A more comprehensive approach to suicide prevention with international students

The existing literature with a variety of ethnoracially minoritized, migrant, and culturally and linguistically diverse groups suggests that a contextualized, strengths-based approach to suicide prevention with international students will likely support better outcomes (Na et al., 2016; Healey et al., 2017; Kirmayer and Jarvis, 2019; Allen et al., 2022). Specifically, by drawing on the strengths of international students while also acknowledging their cultural needs, two primary areas of opportunity for developing and enhancing suicide prevention emerge. Firstly, a culturally contextualized approach can help identify the unique risk and protective factors, mechanisms of change, and treatment gaps that impact international college student suicide. Secondly, this approach can also support the development of novel prevention initiatives that draw upon students’ cultural strengths, capital, and networks. The possibilities of each of these are outlined below.

2.1 Integrating culturally responsive models to improve current prevention approaches
As described earlier, while no evidence-based suicide prevention programs for international students are currently available, a wide range of recommendations exist that can guide research and practice (McKay et al., 2023). Several of these recommendations seek to better meet the cultural needs of international students through adapted risk screening, service provision, and communication tools. However, numerous opportunities exist to improve current host nation services, interventions, and research programs through a culturally contextualized approach, particularly when building upon the Protective Factors Framework.

In our proposed integrated model, we have also expanded upon this framework to include three other important considerations relevant to suicide prevention in education settings with international students. Firstly, we have incorporated a well-established public health prevention framework that categorizes prevention efforts according to the level of risk within the targeted population (World Health Organization, 2021a, 2022). The three levels include universal interventions targeting the whole community regardless of risk, selective interventions for those potentially at risk of suicide, and indicated interventions for those demonstrating suicide-related thoughts or behaviors. Secondly, we have added the target groups for each approach to delineate whether it targets students, staff, or other relevant groups. Incorporating prevention levels and target groups helps to better identify gaps in existing approaches. Lastly, we have added culturally contextualized opportunities to show how current prevention efforts could be improved through taking a culturally contextualized approach to prevention. Figure 1 presents a comprehensive overview of the extended framework, illustrating the iterative process of the key components, while also providing guiding questions and relevant examples for each element.

Figure 1

Figure 1. Extended framework for culturally contextualized suicide prevention.

Based on findings from a recent scoping review that reported recommended suicide prevention approaches for international students (McKay et al., 2023), we have summarized current recommendations and practices within this extended framework in Table 1. In the table, each general recommendation is outlined along with the level of prevention, protective factor, mechanism and associated risk factor, target group of approach, current practice methods, and potential avenues for culturally contextualized enhancements.

Table 1

Table 1. Current suicide prevention recommendations for international students and opportunities for development through culturally contextualized adaptations.

In summarizing current best practice recommendations in this way, several observations can be made. Firstly, most prevention recommendations focus on increasing formal support engagement either directly or through improving help-seeking, with a handful capturing other protective factors such as social connection, academic performance, and coping skills. The recommendations span across universal, selective, and indicated levels of prevention, with a notable emphasis on universal and selective approaches. Aligning with this, the mechanisms underpinning the majority of recommendations concentrate on engaging students — particularly those less likely to utilize services — by enhancing mental health literacy, customizing services for culturally diverse student populations, improving risk screening and referral (see AFSP Interactive Screening Program for a recent example), and overcoming structural barriers such as service costs and availability. Other mechanisms address specific risk factors such as loneliness, distress regarding academic or acculturation issues, and lack of effective coping skills. While most recommendations cater to international students, the roles of educational institutions, service providers, insurers, local communities, and families are also acknowledged. The delivery methods employed are varied, encompassing information dissemination and promotional activities, mental health initiatives such as stigma reduction campaigns, gatekeeper training to identify and respond to crises, peer support, and specialized support services addressing mental health and academic challenges. Importantly, in the final column, we highlight how each of these existing approaches could be improved through a culturally and contextually responsive approach.

Several core themes emerge amid the identified opportunities for improving existing prevention efforts using a culturally responsive approach. These encompass aspects such as community involvement and empowerment, a critical examination of the proposed mechanism of change and its foundational assumptions (e.g., western mental health views), and considerations for implementation and evaluation vital to developing or refining prevention programs. While we do not see these as an exhaustive list, they provide a valuable starting point for improving equitable suicide prevention efforts with international students. A set of questions we used to consider each of these areas is included in the Supplementary materials, and a more detailed explanation is provided below.

Community empowerment and, in some cases, ownership are widely acknowledged as central to improving mental health and suicide prevention efforts with migrants, minoritized groups, and youth populations (Gustavson et al., 2021; Reifels et al., 2021; Allen et al., 2022). In the case of existing programs and recommendations, an examination of current community involvement practices highlights numerous opportunities for enhancement. For example, moving from solely community participation to community empowerment could be used to adapt and improve gatekeeper programs by aligning them with students’ cultural context and real-world experiences. This could increase program acceptability, relevance, engagement, and efficacy, thereby raising the probability that the skills taught will be utilized (Nasir et al., 2016). Moreover, when communities possess some level of ownership and shared leadership over an initiative, it can enhance uptake and program sustainability and positively impact all community members involved (Blignault et al., 2023). Few existing prevention programs or recommendations include community empowerment at this stage, and this should be a focus for future efforts.

Mechanisms of change are also a central consideration in creating culturally responsive approaches. By examining the prevention strategy’s proposed mechanism of change, a multitude of refinement opportunities can also be identified to optimize effectiveness and cultural sensitivity. Building on the existing evidence with minoritized populations’, considerations could include whether the model acknowledges non-Western mental health perspectives, leverages students’ cultural strengths, and is flexible enough to integrate diverse cultural viewpoints and acculturation levels (Na et al., 2016; Bowden et al., 2020; Allen et al., 2022; Meza and Bath, 2022). For example, mental health literacy campaigns could draw upon non-Western views that underpin stigma, such as language (e.g., thinking too much) and use this to better engage students based on their existing perspectives before seeking to change their views (Kaiser et al., 2015). Alternatively, mental health services could adapt to such perspectives as part of making service provision culturally responsive, and promotion activities could then acknowledge how such perspectives are respected.

Implementation and evaluation are also key considerations in effective suicide prevention research and practice (Gustavson et al., 2021; Reifels et al., 2022). While little research has studied implementation in international student suicide prevention, insights can be gleaned from the broader field. A recent scoping review of 64 suicide prevention studies identified key implementation considerations: aligning efforts with community needs, interests, and settings; ensuring those responsible have relevant skills, knowledge, and resources; and engaging community leaders and organizations where possible when working with diverse groups (Kasal et al., 2023). A key consideration, in line with these findings, is who is best placed and should be responsible for delivering prevention efforts for international students. This involves determining who has the power to implement the prevention approach and the willingness to do so. As an example, the removal of systemic barriers to service access could be addressed by governments, insurers, or local health services, and an identification of which entity or combination thereof would be best placed and willing to do so in the local context is an important consideration when defining prevention approaches, policy, and systems (Jamieson, 2021).

Effective implementation paves the way for rigorous evaluation, the linchpin in assessing and refining our approaches. Effective evaluation demands rigorous empirical research employing validated measures or robust qualitative methods, incorporating value considerations, and interpreting findings within the context of current theories and literature (Coryn et al., 2017). Importantly, both prevention effort outcomes and implementation should be assessed (Reifels et al., 2022). This process facilitates vital feedback mechanisms to identify opportunities to enhance programs or services and their associated outcomes. For instance, these processes could help service providers understand why international students are likely to not engage in or drop out of services, providing a basis for subsequent improvements. Moreover, evaluation efforts should be culturally responsive, ensuring that the metrics and methods used are appropriate and meaningful for the diverse international student population being served (McKay et al., 2023).

Each of these overarching considerations, while separate, also have significant overlap and can inform the others. For instance, effective evaluation inherently depends on a degree of community engagement, and careful deliberation of the proposed mechanism of change is essential in determining the most suitable entity to implement programs and deliver the desired outcomes. Aligning with a Public Health Model of Suicide Prevention (Pirkis et al., 2023), adopting a framework that assesses approach, prevention levels, protective factors, mechanisms, target groups, and methods against cultural responsiveness perspectives can reveal significant opportunities to enhance current prevention strategies. This framework is also relevant to the identification of novel prevention strategies for international students.

2.2 Novel suicide prevention opportunities based on a culturally responsive approach

A strengths-based, culturally contextualized approach facilitates opportunities for novel prevention initiatives by highlighting alternate knowledge, perspectives, and needs along with associated strengths and protective factors that are not part of current approaches. We do not aim to present an exhaustive list of potential novel interventions here but instead highlight the ways the framework could facilitate the development of such approaches. As part of this, we draw upon existing evidence with other minoritized and migrant groups to demonstrate how such approaches may work.

There are numerous opportunities for novel prevention strategies for international students based on increasing community empowerment. Co-design and lived experience involvement are obvious starting points. There is a growing body of evidence highlighting the value of co-designed suicide prevention initiatives with young people and diverse communities (Thorn et al., 2020; O’Brien et al., 2021; Fitzpatrick et al., 2023). Lived experience involvement in developing new programs may support the identification of strengths-based prevention approaches better adapted to international students’ cultural expectations and needs. A review of mental health programs co-designed with culturally and linguistically diverse groups revealed that this collaborative approach was instrumental in creating programs more attuned to community needs (O’Brien et al., 2021). These programs commonly embraced peer support and group or family-based therapies to tackle challenges linked to individualistic and non-culturally adapted care models, fostering enhanced engagement and improved outcomes.

Similarly, co-design can support the identification of potential intervention strategies relevant to non-western explanatory models of mental health and community healing. For instance, evidence from several Culturally and Linguistically Diverse (CALD) communities in Australia shows that informal help-seeking through social, religious, and self-help is often preferred to formal help-seeking (Krstanoska-Blazeska et al., 2023). This is particularly true among ethnoracially minoritized college students in the U.S. (Lipson et al., 2018). Considering this, identifying typical informal mental health support sources used by international students and collaborating with them to co-design mental health support training tailored for their community could be highly beneficial. This could increase the capacity of relevant informal support sources to help international students facing mental health difficulties. Similarly, efforts could be made to improve links between these informal help sources and culturally adapted formal support services. Such a strategy could offer international students less daunting and more accessible care pathways than required when navigating formal support services alone. Initiatives to also increase college students’ agency in seeking mental health support may also increase their perceived cultural capital and improve their linkage to care (see Richards, 2022).

Another opportunity lies within international student communities and their shared experiences. While international students represent a diverse range of cultures, the shared identity, knowledge, and experiences of being an international student may provide a starting point for relevant prevention initiatives that traverse cultural divides (Gu et al., 2010). Designing suicide prevention initiatives around international students’ shared experiences can potentially yield programs relevant to a wider audience, thus diminishing the necessity for specific programs for each distinct cultural group of international students. For instance, international students often face challenges and stress related to acculturation when they move to a new country (Orygen, 2020). These acculturation experiences and the related acculturative stress are the central differentiating factor in the experience of international students and other student groups. Evidence suggests that acculturative stress increases suicidality in young people (Polanco-Roman et al., 2023). Psychoeducation programs have been found to be most effective in reducing acculturative stress in international students (Aljaberi et al., 2021), suggesting they could provide a strong foundation for future suicide prevention efforts centered on acculturation. Similar approaches addressing other shared experiences may also present other opportunities for novel prevention initiatives that are applicable to diverse international student groups.

Developmental considerations both generally and as part of the acculturation processes are also important for international student suicide prevention. For instance, cultural continuity and identity should be a primary focus, as students seek to negotiate who they are within a new cultural context, often free of their family and friend networks from their home country (Szabo and Ward, 2015; McKay et al., 2022). While these processes can foster youth development, they can also give rise to complex relationship dynamics when young individuals adopt perspectives differing from their parents’ and such acculturative tension has been identified as influencing suicidal behaviors (Gulbas and Zayas, 2015), this intergenerational acculturation conflict is particularly true among college students (Meza et al., 2024). Research and practice should seek to understand how such developmental processes impact suicidality and can be supported in such a way as to draw upon international students’ unique strengths to reduce suicide risk.

Finally, another key opportunity for improved suicide prevention with international students lies with digital interventions and tools. These tools can effectively integrate the essential components outlined in the ecological validity model, which offers specific considerations crucial for designing culturally responsive prevention and intervention approaches (Bernal et al., 1995). These include delivering the intervention in the participants’ preferred language, involvement of culturally relevant individuals in design and delivery, integration meaningful cultural metaphors, and a focus on ensuring the content reflects the participants’ cultural, social, and historical contexts. Furthermore, it stresses the alignment of psychological concepts, intervention goals, and methods with the participants’ worldviews, values, and needs, all within a comfortable and appropriate setting. Digital tools are well suited to providing adapted content through changing the language, metaphors, and imagery for different groups, all in a setting that may be more comfortable for international students than traditional in-person therapeutic models. For example, core mental health information or therapeutic tools could be delivered in students’ native languages, a preference commonly expressed by international students when engaging with digital mental health content (Choi et al., 2023).

Like the existing interventions, each of these opportunities may overlap. A new approach could involve co-designing a digital tool that incorporates shared acculturation experiences and developmental considerations with the intervention available in multiple languages, each incorporating culturally relevant metaphors and examples. Similarly, a complimentary approach could be taken where components of existing approaches (top-down approach) are combined with the new approaches to create novel (bottom-up approach) international student suicide prevention programs and interventions.

3 Discussion

Our exploration of current approaches and recommendations for international student suicide prevention, using our proposed extended Protective Factors Framework, has highlighted several critical themes for improvement: the importance of community empowerment and ownership in developing and implementing prevention strategies; the need to critically examine and adapt mechanisms of change to align with diverse cultural perspectives; and the significance of culturally contextualized implementation and evaluation processes. These themes build upon existing approaches in culturally contextualized suicide prevention while specifically addressing the unique context of international students in higher education settings (Allen et al., 2022; McKay et al., 2023).

Our findings extend the understanding of culturally contextualized suicide prevention by integrating the Protective Factors Framework with universal, selective, and indicated public health prevention levels, along with opportunities for strength-focused cultural adaptations. This approach offers a more nuanced understanding of how cultural factors interact with traditional risk and protective factors in suicide prevention for international students. It proposes a fundamental shift in conceptualizing and approaching suicide prevention, emphasizing cultural strengths and resources over deficit-focused models, aligning with recent trends in cross-cultural psychology and global mental health that advocate for more culturally aligned interventions (Chu et al., 2019; Bowden et al., 2020).

While this framework provides a broad structure for culturally responsive suicide prevention, we also must acknowledge the inherent complexity of addressing the needs of such a diverse population. International students come from a wide array of countries and cultures, each with its own unique perspectives on mental health, help-seeking behaviors, and suicide (Na et al., 2016; Veresova et al., 2024). This diversity presents both challenges and opportunities. The heterogeneity within the international student population poses significant challenges in developing universally applicable strategies. What works for students from one cultural background may not be effective or culturally appropriate for others. This diversity necessitates a careful balance between creating a broad, inclusive framework and ensuring that interventions can be tailored to specific cultural subgroups. Additionally, the lack of existing evidence-based programs specifically for international students limits our ability to fully assess the effectiveness of the proposed enhancements (McKay et al., 2023).

However, this diversity also presents unique opportunities. The framework’s emphasis on community empowerment and cultural strengths allows for flexibility in implementation. It encourages the development of interventions that can be adapted to various contexts and groups while maintaining core principles of culturally contextualized prevention. Moreover, the shared experience of being an international student, despite differing cultural backgrounds, provides a common ground for developing interventions that address universal challenges such as acculturation stress, language barriers, adapting and learning how to navigate new social systems (i.e., health and education systems) and academic pressures in a new environment.

It is crucial to also acknowledge that international students’ experiences can vary significantly based on their host country and the specific educational system in which they are studying. Major destination countries like the U.S., Australia, and the UK have distinct cultural, social, and educational environments that can profoundly impact students’ experiences, including their acculturation stress and mental health outcomes (Smith and Khawaja, 2011). Additionally, international students may face challenges related to racism, sexism, and other forms of discrimination in their host countries, which can significantly affect their mental health and increase suicide risk (Wang et al., 2013; Taliaferro et al., 2020; Pérez-Rojas et al., 2021). The intersectionality of being an international student with other social identities (e.g., race, gender, sexual orientation) and its interaction with structural systems (e.g., education and health) can further complicate these experiences (Herridge et al., 2023). This may be compounded by students experiencing minority status for the first time, necessitating a re-evaluation of their racial/ethnic identity within unfamiliar social hierarchies (Fries-Britt et al., 2014). These complex processes of identity development and navigation of new cultural and educational contexts necessitate more nuanced prevention approaches that account for these diverse influences and their potential interaction with suicide risk.

Future research should focus on empirically testing culturally contextualized adaptations across different international student subgroups and host countries, conducting longitudinal studies to assess long-term impacts, exploring intersectional impacts, and investigating the potential of tailored digital mental health interventions. Studies on effectively implementing and scaling culturally responsive interventions in diverse university settings are also needed. Additionally, research should explore how this framework can be effectively adapted for different cultural subgroups within the international student population, identifying both universal elements that apply across cultures and specific components that need cultural tailoring.

Despite these limitations, the proposed model presented here contributes significantly to the current understanding of culturally responsive suicide prevention. By providing a structured framework for assessing and enhancing existing approaches, it offers a comprehensive tool for researchers and practitioners working with international students or other diverse groups. This approach not only highlights ways to improve current strategies but also identifies opportunities for novel culturally grounded interventions that leverage the unique strengths and experiences of those people they are seeking to help. It is our hope that this work will inspire continued research and development in this field, leading to more effective and culturally attuned suicide prevention interventions for international students and other culturally diverse at-risk populations.