly from the individual, and, instead, indirect sources such as the deceased’s family, friends and health care and social service agencies must be relied upon.
Implications from our research
There is a need to develop an agreed, operationalised and multidimensional definition of cultural and linguistic diversity to enable accurate and consistent identification of persons from CALD backgrounds. These data need to be routinely collected across various databases and registers, including suicide registries.
Combining diverse CALD people into one group will likely obscure important differences across a heterogenous population. A multidimensional definition of CALD is critical to understand the distinct characteristics and experiences that may contribute to suicide risk.
This definition could be developed by a multidisciplinary group of experts such as the Culturally and Linguistically Diverse Communities Health Advisory Group in consultation with relevant data custodians.
For organisations administering suicide registers and other health datasets, this agreed definition and an accompanying formal coding framework that clearly informs coders in how to identify and record CALD identity is needed to be able to understand how CALD identity and health outcomes (eg, suicidality) may intersect.
The VSR management team reflected on the data and realised that, in practice, CALD identity had largely been approached as a self-evident category in coding.
The VSR Data Dictionary has now been revised to include an expanded introduction to the concept of cultural and linguistic diversity and an expanded account of the types of information that may be relevant to establishing CALD identity (ie, speaking a language other than English, being identified as part of an ethnic/national community, identifying with a religious faith, parents’ countries or birth, years the person had spent in Australia and degree of English proficiency). Coders have been provided with a refresher training on how to identify and record evidence regarding CALD identity.
These are positive steps forward and we hope for more comprehensive action in this area to help understand suicide risk among people from CALD backgrounds and ultimately reduce deaths by suicide among this population.
If this article has caused you or someone you know distress, please contact Lifeline on 13 11 14 or Beyond Blue on 1300 22 46 36.
Further resources for medical practitioners who need support:
Doctors’ Health in Queensland: https://dhq.org.au/
Doctors’ Health New South Wales: https://doctorshealth.org.au/
Victorian Doctors’ Health Program: https://vdhp.org.au/
Doctors’ Health Advisory Service Western Australia: https://www.dhaswa.com.au/
Doctors’ Health South Australia: https://doctorshealthsa.com.au/
Drs4Drs Tasmania: https://www.ama.com.au/drs4drs/tas
Drs4Drs ACT: https://www.ama.com.au/drs4drs/act
Doctors’ Health Northern Territory: https://doctorshealthnt.com.au/confidential-support
Dr Mandy Truong is an Adjunct Research Fellow at Monash Nursing and Midwifery, Monash University.
Dr Jeremy Dwyer is Manager Research and Policy, Coroners Prevention Unit, Coroners Court of Victoria, Southbank, Victoria.
Dr Jocelyn Chan is a Public Health Physician and Research Officer at the Burnet Institute.
Associate Professor Lyndal Bugeja is Research Lead, Violence Investigation Research and Training Unit and Course Coordinator of Postgraduate Programs at the Department of Forensic Medicine, Monash University.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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