Deceased
KCM
Demographics
29y, female
Coroner
Coroner Simon McGregor
Date of death
2020-07-20
Finding date
2023-10-02
Cause of death
hanging
AI-generated summary
A 29-year-old international medical graduate student from Bangladesh died by hanging in July 2020. She was studying a Master of Public Health at Deakin University but had failed multiple units and was struggling academically. Despite the university offering support twice (via letters in July 2019 and November 2019), she declined assistance and did not engage with counselling or medical services. There was no evidence of prior mental health contact or disclosure of suicidality to family or friends. The coroner found her death unforeseeable and that no one bore responsibility. However, the investigation identified a critical systemic issue: international students in Australia show markedly lower help-seeking behaviours compared to domestic students, with only 22% accessing mental health services within 6 weeks of suicide versus 57% of Australian-born students. The coroner emphasised that universities face a significant challenge in encouraging international students to engage with existing support services when experiencing mental health crises, and made recommendations for developing quality frameworks to improve international student mental health support.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
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Error types
IN THE CORONERS COURT COR 2020 003894 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Simon McGregor Deceased: KCM Date of birth: 3 May 1991 Date of death: 20 July 2020 Cause of death: 1(a) HANGING Place of death: Geelong West, Victoria, 3218 Keywords: Suicide, hanging, international university student
On 20 July 2020, KCM was 29 years old when she was found deceased in her bedroom. At the time of her death, KCM lived at Geelong West, with her sister, SCM, her brother-in-law, BCM, and their two children.
KCM was born and raised in Bangladesh with two older sisters and an older brother. She studied medicine at Dinajpur Medical College, completing her degree in 2016.1 In 2018, she moved to Australia after being granted a TU-500 Student Visa.2 She enrolled to undertake a Master of Public Health at Deakin University commencing on 2 July 2018 and was expected to complete those studies in June 2020.3
Whilst in Australia, KCM would speak daily to other family members in Bangladesh and Sydney via video calls. She also spoke with a close group of friends in Bangladesh every few weeks. Due to COVID-19 restrictions, she spent a lot of time at home as her university classes were all being conducted online. It is not clear whether KCM had a local circle of friends or anyone she was close to at university.4
KCM was in good physical health. She liked to go for regular walks and did not consume alcohol, in accordance with her Muslim faith.5 Health insurance records indicate that KCM did not make any claims during the period she was in Australia.6
Deakin University records indicate that KCM had some difficulties with her Master’s studies and had failed a number of units. At the time of her death, she had passed ten units, and had six units left to complete in order to qualify for the degree. Because KCM had failed some units, she was contacted by the Deakin University School of Health & Social Development on two occasions and offered academic support.
An email sent to KCM on 8 July 2019, headed "Support for your academic progress” explained that KCM had failed a compulsory unit once, and explained what she needed to do.
The email included links to study support services, student advisors, relevant policies, 1 Coronial Brief, statement of SCM, p.6; statement of BCM, p.10.
2 Department of Home Affairs records.
3 Coronial Brief, statement of Shirley Rooney, Deakin University, p.14.
4 Coronial Brief, statement of SCM, pp.6-7.
5 Ibid., p.7.
6 Email from Bupa Member Services dated 2 September 2020.
academic supports, financial and personal supports, and had a dedicated section with links to advice and support for international students.
A letter sent to KCM on 11 November 2019, headed "Proposal to place conditions on your enrolment due to unsatisfactory academic progress" explained that KCM had failed multiple units, and had failed a compulsory unit twice. The letter placed conditions on her further enrolment, including that she could not enrol in more than three credit points for the next active study period and must pass all of them. The letter outlined her options for next steps, and included multiple links to support and advice services. It also included specific information and advice and support links for international students.
KCM did not respond to the first of these letters, and declined the offer of assistance in the second letter, stating that she did not need assistance.7
Because KCM had not completed her degree in the initial two-year period of enrolment, she was required to seek an extension of her student visa in order to stay in Australia and continue her studies. Failed units that needed to be repeated also incurred a further fee.8 KCM applied for an extension to coursework and had been issued a confirmation of enrolment for further Master of Public Health coursework, commencing 1 July 2020 and concluding 30 June 2021.
It is not clear how much KCM communicated to her family about her academic performance issues. Her sister was aware she had to re-take a unit,9 but her brother-in-law stated that “she was about to finish her degree and to my knowledge was passing all her subjects”.10
KCM had no known history of mental health problems. The evidence suggests that she did not give any indication to family that she was feeling mentally unwell or suicidal in the leadup to her death.11
7 Coronial Brief, statement of Shirley Rooney, Deakin University, p.14.
8 Deakin University's General Counsel, Shirley Rooney 9 Coronial brief, Statement of SCM, p.8.
10 Coronial brief, statement of BCM, p.10.
11 Ibid., p.8.
The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.
Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.
Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of KCM’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.
This finding draws on the totality of the coronial investigation into the death of KCM including evidence contained in the coronial brief. Whilst I have reviewed all the material, I will only refer to that which is directly relevant to my findings or necessary for narrative clarity. In the coronial jurisdiction, facts must be established on the balance of probabilities.12
In considering the issues associated with this finding, I have been mindful of KCM’s human rights to dignity and wellbeing, as espoused in the Charter of Human Rights and Responsibilities Act 2006, in particular sections 8, 9 and 10.
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
On the evening of 19 July 2020, KCM ate dinner at home with her sister’s family, participating in conversation and retiring to bed as usual.13
On the morning of 20 July 2020, BCM was getting the children ready for school when they requested that KCM do their hair. At approximately 8:00 am, KCM was still not 12 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.
13 Coronial Brief, statement of BCM, p.10.
up and out of her bedroom, which was unusual. BCM knocked on her bedroom door and there was no response. He became concerned and looked through the window of the bedroom. He saw KCM and immediately called 000.
Identity of the deceased
Medical cause of death
A post-mortem computed tomography scan showed no significant trauma or natural disease.
Toxicological analysis of post-mortem blood samples did not identify the presence of any alcohol or any commons drugs or poisons.
Dr Iles provided an opinion that the medical cause of death was 1(a) hanging.
turn point to opportunities to support international students better and thus reduce the risk of further suicides - which have a devastating impact on the student’s family, friends, and the wider university community - in future.
The investigation into KCM’s death was conducted in parallel with my investigations into four other suicides of international students which occurred during 2020. The five deaths related to students born in five different countries who attended four different universities across Victoria, who were studying diverse subjects (at both undergraduate and postgraduate level), and who had diverse living arrangements (including on-campus accommodation, share houses with other international students, and residing with family members).
To assist in this investigation, I requested information and policies from involved universities about how they support the wellbeing and health (including mental health) of international students. I was aided by the response I received from Deakin University’s General Counsel, Shirley Rooney, who provided a detailed statement about KCM’s academic progress and her engagement with student services including health and wellbeing services. Ms Rooney provided copies of relevant policies, procedures and protocols spanning student mental health and wellbeing, suicide prevention, academic progress, and critical incident management, amongst other areas. I thank Deakin University and Ms Rooney for their efforts in this regard.
From my review of the material, the stand-out feature for me was how little engagement KCM had with Deakin University in a health and wellbeing context. The only evidence in this regard was the letters Deakin University sent her on 8 July 2019 and 11 November 2019 when she was making unsatisfactory academic progress; they included detailed advice on her options and the various support services that were available for her to access. KCM declined to engage with those services, and she did not otherwise seek or receive support from Deakin’s counselling or medical services. On the evidence before me, KCM also did not engage with health services external to the university, nor did she disclose mental health issues, stressors or suicidality to her family or friends.
KCM’s lack of engagement with Deakin University health and wellbeing services was echoed across the other four suicides I investigated. In each case the student had not contacted or been linked with relevant university services and was not engaged with any other health services in the community for mental health treatment and support.
CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.
In highlighting this lack of engagement, I make clear that I make no criticism of Deakin University. As mentioned above, Deakin University provided a range of information to me about supports for students in general and international students in particular; I was impressed by the thoroughness of this material, and I have no evidentiary basis for any concern with service design and delivery. Instead, through considering the material gathered across my five investigations, I have come to the conclusion that universities may be facing a different challenge: how to encourage international students to engage with and seek help from existing university services in the first place when they experience mental health crises and/or suicidality. Given that none of the five international students engaged with health services in the wider community or (to the best of my knowledge) disclosed suicidality to family or friends or clinicians, the challenge is even broader than this: how to encourage international students to seek help at all.
I am not the first Victorian coroner to identify this challenge. Coroner Audrey Jamieson of this Court previously investigated the suicides of Zhikai Liu and Nguyen Le, two international students who had not sought any health or wellbeing support either from the universities where they attended, or from health services in the broader community.15 Coroner Jamieson was also supported in her investigations by the CPU, whose case investigators undertook an analysis of Victorian suicides among adult students during the period 2009-2015, comparing between international students and Australia-born students. The CPU reported a number of differences, the most pertinent of which (for present purposes) were as follows: The data shows a far lower prevalence of diagnosed mental illness among international student suicides (14.8%) than Australian-born student suicides (66.7%), and a corresponding higher proportion of deceased with suspected mental illness (33.3% versus 17.9%) or with no evidence of mental ill health (51.9% versus 15.5%).
These differences were reflected in the CPU analysis of most recent health service contacts for reasons relating to mental health […]. Among the international student suicide cohort, 22.2% attended a health service for mental health related issues within six weeks of death. In contrast, 57.1 % of the Australian-born student suicide cohort had attended a health service for reasons relating to mental health within six weeks of death.
The CPU further reviewed the available Coronial material and noted that among international students who did not have a formal diagnosis of mental ill 15 Jamieson A, Finding into death of Zhikai Liu without inquest, Coroners Court of Victoria, reference COR 2016 001035, delivered 10 January 2019; Jamieson A, Finding into death of Nguyen Pham Dinh Le without inquest, Coroners Court of Victoria, reference COR 2018 00622, delivered 13 January 2021.
health, there was often evidence that friends and/or family members were concerned about the student's behaviour and deteriorating mental state in the period leading up to suicide. This suggests that the lower incidence of diagnosed mental illness in the international student cohort may be due to lack of engagement with the Australian health system (a diagnosis must be given by a health practitioner) rather than reflecting a lower incidence of mental illness as such. 16
I acknowledge that greater international student engagement with mental health services is a goal far easier articulated than achieved. Researchers have long identified cultural, linguistic, financial and other barriers to such engagement, and I do not have the evidence before me to make any specific recommendations about how to overcome these barriers.17
These comments resonate strongly with my own experience investigating the deaths of the five international students including KCM during 2020. In reflecting on the circumstances of the five deaths, I have not developed any clear insights into how help-seeking among international students might be promoted, and I suspect a coronial investigation may not be the most suitable mechanism to explore this.
At the early stage of my investigation into these five suicides, when I was still gathering evidence and considering how to approach the issues, I commissioned Orygen18 to prepare resources including a list of questions to ask universities about their health and wellbeing services, and an evidence-based Quality Evaluation Framework to assist me in understanding what types of policies and programs should be in place across universities to support 16 Jamieson A, Finding into death of Zhikai Liu without inquest, Coroners Court of Victoria, reference COR 2016 001035, delivered 10 January 2019, p16.
17 Jamieson A, Finding into death of Zhikai Liu without inquest, Coroners Court of Victoria, reference COR 2016 001035, delivered 10 January 2019, p6.
18 Orygen is a not-for-profit mental health service and research institute dedicated to youth mental health.
international students. My initial intention was to use the Framework to assess the design and delivery of university services that the international students came into contact with prior to their deaths, so I could identify potential gaps to be addressed. As the investigations unfolded and the lack of engagement between the students and their respective universities’ services became clearer, I came to realise that this type of assessment would not generate the insights I was seeking. However, I believe the Quality Evaluation Framework may still have utility for international student prevention.
Orygen developed the Quality Evaluation Framework after a comprehensive review of research on university student and international student health and wellbeing, as well as suicide prevention and mental health promotion in tertiary education settings. The Quality Evaluation Framework identifies ten areas (five university-wide, five specific to international students) where universities are recommended to review their policies, guidelines and practices. The areas include mental health, suicide prevention and postvention, staff training in mental health and suicide awareness, initial orientation for international students, ongoing support for international students, and access to mental health services. In each area, the Quality Evaluation Framework describes minimum expectations that should be met, as well as best practice to aim towards.
I found the Quality Evaluation Framework to be an extremely helpful tool orienting me to elements and features I should be looking for when I reviewed the material that the universities provided to assist my investigations. I consider, therefore, that universities might also find the Quality Evaluation Framework to be a useful tool for developing and reviewing how they support the health and wellbeing of international students.
I am grateful to Orygen and the CPU for their exceptional assistance in these investigations and the valuable insights they have contributed.
Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was KCM, born 03 May 1991; b) the death occurred on 20 July 2020 at Geelong West, Victoria, 3218, from hanging; and c) the death occurred in the circumstances described above.
Having considered all of the circumstances, I am satisfied that KCM intentionally took her own life. It is often difficult to determine what may have precipitated a person’s decision to end their own life. There are sometimes issues known only to the deceased person. It is possible that KCM was struggling with the pressures of her post-graduate studies more than she let on to family or friends. I find that her death could not have been reasonably foreseen, and no one bears responsibility for this tragedy.
(i) With the aim of promoting public health and safety and preventing like deaths, I recommend that the Victorian Department of Health and Human Services takes on the role of leading and coordinating efforts to support mental health and wellbeing of international students studying in Victoria, and to ensure international students can access mental health treatment.
Professor Euan Wallace, the Secretary for the Department of Health, indicated in his response dated 6 April 2021 that the Department would convene a taskforce to discuss the findings and consider the key themes raised by Coroner Jamieson’s investigation. Professor Wallace further noted that the Department was establishing a new Suicide Prevention and Response Office, and that international students would fall within the scope of the Office’s remit.
In this context, I intend to provide a copy of the Orygen Quality Evaluation Framework to the Suicide Prevention and Response Office at the Victorian Department of Health.
Pursuant to section 72(2) of the Act, I make the following recommendations:
(i) I recommend that the Suicide Prevention and Response Office review the Orygen Quality Evaluation Framework (attached as Appendix A) in the context of this finding and its other work relating to international students, and consider whether a resource such as the Quality Evaluation Framework would assist universities to assess and review how they support international student health and wellbeing.
(ii) I recommend that the Victorian Department of Health consider developing and maintaining a resource of this type to assist Victorian universities in implementing and reviewing their programs targeted at international student wellbeing. The resource could be regularly revised in collaboration with the universities to share new research,
program design and ideas for monitoring international student wellbeing and encouraging help-seeking among those who may be experiencing mental health crises or suicidality.
I convey my sincere condolences to KCM’s family for their loss.
Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the rules.
I direct that a copy of this finding be provided to the following: Parents of KCM, Senior Next of Kin Leading Senior Constable Alecia Spalding, Coroner’s Investigator Signature: ___________________________________
CORONER SIMON MCGREGOR Date : 02 October 2023 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
Appendix A
RESPONSE TO THE VICTORIAN CORONER’S OFFICE INTERNATIONAL STUDENT SUICIDE PREVENTION OVERVIEW OF SUGGESTED AREAS FOR REVIEW UNIVERSITY WIDE
Mental health policy - Does the institution have a written policy addressing how mental health issues are managed?
Suicide prevention policy & postvention guidelines - Does the institution have policies or guidelines for suicide prevention and postvention?
Suicide prevention programs - Does the institution have any suicide prevention programs?
Staff training related to mental health and/or suicide - Does the university provide mental health or suicide awareness training to staff?
Clear and accessible pathway to mental health services for all students - Does the university provide mental health services that can be accessed easily and in a timely manner by all students who need support? Are university staff provided with information on community mental health services, including referral pathways, for students experiencing mental illhealth?
Orientation program for international students - Does the university provide an orientation program to support students upon arrival to Australia?
Ongoing support - Does the university provide ongoing support services to international students that address the stressors that may increase risk of suicide?
a. Key risk factors (e.g. acculturation/academic stress/discrimination etc) b. Mental health specifically
Risk screening and monitoring - Does the university have risk screening or monitoring processes in place?
Staff training policies relevant to international student mental health - Does the university provide staff training that addresses international student mental health?
Affordable Mental health service access - Does the university provide free mental health service access or financial aid to international students to access mental health services? Are these services culturally accessible (i.e. are staff trained in cultural awareness and/or are interpreting/liaison supports provided)?
UNIVERSITY WIDE POLICIES AND PROGRAMS There are a variety of institution wide policies and programs that are relevant to suicide prevention that can be implemented by universities. Although these approaches may not directly address international students, they are often foundational to high quality mental health promotion and the provision of services accessible to all students, including international students.
Rationale: Existing evidence shows that demand for university mental health services exceeds capacity, student mental health issues are increasingly complex, and that service delivery is variable across institutions (1). A mental health policy can be used to address such issues (2).
Best practice recommendations: Current best practice recommendations for a mental health policy are
Rationale: Policies and guidelines for suicide prevention and postvention are important tools that may reduce the risk of suicide occurring (3, 4). Prevention policies can shape institutional approaches and responses to suicide risk monitoring, prevention efforts, and support services. Postvention guidelines can cover similar elements, but also address the necessary steps after a suicide occurs to minimise distress (4). Postvention guidelines show promise for preventing suicide clusters where a number of individuals take their life after an initial suicide within their community (4, 5). The university should have suicide prevention and postvention policies and/or guidelines available to staff and students within the larger mental health policy or as a set of specific resources. Alternatively, the university may endorse appropriate guidelines provided by other relevant groups such as Universities Australia (6).
Best practice: Regardless of whether the guidelines are developed internally or by an external body, the university should have a clear documented communication strategy in place so that relevant staff and/or students are aware of the policy or guidelines and associated requirements (2, 6). For example, if using the Universities Australia Postvention guidelines, all staff should be made aware of Part A (e.g., the all staff section), while those responsible for responding to a suicide should be made aware of Part B (e.g., the suicide response team section) of the guidelines. If the institution has developed their own policies or guidelines, the document should ideally outline the development process. Key reported procedures in existing guidelines include how existing evidence, best practice approaches, and expert and lived experience consultation was used to inform guideline development (4).
Rationale: A small but growing body of evidence shows that universities can be an effective context for the implementation of suicide prevention interventions that can reduce suicidal ideation and risk of suicide (7).
Best practice: A common framework in suicide prevention classifies interventions as universal, selective or indicated on the basis of target groups (8, 9). Universal interventions target whole populations regardless of risk through increasing access to services, promoting student mental health, limiting means access for suicide, or promoting appropriate reporting through media (10). For example, mental health campaigns for all staff or students fall into this category. Selected interventions target subgroups who may be vulnerable to suicide due to specific or elevated risk factors such as LGBTQ+ individuals (11) and international students (12). For instance, gatekeeper programs are used to train those in contact with vulnerable populations (e.g., staff, student peers,
community leaders etc) to provide them with the skills necessary to assist at risk individuals and refer them to relevant support services. Gatekeeper training is currently the most widely used and researched suicide prevention strategy implemented within universities (7). Indicated interventions target those already displaying suicidal or self-harm behaviour through linking individuals into relevant support services such as mental health providers. For example, students identified as experiencing suicidal ideation can receive a clinical intervention such as cognitive behavioural therapy (3). This framework may be helpful when reviewing policies and programs at the university by allowing for a clear assessment of each of the different approaches: Assessing Universal approaches) does the university have any universal suicide prevention programs or policies? (E.g., Mental health promotion campaigns, suicide awareness programs, limitations of means access policy etc.) Assessing Selective approaches) Does the university have policies or programs to support at risk groups? (E.g., Gatekeeper training, specific support services for at risk groups etc.) Assessing Indicated approaches) Does the university have processes in place to identify those at risk and/or provide support pathways for individuals who indicate suicide risk or self-harm behaviours?
(E.g., Decreased class attendance monitoring, graduate supervisor training to identify suicide risk, etc.)
STAFF TRAINING RELATED TO MENTAL HEALTH AND/OR SUICIDE – DOES THE UNIVERSITY PROVIDE MENTAL HEALTH OR SUICIDE AWARENESS TRAINING TO STAFF?
Rationale: University staff regularly come into contact with students facing mental ill-health and are well placed to identify potential suicide risk in this group (13). However, staff often lack the skills and confidence to discuss mental health issues or suicide with students (13). Programs such as gatekeeper training or other mental health training can be used to improve staff confidence and skills relevant to supporting student mental health and suicide risk (7, 14, 15).
Best practice: It is important to consider the different staff groups who receive training and their specific needs. For example, academic staff may require training that clarifies their responsibilities related to student mental health, in combination with general capacity building related to identifying and referring on suicide (13). In contrast, staff employed in by the university counselling service may need more targeted training such as methods of safety planning that can be used with at risk individuals (15). Identifying the specific staff training and development pathways for different staff groups may facilitate a clearer picture of any existing gaps in the available training across the organisation.
CLEAR AND ACCESSIBLE PATHWAY TO MENTAL HEALTH SERVICES FOR ALL STUDENTS – DOES THE UNIVERSITY PROVIDE MENTAL HEALTH SERVICES THAT CAN BE ACCESSED EASILY AND IN A TIMELY MANNER BY STUDENTS?
Rationale: Accessible mental health services play a vital role in supporting student mental health by providing therapeutic care and referrals to other relevant health services (14). Existing evidence shows therapeutic care is an effective method for reducing suicidal ideation and suicide attempts (16).
However, university mental health services tend to face greater demand than they can effectively manage, which may lead to long wait times for access or service rationing (14, 17).
Best practice: Current Best Practice Guidelines for the Provision of Counselling Services in the PostSecondary Education Sectors of Australia and New Zealand recommend a student to staff ratio of 1
counsellor per 1000 students. Although current evidence suggests this is rarely the case across the sector with recent reported ratios of 1 staff member to anywhere between 3000-12000 students (17).
INTERNATIONAL STUDENT SPECIFIC POLICIES AND PROGRAMS International students face a unique set of stressors (e.g., financial, language, cultural, discrimination, etc.) (18-20) that can negatively impact mental health (20), increase suicidal ideation (12, 21, 22), and even lead to death by suicide (23, 24). Complicating matters, international students can face specific barriers such as lower mental health literacy and help-seeking intentions that can reduce engagement with support services, especially for suicidal ideation (25, 26). This combination of factors may increase the risk of death by suicide for those who could otherwise receive help (24). Prevention strategies and programs need to account for the unique stressors and barriers to reduce suicide risk in this group (12, 26). Only a small amount of research has directly addressed suicide prevention in international students (7). However, a variety of research, interventions and best practice recommendations have been developed that aim to support international students adapt and manage stressors associated with living and studying in another country (12, 19, 27-32). These strategies can be used to address the stressors and barriers that may increase the risk of suicide. Additionally, research addressing suicide prevention in other migrant communities has identified key areas that should be of focus including acculturation issues, stigma related to help-seeking, and the need for creating supportive communities (33). The combination of this research is used to guide the following suggestions.
ORIENTATION PROGRAM FOR INTERNATIONAL STUDENTS – DOES THE UNIVERSITY PROVIDE PRE-DEPARTURE TRAINING OR AN ORIENTATION PROGRAM TO SUPPORT STUDENTS UPON ARRIVAL TO AUSTRALIA?
Rationale: Orientation programs are important tools that can be used to help students understand the local culture, address early acculturation issues, and promote mental health services, while reducing stigma related to service access (34, 35). Pre-departure training on the host country culture and university systems can also be beneficial for addressing initial adjustment challenges (36). Such programs can decrease stress associated with adapting to a new country, increase awareness and engagement with health services, and help students form connections with their peers (32).
Best practice: Pre-departure programs should prepare students for life in Australia and the challenges that they may face while in country (37). Orientation programs should seek to address any potential misunderstandings (e.g., when to seek support, fear of repercussions, available services, etc.) and stigma related to mental health service access, as students can be reticent to access services due to mental health stigma and visa concerns (28, 37).
ONGOING SUPPORT – DOES THE UNIVERSITY PROVIDE ONGOING SUPPORT SERVICES ADAPTED TO INTERNATIONAL STUDENTS THAT ADDRESS THE STRESSORS THAT MAY INCREASE RISK OF SUICIDE?
Rationale: Students can face a variety of stressors throughout their time studying in Australia (28, 38).
Common stressors for international students include academic stress, financial hardship, experiences of discrimination, language issues, and feelings of loneliness (19, 20, 39). Such stressors can lead to poor mental health (39) and have been identified as risk and contributing factors to suicide deaths of international students (23, 24, 40). Universities can provide ongoing support services that can help students manage such stressors (34). For example, buddy programs are widely used to help international students build connections with local students (34). Similarly, academic support services can help students manage stress associated with academic work or language issues (34). Universities
are also well placed to monitor academic related stress. For example, an emerging field of research has demonstrated that digital technologies can be used to identify students who are potentially at risk of academic failure and notify relevant staff (41). Students who are at risk of failure can then be referred to appropriate academic support services.
Best practice: Culturally competent health services may improve outcomes for migrants accessing services (42). Current evidence indicates that providing written materials or services in the native language of migrants can improve outcomes (42). Additionally, training in symptom recognition for common mental health diagnoses may increase engagement with services, as evidence suggests that international students may not recognise they have a problem until they reach a crisis point (37).
Employment of dedicated international student support staff, and especially those who speak the native languages of common international groups, may facilitate the most culturally appropriate support services (34).
Rationale: Risk screening tools are important for identifying potential suicide risk that may otherwise be missed. This may be especially important for international students because evidence suggests that they are less likely to engage with services before a suicide attempt (43). A number of tools can be used by universities to identify potential risk and opportunities engage students with relevant support services. These include the reporting of mental health issues on intake, monitoring of class attendance, and ongoing check-in surveys (32).
Best practice: A comprehensive approach that involves both initial and ongoing screening for mental health issues and the regular monitoring of other relevant predictors such as class attendance will have the greatest potential to identify suicide risk.
STAFF TRAINING POLICIES RELEVANT TO INTERNATIONAL STUDENT MENTAL HEALTH CONCERNS – DOES THE UNIVERSITY PROVIDE STAFF TRAINING THAT ADDRESSES INTERNATIONAL STUDENT MENTAL HEALTH?
Rationale: Training that provides staff with an understanding of specific stressors and risk factors for international student mental health may help staff better support international student needs (32, 34).
Similar to the general staff training, clarifying staff roles related to international student mental health should be part of the training (32, 34).
Best practice: Training should seek to provide staff with the capacity to deliver culturally appropriate responses to international students (34). Ideally, training should be developed through co-design processes with international students (34).
AFFORDABLE MENTAL HEALTH SERVICE ACCESS – DOES THE UNIVERSITY PROVIDE FREE MENTAL HEALTH SERVICE ACCESS OR FINANCIAL AID TO INTERNATIONAL STUDENTS TO ACCESS MENTAL HEALTH SERVICES?
Rationale: International students are often under financial strain, which can reduce willingness to access fee paying mental health services (44). Providing free services or financial aid to international students for mental health services may reduce this barrier to access (44).
Best practice: Current best practice recommendations suggest that promotion of available mental health services for international students should occur on a regular basis, as this group report poor levels of awareness of available services (35). Ideally, students should also have a single point of contact that can help them navigate the available options and find the appropriate service to make sure they don’t slip through the cracks (37). Unfortunately, most university health services only provide short term support, and are ill-equipped to manage more complex cases (37). This means that students may need to seek help external to the university. However, few free or cheap external services provide long term support to international students, and this may increase the risk of suicide in this cohort due to the financial barriers.
LEVELS OF ACTION/RESPONSE USING A SUICIDE PREVENTION FRAMEWORK Universal: Whole of univeresity mental health and suicide prevention/postvention -policies/programs and services for all students domestic and international includes: awareness campaigns, .
Targeted programs and supports that address identified risk groups, e.g. training specific to identifying risk for international students, information delivered specifically to international students; peer-support programs for international students.
Indicated programs and supports that identify an international student at risk or in distress/crisis and connects them with support e.g. risk screening and monitoring and counselling supports delivered by culturally competent and accessible services.
QUALITY EVALUATION FRAMEWORK AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS UNIVERSITY WIDE Mental health policy - Does the Policy describes aims, objectives, Policy PLUS implementation and action How is the policy communicated and institution have a written policy rationale and high level activities to plan to accompany policy with promoted to all members of the university addressing how mental health issues respond to mental health issues and timeframes, deliverables and community including staff, students, are managed? support wellbeing. responsibilities described. services?
The policy spans mental health Endorsed/approved and supported by Are there dedicated resources allocated promotion, prevention, early identification university leadership including VC. to delivering the policy?
of risk and responses for mental illHas the policy/will the policy be health.
evaluated?
How often is the policy reviewed? What type of stakeholders (internal/external) are involved in the review process?
Suicide prevention policy & Suicide Prevention Policy/Guidelines Policy PLUS implementation and action How is the policy communicated and postvention guidelines - Does the describes aims, objectives, rationale and plan to accompany policy with promoted to all members of the university institution have policies or guidelines high level activities to respond to: timeframes, deliverables and community including staff, students, for suicide prevention and responsibilities described. services?
preventing suicide and suicide postvention?
related behaviours (including Endorsed/approved and supported by Are there dedicated resources allocated addressing risk factors) university leadership including VC. to delivering the policy?
responding to suicide related Has the policy/will the policy be behaviours (including ideation and evaluated?
attempts) How often is the policy reviewed? What postvention responses to a type of stakeholders (internal/external) completed suicide. are involved in the review process?
Suicide prevention programs - Does Mental health promotion, campaigns and Provides activities and programs across How are these programs communicated the institution have any suicide suicide awareness programs to assist all of the following: and promoted to all members of the prevention programs? students and staff to: university community (for universal Universal approaches for entire approaches) and to specific cohorts look after their mental health and university community (mental health wellbeing promotion, limitations of means etc).
AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS understand the signs if they/or Selective approaches targeted at (targeted) or individual students and staff someone else is at risk risk groups of students, e.g. specific (indicated)?
services for students with mental know about university and How are the programs delivered chosen?
health conditions.
community based Are they evidence-based?
services/supports that are Indicated approaches which How are they resourced and who is available. actively identify individual responsible for their delivery?
staff/students who might be at risk How often are the programs run?
either through drop in performance, drop in attendance, suicide related Have the programs been evaluated?
behaviours. Are student focused programs coproduced and/or delivered by students.
Staff training related to mental health Support services staff receive appropriate All staff and students are provided How is the training resourced and who is and/or suicide - Does the university and ongoing professional development mental health literacy or suicide responsible for their delivery?
provide mental health or suicide and training in relation to mental health awareness training as a core learning Is the training available to all staff (and awareness training to staff? conditions and suicide risk. module.
students) or only available to identified Training is made available to all staff who Training is tailored to specific groups, e.g. staff or only available if the faculty/staff are interested at no cost on: academic staff, different to student member agrees to pay cost?
support staff.
Communicating with students about How often is the training delivered during mental health issues or suicide risk. Specific training is provided to support an academic year?
staff on working with diverse student Responding to disclosure. Has the training been evaluated?
population groups, including CALD, Designing curriculum to mitigate Is the training delivered or co-delivered against unnecessary stress. Aboriginal and Torres Strait Islander by trainers with lived experience of Making adjustments for a student students, LGBTIQA+ and students with mental ill-health?
with a mental illness. disabilities.
Is the training flexible and/or adaptable to Responding to a mental health crisis.
suit a range of learning styles and audiences?
Clear and accessible pathway to Students are supported to navigate A coordinated approach to providing How are services promoted to students mental health services for all students mental health services: support both on and off campus and are they promoted more at certain
Services and supports (both on health services that can be accessed services in order to meet students’ and off campus) are promoted How does the university monitor service easily and in a timely manner by needs.
to students. use and evaluate service provision and students?
Services and supports respond to outcomes?
On campus services and complexities among specific supports are free and accessible
AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS both face to face and digital cohorts of students at increased What is the counsellor to student ratio in services. risk of mental ill-health. the university student support services?
Targeted strategies and Clear relationships/agreements are What are the average wait times for outreach programs that support in place with community based student services provided directly by the early detection and intervention mental health services. university during the academic year?
for students experiencing mental Services and supports are cohealth issues.
designed with lived experience.
Clear processes and procedures for supporting a student in significant distress or crisis.
INTERNATIONAL STUDENT SPECIFIC Orientation program for international International students are required to Mental health and wellbeing information At what point in the prestudents - Does the university provide participate in an information session provided to students (as per minimum departure/orientation process does the an orientation program to support specifically on mental health and expectation) is also: university provide international students students upon arrival to Australia? wellbeing during orientation with specific with mental health related information?
Co-designed with other international focus on: students. In what format is that information Destigmatising mental health issues provided?
Available in languages other than and addressing reluctance in helpEnglish. Are all students provided this seeking behaviours.
information?
Followed up and re-provided at Information on what to do if you or other times across the course of someone you know is struggling.
their studies.
Service access and contact Clear guidelines on how mental information.
health disclosure is managed by Information on privacy and universities and health providers in confidentiality of sharing Australia.
personal/health information with education providers.
Ongoing support - Does the university Provision of support and services to Culturally competent services which Which area of the university is provide ongoing support services to international students which respond to includes cultural competency training and responsible for developing and delivering international students that address the stressors they may experience, including access to tools for student services and supports that respond to international stressors that may increase risk of (but not limited to): support staff. student stressors and/or needs?
suicide?
financial stress, Engagement of specific international Does the university maintain a working student support/wellbeing staff. list of interpreters; ethnic community discrimination, organisations and religious
AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS Key risk factors (e.g. academic and Translators/translation of information into organisations/services to support acculturation/academic languages other than English are made culturally appropriate responses?
cultural stress.
stress/discrimination etc) available for international students.
Provision of peer supports and Mental health specifically Relationships with professionals and networking/social connection programs organisations that can assist with for international students (with each other complexities that are arising because of and with domestic student and other the diversity of linguistic, cultural or ethnic community members) background of International students.
Risk screening and monitoring - Does Standard process for university to provide A comprehensive approach that involves How are these processes monitored and the university have risk screening or opportunity to disclose any existing both initial and ongoing screening for reviewed?
monitoring processes in place? mental health issue(s) on Enrolment mental health issues (including an online How are these processes communicated Forms. Should be clear that this check-in survey) and the regular to staff and students?
information will only be used to connect monitoring of other relevant predictors Are online systems/data on academic students with appropriate support such as class attendance.
performance and attendance linked with services if need identified and no other Where education is delivered online, student services/supports to identify and purpose.
teaching and/or student support staff respond to emerging issues?
Standard process for staff who have proactive check-in with students How are staff supported to manage identified a drop in academic periodically during the semester.
disclosures of mental ill-health? Do they performance or class have adequate time and resourcing to attendance/engagement to connect to identify and respond to risk?
student services for follow up.
Simple reporting processes outside of staff including housemates, other students and friends. There should be clear and simple ways for these people to advise responsible staff of their concern.
Staff training policies relevant to All staff provided information, resources Training on culturally appropriate Which area of the university is international student mental health - and training (if resourced to deliver and responses to international students responsible for developing, contracting Does the university provide staff attend) which focuses on the specific related to suicide prevention, mental and/or delivering this training?
training that addresses international stressors for international students, health and wellbeing.
How is the training promoted?
student mental health? stigma relating to mental health issues Ideally, training should be developed How often is the training provided and at and communication strategies to discuss through co-design processes with what time of the year?
these issues with international students.
international students.
Is the training evaluated?
AREA FOR REVIEW MINIMUM EXPECTATION TOWARD BEST PRACTICE SUPPLEMENTARY QUESTIONS Affordable Mental health service Promotion and provision of financial Dedicated international student How are these services promoted to access - Does the university provide counselling and support services for wellbeing/support service or dedicated international students?
free mental health service access or international students on a regular basis. staff within student services that provides Is financial aid available to address financial aid to international students a single point of contact who can then Promotion and provision of free university financial barriers to accessing mental to access mental health services? assist with service navigation, referrals support services which deliver mental health care?
and advice on health cover service health supports.
Are students services staff trained in eligibility and costs.
Promotion of Overseas Student Health cultural awareness and/or are Information and promotion of free or lowCover (OSHC) entitlements and interpreting/liaison supports provided?
cost culturally sensitive counselling and information on how to pay for and access support services available in the treatment.
community.
Mental health care for university students: a way forward? The Lancet Psychiatry.
2019;6(11):885-7.
Reavley NJ, Ross AM, Killackey E, Jorm AF. Development of guidelines for tertiary education institutions to assist them in supporting students with a mental illness: a Delphi consensus study with Australian professionals and consumers. PeerJ. 2013;1:e43.
Robinson J, Bailey E, Witt K, Stefanac N, Milner A, Currier D, et al. What Works in Youth Suicide Prevention? A Systematic Review and Meta-Analysis. EClinicalMedicine. 2018.
Andriessen K, Krysinska K, Kõlves K, Reavley N. Suicide Postvention Service Models and Guidelines 2014–2019: A Systematic Review. 2019;10(2677).
Cox GC, Robinson J, Williamson M, Lockley A, Cheung D, Pirkis J. Suicide clusters in young people: Evidence for the effectiveness of postvention strategies. Crisis. 2012;33(4):208-14.
Universities Australia, Headspace: National Youth Mental Health Foundation. Responding to suicide: A toolkit for Australian universities. 2020.
Wolitzky-Taylor K, LeBeau RT, Perez M, Gong-Guy E, Fong T. Suicide prevention on college campuses: What works and what are the existing gaps? A systematic review and meta-analysis. J Am Coll Health. 2020;68(4):419-29.
Mrazek PJ, Haggerty RJ. Reducing risks for mental disorders: Frontiers for preventive intervention research Washington, D.C.: National Academy Press; 1994.
Silverman M, Maris RW. The prevention of suicidal behaviors: An overview. Suicide and LifeThreatening Behavior. 1995;25(1):10-21.
World Health Organization. Preventing Suicide: A global imperative. Switzerland: World Health Organization; 2014.
Marshal MP, Dietz LJ, Friedman MS, Stall R, Smith HA, McGinley J, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49(2):115-23.
Taliaferro LA, Muehlenkamp JJ, Jeevanba SB. Factors associated with emotional distress and suicide ideation among international college students. J Am Coll Health. 2020;68(6):565-9.
Gulliver A, Farrer L, Bennett K, Ali K, Hellsing A, Katruss N, et al. University staff experiences of students with mental health problems and their perceptions of staff training needs. Journal of Mental Health. 2018;27(3):247-56.
Orygen: That National Centre of Excellence in Youth Mental Health. Under the radar: The mental health of Australian university students. 2016.
Stewart KL, Darling EV, Yen S, Stanley B, Brown GK, Weinstock LM. Dissemination of the Safety Planning Intervention (SPI) to University Counseling Center Clinicians to Reduce Suicide Risk Among College Students. Archives of Suicide Research. 2020;24(sup1):75-85.
Méndez-Bustos P, Calati R, Rubio-Ramírez F, Olié E, Courtet P, Lopez-Castroman J.
Effectiveness of Psychotherapy on Suicidal Risk: A Systematic Review of Observational Studies.
2019;10(277).
2018;27(1):68-127.
Psychiatr Serv. 2008;59(4):392-9.
2011;35(2):139-62.
Brunsting NC, Zachry C, Takeuchi R. Predictors of undergraduate international student psychosocial adjustment to US universities: A systematic review from 2009-2018. International Journal of Intercultural Relations. 2018;66:22-33.
Pérez-Rojas AE, Choi N-Y, Yang M, Bartholomew TT, Pérez GM. Suicidal Ideation Among International Students: The Role of Cultural, Academic, and Interpersonal Factors. The Counseling Psychologist. 2021;49(5):673-700.
Wang KT, Wong YJ, Fu CC. Moderation effects of perfectionism and discrimination on interpersonal factors and suicide ideation. J Couns Psychol. 2013;60(3):367-78.
McLaughlin JC, Gunnell D. Suicide Deaths in University Students in a UK City Between 2010 and 2018 - Case Series. Crisis. 2021;42(3):171-8.
Jamieson A. Findings into death of Zhikai Liu. Coroners Court of Victoria; 2019. Contract No.: COR 2016 1035.
Nguyen MH, Le TT, Nguyen HT, Ho MT, Nguyen HTT, Vuong QH. Alice in Suicideland: Exploring the Suicidal Ideation Mechanism through the Sense of Connectedness and Help-Seeking Behaviors. Int J Environ Res Public Health. 2021;18(7).
Clough BA, Nazareth SM, Day JJ, Casey LM. A comparison of mental health literacy, attitudes, and help-seeking intentions among domestic and international tertiary students. British Journal of Guidance & Counselling. 2018;47(1):123-35.
Cao C, Meng Q. A systematic review of predictors of international students’ cross-cultural adjustment in China: current knowledge and agenda for future research. Asia Pacific Education Review. 2021.
Forbes-Mewett H. Mental health and international students: issues, challenges and effective practice’, Res. International Education Association of Australia (IEAA); 2019.
Sakurai T, McCall-Wolf F, Kashima ES. Building intercultural links: The impact of a multicultural intervention programme on social ties of international students in Australia.
International Journal of Intercultural Relations. 2010;34(2):176-85.
Zhuang XY, Wong DFK, Ng TK, Poon A. Effectiveness of Mental Health First Aid for ChineseSpeaking International Students in Melbourne. Research on Social Work Practice. 2019;30(3):275-87.
Servaty-Seib HL, Lockman J, Shemwell D, Reid Marks L. International and Domestic Students, Perceived Burdensomeness, Belongingness, and Suicidal Ideation. Suicide Life Threat Behav.
2016;46(2):141-53.
2016;68(4):281-9.
IGI Global; 2016. p. 201-22.
Newton DC, LaMontagne A, Tomyn AJJ-JotA, Association NZSS. Exploring the Challenges and Opportunities for Improving the Health and Wellbeing of International Students: Perspectives of Professional Staff at an Australian University. 2021;29(1):74-92.
Forbes-Mewett H, Sawyer A-M. International Students and Mental Health. Journal of International Students. 2016;6(3):661-77.
Yeung TS, Hyun S, Zhang E, Wong F, Stevens C, Liu CH, et al. Prevalence and correlates of mental health symptoms and disorders among US international college students. J Am Coll Health.
2021:1-7.
Sáiz-Manzanares MC, Marticorena-Sánchez R, García-Osorio CI. Monitoring Students at the University: Design and Application of a Moodle Plugin. Applied Sciences. 2020;10(10):3469.
Handtke O, Schilgen B, Mösko M. Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLOS ONE. 2019;14(7):e0219971.
Hong V, Busby DR, O'Chel S, King CA. University students presenting for psychiatric emergency services: Socio-demographic and clinical factors related to service utilization and suicide risk. J Am Coll Health. 2020:1-10.
Sherry M, Thomas P, Chui WH. International students: a vulnerable student population.
Higher Education. 2010;60(1):33-46.
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