A REVIEW STUDY OF FACTORS INFLUENCING SUICIDE AMONG SOUTH ASIANS IN THE UK

Purpose of the study: A systematic review of studies on factors in the suicide of South Asians in the UK was reviewed to enhance understanding by aggregating those factors contributing to suicide in this diverse group. Methodology: Digital databases PsycArticles, PsycINFO, PubMed, JSTOR, Science Direct, Web of sciences, and Google Scholar, were searched from 1990 to 2018 and, six studies were included for the review. Main Findings: Factors like cultural conflict, mental health issues, family relationships, and religious & other social aspects influence suicide in South Asians in the UK. Also, better family contact, culturally sensitive interventions & services, and educational pamphlets could support preventive strategies. Applications of this study: Future research needs to concentrate on the reasons behind high rates of suicide in social class 1 and disaggregation of factors in sub-groups of South Asians in the UK to support the development of sound preventive strategies. Novelty/Originality of this study: First study ever to aggregate factors in the suicide of South Asians in the UK.


INTRODUCTION
Suicide is a complex and significant global concern (Lai et al., 2017). Rates of suicide in the world are reported as 10.5/100,000 people (WHO,2016). In the UK, suicide is one of the leading causes of death, with a rate of 11.2/100,000 people. Rates in males and females reported 17.2 per 100,000 and 5.4 per 100,000 people, respectively (Office of National Statistic, 2018). Suicide also prevails among immigrants in the UK that constitute 7.9% of the total population. South Asians amongst them represent 35% of that population. Evidence regarding suicide in South Asians revealed an increase in the number since after the first analysis in 1970. Suicide in British South Asians was identified as 2 % & 2.6% of the total suicide reported between 1996 to 2000 and 1993 to 2003, respectively (Ineichen, 2008;Mckenzie et al., 2008).
Suicide in immigrants is a multi-dimensional phenomenon because different factors can play their role. These factors may include social issues, cultural differences, economic strains, psychological stressors, mental health illness, family problems, discrimination, racism, migration process, and adaptation problems (Lai et al., 2017). These factors can pose potential risks to immigrants that may vary from group to group. South Asians as immigrants living away from their homeland with a new culture may also face challenges such as stress, accommodation problems, the gap between generations, economic deprivation (Low socioeconomic position, poverty, unemployment), low ethnic status, acculturative stress, parental pressure, family control, family honor, psychiatric illness, depression, minority status, ethnic identity, discrimination, racism, teenage freedom and religious variations (Raleigh et al.,1990;Patel &Gaw, 1996;Khan & Waheed, 2006;Ineichen,2008;Mckenzie et al., 2008).
These aspects elucidate the necessity for understanding factors responsible for articulating suicide in South Asians in the UK to help developing sound preventive strategies. Studies that have covered suicide in British South Asians figured out rates, trends, and patterns where each study revealed different contributory factors. Additionally, some studies have covered South Asians as ethnic-minorities, factors pooled together where the overlapping of results affect an understanding of the phenomena in South Asians (Lester,2000). Furthermore, studies on suicidal behaviour in immigrants or ethnic minorities addressed suicide attempts and suicide where factors explored for both the phenomena without disaggregation (Kliewer, 1991). These mixed explanations of factors may lead to the misunderstanding that could act as barriers in implementing preventive strategies and delivering services.
The UK established its first prevention plan in 2019, where the role of social media and the latest technology stressed with a better understanding of factors that can lead to suicide. Immigrants may face problems while accessing mainstream health services, possibly because of less cultural appropriateness of services or lack of information (Lai,2017). These could link to the misunderstanding of the factors in the suicide of South Asians in the UK.

Rationale and Objective
To our awareness, limited literature studied factors in the suicide of South Asians living in the UK. Available studies revealed that each study has reported different factors in South Asians as cultural differences, familial problems, religious influences, etc. Exploration of such a single factor represents a uni-dimensional explanation of the phenomena. Hence it may not help draw a comprehensive picture of factors in the suicide of South Asians in the UK that may lead to an incomplete understanding of suicide in this diverse group. Furthermore, some studies lacked disaggregation of factors for suicide in South Asians while discussing other suicidal behaviours. These also develop confusion, which may act as hurdles in understanding suicide. Therefore, the current review focuses on aggregating only those factors that lead to suicide in South Asians in the UK.
The purpose of the review is to comprehensively highlight factors in the suicide of South Asians in the UK to enhance understanding of the phenomena in this diverse group. Also, the focus is on South Asians in the UK only because groupspecific factors associated with suicide ensures valuable addition to knowledge and practice. Additionally, previous research conducted in Canada stressed the need to study immigrant groups in different host countries (Lai et al., 2017); hence this review is a partial effort to address that gap in suicide research identified by the researchers.

METHODOLOGY
Internet sources were used for the identification of literature in November 2018. These included PsycArticles, PsycINFO, PubMed, JSTOR, Science Direct, Web of sciences, and Google Scholar. Initially, the full text was downloaded from each database. The inclusion of these databases relied on the availability of content regarding suicide. Articles in the English language only were included. Search items used: suicide, suicidal, and South Asians or South Asian immigrants or immigrants from Indians subcontinent or Indian immigrants and UK or British or England & Wales. Articles for the year 1990 to 2018 are included in this review.
A total of 177 articles were downloaded, where initially, titles of the studies were screened for relevancy. At this stage, 77 articles were deleted, which was followed by abstract reading, so 55 more were excluded because of irrelevancy. Finally, after full reading, thirty-nine more research articles were excluded. Hence six research articles were identified as fully potential articles for this study. Each research article was read many times, where a matrix was developed to classify definitions of concepts, methods, results, findings, and factors. This process helped in the identification of the factors discussed in each article. Criteria for inclusion of research articles focused on (1) Research articles published between 1990 to 2018 (2) peer-reviewed in the English language (3) title mentioning suicide, South Asian or Indians immigrants and the UK or British or England & Wales.

Study Concepts
Suicide is defined as "an intentional act of self-killing; hence it means that it is an act with intentions of death but, the act where intentions of death are not involved would be a non-suicidal act. The act where people risk their lives with a possibility of death, but their actual end is not death. Then this could be gambling with life and death" (Taylor, 1988 cited by Maskill, et al., 2005.p.4). In this review, the focus is only on suicide; therefore, other related suicidal behaviours such as suicide attempts, suicide ideation, or thoughts and suicide plans are excluded to avoid overlapping the understanding of contributory factors.
Immigrants are defined as "Persons residing in a country who was born outside of that country, and who arrived through an immigration or refugee program." South Asians are those immigrants having their origin in Pakistan, India, and Bangladesh. In the UK, they are categorized as Asian or Asian British: Bangladeshi, Indian and Pakistani. South Asians are not homogenous to other immigrant groups because of their diversity, reports by researchers claimed that generalization of results could silence the diversity of the immigrant group (Lai et al.,2017, Mckenzie et al., 2008, Ineichen, 2012.
In this review, most of the studies have mentioned South Asians as Pakistanis, Indians, and Bangladeshis while, one study also included Sri Lankans (Raleigh et al., 1990). Hence in this review, South Asians are referred to as Pakistani, Indians, and Bangladeshis in UK Studies in this review have also used the terms immigrants from Indian Subcontinent or Indian immigrants and British South Asians for South Asians in the UK Pakistani, Indians, and Bangladeshi share some similarities in terms, of geographical origin, cultural traits, social structure, etc., (Khan & Waheed, 2006, Ineichen, 2008, Raleigh et al., 1990. Due to these homogenous features, they are grouped as South Asians in this review. However, there are also differences in them, such as religious differences that make each of them a sub-group. This review cannot cover each as a sub-group.

SEARCH RESULTS AND ANALYSIS
Six studies were included in this review. Of these, three were qualitative ( Research articles read again & again for the identification of themes/categories and key factors with similarities and differences. Factors identified in the context of suicide grouped along with prevention strategies. The analysis was conducted by reviewing articles in detail. In the next phase, factors responsible for suicide were grouped, and lastly main themes with the help of grouped factors identified from detailed study (i) Cultural conflict (ii) Mental health issues (iii) Family relationships (iv) Religious and other social aspects. Details are mentioned in the table.1 below.

RESULTS
Cultural Conflict: Turner defines it as a conflict caused by "differences in cultural values and beliefs that place people at odds with one another" (Turner, 2005). Alexander Grewe defines this conflict as one that occurs when people's expectations of certain behaviours coming from their cultural backgrounds are not met, as others have different cultural backgrounds and different expectations (Grewe, 2005). Study findings explored cultural conflict as a risk and contributory factor in the suicide of South Asians in the UK (Mckenzie et al., 2008& Raleigh et al.,1990. Study findings regarding the influence of cultural conflict on suicide in South Asians in the UK explore different aspects. For instance, a qualitative study reports a difference between home and host culture with experience of acculturative stress is related to suicide. The rate of acculturation for earlier and later generations of South Asians is leading to a family conflict: associated with suicidal behaviour (Khan & Waheed, 2006). Another qualitative study identifies that eastern culture imposes restrictions on girls within a western culture is connected to suicide in them. Conflict over parental influence and children's freedom may also lead to suicide (Ineichen, 2008). Traditional rules abolishing an individual's decision-making over personal matters leave no option but to commit suicide, reported in a qualitative study. Attraction in host culture may lead to an ethnic-cultural conflict identified as a risk factor (Khan & Waheed, 2006).

Mental Health issues
Mental illness is a risk factor for suicide, high rates of depression, self-harm, and suicide are identified in South Asians (Mckenzie et al., 2008). Two qualitative studies report that South Asians do experience a high level of stress which is associated with depression and Impulsive acts of self-harm due to interpersonal stress: these are more frequent in young people but, due to improper diagnosis mostly just referred to mood disorder (Khan & Waheed, 2006, Ineichen, 2012. The studies also explore that doctors overlook South Asians with psychological problems. Also, a lack of trust in care providers could be a factor. Besides, delay in seeking help with perception and response to depression has been identified as a responsible factor (Khan & Waheed, 2006). South Asians may withhold psychological problems from their doctors. Failure to recognize depression and low rate of children referral to service providers while the difference in symptomatology could also be prominent factors (Ineichen, 2008). Therefore, a qualitative study further explores that culturally sensitive psychological interventions and health services may help in preventive strategies. Also, educational pamphlets and multilingual services for a newly arrived bride to the UK can play a positive role (Khan & Waheed, 2006;Ineichen, 2008).

Family Relationships
Family relationships influence suicide in immigrants because of the migration process and difference in culture. Its influence can be significant in South Asians because they may experience social transformation. Two qualitative studies explored that family conflicts and family problems are associated with suicide: Such as conflicts due to family structure, decision making, and interpersonal conflicts within a family (Khan & Waheed, 2006, Ineichen, 2008. A quantitative study identified that marital status could be a risk factor for women, and arranged marriages are considered as contributory factors (Raleigh, 1990). Bereavement and long-term illness in old age linked with family life in South Asians identified as a risk factor for depression and suicide (Mckenzie et al.,2008). A qualitative study also identifies relations with in-laws and depressed family members as responsible factors in suicide. This study further explores that better family contact can decline the suicide rate (Ineichen, 2008).

Religious and Other Social aspects
Religious and other social aspects can influence suicide. South Asians in the UK may have variations in their suicide because of religious differences. Other social issues may vary from group to group in terms of influence on suicide in South Asians.
Muslims have lower rates of suicide as compared to practising Hindus or Sikhs. Pakistani and Bangladeshi groups are 90% Muslim, while the Indian group is 75% Hindu or Sikh. A quantitative study identifies that a high proportion of Indians who committed suicide were Hindus or Sikh (69% of men and 83% of women). In comparison, Muslims were lower in percentage (26% of men and 15% of women) (Raleigh et al., 1990;Tuck et al., 2015).
In South Asians, higher rates of suicide are reported in the upper social class compared to the lower. Variations seen in social class 1 of different cultural groups such as Social class 1 of Indian women reported with 13.8% suicide compared to 4.9% of the general population (Raleigh et al., 1990).
Furthermore, language in-proficiency and the absence of confiding relationships can also be factors in the suicide of South Asian women (Khan & Waheed, 2006).

DISCUSSIONS
To our awareness, this is the first-ever effort to review research studies on suicide in South Asians in the UK. This review identified some issues in the respective studies. A study in the decade of 1990 reported higher rates in young Asian women (Raleigh et al., 1990). Another study in the decade of 2000 explored higher rates in older women (Mckenzie et al., 2008), that shift in the rates within a decade indicates that South Asians in the UK, especially females, are confronting variations in their rates of suicide with time. Now another decade has passed over the previous research so, is there any change in the suicide rate of South Asian females? And are those earlier results still reliable? Hence new research in this decade will help to avoid over-generalization or misunderstanding of available data.
Higher rates of suicide are reported in South Asian young females previously but recently in older females (Raleigh et al., 1990& Mckenzie et al., 2008. They explored that culture imposes more restrictions on females than males: they may face more confusion while developing separate identities for home and school and can be troubled at getting higher education or employment. These cultural aspects are resulting in interpersonal conflicts (Leach, 2006;Leong and Leach, 2008). Furthermore, earlier generations adhere to their cultural systems while later generations, becoming more westernized in their approach to life and social values. These lead to a difference in the rate of acculturation that is leading to a gap between generations (Goldston et al., 2008; Langhinrichsen-Rohling, Friend, and Powell,2009). Also, the traditional family structure in South Asians highlights male dominancy, especially in decision making (Khan & Waheed, 2006), which leads to clashes between teenagers and their parents . These clashes may emerge over love marriages or arranged marriages (Ineichen, 2008). Therefore, such cultural issues are also exposing South Asians to suicide.
Mental illness is a prominent factor in the suicide of the European countries but is occasionally reported in South Asians (Patel & Gaw, 1996). Depressive episodes and anxiety disorders are most common among Indian and Pakistani women, while they consider mental illness as a stigma socially unacceptable. This fear of stigmatization compels patients to delay help-seeking or leaves patients under-carpeted and undiagnosed (Khan & Waheed, 2006). Hence, underrating of severe cases may lead to suicide (Patel & Gaw, 1996). Additionally, doctors mostly overlook mental illness in South Asian patients or most commonly referred to as physical problems. For example, five South Asian women patients had symptoms of depression for a year, and the doctor diagnosed only one patient. Also, white women patients were mostly referred to mental services while South Asian women were sent home under the observation of local medical care. The lower dosage of anti-depressants prescribed by a doctor is also a problem identified in South Asian patients than white patients (Ineichen, 2008). Also, the issue of trust deficit over service providers and doctors could leave South Asian women vulnerable to worse mental conditions. These women fear a service provider from a local community or a family doctor because it may expose them to the community or share information with their families. Also, there are variations in the attitude of South Asians towards the treatment of mental illness. For instance, they may visit the shrines of holy men in times of stress or may believe in the influence of spirit in depression or other mental illness and exorcise by religious leaders for healing a mental issue. There is a tendency of low referral of a child to guidance services in some parents so, could be hiding child's problem, or there may be no problem at all, but genuine reason not known yet. The Attitude of South Asians toward symptoms of mental illness may vary. For instance, a Muslim teenage girl might get appreciation and praise for social disconnectedness and solitude but might be considered a psychological issue for a white girl (Ineichen, 2008). It is suggested that culturally approved healing may have the effect of enhancing cohesion in minority groups. For instance, effective GP intervention can be problematic, especially when the doctor and patient are of the opposite sex (Ineichen, 2012).
Family relations are vital in articulating problematic zones for suicide and patients of depression (Ineichen, 2012). In the suicide of married women, marital difficulties and violence are prominent. It is problematic in-laws who may frequently be insulting, taunting those women, and physical abuse by their husbands that could develop posttraumatic stress disorder (Lester, 1995). Also, disputes with parents-in-law and infertility or inability to bear a male child explored as reasons for higher rates of suicide in South Asian women compared to their counterparts in the local population or other ethnic groups. Infertility could be a source of family conflict for married women because, in South Asian culture children; is given priority especially, male: hence women are considered responsible for this matter (Gibbs, 2000;Maris et al., 2000). These factors were also reported for South Asian married women with immigrant status outside the UK. South Asian single females may face interpersonal conflict with immediate family members at times of love affair or premarital relations (Patel & Gaw, 1996). These may partially help in elaborating suicide because girls are under strict protection with the expectation of virginity at marriage otherwise rejected by family and community (Khan & Waheed, 2006). Also, Traditional South Asian parents having expectations from their westernized children bring some evidence to explain suicide in young females (Patel & Gaw, 1996). South Asian families also reported with siblings having problematic relations: it could partially be explained by expecting daughters to participate in household work with their mothers. In contrast, boys do not have such obligations (Ineichen, 2008). It is suggested that better family contacts such as supporting family interactions, relationships, and family counseling can help in preventive strategies (Lai et al., 2017).
Chronic ill health or a depressed family member could be a causing factor in suicide, which is a possible link to family conflicts (Patel & Gaw, 1996;Ineichen, 2008). Evidence explores that in South Asian women, bereavement and longterm illness are associated with depression and suicide. These could be linked to the lower life expectancy of South Asian men as they are leaving a large number of bereaved older females who may also be suffering from a long-term illness (Mckenzie et al., 2008). In this regard, the death of a family member is also noted as a contributory factor in the suicide of South Asian immigrants in Fiji (Patel & Gaw, 1996).
Studies on suicide in South Asian immigrants consistently reported higher rates of suicide in Hindus and lower rates in Muslims. Lower rates may be due to strong endorsement of moral and religious reasons for living in Muslims than Hindus. It could also be linked to the prohibition of suicide in Islam such results also reported by (Phillips, 2013). A notion that artificial lowering of suicide in Muslim countries could be responsible for lower suicide rates (Stack, 2000). These are mainly due to the absence of suicide registration process or inclusion of suicide in other violent deaths but, consistent reports regarding lower rates of suicide in Muslims possibly indicate that Islam has an independent effect on lowering suicide rates (Simpson and Conklin, 1989.pp,947; Wray, Colen & Pescosolido, 2011 ), possibly because in Islam suicide is a disobedience to Allah (God) (Tuck et al., 2015).
Regarding higher rates in Hindus the ritual of 'sati' (a window woman killing herself in a fire with the dead body of her husband) allowed by ancient Hindu text could be, mirrored though banned by law now but still functioning with rarity (Khan & Waheed, 2006). The religiosity influence can be phenomenal as it lowers the risk of suicide reported by (Hilton, Fellingham & Lyon, 2002;Pescosolido & Georgianna, 1989;Pescosolido, 1990). That means religiosity in South Asian Hindus could be negatively affected by western culture.
Higher rates of suicide reported in the upper social class of South Asian immigrants. These include professionals and managers amongst both males and females. Amongst them, doctors and dentists found a larger proportion (Raleigh et al., 1990). These rates for South Asian women were also higher when compared to women in the local population. Why the suicide rate is higher in the upper social class than the lower in the same population.? To our awareness, no data available on this matter. It would need further investigation to clarify the reasons. The belief that easy and legalized access to medicines & poisonous materials might be facilitating their action, especially in doctors and dentists.
Studies on suicide in South Asians reported language in-proficiency as a factor leading to stress and anxiety while influencing suicide (Khan &Waheed, 2006;Singh, 2000). Language in-proficiency limits the ability to communicate with local people in the host country, thereby increasing isolation. Women were reported with self-harm in response to isolation, but such women may also be going through a lack of friendship networks (Khan & Waheed, 2006).