Abstract
Suicide among older adults in rural areas is widespread. However, research on this issue is rare, and studies focusing on protective factors against suicidal behavior among this population are even scarcer. Based on Bronfenbrenner’s ecological framework, this systematic literature review examined protective factors against suicidal behavior among community-dwelling older adults in rural areas. The results found that there were individual-, family-, and community-level protective factors against suicidal behavior. Multi-level interventions are needed to reduce and prevent suicidal behavior among older adults in rural areas. Cultural differences should also be considered.
Introduction
Suicide is a critical social and public concern globally. Researchers have reported that one person dies by suicide every 40 seconds (Fiske & O’Riley, 2016; Hirsch & Cukrowicz, 2014; Ivey-Stephenson et al., 2017; Ra & Cho, 2013; WHO, 2014). Data from a cross-national study including 17 nations indicated that approximately 9% of the global population reported seriously considering suicide at some point in their lifetime (Nock et al., 2008). In nearly every region of the world, adults over 70 complete suicide at a higher rate than any other age range (WHO, 2014), and suicide rates are expected to continue to escalate as baby-boomers age (Phillips, 2014). However, suicide is underreported due to the misclassification of deaths and unreliable suicide tracking systems across nations (WHO, 2014).
Researchers in both western and eastern countries have reported that suicide among older adults is considerably more prevalent in rural areas than in urban areas (Cukrowicz et al., 2018; Hirsch & Cukrowicz, 2014; Ojagbemi et al., 2013). Although approximately 3.4 billion people around the world—just over 45% of the world’s population—live in areas classified as rural (Ritchie & Roser, 2019), older adults with suicidal thoughts and behaviors in rural communities tend to be ignored or understudied (Hirsch & Cukrowicz, 2014).
Although previous research has explored factors surrounding suicides occurring in rural settings (Hirsch & Cukrowicz, 2014), the primary research focus has tended to be risk factors for suicidal behaviors (De Beurs et al., 2019; Yoon & Cummings, 2019). While critical for our understanding of suicidal behaviors, risk factors such as physical dysfunction, ethnicity, a family history of suicide, and past suicide attempts may be beyond individuals’ or practitioners’ control (Eom, 2007; Yoon & Cummings, 2019). Therefore, identifying protective factors along with risk factors may be necessary to prevent and reduce suicidal behaviors among rural older adults (Yoon & Cummings, 2019).
Bronfenbrenner (Bronfenbrenner, 1979) provides an ecological framework that describes the effects on individuals of their social environments (Lee et al., 2014; Yoon & Cummings, 2019) by modeling the interaction among systems of connectedness at multiple levels including individual traits, family constellations, and broader social conditions. The Bronfenbrenner framework facilitates a contextualized understanding of protective factors against suicidal behaviors, which may be especially helpful for understanding the dynamics of this phenomenon in rural settings. For example, across the globe, rural communities often have fewer resources and smaller social networks than urban communities. Understanding how different levels of connectedness interact is especially critical in the wake of the COVID 19 pandemic, which has destabilized social connectedness at many levels for a large portion of the world’s population.
The aim of this systematic literature review is to identify factors that may reduce or prevent suicidal behaviors among older adults living in rural communities, using Bronfenbrenner’s ecological model as a frame of reference. Suicidal behaviors include suicidal ideation (SI), suicide attempts, and suicide completion. This review may help older adults and their families as well as health professionals and practitioners to better understand the factors that reduce or prevent suicidal behaviors and so apply timely and appropriate interventions for vulnerable older populations in rural areas.
Method
Search Criteria
This review examined peer-reviewed research articles published in English. The electronic search included the following databases: PubMed, Web of Science, EBSCO, PsycINFO, Proquest Central, Scopus, and Google Scholar. Articles published between January 1, 2000 and December 31, 2020 were included in the search to capture the most recent research. The same terms were employed to search each database: “suicide” OR “suicidal ideation” OR “death desire” OR “death thoughts” OR “death wishes” OR “nonfatal suicidal behavior” OR “self-harm” AND “older adults” OR “elderly” AND “protective factor” OR “buffer” OR “resiliency” OR “protection” AND “rural.” When these search terms yielded more than 100,000 search hits, the results were narrowed by using filter options unique to each database. These filters included peer-reviewed, full-text, human subjects only, and age filters for subjects 50 years and older. For example, the Web of Science database “Search Within Results” function was utilized to further limit the search with the key term “older adult.” This narrowed the search findings from 221,992 findings to 7,391. The search was conducted from February 10, 2020 to March 25, 2020.
Inclusion and Exclusion Criteria
The following inclusion criteria were used to hand-select articles: (1) Participants had to be aged 50 or older; however, studies with younger participants were included if the results differentiated older and younger age groups; (2) Participants had to be community-dwelling in rural areas; however, studies with urban participants were included if the results differentiated rural and urban dwelling participants; and (3) the results section had to identify protective factors, buffers, resiliency factors, or mediating or moderating variables related to suicidal behaviors among community-dwelling older adults in rural areas. Articles were excluded if the study did not identify any of the associated factors as described above or if all the participants were younger than 50 or were not community-dwelling in rural areas. The type of data source (primary or secondary) was not a criterion for selection, but literature reviews and systematic reviews were excluded.
Screening Process
Using the search criteria (Figure 1), 171,367 articles were included as potential qualifying papers. This broad collection was screened by title and abstract. A total of 45 qualifying articles were identified through this process; however, 14 duplicates were identified and removed. Next, the full texts of the remaining 31 articles were scanned and reviewed to ensure that the articles included all eligible criteria. A further 19 articles were removed at this stage: nine articles were removed because the content related only to depression and not suicidal behaviors; six were removed because the content did not meet the “rural” criteria; two were removed because they were literature reviews, and two articles did not include community-dwelling older adults in their studies. After these exclusions, 12 articles (Table 1) were selected for this study.
Database screening.
Protective Factors Against Suicidal Behaviors Among Community-Dwelling Rural Older Adults.
Results
Individual-Level Protective Factors
Of the 12 studies selected for inclusion, 10 (83.33%) examined individual protective factors against suicidal behaviors. Individual factors included internal variables such as genetics, ego-resilience, life satisfaction, and functional impulsivity (Cha & Lee, 2018; Ge et al., 2017; Y.-Y. Liu et al., 2017; Wang et al., 2015). External individual protective factors included education, income, and limited alcohol intake (Handley et al., 2012; Li et al., 2016; Wahlin et al., 2015; Yi et al., 2016).
Education Level
Education level was identified as a protective factor against suicidal ideation (SI) among community-dwelling older adults in rural areas across multiple countries. A study conducted among older adults in rural Bangladesh found an association between literacy rates and SI (Wahlin et al., 2015). Specifically, literate Bangladeshi older adults were less likely than illiterate older adults to report depressive symptoms and suicidal thoughts (Wahlin et al., 2015). South Korean older adults were also less likely to report depression and SI if they had higher levels of education (Cha & Lee, 2018).
Subjective Better Economic Status
Perceived better economic status was protective against suicidal behaviors. A study of rural older adults in Shandong Province, China found an inverse relationship between perceived economic status and SI, directly and indirectly (Ge et al., 2017). Another study of rural older adults in Shandong Province (B.-P. Liu et al., 2018) found a link to perceived economic status and completed suicide. The researchers found that many of the older adults who completed suicide had poor socioeconomic status compared to the case-controlled population that did not complete suicide. Lastly, having personal income was a protective factor against SI among rural Bangladeshi older adults compared to those with no income (Wahlin et al., 2015).
Mental Health
Three studies examined mental health status as a protective factor against suicidal behaviors. According to Wang et al. (2015), the prevalence of a mental disorder was associated with higher rates of suicide attempts, whereas participants with no history of mental disorder were less likely to have attempted suicide. Furthermore, in a sample of older adults in Mainland China, individuals who had fewer depressive symptoms were less likely to experience SI (Li et al., 2016).
A study of rural older adults in Australia also found a link between mental health and SI. Individuals who did not report anxiety disorders or lifetime psychiatric disorders were less likely to experience SI throughout their lifespan (Inder et al., 2014). Older adults who had not experienced psychological distress in the last 12 months were less likely than others to report SI, and they were less likely to attempt suicide throughout their lifespan (Inder et al., 2014). Furthermore, older adults who did not have an affective disorder, anxiety disorder, substance use disorder, or lifetime psychiatric disorder were less likely to attempt suicide throughout their lifespan (Inder et al., 2014).
Optimism
One study found a link between the personality trait of optimism and SI. Inder et al. (2014) measured optimism using the Hunter Opinions and Personal Expectations Scale (HOPES-12). Rural Australian older adults with higher rates of optimism and lower rates of psychological distress were less likely to report SI than those with lower optimism and higher psychological distress (Inder et al., 2014).
Genetics
Wang et al. (2015) found a genetic protective factor, the brain-derived neurotrophic factor (BDNF) 196A-carrying genotypes, to be a protective factor against suicidal attempts among rural older adults in Shandong, China. The BDNF gene is located on chromosome 11 and is responsible for maintaining neurological functions (Wang et al., 2015). This study suggested that older adults with the BDNF 196-A allele may be protected against suicidal attempts compared to those who do not carry the allele.
Positive Functional Impulsivity
Liu et al. defined functional impulsivity as a tendency towards “enthusiasm, adventurousness, and activity” (Y.-Y. Liu et al., 2017, p. 22). The positive functions of impulsivity were found to be protective against suicidal attempts among rural Chinese adults between the ages of 50 to 59 years old (Y.-Y. Liu et al., 2017). However, functional impulsivity had no significant impact on suicide attempts among adults between the ages of 60 and 70 years old (Y.-Y. Liu et al., 2017).
Ego-Resilience
Cha and Lee (2018) defined ego-resilience as the ability to cope with negative life events and adapt to negative situations throughout one’s life. Their study of older adults in the Chungcheong Province of South Korea found that ego-resilience had a direct impact on both depression and SI (Cha & Lee, 2018). Furthermore, ego-resilience influenced SI indirectly through social support (Cha & Lee, 2018).
Life Satisfaction
According to Ge et al. (2017), life satisfaction is a direct and indirect protective factor against SI among rural older adults in Shandong, China. Those who reported poor life satisfaction had a 27.7% rate of SI at some point in their lifetime (Ge et al., 2017). In contrast, only 3% of participants with good life satisfaction reported SI at any point throughout their lifetime (Ge et al., 2017). Additionally, life satisfaction was found to indirectly protect against SI by reducing depression (Ge et al., 2017).
Alcohol Abstinence
Yi et al. (2016) established a link between alcohol consumption rates and suicide mortality among rural Korean older adults. The longitudinal study tracked deaths by suicide from 1985 to 2008. The researchers determined that individuals who abstained from alcohol were less likely to die of suicide than drinkers in any of these categories: Those who drank 2 days or more a week, had 5 drinks a week, or drank 15 drinks or more per week (Yi et al., 2016).
Perceived Physical Health
A study by B.-P. Liu et al. (2018) of rural older adults in Shandong Province, China found a connection between perceived physical health and suicide completion. The researchers interviewed either the deceased individual’s family member or close friend to determine factors leading to the person’s suicide. Individuals who had completed suicide were likely to have a “serious or chronic” physical illness (B.-P. Liu et al., 2018, p. 196) compared to the case-control group. Another study of Chinese older adults also found a link between physical ability and SI (Li et al., 2016). The researchers found that individuals with fewer functional limitations were less likely to report SI (Li et al., 2016). Individuals with high functional limitations were more likely to report SI within the previous 5 years (Li et al., 2016). A study of Aboriginal Taiwanese older women demonstrated that women who had better perceived health were less likely to experience SI than women who had poorer perceived physical health (Chen et al., 2008). Lastly, a study of South Korean rural older adults found that the ability to complete activities of daily living (ADL) was closely connected to depression and SI (Cha & Lee, 2018). Individuals who had several impairments in ADL were significantly more likely to experience SI compared to those with few or no physical impairments. The higher the ADL, the lower the level of depression and SI (Cha & Lee, 2018).
Fewer Negative Life Events
Three studies found a link between having fewer negative life events and protection against suicidal completion and suicide attempts. One study of rural Chinese older adults found a link between suicidal completion and negative life events (B.-P. Liu et al., 2018). A total of 93.3% of individuals who completed suicide in their study had experienced multiple negative life events within the year before they died (B.-P. Liu et al., 2018). In comparison, individuals in the case-control study who did not complete suicide had experienced fewer negative life events within the year of the interview (B.-P. Liu et al., 2018). This research shows that experiencing fewer negative life events may be protective against suicide completion (B.-P. Liu et al., 2018).
Another study of rural individuals in China by Y.-Y. Liu et al. (2017) found a connection between negative life events and suicide attempts. Individuals who had experienced a negative life event in the last year (based on Paykel’s Interview for Recent Life Events measure) (Paykel et al., 1971; Zhang & Ma, 2012) were more likely to attempt suicide compared to those who had not (Y.-Y. Liu et al., 2017). Only 33.7% of individuals who had not experienced a recent negative life event attempted suicide compared to 83.0% of individuals who had experienced a recent negative life event (Y.-Y. Liu et al., 2017). A third study of rural older adults in China also found a link between negative life events and suicide attempts (Wang et al., 2015). Adults aged 60 or older who experienced negative life events based on Paykel’s Interview for Recent Life Events measure ((Paykel et al., 1971) were more likely to attempt suicide compared to an age-sex matched control population (Wang et al., 2015). Their study also showed that older adults who had not had a recent negative event occur in their life may also have been at a lower risk of a suicide attempts than those who had experienced one or more recent negative events (Wang et al., 2015).
Occupation
B.-P. Liu et al. (2018) found a link between an individual’s occupation and the likelihood of completing suicide. The researchers found that rural older adults in Shandong Province, China were more likely to complete suicide if they worked as farmers (B.-P. Liu et al., 2018) compared to all other occupations, and older adults who held any other occupation were less likely to have completed suicide (B.-P. Liu et al., 2018). Therefore, it may be a protective factor for rural Chinese older adults to work in an occupation not related to farming.
Family-Level Protective Factors
Six articles (50%) examined family-level protective factors among rural older adults. Family-level protective factors included support from family members, living with one’s children, positive relationships with one’s children, filial piety, and marital status (Cha & Lee, 2018; Chen et al., 2008; Inder et al., 2014; Li et al., 2016; B.-P. Liu et al., 2018; Wahlin et al., 2015). Familial support was effective in both eastern and western cultural contexts. Rural older adults across the studies appeared to benefit from family-level protective factors against SI and suicide attempts; no articles explored the impact of family-level protective factors against suicidal completion among rural older adults.
Living with Children
Support gained from one’s adult children is vital for rural older adults. Support from one’s children in old age is especially important among populations with cultural expectations for the child to care for their aging parent. Rural Bangladeshi older adults living with their adult children in the same household or neighborhood (“bari”) reported significantly less SI than adults who did not live with their children (Wahlin et al., 2015).
Positive Relationships with One’s Children
Positive, satisfying relationships between rural older adults and their children also proved to be protective against SI (Wahlin et al., 2015). Rural older adults in Bangladesh who perceived that they had a high-quality relationship with their adult children had a lower prevalence of both SI and depressive symptoms (Wahlin et al., 2015).
Filial Piety
Chinese older populations have a cultural expectation that they will be cared for in old age by their adult children, referred to as filial piety. According to Chinese cultural values, it is the duty of adult children to love, respect, accompany, and support their parents (Li et al., 2016). Li et al. (2016) found that filial piety protected rural Chinese adults against both SI and suicidal attempts.
Marital Status
Marriage to a living spouse was also found to be a protective factor among rural older adults across the globe. Support gained from one’s spouse protects older adults against SI and suicide attempts. Rural older adults in Australia were less likely to report recent (within 12 months) or lifetime SI if they were currently married (Inder et al., 2014). In addition, currently married older adults were significantly less likely to report any suicidal attempts throughout their lifespan (Inder et al., 2014). Rural Bangladeshi older adults also reported significantly fewer rates of depressive symptoms and SI compared to older adults who were single, divorced, or widowed (Wahlin et al., 2015). A study of suicide completions among rural Chinese older adults also found a connection between marital status and suicide (B.-P. Liu et al., 2018). Individuals who completed suicide were more likely to be living without a spouse compared to the control sample (B.-P. Liu et al., 2018).
Support from Family Members
While marriage to a supportive spouse was identified as a protective factor for many rural older adults, marital discord and physical/verbal abuse from a spouse were serious risk factors that could increase SI (Chen et al., 2008). Aboriginal Taiwanese older women in one study who reported high prevalence of marital discord also reported SI (Chen et al., 2008). However, women in this group who received emotional support from friends or their family members were less likely to report SI (Chen et al., 2008).
A study of rural older adults in South Korea also showed that support from family and significant others was protective. Cha and Lee (2018) measured family support using the Korean version of the Multidimensional Scale of Perceived Social Support, MSPSS (Ko & Seo, 2011), originally developed by Zimet et al. (1988), which measures both family support and support from one’s significant other. The results showed that people who had high scores for social support were significantly less likely to experience SI and depression than those who had low scores (Cha & Lee, 2018).
Community-Level Protective Factors
Seven articles (about 67%) identified community-level protective factors among rural older adults, including social support from friends and neighbors, social capital, and community resources. Important considerations at this level are the individual’s satisfaction with the social support they received along with how often they had contact with members of their social network.
Social Support from Friends and Neighbors
Social support from community members and neighbors was found to be protective in one Japanese study. Noguchi et al. (2017) measured social support as the subscales “instrumental support” and “emotional support.” Instrumental support was defined as help completing tasks such as shopping, cleaning, errands, and cooking. Emotional support was defined as providing emotional reassurance, being on the individual’s “side,” and supporting them in times of need. The researchers found both forms of social support to be protective against SI for Japanese rural older adults (Noguchi et al., 2017).
Chinese rural older adults in three studies also benefited from social support. The first study was conducted in both urban and rural areas in Mainland, China. Li et al. (2016) reported that an individual’s connection to a social network consisting of friends, neighbors, and relatives reduced the likelihood of SI and suicide attempts among older rural adults within a 12-month and 5-year time span (Li et al., 2016). The second study was conducted by Ge et al. (2017) in Shandong, China. The authors measured social support as “subjective support,”“objective support,” and the “utilization” of offered support. Rural Chinese older adults with high overall levels of social support were less likely to experience SI (Ge et al., 2017). Additionally, social support reduced SI by mediating depression, the strongest risk factor of SI in the study (Ge et al., 2017). The third study was conducted by B.-P. Liu et al. (2018) in Shandong Province. Pair-matched case-control was used to compare individuals who had completed suicide with comparable living individuals of the same sex and similar age. Family members of the deceased individual were interviewed to determine various measures related to the person’s suicide completion. The researchers found that many of the older adults who completed suicide lacked social support from a spouse, friends, family, or community groups. Compared with paired controls, social support was an important protective factor against suicide completion for rural older adults (B.-P. Liu et al., 2018).
Social support was also found to be beneficial for South Korean older adults. Cha and Lee (2018) found that older adults who received high levels of social support were less likely to experience SI than older adults who had lower levels of social support. In particular, the direct effects of social support on SI (r = −.33) were stronger than the direct effects of depression (r = .17) on SI (Cha & Lee, 2018). Another study found that social support from the community was protective for Aboriginal Taiwanese rural older women (Chen et al., 2008). Women who received emotional support from their community and friends were less likely to report SI. According to the authors, social support from friends and the community may have reduced the risk of suicide among this population by as much as 60% (Chen et al., 2008). These studies showed that social support was highly effective in providing protection against suicidal behaviors in women who were experiencing high rates of marital discord.
Satisfaction with Social Support
In a study that found social support to be protective among rural adults and older adults in Australia, Handley et al. (2012) also considered the size of the social network, the frequency of contact, and the individual’s satisfaction with their support system. According to Handley et al. (2012), those who reported “high” satisfaction with their social support were significantly less likely to report SI compared to those who reported “low” to “moderate” satisfaction (Handley et al., 2012).
Frequency of Contact
Rural adults and older adults in Australia who reported frequent social interaction were less likely to report SI than individuals who reported infrequent social interaction. Perceived availability of social support and a sense of community decreased the prevalence of SI among rural Australians (Handley et al., 2012).
Social Capital
Social capital is defined as “resources that are accessed by individuals as a result of their membership in a network or a group” (Noguchi et al., 2017, p. 38). Social capital is distinct from social support in that it can be derived from weaker acquaintance ties or from close ties (Berkman & Kawachi, 2014). Noguchi et al. (2017) measured social capital through the perception of trust for one’s community and rates of reciprocity among community members. The researchers found that community-level social capital (trust and reciprocity) was inversely associated with SI. In other words, rural older adults who lived in communities with high levels of trust and reciprocity were less likely to report SI (Noguchi et al., 2017). Interestingly, living in a community with a high overall perception of trustworthiness was a protective factor regardless of the individual’s own perceptions. An individual who lives in a community whose members have high levels of trust in each other was less likely to experience SI even if that individual did not trust their own neighbors (Noguchi et al., 2017).
Access to Medical Care
A study of Aboriginal Taiwanese older women demonstrated a relationship between medical access, self-perception of physical health, and SI. Women with limited access to medical care were more likely to experience SI than women who had adequate access to medical resources (Chen et al., 2008). The women in Chen and her colleagues’ population had few medical care resources due to their isolated mountainous environment.
Discussion
This systematic literature review has employed Bronfenbrenner’s ecological model (Bronfenbrenner, 1979) as a framework for examining 12 studies that shed light on individual-, family-, and community-level protective factors against suicidal behaviors among community-dwelling older adults in rural areas (Figure 2). At the individual level, the study has identified a number of internal and external factors that protect against suicidal behavior: education, income, limited alcohol intake, genetics, ego-resilience, optimism, life satisfaction, and functional impulsivity (Cha & Lee, 2018; Ge et al., 2017; Handley et al., 2012; Li et al., 2016; Y.-Y. Liu et al., 2017; Wahlin et al., 2015; Wang et al., 2015; Yi et al., 2016). At the family level, it illuminates the following protective factors: support from family members, living with children, positive relationships with adult children, filial piety, and marital status (Chen et al., 2008; Inder et al., 2014; Li et al., 2016; B.-P. Liu et al., 2018; Wahlin et al., 2015). At the community level, it shows the following protective factors : social support from friends and neighbors, size of one’s social network, frequency of contact, social capital, and medical accessibility (Cha & Lee, 2018; Chen et al., 2008; Ge et al., 2017; Handley et al., 2012; Li et al., 2016; B.-P. Liu et al., 2018; Noguchi et al., 2017). The literature review also revealed that factors at one level interact with factors at the other levels (Cha & Lee, 2018; Li et al., 2016; Wahlin et al., 2015), which supports Bronfenbrenner’s ecological frame (Bronfenbrenner, 1979).
Protective factors against suicidal behavior.
Cultural Differences and Similarities
Because of its global scale, this literature review provides an opportunity to identify broad cultural patterns that may be worthy of further investigation. One interesting pattern in the studies reviewed here relates to education. A higher educational level was an individual protective factor against suicidal behaviors among rural older adults only in eastern countries (Cha & Lee, 2018; Wahlin et al., 2015), which is consistent with other studies that make no distinction between rural and urban older adults in eastern countries (Park, 2014; Yen et al., 2005). Although the current study is framed to emphasize protective factors, research relating to Marginalization-related Diminished Returns (MDRs) may provide further insight into its findings. MDR research seeks to understand how race and ethnicity as marginalizing factors affect health outcomes, particularly by focusing on the diminished capacity of protective factors in Black adults compared to White adults (Assari et al., 2019, 2020). MDR theory might apply to rural-dwelling older adults, with rurality being either a primary or shared cause of marginalization, underscoring findings that indicate that there is no universal protective factor for suicide, including higher educational attainment (Assari et al., 2019, 2020). The cultural differences noted in this study suggest that the individual-level factor of education may interact with community- and/or macro-level factors related to the cultural, social, and economic value that a higher education offers individuals in particular cultural or socio-economic contexts.
Another interesting pattern in the findings illuminates the possible interactions between macro-level factors and individual circumstances regarding family relations. Several studies in eastern countries such as Taiwan, China, and Bangladesh have highlighted the protective impacts of living with one’s adult children (Wahlin et al., 2015), receiving emotional support from one’s family while experiencing marital discord (Chen et al., 2008), and filial piety (Li et al., 2016). These results are consistent with the findings of another systematic literature review conducted in the context of South Korea that identified family-level factors as an important protection against SI (Yoon & Cummings, 2019). The strong impact of family-level factors in these contexts may reflect the high value that eastern countries place on collectivism compared to western countries (Yoon & Choi, 2022; Yoon & Cummings, 2019).
One protective factor that seems to have a universally significant impact is better economic status (Cha & Lee, 2018; Park, 2014). The finding that economic status protects against SI has been confirmed by many studies in both western and eastern contexts, but previous studies have made no distinction between rural and urban populations (Ge et al., 2017; Inder et al., 2014; B.-P. Liu et al., 2018; Wahlin et al., 2015). The current review reinforces the widespread significance of this factor by showing that it also holds within the delimited context of rural populations.
Financial Support
As noted above, better economic status has been identified as a significant protective factor against SI for older rural adults (Cha & Lee, 2018; Park, 2014). In contrast, economic hardship has been found to be a common negative life event that precedes suicidal behaviors (Zhou et al., 2004). Because the economic status of rural older adults—especially farmers—is likely to be more vulnerable to the forces of nature, climate change, and risk factors such as pesticides than that of urban dwellers (Inder et al., 2014; B.-P. Liu et al., 2018), it may be wise to more closely examine how environmental factors and individual-level factors interact in terms of their impact on suicidal behavior. In addition, the current study points to the value of economic policy initiatives at the macro level to support vulnerable older populations in rural communities including the expansion of medical reimbursement services, the provision of medical service, financial support, emotional and policy support programs for family caregivers, and more secure pension systems (Cavalieri, 2013; Y.-Y. Liu et al., 2017; B.-P. Liu et al., 2018; Yoon & Cummings, 2019). Previous research in South Korea reported that, in general, societal and governmental financial support for low-income older adults acted as a protective factor to reduce suicidality especially during national and/or global economic crises (Y.-J. Kim, 2011; M. Y. Kim, 2013). In rural areas, such community-level and macro-level interventions may be even more necessary to increase support for older rural adults’ daily practical needs and reduce the financial burdens on farm communities and isolated areas that are under economic stress.
Multi-Levels Education
Mental health screenings and timely intervention are critical against suicidal behaviors (Handley et al., 2012; B.-P. Liu et al., 2018). Menon et al. (2018) found evidence that most people who die by suicide have contacted their primary care provider within the last month. Thus, it is vital to train and educate healthcare professionals and practitioners to recognize and more actively monitor signs of depression or SI (Ge et al., 2017; Handley et al., 2012). In addition, it is common for people contemplating suicide to reach out to family or friends before requesting professional help (Vogel et al., 2007). However, family or significant others may not possess the skills or knowledge to seek help for a loved one who is contemplating suicide (Barton et al., 2013). Practitioners need to provide educational programs and training services to help family members and gatekeepers understand suicidal behaviors in later life and make it easier for them to gain access professional care in a timely manner.
Healthcare Accessibility and Timely Interventions
A consistent pattern in previous literature has been that perceived better health status is a significant individual protective factor against suicidal behavior for rural older adults. Rural older adults may be at an increased risk of suicidal behaviors due to poor management of acute or chronic illnesses (B.-P. Liu et al., 2018), increased functional limitations (Li et al., 2016), and limited access to healthcare facilities (Chen et al., 2008). To protect older rural populations against these risks, medical practitioners should increase attentiveness to the unique challenges that they face. Many rural and financially disadvantaged older populations have very few medical care options, are required to travel long distances to receive care, and lack the means to effectively access these services (Chen et al., 2008; B.-P. Liu et al., 2018). Virtual meetings with healthcare providers, telephone or online counseling programs, and telehealth information may be helpful for timely interventions for older adults who lack the ability to receive regular in-person care or counseling services from medical professionals (Birditt et al., 2021), especially during crises like the recent COVID-19 pandemic (Galea et al., 2020). Furthermore, efforts should be made by healthcare providers, practitioners, family members, and/or volunteers to improve access to communication technologies so that those in need can gain access these online benefits (Conroy et al., 2020).
Social Support and Social Connectedness
A striking pattern in this literature review is the critical role that social support plays as a crucial protective factor for suicidal behaviors in both eastern and western contexts. Social support from family members, whether it be from a spouse, child, family member, or community member, has consistently been found to be protective against suicidal behaviors. Researchers have also found that negative relationships with family members such as marital discord seriously impacts older rural adults’ suicidal ideation (Chen et al., 2008). These results are consistent with previous studies that make no distinction between rural and urban populations (Yoon & Cummings, 2019; Yoon et al., 2020, 2022). The practical take-away from these findings is that rural older adults will benefit from programs to reduce family discord and address relationship conflicts, as well as to help people develop appropriate coping and communication strategies (Birditt et al., 2020, 2021; Yoon et al., 2020, 2022). Also, social support has been reported as a predictor of resilience, a protective factor against adverse mental health outcomes (Yoon & Choi, 2022), including suicidal behaviors (Cha & Lee, 2018), after experiencing stressful life events. (Y.-Y. Liu et al., 2017; B.-P. Liu et al., 2018; Wang et al., 2015). Exercise programs and physical activity have been reported to boost resilience, improving vulnerable older populations’ self-esteem, social support, and mental health outcomes, along with their physical health (Callow et al., 2020; Hall et al., 2020; Yoon, 2024). Thus, health care professionals should develop and provide tailored exercise programs for rural older adults, with the understanding that these measures will not only to improve older adults’ physical and mental health, but also strengthen their resilience and social support, making them less vulnerable to suicidal behaviors.
In the context of social support, it is important to acknowledge that older populations make up a growing proportion of the population in rural areas (Baernholdt et al., 2012; Smith & Trevelyan, 2019). As young people migrate away from rural areas, the older adults who remain behind may not have any close family members close by. Nevertheless, they can benefit from significant protection against depression and SI in the form of social support from friends, neighbors, and volunteers, who may be their own peers (Yoon et al., 2020, 2022). Practitioners, healthcare providers, and religious organizations should develop and provide appropriate programs and services for older adults living alone with or without physical and/or mental dysfunction to boost social connectedness and social participation (Yoon & Cummings, 2019). In rural areas in particular, older adults with physical dysfunction and/or lack of transportation may benefit greatly from out-reach programs, home-delivery services, regular tele-check-in services, and computer-based programs (Kahlon et al., 2021; Yoon & Cummings, 2019). As noted above, access to online or computer-based programs and services should be guaranteed in rural areas (Fiske & O’Riley, 2016; Galea et al., 2020). Neighbor check-in programs, pen pal programs, community engagement events, as well as social groups for rural older adults may provide additional means of support and connection (Dumesnil & Verger, 2009; Tsai et al., 2010).
Reducing Stigma
Multi-levels interventions may be helpful in rural communities to counter the stigma that is often associated with seeking mental health services (Peel et al., 2017). Specifically, healthcare professionals can help reduce the stigma of mental illness by implementing mental health awareness campaigns and educational programs. Increasing mental health literacy has also been reported to reduce stigma related to suicidal behaviors (Peel et al., 2017). Public mental health awareness campaigns and/or educational training programs may strengthen the safety net for older adults in rural areas by promoting community values, fostering community ties, educating older adults and their family members about appropriate resources, and training volunteers including religious leaders, caregivers, and family members who can help challenge social stigma against help-seeking services (Kennedy et al., 2018; Li et al., 2016; B.-P. Liu et al., 2018; Menon et al., 2018; Peel et al., 2017; Yoon & Cummings, 2019).
Limitations and Strengths
This literature review by design delimits a very narrow slice of research published in English and addressing protective factors against suicidal behaviors among community-dwelling older adults in rural areas. It includes relatively few studies, a fact that may stand in the way of drawing large conclusions. The paucity of research in this area points to the need for more studies centering on protective factors against the distinctive challenges faced by rural older populations. Yet, despite the review’s small sample size, it has illuminated significant individual-, family- and community-level protective factors that can reduce or prevent suicidal behaviors among older adults in rural areas, based on Bronfenbrenner’s ecological frame (Bronfenbrenner, 1979). It has also underlined the need for healthcare professionals, policy makers, educators, and researchers to consider not only risk factors but also protective factors when setting their research and policy agendas, since the incidence of suicidal thoughts and behaviors does seem to be tempered by protections offered, at multiple levels, within the complex social ecologies of people’s lives.
The impact of the protective factors identified in this research against suicidal behaviors among community-dwelling rural older adults may vary depending on age (Y.-Y. Liu et al., 2017), gender (Chen et al., 2008), and racial and cultural differences (Cha & Lee, 2018; Wahlin et al., 2015; Wang et al., 2015). For future research, studies focusing on age, gender, racial, and/or cultural differences among rural older adults may help deepen our understanding of the protective factors against suicidal behaviors and of how the impacts of these protective factors may be enhanced or diminished by circumstances of marginalization. Research is also needed on macro-level protective factors against suicidal behaviors among various older populations in rural areas.
Conclusion
The current systematic literature review identified individual-, family-, and community-level protective factors against suicidal behaviors among community-dwelling older adults in rural areas based on Bronfenbrenner’s ecological model. Prevention and intervention programs that target multiple levels of protective factors at once may be the most efficient and effective way to reduce suicidal behaviors among rural older adults. Healthcare professionals, educators, policy makers, and researchers should also take cultural, age and gender differences among rural older adults into account when studying or attempting to boost protective factors.
Footnotes
Acknowledgements
None.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Social Justice Funding at the University of Wyoming partially supported this research.
