Introduction

Since the 19th century, considerable numbers of Bhutan’s population included ethnic Nepalis (Lhotsampas) whose forefathers migrated from Nepal. In the mid-1980s, the Bhutanese government implemented a “One Country, One People” campaign which sought to unify the country under the Druk culture, religion, and language [1]. The campaign stripped away age-long distinct cultural and religious traditions of Bhutanese-born ethnic Nepalis. The early 1990s witnessed demonstrations in Bhutan followed by a mass exodus of Bhutanese Nepalis fleeing violence and persecution in Bhutan to eventually resettle in refugee camps set-up by the Nepal government. Bhutanese Nepali refugees endured a long stay (16–20 years) at the seven refugee camps in Nepal with many showing symptoms of mental illness and disorders. Studies on Bhutanese refugees in Nepal found a higher prevalence of depression and posttraumatic stress disorder [2], persistent somatoform pain disorder among those reporting torture [3], and elevated levels of serious mental health disorders [4].

The United Nations estimated that as of April 2019, about 96,000 Bhutanese refugees have successfully resettled in the United States [5]. Prior research has found an increased risk of adverse mental health [6] and elevated suicide rates among the Bhutanese refugees [7, 8]. The epidemic of suicides in the Bhutanese refugee communities in the United States triggered a multi-state Centers for Disease Control and Prevention (CDC) study that was conducted in 2012 [9]. The study estimated that the rate of suicides among the United States resettled Bhutanese refugees was 20.3 per 100,000, significantly greater than the United States rate of 12.4 per 100,000 [6]. The CDC study also found that among 423 individuals who agreed to participate in the research interviews, about 3% indicated that they had seriously thought about committing suicide, and suicidal ideation was significantly associated with the symptomatology of mental illness and difficulties experienced after arriving in the United States, such as family conflict and being unable to find work [6].

While the CDC seminal study provided important epidemiological data on suicidal ideation and other mental health indicators among the resettled Bhutanese refugees, more research is needed to better understand the complexity of risk factors associated with suicidal ideation in this vulnerable population. Our study was designed to build on the CDC findings and to extend our understanding of demographic and psycho-social characteristics associated with suicidal ideation among resettled Bhutanese refugees in Ohio. Informal conversations with the key community gatekeepers revealed rapidly growing numbers of resettled Bhutanese refugees across Ohio (reaching an estimated 25,000 around 2015) and indicated that many resettled individuals faced complex challenges and difficulties trying to adjust to their new life in the United States. No midwestern states were included in the CDC study, and prior research has highlighted notable regional and state-level variations in suicide-related risks in the general United States population [10]. Besides, the aforementioned CDC study also noted important geographic differences concerning community-related challenges associated with suicidal ideation among Bhutanese refugees across the four research sites in Texas, Arizona, Georgia, and New York [6], suggesting a need for more studies across different states and communities in the United States.

This study included a more focused assessment of the caste variable in analyzing correlates of suicidal ideation. There is a limited understanding of how the caste system may impact the risk of suicidal behaviors among resettled Bhutanese refugees in Ohio. The caste system is deeply rooted in the social and cultural framework of this community, and it is used to define social hierarchy and exclude groups of people simply based on their ancestral lineage [11]. The caste system among Nepalese, including Bhutanese refugees of Nepali descent, is a highly complicated, multi-layered system of ethnic and social identities, but it could be summed up into 4 main categories, starting from the highest Bahun caste (Brahmans), followed by Chhetris, and Janajati (ethnic minorities) castes. The Dalits (“lower caste”) are at the lowest level of the caste system [11, 12]. Despite official attempts in Nepal to end the caste system, caste-based discrimination remains a significant problem [11], including among migrant and refugee communities [13].

The overall aim of our study was to identify socio-demographic and psychosocial characteristics associated with suicidal ideation among resettled Bhutanese refugees in Ohio to help design effective and culturally competent prevention and intervention programs.

Methods

Study Participants and Settings

The study recruited 200 adult (18 years of age and older) Bhutanese refugees resettled in Franklin County (Columbus), Ohio—a Midwestern state in the United States. The study was conducted in 2015. This study utilized both convenience and snowball sampling techniques. Each survey respondent was asked to recommend another individual for study participation. Participants were compensated with a gift card of $15 for their time responding to the questions. Out of 205 individuals, who were approached for participation, all agreed to take part in the study. However, 5 individuals did not meet eligibility requirements (were younger than 18 years of age), and thus were not included in the study, resulting in an overall participation rate of 97% [14].

Data Collection

Face-to-face structured interviews were conducted in a culturally and linguistically competent manner by trained interviewers who were fluent both in Nepali and English. Interviews were conducted in participants’ homes, in a private setting, without other family members present. Interviews lasted 65–90 min and comprised of 169 questions. We utilized a community-based participatory research partnership to mobilize community gatekeepers in the recruitment of bilingual (Nepali and English) and native Bhutanese interviewers who we later trained for ensuring fidelity and consistency in the survey administration.

Several precautionary measures were implemented due to the sensitive nature of the questions. First, male participants were interviewed by research staff who were also male, while females were interviewed by female staff. Second, any respondent who felt distressed was linked to a caseworker for counseling and/or referred to appropriate clinical providers as needed. Written informed consent was obtained from those who could read and write Nepali or English, and verbal consent was secured from those participants who were not able to read and write. Research staff ensured that a consent form was read, understood, and signed before the administration of the survey. The study was approved by the Institutional Review Board of the Ohio Department of Mental Health and Addiction Services [14].

Measures

Study questions were modeled after the prior CDC study conducted with the resettled Bhutanese refugees in the United States [6]. The original suicidal ideation questions were left intact to preserve the psychometric properties and to allow easier comparison across studies. Lifetime suicidal ideation was assessed with the question: “Have you ever seriously thought about committing suicide?” Lifetime mental health diagnosis was assessed by asking: “Have you ever been told by a doctor, medical health professional, or a healer that you have a mental health condition?” The socio-demographic section included questions about participant’s age, sex, marital status, and educational background. We added a question about ethnicity/caste (“What is your ethnicity/caste?”) which included the following response options: Bahun (Brahmin), Chhetri, Janajati, and Dalit (lower caste).

The study adapted 22 questions from the Harvard Trauma Questionnaire (HTQ) to ask respondents about their past exposure to traumatic events (e.g. rape, forced separation from family, imprisonment, lack of adequate shelter, and physical violence by government authorities) experienced in Bhutan. Nineteen items from the HTQ were used to calculate composite scores of traumatic stress personal experience [15]. These raw scores were then collapsed into a three-category exposure to trauma variable computed as ‘no exposure’ (zero, encountered or experienced no trauma), low (experienced one to five trauma), and high (experienced six to nine trauma). For bivariate and multivariable logistics regression analysis, past trauma exposure was converted into a two-level variable: higher vs. lower/no exposure.

Post-settlement difficulties were assessed with 16 questions [6] about problems after arriving in the United States (e.g. “Little help from charities or other agencies”, “Little help from the government”, “Language barriers”, “Treated poorly because of one’s race or religion”, “Lack of community structures for resolving family disputes”, “Crime committed against the respondent and family”). Positive responses to the 16 questions were added to obtain a total score of post-settlement difficulties.

Perceived social support was assessed using 12 questions (e.g. emotional closeness with another person, having someone they could turn for guidance in times of stress; feeling respect for their skills and abilities; having people they could depend on to help them if help was really needed; having close relationships that provided them with a sense of emotional security and well-being), with each item being rated on a 5 point scale. Perceived social support variable was created by summing up across all 12 items to produce scores indicative of low (score 0–39), moderate (score 40–49), and high (score 50–60) social support [16]. In the analyses, we used low vs. high/moderate social support.

Analysis

To characterize the sample, frequencies and proportions were computed for all categorical variables, and means and standard deviations (SD) for all continuous variables. Next, suicidal ideation groups (those who expressed suicidal ideation vs. those who did not) were compared using the Chi-square test for categorical variables and t-test for continuous variables. Building on prior research [6], the following demographic and psychosocial variables were selected to compare the two groups: age (continuous variable), sex (male vs. female), marital status (married vs. other), education (no formal schooling vs. formal schooling), caste (Dalit vs. other), past trauma exposure (higher vs. none/lower), post-settlement difficulties (continuous variable), ever diagnosed with a mental health problem (yes vs. no), and social support (low vs. high/moderate). Variables with p-values <0.05 in the bivariate analyses were selected for inclusion in the multivariable logistic regression model. The Hosmer and Lemeshow test was used to assess the “goodness of fit” of the model. All analyses were conducted using SPSS version 26.0.

Results

Demographic and Psychosocial Characteristics

Nearly 60% of the total sample (n = 200) were male. Most participants (77.9%) were married. The mean (M) age of the participants was 45.3 (SD 15.1). More than half of the study participants (55.0%) had no formal education. Most of the study participants were of Bahun (42%) and Chhetri (27.0%) castes. Twenty-four participants (12.0%) belonged to the Dalit caste (Table 1).

Table 1 Socio-demographics, suicidal ideation, and psychosocial characteristics of resettled Bhutanese refugees in Ohio (n = 200)
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Eighty-three individuals (41.5%) reported high exposure to trauma due to their forced migration from Bhutan to Nepal (past exposure to trauma). Twenty-six individuals (13%) reported being told by a doctor or a mental health professional that they had a mental health condition, with 61.5% of them reporting depression.

The mean number of post-settlement difficulties endorsed by the study participants was 5.1 (SD 3.2). Most reported post-settlement difficulties the study participants experienced were: “Little help from charities or other agencies” (81.5%), “little help from the government” (79.5%), and “language barriers” (76.4%). In terms of perceived social support, over half (59.0%) fell in the high support range, and 11.5% reported low social support (Table 1).

Factors Associated with Suicidal Ideation

Out of 200 participants, 12 (6.0%) reported lifetime suicidal ideation. Bivariate analyses of selected socio-demographic and psychosocial factors identified four variables that showed a statistically significant association with suicidal ideation (Table 2). Individuals who reported suicidal ideation (compared to those who did not) were more likely to be of Dalit caste (33.3% vs. 9.8%, p < 0.05) and those experiencing a greater number of post-settlement difficulties (M of 8.0 vs. 4.9, p < 0.01). Individuals with suicidal ideation were also more likely to have a diagnosed mental health condition (54.5% vs. 10.4%, p < 0.001) and to report low social support than the group without suicidal ideation (66.7% vs. 7.7%, p < 0.001). There were no statistically significant differences between the two groups in terms of age, sex, marital status, education, and past trauma exposure (Table 2).

Table 2 Bivariate comparisons of sociodemographic and psycho-social characteristics by suicidal ideation group of resettled Bhutanese refugees in Ohio (N = 200)
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Multivariable logistic regression analysis included four independent variables that were significant at p < 0.05 in bivariate analyses: caste, post-settlement difficulties, ever diagnosed with a mental health condition, and social support (Table 3). Multivariable logistics analysis results show that individuals with mental health diagnosis had nearly nine times greater odds of having suicidal ideation [adjusted odds ratio (AOR): 8.7, 95% CI (Confidence Interval): 1.7–43.9] compared to individuals who did not have a prior diagnosis of mental health condition. Low social support (AOR: 23.6, 95% CI: 4.5–124.8) was also associated with significantly greater odds of suicidal ideation. Odds of suicidal ideation increased about 40% with each additional post-settlement difficulty reported by the study participants (AOR: 1.4, 95% CI: 1.1, 1.8). Dalit caste had elevated odds of suicidal ideation but was statistically not significant (Table 3).

Table 3 Multivariable logistic regression analysis to identify correlates of suicidal ideation among Bhutanese refugees in Ohio (n = 200)
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Discussion

Our study found that 6% of the resettled Bhutanese recruited in Ohio expressed suicidal ideation. This is twice the 3% prevalence of suicidal ideation found in the CDC 2012 study of resettled Bhutanese refugees in Texas, Arizona, Georgia, and New York [17]. Our study also identified a higher prevalence of suicidal ideation among individuals with prior diagnoses of mental health conditions (13.0%), compared to the CDC study (4.0%) [18]. There could be several distinct reasons for findings of higher prevalence of suicidal ideation and mental health conditions in our study population in Ohio, in comparison to the CDC study. First, there may be regional differences, as national mental health statistics indicate [19]. Second, our sample recruitment built on convenience methods, while the CDC study built on random sampling and had a response rate of 73% [9]. Third, in the CDC study, persons who had more troubling mental health histories might have been more likely to decline participation when approached through a random recruitment mechanism. In contrast, because our study in Ohio built on social connections through snowball sampling and convenience-based recruitment, participants might have felt more comfortable to participate and open up about their troubled histories and experiences. Fourth and finally, greater prevalence of diagnosed mental health conditions in the Ohio sample might also suggest that individuals had more access to mental health providers due to regional differences in service provision and health care policy changes associated with the Affordable Care Act [20] as our study in Ohio was conducted in 2015, while data collection for the CDC study occurred in 2012 [17].

Multivariable logistics regression analysis determined that prior diagnosis of mental health condition was a strong predictor of suicidal ideation in our sample. Overall, the association between mental disorders and suicidal behavior has been well established, and prior research in the United States and other countries has demonstrated that mental disorders play an important role in a large majority of all suicides [21, 22]. The provision of accessible and culturally competent mental health services to resettled Bhutanese refugee communities is of key importance for helping to reduce suicidal behaviors in this community. More research is needed to better understand knowledge, attitudes, and behaviors associated with mental health service use among Bhutanese refugees to develop culturally tailored approaches to individuals in need.

Low social support was another strong predictor of suicidal ideation in our multivariable regression model. Prior studies have shown that social support often has a buffering effect against life stressors, and individuals with better social support systems have better mental health outcomes and lower risks of suicidal behaviors [23]. Social support is considered a highly modifiable factor in designing suicide risk reduction interventions [23]. It is also important to recognize that culture has a profound impact on how social support is defined, perceived, and experienced [24]. The cumulative impact of forced migrations, resettlements, and evolving acculturation to the new way of life in the United States has disrupted the social support systems and associated expectations and feelings of social belonging and support among the resettled Bhutanese refugee communities. Therefore, service providers working with the resettled Bhutanese refugee communities require an in-depth understanding of social processes and cultural norms related to social support systems and associated behaviors.

Our study included a caste variable to assess the potential impact of caste-related discrimination on suicidal ideation. Dalits, also referred to as “oppressed” or “lower caste,” are the lowest caste in the complex social hierarchy of Bhutanese society [25, 26]. As compared to members of higher castes, Dalits have experienced a long history of discrimination and have often shown a greater prevalence of poor health [11, 25, 26]. In the bivariate analyses, Dalit caste was associated with a greater likelihood of suicidal ideation, and this association was statistically significant (p < 0.05). In the multivariable logistic regression model, controlling for mental health, low social support, and post-settlement difficulties variables, the association between Dalit caste and suicidal ideation did not reach statistical significance. Prior research conducted in rural Nepal (with cultural and social context like those in Bhutanese refugee communities) found that the caste-based disparities in mental health were mediated by poverty, low social support, and stressful life events [11]. Due to sample size limitations, our study did not conduct mediation analyses. The observed association between caste and suicidal ideation in this study might be due to chance. More research with larger samples of resettled Bhutanese refugees is needed to identify and characterize potential mediation mechanisms associated with caste effects on suicidal ideation.

Post-settlement difficulties were also linked to greater odds of reported suicidal ideation. It is important to recognize that the observed association between the two variables does not indicate causation. Since the study assessed a lifetime history of suicidal ideation, in some cases, suicidality might have occurred prior to moving to the United States (and thus experiencing post-settlement difficulties). Prior studies have also identified similar associations noting issues such as lack of help from the government, other organizations, and language barriers [17]. From a policy and service provision standpoint, it is critical to create awareness among resettled Bhutanese refugees about available resources. Service providers should implement community-based strategic outreach to raise awareness about available resources and enhance collaborations with the Bhutanese refugee community to establish trust [15].

Limitations

This study utilized both convenience and snowball sample recruitment methods and was limited geographically to Ohio, unlike the multi-state CDC survey which utilized random sampling. Hence the findings may not be generalizable to the broader Bhutanese refugees resettled in the United States. The study is also vulnerable to limitations that are common to previous studies. First, suicidal ideation was likely subject to reporting bias and increased variance due to the small sample size [17]. Second, suicide attempts and self-reported mental health conditions might have been under-reported because of the sensitivity of the topic [7, 17]. The study took several steps to minimize these limitations. Trained interviewers conducted the interviews in private settings, with no family members present. Interviewers did not interview participants if they knew them personally and interviews were conducted in a culturally competent manner by mobilizing bilingual (Nepali, English) interviewers and by providing surveys in Nepali and English version. Finally, another important limitation in our study is that the findings are limited due to the cross-sectional nature of the study. Especially it is relevant to note that in a cross-sectional study, temporality between the outcome and the risk factor is a major challenge. In our case, it is even more problematic considering many cases where suicidal ideation may have occurred prior to the resettlement in the United States.

Conclusions

Suicidal ideation among Bhutanese refugees is associated with a mental health history, low levels of social support, and post-settlement difficulties. Culturally and linguistically competent mental health prevention and treatment, and community support programs are required to support resettled refugees in the United States.