The roles of culture and gender in the relationship between divorce and suicide risk: A meta-analysis Paul S.F. Yip a, b , Saman Yousuf a, b , Chee Hon Chan a, b , Tiffany Yung b , Kevin C.-C. Wu c, d, * a Department of Social Work and Social Administration, Faculty of Social Sciences, University of Hong Kong, Hong Kong b Hong Kong Jockey Club Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong c Department of Medical Education and Bioethics, National Taiwan University College of Medicine, School of Medicine, Taipei, Taiwan d Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan article info Article history: Available online 31 December 2014 Keywords: Divorce Suicide Culture Gender Hofstede Coefficient of aggravation Meta-analysis abstract With some exceptions, literature has consistently shown that divorced populations are at higher risk for suicide than married ones. Here we make use of coefficients of aggravation (COAs), suicide rate ratios of the divorcees over the married, to study patterns of COAs and test the contribution of international sociocultural factors and gender to the relationship between divorce and suicide. We conducted a sys- tematic search of electronic databases to identify ecological studies reporting suicide rates and ratios of those rates within different marital statuses between Jan 1, 2000 and Dec 31, 2013. In total, ten studies consisting in suicide statistics of eleven countries/areas were selected. Using random-effect modeling, we noted that the pooled COA for men and women were 3.49 (95% CI 2.43e4.56) and 3.15 (95% CI 1.74e4.56), suggesting both divorced men and women exhibited a greater risk of suicide than their married coun- terparts. Subgroup analyses revealed that COAs in Asian countries are significantly higher than those in non-Asian ones. Among the sociocultural measures retrieved from the HOFSTEDE index and the World Values Surveys, we noted significant associations between COA and four measures, including the indi- vidualismecollectivism score, the long-term orientation scores, the survival/self-expression score, and the gender inequality indices. The magnitudes and the directions of the associations however differ by sex. The results confirm that overall divorced people have an aggregate higher suicide risk than married ones. The method used in our research could reveal what cultural indicators are exerting effect on the relationship between divorce and suicide risk, which might change with sociocultural transition. More investigation into the relationships and then the construction of culturally appropriate suicide preven- tion policy is recommended. © 2015 Elsevier Ltd. All rights reserved. 1. Introduction Marital dissolution or divorce is a consistently observed risk factor for suicide in most literature. This is evident in the high correlation between aggregate divorce and suicide rates (Bridges and Tankersley, 2009; Chuang and Huang, 2007; Inoue, 2009a, 2009b; Kondrichin and Lester, 2002; Leenaars and Lester, 1999; Park and Lester, 2006) as well as the higher risk of suicide among divorced populations compared to their married counterparts in population-level studies (Corcoran and Nagar, 2010; Denney et al., 2009; Kposowa, 2003; Stack and Wasserman, 1993; Yeh et al., 2008). It is an intriguing question whether the positive relationship between divorce and suicide holds in different sociocultural con- texts (Stack, 1987; Stack and Kposowa, 2011). The above effect has been found in countries of Western culture such as the U.S. (Denney et al., 2009; Inoue, 2009b; Stack, 1990b), Denmark (Stack, 1990a), Finland (Stack, 1992a), Norway (Stack, 1989), Canada (Trovato, 1987), Italy (Masocco et al., 2008), Northern Ireland (Corcoran and Nagar, 2010), Southeastern Serbia (Petrovi c et al., 2009), En- gland and Wales (Yip and Thorburn, 2004) and Australia. In countries of Eastern culture, findings were not as consistent as above. For example, in Hong Kong, the widowed and divorced women tended to have lower suicide rates than the married ones among older adults (Yip, 1998). In Japan, where family integration * Corresponding author. Department and Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine, School of Medicine, 2nd Floor, Medical Humanity Building, No.1 Ren-Ai Road Sec. 1, Taipei 100, Taiwan. E-mail address: ccwu88@ntu.edu.tw (K.C.-C. Wu). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed http://dx.doi.org/10.1016/j.socscimed.2014.12.034 0277-9536/© 2015 Elsevier Ltd. All rights reserved. Social Science & Medicine 128 (2015) 87e94