Review of Literature

the CHURCHILL fellowship

Fellowship Report

Suicide Intervention: British, Punjabi Sikh Women

A Holistic Approach

The references to the terms Punjabi for the purposes of this report is positioned from post partition British India (1947) and the Sikh religion centuries prior to partition. A holistic approach entails the need for an overall sociocultural perspective due to the fact that the diaspora communities discussed in this report are interconnected globally and ancestrally from all regions of Punjab, including bordered lands. For further reading Ruprai (2016) in her thesis, details British occupied Punjab from a wider historical context. It informs us of colonial timelines and generational deracination post-annexation of Punjab in 1849 by the British Empire. Ruprai (2016)

Academic research informs us of the increased risk of self-harm, attempted suicide and completion of suicide among South Asian women and of the low uptake of mental health services for this demographic (Husain et al, 2011). Inequalities and differences in referrals to psychiatric services in comparison with non-South Asian women results in a reluctance for South Asian women to access mental health services (Husain et al, 2011). The Samaritans Ethnicity and Suicide paper (2022) evidences 'unequal rates of suicide between ethnic groups'. Researchers have stated postvention support for bereaved families to be ‘limited and inconsistent’ further highlighting the need for a cultured approach to meet the needs of ethnic groups (Rivart et al, 2021).

The nature of suicide ideation and of the deliberate ending of life lead to wider social and individual repercussions. Global migration from Punjab makes it difficult to ascertain the changeability of this problem as recent findings in India reveals that the suicide rate among adolescents has been increasing in recent years (Senapati et al, 2024). Suicide bereavement as a result of death by suicide is ruinous to the quality of life of those close to the deceased. It is 'largely unknown' how South Asian communities in the UK experience suicide bereavement (Rivart et al, 2021). Furthermore, it is unknown how to support them in order to reduce the impact of suicide bereavement for their long-term health. The ‘heterogeneous’ nature of ethnic minority groups require different support and evidence suggests that the mental health needs of immigrants in particular, differ from the majority population (Rivart et al, 2021).

A UK report on British South Asian communities by Sharing Voices Bradford (2022) highlighted views from South Asian diaspora. They state that support was not always available from culturally competent practitioners, pastoral support workers or faith leaders resulting in the potential for misunderstanding of suicidality. Notably, this challenges the perspectives of Currie and Bedi (2019) who advocate for integrating culturally adapted counselling practices to specifically meet the needs of Canadian Punjabi Sikh communities. This literature review offers further insight into potential stressors that can lead to ideation.

Review of Literature

Theories

Bronfenbrenner's (1979) model of human ecological theory provides a multidimensional approach in understanding the context that suicide arises in through interconnectedness via an individual, their environment and the social systems that they live in. It is the belief that suicide does not occur in isolation (Harvey and Delfabbro, 2004). Durkheim's (1966) theory of integration and regulation highlights the varied levels of social connectedness of a group with the belief that these are key determinants of the level of risk for an individual (Gill, 2010). The concept of the individual 'self' connected to kinship and family is explained further by Bhugra (2020) who suggests that the deliberate act of self-harm (intent unclear) may be aimed towards others and less towards self.

Bhabha (1994) describes the 'third space' theory in the context of a postcolonial theory of identity and cultural representation where cultural boundaries meet and blend. 'Hybrid identities' are formed as markers of identity emerging from exposure to parental language, diaspora traditions, inherited religious practices and other influences. The discourse of colonialism and its concept of fixity (cultural, historical, racial differences) further forms stereotypes of individuals (Bhabha, 1994 in The Location of Culture). In contemporary society the use of terminology like 'South Asian' is one example of categorizing people from 'Eastern' or Global South regions of the subcontinent. Often referenced in research material limiting the inherent distinction of regions, tribes, family name (based on the name of the ancestral village) or a caste name.

Further to identity and representation theories, Gill (2010) explains that an acculturation process occurs for groups who immigrate and settle in other countries. The learned behaviours and belief systems passed down through generations shift and alter to the host country's dominant culture and a 'cultural redefinition process' occurs. An example is observed in educational advancement which according to Bhopal (1998 cited in Snape, 2011), provides Asian women with a sense of empowerment, a desire for freedom of choice and a willingness to adopt to the values of the majority society in which they live.

Punjabi Sikh

Religion

Religion is defined as the belief in a higher being of power able to influence conscious and unconscious behaviours, thoughts and emotions (Gill, 2010). The role of religion is thought to be supportive as a protective factor against suicide. Particularly as a method of coping with life stresses, as a source of hope and meaning and as a motivational resource for social participation (Wasserman et al, 2021). The identity of Sikh women of Punjabi heritage is found to be rooted in Sikh principles of gender and equality through the Bani or Wisdom of the Sikh scriptures (Sikri, 2023). It is explained in 'Report 9 Women & Gender in Sikhi' (2023), of the distinction between Sikh principles as defined by Amritdhari (baptized Sikhs) and of Punjabi Sikh culture which is viewed as an external, socio-culturalized existence. Sikhi Resources | Explore and Learn Sikhism with Our Extensive Collection (sikhri.org

Therefore, it is to be understood in the context of this research, that Punjabi Sikh women are to be recognised as being on a faith continuum of self-awareness, belief and commitment to the religion. Iqbal Kaur Gill (2010) states that "for many Punjabi Sikhs religion is as much about culture as it is about religion". There is a dichotomy within Punjabi society and it is important to recognise this to avoid unwarranted judgment of individuals expression of religious practices. We ALL Experience Mental Health [Podcast Clips] @BasicsofsikhiTV - YouTube

Visibility

Nayak and Jaswinder (2023) explain in detail of the global visibility and movement of Punjabi Sikhs as diaspora who thrived in westernised countries such as Canada, USA and UK during phases of post-war immigration. Notably, discriminatory issues of structural racism, sexism and polarisation were part and parcel of the global movement experience. More recently, the Doaba region of Punjab continues to be the main region where an acceleration of immigration stems from due to regional, economical and political factors. The current Chief Minister of Punjab petitioning for an industrialist approach to boost the workforce. Although, policies set to benefit Punjabi working women are unclear (Roy, 2023).

In terms of the visibility of the Sikh population in the UK, the Office of National Statistics (2023) recently published recorded figures from the 'Sikh identity, England and Wales: Census, 2021' with over half a million participants identifying themselves as religiously Sikh. It reveals that older Sikh people are more likely to not speak English with three quarters of Sikh young people not speaking Punjabi as their main language. The data further indicates inter-generational variations linked to identity, language and communication, work and education and living status. Sikh identity, England and Wales - Office for National Statistics (ons.gov.uk)

Representation

Wasserman et al (2021) in the Oxford Textbook of Suicidology and Suicide Prevention, introduces us to the interconnectedness of religion and suicide and of the usefulness of applying religiosity within suicide preventative programmes. The authors discuss the influence of individual faith as playing a crucial role in reducing suicidality. They mention the impact of religious communities who impart their beliefs and traditions onto those born into their respective cultured environments. It is disappointedly the absence of the Sikh faith perspective that prompted enquiry into further research, particularly that of the Sikh diasporas’ visibility in suicidology literature and mental health resources. The indifference may have been a deliberate omission as Wasserman et al (2021, p4) states that "an effort was made to move away from rigid and essential ideas of cultural territories, regional identities and a static view of customs". This approach (in my opinion), inevitably overlooked and excluded a substantial population (just under 30 million globally) of Sikh communities and risks the omission of cultural research education that Hall (2008) defines as a ‘key site of power’. Furthermore, Crozier and Davies (2008) remind us of the referencing of South Asian communities in the UK as homogenous and monolithic, othered in their culturalization, excluded from educational spaces yet criticised for disassociating and ‘not mixing in’.

Data

The recording of data relating to minority groups and especially of women has been problematic in the past. Hendin et al (2008) explain that "some countries make no effort to collect data on the causes of death" and available research has "generally been gleaned" from studies conducted in European countries and the United States of America. Furthermore, in India itself particularly in rural regions, under-reporting or insufficient registering of events leads to a distortion of actual figures of suicidal attempts or confirmed deaths (Hendin et al, 2008). It seems that recent national figures of suicide rates in India, as compiled in the National Suicide Prevention Strategy (MHIN, 2022), evidences a contemporary viewpoint. Proclaiming to be the first policy in India to make the prevention of suicide a priority with an aim to reduce mortality by 10% by 2030. There are revisions within India’s Mental Healthcare Act (2017) challenging former clauses that threaten punishable outcomes (Section 309). A seemingly progressive approach includes a 'duty of care to support' suicidal individuals with rehabilitation (Section 115), meaning that the reporting of suicide attempts is communicated with less hesitancy (MHCA, 2017). It is however, important to note that Section 309 remains in law to prosecute those who intend to attempt suicide. Attempted Suicide and Legal Issues (Medicolegal issues regarding attempted suicide) (youtube.com)

Research

Mental health "must be viewed through a unique cultural lens" and although Gill (2010) writes from a Canadian perspective, she believes that the UK leads the field in terms of research of South Asian subjects. There is proven research determining that Punjabi Sikh communities are at risk of suicide and self harm (Husain et al, 2011). Although, no correlation between the influence of the Sikh religion on planned or attempted suicide (as may emerge from other religions).

The need to investigate intervention and prevention methods that link to wider Punjabi diaspora communities was imperative. Research findings by Dandona, George and Kumar (2023) revealed that the suicide death rate for women and girls in India was twice as high in comparison with the global average for women. Family problems were the most common reason for suicide from 2014 to 2020, accounting for 16,140 (36·3%) of 44,498 suicide deaths in India. Furthermore, research from India’s National Suicide Prevention Strategy (MHIN, 2022) states that India’s contribution to global suicide figures, particularly of youth-aged individuals, continues to increase and is highly problematic in terms of global migration. The policy has gathered much of its sociodemographic data from the National Crimes Record Bureau (2014-2020) on the reported suicide deaths of women and girls. It discloses marital status, occupation and educational status providing indications of social status and methods of the suicide deaths (Dandona et al, 2023). What's behind suicides by thousands of Indian housewives? - BBC News

Immigration

An immigrant is described as a person who chooses to move across countries largely due to economic motivations. This may be to escape economic hardship or to unify with family (Bartlett and Ghaffar-Kucher, 2013). Globalisation is defined by Hall (2008) as a 'division of labour' between developed and developing societies. We understand globalisation in simple terms as the growth of consumption, the emergence of multinational corporations, the dominance of financial investment in markets and a weakening of economies elsewhere. The effects of immigration and globalisation on Punjabi Sikh women vary on how they manage the pressures of movement and align with societal structures in a different country. On arrival it is anticipated that women and girls who engage in study abroad are more likely to struggle with educational performance in comparison with native-born students (Bartlett and Ghaffar-Kucher, 2013). They are likely to self-harm due to factors relating to family conflict, cultural pressures to conform and not seeking or hesitating to access healthcare services during moments of developing crisis (Husain et al, 2011).

Movement

Dhyani et al (2022) stipulate that depression is anticipated to become more prevalent in India over the next few years due to the changes in migration and urbanization. The migration of skilled workers and of international students from Punjab into the UK (and globally) is described as an "expanding trend difficult to predict" by Nayak and Jaswinder (2023). Punjabis seek to earn better, gain a higher standard of living status and commit to family obligations via immigration. Push factors out of Punjab currently include very high youth unemployment, an increase in population, less resourced educational facilities and worryingly scarce skills opportunities for young people. Societal problems include high drug and alcohol rates, the 'brain drain' lack of jobs and immense family debt. These are underlined by patriarchy, which impacts the lives of women and girls, further entrenching inequalities that may be viewed by outsiders as ‘cultural’ or ‘traditional’ (Nayak and Jaswinder, 2023). JETIR2301154.pdf

Women

Punjabi women who have migrated out of Punjab are commonly skilled in low-earning professions where manual labour such as sewing and care work meets the labour needs of the countries that they immigrate to. It is estimated that close to 20,000 Punjabis attempt to migrate out of Punjab every year. The number of non-bank loans to fund study and travel fees has increased exponentially over the past decade putting families at risk of extreme debt. It is almost certain that when social mobility does improve on settling abroad, financial reinvestments are made to the societies in which they primarily came from (Nayak and Jaswinder, 2023). Punjabi women and girls are largely marginalised due to their gender. According to Malu (2021), the normalisation of maintaining the stereotypical mindset of women being lower than men denies women and girls their rights from birth, imbeds inequalities and suppresses autonomy.

Parenting

Jay Belsky (1984) highlights the model of parental functioning suggesting that parenting outcomes may be influenced by one's own childhood parenting experiences. Wider to this, the impact of social support on psychological and physical health as influenced by friends, relatives and spouses, would determine parenting techniques. A range of authoritarian or responsive techniques link to mental health and wellbeing outcomes for both parent-child (Belsky, 1984, p87). Culturally, parenting techniques differ in Global South countries as will childhood psychological outcomes. Archard (2015) highlights that in relation to gender, men and women are expected to follow 'family' roles which reproduce relationships between un-equals of subordination and oppression. Injustices and disputes between families also perpetuate social injustice. Children may inherit inequalities from their parents leading to pent up anxieties and depression as young people.

Childhood

The ideology of childhood in the global South dictates that children are 'demarcated from adults' biologically and psychologically (Boyden cited in James and Prout, 2015). Yet, the daily prevalence of socioeconomic crises impact on the life choices of young people by exposure to adulthood themes with the uncertainty of any protection. In relation to the most marginalised and disadvantaged young people, there is often an absence of choice, autonomy and minimal rights over their life direction. Qvortrup (cited in James and Prout 2015, p75) explains that "children are seen as having to mature before they can obtain freedom to act on behalf of themselves". The status of children in their fleeting childhood phases are often categorised according to their parents income, occupation, education and for children themselves childhood is a temporary period fixed in 'adultified' societal structures (Corsaro, 2005 cited in Oswell, 2013). In relation to the global movement and mental health of young people moving into adulthood, it was concerning to read The World Health Organization (WHO 2023, p9) report on Adverse Childhood Experiences (ACES's). It highlights studies conducted around the world (European and North American) which show that a substantial proportion of adults suffer ACEs during childhood. With 42% of adults suffering at least one ACE whilst growing up and 19% having suffered more than one ACE. Equivalent figures for studies in North America were 58% and 35% respectively. Immigration data was included in the figures.

Resilience

Resilience researchers make no claims against the fact that young people are exposed to situations that significantly challenge their psychological coping abilities. Harvey and Delfabbro (2004,p5) believe that people who are resilient are "successfully able to manipulate their environments" to insulate from the consequences of adverse events. Previous life experiences play a role in resilience and coping strategies and skills can be developed from this. Interestingly, the authors Harvey and Delfabbro (2004, p6) note that "cultural influences mainly from westernised countries, use markers of achievement such as social and financial success in the face of resisting disadvantage" and is indicative of displaying resilience. It is also suggested that an individual can be deemed resilient if they are able to successfully cope with the challenges that they encounter. If we take the example of the bereaved farmer wives of Punjab who inform us of generational suicide trauma, they remain resilient in protest towards government disregard and of societal ignorance (Sala and Anand, 2022).

Healthcare and self-care

Self-care is vital in order to maintain good mental and emotional health and something as simple as participating in an activity proves beneficial to minimising ideation. Sporting Equals (one of the only organisations in the UK to actively promote ethnic diversity across sport and physical activity) endorses participation for ethnic women and girls. But participation in itself presents other challenges. Ratna (2013) explains of the misconceptions that British Asian women and girls are 'not allowed' to play sport due to religious and cultural beliefs or that it may be inappropriate (in a gendered context). The ease of stereotyping deflects from the needs of ethnic women. Ruprai (2016) states on healthcare that service providers have taken the 'colour-blind' approach by assuming that ethnically diverse service users could be integrated into existing healthcare service provisions. Exercise proves to be an evidence based treatment option for depression - BJSM blog - social media's leading SEM voice (bmj.com)

Comparatively, Canadian researchers Currie and Bedi (2019) highlight that the effectiveness of Western psychotherapeutic practices does not extend to all cultures and it would be beneficial to have culturally adapted counselling and psychotherapy. They suggest that this would be done by systematically modifying practices by accounting for cultural values, worldviews, and other diversity variables to provide culturally sensitive and specific interventions. With spa and wellness industries in the UK today growing exponentially (as it is in India), companies like Therme Group make claim to ensure that 'a Therme Group wellbeing resort is within 90% of the UK population' by working with central and local government bodies, investors and stakeholders to deliver its UK development plan. It remains to be seen if stakeholders consider an inclusive approach taking into consideration of minority community needs. Therme Group confirms plans for more UK wellness centres | European Spa Magazine

the CHURCHILL fellowship

Fellowship Report

Suicide Intervention: British, Punjabi Sikh Women

A Holistic Approach

If girls are sitting at home doing nothing then marriage is the only option. Somehow, I've managed to say 'no', it's too early, I'm only 23. My dad has spent £15,000 on my studies abroad already. I want to do my Masters in Australia, that's the only way I can escape from here.

Review of Literature

Theories

Punjabi Sikh

Religion

Visibility

Representation

Data

Research

Immigration

Movement

Women

Parenting

Childhood

If members of the working class and minority groups act like children it is because children of every class are lower class, just as women have always been. Women and children are now in the same lousy boat. Their oppressions began to reinforce one another.

Resilience

Healthcare and self-care