Congratulations on a wonderful job in developing the New Zealand Suicide Prevention Strategy. I am pleased to see an inter-sectoral approach that is both evidence and strengths based. It is also encouraging to see mention of diverse communities and an approach that integrates protection, promotion, early identification, crisis support, attention to families and support in the aftermath of suicide. Thanks for the opportunity to add my rather swiftly developed submission to the New Zealand suicide prevention strategy. I am focussing this submission on Asians and South Asians in particular, but am aware (as per our teleconference on Friday) that these issues pertain to other migrant and refugee groups as well.

My key points are:

  1. Asians are a high risk group for suicide and attempted suicide according to overseas research (especially South Asian young women).
  2. We need better ethnicity data collection practices as data is limited.
  3. There are issues with the umbrella term Asian which disguise differenceswithin groups.
  4. There are significant barriers in accessing services, particularly mental health services.
  5. Further research is needed that is clinical and epidemiological in order to identify prevention and intervention strategies that may vary from other groups.

Asians and statistics

Asians are a growing population in New Zealand. By 2016 they are expected to make up 9% of New Zealand’s and 20% of the Auckland Region’s total population. As such the health and social service needs of Asians must be considered by service providers. As you are aware there is limited research data available in New Zealand, 12 Asian people died by suicide (10 males and two females) in 2002, compared to 20 deaths

in 2001 and 21 deaths in 2000 (Ministry of Health, 2005). In our teleconference we also expressed concern the underreporting of suicide and coronial issues. I am concerned about the category as there is diversity within the people subsumed into the category Asian, with some groups especially at risk and others well protected) and the concept has limited use (Aspinall, 2003; Henare & Ehrhardt, 2004).

High rates of suicide and attempted suicide

Disproportionally high rates of suicide and attempted suicide have been found among South Asians in the diaspora (Batsleer, Chantler, & Burman, 2003; Bhugra & Desai, 2002; Bhugra & Hicks, 2004; Burr, 2002; Hicks & Bhugra, 2003). The highest were in young women of South Asian origin who have rates that are double that of the White population in the United Kingdom of completed suicide and 1.6 times more likely to attempt suicide(Hicks & Bhugra, 2003). Hicks and Bhugra examined perceived causes of suicide attempts in 180 ethnic South Asian women living in the London area. The three factors endorsed most frequently and strongly as causes of suicide attempts in South Asian women were violence by the husband, being trapped in an unhappy family situation, and depression. South Asian women are also two and a half times more likely to attempt suicide that South Asian men.

Barriers to accessing services

Recent New Zealand research has found that barriers for Chinese people accessing services include a lack of English language proficiency leading to communication difficulties and knowledge gaps, for example, being unaware of what services are available; the important role of primary healthy care and General Practitioners in particular as a first point of contact and a lack of awareness of the health and civil rights of citizens in New Zealand (Ruth DeSouza & Garrett, 2005). The research identified regional differences in terms of the place of birth of respondents and, in particularly, it was noted that Chinese-born respondents experienced more communication difficulties than those born in Hong Kong or Taiwan. Some of the strategies recommended in the report which are pertinent here include: encouraging cultural competence in health services (clinical, systemic and organisational), staff training and workforce development, developing partnerships with ethnic communities and community organisations, involving ethnic communities in strategic planning and linguistic competence. The latter involves not only ensuring that resources are available in several languages but also that interpreting and translation services are available.

Accessing mental health services

There are issues in attempting to access mental health services as well which are compounded by stigma within ethnic communities and anxiety from the mental health workforce. Increasingly mental health services are being called on to provide culturally appropriate care, but little is known about what that constitutes. Such a call cannot be answered if mental health professionals are not prepared for working in ways that are culturally competent. Despite the emphasis on cultural safety as part of the curricula of undergraduate health professional preparation, it has largely been concerned with Treaty obligations to Tangata whenua rather than evolving to meet the needs of ethnic communities (R. DeSouza, 2004). Burman, 2003, p.106) found in a research project investigating suicide and self-harm in the United Kingdom among South Asians that staff working with the women were caught in ‘race anxiety’ whereby white staff were hesitant and silent around issues to do with race, gender and mental health and were concerned that their actions were not misinterpreted. Their responses were to pass on issues to their South Asian counterparts or to avoid them. For the South Asian workers there was concern that discussing issues like this would reinforce or add to the existing stereotypes. This culture of silence within mainstream services was viewed as frustrating and annoying.

Ruth DeSouza Centre Co-ordinator/Senior Research Fellow Centre for Asian and Migrant Health Research Faculty of Health & Environmental Science Auckland University of Technology Address: Private Bag 92006, Auckland 1020

Ethnicity data collection

There is a need for improvements in quality ethnicity data collection so as to more clearly ascertain health needs and dispraities (Aspinall, 2003; British Medical Journal, 1996; Klajakovic, 1993; Latimer, 2003; McLeod et al., 2000; Ministry of Health, 2001, 2003, nd-a, nd-b; New Zealand Health Information System, 1996; Pringle & Rothera, 1996; Senior & Bhopal, 1994; Statistics New Zealand, 1996; Thiru, Hassey, & Sullivan, 2003; D. R. Thomas, 2000; S. B. Thomas, 2001). Several reports and research findings confirm that ethnicity data collection is poorly conducted by staff. A Waitemata District Health Board review found that staff were unaware of national guidelines for collecting data, had not received training on why and how ethnicity data was collected and consequently collected it inconsistently (Latimer, 2003). An internal paper for the Ministry of Health based on interviews with key stakeholders and a literature review found that there was inconsistency in the way in which data was collected and that what was collected was inaccurate and incomplete and that the concept of ethnicity was misunderstood (Ministry of Health, nd-a). These factors point to the need for support and training to facilitate accurate data collection. In order that ethnicity data is collected consistently and accurately ethnicity questions need to be aligned with Statistics New Zealand Census question for 2001 so that they are standardised. Variation exists across health providers around the method of ethnicity data collection, ranging from not asking and using previous admission information, to asking verbally to postal or using a show card. Furthermore, in secondary care, staff rely on information from GP’s which has been found to be problematic. A national survey of 1,062 members of the Royal New Zealand College of General Practitioners (RNZCGP) found that only 20% of practices collected ethnicity data. A recent study of 12 South Island practices found ethnicity was recorded for only 5% of patients (McLeod et al., 2000). Other problematic areas include the assumption of ethnicity by a provider.

Recommendations

• Further research and exploration of factors is needed in clinical and epidemiological studies of suicidality in South Asian women which might then contribute to prevention and intervention strategies.

• Better collection of ethnicity data (McKenzie, Serfaty, & Crawford, 2003). • Access to information in commonly used languages. • Encouraging cultural competence in health services (clinical, systemic and

organisational). • Staff training and workforce development. • Developing partnerships with ethnic communities and community

organisations. • Involving ethnic communities in the design of services.

Ruth DeSouza Centre Co-ordinator/Senior Research Fellow Centre for Asian and Migrant Health Research Faculty of Health & Environmental Science Auckland University of Technology Address: Private Bag 92006, Auckland 1020

References

Aspinall, P. J. (2003). Who is Asian? A Category that Remains Contrived in Population and Health Research. Journal of Public Health Medicine, 25(2), 91-97.

Batsleer, J., Chantler, K., & Burman, E. (2003). Responses of health and social care staff top South Asian women who attempt suicide and/or self-harm. Journal of Social Work Practice, 17(1), 103-114.

Bhugra, D., & Desai, M. (2002). Attempted suicide in South Asian women. Adv Psychiatr Treat, 8(6), 418-423.

Bhugra, D., & Hicks, M. H.-R. (2004). Effect of an Educational Pamphlet on Help- Seeking Attitudes for Depression Among British South Asian Women. Psychiatric Services, 55(7), 827-829.

British Medical Journal. (1996). Style Matters: Ethnicity, race, and culture: guidelines for research, audit, and publication. British Medical Journal, 312, 1094. Burr, J. (2002). Cultural stereotypes of women from South Asian communities: mental health care professionals’ explanations for patterns of suicide anddepression. Social Science & Medicine, 55(5), 835-845.

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Culturalsafety (pp. 122-133). Auckland: Pearson Education New Zealand.

DeSouza, R., & Garrett, N. (2005). Access Issues for Chinese People in New Zealand(draft). Auckland: Accident Compensation Corporation.

Henare, K., & Ehrhardt, P. (2004). Support for Maori, Pacific and Asian Family,Whanau, and Significant Others who have been bereaved by suicide: Findings of a literature search. Wellington: Ministry of Youth Development.

Hicks, M. H. R., & Bhugra, D. ( 2003). Perceived Causes of Suicide Attempts by U.K. South Asian Women. American Journal of Orthopsychiatry, 73(4), 455-462.

Klajakovic, M. (1993). Is it easy collecting ethnicity data in general practice? NewZealand Medical Journal, 106, 103-104.

Latimer, S. (2003). Waitemata District Health Board: Ethnicity Data Collection Baseline Review. Auckland: Waitemata District Health Board.

McKenzie, K., Serfaty, M., & Crawford, M. (2003). Suicide in ethnic minoritygroups. British Journal of Psychiatry, 183(2), 100-101.

McLeod, D., Harris, R., Bailey, T., Dowell, A., Robson, B., & Reid, P. (2000). The collection of patient ethnicity data: a challenge for general practice. New Zealand Family Physician, 27(3), 51-57.

Ministry of Health. (2001). Monitoring Ethnic Inequalities in Health. Wellington:

Ministry of Health. Ministry of Health. (2003). Health and disability sector ethnicity data protocols. Wellington:

Ministry of Health. Ministry of Health. (2005). Suicide Facts: Provisional 2002 All-Ages Statistics. Wellington: Ministry of Health. Ministry of Health. (nd-a). Environmental scan: Ethnicity data collection issues.Wellington: Ministry of Health.

Ministry of Health. (nd-b). Submission on the review of the measurement of ethnicity. New Zealand Health Information System. (1996). Recording patient information:Ethnicity. Wellington: New Zealand Health Information System.

Pringle, M., & Rothera, I. (1996). Practicality of recording patient ethnicity in general practice: descriptive intervention study and attitude survey. Retrieved 8th February, 2004, from http://bmj.bmjjournals.com/cgi/content/full/312/7038/1080

Senior, P., & Bhopal, R. (1994). Ethnicity as a variable in epidemiological research. British Medical Journal, 309, 327-330.

Statistics New Zealand. (1996). Ethnicity – Standard Classification 1996. Retrieved 8th February, 2003, from http://www.stats.govt.nz/domino/external/web/carsweb.nsf/Classifications/Ethnicity+-+Standard+Classification+1996

Thiru, K., Hassey, A., & Sullivan, F. (2003). Systematic review of scope and quality of electronic patient record data in primary care. BMJ, 326(7398), 1070-1070.

Thomas, D. R. (2000). Assessing Ethnicity in New Zealand Health Research. New Zealand Medical Journal, 114, 12-14.

Thomas, S. B. (2001). The color line: Race matters in the elimination of health disparities. American Journal of Public Health, 91(7), 1046-1049.

 

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