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Main, moderating, and mediating effects of social network compositions on suicidal ideation among North Korean refugees in South Korea

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Main, moderating, and mediating effects of social network compositions on suicidal ideation among North Korean refugees in South Korea

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Main, Moderating, and Mediating Effects of Social Network Compositions on Suicidal Ideation
among North Korean Refugees in South Korea

by
Mee Young Um, MSW, MIS

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

August 2017

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 2
Dedication
This dissertation is dedicated to all North Korean refugees who are living in South Korea,
the United States, and many other countries. It is especially dedicated to the North Korean
refugee students I met at Jayoutuh School whose souls inspired me to pursue a journey that I
would have never planned alone. I also dedicate this dissertation to my North Korean supervisor
I met at UNESCO Headquarters, Mr. J.C. Li, who allowed me to develop an interest in North
Korea for the first time.
I could not have gone through this journey without the love and support from my family
and friends. I cannot describe in words how much I thank my father and mother, for their
unconditional love and sacrifice. To my elder sister, Mee Nah, and my brother-in-law, Andrew,
who always provided me with advice and material aid whenever I was in need. To my 26-month-
old niece, Leah, who brought indescribable joy to our family. To all my precious friends in South
Korea and Southern California, who gave me so much support and laughter.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 3
Acknowledgements
I would like to take this opportunity to express my wholehearted gratitude:
To Dr. Lawrence Palinkas, for your tremendous amount of support and guidance you
have provided me; for the faith you had in me even when I didn't; and for your wisdom and
brilliance that have always inspired me for the past six years.
To Dr. Eric Rice, for being my unofficial mentor; for answering my numerous questions;
and for sharing your genius ideas with me.
To Dr. Olivia Lee, for your meticulous advice and feedback, and for your warm support
that you showed me beyond my academic concerns.
To Dr. Jennifer Unger, for accepting to serve as my committee member although you
initially did not know me and for providing me kind support.
To Dr. Hee Jin Kim, for being my mentor for both academic and personal matters; for
your prayers and wisdom; and for generously allowing me access to your datasets.
To Dr. Charles Kaplan, for being my job advisor; for your sincere care about my well-
being; and for pushing me to get out of my comfort zone.
To my dearest cohort and other friends I have made in the program, for your emotional
support. I will never forget the numerous days and nights we spent at the City Center together!
To Drs. Michael Hurlburt, Julie Cederbaum, Alice Cepeda, Iris Chi, and other faculty
members at USC, for your sincere support and guidance. To Eric Lindberg, for your thorough
reviews and edits. And to the USC Suzanne Dworak-Peck School of Social Work and the USC
Graduate School Research Enhancement Fellowship, for your generous financial support.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 4
Table of Contents
Dedication ....................................................................................................................................... 2
Acknowledgements ......................................................................................................................... 3
List of Figures and Tables............................................................................................................... 6
Abstract ........................................................................................................................................... 7
Chapter 1: Overview of the Three Studies ...................................................................................... 9
Introduction ............................................................................................................................... 9
North Korean Refugees ..................................................................................................... 10
Research Gaps ................................................................................................................... 13
Social Network Analysis................................................................................................... 16
Theoretical Framework ........................................................................................................... 17
Interpersonal Theory of Suicide ........................................................................................ 17
Stress-Buffering Hypothesis ............................................................................................. 18
Stress and Coping Theory ................................................................................................. 18
Social Capital Theory ....................................................................................................... 19
Overview of the Dissertation .................................................................................................. 20
References ............................................................................................................................... 24
Chapter 2 (Study 1): Suicidal Ideation among North Korean Refugees in South Korea: Exploring
the Influence of Social Network Compositions by Gender .............................................. 34
Introduction ................................................................................................................................... 34
Current Study .................................................................................................................... 36
Methods................................................................................................................................... 38
Study Participants ............................................................................................................. 38
Measures ........................................................................................................................... 39
Statistical Analyses ........................................................................................................... 41
Results ..................................................................................................................................... 42
Discussion ............................................................................................................................... 44
References ............................................................................................................................... 50
Chapter 3 (Study 2): Migration-Related Stressors and Suicidal Ideation of North Korean
Refugees: Moderating Effects of Social Networks ........................................................... 63
Introduction ............................................................................................................................. 63
Current Study .................................................................................................................... 65
Methods................................................................................................................................... 67
Study Participants ............................................................................................................. 67
Measures ........................................................................................................................... 67
Statistical Analyses ........................................................................................................... 71
Results ..................................................................................................................................... 72
Discussion ............................................................................................................................... 75
References ............................................................................................................................... 79
Chapter 4 (Study 3): Testing the Pathway from Pre-Migration Sexual Violence to Suicidality
among North Korean Refugee Women Living in South Korea: Do Social Networks
Matter? .............................................................................................................................. 91
Introduction ............................................................................................................................. 91
Methods................................................................................................................................... 94
Study Participants ............................................................................................................. 94
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 5
Measures ........................................................................................................................... 95
Statistical Analyses ........................................................................................................... 98
Results ..................................................................................................................................... 99
Discussion ............................................................................................................................. 100
References ............................................................................................................................. 104
Chapter 5: Conclusions, Implications, and Future Directions .................................................... 113
Summary ............................................................................................................................... 113
Major Findings ................................................................................................................ 113
Limitations and Future Research .......................................................................................... 115
Overall Implications and Contributions ................................................................................ 116
References ............................................................................................................................. 118

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 6
List of Figures and Tables
Figure 1.1. Conceptual Models of the Three Studies .................................................................... 33
Table 2.1. Intersection of Types and Functions of Social Ties ..................................................... 56
Table 2.2. Univariable Comparison of Descriptive Statistics and Social Network Variables by
Past-Year Suicidal Ideation (Stratified by Gender) .......................................................... 57
Table 2.3. Multivariable Logistic Regression Analyses of Network Diversity and Past-Year
Suicidal Ideation (Stratified by Gender) ........................................................................... 59
Table 2.4. Multivariable Logistic Regression Analyses of Social Network Compositions and
Past-Year Suicidal Ideation (Male; n = 132) .................................................................... 60
Table 2.5. Multivariable Logistic Regression Analyses of Social Network Compositions and
Past-Year Suicidal Ideation (Female; n = 273) ................................................................. 61
Figure 2.1. Predicted Change in Past-Year Suicidal Ideation by Specific Social Network
Composition (Stratified by Gender) .................................................................................. 62
Table 3.1. Univariable Comparison of Descriptive Statistics and Study Variables by Past-Year
Suicidal Ideation and Gender ............................................................................................ 85
Table 3.2. Multivariable Logistic Regression of Moderating Effect of Network Diversity on
Migration-Related Stressors and Past-Year Suicidal Ideation by Gender ........................ 87
Table 3.3. Multivariable Logistic Regression Analyses of Moderating Effects of Social Network
Ties on Migration-Related Stressors and Past-Year Suicidal Ideation among Men (n =
132) ................................................................................................................................... 88
Table 3.4. Multivariable Logistic Regression Analyses of Moderating Effects of Social Network
Ties on Migration-Related Stressors and Past-Year Suicidal Ideation among Women (n =
273) ................................................................................................................................... 89
Figure 3.1. Moderating Effect of Network Diversity on the Association between Post-Migration
Discrimination and Past-Year Suicidal Ideation among Women (n = 273) ..................... 90
Table 4.1. Descriptive Statistics of Total Sample and by Past-Year Suicidal Ideation .............. 110
Figure 4.1. Mediation Model of Pre-Migration Sexual Violence and Past-Year Suicidal Ideation
via Absence of Network Diversity (N = 273) ................................................................. 111
Figure 4.2. Mediation Model of Pre-Migration Sexual Violence and Past-Year Suicidal Ideation
via Absence of Kin Ties (N = 273) ................................................................................. 112

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 7
Abstract
North Korean (NK) refugees are vulnerable to experiencing various types of traumatic
events, particularly sexual violence among women, before and during migration. Many of them
lose their significant social networks due to the nature of forced migration, which requires them
to establish new networks to access resources and support in the host society. They often face
discriminatory treatment by South Koreans (SKs) upon resettlement. In SK, where suicide rates
are double the average rate of all Organisation for Economic Co-operation and Development
countries, NK refugees have died by suicide at 3 times the rate of their host country counterparts.
Despite the urgent need to create suicide intervention and prevention programs designed for this
high-risk population, the dearth of research prevents our understanding of salient factors
predicting suicidality and how these factors might exacerbate or mitigate suicidal behavior
among NK refugees. Because interventions using social connectedness have been shown to be
particularly effective for suicide prevention, this dissertation examined the main, moderating,
and mediating effects of social network compositions on suicidal ideation among NK refugees
living in SK.
This dissertation consists of three independent studies. The main purpose of this
dissertation is to contribute to the literature regarding the various effects of social networks on
suicidality among refugees in general and NK refugees in particular. Social network
compositions in this dissertation were operationalized as network diversity, the intersection of
types and functions of social ties, and the absence of important social ties. Personal social
network (egocentric) data collected from a sample of 405 NK refugee adults living in three
metropolises and provinces of SK were used in this dissertation. The specific aims of this
dissertation are to examine: (a) how different social network compositions affect suicidal
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 8
ideation; (b) how pre-migration trauma and post-migration discrimination are associated with
suicidal ideation; (c) whether social network compositions moderate the associations among pre-
migration trauma, post-migration discrimination, and suicidal ideation in men and women; (d)
how pre-migration sexual violence is associated with suicidal ideation among women; and (e)
whether the absence of important social networks mediate the effect of pre-migration sexual
violence on suicidal ideation among women.
The first study found that network diversity was a protective factor for suicidal ideation
among women only. In addition, being connected to a help-providing or trustworthy kin tie was a
protective factor for women. Interestingly, having a help-providing or trustworthy church-based
tie was a risk factor for men, whereas having a trustworthy church-based tie was a protective
factor for women. The second study revealed that pre-migration trauma was a risk factor for
suicidal ideation only among women, whereas post-migration discrimination was a risk factor for
both men and women. In addition, network diversity moderated the relationship between post-
migration discrimination and suicidal ideation among women only. The third study indicated that
both the absence of network diversity and absence of kin ties mediated the association between
pre-migration sexual violence and suicidal ideation among women.
Altogether, findings of this dissertation highlight that social network compositions are
critical factors that affect suicidal ideation in various ways among NK refugees living in SK.
Results of this dissertation can inform the development of effective social network interventions
to prevent suicidal behavior in this high-risk population. This dissertation contributes to the
literature by being the first to examine detailed measures of social network compositions and
their various effects on suicidality among NK refugees.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 9
Chapter 1: Overview of the Three Studies
Introduction
South Korea’s (SK) suicide rate has remained the highest among all Organisation for
Economic Co-operation and Development (OECD) countries since 2002 (Jee & Jo, 2014; OECD,
2016). According to OECD health statistics, in 2012, 29.1 deaths per 100,000 persons occurred
by suicide in SK, which is more than twice the rate of the average of all OECD countries (12.0
deaths per 100,000) and a 10-fold difference compared to Greece, the country with the lowest
rate (OECD, 2014). In this society with an exceptionally high suicide, North Korean (NK)
refugees have died by suicide at an even higher rate than their host country counterparts (H. J.
Kim & Jung, 2015; J. Y. Kim, Choi, Chae, & Hwang, 2013). Specifically, SK’s Ministry of
Unification reported that the rate of suicide deaths among NK refugees in SK was 3 times higher
(0.09%) than that of SKs (H. J. Kim & Jung, 2015), and a national social survey found that NK
refugees were also 3 times more likely to contemplate suicide (20.9%) than their SK counterparts
(Korea Hana Foundation, 2014). Given these statistics, it is critical to identify risk and protective
factors for suicidal behavior among NK refugees in SK; however, very little is known about what
factors predict suicidal behavior or how potential factors operate to exacerbate or ameliorate
suicide risks in this population.
Refugees often experience trauma, violence, and other life-threatening conditions before
and during migration (Fenta, Hyman, & Noh, 2004; Ferrada-Noli, Asberg, Ormstad, Lundin, &
Sundbom, 1998; Hovey, 2000) and continue experiencing stressful events during resettlement in
a host country (Jankovic et al., 2013; McMichael & Manderson, 2004; Um, Chi, Kim, Palinkas,
& Kim, 2015), which can jeopardize their mental health and contribute to suicidality (Iliceto et
al., 2013; Jankovic et al., 2013).

NK refugees suffer from various types of traumatic events and
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 10
human rights violations in NK, and NK refugee women in particular experience sexual violence
in intermediary countries due to their illegal status and the possibility of being repatriated to NK
(B. H. Jeon et al., 2009; W. Jeon et al., 2005). While resettling in SK, they often face
discrimination by SKs (J. U. Kim & Jang, 2007). These stressful experiences before, during, and
after migration have been associated with poor mental health outcomes in this population (Um et
al., 2015).

In addition, many refugees are separated from their families and other significant
social networks as a result of forced migration, which might increase their vulnerability to
suicidality (Fenta et al., 2004; Hovey, 2000). In fact, a national social survey reported that social
isolation was one of the top five reasons that NK refugees had considered suicide (Korea Hana
Foundation, 2014).
Although the literature on suicidality has documented that adverse circumstances and
stressful life events are associated with increased suicide risk (Cho & Haslam, 2010; Johnson,
Wood, Gooding, Taylor, & Tarrier, 2011; Nock et al., 2008; Van Orden et al., 2010), social
isolation in particular is among the strongest predictors of suicidality across various populations
(Fässberg et al., 2012; Joiner, 2005; Kuramoto, Wilcox, & Latkin, 2013; Van Orden et al., 2010).

However, the effects of social networks, pre-migration trauma, post-migration discrimination,
and sexual violence on suicidality have been understudied among refugees in general and NK
refugees in particular.
North Korean Refugees
NK is an internationally closed country where violence is commonly used for political
purposes (H. Y. Lee & Gerber, 2009). It is also common for NK officials to sexually abuse NK
women when considered politically necessary (Um, Kim, & Palinkas, 2016). A series of floods
and droughts in the mid-1990s caused a severe food crisis in NK, triggering a large number of
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 11
NKs fleeing to neighboring China to search for food and freedom (Lankov, 2006). Due to
China’s agreement with NK to repatriate NKs who cross the NK-China border, NKs in China are
considered illegal migrants and are immediately sent back to NK (Ko, Chung, & Oh, 2004).
Because of these circumstances, NKs in China beg for food and shelter, and constantly hide in
fear of being noticed by Chinese authorities (W. Jeon et al., 2005; Ko et al., 2004). NKs who are
repatriated face severe punishment from the NK government, such as torture, imprisonment in
concentration camps, or execution (Um et al., 2015). Hence, NKs in China are vulnerable to
human trafficking, forced labor, and other forms of human rights violations. Particularly for NK
women in China, previous studies estimated that the majority of them are often forced into
marriage with Chinese men, or are kidnapped for prostitution and sexual slavery (E. Kim, Yun,
Park, & Williams, 2009; Ko et al., 2004; Um et al., 2016). Consequently, many NKs flee to
Mongolia, Vietnam, or other Southeast Asian countries where policies concerning their status are
less strict than in China (Lankov, 2006). The fortunate ones visit foreign embassies or
consulates and demand a safe flight to South Korea, while others must make deals with brokers
who will guide them to SK (Ko et al., 2004; Lankov, 2006). As of March 2017, the number of
NK refugees who have been admitted to SK exceeded 30,000 (Ministry of Unification, 2017).
When an NK refugee arrives in SK, the individual is mandated to enter Hanawon, a
mandatory resettlement facility that every NK refugee enters and stays at for 3 months prior to
being transferred to a new residence (Ministry of Unification, 2017). Hanawon provides newly
arrived NK refugees with education about the SK society, law, democracy and capitalism, and
also basic job training and career counseling (Lankov, 2006). In addition, education on various
life skills, such as how to use computers, cook, drive, use mobile phones, and use public
transportation, are provided (Lankov, 2006). When released to the society, NK refugees are
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 12
granted SK citizenship and provided with financial support for initial settlement and other
assistance such as housing, vocational training, tuition, and medical care (Ministry of Unification,
2017). Despite these various forms of support received from the SK government, NK refugees
face difficulties in making social relationships with SKs who have historically valued
monoculturalism. Although NK refugees share the same ethnicity as SKs, discrimination by SKs
has been reported to be a serious problem that hinders overall adaptation to the homogenous host
society (B. H. Jeon et al., 2009; J. U. Kim & Jang, 2007). Hence, NK refugees’ experiences of
trauma before and during migration, and discrimination after resettlement are potent risk factors
for their mental health and well-being.
Many SK churches play a pivotal role in supporting NK refugees before and after their
arrival in SK. SK protestant missionaries provide shelter and material aid to NK refugees who
hide in China (Han, 2016). In SK, churches provide tailored services and stipends or scholarships
to NK refugees, motivating the majority (70–90%) of NK refugees to become members of
churches (Bell, 2013). Specifically, qualitative studies indicated that NK refugees in SK go to
church because of their appreciation for the aid received in China and to seek emotional and
material support (M. S. Lee, 2005) and that they want to get job placements, network with others,
be treated as SKs, and become successful as SK Christians by attending church (Han, 2016; M. S.
Lee, 2005). Prior research has showed that NK refugees form strong relationships with people
they meet in churches, which were significant sources of emotional support (Bell, 2013).
However, despite the positive intentions of SK churches helping NK refugees, unintended
consequences were also found in the literature. Previous studies have noted that NK refugees
expressed to be distressed by feeling inferior to SKs with respect to their physical appearances
and social statuses (Chung, 2016) and were also sometimes humiliated and pressured to meet the
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 13
requirements for financial aid (M. S. Lee, 2016). Thus, empirical examination on how networks
with church-based ties affect NK refugees’ mental health is necessary.
Research Gaps
Despite the extensive literature on the general population indicating that social support is
either directly associated with less suicidality (main effect; Cho & Haslam, 2010; Coker et al.,
2004; Fässberg et al., 2012; Kleiman & Liu, 2013; Nock et al., 2008; Tsai, Lucas, Sania, Kim, &
Kawachi, 2014) or protects against suicide in the presence of stressful events (moderating effect;
Devries et al., 2011; Johnson et al., 2011; Kleiman & Riskind, 2012),

critical gaps remain
unaddressed. First, these studies generally have measured social support or connectedness
merely by aggregating them into a global scale (Cho & Haslam, 2010; J. Y. Kim et al., 2013;
Kleiman & Liu, 2013), which impedes the ability to understand specifically who is providing the
support and the nature of relationships that are associated with suicidality. To inform culturally
sensitive interventions, prior research has stressed the need for deeper investigation of social
networks because different types and qualities of networks surrounding an individual have
differential effects on mental health (Charuvastra & Cloitre, 2008; Kawachi & Berkman, 2001;
Levendosky et al., 2004; Lincoln, 2000; Tsai et al., 2014). It cannot be simply assumed that
increasing any type of social network will be an effective intervention for better well-being,
because social ties (i.e., links between two social units) can produce not only support but also
negative influences on mental health and behavior (Abrutyn & Mueller, 2014; Fulginiti, Rice,
Hsu, Rhoades, & Winetrobe, 2016; Rice, Kurzban, & Ray, 2012; Thoits, 2011). For example,
being connected to some people can generate greater role strain or responsibility (Kawachi &
Berkman, 2001; Kuramoto et al., 2013), and the absence of a protective tie in an individual’s
network (Charuvastra & Cloitre, 2008; Rice & Yoshioka-Maxwell, 2015) can cause deleterious
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 14
effects on suicidal ideation. Without detailed measures of social networks, it is impossible to
fully understand which social tie is the source of positive or negative influence on an individual’s
mental health, specifically suicidality.
Second, unlike the main and moderating effects of social support or networks on
suicidality, the mediating effects of social networks on the association between stressors and
suicidal behavior have received less empirical attention. Although the literature has consistently
revealed that victims of interpersonal trauma, particularly sexual violence, are more likely to
have limited social networks (Golding, Wilsnack, & Cooper, 2002; Jankovic et al., 2013) and
elevated suicidality (Coker et al., 2004; Devries et al., 2011; O’Neill et al., 2014; Stein et al.,
2010), little is known about the mediating effect of social networks on the association between
sexual violence and suicidality. To reduce the global public health burden of sexual violence and
suicidal behaviors among women (Devries et al., 2011), it is necessary to elucidate the
underlying mechanisms through which sexual abuse victims manifest suicidality. Because many
refugee women are particularly vulnerable to sexual violence before and during migration and
exhibit poorer mental health (Hynes & Cardozo, 2000; Vu et al., 2014), it is important to
examine the processes by which these women demonstrate suicidal behavior.
Third, although numerous studies on suicidality have emphasized the need to stratify
analyses by gender because salient gender differences have been consistently found in suicidal
behavior (Canetto & Sakinofsky, 1998; Cheng et al., 2010; Duldulao, Takeuchi, & Hong, 2009;
Fässberg et al., 2012; Van Orden et al., 2010), only a few studies of social connectedness and
suicidality have used gender-stratified models (Abrutyn & Mueller, 2014; Bearman & Moody,
2004). The literature has consistently found that the rate of suicide among men is higher than
among women, whereas the rate of suicidal ideation and nonfatal suicidal behavior among
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 15
women is higher compared to men (Canetto & Sakinofsky, 1998; Fässberg et al., 2012; O’Neill
et al., 2014; Van Orden et al., 2010). Some scholars have explained that such gender differences
in suicidality are due to cultural expectations about gender and suicidal behavior in which suicide
is viewed as masculine whereas nonfatal self-harm is considered feminine (Canetto &
Sakinofsky, 1998). In addition, previous research has indicated that men are more likely to
become suicidal in response to financial or work-related issues, whereas women are more likely
to become suicidal due to relationship issues (Canetto & Lester, 1998; Heikkinen, Aro, &
Lönnqvist, 1994). Moreover, gender differences have emerged in terms of styles of coping with
stress (Cohen & Wills, 1985), social network involvement (Kawachi & Berkman, 2001), and the
effects of social networks on mental health (Kawachi & Berkman, 2001; Thoits, 2011).
Specifically, prior research has indicated that Korean men considered instrumentality (defined by
independence, utilitarianism, initiative, and competence) most important, expected practical
returns and mutual help, and were active in social relationships, whereas Korean women
considered expressivity (defined by dependence, empathy, passiveness, and consideration) most
important, expected emotional support and sympathy, and were passive in social relationships (J.
K. Kim & Kim, 2003). These differences were also significantly associated with distinct gender
role identities between Korean men and women (J. K. Kim & Kim, 2003). Thus, considering that
cultural expectations about gender roles are more rigid in Korean culture than in most Western
cultures and have been associated with different meanings and expectations in social
relationships between Korean men and women, it is important to identify potentially different
patterns of risk and protective factors related to suicidality by gender in research on NK refugees.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 16
Social Network Analysis
Using social networks as a strategy to prevent suicidality is important because prior
research has indicated that indexes of social connectedness are modifiable and that social support
interventions are readily available, easily implemented, and highly effective (Centers for Disease
Control and Prevention, 2015; Fässberg et al., 2012; Kleiman & Liu, 2013). Personal social
network (egocentric) data provide information on to whom people are connected (i.e., alters),
types of relationships with alters (e.g., family, friend, coworker, etc.), characteristics of alters
(e.g., age, gender, ethnicity, etc.), function of the relationship (e.g., emotional, instrumental, or
informational support, etc.), and whether alters are connected to one another. With such data,
researchers can generate several forms of social network compositions and understand how these
social networks might affect an individual’s well-being (Rice & Yoshioka-Maxwell, 2015).
Examination of specific social network compositions is required to generate findings not
apparent at the aggregate level and better inform culturally appropriate suicide interventions. The
literature states that having diversified networks enables people to develop a better sense of
control of their lives and be well informed about a wider range of information, which can
directly or indirectly promote their mental health (Erickson, 2003; Ferlander, 2007; Fiori,
Antonucci, & Cortina, 2006; Lin & Erickson, 2008). In addition, previous studies have found
that social support from family (Cho & Haslam, 2010; Nock et al., 2008), friends (Bearman &
Moody, 2004; Van Orden et al., 2010), and church-based acquaintances (Tsai et al., 2014) are
the most salient predictors of suicidal behaviors; however, their global measures of social
support limit our understanding of what kinds of support from these ties were specifically
associated with suicidality. Moreover, it is unclear whether the absence of these important social
ties also predicts suicidality. To fill these methodological gaps, this dissertation operationalized
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 17
social network compositions as network diversity, the intersection of types and functions of
social ties, and the absence of important social ties. Network diversity was defined as the total
number of different types of ties (e.g., family, friend, neighbor, coworker, etc.). Regarding the
intersections of types and functions of ties, this dissertation used kin, friend, and church ties for
the types of ties and help-providing and trustworthy ties for the function of ties, generating
categories of kin-help, kin-trust, friend-help, friend-trust, church-help, and church-trust ties. With
respect to the absence of important social ties, this dissertation used the absence of network
diversity and absence of kin ties. Further descriptions of which social network compositions
were used in each study are discussed at the end of this chapter.
Theoretical Framework
The three studies in this dissertation were guided by the interpersonal theory of suicide,
the stress-buffering hypothesis, and stress and coping theory. The design of social network
compositions in this dissertation was based in part on social capital theory.
Interpersonal Theory of Suicide
Joiner’s (2005) interpersonal theory of suicide posits that individuals who possess either
the perception of social isolation or a sense of burdensomeness on others are likely to experience
suicidal ideation. The sense of being alienated from others is conceptualized as loneliness and
the absence of reciprocally caring social relationships (Joiner, 2005; Van Orden et al., 2010). The
sense of being a burden on significant others is conceptualized as the feeling of being a liability
to others and cognitions of self-hatred (Joiner, 2005; Van Orden et al., 2010). This theory also
posits that passive thoughts of suicide will intensify into an active desire for death when senses
of social isolation and perceived burdensomeness are present simultaneously (Joiner, 2005).
Thus, Joiner (2005) suggested that increasing social connectedness and improving a sense of
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 18
meaningful contribution to others might offer a reminder of reasons for living and help restore
hope among suicidal individuals.
Stress-Buffering Hypothesis
The stress-buffering hypothesis posits that social support buffers (protects) the potentially
adverse impact of stress on mental health, primarily among individuals under stress (Cohen &
Wills, 1985; Kawachi & Berkman, 2001; Thoits, 2011). An individual may perceive a situation
as stressful or threatening when the ability to cope with the situation is not immediately available
(Cohen & Wills, 1985; Lazarus & Folkman, 1984). Cohen and Wills (1985) stated that social
support might attenuate the stress appraisal response from stress exposure by strengthening the
ability to cope with stress and preventing the situation from being perceived as stressful. They
also articulated that when a situation has already been appraised as stressful, support might
prevent the onset of possible pathological outcomes by providing solutions and necessary
resources to a particular situation, which in turn will alleviate the harmful impact of stress
appraisal (Cohen & Wills, 1985). Because support will most effectively protect an individual
from the negative influence of stressful events when resources and support provided from social
networks fit closely with the individual’s specific needs (Cohen & Wills, 1985), examining
which network members are providing what type of support that can explicate these buffering
effects (Thoits, 2011).
Stress and Coping Theory
Stress and coping theory suggests that an environment is appraised as stressful when
perceived as exceeding an individual’s resources and endangering well-being (Lazarus &
Folkman, 1984). Following such a cognitive appraisal of stress, the individual constantly
generates thoughts and behaviors to cope with the demands of the stressful environment (Lazarus
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 19
& Folkman, 1984). Such coping efforts manifest as problem-focused coping, emotion-focused
coping, or both (Folkman, Lazarus, Gruen, & DeLongis, 1986). Examples of problem-focused
coping include altering the stressful situation and actively solving the problem, whereas
examples of emotion-focused coping include distancing, seeking social support, and pursuing
escape or avoidance tactics (Folkman et al., 1986). Active problem solving is often used when
the situation is amenable to change, whereas avoidance coping is used when the situation is
uncontrollable (Roth & Cohen, 1986). The individual’s judgment of the extent to which the
stressful encounter is successfully managed will result in immediate and long-term outcomes
(Folkman et al., 1986). Thus, this theory indicates that coping efforts mediate the stressful
encounter and long-term outcomes (Lazarus & Folkman, 1984).
There are some differences between the stress and coping theory and the stress-buffering
hypothesis. While the former focuses more on individual characteristics (e.g., personality traits,
willingness and ability to use social support as a way of coping with stress), the latter focuses
more on interpersonal dynamics of the way that social support could influence the relationship
between stress and mental health. In addition, while the stress and coping theory suggests that
coping is a mediator of stressful events and emotional outcomes (Lazarus & Folkman, 1984),
which specifies the mechanism of how stress affects psychopathology (Holmbeck, 1997), the
stress-buffering hypothesis suggests that coping is a moderator between stress and mental health,
which indicates that the association between stress and psychopathology depends on the type of
coping an individual uses (Cohen & Wills, 1985).
Social Capital Theory
Social capital theory defines social capital as resources embedded in social networks (Lin,
1999). Individuals can gain advantages by investing in these social relationships (Lin & Erickson,
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 20
2008). For example, an individual can borrow resources (e.g., power, reputation, etc.) from his or
her networks or can benefit from information flow, influence flow, and affirmation of self-
identity facilitated through these relationships (Lin & Erickson, 2008). This theory also suggests
that individuals who have access to diverse sources of networks gain more returns because
diverse networks stimulate a wider range of interests, provide richer information, and enable
individuals to develop a better sense of control of their lives (Erickson, 2003; Lin & Erickson,
2008). Thus, the focal point of this theory is to understand how individuals invest in their social
networks and how they capture the resources embedded in these relationships to generate returns
(Lin, 1999).
Overview of the Dissertation
This three-study dissertation has an overarching goal of contributing to a greater
understanding of the effects of social network compositions on suicidal ideation among NK
refugees who live in SK. Specifically, the main, moderating, and mediating effects of social
networks on suicidal ideation were examined. This dissertation used cross-sectional data from a
sample of 405 NK refugees living in various districts across three metropolises and provinces of
SK. Participants were aged 19 or older and recruited by snowball sampling from April to May
2014. Egocentric data were also collected as part of the self-administered surveys. Social
network compositions in this dissertation were operationalized based on social capital theory and
evidence from the literature. The sociodemographic characteristics, such as age, major areas of
residence, male to female ratio, perceived socioeconomic status in SK, length of time lived in SK,
and marital status, of these data were fairly comparable to those of a nationally representative
sample from a recent national social survey (Korea Hana Foundation, 2014).
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 21
This dissertation consists of five chapters. Chapter 1 presents a review of the literature
and major research gaps, a brief introduction to social network analysis, a description of the three
theoretical frameworks that informed this dissertation, and an overview of the dissertation.
Chapter 2, Suicidal Ideation among North Korean Refugees in South Korea: Exploring
the Influence of Social Network Compositions by Gender, is an empirical study that examined the
main effects of several social network compositions on suicidal ideation in men and women.
This study is based on the interpersonal theory of suicide. Social network compositions were
defined as network diversity and the intersection of types and functions of social ties in this study.
Because kin, friend, and church ties were of interest regarding the types of ties and help-
providing and trustworthy ties were of interest regarding the function of ties, social network
composition variables used in this study were network diversity and kin-help, kin-trust, friend-
help, friend-trust, church-help, and church-trust ties. The specific research questions addressed in
this study were: (a) How do different social network compositions affect suicidal ideation among
NK refugees in SK? (b) Do all social networks have beneficial effects on suicidal ideation? (c)
Are these effects similar or different by gender? A conceptual model of this study is presented in
Figure 1.1.
Chapter 3, Migration-Related Stressors and Suicidal Ideation of North Korean Refugees:
Moderating Effects of Social Networks, describes an empirical study that tested the moderating
effects of social network compositions on the associations between migration-related stressors
and suicidal ideation in men and women. Specific migration-related stressors examined in this
study were pre-migration traumatic events and post-migration perceived discrimination. This
study was informed by the stress-buffering hypothesis. Social network compositions used in this
study were network diversity and church-help and church-trust ties, which were derived in part
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 22
from results found in Chapter 2. The specific research questions addressed in this study were: (a)
How are pre-migration trauma and post-migration discrimination associated with suicidal
ideation among NK refugees in SK? (b) Do social network compositions (network diversity and
church-based ties) moderate the association between these migration-related stressors and
suicidal ideation? (c) Are these effects similar or different in men and women? A conceptual
model of this study is also presented in Figure 1.1.
Chapter 4, Testing the Pathway from Pre-Migration Sexual Violence to Suicidality among
North Korean Refugee Women Living in South Korea: Do Social Networks Matter?, presents an
empirical study that investigated the mediating pathways by which experiences of pre-migration
sexual violence among NK refugee women cause suicidality via the absence of important social
networks. This study only used the female sample from the data because NK refugee women are
much more likely to be victims of sexual exploitation before or during migration than their male
counterparts (E. Kim et al., 2009). This study was framed by stress and coping theory. Social
network compositions were defined as the absence of network diversity and absence of kin ties,
which were also derived in part from results found in Chapter 2. The specific research questions
addressed in this study were: (a) How is pre-migration sexual violence associated with suicidal
ideation among NK refugee women? (b) Do women who experienced pre-migration sexual
violence report no network diversity in their networks? (c) Do women who experienced pre-
migration sexual violence report no kin ties in their networks? (d) Does absence of network
diversity mediate the relationship between pre-migration sexual violence and suicidal ideation?,
and (e) Does absence of kin ties mediate the relationship between pre-migration sexual violence
and suicidal ideation? A conceptual model of this study is presented in Figure 1.1.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 23
Chapter 5 presents overall conclusions, implications, and future directions. This chapter
summarizes the main findings of the three studies, presents limitations and suggestions for future
research, and concludes with implications and contributions to the literature.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 24
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SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 33
Figure 1.1. Conceptual Models of the Three Studies

Study 1: Main Effects of Social Network Compositions
Note. Stratified by gender.
Social Network
Compositions
Suicidal Ideation
Study 2: Moderating Effects of Social Network Compositions
Pre-migration
Trauma
Post-migration
Discrimination
Suicidal Ideation
Social Network
Compositions
Note. Stratified by gender.
Study 3: Mediating Effects of the Absence of Important Social Networks
Pre-migration Sexual
Violence
Suicidal Ideation
Absence of
Social Networks
Note. Women only.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 34
Chapter 2 (Study 1): Suicidal Ideation among North Korean Refugees in South Korea:
Exploring the Influence of Social Network Compositions by Gender
Introduction
Rates of completed suicide among North Korean (NK) refugees are 3 times higher than
similar rates among their host country counterparts in South Korea (SK; H. J. Kim & Jung, 2015),
which in turn are twice the average rate of all Organisation for Economic Co-operation and
Development (OECD) countries (OECD, 2016). Further, although OECD reported that suicide
rates have decreased in many member countries since 1990, they have sharply increased in SK
(OECD, 2016). Some researchers have argued that suicide is contagious in a shared social
environment (Abrutyn & Mueller, 2014; Romer, Jamieson, & Jamieson, 2006), thus the high and
increasing rate of suicide in SK may place NK refugees living in SK at higher risk of suicidality.
However, despite the urgent need to investigate suicidal behavior in this high-risk population,
very little is known about what factors predict suicide risk among NK refugees. This knowledge
is critical to inform the design of effective interventions and prevention initiatives.
Prior studies have shown that adverse circumstances and life event stress are associated
with suicide risk (Cho & Haslam, 2010; Stein et al., 2010). Social isolation in particular has been
found to be a potent risk factor for suicidality across various populations (Fässberg et al., 2012;
Joiner, 2005; Kuramoto, Wilcox, & Latkin, 2013; Van Orden et al., 2010), which is the premise
of Joiner’s (2005) interpersonal theory of suicide. Hence, interventions using social
connectedness are a promising avenue for suicide prevention in the general population (Centers
for Disease Control and Prevention, 2015). However, previous studies on suicidality generally
have measured social connectedness merely by aggregating them into a scale of social support
(Cho & Haslam, 2010; J. Y. Kim, Choi, Chae, & Hwang, 2013; Kleiman & Liu, 2013). This
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 35
methodology precludes our understanding of who provides support and the nature of their
relationships (Smith & Christakis, 2008) with regard to suicidal behavior. Such methodological
limitations might explain why some of the very few studies on NK refugees’ social support and
mental health or suicidality produced mixed findings (Eom & Lee, 2004; J. Y. Kim et al., 2013;
Park & Yoon, 2007). Because social support is only one of the possible functions of an
individual’s social network (i.e., the web of social relationships around an individual; Smith &
Christakis, 2008), it is important to analyze specific social networks to generate findings not
apparent at the aggregate level and better inform culturally appropriate interventions.
Social capital (i.e., resources embedded in social networks; Lin, 1999) theory posits that
an individual’s network diversity is associated with positive well-being and mental health
(Erickson, 2003). That is, different types of social ties (i.e., links between two social units)
provide varying types of support and resources (Ryan, Sales, Tilki, & Siara, 2008; Wellman &
Wortley, 1990); hence, diversified networks enable people to develop a better sense of control of
their lives and be well informed about a wider range of information, which can directly or
indirectly improve their mental health (Erickson, 2003; Ferlander, 2007; Fiori, Antonucci, &
Cortina, 2006; Lin & Erickson, 2008). At the same time, some scholars have cautioned that not
all forms of social ties are associated with beneficial effects on mental health and that negative
social interactions can produce more harm than good (Abrutyn & Mueller, 2014; Fulginiti, Rice,
Hsu, Rhoades, & Winetrobe, 2016; Rice, Kurzban, & Ray, 2012; Thoits, 2011). Likewise,
studies have found that different types and qualities of social networks surrounding an individual
have differential effects on mental health (Ferlander, 2007; Wellman & Wortley, 1990). Clearly,
detailed measures of social networks need to be examined to understand social ties and their
positive or negative influences on mental health, particularly suicidality. Acknowledging this
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 36
need, a previous study (Kuramoto et al., 2013) suggested using such an approach to studying
social networks to advance our understanding of etiologies of suicidal behavior.
Personal social network (egocentric) data provide information on to whom people are
connected (i.e., alters), types of relationships with alters (e.g., family, friend, coworker, etc.),
characteristics of alters (e.g., age, gender, race, etc.), function of the relationship (e.g., emotional,
instrumental, or informational support, etc.), and whether the alters are connected to one another.
With such data, we can generate several forms of social network compositions and understand
how these social networks might affect an individual’s behavior (Rice & Yoshioka-Maxwell,
2015). Many existing social networks of NK refugees have been disrupted as a result of forced
migration, making it important to understand how they establish new social ties in the host
society to access resources and support. However, to date, very little is known about the social
network compositions of NK refugees (Yeom & Kim, 2011).
Current Study
To fill these research gaps, the current study used egocentric data collected from a sample
of 405 NK refugees living in SK and explored the effects of social network compositions on
suicidal ideation in men and women. Social network compositions are defined as network
diversity, and as the intersection of types and functions of social ties in this study. We first
examined whether network diversity (number of different types of ties) was associated with past-
year suicidal ideation. Then, we examined how different intersections of types and functions of
social ties were associated with past-year suicidal ideation. With respect to the types of ties,
because the literature has found that social support from family (Cho & Haslam, 2010; Nock et
al., 2008), friends (Bearman & Moody, 2004; Van Orden et al., 2010), and church-based
acquaintances (Tsai, Lucas, Sania, Kim, & Kawachi, 2014) are the most salient predictors of
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 37
suicidal behaviors, we focused on these three types of ties in the current study. Examination of
these types of ties among NK refugees is important because family and friends are significant
sources of support, reducing mental distress in this population (Park & Yoon, 2007). More
importantly, many churches in SK provide special services and stipends to NK refugees,
motivating a large number of NK refugees to become members of churches (Bell, 2013).
However, we have no knowledge of how church-based ties are associated with NK refugees’
mental health. Regarding the function of social ties, we focused on individuals our respondents
could trust and who provided instrumental help to respondents during hardship. Because NK
refugees tend to be very suspicious toward others, a learned behavior in NK (Min, 2008), it is
critical to examine their trusted social ties rather than assuming that they trust everyone in their
networks. In addition, examining ties who provide instrumental help is important because studies
have found that the majority of NK refugees receive instrumental support from governmental or
nongovernmental organizations, churches, volunteer helpers, and many other individuals due to
their multidimensional hardships (Bell, 2013; M. R. Kim, 2005; Min, 2008). Thus, the
intersections of types and functions ties in our study were classified as kin-help, kin-trust, friend-
help, friend-trust, church-help, and church-trust ties.
The current study employed gender-stratified analyses throughout all models because
salient gender differences have been consistently found with regard to suicidal behavior (Canetto
& Sakinofsky, 1998; Fässberg et al., 2012; Van Orden et al., 2010) and the effects of social
networks on mental health (Abrutyn & Mueller, 2014; Bearman & Moody, 2004; Thoits, 2011).
With respect to research on NK refugees, although one study found that women were more likely
to participate in social communities than men (M. R. Kim, 2005) and another study found that
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 38
women had significantly higher levels of suicidal ideation than men (H. J. Kim & Jung, 2015),
no study to date has used gender-stratified models to explore suicidality in this population.
Accordingly, the current study explored three research questions: (a) How do different
social network compositions affect suicidal ideation among NK refugees in SK? (b) Do all social
networks have beneficial effects on suicidal ideation? (c) Are these effects similar or different by
gender? To the best of our knowledge, this is the first empirical study to examine detailed
measures of social network compositions, particularly in relation to suicidality, among NK
refugees.
Methods
Study Participants
A sample of NK refugees living in SK and aged 19 or older was recruited from April to
May 2014. Recruitment occurred by snowball sampling, whereby trained recruiters initially
reached out to some participants (i.e., seeds), who in turn introduced other participants to the
researchers. Snowball sampling is the most commonly used sampling strategy to collect data
from NK refugee participants (Um, Kim, & Palinkas, 2016). Because information on NK
refugees who reside in SK is strictly confidential for security purposes, random sampling is
inherently impractical for this population (Um et al., 2016). To reduce potential recruitment bias,
the number of participants whom seeds could recruit was limited to four and long chains of
recruitment occurred to minimize the initial seeds’ influence on the final composition of the
study sample (H. J. Kim & Jung, 2015). Participants recruited by this procedure were living in
various districts across three metropolises and provinces (Seoul, Gyeonggi province, and
Incheon), where more than half of all NK refugees are reported to reside (Ministry of Unification,
2016). A trained researcher and interviewer visited each household. Surveys were self-
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 39
administered after obtaining informed consent. Each participant received 20,000 Korean won
(approximately $20) as compensation for their participation. Among 407 participants who were
interviewed, two participants with incomplete data were removed, generating a sample of 405
participants. The institutional review board at Korea University approved all survey items and
procedures. This dataset also includes a sample of 400 SK adults; however, this study only used
the sample of NK refugees due to its focus on this population.
Measures
Suicidal ideation. Suicidal ideation was assessed by a 5-item suicidal ideation scale
(Harlow, Newcomb, & Bentler, 1986). Participants were asked how often during the previous
year they had suicidal thoughts and attempted suicide, with response options ranging on a 5-
point Likert scale from 0 (almost never) to 4 (almost always). Items were “I have thought about
suicide,” “I have recently wanted to die,” “I have told someone that I wanted to commit suicide,”
“I have thought that my life will end by committing suicide,” and “I have attempted to commit
suicide.” (Cronbach’s alpha = .93). A total score was calculated by summing the five items. In
the present study, a dichotomous variable was created to indicate at least one experience of
suicidal ideation during the previous year, considering the distributional nature of suicidal
ideation measures (i.e., showing positive skewness and signs of excessive zeros), which is
commonly observed in the relevant literature (Johnson, Wood, Gooding, Taylor, & Tarrier,
2011).
Social networks. Social networks were measured using each respondent’s egocentric
(personal) network data, which were collected by employing a technique used in previous studies
(Burt, 1984; Rice et al., 2012; Rice, Milburn, & Monro, 2011). As part of the self-administered
survey, participants were asked about alters in their social networks: “We would like to
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 40
understand your social relationships with the most important people to you. Please name 5
people who you have stayed in contact with and have significantly influenced you the most
during the past 6 months. These people can include family, friends, coworkers, teachers, doctors,
and so on.” Participants were then asked about the following information for each alter: (a) type
of relationship (spouse, parent, sibling, children, other family, coworker, friend, neighbor, church
acquaintance, and other); (b) demographic characteristics of each alter, including gender, age,
and nationality; (c) length of relationship (in years); and (d) the function of relationship as a
source of social support (i.e., degree of emotional closeness, degree of trustworthiness, and
degree of helpfulness during hardship) using a 5-point Likert scale ranging from 1 (not at all) to
5 (extremely).
In the present study, social network compositions were operationalized as network
diversity and the intersection of types and functions of social ties. Network diversity was defined
as the total number of different types of ties. Intersections of types and functions of ties were
created by intersecting these two characteristics (i.e., types and functions) and dichotomizing
each variable to indicate the presence of at least one tie (coded as 1) or the absence of a tie
(coded as 0) in each participant’s network, as shown in Table 2.1. For the purpose of this study,
we used kin, friend, and church ties for the types of ties and help-providing and trustworthy ties
for the function of ties. A tie’s function as trustworthiness or helpfulness was determined by
responses of 4 (very) or 5 (extremely) in the corresponding questions. Thus, social network
composition variables used in this study were network diversity and kin-help, kin-trust, friend-
help, friend-trust, church-help, and church-trust ties.
Covariates. Sociodemographic characteristics of age (years), marital status (1 = married
or cohabiting, 0 = separated or single), duration of residence in SK (years), religious affiliation
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 41
(1 = Christian, 0 = not Christian; 85% of Christians in our study reported attending church at
least 3 or 4 times a month), and perceived socioeconomic status in SK (1 = low, 0 = low to
middle, middle, middle to high, or high) were included as covariates. Self-esteem has been found
to be associated with suicidal ideation in previous studies (Bearman & Moody, 2004; Johnson et
al., 2011). The Rosenberg Self-Esteem Scale (Rosenberg, 1965) was used to measure global self-
esteem. Ten items were asked using a 4-point Likert scale ranging from 1 (strongly disagree) to
4 (strongly agree). Negatively worded items were reverse scored. A total score was calculated by
summing the items, with higher scores indicating higher self-esteem. (Cronbach’s alpha = .80).
Self-rated health is also known to be associated with suicidal ideation (Van Orden et al., 2010).
Participants’ self-rated health status was measured by one item with a 5-point scale: “Compared
to your past (e.g., in NK or during migration), how would you rate your health?” Response
options were 1 (very poor), 2 (poor), 3 (similar), 4 (good), and 5 (very good).
Statistical Analyses
As described previously, this study used gender-stratified models to identify potentially
different patterns of risk and protective factors related to suicidality in men and women. Chi-
square tests and independent-group t-tests were performed to compare descriptive statistics and
social networks by past-year suicidal ideation in men and women. Based on the methodology
suggested by Hosmer, Lemeshow, and Sturdivant (2013), covariates associated with suicidal
ideation at p < .25 in either men or women were included in the subsequent multivariable models
to avoid numerically unstable estimates and large standard errors. The only exception was the
religious affiliation variable when the independent variable included a church-based tie, given
the importance of controlling for this variable in this case.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 42
Multivariable logistic regression analyses were divided into two parts: analyses
examining (a) the main effect of network diversity on suicidal ideation and (b) the effects of
different intersections of types and functions of ties on suicidal ideation. Each multivariable
logistic regression model was performed with only one social network independent variable to
avoid multicollinearity issues, resulting in seven models for men and women each. All analyses
for the current study were performed using Stata 12.0.
Results
The mean age of the male respondents was 39.1 years (range = 19–68) and that of female
respondents was 41.4 years (range = 19–69). The majority of the sample was married (71.2% of
men, 69.2% of women) and identified as Christian (65.9% of men, 69.2% of women), and almost
half of the sample reported having the lowest socioeconomic status in SK (45.5% of men, 46.5%
of women). The average length of time lived in SK was 6.8 years (range = 0.9–17.3) for men and
6.1 years (range = 0.6–16.0) for women in our sample. Compared to when they lived in NK or
were fleeing to other countries, male respondents rated their current health status to be between
similar and better (M = 3.3, SD = 1.1), which was significantly better than how women rated
their health to be between similar and worse (M = 2.9, SD = 1.1) on average. 25.0% of men and
34.4% of women reported contemplating suicide during the previous year, which was different at
a trending level ( χ
2
[1] = 3.68, p = .06).
With regard to social networks, both men and women had an average of two types of
social ties in their networks, ranging from one to five types for men and one to four types for
women. Regarding specific social ties, 46.2% of men and 49.1% of women had at least one help-
providing kin tie; 47.0% of men and 52.0% of women had at least one trustworthy kin tie; men
had significantly more help-providing friend ties (72.0%) than women (60.8%); 73.5% of men
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 43
and 66.7% of women had at least one trustworthy friend tie; 13.6% of men and 19.1% of women
had at least one help-providing church tie; and men had significantly less trustworthy church ties
(12.1%) than women (20.2%) in their networks.
Table 2.2 presents univariable comparisons of demographic and social network
characteristics by suicidal ideation in men and women. Among male respondents, having a help-
providing church tie ( χ
2
[1] = 6.95, p < .01) and a trustworthy church tie ( χ
2
[1] = 6.07, p < .05)
were positively associated with suicidal ideation. Longer years lived in SK (t[130] = -2.09, p
< .05), and lower levels of self-esteem (t[130] = 3.42, p < .001) and self-rated health (t[130] =
2.63, p < .01) were positively associated with suicidal thoughts among men. Among female
respondents, higher levels of network diversity (t[271] = 2.90, p < .01) and having a kin-help tie
( χ
2
[1] = 9.57, p < .01), a kin-trust tie ( χ
2
[1] = 10.81, p < .01), a church-help tie ( χ
2
[1] = 5.02, p
< .05), and a church-trust tie ( χ
2
[1] = 4.85, p < .05) were inversely associated with suicidal
thoughts. Lower levels of self-esteem (t[271] = 6.14, p < .001) and self-rated health (t[271] =
4.73, p < .001) were positively associated with suicidal ideation among women.
Results of the multivariable logistic regression analyses of network diversity and past-
year suicidal ideation are presented in Table 2.3. Network diversity (OR = 0.62; 95% CI = 0.44,
0.88) decreased the odds of suicidal ideation, whereas years lived in SK (OR = 1.10; 95% CI =
1.01, 1.20) increased the odds of past-year suicidal ideation. Table 2.4 shows results of
multivariable logistic regressions of six social network compositions and suicidal ideation among
male respondents. Having at least one help-providing church-based tie (OR = 5.07; 95% CI =
1.34, 19.23) and trustworthy church-based tie (OR = 4.84; 95% CI = 1.23, 19.06) increased the
odds of suicidal ideation among men. Table 2.5 presents results of multivariable logistic
regressions of six social network compositions and suicidal ideation among women. Having at
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 44
least one help-providing kin tie (OR = 0.44; 95% CI = 0.24, 0.80), trustworthy kin tie (OR = 0.47;
95% CI = 0.26, 0.84), and trustworthy church tie (OR = 0.43; 95% CI = 0.19, 0.96) decreased the
odds of suicidal ideation among women. Graphical presentations of the results in Tables 2.4 and
2.5 are depicted in Figure 2.1.
Discussion
The current study examined the associations between social network compositions and
past-year suicidal ideation among NK refugees who live in SK. This study also examined
whether these associations were similar or different by gender. Guided by social capital theory
and evidence from the literature, this study conceptualized social network compositions as
network diversity and the intersection of types and functions of social ties. We found that
network diversity was a protective factor for suicidal ideation among women only. In addition,
being connected to a help-providing or trustworthy kin tie was a protective factor for women in
our study sample. Interestingly, having a help-providing or trustworthy church-based tie was a
risk factor for men, whereas having a trustworthy church-based tie was a protective factor for
women. Findings of this study reinforce the importance of using detailed measures of social
networks and developing suicide prevention programs tailored for NK refugees while paying
attention to gender differences.
This study found that having a more diverse network protected NK refugee women from
contemplating suicide, which is consistent with previous studies that found a protective effect of
network diversity on mental illness in the general population (Erickson, 2003; Ferlander, 2007;
Lin & Erickson, 2008). It is likely that NK refugee women who had more social relationships
with people in various social contexts received more resources and support to deal effectively
with adversities in their lives. In addition, NK refugee women in our study reported having less
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 45
diverse social networks than men, which is consistent with findings of previous studies in the
general population (Erickson, 2003; Lin & Erickson, 2008) and among NK refugees living in SK
(Yeom & Kim, 2011). Lin (1999) argued that the focal point of social capital is the “investment
in social relations with expected returns” (p. 30). It is possible that women in our study gained
more from their relationships than they expected, whereas men did not, thus explaining why
social support served as a protective factor regarding suicidal ideation for women only. In fact,
these findings are in line with those of a qualitative study that found NK refugee men were more
likely to form diverse networks so that they can actively seek resources when necessary, whereas
NK refugee women generally maintained networks limited to their spouse, intimate partner, or
children; however, women’s level of life satisfaction was higher than men (Yeom & Kim, 2011).
This qualitative study had a very small sample (N = 15) of individuals who had lived in SK for 3
years, which might not be a sufficient timeframe to develop social networks. Future studies
should further investigate why diverse networks are negatively associated with suicidality among
NK refugee women, but not their male counterparts.
Results from the current study indicate that NK refugee women who had at least one
help-providing kin tie or a trustworthy kin tie were less likely to report suicidal ideation during
the previous year. This is consistent with previous studies that found family is an important
source of social support in reducing suicidal behavior among other populations (Cho & Haslam,
2010; Nock et al., 2008). A surprisingly large proportion of our study sample (40% of men, 29%
of women) did not indicate any kin ties in their significant social networks, despite living with at
least one family member. This may reflect marital or familial conflicts of NK refugee families,
as discussed in another study (Um et al., 2016). Hence, future studies might consider associations
of absence of kin ties with mental health or suicidality among NK refugees. Further investigation
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 46
is required to understand why many NK refugees in our study did not consider their family
members as significant social ties. It is possible that participants excluded some social ties in
favor of others, because the network survey used in this study only asks for the five most
important people in each participant’s network.
Findings of this study show that being connected to help-providing or trustworthy church
ties was a risk factor for suicidal ideation among men, whereas being connected to trustworthy
church ties was a protective factor among women. A post hoc analysis to test an interaction term
of gender and trustworthy church ties confirmed significant gender differences. Results from the
male sample were inconsistent with previous studies, whereas those from the female sample
were consistent with the literature (Tsai et al., 2014). These mixed findings are consistent with
previous studies that indicated social ties can have both positive and negative influences on
mental health (Abrutyn & Mueller, 2014; Rice et al., 2012; Thoits, 2011). The literature has
indicated that church-based social ties exert a positive influence on mental health because these
relationships are usually strong and unique due to the nature of shared beliefs and values, which
enhances an individual’s sense of belongingness (Krause & Wulff, 2005). In addition, previous
studies have documented that women are more likely to exchange emotional support and be
satisfied with their networks, whereas men are more likely to exchange material support in their
social networks (Fiori et al., 2006; Wellman & Wortley, 1990). Likewise, NK refugee women in
our study might have received emotional comfort through relationships with church ties who
they can trust. In contrast, NK refugee men might have become distressed about being
financially dependent on others, which contradicts cultural expectations regarding a man’s
traditional role. Moreover, according to a male NK refugee who is actively involved in churches
in SK, many SK churches set strict benchmarks so that only the most committed NK refugees
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 47
can receive stipends, such as 100% attendance rate for Sunday services and Bible study or prayer
meetings for several consecutive months, making it very stressful to meet the requirements (Y.
Choi, personal communication, August 18, 2016). He also mentioned that church-based
acquaintances frequently call NK refugees during the week to make sure they will attend church
on Sunday and remind them that full attendance is the only way to receive funding. Hence,
although church-based social ties might be trustworthy or provide instrumental support to NK
refugee men, the subtle power dynamics created in these relationships may have harmed these
men’s egos, potentially causing increased distress related to suicidal thoughts. However, gains
related to emotional support might have surpassed the stress caused by these relationships for
NK refugee women.
Our study findings echo the alarmingly high prevalence of suicidal ideation among NK
refugees in SK found in previous studies (H. J. Kim & Jung, 2015; J. Y. Kim et al., 2013). In
addition, a post hoc analysis of our dataset revealed that compared to their SK counterparts, the
rate of suicidal ideation was more than twice as high in our NK male sample (11.8% vs. 25.0%,
respectively) and more than three times as high in our NK female sample (11.0% vs. 34.4%,
respectively). Our study underscores the urgency for more research and practice related to
suicide prevention for NK refugees. In particular, suicide screening and assessment are needed in
the early stage of resettlement because our study findings indicate that the longer NK refugees
lived in SK, the more they contemplated suicide. This is in line with prior research on suicidality,
which has shown that suicide prevention efforts should start at the point of ideation (Johnson et
al., 2011) because suicidal ideation and attempts are viewed on a continuum of suicide and
among the strongest predictors of completed suicide (Nock et al., 2008).
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 48
Findings of this study have implications for public health practitioners serving vulnerable
populations. They also underscore the importance of paying particular attention to the cultural
context of social networks and gender when conducting research on suicidal behavior. Our study
findings suggest that suicide intervention and prevention programs for NK refugees can be
designed using their significant social networks. For example, programs for NK refugee women
can aim to help these women navigate various types of social ties or involve the participation of
kin ties and trustworthy church-based ties during sessions. With respect to programs for NK
refugee men, it may be important to understand their relationships with church-based ties and
address negative emotions or experiences caused by these ties. More importantly, our research
suggests that further investigation of how SK churches and their members are providing help to
and interacting with NK refugee men and the provision of culturally sensitive training to church
leaders on how to better interact with these men are necessary.
It should be noted that the current study has some limitations. First, the cross-sectional
design did not allow for causal inferences regarding the relationship between social network
compositions and suicidal ideation. NK refugee men who were more likely to contemplate
suicide might have developed more negative relationships with people at church. NK refugee
women who were less likely to consider suicide might have had more diversity in their networks
or more positive social ties in their networks. Future studies should use longitudinal data to
confirm the influence of social networks on suicidality. Second, despite the previously
mentioned efforts to reduce possible recruitment bias, the use of snowball sampling limits our
ability to generalize our findings to all NK refugees living in SK. A more systematic sampling
strategy, such as respondent-driven sampling (Heckathorn, 1997), would help to minimize
recruitment bias. Third, the nationality of each alter was sought in the social network survey;
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 49
however, the responses were invalid because respondents wrote “North Korean,” “South Korean,”
or “Korean.” A Korean alter could be from North or South Korea. Future researchers should
design this question using multiple choices rather than an open-ended format. With such
information, future studies can examine bonding and bridging ties, which are important concepts
of social capital (Lin, 1999), and their effects on suicidal ideation in this population. Last, the
decision to limit the size of respondents’ networks to five to prevent nonresponse might have
obscured our understanding of individuals who have many more ties and those who are socially
isolated.
Despite the limitations noted, the current study made significant contributions to the
literature on refugees in general and NK refugees in particular. First, this study increased our
understanding of risk and protective factors of suicidal ideation among NK refugees living in SK
and social networks compositions in this population. To our knowledge, only two previous
studies have examined suicidality in this population to date (H. J. Kim & Jung, 2015; J. Y. Kim
et al., 2013), and only a few studies have investigated suicidality among other refugees
(Vijayakumar, 2016). Future research should explore social network compositions among other
refugee populations and their effects on suicidality. Second, this study showed that using detailed
measures of social networks is necessary to identify the differential effects of social relationships
on suicidal behavior, rather than assuming that every relationship has a positive influence on
such behavior. Last, our research confirmed that considering gender differences are important
when examining risk and protective factors of suicidality. Thus, culturally adapted interventions
and prevention for suicidality among NK refugees in SK should be developed considering the
contexts of social networks and gender.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 50
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SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 56
Table 2.1. Intersection of Types and Functions of Social Ties
Type of Relationship Function of Relationship
Helpfulness Trustworthiness
Kin Kin-help Kin-trust
Friend Friend-help Friend-trust
Church Church-help Church-trust

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 57
Table 2.2. Univariable Comparison of Descriptive Statistics and Social Network Variables by Past-Year Suicidal Ideation (Stratified
by Gender)
Male (n = 132) Female (n = 273)
Yes No Yes No
% or M (SD) χ
2
or t
b
% or M (SD) χ
2
or t
b

n 33 99 94 179
Social network variables
Network diversity
a
2.18 (0.81) 2.16 (1.00) -0.11 1.91 (0.91) 2.23 (0.84) 2.90
Any kin-help tie 36.36 49.49 1.72 36.17 55.87 9.57
Any kin-trust tie 36.36 50.51 1.99 38.30 59.22 10.81
Any friend-help tie 81.82 68.69 2.12 64.89 58.66 1.01
Any friend-trust tie 75.76 72.73 0.12 68.09 65.92 0.13
Any church-help tie 27.27 9.09 6.95 11.70 22.91 5.02
Any church-trust tie 24.24 8.08 6.07 12.77 24.02 4.85
Covariates
Age 34.33 (9.82) 40.65 (11.87) 2.76 40.03 (12.07) 42.08 (13.01) 1.27
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 58
Married 63.64 73.74 1.23 65.96 70.95 0.72
Low socioeconomic status in SK 51.52 43.43 0.65 48.94 45.25 0.34
Years lived in SK 8.05 (3.62) 6.40 (3.99) -2.09 6.54 (3.33) 5.83 (3.31) -1.68
Christian 72.73 63.64 0.91 65.96 70.95 0.72
Self-esteem 27.58 (5.73) 30.63 (3.93) 3.42 27.13 (4.03) 30.15 (3.77) 6.14
Self-rated health 2.85 (1.00) 3.42 (1.12) 2.63 2.43 (0.99) 3.08 (1.13) 4.73
Note. Numbers in bold are statistically significant at p < .05.
a
Number of network types
b
Chi-square tests for percentage difference, t-tests for mean differences.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 59
Table 2.3. Multivariable Logistic Regression Analyses of Network Diversity and Past-Year
Suicidal Ideation (Stratified by Gender)
Male (n = 132) Female (n = 273)
OR 95% CI OR 95% CI
Network diversity
a
1.07 0.65, 1.74 0.62 0.44, 0.88
Age 0.93 0.89, 0.97 0.97 0.95, 0.99
Years lived in SK 1.10 0.99, 1.24 1.10 1.01, 1.20
Self-esteem 0.85 0.77, 0.95 0.81 0.75, 0.88
Self-rated health 0.58 0.38, 0.89 0.59 0.45, 0.79
Note. Numbers in bold are statistically significant at p < .05. Dependent
variable for both models is past-year suicidal ideation.
a
Number of network types.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 60
Table 2.4. Multivariable Logistic Regression Analyses of Social Network Compositions and Past-Year Suicidal Ideation (Male; n =
132)
Kin-Help Kin-Trust Friend-Help Friend-Trust Church-Help Church-Trust
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Social network ties
a
0.57 0.22, 1.45 0.56 0.22, 1.43 1.51 0.48, 4.70 1.03 0.36, 2.92 5.07 1.34, 19.23 4.84 1.23, 19.06
Age 0.93 0.89, 0.97 0.93 0.89, 0.98 0.93 0.89, 0.98 0.93 0.89, 0.97 0.93 0.88, 0.97 0.93 0.89, 0.97
Years lived in SK 1.10 0.98, 1.24 1.10 0.98, 1.24 1.10 0.98, 1.23 1.10 0.98, 1.23 1.10 0.98, 1.23 1.09 0.97, 1.23
Christian
b
-- -- -- -- -- -- -- -- 1.02 0.35, 2.95 1.08 0.37, 3.09
Self-esteem 0.85 0.77, 0.95 0.85 0.77, 0.95 0.85 0.77, 0.95 0.85 0.77, 0.95 0.84 0.75, 0.93 0.83 0.75, 0.93
Self-rated health 0.56 0.36, 0.87 0.56 0.36, 0.87 0.57 0.37, 0.88 0.58 0.38, 0.89 0.61 0.39, 0.94 0.59 0.38, 0.92
Note. Numbers in bold are statistically significant at p < .05. Dependent variable for all six models is past-year suicidal ideation.
a
Corresponding social network ties appear in columns.
b
Only controlled for models examining church-based ties.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 61
Table 2.5. Multivariable Logistic Regression Analyses of Social Network Compositions and Past-Year Suicidal Ideation (Female; n =
273)
Kin-Help Kin-Trust Friend-Help Friend-Trust Church-Help Church-Trust
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Social network ties
b
0.44 0.24, 0.80 0.47 0.26, 0.84 1.40 0.78, 2.51 1.19 0.65, 2.17 0.44 0.19, 1.01 0.43 0.19, 0.96
Age 0.97 0.95, 0.99 0.97 0.95, 0.99 0.97 0.94, 0.99 0.97 0.94, 0.99 0.97 0.94, 0.99 0.97 0.94, 0.99
Years lived in SK 1.11 1.01, 1.21 1.10 1.01, 1.20 1.09 1.00, 1.19 1.09 1.00, 1.19 1.10 1.01, 1.20 1.10 1.01, 1.20
Christian
a
-- -- -- -- -- -- -- -- 1.34 0.70, 2.55 1.37 0.72, 2.63
Self-esteem 0.81 0.74, 0.88 0.81 0.75, 0.88 0.81 0.74, 0.88 0.81 0.74, 0.88 0.81 0.74, 0.88 0.81 0.74, 0.87
Self-rated health 0.62 0.47, 0.81 0.62 0.47, 0.82 0.61 0.46, 0.80 0.61 0.46, 0.80 0.60 0.46, 0.79 0.61 0.46, 0.80
Note. Numbers in bold are statistically significant at p < .05. Dependent variable for all six models is past-year suicidal ideation.
a
Only controlled for models examining church-based ties.
b
Corresponding social network ties appear in columns.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 62
Figure 2.1. Predicted Change in Past-Year Suicidal Ideation by Specific Social Network
Composition (Stratified by Gender)
Note. Covariates for all six models included age, years lived in SK, self-esteem, and self-rated health. Religious
affiliation (Christian) was only controlled for in the church-help and church-trust models. Regression coefficients
(log odds) are depicted as circles and 95% confidence intervals are depicted as lines.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 63
Chapter 3 (Study 2): Migration-Related Stressors and Suicidal Ideation of North Korean
Refugees: Moderating Effects of Social Networks
Introduction
Refugees often experience war, trauma, violence, and other life-threatening conditions
before and during migration (Fenta, Hyman, & Noh, 2004; Ferrada-Noli, Asberg, Ormstad,
Lundin, & Sundbom, 1998; Hovey, 2000) and continue experiencing stressful events during
resettlement in a new host country (Jankovic et al., 2013; McMichael & Manderson, 2004; Um,
Chi, Kim, Palinkas, & Kim, 2015), which can jeopardize their mental health and contribute to
suicidality (Iliceto et al., 2013; Jankovic et al., 2013). However, although prior research has
found that refugees exhibit higher rates of suicidal behavior than the general population
(Jankovic et al., 2013), the effects of pre-migration trauma and post-migration discrimination on
suicidality have been understudied among refugees.
In a similar vein, the prevalence of suicidal behavior among North Korean (NK) refugees
who live in South Korea (SK) has been found to be much higher than their SK counterparts (H. J.
Kim & Jung, 2015; Um, Rice, Lee, Kim, & Palinkas, 2017). Before migration, NK refugees
typically endure traumatic experiences in NK, such as chronic famine, political oppression,
institutionalized violence, and witnessing death caused by starvation or public execution (W.
Jeon et al., 2005; Lee & Gerber, 2009). In intermediary countries such as China, many of these
individuals are easily manipulated into human trafficking and exploitation because of their illegal
status and adverse consequences of repatriation (E. Kim, Yun, Park, & Williams, 2009; Ko,
Chung, & Oh, 2004). Previous studies with other populations have found that the number of
traumatic events experienced is significantly associated with subsequent suicidal ideation
(Ferrada-Noli et al., 1998; Jankovic et al., 2013; Krysinska & Lester, 2010; O’Neill et al., 2014)
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 64
and indicated that exposure to trauma has a stronger negative influence on suicidality than
genetic markers, such as serotonin transporter promoter polymorphism (Roy, Hu, Janal, &
Goldman, 2007). Further, following resettlement in SK, NK refugees continue facing multiple
hardships, such as acculturative stress, discrimination by SKs, and social exclusion (J. U. Kim &
Jang, 2007; Um et al., 2015). Perceived discrimination in particular has been associated with
increased risk of suicidal ideation among ethnic minorities (Cheng et al., 2010; Gomez, Miranda,
& Polanco, 2011). Although NK refugees share the same ethnicity as SKs, discrimination by
SKs has been reported to be a serious problem that hinders overall adaptation to the homogenous
host society (B. H. Jeon et al., 2009; J. U. Kim & Jang, 2007) and negatively affects mental
health (Um et al., 2015). However, no study to date has examined the associations among pre-
migration trauma, post-migration discrimination, and suicidal ideation among NK refugees.
Social networks of migrants are significant sources of social capital that facilitate their
adaptation to the new host society by providing information, support, companionship, and
material aid (Jasinskaja-Lahti, Liebkind, Jaakkola, & Reuter, 2006; McMichael & Manderson,
2004; Ryan, Sales, Tilki, & Siara, 2008). As a result of forced migration, however, many
refugees are separated from their families and other significant social networks, which might
increase their vulnerability to suicidality (Fenta et al., 2004; Hovey, 2000). Establishing new
social networks after resettlement can be challenging but important for refugees to gain access to
various resources during times of need (McMichael & Manderson, 2004).
In addition, support from social networks can buffer the harmful impacts of pre-migration
and post-migration stressors on refugees’ mental health (Fenta et al., 2004). The caring,
understanding, and sympathetic presence of important social ties can reduce the impact of stress
appraisal by providing aid directly related to the stressor, helping the refugee view an adverse
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 65
situation differently and sustaining the refugee’s sense of self-worth (Cohen & Wills, 1985;
Thoits, 2011). However, previous studies have generally relied on the use of aggregated
measures of social support (Smith & Christakis, 2008), rather than identifying specific
individuals in a network who provide various kinds of support that have stress-buffering effects.
Empirical evidence of how specific social networks moderate the association between migration-
related stressors and suicidal ideation is lacking among refugees in general and NK refugees in
particular. Because some social relationships can provide not only support but also have negative
influences on mental health and behavior, having such social ties can amplify the deleterious
consequences of stressors on suicidal ideation among refugees. For example, if a social tie’s
advice or help is regarded as inappropriate, a refugee has to ask for help from social ties who are
already aware of the stressful event, or a refugee is seen as responsible for his or her problem, the
presence of these social ties can exacerbate the stress on mental health (Thoits, 2011). In addition,
when tangible aid is received but cannot be reciprocated in a social relationship, the refugee can
feel indebted or incompetent to the social tie (Gee et al., 2006; Kuramoto, Wilcox, & Latkin,
2013; Thoits, 2011). Moreover, when a refugee who is most in need of support mostly acts as a
support provider in the relationship, more distress than benefits can be generated (Kawachi &
Berkman, 2001). Thus, a detailed examination of to whom an individual is connected is
important to better inform effective social network interventions for suicide. To date, no study
has examined the moderating effects of social network compositions on the associations between
migration-related stressors and suicidality among NK refugees.
Current Study
Guided by the stress-buffering hypothesis (Cohen & Wills, 1985), the current study tested
the moderating effects of social network compositions on the relationships among pre-migration
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 66
trauma, post-migration discrimination, and past-year suicidal ideation for NK refugees living in
SK. Social network compositions in this study were defined as network diversity (number of
different types of social ties) and the intersection of types and functions of social ties. Previous
studies have found direct effects of having diversified networks and support from church-based
ties on mental health (Erickson, 2003; Tsai, Lucas, Sania, Kim, & Kawachi, 2014). Particularly,
an earlier study found that having a diverse network and being connected to a trustworthy
church-based tie were protective factors for suicidal ideation among NK refugee women,
whereas having a help-providing church tie or a trustworthy church tie was a risk factor for NK
refugee men (Um et al., 2017). Because churches in SK play a pivotal role in providing
instrumental assistance to NK refugees (Bell, 2013), investigating whether church-based social
ties can mitigate or amplify the association between migration-related stressors (i.e., trauma and
discrimination) and suicidal ideation is important. However, little is known about the moderating
effects of these social network compositions on suicidality. Thus, the current study specifically
focused on the moderating roles of network diversity, help-providing church ties, and
trustworthy church ties.
Because the literature has consistently found marked gender differences in suicidal
behavior (Van Orden et al., 2010), styles of coping with stress (Cohen & Wills, 1985), social
network involvement (Kawachi & Berkman, 2001), and effects of social ties on suicidality
(Bearman & Moody, 2004),

the current study used gender-stratified models. The current study
tested three research questions: (a) How are pre-migration trauma and post-migration
discrimination associated with suicidal ideation among NK refugees in SK? (b) Do social
network compositions (network diversity and church-based ties) moderate the association
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 67
between these migration-related stressors and suicidal ideation? (c) Are these effects similar or
different in men and women?
Methods
Study Participants
From April to May 2014, a sample of NK refugees living in SK and aged 19 or older was
recruited by snowball sampling, whereby trained recruiters initially reached out to some
participants (i.e., seeds) who in turn introduced other participants to the researchers. To reduce
the initial seeds’ potential influence on the final composition of the study sample (i.e.,
recruitment bias), the number of participants whom seeds could recruit was limited to four,
resulting in long chains of recruitment

(H. J. Kim & Jung, 2015). Participants recruited by this
procedure were living in various districts across three metropolises and provinces in SK (Seoul,
Gyeonggi province, and Incheon), where more than half of all NK refugees reportedly reside
(Ministry of Unification, 2016). A trained researcher and interviewer visited each household.
Surveys were self-administered after obtaining informed consent. Each participant received
20,000 Korean won (approximately $20) as compensation for their participation. Among 407
participants who were interviewed, two participants with incomplete data were removed,
generating a sample of 405 participants. The institutional review board at Korea University
approved all survey items and procedures.
Measures
Dependent variable. Suicidal ideation was assessed by a 5-item suicidal ideation scale
(Harlow, Newcomb, & Bentler, 1986). Participants were asked how often during the previous
year they had suicidal thoughts and attempted suicide, with response options ranging on a 5-
point Likert scale from 0 (almost never) to 4 (almost always). Items were “I have thought about
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 68
suicide,” “I have recently wanted to die,” “I have told someone that I wanted to commit suicide,”
“I have thought that my life will end by committing suicide,” and “I have attempted to commit
suicide.” (Cronbach’s alpha = .93). A total score was calculated by summing the five items. In
the current study, a dichotomous variable was created to indicate at least one experience of
suicidal ideation during the previous year, considering the distributional nature of suicidal
ideation measures (i.e., showing positive skewness and signs of excessive zeros), a common
observation in the relevant literature (Johnson, Wood, Gooding, Taylor, & Tarrier, 2011).
Independent variables. Pre-migration traumatic events were assessed using a trauma
checklist developed for NK refugees (Y. H. Kim, Jeon, & Cho, 2010). Traumatic events included
life-threatening experiences due to starvation, severe illness, or cold weather; being shot or
severely beaten; political punishment such as imprisonment or torture; witnessing death by
public execution or starvation; unwanted separation from family due to food searching or other
reasons; sexual violence; and natural disasters. Eighteen identical items related to traumatic
events were asked regarding experiences in NK and China or other intermediary countries. One
additional item (“Were you repatriated or almost repatriated to North Korea?”) was asked only
with regard to experiences in China or other intermediary countries. Response options for all 39
items were yes or no. These items were summed to create a total score, with higher scores
indicating more experiences of pre-migration trauma (Cronbach’s alpha = .85).
Post-migration perceived discrimination was measured by the Everyday Discrimination
Scale, which captures chronic, routine, and generally minor experiences of unfair treatment
(Williams, Yu, Jackson, & Anderson, 1997). Measures of routine discrimination have been
found to be more predictive of health outcomes than those of acute discrimination (Gee et al.,
2006). The original scale consists of nine items, but 10 items were used to collect these data. One
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 69
item (“You are treated with less respect than other people are”) that appeared to somewhat
overlap with another item (“You are treated with less courtesy than other people are”) was
excluded. Two items (i.e., “People exclude you from social activities at your school or work
place” and “People make fun of my accent/dialect”) were added to better reflect discriminatory
experiences of NK refugees in SK. Participants were asked how often they had experienced these
10 items in their everyday lives in SK on a 5-point Likert scale ranging from 1 (almost never) to
5 (almost always). A total score was calculated by summing the items, with higher scores
indicating more frequent experiences of perceived discrimination in SK (Cronbach’s alpha = .91).
Moderating variables. Social networks were measured using each respondent’s
egocentric (personal) network data, which were collected via a technique used in previous
studies (Burt, 1984; Rice, Kurzban, & Ray, 2012; Rice, Milburn, & Monro, 2011). As part of the
self-administered survey, participants were asked, “We would like to understand your social
relationships with the most important people to you. Please name 5 people who you have stayed
in contact with and have significantly influenced you the most during the past 6 months. These
people can include family, friends, coworkers, teachers, doctors, and so on.” Participants were
then asked about the following information for each network member, or alter: type of
relationship (spouse, parent, sibling, children, other family, coworker, friend, neighbor, church
acquaintance, and other), gender, age, length of relationship (years), nationality, and the function
of relationship (degree of emotional closeness, degree of trustworthiness, and degree of
helpfulness during hardship) using a 5-point Likert scale ranging from 1 (not at all) to 5
(extremely).
In the current study, social network compositions were operationalized as network
diversity and the intersection of types and functions of social ties. Network diversity was defined
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 70
as the total number of different types of ties. Regarding the intersection of types and functions of
social ties, we used church-based ties for type and help-providing and trustworthy ties for
functions. Hence, two variables, help-providing church ties and trustworthy church ties, were
created by intersecting church-based ties with these two functional characteristics (helpfulness
and trustworthiness) and dichotomizing each variable to indicate the presence of at least one tie
(coded as 1) or the absence of a tie (coded as 0). A tie’s function as helpful or trustworthy was
determined by responses of 4 (very) or 5 (extremely) to the corresponding questions.
Covariates. Sociodemographic characteristics of age (years), married (1 = married or
cohabiting, 0 = separated or single), years since leaving NK (created by summing years fleeing
in China and other intermediary countries and years lived in SK), religious affiliation (1 =
Christian, 0 = not Christian; 85% of Christians in our study reported attending church at least 3
or 4 times a month), and perceived low socioeconomic status in SK (1 = low, 0 = low to middle,
middle, middle to high, or high) were included as covariates. Self-esteem has been found to be
associated with suicidal ideation in previous studies (Bearman & Moody, 2004; Johnson et al.,
2011). The Rosenberg Self-Esteem Scale (Rosenberg, 1965) was used to measure global self-
esteem. Ten items were asked using a 4-point Likert scale ranging from 1 (strongly disagree) to
4 (strongly agree). Negatively worded items were reverse scored. A total score was calculated by
summing the items, with higher scores indicating higher self-esteem (Cronbach’s alpha = .80).
Self-rated health is also known to be associated with suicidal ideation (Van Orden et al., 2010).
Participants’ self-rated health status was measured by one item with a 5-point scale: “Compared
to your past (e.g., in North Korea or during migration), how would you rate your health?”
Response options were 1 (very poor), 2 (poor), 3 (similar), 4 (good), and 5 (very good).
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 71
Statistical Analyses
As previously noted, this study used gender-stratified models to identify potentially
different patterns of the moderating effects of social network compositions on the association
between migration-related stressors and suicidality in men and women. Chi-square tests and
independent-group t-tests were performed to compare descriptive statistics and social network
variables by past-year suicidal ideation in men and women. Based on the methodology suggested
by Hosmer, Lemeshow, and Sturdivant (2013), covariates associated with suicidal ideation at p
< .25 in either men or women were included in the subsequent multivariable models to avoid
numerically unstable estimates and large standard errors. The only exception was applied to
religious affiliation when the independent variable included a church-based tie, because it is
important to control for this variable in this case.
Multivariable logistic regression analyses were divided into two parts: analyses
examining (a) the moderating effect of network diversity on suicidal ideation and (b) the
moderating effects of help-providing and trustworthy church ties on suicidal ideation. All
continuous variables were mean-centered. To test the moderating effect of social networks, each
analysis started with the main-effects model before examining one interaction term of the social
network variable and one independent variable at a time. If both interaction terms were
significant at p < .05, the subsequent model would include two interaction terms; however, this
was not the case in our study. Likelihood ratio tests were conducted to compare whether the fit of
the model with an interaction term was significantly improved compared to the model without an
interaction term. Each multivariable logistic regression model was performed with only one
social network variable to avoid multicollinearity issues, resulting in nine separate models for
men and women each. All analyses for this study were performed using Stata 12.0.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 72
Results
Male respondents were 39.1 years old (range = 19–68) and female respondents were 41.4
years old (range = 19–69) on average. More than half of participants were married or cohabiting
with a partner (71.2% of men, 69.2% of women) and were Christian (65.9% of men, 69.2% of
women). Average time since leaving NK was 8.7 years (range = 1.3–19.8) for men and 8.6 years
(range = 0.8–24.3) for women in our sample. Almost half of participants perceived themselves to
have the lowest socioeconomic status in SK (45.5% of men, 46.5% of women). Men rated their
current health status to be between similar and better (M = 3.3, SD = 1.1), which was
significantly better than how women rated their health to be between similar and worse (M = 2.9,
SD = 1.1) on average, compared to when they lived in NK or were fleeing to other countries. In
this sample, 25.0% of men and 34.4% of women reported contemplating suicide during the
previous year, which was different at a trending level ( χ
2
[1] = 3.68, p = .06).
Men reported to had experienced significantly more types of pre-migration traumatic
events (M = 8.8 types, SD = 5.97) than women (M = 7.2 types, SD = 5.10). The mean scores for
post-migration discrimination was 16.0 (SD = 7.0) for men and 15.9 (SD = 6.0) for women.
Regarding social networks, both men and women had approximately two types of social ties on
average in their networks, ranging from one to five types for men and from one to four for
women. In this sample, 13.6% of men and 19.1% of women had at least one help-providing
church tie in their networks. Men had significantly less trustworthy church ties (12.1%) than
women (20.2%).
Descriptive statistics and other study variables were compared by suicidal ideation in
men and women (Table 3.1). Higher levels of post-migration discrimination (t[130] = -4.22, p
< .001), having a help-providing church tie ( χ
2
[1] = 6.95, p < .01), and having a trustworthy
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 73
church tie ( χ
2
[1] = 6.07, p < .05) were positively associated with suicidal ideation among men.
Younger age (t[130] = 2.76, p < .01), longer years since leaving NK (t[130] = -2.13, p < .05) and
lower levels of self-esteem (t[130] = 3.42, p < .001) and self-rated health (t[130] = 2.63, p < .001)
were positively associated with suicidal ideation among men. Higher levels of pre-migration
trauma (t[271] = -5.64, p < .001) and post-migration discrimination (t[271] = -6.29, p < .001 )
were positively associated with suicidal ideation and higher levels of network diversity (t[271] =
2.90, p < .01), having a help-providing church tie ( χ
2
[1] = 5.02, p < .05), and having a
trustworthy church tie ( χ
2
[1] = 4.85, p < .05) were inversely associated with suicidal ideation
among women. Lower levels of self-esteem (t[271] = 6.14, p < .001) and self-rated health (t[271]
= 4.73, p < .001) were positively associated with suicidal ideation among women.
Table 3.2 presents the results of multivariable logistic regression models testing the
moderating effect of network diversity on the associations between pre-migration trauma and
post-migration discrimination and suicidal ideation. Model 1 shows the main-effects model of all
study variables on past-year suicidal ideation. Model 2 includes the interaction term of network
diversity and pre-migration trauma, whereas Model 3 includes the interaction term of network
diversity and post-migration discrimination in men and women. Experiencing post-migration
discrimination (odds ratio [OR] = 1.09; 95% confidence interval [CI] = 1.02, 1.17) increased the
odds of past-year suicidal ideation for men. Network diversity of men did not moderate the
associations between trauma and discrimination on suicidal ideation. Experiences of pre-
migration trauma (OR = 1.12; 95% CI = 1.05, 1.20) and post-migration discrimination (OR =
1.09; 95% CI = 1.03, 1.15) were significantly associated with increased odds of past-year
suicidal ideation for women. Network diversity among women significantly moderated the
association between discrimination and suicidal ideation (OR = 0.91; 95% CI = 0.85, 0.97). This
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 74
association is graphically depicted in Figure 3.1, which shows that as network diversity among
women increased, the positive association between post-migration discrimination and suicidal
ideation became a negative association.
Results of the multivariable logistic regression models testing the moderating effects of
help-providing and trustworthy church ties on the associations between pre-migration trauma and
post-migration discrimination and suicidal ideation are presented in Table 3.3 for men and Table
3.4 for women. With respect to help-providing church tie models, post-migration discrimination
(OR = 1.11; 95% CI = 1.03, 1.20) and having at least one help-providing church tie (OR = 8.72;
95% CI = 2.07, 36.74) were positively associated with suicidal ideation among male respondents.
However, help-providing church ties did not moderate the associations between trauma and
discrimination on suicidal ideation for men. In the trustworthy church tie models, post-migration
discrimination (OR = 1.10; 95% CI = 1.03, 1.19) and having at least one trustworthy church tie
(OR = 7.29; 95% CI = 1.72, 30.88) were positively associated with suicidal ideation among men.
Although trustworthy church ties moderated the association between discrimination and suicidal
ideation for men at a trending level (OR = 1.53; 95% CI = 0.94, 2.48; p = .08), results of a
likelihood ratio test indicated that this model (Model 3 in Table 3) fit the data significantly better
than the main-effects model (Model 1 in Table 3). Table 4 shows that post-migration
discrimination was positively associated with suicidal ideation among female respondents in the
help-providing church tie (OR = 1.10; 95% CI = 1.04, 1.16) and trustworthy church tie (OR =
1.09; 95% CI = 1.03, 1.15) models. No significant moderating effect of help-providing or
trustworthy church ties was found for women.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 75
Discussion
The current study tested the moderating effects of social network compositions on the
associations between migration-related stressors and suicidality among NK refugees living in SK.
This study also examined whether these effects differed by gender. We found that pre-migration
trauma was a risk factor for suicidal ideation only among women, whereas post-migration
discrimination was a risk factor for both men and women. In addition, this study found that
network diversity moderated the relationship between post-migration discrimination and suicidal
ideation among NK refugee women only. Our study findings provide empirical evidence that
partially supports the stress-buffering hypothesis and highlights gender differences in the
suicidality and social network literature. This study extended previous literature by using social
network compositions rather than a global scale of social support.
Consistent with previous studies (Ferrada-Noli et al., 1998; Jankovic et al., 2013;
Krysinska & Lester, 2010; O’Neill et al., 2014), this study found that experiencing more pre-
migration trauma was associated with increased risk of suicidal thoughts. Although NK refugee
men in our study reported experiencing significantly more traumatic events than women, this
association was found only for NK refugee women. Some studies have noted that the effects of
trauma on suicidal behavior might vary depending on whether the trauma was a time-limited and
solitary event or a chronic or repeated experience and whether it was an individually focused
trauma or collective trauma (Krysinska & Lester, 2010; Stein et al., 2010). Hence, it is possible
that NK refugee men in our study might have experienced time-limited, singular events of
collective trauma before arriving at SK, whereas women might have experienced chronic
individual trauma, such as sexual abuse, that made the deleterious consequences of trauma
persist for a prolonged period and affect suicidal thoughts after resettlement. Future studies can
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 76
shed light on this issue by examining the intensity, length, and types of traumatic events that are
linked to suicidal behavior.
Perceived discrimination after resettlement in SK was found to harmfully affect suicidal
ideation among both men and women. This is consistent with previous studies with other ethnic
minorities (Cheng et al., 2010; Gomez et al., 2011). Because previous studies have indicated that
discriminatory and prejudicial attitudes toward NK refugees are widespread in SK (J. U. Kim &
Jang, 2007; Um et al., 2015), findings of this study indicate the need to create multicultural
educational programs and campaigns in schools, workplaces, and broader SK society to ensure
diversity and cultural differences are respected. Moreover, practitioners who work with NK
refugees should strive to identify perceptions of unfair treatment and help these individuals cope
with such issues.
We found that network diversity among women moderated the relationship between post-
migration discrimination and suicidal ideation, which supports the stress-buffering hypothesis
(Cohen & Wills, 1985). NK refugee women with more diverse networks were less likely to be
negatively affected by the detrimental consequences of discrimination on suicidality. In
particular, network diversity appeared to protect or prevent the stress reaction of discrimination
among women with three or four types of social networks. It is possible that this moderating
effect was not found among men because NK refugee men might be connected to diverse types
of networks but cannot mobilize effective support or resources in these networks when they
experience stressful events. As the literature has noted, men who maintain traditional gender
roles tend to withhold information about their hardships from their social ties (Thoits, 2011),
which could be the case for NK refugee men in our study. Suicide prevention and intervention
programs for NK refugees can emphasize the importance of participating in diverse types of
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 77
social settings and building relationships with diverse people, especially for women. It might
also be beneficial if governmental and nongovernmental officials and volunteers who interact
with NK refugees try to maintain relationships with and actively keep in contact with these
refugees.
The current study did not find significant moderating effects of any church-based ties on
the association between migration-related stressors and suicidal ideation. However, a trend
toward significance was found in the moderating effect of trustworthy church ties on the
relationship between discrimination and suicidal ideation among men. Although such effect was
not statistically significant, this might indicate that the presence of trustworthy church ties
exacerbates the stress appraisal response of discriminatory treatment to some extent. As noted in
a previous study (Um et al., 2017), how people in SK churches provide financial aid to NK
refugees might generate feelings of indebtedness and dependence among NK refugee men,
which might negate intended support from trustworthy church ties. In-depth investigation of the
relationships and interactions between people in churches and NK refugee men is required to
explicate the underlying reason for this finding. This finding underscores the importance of
employing detailed measures of social networks rather than merely aggregating social support.
Our findings should be interpreted in the context of some limitations. First, our use of
cross-sectional data did not allow inferences regarding causality between migration-related
stressors and suicidal ideation. NK refugees who are at higher risk of suicidality might have
perceived more unfair treatment on a daily basis. Future research should seek to identify the
causal relationship between these stressors and suicidal ideation using longitudinal data. Second,
the use of snowball sampling prevents generalization of study findings to all NK refugees who
live in SK. We encourage future researchers to use a more systematic sampling method, such as
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 78
respondent-driven sampling (Heckathorn, 1997), to minimize recruitment bias. Third, our data
did not include valid information on the nationalities of alters, which could have increased our
understanding of whether SK or NK social ties moderated the association between post-
migration discrimination and suicidal ideation. The nationality of each alter was sought in the
social network survey; however, respondents wrote “North Korean,” “South Korean,” or
“Korean.” Thus, responses were considered invalid because a Korean alter could be originally
from North or South Korea. We recommend that future researchers ask this question using
multiple choices, not an open-ended format. Last, our measure of pre-migration trauma did not
account for the frequency or intensity of each traumatic event. As previously mentioned, this
information might better explain the effects of pre-migration trauma on suicidal ideation among
NK refugees.
Our findings represent an important contribution to the literature. First, our research
underscores the importance of examining stressful events experienced by refugees before and
after migration. The current study suggests that the detrimental consequences of pre-migration
trauma can persist until several years of resettlement and lead to suicidal behavior. Second, this
study bolsters the hypothesis that social ties can buffer or exacerbate the appraisal of migration-
related stressors on suicidality. More importantly, we generated findings not apparent at the
aggregate level by using detailed measures of social network compositions rather than an overall
scale of social support. Furthermore, our research suggests that intervention and prevention
efforts involving social networks designed to reduce suicidal behavior among NK refugees are
urgently needed.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 79
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SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 85
Table 3.1. Univariable Comparison of Descriptive Statistics and Study Variables by Past-Year Suicidal Ideation and Gender
Male (n = 132) Female (n = 273)
Yes No Yes No
% or M (SD) χ
2
or t
a
% or M (SD) χ
2
or t
a

n 33 99 94 179
Migration-related stressors
Pre-migration trauma 9.58 (5.92) 8.48 (5.99) -0.91 9.48 (6.00) 6.01 (4.09) -5.64
Post-migration discrimination 20.24 (9.18) 14.65 (5.48) -4.22 18.88 (7.02) 14.37 (4.75) -6.29
Social network variables
Network diversity 2.18 (0.81) 2.16 (1.00) -0.11 1.91 (0.91) 2.23 (0.84) 2.90
Any church-help tie 27.27 9.09 6.95 11.70 22.91 5.02
Any church-trust tie 24.24 8.08 6.07 12.77 24.02 4.85
Covariates
Age 34.33 (9.82) 40.65 (11.87) 2.76 40.03 (12.07) 42.08 (13.01) 1.27
Married 63.64 73.74 1.23 65.96 70.95 0.72
Years since leaving NK 10.31 (4.98) 8.14 (5.09) -2.13 9.40 (4.97) 8.19 (4.88) -1.93
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 86
Christian 72.73 63.64 0.91 65.96 70.95 0.72
Low socioeconomic status in SK 51.52 43.43 0.65 48.94 45.25 0.34
Self-esteem 27.58 (5.73) 30.63 (3.93) 3.42 27.13 (4.03) 30.15 (3.77) 6.14
Self-rated health 2.85 (1.00) 3.42 (1.12) 2.63 2.43 (0.99) 3.08 (1.13) 4.73
Note. Numbers in bold are statistically significant at p < .05. NK, North Korea; SK, South Korea.
a
Chi-square test for percentage difference, t-test for mean differences.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 87
Table 3.2. Multivariable Logistic Regression of Moderating Effect of Network Diversity on Migration-Related Stressors and Past-
Year Suicidal Ideation by Gender
Male (n = 132) Female (n = 273)
Model 1 Model 2 Model 3 Model 1 Model 2 Model 3
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Pre-migration trauma 1.02 0.94, 1.10 1.03 0.94, 1.13 1.02 0.94, 1.10 1.12 1.05, 1.20 1.12 1.04, 1.20 1.13 1.05, 1.21
Post-migration discrimination 1.09 1.02, 1.17 1.09 1.01, 1.17 1.09 1.02, 1.17 1.09 1.03, 1.15 1.09 1.03, 1.15 1.07 1.01, 1.14
Network diversity

1.11 0.66, 1.87 1.15 0.67, 2.00 1.10 0.65, 1.87 0.69 0.48, 0.99 0.70 0.49, 1.01 0.74 0.51, 1.07
Age 0.92 0.87, 0.97 0.92 0.87, 0.97 0.92 0.87, 0.97 0.95 0.92, 0.98 0.95 0.93, 0.98 0.94 0.92, 0.97
Years since leaving NK 1.07 0.98, 1.18 1.07 0.98, 1.18 1.07 0.98, 1.18 1.07 1.01, 1.13 1.07 1.01, 1.14 1.07 1.01, 1.14
Self-esteem 0.89 0.79, 0.99 0.89 0.79, 0.99 0.89 0.79, 0.99 0.86 0.79, 0.94 0.86 0.79, 0.94 0.84 0.77, 0.92
Self-rated health 0.62 0.39, 0.97 0.61 0.38, 0.97 0.62 0.39, 0.97 0.60 0.44, 0.80 0.59 0.44, 0.80 0.58 0.43, 0.78
Trauma × network diversity 0.98 0.91, 1.06 0.98 0.90, 1.06
Discrimination × network diversity 1.01 0.93, 1.09 0.91 0.85, 0.97
Likelihood ratio test
a
0.26 0.02 0.32 8.32
Note. Numbers in bold are statistically significant at p < .05. Dependent variable for all six models is suicidal ideation. Model 1 is the main-effects model.
Models 2 and 3 include interaction terms. NK, North Korea.
a
Model 1 is the reference model; chi-square test (df = 1).

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 88
Table 3.3. Multivariable Logistic Regression Analyses of Moderating Effects of Social Network Ties on Migration-Related Stressors
and Past-Year Suicidal Ideation among Men (n = 132)
Help-Providing Church Ties Trustworthy Church Ties
Model 1 Model 2 Model 3 Model 1 Model 2 Model 3
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Pre-migration trauma 1.03 0.95, 1.12 1.03 0.95, 1.12 1.04 0.96, 1.13 1.03 0.95, 1.12 1.03 0.95, 1.12 1.04 0.96, 1.12
Post-migration discrimination 1.11 1.03, 1.20 1.11 1.03, 1.20 1.10 1.01, 1.18 1.10 1.03, 1.19 1.10 1.03, 1.19 1.08 1.01, 1.17
Network ties 8.72 2.07,36.74 8.43 1.96,36.18 15.12 2.31,98.78 7.29 1.72,30.88 7.19 1.66,31.03 24.41 1.66,31.03
Age 0.91 0.87, 0.97 0.92 0.87, 0.96 0.91 0.86, 0.96 0.92 0.87, 0.97 0.92 0.87, 0.97 0.91 0.86, 0.97
Years since leaving NK 1.09 0.98, 1.20 1.09 0.98, 1.20 1.08 0.97, 1.19 1.07 0.97, 1.18 1.07 0.97, 1.18 1.05 0.95, 1.16
Christian 0.92 0.29, 2.97 0.93 0.29, 2.97 0.92 0.29, 2.93 1.04 0.33, 3.25 1.03 0.33, 3.25 1.03 0.33, 3.25
Self-esteem 0.86 0.77, 0.97 0.86 0.77, 0.97 0.85 0.76, 0.96 0.86 0.76, 0.96 0.86 0.76, 0.97 0.83 0.73, 0.94
Self-rated health 0.65 0.40, 1.07 0.65 0.40, 1.07 0.66 0.40, 1.09 0.63 0.39, 1.01 0.63 0.39, 1.02 0.61 0.37, 1.01
Trauma × network ties 1.03 0.80, 1.34 1.01 0.78, 1.32
Discrimination × network ties 1.24 0.87, 1.77 1.53 0.94, 2.48
Likelihood ratio test
a
0.07 1.73 0.01 4.07
Note. Numbers in bold are statistically significant at p < .05. Dependent variable for all six models is suicidal ideation. Model 1 is the main-effects model.
Models 2 and 3 include interaction terms. NK, North Korea. Corresponding types of social network ties appear in columns.
a
Model 1 is the reference model; chi-square test (df = 1).

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 89
Table 3.4. Multivariable Logistic Regression Analyses of Moderating Effects of Social Network Ties on Migration-Related Stressors
and Past-Year Suicidal Ideation among Women (n = 273)
Help-Providing Church Ties Trustworthy Church Ties
Model 1 Model 2 Model 3 Model 1 Model 2 Model 3
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Pre-migration trauma 1.13 1.06, 1.21 1.13 1.05, 1.21 1.13 1.05, 1.21 1.13 1.06, 1.21 1.14 1.06, 1.23 1.13 1.06, 1.21
Post-migration discrimination 1.10 1.04, 1.16 1.10 1.04, 1.16 1.10 1.04, 1.17 1.09 1.03, 1.15 1.09 1.03, 1.15 1.10 1.03, 1.16
Network ties 0.42 0.17, 1.05 0.42 0.16, 1.07 0.43 0.17, 1.05 0.42 0.17, 1.01 0.42 0.17, 1.01 0.42 0.17, 1.01
Age 0.95 0.92, 0.98 0.95 0.92, 0.98 0.95 0.92, 0.98 0.95 0.92, 0.98 0.95 0.92, 0.98 0.95 0.92, 0.98
Years since leaving NK 1.06 1.00, 1.13 1.06 1.00, 1.13 1.06 1.00, 1.13 1.06 1.01, 1.13 1.07 1.01, 1.14 1.06 1.01, 1.13
Christian 1.28 0.64, 2.56 1.28 0.64, 2.56 1.29 0.64, 2.58 1.31 0.65, 2.62 1.30 0.65, 2.62 1.31 0.65, 2.63
Self-esteem 0.86 0.79, 0.94 0.86 0.79, 0.94 0.86 0.79, 0.94 0.86 0.79, 0.94 0.86 0.78, 0.94 0.86 0.78, 0.94
Self-rated health 0.59 0.44, 0.80 0.59 0.44, 0.80 0.59 0.44, 0.80 0.60 0.45, 0.81 0.60 0.44, 0.81 0.60 0.44, 0.81
Trauma × network ties 1.02 0.84, 1.22 0.95 0.81, 1.12
Discrimination × network ties 0.98 0.83, 1.15 0.98 0.84, 1.14
Likelihood ratio test
a
0.03 0.08 0.32 0.06
Note. Numbers in bold are statistically significant at p < .05. Dependent variable for all six models is suicidal ideation. Model 1 is the main-effects
model. Models 2 and 3 include interaction terms. NK, North Korea. Corresponding types of social network ties appear in columns.
a
Model 1 is the reference model; chi-square test (df = 1).
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 90
Figure 3.1. Moderating Effect of Network Diversity on the Association between Post-Migration
Discrimination and Past-Year Suicidal Ideation among Women (n = 273)
Note. Controlled for age, years since leaving North Korea, self-esteem, self-rated health, and pre-migration trauma.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 91
Chapter 4 (Study 3): Testing the Pathway from Pre-Migration Sexual Violence to
Suicidality among North Korean Refugee Women Living in South Korea: Do Social
Networks Matter?
Introduction
The World Health Organization (WHO; 2013) reported that 7.2% of women worldwide
have been sexually abused by a person other than a partner and that those who experience sexual
violence are 2.6 times more likely to exhibit poorer mental health. Sexual abuse is also known to
cause multiple negative mental health outcomes that persist for prolonged periods among women
(Campbell, Dworkin, & Cabral, 2009). Previous large-scale, multicounty studies have found that
among all types of trauma, experiences of sexual violence consistently have the strongest
deleterious effects on suicidal behavior (Devries et al., 2011; Stein et al., 2010). Refugee women
are particularly vulnerable to sexual violence due to the insecure circumstances in their home
countries and during their flight to asylum countries (Hynes & Cardozo, 2000). In fact, a
systematic review indicated that 21.4% of refugee women and internally displaced women in
humanitarian settings across 14 countries experienced sexual violence by a partner or non-
partner (Vu et al., 2014). Although sexual violence and suicidal behaviors are considered
substantial public health burdens among women (Devries et al., 2011), to date, empirical
evidence of the effects of sexual violence on suicidal ideation among refugee women is lacking.
In case of North Korea (NK), governmental officials often abuse their political power to
force NK women into sexual exploitation (Lee & Gerber, 2009; Park, 2012). While in
intermediary countries during migration, majority of NK refugee women are forced into
unwanted marriages with Chinese men, prostitution or sexual slavery, and other forms of sexual
violence (Davis, 2006; E. Kim, Yun, Park, & Williams, 2009). Although the Ministry of Gender
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 92
Equality and Family (2012) reported that the prevalence of past-year suicidal ideation or
attempts among NK refugee women in South Korea (SK) who experienced sexual violence was
52.6% in 2012, almost 15 times higher than the rate among SK women in the same year, the
mental health outcomes among these female victims have rarely received empirical attention (J.
Y. Kim, Kim, Choi, & Nam, 2017).
Victims of sexual abuse commonly engage in avoidance coping, such as social
withdrawal, to avoid distressful thoughts and reduce feelings about the trauma (Ullman,
Townsend, Filipas, & Starzynski, 2007). Hence, prior research has found that most women who
experience sexual violence demonstrate difficulty in trusting others and forming and maintaining
interpersonal relationships (Campbell et al., 2009; Jankovic et al., 2013; Tankink & Richters,
2007). As a result, these women are more likely to have a limited number of social contacts and
impaired quality of support from their social ties, including family members, and are less likely
to be married and have frequent contact with friends or family (Golding, Wilsnack, & Cooper,
2002; Katerndahl, Burge, Ferrer, Becho, & Wood, 2013; Levendosky et al, 2004; Savage &
Russell, 2005). Withdrawal from the most intimate social ties such as family may also be a result
of negative reactions (e.g., blaming the victim) from these networks following the disclosure of
sexual violence victimization (Ahrens & Aldana, 2012; Coker et al., 2004; Savage & Russell,
2005). In a similar vein, for refugee women in particular, the stigma associated with sexual abuse
is so strong that they tend to isolate themselves from their family and community groups (Hynes
& Cardozo, 2000; Tankink & Richters, 2007). However, examination of the specific social
networks of these women following their experiences of sexual violence has not been
sufficiently addressed in empirical studies (Ullman et al., 2007). That is, rather than identifying
with whom victims are connected to or isolated from, previous studies generally examined global
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 93
measures of perceived social support among victims (Golding et al., 2002; Levendosky et al,
2004; Savage & Russell, 2005).
Although an avoidance coping strategy can be adaptive in the short term, engaging in this
strategy for a prolonged period has been found to predict poorer mental health outcomes for
sexual violence victims (Ullman et al., 2007). Likewise, deleterious mental health symptoms
were reported to be significantly elevated when victims lacked support from significant social
ties as a result of avoidance coping (Beeble, Bybee, Sullivan, & Adams, 2009; Scarpa, Haden, &
Hurley, 2006; Ullman et al., 2007). Hence, it is possible that victims of sexual violence exert
increased levels of suicidality via the absence of important social networks. Despite calls for
future research to examine plausible causal pathways that limited or impaired social networks
might mediate the association between sexual abuse history and poor mental health among
women (Golding et al., 2002; Ullman & Brecklin, 2002), to date, these pathways have not been
empirically tested. It is particularly important to examine the process by which refugee women
might exhibit suicidality due to the high prevalence of pre-migration sexual violence experiences
and suicidal behavior.
To fill this research gap, the current study examined the effect of pre-migration sexual
violence on suicidal ideation among NK refugee women living in SK and further tested whether
the absence of important social networks mediated this association. A previous study (Um, Rice,
Lee, Kim, & Palinkas, 2017) found that having a diversified social network (i.e., multiple types
of social ties) and kin ties in NK refugee women’s network were associated with decreased
suicidal behavior. This study also found that almost one third of these women who were living
with at least one family member did not report any kin ties in their significant networks (Um et
al., 2017). Thus, based on stress and coping theory (Lazarus & Folkman, 1984), this study
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 94
examined whether NK refugee women who experienced sexual violence before arriving in SK
were more likely to report the absence of network diversity (i.e., having only one type of social
tie) or the absence of kin ties, which in turn led to increased risk of suicidal ideation.
Accordingly, the current study explored five research questions: (a) How is pre-migration sexual
violence associated with suicidal ideation among NK refugee women? (b) Do women who
experienced pre-migration sexual violence report no network diversity in their networks? (c) Do
women who experienced pre-migration sexual violence report no kin ties in their networks? (d)
Does absence of network diversity mediate the relationship between pre-migration sexual
violence and suicidal ideation? (e) Does absence of kin ties mediate the relationship between pre-
migration sexual violence and suicidal ideation? To our knowledge, this is the first empirical
study to examine the process by which sexual violence victims exhibit suicidal behavior among
refugee women in general and NK refugee women in particular.
Methods
Study Participants
A sample of NK refugees living in South Korea and aged 19 or older was recruited from
April to May 2014. Recruitment occurred by snowball sampling, whereby trained recruiters
initially reached out to some participants (i.e., seeds), who in turn introduced other participants to
the researchers. Snowball sampling was employed because information on NK refugees who
reside in South Korea is strictly confidential for security purposes (Um, Kim, & Palinkas, 2016).
To minimize the initial seeds’ influence on the final composition of the study sample, the number
of participants whom seeds could recruit was limited to four and long chains of recruitment

were
present (H. J. Kim & Jung, 2015). Participants recruited by this procedure were living in various
districts across three metropolises and provinces (Seoul, Gyeonggi province, Incheon), where
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 95
more than half of all NK refugees are reported to reside (Ministry of Unification, 2016). A
trained researcher and interviewer visited each household. Surveys were self-administered after
obtaining informed consent. Each participant received 20,000 Korean won (approximately $20)
as compensation for their participation. Although 407 participants were interviewed, two
participants with incomplete data were excluded, generating a sample of 405 participants. The
institutional review board at Korea University approved all survey items and procedures. For the
purpose of this study, only the female sample of these data was used, namely 273 NK refugee
women.
Measures
Dependent variable. Suicidal ideation was assessed by a 5-item suicidal ideation scale
(Harlow, Newcomb, & Bentler, 1986). Participants were asked how often during the previous
year they had suicidal thoughts and attempted suicide, with response options ranging on a 5-
point Likert scale from 0 (almost never) to 4 (almost always). Items were “I have thought about
suicide,” “I have recently wanted to die,” “I have told someone that I wanted to commit suicide,”
“I have thought that my life will end by committing suicide,” and “I have attempted to commit
suicide” (Cronbach’s alpha = .94). Because 65.6% of the participants scored 0 on all five items,
this variable was subject to a high degree of skewness and kurtosis, which is common in
suicidality research (Johnson, Wood, Gooding, Taylor, & Tarrier, 2011). Thus, a dichotomous
variable was created to indicate at least one experience of suicidal ideation during the previous
year because other transformations

(Johnson et al., 2011) were not possible.
Independent variable. Pre-migration sexual violence was assessed by a checklist that
included various types of sexual violence. Participants were asked about 11 items and whether
they had such experiences in NK and intermediary countries during migration, separately.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 96
Experiences of sexual violence included obscene phone calls, texts, or emails; stalking; indecent
exposure; sexual harassment; moderate and severe sexual molestation; rape; unwanted
intercourse in return for goods or services, etc. Response options for all 22 items were yes or no.
Because only a small proportion (16.1%) of participants reported experiencing at least one type
of sexual violence before arriving in SK and because this checklist did not include incidents of
migration-specific sexual violence, this variable was supplemented by three items related to
sexual violence from a pre-migration trauma checklist developed for NK refugees (Y. H. Kim,
Jeon, & Cho, 2010). These three additional items were “I was sexually assaulted or was raped,”
“I was forced into an unwanted marriage or was trafficked,” and “I was forced into prostitution
by being beaten up or threatened.” These items were also asked regarding respondents’
experiences in NK and intermediary countries during migration, separately. Response options for
all six items were yes or no. For these items, more respondents (21.6%) reported experiencing at
least one type of sexual violence before arriving in SK. Thus, this 28-item variable was summed
to indicate the number of pre-migration sexual violence experiences (Cronbach’s alpha = .88).
Mediating variables. Social networks were measured using each respondent’s egocentric
(personal) network data, which were collected by employing a technique used in previous studies
(Burt, 1984; Rice, Kurzban, & Ray, 2012; Rice, Milburn, & Monro, 2011). As part of the self-
administered survey, participants were asked, “We would like to understand your social
relationships with the most important people to you. Please name 5 people who you have stayed
in contact with and have significantly influenced you the most during the past 6 months. These
people can include family, friends, coworkers, teachers, doctors, and so on.” Participants were
then asked about the following information for each alter: type of relationship (spouse, parent,
sibling, children, other family, coworker, friend, neighbor, church acquaintance, and other),
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 97
gender, age, length of relationship (years), nationality of the alter, and the function of
relationship (degree of emotional closeness, degree of trustworthiness, and degree of helpfulness
during hardships) using a 5-point Likert scale ranging from 1 (not at all) to 5 (extremely).
In the current study, the absence of important social networks was conceptualized as the
absence of network diversity and absence of kin ties. Network diversity was defined as the total
number of different types of ties, which ranged from 1 to 5 types in these data. Hence, the
absence of network diversity variable was created when participants reported to have only 1 type
of social ties in their networks (1 = only 1 type of tie, 0 = 2 or more types of ties). The absence of
kin ties variable was created by dichotomizing the total number of kin ties and reverse coding it
to indicate absence of kin ties (coded as 1) and presence of kin ties (coded as 0) in one’s network.
Covariates. Sociodemographic characteristics of age (years), living with family (1 =
living with at least one family member, 0 = not living with any family), years spent in China and
other intermediary countries, and years since leaving NK (created by summing years spent in
China and other intermediary countries and years of residence in SK) were included as covariates.
Self-esteem has been found to be associated with suicidal ideation in previous studies (Johnson et
al., 2011). The Rosenberg Self-Esteem Scale (Rosenberg, 1965) was used to measure global self-
esteem. Ten items were asked using a 4-point Likert scale ranging from 1 (strongly disagree) to
4 (strongly agree). Negatively worded items were reverse scored. A total score was calculated by
summing the items, with higher scores indicating higher self-esteem (Cronbach’s alpha = .78).
Self-rated health is also known to be associated with suicidal ideation (Van Orden et al., 2010).
Participants’ self-rated health status was measured by one item with a 5-point scale: “Compared
to your past (e.g., in North Korea or during migration), how would you rate your health?”
Response options were 1 (very poor), 2 (poor), 3 (similar), 4 (good), and 5 (very good).
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 98
Statistical Analyses
Chi-square tests and independent group t-tests were performed to compare descriptive
statistics and social networks by past-year suicidal ideation. Because this study examined a
mediation model from pre-migration sexual violence (independent variable) to suicidal ideation
(dependent variable) via social networks (mediators), covariates were selected in two steps: the
direct effect of the independent variable on the mediator (path a) and the direct effect of the
mediator on the dependent variable (path b). Guided by the methodology suggested by Hosmer,
Lemeshow, and Sturdivant (2013) for main-effects models, theoretically driven covariates
associated with the potentially mediating social network variables at p < .25 were included in
path a and those associated with suicidal ideation at p < .25 were included in path b. As a result,
for the model testing the mediating effect of absence of network diversity, age and years spent in
China and other intermediary countries were included as covariates in path a, whereas age, years
since leaving NK, self-rated health, and self-esteem were included as covariates in path b. For
the model testing the mediating effect of absence of kin ties, age and living with family were
included as covariates in path a, whereas age, years since leaving NK, self-rated health, and self-
esteem were included as covariates in path b. This strategy was employed to avoid numerically
unstable estimates, large standard errors, and zero degrees of freedom. Two multivariable
mediation analyses were performed to test absence of network variety and absence of kin ties as
potential mediators. These two models were examined separately due to multicollinearity
between the two tested mediators. For both models, model fit indexes, such as root-mean-square
error of approximation (RMSEA) ≤ .06 (Hu & Bentler, 1999), comparative fit index (CFI) ≥ .95
(Hu & Bentler, 1999), and weighted root mean square residual (WRMR) ≤ 1.0 (Yu, 2002), were
used to evaluate the whether the models fit the data adequately. A bootstrapping procedure
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 99
(1,000 bootstrap resamples) was used, as suggested for models with non-continuous mediators
(Preacher & Hayes, 2004). An indirect effect was considered significant when the 95%
confidence interval (CI) did not include 0. All analyses for the current study were performed
using Mplus Version 7.4 (Muthén & Muthén, 2015).
Results
Table 4.1 presents descriptive statistics of the independent and social network variables,
demographic characteristics for the total sample, and a comparison of these statistics by suicidal
ideation. The prevalence of past-year suicidal ideation was 34.4% for the sample in this study.
The average number of types of pre-migration sexual violence experienced in the sample was 1.1
(SD = 2.6). Higher numbers of types of pre-migration sexual violence were positively associated
with suicidal ideation (t[271] = 4.42, p < .001). Of these respondents, 25.3% and 46.5% did not
have a diverse network or any kin ties in their networks, respectively. Absence of network
diversity ( χ
2
[1] = 12.87, p < .001) and absence of kin ties ( χ
2
[1] = 15.21, p < .001) were
positively associated with suicidal ideation. Lower levels of self-esteem (t[271] = 6.14, p < .001)
and self-rated health (t[271] = 4.73, p < .001) were positively associated with suicidal ideation.
Figure 4.1 shows unstandardized coefficients and standardized errors of the mediation
model testing the pathway from pre-migration sexual violence to suicidal ideation via the
absence of network diversity. Experiencing pre-migration sexual violence was associated with
absence of network diversity (b = .07, p < .05), which in turn was associated with suicidal
ideation (b = .41, p < .001). Because the effect of pre-migration sexual violence remained
significant after controlling for absence of network diversity and covariates, this model indicated
partial mediation. The mediating (indirect) effect of absence of network diversity was significant
(b = .03; 95% CI = .01, .07).
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 100
Figure 4.2 presents unstandardized coefficients and standardized errors of the mediation
model testing the pathway from pre-migration sexual violence to suicidal ideation via the
absence of kin ties. Experiencing pre-migration sexual violence was associated with absence of
kin ties (b = .12, p < .05), which in turn was associated with suicidal ideation (b = .25, p < .05).
As in the previous model, the effect of pre-migration sexual violence remained significant after
controlling for absence of kin ties and covariates, indicating partial mediation. The mediating
(indirect) effect of absence of kin ties was significant (b = .03; 95% CI = .01, .07).
Discussion
The current study tested the pathways from pre-migration sexual violence to suicidal
ideation via the absence of significant social networks among NK refugee women living in SK.
We found that experiencing pre-migration sexual violence was associated with contemplating
suicide during the previous year, the absence of network diversity, and the absence of kin ties,
which supports stress and coping theory. Findings of the current study provide further insight
into from whom victims of sexual violence were isolated, rather than measuring their perceived
levels of social support. More importantly, this study found that the absence of network diversity
and the absence of kin ties mediated the link between sexual violence and suicidality. The
current study extended the public health literature on refugee women by improving our
knowledge of the underlying mechanisms by which pre-migration sexual violence experiences of
these women led to suicidal behavior. Our findings may inform the design of suicide
interventions and prevention for high-risk refugee women.
Consistent with previous studies (Devries et al., 2011; J. Y. Kim et al., 2017; Ministry of
Gender Equality and Family, 2012; Stein et al., 2010), these findings indicate that experiencing
more types of pre-migration sexual violence increases the risk of past-year suicidal thoughts.
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 101
These findings illustrate the necessity of screening for sexual violence in suicide prevention
programs for NK refugee women. To prevent the long-term sequelae of sexual abuse on
suicidality among NK refugee women, assessment of pre-migration sexual violence
victimization should occur at an early stage of resettlement and long-term care should be
provided. Because female victims of sexual abuse do not generally seek mental health services
voluntarily (Ullman & Brecklin, 2002), assessment of pre-migration sexual violence and
suicidality should begin at Hanawon, the mandatory resettlement facility that every NK refugee
enters and stays at for 3 months prior to being transferred to a new residence (Ministry of
Unification, 2017). When high-risk individuals identified at Hanawon resettle in society, they
should be referred to community social services so that continued treatment is provided.
The current study found that NK refugee women who experienced sexual violence prior
to arriving at SK were more likely to lack network diversity. This is consistent with the literature
that revealed the limited nature of social networks among sexual abuse victims (Golding et al.,
2002; Katerndahl et al., 2013; Levendosky et al., 2004). In addition, we found that the absence of
network diversity mediated the pathway from sexual violence experience to suicidality. It is
possible that sexual violence victims found it difficult to trust and build relationships with people
in diverse settings, preventing them from receiving varying types of support and resources when
necessary, which in turn increased their mental distress, leading to suicidal thoughts. Moreover,
because social relationships are reciprocal in nature, the inability of these women to provide
support to others across diverse social settings might have encouraged them to limit their social
spheres. Suicide prevention programs should aim to help NK refugee women participate in
diverse social activities to increase their informal social networks and promote interactions with
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 102
formal social networks, such as social workers, mental health practitioners, teachers, and
governmental officials, who interact with NK refugees.
We found that NK refugee women who reported experiencing pre-migration sexual
violence were more likely to lack a kin tie in their important social networks, which is consistent
with previous studies in other populations (Ahrens & Aldana, 2012; Coker et al., 2004; Hynes &
Cardozo, 2000; Savage & Russell, 2005; Tankink & Richters, 2007). We also found that absence
of kin ties mediated the association between sexual violence and suicidal ideation, even when
controlling for living with at least one family member. Victims of sexual violence may withdraw
from their kin ties due to negative reactions from family following disclosure or feelings of
shame toward the family, which in turn increases suicidal behavior. Moreover, prior research
indicated that the arduous journey of migration did not strengthen family bonds but instead
caused more family maladjustment in NK refugee families, particularly because too much
sacrifice (e.g., taking the roles of a breadwinner, a devoted wife and mother, and filial daughter
at the same time) was expected of women (Yi, Cho, Kim, & Chin, 2007). Hence, our finding
may also imply that NK refugee women’s sense of obligation to support the family during times
of significant need of support might have resulted in isolation from the family. Thus, we suggest
developing programs that improve communication, trust, and functioning in NK refugee families
to ultimately promote the mental health of NK refugee women, who comprise 71% of the
population (Ministry of Unification, 2017).
This study was subject to limitations. First, because we used cross-sectional data, our
ability to draw causal inferences in the pathways we examined was limited. For instance, the lack
of network diversity or lack of kin ties may have exposed NK refugee women to more sexual
violence victimization. In addition, women who demonstrated suicidal behavior may have
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 103
isolated themselves from important social networks. Hence, future studies should examine these
causal pathways using longitudinal data. Second, our measure of pre-migration sexual violence
precluded our understanding of the frequency or intensity of each type of sexual abuse. With this
information, we may be able to better capture experiences of abuse. Third, our data did not
include information on the context or nature of participants’ interactions with their social
networks (e.g., how social networks reacted to their disclosure of sexual violence). Thus,
interpretations of our findings require caution.
Despite these limitations, this study has contributed to the public health literature by
testing the possible mediating pathways by which experiences of sexual violence among NK
refugee women cause suicidality via the absence of important social networks for the first time.
In addition, this study increased our knowledge of from whom sexual abuse victims were
isolated by using egocentric data, rather than merely examining their levels of social support.
Furthermore, our research highlights the urgent need to create suicide prevention programs that
incorporate social network interventions, especially for NK refugee women who have
experienced sexual violence during migration.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 104
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SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 110
Table 4.1. Descriptive Statistics of Total Sample and by Past-Year Suicidal Ideation
Total Sample Suicidal Ideation
Yes No
(n = 273) (n = 94) (n = 179)
% or M (SD) % or M (SD) % or M (SD) χ
2
or t
a

Independent variable
Pre-migration sexual violence 1.12 (2.58) 2.04 (3.61) 0.64 (1.64) -4.42
Social network variables
Absence of network diversity 25.27 38.30 18.44 12.87
Absence of kin ties 46.52 62.77 37.99 15.21
Covariates
Age 41.38 (12.71) 40.03 (12.07) 42.08 (13.01) 1.27
Living with family 79.85 76.60 81.56 0.95
Years spent in China and other
intermediary countries
2.53 (3.13) 2.86 (3.33) 2.36 (3.02) -1.25
Years since leaving NK 8.60 (4.94) 9.40 (4.97) 8.19 (4.88) -1.93
Self-esteem 29.11 (4.11) 27.13 (4.03) 30.15 (3.77) 6.14
Self-rated health 2.85 (1.12) 2.43 (0.99) 3.08 (1.13) 4.73
Note. Numbers in bold are statistically significant at p < .05. NK, North Korea.
a
Chi-square values for percentage difference, t-values for mean differences.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 111
Figure 4.1. Mediation Model of Pre-Migration Sexual Violence and Past-Year Suicidal Ideation
via Absence of Network Diversity (N = 273)

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 112
Figure 4.2. Mediation Model of Pre-Migration Sexual Violence and Past-Year Suicidal Ideation
via Absence of Kin Ties (N = 273)

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 113
Chapter 5: Conclusions, Implications, and Future Directions
Summary
The goal of this dissertation study was to explore potent factors associated with suicide
risk among NK refugees living in SK. Despite the urgent need to investigate suicidal behavior in
this high-risk population, empirical evidence in this area has been lacking in the literature. Thus,
using personal social network data, this dissertation examined how different social network
compositions affect past-year suicidal ideation in three ways. Guided by social capital theory and
empirical evidence from the literature, this dissertation operationalized social network
compositions as network diversity, the intersection of types and functions of social ties, and the
absence of important social ties. To the best of my knowledge, this is the first use of this type of
social network data and its examination with suicidality among NK refugees.
Major Findings
The purpose of Study 1 (Chapter 2) was to examine the main effects of different types of
social network compositions on suicidal ideation among NK refugees in SK and to identify
similarities and differences among these effects by gender. The interpersonal theory of suicide
guided the design of this study. This is the first empirical study to use detailed measures of social
network compositions among refugees in general and NK refugees in particular. Findings of this
study demonstrate that having a help-providing or trustworthy church-based tie was a risk factor
for men. Network diversity and being connected to a help-providing or trustworthy kin tie and a
trustworthy church-based tie were protective factors for women. These findings support previous
research that indicated social ties can have both positive and negative effects on mental health
(Abrutyn & Mueller, 2014; Rice, Kurzban, & Ray, 2012; Thoits, 2011) and provide further
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 114
evidence that the effects of social ties on suicidal behavior can differ between men and women
(Kawachi & Berkman, 2001; Thoits, 2011).
The purpose of Study 2 (Chapter 3) was to examine the moderating effects of social
network compositions on the relationships between pre-migration trauma and post-migration
discrimination and suicidal ideation among NK refugees and to identify similarities and
differences among these effects by gender. The stress-buffering hypothesis guided the design of
the study. This study extended previous literature by using social network compositions to test
this hypothesis rather than a global scale of social support. Results of this study indicate that pre-
migration trauma was a risk factor for suicidal ideation among women, whereas post-migration
discrimination was a risk factor for both men and women. In addition, network diversity
moderated the association between post-migration discrimination and suicidal ideation among
women. These findings emphasize the importance of examining stressful encounters of refugees
experienced before and after migration and partially support the hypothesis that social ties can
buffer the negative consequences of stressors on mental health (Cohen & Wills, 1985). They also
provide evidence of gender differences in stress-buffering processes (Kawachi & Berkman,
2001).
The purpose of Study 3 (Chapter 4) was to examine the mediating effects of the absence
of important social networks on the association between pre-migration sexual violence and
suicidal ideation among NK refugee women. Stress and coping theory guided the design of this
study. Findings of this study show that experiencing pre-migration sexual violence led to suicidal
ideation via the absence of network diversity and absence of kin ties. This study provides
insights regarding from whom victims of sexual violence were isolated. Results also demonstrate
the plausible mediating pathways through which these women exhibited increased suicidal
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 115
behavior by limited or impaired social networks, which supports the premise of stress and coping
theory (Lazarus & Folkman, 1984).
Limitations and Future Research
This dissertation was subject to some limitations. First, the use of cross-sectional data did
not allow for causal inferences regarding the associations among social networks, migration-
related stressors, and suicidal ideation. Hence, future researchers are encouraged to collect
longitudinal data and examine such data to confirm these associations. Because the social
network compositions of NK refugees might vary significantly depending on the stages of
resettlement, data collected at several time points might provide a better understanding of their
networks and how they affect suicidal behavior. Second, information collected on the nationality
of alters was invalid in these data. With such data, future studies can examine bonding (i.e.,
social ties to people who are generally similar to an individual) and bridging (i.e., social ties to
people who are generally different than an individual) ties and their various effects on suicidal
ideation in this population. Third, the decision to limit the size of social networks to five to
prevent nonresponse might have obscured our understanding of individuals who have many more
ties and those who are socially isolated. Hence, future studies may capture a clearer
understanding of NK refugees’ personal social networks by allowing respondents to report on
their full social networks.
Future research may supplement findings of this dissertation by collecting qualitative
data on social network compositions and the nature of relationships with these social ties. In
particular, such data could elucidate why a large number of NK refugees did not report having
any kin ties despite cohabiting with family members (see Chapters 2 and 4 of this dissertation)
and how SK churches and their members are providing help to and interacting with NK refugee
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 116
men, which resulted in increased suicide risk (see Chapter 2 of this dissertation). Moreover,
collection and examination of whole network (sociometric) data in SK churches might also
provide further insights regarding the findings of this dissertation. Furthermore, the collection of
sociometric data might be useful to test the social contagion theory of suicidal behavior among
NK refugees, which has been tested in other populations (Abrutyn & Mueller, 2014; Fulginiti,
Rice, Hsu, Rhoades, & Winetrobe, 2016).
Overall Implications and Contributions
Findings of this dissertation reveal the extremely high prevalence of suicidal ideation
among NK refugees who live in SK and highlight the urgency of more research and practice
related to suicide prevention in this high-risk population. Because suicidal thoughts and attempts
are among the strongest predictors of completed suicide, suicide prevention should start from the
point of ideation (Johnson, Wood, Gooding, Taylor, & Tarrier, 2011). Results of this dissertation
suggest that suicide intervention and prevention efforts can be designed to incorporate NK
refugees’ significant social networks and underscore the importance of considering the cultural
context of social networks and gender differences in research and practice. In addition, findings
from this dissertation indicate suicide screening and assessment should take place during the
early stage of resettlement, such as in Hanawon (the mandatory resettlement facility where every
NK refugee stays for 3 months prior to being transferred to a new residence; Ministry of
Unification, 2017), and long-term care that continues after resettlement in the society. This
strategy might be particularly effective because a national social survey showed that 80% of NK
refugees have never voluntarily sought professional services for mental health issues (Korea
Hana Foundation, 2014).
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 117
In particular, this dissertation consistently found that network diversity is important for
reducing suicidal thoughts among NK refugee women throughout the three studies. These
findings suggest the need for programs that promote participation in diverse social activities and
ultimately increase both formal and informal types of social networks among these women.
Particularly when NK refugee women are identified as victims of pre-migration sexual violence,
caseworkers and other practitioners are encouraged to create a nonjudgmental and safe
environment when interacting with these women and make efforts to keep in contact with them
to prevent social isolation.
In sum, this dissertation increased our knowledge of how social networks affect suicidal
behavior in various ways and how these networks interacted with or processed through
migration-related stressors among NK refugees. Future researchers should consider examining
social network compositions among other refugee populations and their potential effects on
suicidality to set a foundation for effective suicide prevention initiatives designed for refugees.

SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 118
References
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longitudinal data to examine suicide suggestion. American Sociological Review, 79, 211–
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Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis.
Psychological Bulletin, 98, 310–357. doi:10.1037/0033-2909.98.2.310
Fulginiti, A., Rice, E., Hsu, H.-T., Rhoades, H., & Winetrobe, H. (2016). Risky integration: A
social network analysis of network position, exposure, and suicidal ideation among
homeless youth. Crisis, 37, 184–193. doi:10.1027/0227-5910/a000374
Johnson, J., Wood, A. M., Gooding, P., Taylor, P. J., & Tarrier, N. (2011). Resilience to
suicidality: The buffering hypothesis. Clinical Psychology Review, 31, 563–591.
doi:10.1016/j.cpr.2010.12.007
Kawachi, I., & Berkman, L. F. (2001). Social ties and mental health. Journal of Urban Health,
78, 458–467. doi:10.1093/jurban/78.3.458
Korea Hana Foundation. (2014). 2014 national social survey on North Korean refugees [In
Korean]. Retrieved from
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Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer.
Ministry of Unification. (2017). Settlement support process for North Korean refugees.
Retrieved from http://eng.unikorea.go.kr/content.do?cmsid=3027
Rice, E., Kurzban, S., & Ray, D. (2012). Homeless but connected: The role of heterogeneous
social network ties and social networking technology in the mental health outcomes of
SOCIAL NETWORKS, SUICIDAL IDEATION, AND NORTH KOREAN REFUGEES 119
street-living adolescents. Community Mental Health Journal, 48, 692–698.
doi:10.1007/s10597-011-9462-1
Thoits, P. A. (2011). Mechanisms linking social ties and support to physical and mental health.
Journal of Health and Social Behavior, 52, 145–161. doi:10.1177/0022146510395592

Abstract (if available)

Abstract North Korean (NK) refugees are vulnerable to experiencing various types of traumatic events, particularly sexual violence among women, before and during migration. Many of them lose their significant social networks due to the nature of forced migration, which requires them to establish new networks to access resources and support in the host society. They often face discriminatory treatment by South Koreans (SKs) upon resettlement. In SK, where suicide rates are double the average rate of all Organisation for Economic Co-operation and Development countries, NK refugees have died by suicide at 3 times the rate of their host country counterparts. Despite the urgent need to create suicide intervention and prevention programs designed for this high-risk population, the dearth of research prevents our understanding of salient factors predicting suicidality and how these factors might exacerbate or mitigate suicidal behavior among NK refugees. Because interventions using social connectedness have been shown to be particularly effective for suicide prevention, this dissertation examined the main, moderating, and mediating effects of social network compositions on suicidal ideation among NK refugees living in SK. ❧ This dissertation consists of three independent studies. The main purpose of this dissertation is to contribute to the literature regarding the various effects of social networks on suicidality among refugees in general and NK refugees in particular. Social network compositions in this dissertation were operationalized as network diversity, the intersection of types and functions of social ties, and the absence of important social ties. Personal social network (egocentric) data collected from a sample of 405 NK refugee adults living in three metropolises and provinces of SK were used in this dissertation. The specific aims of this dissertation are to examine: (a) how different social network compositions affect suicidal ideation

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Creator Um, Mee Young (author)

Core Title Main, moderating, and mediating effects of social network compositions on suicidal ideation among North Korean refugees in South Korea

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 07/17/2019

Defense Date 05/08/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Discrimination,North Korean refugees,OAI-PMH Harvest,sexual violence,social networks,suicidal ideation,trauma

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Palinkas, Lawrence (committee chair), Lee, Olivia (committee member), Rice, Eric (committee member), Unger, Jennifer (committee member)

Creator Email jennyum79@gmail.com,mum@usc.edu

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Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA