摘要：Objectives. We examined how US cultural involvement related to suicide attempts among youths in the Dominican Republic. Methods. We analyzed data from a nationally representative sample of youths attending high school in the Dominican Republic (n = 8446). The outcome of interest was a suicide attempt during the past year. The US cultural involvement indicators included time spent living in the United States, number of friends who had lived in the United States, English proficiency, and use of US electronic media and language. Results. Time lived in the United States, US electronic media and language, and number of friends who had lived in the United States had robust positive relationships with suicide attempts among youths residing in the Dominican Republic. Conclusions. Our results are consistent with previous research that found increased risk for suicide or suicide attempts among Latino youths with greater US cultural involvement. Our study adds to this research by finding similar results in a nonimmigrant Latin American sample. Our results also indicate that suicide attempts are a major public health problem among youths in the Dominican Republic. There is growing evidence that US nativity increases risk for suicide ideation, suicide attempts, and death by suicide for Latino youths and adults. Foreign-born Latinos have lower rates of completed suicide compared with US-born Latinos across several national and regional cohorts. 1–3 Moreover, rates for suicide ideation or attempts among foreign-born or less acculturated Latinos have been lower than those of their US-born counterparts. 4–7 The phenomenon of immigrant Latinos having better health outcomes than US-born Latinos has been referred to by various names, including the healthy immigrant effect, the Latino paradox, and the epidemiological paradox. Moreover, this trend has been found for numerous outcomes. 8 A number of models have been proposed to explain this finding including cultural protective factors associated with Latino culture, 9,10 discrepancies in intergenerational values between immigrant parents and their US-born children, 11 and selection bias related to immigration of healthier or more resilient individuals. 12,13 Methodological constraints have unfortunately limited the ability to test determinants that could explain these differences. One constraint that has limited the ability to test the selection bias hypothesis has been the scarcity of comparable data from “feeder” nations that provide US Latino immigrant populations. In one of the few studies that used cross-national data, Mexican youths in high schools near the US–Mexico border reported lower rates of suicide ideation than Mexican American youths in high schools on the US side of the border. 14 In another study using a binational (United States and Mexico) sample of Mexicans, US-born Mexicans and Mexican-born immigrants who arrived in the United States when aged 12 years or younger had higher rates of suicide ideation than Mexicans without a history of migration to the United States or a family member living there. Mexicans with family members living in the United States and US-born Mexicans were also at higher risk for suicide attempts. 15 These findings do not support the selection bias explanation for nativity differences in suicide behaviors among adults or youths of Mexican ancestry living in the United States. Although the literature suggests that Latinos share certain core panethnic cultural values such as familism and respect, 16–18 the peoples of Latin America have distinct historical, social, immigration, and cultural contexts. It is therefore prudent to test, validate, or disprove explanatory mechanisms such as immigration selection bias across different Hispanic subgroups. One variation on the approach of using data from feeder countries is to examine how US cultural involvement may relate to risk for suicidal behavior within a non–US setting via mechanisms related to “cultural globalization.” Cultural globalization parallels the process known as economic globalization and refers to the penetration of cultural influences (e.g., US cultural influence) on the lifestyles, values, norms, and retention of cultural heritage in youths around the world. 19,20 The strength of this approach is that it examines the relationship between US cultural influence and suicidal behavior in a nonimmigrant Latino population. The Dominican Republic (DR)—because of its large US-based population, 21 relatively close proximity to the United States, and historical connections to the United States 22,23 —offers an excellent natural experiment to test whether US cultural influence relates to outcomes such as suicide risk behaviors among youths. For example, there are approximately 1.3 million Dominicans living in the United States, 21 compared with a relatively modest population of approximately 10 million Dominicans living in the Dominican Republic. 24 This ratio of US Dominicans to DR Dominicans makes possible several mechanisms for how cultural globalization in the Dominican Republic may occur, especially as it relates to US cultural influence. The first, circular migration, has been conceptualized and operationalized in multiple ways. We use a literal definition: leaving and then returning to a country of origin, once or repeatedly. Circular migration is often driven by immigrants’ economic circumstances, legal status, and US labor market demands. 25 Another mechanism for US cultural influence in the Dominican Republic occurs through ties that Dominicans have with relatives, friends, or acquaintances who live in the United States or who have lived in the United States. The US cultural influence in the Dominican Republic also occurs indirectly via the influences of electronic media such as US-based movies, television, and music. We examined how US cultural involvement indicators relate to suicide attempts among a nationally representative sample of public high school students in the Dominican Republic. We focused on suicide behavior because it has been identified as a growing worldwide public health concern for youths and young adults. 26,27 Moreover, suicide attempts are associated with hospitalization, future attempts, 28 and future death by suicide. 29,30 Despite prevalent concern about adolescent suicide attempts, little is known about the epidemiology of suicide behaviors in the Dominican Republic. To our knowledge, this is the first study to publish data on suicide attempts among DR youths that used a nationally representative sample. However, in one unpublished report that used data from a national sample of DR youths attending public school in 1997, as many as 7.9% of the youths reported a suicide attempt during the past year. 31 This rate is on par with the 7.7% of youths who reported a suicide attempt during that same year in the United States, but lower than the 10.7% of US Hispanics who reported a suicide attempt in 1997. 32 These rates for suicide behavior represent a public health problem among youths in the Dominican Republic. This study will add to the literature by publishing results related to suicide attempts among DR youths in a nationally representative sample and by increasing knowledge regarding the healthy immigrant effect pertaining to suicide attempts. On the basis of the robust associations found between suicide behaviors and US involvement among US Latino and Mexican populations, we hypothesized that greater US cultural involvement would increase risks for suicide attempts among DR youths.
