Suicidal Behaviors Among Dominican Youth

“US Cultural Involvement and its Relationship with
Suicidal Behaviors among Dominican Youth:
Findings from the Dominican Republic Youth Survey ”

Juan B. Peña, Ph.D., LCSW

Acknowledgment
• Substance Abuse and Mental Health Services
Administration (SAMHSA), Minority Fellowship Program
– Predoctoral and Postdoctoral Fellowships, T06 SM56573-01 (PI: Francis)
• National Institute of Mental Health (NIMH)
– 1R03MH069102-01 (PI: Peña)
– T32MH020061-06 (PI: Conwell)
– Contract No. 263-MD-507221 (PI: Peña)
– 1R01MH070689-01A1 (PI: Zayas)
– 1R03MH085203-01A1 (PI: Peña)
• Center for Diseases Control and Prevention (CDC)
– Profiling Risk and Need for Mental Health Services among a National
Cohort of Youth Suicide Attempters, 1R49CE001510
• Center for Latino Family Research
– Pilot Study of Suicidal Behavior Among Dominican Youth
– National Survey of Suicidal Behavior Among Dominican Youth

Acknowledgment

• Universidad Autónoma de
Santo Domingo (UASD)
– Gloria Madera
• Fundación Familia Sana
– Ludovina Rodriguez
– Romero Rodriguez
– Wayne Westhoff
• Secretaria de Estado de
Educación
– Cristina Molina

Enola K. Proctor Luis H. Zayas

Brett Drake Melissa Jonson-Reid

Eric D. Caine
Center for the Study and Prevention of Suicide

William A. Vega
Edward R. Roybal Institute on Aging

John Landsverk
Child and Adolescent Services Research Center

Overview

• Research
– Dominican Republic Youth Survey
– U.S. Cultural Involvement and its Association with Suicidal
Behavior among Dominican Youth
• Study 1
• Study 2
• Study 3
– Next Steps
• Service

Dominican Republic Youth Survey

PI Juan B Pena

Overview
• Nationally representative school-based survey of risk
behaviors among youth in the Dominican Republic
– 2009
– 2010
• Modeled after US-based surveys such as the CDC’s Youth
Risk Behavior Survey and Monitoring the Future
– School-based, anonymous, voluntary
• Designed to take into account context, place, and culture
• Designed to allow for comparisons across regions,
nations, and time
• Designed to test and explore different theoretical
frameworks

Rationale for Study

• Dominican Republic currently has no national
youth risk behavior survey
• Dominicans are among the largest Latino
immigrant group in the United States
– Effects of immigration to the US
• Dominican Republic provides excellent natural
setting to study processes related to cultural
globalization

Theoretical Frameworks

• Ecological Systems Theory
• Psychiatric eco-epidemiology
• Family Systems Theory
• Social Learning Theory
• Social Control Theory
• Anomie Theory
• Interpersonal-psychological Theory of Suicidal
Behavior
• Cultural Globalization
• Healthy Immigrant Effect

Samples

• DR 2009
• DR 2010

• NYC 2009 YRBSS – Added 4 questions to the
survey
– Nativity of parents
– Language in household
– Time lived in US

Sampling Frame - Public High Schools in DR
Total public high schools in DR = 812

Strata – 18 Educational Regions in DR

Random selection of 80 public high schools by cohort year, and
proportionate representation by educational region.

Grade 9 Grade 10 Grade 11 Grade 12

A B C D A B C D A B C D A B C D

Students sample N= 10,334 (2009) & N= 9,139 (2010)
Sample weights created - approximately 415,000 youth

Proportion of Schools by Educational Region
N = 80 high schools per cohort year, 160 in total
1. Barahona 2%
2. San Juan 7%
3. Azua 7%
4. San Cristobal 4%
5. San Pedro de M. 5%
6. La Vega 6%
7. San Francisco de M. 7%
8. Santiago 10%
9. Mao 4%
10. Santo Domingo I 9%
11. Puerto Plata 5%
12. Higuey 4%
13. Monte Cristi 4%
14. Nagua 4%
15. Santo Domingo II 8%
16. Cotui 5%
17. Monte Plata 4%
18. Bahoruco 4%
Total 100% = 812 schools

Total sample of
Total HS
Educational Region students
Students
(2009 & 2010)
1. Barahona 10,609 752
2. San Juan 14,577 1218
3. Azua 21,394 1176
4. San Cristobal 27,191 915
5. San Pedro de M. 25,738 896
6. La Vega 29,460 1123
7. San Francisco de M. 22,578 1288
8. Santiago 45,348 1691
9. Mao 10,843 782
10. Santo Domingo I 62,150 2435
11. Puerto Plata 16,641 900
12. Higuey 10,852 620
13. Monte Cristi 10,893 536
14. Nagua 14,734 795
15. Santo Domingo II 52,538 2081
16. Cotui 19,776 863
17. Monte Plata 10,184 654
18. Bahoruco 8,294 748
Total 413,800 19,473

2009 2010
Demographics -- Violence and Delinquency -- Suicidal Behavior -- Cigarette Use -- Alcohol
Use -- Marijuana Use -- Other Drug Use -- Sexual Behaviors -- Parents Level of Education --
Socio Economical Status -- US Exposure
Nutrition & Physical Activity -- Academic
expectations

Violence and Delinquency -- Youth attitude Familism, Respect, Religiosity,
towards delinquency -- Friends Substance Gender Roles, Material success,

A Use -- Friends perception of SU -- Attitudes
towards school -- School Environment --
Availability of Substances -
Independence, Competition,
Belonging, Burden

Violence and Delinquency -- Youth attitude Familism, Respect, Religiosity,
towards delinquency-- Family control – Gender Roles, Material success,

B
Religiosity -- Suicidal Thoughts -- Parents Independence, Competition– Friends
attitudes towards SU -- Same age attitudes Substance Use -- Family Environment
towards SU -- Close friends attitudes towards (Cohesion) -- Family Environment
SU -- Social activities involvement -- Family (Conflict)
Environment (Cohesion) -- Family
Environment (Conflict)
Relationship with Mother -- Relationship with Friends Substance Use -- Violence and

C Father -- Familism Delinquency -- Familiy control –
Religiosity -- Social activities
involvement -- Youth attitude towards
delinquency “Impulsiveness” (BIS)

DR NYC
Youth Risk Behavior Surveillance (YRBS)

National Survey on Drug Use and Health
(NSDUH)
Monitoring the Future (MTF)
The National Longitudinal Study of
Adolescent Health
Bidimensional Acculturation Scale (BAS)

Family Environment Scale (FES) - Cohesion
Family Environment Scale (FES) - Conflict
Lugo's Familism Scale
Mutual Psychological Development
Questionnaire (MPDQ)
Interpersonal Needs Questionnaire (INQ)
Mexican American Cultural
Values Scale (MACVS)
Conflict Behavior Questionnaire (CBQ)
Denver Youth Survey
Barratt Impulsiveness Scale (BIS)

Dominican Republic Youth Survey
• Data will be used to publish manuscripts about:
– US cultural involvement/cultural globalization and youth risk
behavior – suicide attempts, substance use, violence, sexual risk etc.
– Cross national comparisons including with Dominicans in NYC –
testing factors related to healthy immigrant effect
– Identifying cultural protective factors related to youth risk behaviors
– Identifying mechanisms for how cultural factors relates to risk
behaviors via family, peers, school, and individual level factors
– Setting an agenda for prevention of youth risk behaviors of
Dominican Youth
• Research will inform practice and policy in US and
DR related to Latino youth and family, in particular
Dominicans

U.S. Cultural Involvement and its
Association with Suicidal Behavior among
Dominican Youth

Manuscript 1

Rational for Examining Suicide Attempts for
Latino Youth
• While rare during childhood, the rates of suicide attempts peak
during adolescence and young adulthood and steadily decline
through adulthood (Gould et al., 2003; Nock et al., 2008).
• A major source of morbidity, attempts are associated with
hospitalization, future attempts, and death by suicide and
other causes (Ostamo & Lonnqvist, 2001; Pfeffer et al., 1993;
Suokas et al., 2001).
• They also serve as an expression of serious and costly
underlying conditions such as mood and substance-use
disorders and the co-occurrence of multiple behavioral
problems (Gould et al., 2003).
• Latino youth have higher attempt rates than their non-Hispanic
African American and White Counterparts (CDC, YRBSS) and
are largest ethnic minority group
• Suicide Attempts vs. Suicide vs. Suicide Ideation

Background
• Suicide behavior is related to immigrant generation status
among Latino youth in the USA
• Findings are consistent with Healthy Immigrant Effect

Rational for Understanding the
Healthy Immigrant Effect
• Significance for Social Work and Public Health
– Inform interventions for immigrant youth and families
– Inform policies and advocacy for immigrant youth and families
• “A greater understanding of the healthy immigrant
effect has the potential to help improve the health
and health outcomes of all children. Precise
identification of the salutary components of
traditional Latino culture and unhealthy aspects of
US culture could produce fresh approaches and
innovations to prevent morbidity and mortality in
children from all racial/ethnic and socioeconomic
backgrounds.” (Flores, 2005)

Background
• Potential Explanations
– Selection processes
– Cultural protective factors
– Intergenerational value discrepancies and conflict

• A limitation of many studies :
– Lack of differentiation between Latino groups
– Lack of measures to test mechanism
– Lack of international samples to differentiate between self-selection
processes and the cultural protective factors
– Lack of attention to cultural globalization processes

• A new approach
– Focus on one group
– Collect data from country of origin to allow for cross national comparisons
– Examine how processes related to cultural globalization may influence
youth risk behaviors among non-immigrant populations

Study Aim

• To test if indicators of US cultural involvement are
related to suicidal behavior among a sample of
youth residing in the Dominican Republic

Sample

• Dominican Republic 2009

Measures

• Independent Variables
– Latent factor 1: English proficiency
– Latent factor 2: Use of English and US electronic media
– Time lived in the US (9% lived in US)
– Number of friends lived in US

• Dependent Variable
– Suicide attempt during past year

Measures

• Control Variables
– Demographic characteristics
– Residency in Urban Area
– Family Structure
– SES indicators
• Corrugated Zinc Roof
• Parental level of education

Analysis

• Logistic regression
• Design effect of study was taken into account using
“Type = Complex” command in Mplus
• Sample weights were created by statistician and
used in analysis to ensure representativeness
• We used a combination of observed and latent
variables

Use of US electronic media and English

Odds Ratio and 95% Confidence Intervals for
Suicide Attempt during Past Year
Variable Unadjusted Odds Adjusted Odds

Ratio Ratio1

Lived in US, 1 year or more 2.54 (1.67, 3.87)* 2.11 (1.35, 3.29)*

Lived in US, 1 year or less 1.65 (1.19, 2.27)* 1.53 (1.10, 2.11)*

No. best friends have lived in the 1.07 (1.03, 1.11)* 1.05 (1.01, 1.09)*

US

US electronic media and English 1.20 (1.10, 1.30)* 1.16 (1.02, 1.31)*

English proficiency 1.15 (1.05, 1.26)* 0.98 (0.87, 1.11)

1. Adjusted for age, gender, SES indicators, family structure, urban residency, and all US

cultural involvement variables.

Discussion

• There is a robust relationship between variables
related to US cultural involvement and suicide
behavior among youth in the DR
• This finding is consistent with previous research
showing increase risk for suicide behavior for US vs.
foreign born Latinos
• This finding is not consistent with self-selection
processes being the predominant reason for the
healthy immigrant effect
• Future research needs to identify and test
mechanisms related to this association

Limitations and Strengths

• Limitations
– Self-report
– Exclusion of youth not attending school or attending private school
– Did not include US comparison group
– Results have not been replicated
• Strengths
– This study used a non-immigrant population
– Nationally representative of students attending public high school in
the DR

A Binational Study on U.S. Cultural
Involvement and Suicidal Behavior among
Dominican Youth

Pena J.B., Vega W.A., Chaves D., Zayas L.H., &
Caine E.D.
Manuscript 2

Sample

• NYC 2009 Dominican

Measures

• Independent Variables
– DR 2010 Sample
• Latent factor: Use of English and US electronic media
• Time lived in the US
• Number of friends lived in US
– NYC 2009 Sample
• Spanish-speaking vs. English-speaking household
– DR and NYC 2009 Sample
• NYC Dominicans vs. DR Youth that never lived in US
• Dependent Variable
– Suicide attempt during past year

Measures

• Control Variables
– Demographic characteristics
– Residency in Urban Area
– Family Structure
– SES indicators

Analysis

• Logistic regression
• A combination of observed and latent variables
were used

Simple Logistic Multiple Logistic
Regression Regression
DR 2010 Sample
US Electronic Media and Language 1.08 (1.03, 1.13)*** 1.16 (1.06, 1.28)***

Lived in US > 1 a 2.70 (1.78, 4.11)*** 2.57 (1.64, 4.02)***

Lived in US < 1 a 1.59 (1.26, 2.00)*** 1.47 (1.14, 1.89)**
Number of Friends Lived in US 1.03 (1.00, 1.06)* 1.03 (0.99, 1.07)

NYC 2009 Sample

English-speaking household 1.58 (1.00, 2.47)* 1.63 (1.00, 2.65)*

DR and NYC 2009 Sample

English-speaking household 2.39 (1.67, 3.43)*** 2.70 (1.87, 3.90)***

Spanish-speaking household 1.52 (1.03, 2.24)* 1.61 (1.08, 2.39)*

Discussion
• There is a robust relationship between variables related to
US cultural involvement and suicide behavior within the
context of the DR, NYC, and between DR and NYC
• This finding is consistent with previous research showing
increase risk for suicide behavior for US vs. foreign born
Latinos, replicates previous findings for 2009 sample, and
other binational comparisons that have been made using
Mexican samples.
• This finding is not consistent with self-selection processes
being the predominant reason for the healthy immigrant
effect.
• Future research needs to identify and test mechanisms
related to this association


• Limitations
– Self-report
• Strengths
– This study used a non-immigrant and immigrant populations
– Showed robust effects across multiple indicators and context
the DR and NYC

The Role of Substance Use in Explaining
the Relationship between U.S. Cultural
Dominican Youth

Pena J.B., & Vega W.A., Hausmann-Stabile
C.H., & Caine E.D.
Manuscript 3

Sample

• NYC 2009 Dominican

Drugs and Depression Hypothesis

0.31 (0.78)***

0.53 (0.53) *** 0.29 (0.73)***

0.54 (0.54) *** 0.68 (0.68)*** 0.24 (0.62)***

Problematic Alcohol Use Repeated Marijuana Use Repeated Other Drug Use Depressive Symptoms
R2 = 0.13 R2 = 0.21 R2 = 013 R2 = 0.07

0.27 (0
0.
46
* (0
** -0. .4
8)

.11)***
04 6)
.4 (-
0.0 * **
(0 0.05 4)
21
0. *
(0.0
5)
)* *
53
2 (0. *
0.2 9)*
0.3
7( 9)
0.1 (0.1
0.03 Suicide Attempt
0.31 (0.68)***

6)
*
** R2 = 0.45
)**
)* .2
50 (-0
77

. .24)
5 0.11 (0
(0.

(0 .0
23 -0
3

0.
0.3

6)
(0.2
0.12
Second-Generation 1,2

Later-Generations 1,2

Pena, J. B., Wyman, P. A., Brown, C. H., Matthieu, M. M., Olivares, T. E., Hartelfooter, D., et al.
(2008). Immigration generation status and its association with suicide attempts, substance use,
and depressive symptoms among

100% 100%

80% 80%

60% 60%

40%
40%

20%
20%

0%
0%

Low SU-VB High SU-VB Extreme SU-VB Low SU-VB High SU-VB Extreme SU-VB

Pena J.B., Matthieu M.M., Zayas L.H., Masyn K.E., & Caine E.D. Co-occurrence of risk behaviors
among White, Black, and Hispanic US high school adolescents who have attempted suicide
1999 to 2007. Social Psychiatry and Psychiatric Epidemiology

Analysis

• Structural Equation Model
• A combination of observed and latent variables
were used

Substance Substance
use with use without
depressive depressive
symptoms symptoms

US Cultural
Suicide
Involvement
Attempt
Indicators

Depressive
symptoms
with no
substance use

23.4%

Substance Use with Depressive Symptoms 18.2%

12.6%

0.0 5.0 10.0 15.0 20.0 25.0

NYC Dominicans English Speaking Households NYC Dominicans Spanish Speaking Households DR Youth Never Lived in US

Substance Use
with Depressive
Symptoms

US Cultural Suicidal
Involvement Behavior

Substance Use
Depressive
with no
Symptoms with
Depressive
no Substance Use
Symptoms

Discussion

• Substance use and depressive symptoms for
Dominican youth mediates the relationship
between US cultural involvement and suicidal
behavior within DR context, NYC context, and
between DR and NYC context
• Exploring cultural and social factors related to
substance use may provide important clues to
mechanisms related to increase propensity for
suicidal behavior among Dominican youth


• Limitations
– Self-report
– Relationship between substance use and depressive symptoms
unclear
– Relationship between substance use and suicidal behavior unclear
• Strengths
– This study used a non-immigrant and immigrant populations
– Showed robust effects across multiple indicators and context
the DR and NYC

Exploring Mechanisms Related to US Cultural
Dominican and Other Youth
1. Mining the Dominican Republic Youth Survey to further identify
potential mechanisms
– Latino cultural values
– American cultural values
– Family, peer, and school environments
– Individual level data
2. Follow up study in NYC and DR
– Mixed methods approach
– Further explore the role of substance use
– Build on findings from current study to examine mechanisms explaining
“healthy immigrant effect” for suicidal behavior among Dominican Youth
such as role of culture, family environment, peer environments etc.
3. Follow up study to examine if similar phenomena is occurring in
other developing nations and groups

Next Steps

• Develop models that can inform practice and policy
in the US and abroad
– Integrate the strengths of immigrant and native populations in
family and youth interventions designed to reduce risk behaviors in
context of acculturation and cultural globalization
– Promote polices that embrace biculturalism to reduce risk behaviors
among adolescence and improve health and educational success
among youth

Developing Prevention Framework for
Youth Risk Behaviors in Dominican Republic

1. Funding to help develop the research and prevention
infrastructure to respond to youth risk behaviors in the
Dominican Republic
– Create surveillance system for youth risk behaviors
• Model - CDC YRBSS, Monitoring Future
– Create goals, objectives, and strategies to reduce risk behaviors among
youth in the Dominican Republic
• Model - Healthy People 2020
– Create dissemination system for surveillance results, goals, objectives, and
strategies to reduce risk behaviors among youth in the Dominican Republic
– Develop social work field and presence in prevention work in DR

Prevention of Youth Risk Behaviors among
Dominican Youth

Report in Spanish for the Dominican Republic
- Results 2009 -

Prevention of Suicidal Behavior among
Dominican Youth
1. Study to test a comprehensive public health
approach to suicide prevention and related
behaviors among youth within school settings
– Universal program to decrease number of youth within the school
population with suicide risk factors such as substance use and
violence – use existing evidence based programs
– Selective programs to treat and reduce risk factors for youth that are
starting to exhibit risk factors such as substance use, violence, and
depressive symptoms – use existing evidence based programs
– Indicated programs for youth exhibiting suicidal ideation or
behaviors – use existing evidence based programs

Team members in the Dominican Republic,
from left to right: Juan Isidro Rodríguez,
Diana Chaves, Juan Peña, Ludovina
Rodríguez, Cristina Molina, Luis Zayas,
Gloria Madera

Team members working on the
logistics for the national study in the
Dominican Republic

Presentation at the 3rd Subregional Meeting in Education,
sponsored by the UNESCO Regional Office of Culture in
Latin America and the Caribbean

Motivational Interviewing Workshop at the Autonomous
University of Santo Domingo in Bonao

“Service Across Borders” summit, sponsored by the
NY State Senate Puerto Rican/Latino Caucus

Comments from teaching evaluations
“Juan Pena's expansive “This has been by far my favorite class that I
knowledge and commitment to have taken at Brown! Professor Pena was a
students is amazing. He is very fantastic teacher, and I learned a lot. I was
well organized, and structures happy that this class was both interesting as
the class very well. I liked that well as required a fair amount of student
there were a variety of small work outside of class, which made me feel like
assignments rather than one my tuition money was being well spent.
huge paper or test. Also, Dr. Pena Professor Pena loves the material he is
is very engaging and teaching, he knows it well, and he encourages
understanding, he seems to take class participation, and he is very personable”.
students' learning very
seriously”.
“His understanding towards the
diverse issues and different culture.
“The professor did an outstanding job teaching the The instructor is very helpful and
material and keeping the class engaged through his encouraging. He uses different
power points. I also really enjoyed the skills lab of materials: videos, online resources,
Motivational Interviewing and found it very etc. The instructor is open and
relevant in terms of practice and was able to use flexible”.
this type of therapy at my practicum”.

Suicidal Behaviors Among Dominican Youth

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