Expanding our paradigms: Intersectional and socioecological approaches to suicide prevention

Intersectional trends in child and adolescent suicide-related emergency department encounters in Florida (2016‒2021)

Objectives

Emergency department (ED) visits resulting from suicidal thoughts and behaviors have increased at alarming rates among youth in the United States in recent years. Understanding trends among specific racial, ethnic, gender, and/or age subgroups can provide the foundation for tailored solutions for those with the greatest need for support.

Methods

Using data from the Florida State Emergency Department Database from 2016 to 2021, we calculated annual rates of ED suicide-related diagnoses per 1000 young people aged 8‒21 years. We explored annual trends by age and intersectional race/ethnicity and sex subgroups. Additionally, we examined subgroup-specific stratified percent changes from 2016 to 2019 and 2016 to 2021.

Results

Among 8‒12-year olds, the highest rates of suicide-related ED encounters occurred among Black males and females and this trend was steady over time. Among 13‒21-year-old patients, Black and White females displayed the highest rates of suicide-related ED encounters across 2016‒2021, and all subgroups experienced a slight decline in 2020 and 2021. Rates generally increased between 2016 and 2019, with the largest percent increase (10.6%) occurring among Black females aged 18‒21 years, whereas there was a trend of decreased rates among most subgroups between 2019 and 2021.

Conclusions

Across all years and age groups, Black females showed consistently higher rates of suicide-related ED encounters than almost any other subgroup, supporting previous research that Black adolescent females may be disproportionately suffering from the mental health crisis faced by young people. Furthermore, preteen Black males need additional mental health support, as do adolescent and young adult White females.

Immigration Status, Legal Vulnerability, and Suicidal/Self-harm Ideation Disparities Among Immigrant-Origin Latinx Young Adults in the U.S

Theories of suicidality typically center intrapersonal processes, with limited attention to social determinants of mental health disparities. Using a legal vulnerability framework, we examined the association between self/parental immigration status and suicidal and self-harm ideation (SI) disparities in three groups of immigrant-origin Latinx young adults attending college in the USA: undocumented students (n = 564), US citizens with undocumented parents (n = 605), and US citizens with lawfully present parents (n = 596). We also evaluated whether self/parental immigration status differences in SI could be accounted for by six dimensions of legal vulnerability and, based on prominent theories of suicidality, explored the role of campus belongingness as a protective factor. Participants completed self-report measures, and SI was assessed using one item from the Patient Health Questionnaire-9, a screening tool that assesses the severity of depression symptomatology. Rates of SI were significantly higher among undocumented students (23.1%) and US citizens with undocumented parents (24.3%) compared to US citizens with lawfully present parents (17.8%). Immigration policy-related social exclusion and discrimination-mediated self/parental immigration status differences in SI. Although food insecurity did not differ by self/parental immigration status, greater food insecurity was associated with higher likelihood of SI. Greater campus belongingness was associated with a lower likelihood of endorsing SI for all students regardless of immigration status or legal vulnerability factors. Findings underscore the importance of examining self and parental immigration status as a social determinant of SI and the value of investigating aspects of legal vulnerability as explanatory factors.

COVID-19 and Youth Mental Health Disparities: Intersectional Trends in Depression, Anxiety and Suicide Risk-Related Diagnoses

OBJECTIVES

Mental health disparities were prevalent among racially and ethnically minoritized youth prior to the COVID-19 pandemic. As complete datasets from 2022 become available, we can estimate the extent to which the pandemic further magnified existing inequities. Our objective was to quantify disparities in trajectories of depression, anxiety, and suicide risk-related diagnoses in youth before and after the start of the COVID-19 pandemic, using an intersectional lens of race, ethnicity and gender.

METHODS

Using electronic medical record data from one mid-Atlantic health care system (2015-2022), we evaluated changes in annual rates of depression, anxiety and suicide risk-related diagnoses in 29,117 youths, aged 8-20 years, using graphical analysis, comparison of adjusted mean differences (AMD) and adjusted mixed multilevel logistic regression.

RESULTS

Almost all racial and gender subgroups had significantly higher rates of depression and anxiety after the start of COVID-19 compared to the years prior, with the greatest changes observed in Hispanic and Asian females. Suicide risk-related diagnoses significantly increased among all female subgroups, with the largest increase among Asian females (AMD 4.8, 95% CI 0.2-9.3) and Black females (AMD 4.6, 95% CI 2.2-6.9).

CONCLUSIONS

Rates of depression, anxiety, and suicidal thoughts and/or behaviors in young people continued to increase in the post-pandemic period. Many pre-existing disparities between subgroups, especially females, significantly widened, highlighting the importance of using an intersectional lens. Urgent action is warranted, including universal screening of pediatric patients for suicide risk, broadening effective treatment and support options in minoritized patients, and increasing support services to patients and families.

Factor Structure and Measurement Invariance of the Suicide Status Form-IV

The Suicide Status Form-IV (SSF-IV) is the measure used in the Collaborative Assessment and Management of Suicidality (CAMS). The SSF-IV Core Assessment measures various domains of suicide risk. Previous studies established a two-factor solution in small, homogeneous samples; no investigations have assessed measurement invariance. The current investigation sought to replicate previous factor analyses and used measurement invariance to identify differences in the Core Assessment by race and gender. Adults (N = 731) were referred for a CAMS consultation after exhibiting risk for suicide. Confirmatory factor analyses indicated good fit for both one- and two-factor solutions while the two-factor solution is potentially redundant. Configural, metric, and scalar invariance held across race and gender. Ordinal logistic regression models indicated that neither race nor gender significantly moderated the relationship between the Core Assessment total score and clinical outcomes. Findings support a measurement invariant, one-factor solution for the SSF-IV Core Assessment.

Physiotherapists often encounter clients disclosing suicidal thoughts and behaviors: a cross-sectional survey of Australian physiotherapists

BACKGROUND

All health professionals have a role in suicide prevention, although little is known about physiotherapists' contact with clients experiencing suicidal thoughts and behaviors.

OBJECTIVE

The aims of this study were to investigate physiotherapists' self-reported frequency of contact with clients who disclose suicidal thoughts and behaviors and to identify potential factors associated with frequency of contact.

METHODS

Three-hundred and thirty-eight Australian physiotherapists were surveyed using an online questionnaire, with an estimated response rate of 6.1%. Data were analyzed using descriptive analysis and logistic regression.

RESULTS

Over half the respondents (52.1%) reported encountering clients at least once a year who disclosed suicidal thoughts, and nearly half (49.4%) reported having received at least one disclosure of a suicide plan at some point in their career. Among those working in the public sector, 67.5% of respondents reported having received a disclosure of a suicide plan, and almost all physiotherapists working in pain management reported having received such a disclosure (93.8%). The binary logistic regression model explained approximately 39.7% of the variance in whether a physiotherapist had a client disclose a plan for suicide at some point in their career or not.

CONCLUSION

The results highlight that all physiotherapists should receive training in suicide prevention.

The Culturally Infused Curricular Framework (CICF) for Suicide Prevention Trainings

Although suicide prevention trainings (SPT) have been a standard approach for suicide prevention for years, researchers have noted a need for more clarity in the definition of core competencies for SPTs, particularly in the areas of diversity and culture. Recent research has identified key theoretically- and empirically-based cultural considerations for suicide prevention, but translation is needed to infuse these standards for culture-related competencies into SPTs. This study performed a systematic literature review with a thematic synthesis analytic approach to establish a set of curricular guidelines for infusion of cultural considerations into SPTs. The study also examined the extent to which existing community trainings already incorporate cultural components. Based on the thematic synthesis of 39 SPT studies from 2010 to 2020 and seminal reviews of the cultural and suicide literature, results identified three overarching categories of cultural curricular competencies (suicide knowledge and awareness, suicide intervention skills, and curriculum delivery) and 14 core cultural curricular subthemes for community trainings (e.g., culturally informed risk factors and warning signs, systemic inequities, etc.). These three categories with 14 core cultural curricular competencies comprise the Culturally Infused Curricular Framework (CICF) for Suicide Prevention Trainings. The majority of trainings (62%) included five or less out of 14 total possible core cultural competencies in their training curricula, pointing to insufficient integration of cultural components in existing community trainings. This study's research-based guideline establishes a culture-inclusive framework to strengthen content and approach of community trainings and suicide prevention across cultural groups.

Daily Levels and Dynamic Metrics of Affective-Cognitive Constructs Associate With Suicidal Thoughts and Behaviours in Adults After Psychiatric Hospitalization

The period after psychiatric hospitalization is an extraordinarily high-risk period for suicidal thoughts and behaviours (STBs). Affective-cognitive constructs (ACCs) are salient risk factors for STBs, and intensive longitudinal metrics of these constructs may improve personalized risk detection and intervention. However, limited research has examined how within-person daily levels and between-person dynamic metrics of ACCs relate to STBs after hospital discharge. Adult psychiatric inpatients (N = 95) completed a 65-day ecological momentary assessment protocol after discharge as part of a 6-month follow-up period. Using dynamic structural equation models, we examined both within-person daily levels and between-person dynamic metrics (intensity, variability and inertia) of positive and negative affect, rumination, distress intolerance and emotion dysregulation as risk factors for STBs. Within-person lower daily levels of positive affect and higher daily levels of negative affect, rumination, distress intolerance and emotion dysregulation were risk factors for next-day suicidal ideation (SI). Same-day within-person higher rumination and negative affect were also risk factors for same-day SI. At the between-person level, higher overall positive affect was protective against active SI and suicidal behaviour over the 6-month follow-up, while greater variability of rumination and distress intolerance increased risk for active SI, suicidal behaviour and suicide attempt. The present study provides the most comprehensive examination to date of intensive longitudinal metrics of ACCs as risk factors for STBs. Results support the continued use of intensive longitudinal methods to improve STB risk detection. Interventions focusing on rumination and distress intolerance may specifically help to prevent suicidal crises during critical transitions in care.

Examining the integrated model of the interpersonal-psychological theory of suicide and intersectionality theory among Black male adolescents

INTRODUCTION

Guided by Opara et al.'s (2022), Integrated Model of the Interpersonal Psychological Theory of Suicide and Intersectionality Theory, the current study examined contextual stressors experienced disparately by Black youth (racial discrimination, poverty, and community violence) as moderators of the association between individual motivating factors for suicidal thoughts and behaviors (perceived burdensomeness, thwarted belongingness, and hopelessness) and active suicidal ideation.

METHOD

Participants were 457 Black adolescent boys (mean age = 15.31, SD = 1.26) who completed self-report surveys.

RESULTS

As predicted, the association between perceived burdensomeness and active suicidal ideation was significantly moderated by economic stress. In addition, the association between peer belongingness and suicidal ideation was significantly moderated by racial discrimination, but there were no moderating effects for school belongingness. Finally, the association between hopelessness and suicidal ideation was significantly moderated by both racial discrimination and witnessing community violence.

CONCLUSION

These findings highlight the need for research, interventions, and policy work devoted to using integrated approaches of individual and socioeconomically relevant patterns of suicidal thoughts and behaviors to support Black youth exposed to various forms of structural oppression.

The politics of LGBT+ suicide and suicide prevention in the UK: risk, responsibility and rhetoric

Suicide is a major public health concern, patterned by systematic inequalities, with lesbian, gay, bisexual and trans (LGBT+) people being one example of a minoritised group that is more likely to think about and attempt suicide worldwide. To address this, UK national suicide prevention policies have suggested that LGBT+ people should be prioritised in prevention activities. However, there is little research seeking to understand how LGBT+ suicide is re/presented in political and policy spheres. In this article, we critically analyse all mentions of LGBT+ suicide in UK parliamentary debates between 2009 and 2019 and in the eight suicide prevention policies in use during this period. We argue that LGBT+ suicide is understood in two contrasting ways: firstly, as a pathological 'problem', positioning LGBT+ people either as risks or as at risk and in need of mental health support. Alternatively, suicide can be seen as externally attributable to perpetrators of homophobic, biphobic and transphobic hate, requiring anti-hate activities as part of suicide prevention. In response, we argue that although these explanations may appear oppositional; they both draw on reductive explanations of LGBT+ suicide, failing to consider the complexity of suicidal distress, thus constraining understandings of suicide and suicide prevention.

Development of the Life Gatekeeper suicide prevention training programme in China: a Delphi study

Background

Youth suicide has been a pressing public mental health concern in China, yet there is a lack of gatekeeper intervention programmes developed locally to prevent suicide among Chinese adolescents.

Aims

The current Delphi study was the first step in the systematic development of the Life Gatekeeper programme, the first gatekeeper programme to be developed locally in China that aims to equip teachers and parents with the knowledge, skills and ability to identify and intervene with students at high risk of suicide.

Methods

The Delphi method was used to elicit a consensus of experts who were invited to evaluate the importance of training content, the feasibility of the training delivery method, the possibility of achieving the training goals and, finally, the appropriateness of the training materials. Two Delphi rounds were conducted among local experts with diversified professional backgrounds in suicide research and practice. Statements were accepted for inclusion in the adjusted training programme if they were endorsed by at least 80% of the panel.

Results

Consensus was achieved on 201 out of 207 statements for inclusion into the adapted guidelines for the gatekeeper programme, with 151 from the original questionnaire and 50 generated from comments of the panel members. These endorsed statements were synthesised to develop the content of the Life Gatekeeper training programme.

Conclusions

This Delphi study provided an evidence base for developing the first gatekeeper training programme systematically and locally in China. We hope that the current study can pave the way for more evidence-based suicide prevention programmes in China. Further study is warranted to evaluate the effectiveness of the Life Gatekeeper training programme.

Investigating the Role of Suicidality and Ethnic Identity among Black Adolescents: A Latent Profile Analysis

OBJECTIVE

Suicide among Black adolescent youth has steadily increased in recent years, yet few studies describe how facets of social identity shape suicidal thoughts and behaviors (STBs) during this critical stage of development. Ethnic identity represents an underexplored, yet important element of social identity among Black youth that may contribute to differential associations with STBs. This study examined the association between ethnic identity and self-reported suicidal ideation, planning, and attempts.

METHODS

Data were drawn from 1,170 African American (n = 810) and Caribbean Black (n = 368) adolescents aged 13-17 (Mean age = 15) that participated in the National Survey of American Life Adolescent supplement study.

RESULTS

Using latent profile analyses, three patterns of ethnic identity were identified: Undifferentiated, Low Ethnic Identification, and Alienated. Caribbean Black adolescents were more likely to be in the Low Ethnic Identification class relative to the Undifferentiated class. Adolescents in the Undifferentiated group reported higher proportions of suicidal ideation, planning, and attempts compared to the remaining latent profile groups.

CONCLUSION

Findings demonstrate that ethnic identity is an important aspect of social identity that can influence STBs among Black adolescents. Considering increased suicide attempts and death rates among Black youth, findings underscore the importance of examining culturally relevant developmental processes that may shape suicidal beliefs and behaviors.

Cultural Consensus Modeling to identify culturally relevant reasons for and against suicide among Black adolescents

INTRODUCTION

The development of evidence-based treatments relies on accurate theoretical frameworks sensitive to the lived realities of the populations from which they are derived. Yet, the perspectives of Black youth are vastly underrepresented in extant theories of suicidal behavior. Cultural Consensus Modeling provides an evidence-based approach for developing a culturally informed understanding of suicide risk among Black youth.

METHOD

Participants were 50 Black adolescents (Mage  = 16.20 years; 76.0% male) who completed Phase 1 of a Cultural Consensus Modeling study. Participants freely listed reasons for suicide and reasons for living among similar peer Black youth. Responses were synthesized and coded for major themes.

RESULTS

The most common reasons for suicide were racism (40%), depression (32%), poverty (26%), and bullying (22%). The most common reasons for living were family (58%), having a purpose or goals (36%), friends (30%), and hope for a better future (26%).

CONCLUSION

Responses highlighted issues of racism and social justice, depression, and poverty, as well as the protective role of relationships, living for the future, and contributing to Black empowerment. Future research should utilize Cultural Consensus Modeling to elevate the voices of Black youth, improving extant theories of suicide, and identifying unique mechanisms or opportunities for prevention.

The Burden of Not Belonging: A Qualitative Study of the Applicability of the Interpersonal Theory of Suicide Constructs of Belongingness and Burdensomeness to Ethnocultural Minoritized Youth

Guided by the Interpersonal Theory of Suicide (IPTS), this study aims to understand the applicability of the constructs of belongingness and burdensomeness and their relevance to suicide risk and mental health among ethnocultural minoritized youth. A qualitative exploratory study was conducted using five focus groups with 29 self-identified Latinx and Black adolescents aged 13-17 years to explore the meaning they ascribed to belongingness and burdensomeness. Views of social media related to these constructs were also explored. Template analysis was used to analyze the data. Themes highlighted dimensions such as caring, self-worth, and liability, congruent with the IPTS dimensions of belongingness and burdensomeness. Notably, new themes emerged reflecting the distinctive experiences of these populations, such as the importance of being true to themselves, the burden of not belonging to families, and cultural aspects of liability, highlighting dimensions not found in the existing IPTS theoretical constructs. Consideration of the diverse experiences of ethnocultural minoritized youth can strengthen theoretical constructs, clinical practice, and aid in developing intervention strategies to increase protective factors and decrease risk factors for suicide behaviors relevant to such youth.

Understanding suicide risk for youth who are both Black and Native American: The role of intersectionality and multiple marginalization

INTRODUCTION

Native American and multiracial youth experience elevated risk for suicide ideation (SI) and suicide attempts (SA); however, intersectional identities are often unexamined in suicide research.

METHOD

We examined the prevalence of SI and SA, and the impact of intersectional identities (sex, sexual minority identity, and economic insecurity) on these rates, in 496 biracial Black-Native American, 2,804 Native American, 14,220 Black, 5,569 biracial Native American-White, 4,076 biracial Black-White, and 118,816 White youth who participated in the Minnesota Student Survey.

RESULTS

Black-Native American youth reports of SI and SA resembled other Native American youth and were significantly higher than those reported by Black, White, and Black-White (SA only) youth. While sexual minority youth reported higher rates of SI and SA than heterosexual youth, this difference between sexual minority and heterosexual Black-Native American youth was smaller as compared to their peers.

CONCLUSION

Though they largely resemble their mono/biracial Native American peers, Black-Native American youth show some distinct patterns of SA when accounting for their intersectional identities. Despite presumed similarities in systemic risk factors, Black and Black-Native American youth differ considerably in reported suicidality. The experiences of Black-Native American teens warrant further examination.

Suicide attempt endophenotypes: Latent profiles of child and adolescent aggression and impulsivity differentially predict suicide attempt in females

Suicide is a leading cause of death in young adulthood. Identifying early prevention targets to reduce later suicide is a public health priority. Impulsivity and aggression in early childhood may represent actionable early prevention candidate endophenotypes for later suicidal behavior. Our objective is to to understand the association of aggression and impulsivity trajectories with mental health outcomes to inform future prevention efforts. Participants were part of a longitudinal cohort of a preventative intervention trial (n = 597) and predominantly Black. They were assessed for aggressive and impulsive behaviors yearly in 1st-3rd and 6th-12th grades, and provided mental health data via self-report beginning in 6th grade. Longitudinal latent profiles of aggressive and impulsive behaviors were derived for males and females and used to determine whether profiles was associated with lifetime suicide attempt and meeting diagnostic criteria for major depressive disorder. Two impulsivity and aggression classes were found for males, characterized by low behaviors or moderate to high behaviors across development. Three classes were found for females, one of which was characterized by an undulating pattern of behaviors. For females, the class of severe behaviors was associated with significant risk of suicide attempt (Wald = 6.01, p = 0.05). No relationship was found for males or for MDD diagnosis. An endophenotype model of impulsivity and aggression in predicting later suicide attempt was supported in females, but not males. Results underscore the importance of evaluating sex differences in suicide research and the potential identification of females at risk for later suicidal behavior in school settings.

Social and Psychiatric Factors of Suicidal Thoughts and Behaviors in Mozambican Adolescents

Globally, suicide is the second leading cause of death for youth ages 10-24 years, and more than 75% of all deaths by suicide occur in low- and middle-income countries (LMIC).1 Suicidal thoughts (ST) and suicidal behaviors (SB), valuable signals for early detection and prevention of suicide deaths, have been associated with a number of different factors in adolescents, including gender and age, socioeconomic status, exposure to childhood adversity, and psychopathology.2 However, research has largely focused on Western, White populations from high-income countries (HIC).2 To lessen the suicide burden among adolescents in LMIC, there is an urgent need to identify contextually relevant risk identification and treatment targets. In Mozambique, the country with the highest suicide rate in southern Africa, this need is particularly dire, as there are fewer than 2 mental health specialists per 100,000 inhabitants,3 and limited resources must be efficiently targeted in youth suicide prevention efforts. We conducted a cross-sectional study at 2 secondary schools in the Mozambican capital Maputo City to identify the social and psychiatric factors associated with ST and SB in Mozambican adolescents.

Structural Racism and Suicide Prevention for Ethnoracially Minoritized Youth: A Conceptual Framework and Illustration Across Systems

Suicide rates among ethnoracially minoritized youth (i.e., youth of color) peak before the age of 30, and striking disparities in access to mental health services have been identified in this age group. However, suicide prevention strategies have yet to fully address structural racism as a mechanism in producing disparities in risk, protective factors, and access to quality effective intervention for youth of color. Such an approach is critical to provide more culturally responsive mental health care. Through an adapted socio-ecological model, the authors propose the Structural Racism and Suicide Prevention Systems Framework and illustrate pathways through which structural racism impacts suicide prevention and intervention for youth of color in the United States. The authors contextualize the impact of structural racism in three key settings where youth suicide prevention occurs: mental health services, schools, and the interface between crisis care and law enforcement. The authors posit that critical attention must be paid to the intersection of mutually reinforcing, interdependent systems rather than to systems in isolation. The authors then propose recommendations to address structural racism in suicide prevention, including macro-level interventions to improve societal conditions, research strategies to inform structural solutions, training approaches to address institutional racism, and clinical approaches to address the impact of racism and racial trauma on youths and families.

A Systematic Review of the Effects of Urban Living on Suicidality and Self-Harm in the UK and Ireland

We conducted a systematic review to answer the following: (a) Is there any evidence to support increased prevalence of suicidality and self-harm (i.e. self-harm or suicidality) in urban versus rural environments? (b) What aspects of the urban environment pose risk for suicidality and self-harm? Thirty-five studies met our criteria. Our findings reflect a mixed picture, but with a tendency for urban living to be associated with an increased risk of suicidality and self-harm over rural living, particularly for those living in deprived areas. Further research should focus on the clustering and additive effects of risk and protective factors for suicidality and self-harm in urban environments.

Diversity and Inclusion: Impacts on Psychological Wellbeing Among Lesbian, Gay, Bisexual, Transgender, and Queer Communities

For scholars, practitioners, and legislators concerned about sexual minority adolescents, one of the main goals is to create more positive and inclusive learning environments for this minority group. Numerous factors, such as repeated patterns of homophobic bullying by classmates and others in school, have been a significant barrier to achieving this goal. In addition, lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents encounter substantial inequality across a broad spectrum of wellbeing and education consequences. Compared with their heterosexual counterparts, LGBTQ adolescents experience more anxiety, depression, suicidal thoughts, antisocial behavior, poorer academic performance, less school attachment and protection, and a weaker desire to finish their studies. Such discrepancies based on gender and sexuality were linked to more maltreatment encountered by LGBTQ adolescents. It is crucial to recognize the backgrounds and expectations of LGBTQ adolescents to offer them the best resources. To overcome the inequality and obstacles faced by these LGBTQ adolescents, it is essential to examine tools and techniques that can be utilized. This study examined the literature that explains why society fails to provide enough support to LGBTQ students. Specifically, mechanisms explaining how LGBTQ adolescents interact with others in the learning environment and how such discrepancies arise will be examined. Following that, violence and prejudice, which are fundamental causes of psychological problems among LGBTQ adolescents, will be explored. This review paper thus provides supportive strategies for schools to develop more inclusive learning environments for LGBTQ adolescents.

The mediation and moderation effect of social support on the relationship between opioid misuse and suicide attempts among native American youth in New Mexico: 2009-2019 Youth Risk Resiliency Survey (NM-YRRS)

BACKGROUND

Suicide attempt and opioid misuse continue to be major behavioral health challenges among American Indians and Alaska Natives (AI/AN). The aim of the study is to evaluate the mediating and moderating role that social support (SS) plays in their association among AI/AN high-school students in New Mexico (NM).

METHODS

An aggregated NM Youth Resiliency and Risk Survey (NM-YRRS, 2009-2019: odd years) dataset was used. Multivariable logistic regression modeling and mediation analysis were conducted while adjusting for confounding variables.

RESULTS

Overall, 12.0 and 14.0% of AI/AN students reported opioid misuse and suicide attempt, respectively. The adjusted odds ratio of suicide attempt in students with high SS relative to low SS who misused opioids was 0.43 (p-value = 0.007). The effect of high SS relative to low SS among males who misused opioids was more pronounced (AOR = 0.24, p-value < 0.0001) compared to females (AOR = 0.43, p-value = 0.007). Relative to low SS, high SS was protective for suicide attempt among AI/AN students who misused opioids and attended school in off-reservation (AOR = 0.42, p-value = 0.012) communities, rural communities (AOR = 0.44, p = 0.040), and in communities that are both rural and off-reservation (AOR = 0.39, p = 0.035). Overall, 23.64, and 41.05% of the association between opioid misuse, and suicide attempt was mediated and moderated by SS, respectively. The mediation effect of SS was lowest for rural, on-reservation schools.

CONCLUSION

More resources need to be allocated to rural on-reservation schools to enhance social support. The study highlights key insights into the significant role SS plays in promoting health and mitigating the association between opioid misuse and suicide attempt.

Who Has Access to Livestock Vaccines? Using the Social-Ecological Model and Intersectionality Frameworks to Identify the Social Barriers to Peste des Petits Ruminants Vaccines in Karamoja, Uganda

Access to veterinary services is important in Karamoja, northeastern part of Uganda, as livestock is a primary source of livelihood. Gender is often overlooked in animal health programs, let alone intersectionality. However, given the socio-cultural intricacies of Karamoja, ignoring these factors may hinder animal vaccination practices, limiting the success of programs designed to control and prevent animal diseases, such as peste des petits ruminants (PPR). The study used qualitative research methods, including focus group discussions, individual interviews, and key informant interviews in a participatory research approach to investigate the constraints faced by livestock keepers when accessing vaccines. The study was carried out in Abim, Amudat, Kotido, and Moroto, four districts in the Karamoja Subregion of Uganda. A modified version of the socio-ecological model (SEM) blended with an intersectional approach were used as frameworks to analyze underlying individual, social and structural determinants of vaccine access with intersecting factors of social inequalities. The results show there are seven intersecting factors that influence access to vaccination the most. These are: gender, ethnicity, geographic location, age, physical ability, marital status, and access to education. The impact of these intersections across the different levels of the SEM highlight that there are vast inequalities within the current system. Access to vaccines and information about animal health was most limited among women, widows, the elderly, the disabled, geographically isolated, and those with unfavorable knowledge, attitudes, and practices about vaccination. Cultural norms of communities were also important factors determining access to PPR vaccines. Norms that burden women with household chores and beliefs that women cannot manage livestock, combined with gender-based violence, leaves them unable to participate in and benefit from the livestock vaccine value chain. Trainings and sensitization on gendered intersectional approaches for those involved in the distribution and delivery of vaccines are necessary to avoid exacerbating existing inequalities in Karamoja.

Self-inflicted. Deliberate. Death-intentioned. A critical policy analysis of UK suicide prevention policies 2009-2019

Purpose

With encouragement from the World Health Organisation, national suicide prevention policies have come to be regarded as an essential component of the global effort to reduce suicide. However, despite their global significance, the construction, conceptualisation and proposed provisions offered in suicide prevention policies have, to date, been under researched; this study aims to address this gap.

Design/methodology/approach

we critically analysed eight contemporary UK suicide prevention policy documents in use in all four nations of the UK between 2009 and 2019, using Bacchi and Goodwin’s post-structural critical policy analysis.

Findings

The authors argue that across this sample of suicide prevention policies, suicide is constructed as self-inflicted, deliberate and death-intentioned. Consequently, these supposedly neutral definitions of suicide have some significant and problematic effects, often individualising, pathologising and depoliticising suicide in ways that dislocate suicides from the emotional worlds in which they occur. Accordingly, although suicide prevention policies have the potential to think beyond the boundaries of clinical practice, and consider suicide prevention more holistically, the policies in this sample take a relatively narrow focus, often reducing suicide to a single momentary act and centring death prevention at the expense of considering ways to make individual lives more liveable.

Originality/value

UK suicide prevention policies have not been subject to critical analysis; to the best of the authors’ knowledge, this study represents the first attempt to examine the way in which suicide is constructed in UK suicide prevention policy documents.

An analysis of suicidal thoughts and behaviors among transgender and gender diverse adults

PURPOSE

Suicidal thoughts and behaviors (STBs) remain a pressing public health problem for transgender and gender diverse (TGD) persons. The goal of this study was to apply social-ecological and minority stress frameworks to identify individual and interpersonal-level TGD-specific STB risk and protective factors.

METHODS

This is a secondary analysis of the 2015 United States Transgender Health Survey, a comprehensive cross-sectional health assessment of a national sample of TGD adults (N = 27,658). Chi-square and Analysis of Variance (ANOVA) were used to identify bivariate correlates of 12-month and lifetime suicidal ideation (SI) and suicide attempt (SA). Logistic regression was employed to identify the strongest STB risk and protective factors across levels.

RESULTS

Sexual minority identification, racial minority identification, and having a disability were lifetime STB risk factors. TGD identity, sexual minority identification, racial minority identification (SA only), lower education, lower income, military experience, having a disability, and being uninsured were 12-month STB risk factors. Psychological distress was the most robust STB risk factor. Workplace discrimination, family rejection, healthcare discrimination, and childhood bias-based victimization were lifetime STB risk factors. All forms of discrimination and victimization (with the exception of family rejection for SI) were 12-month STB risk factors. Family and coworker support were protective factors for lifetime SA (but not SI) and all 12-month STBs. Being less out about TGD identity was a protective factor for STBs (except for 12-month SI).

CONCLUSION

Findings support social-ecological and minority stress STB risk frameworks. Recommendations are provided for a comprehensive approach to TGD suicide prevention.

Embracing challenging complexity: exploring handwashing behavior from a combined socioecological and intersectional perspective in Sierra Leone

Background

Handwashing with soap is a cost-effective, efficient health behavior to prevent various diseases. Despite its immense health benefits, the lowest prevalence of handwashing is found in low-income countries. Here, its practice is not only determined by individual behavior, but also heavily shaped by deprivations in the social and structural ecology. Moreover, handwashing barriers are not equally experienced as overlapping social identities (e.g., age and gender) intersect and create inequities between members of different social groups. To embrace the complexities of handwashing beyond individual-level behavior and singular social identities, a combined socioecological and intersectional perspective is employed. This multi-level approach with regards to intersecting privileges and disadvantages serves as a basis to promote this highly important health behavior.

Methods

This study used a qualitative, theory-based approach and combined data from two samples: experts in health promotion (n = 22) and local citizens stratified by gender and rural/urban location (n = 56). Data was collected in face-to-face interviews in Sierra Leone between November 2018 and January 2019 and analyzed using thematic analysis and typology of the qualitative data.

Results

The conceptualization of multi-level determinants of handwashing within a socioecological model showed the high relevance of inhibiting social and structural factors for handwashing practice. By establishing seven distinguishing social identity dimensions, data demonstrates that individuals within the same social setting yet with distinct social identities experience strikingly differing degrees of power and privileges to enact handwashing. While a local leader is influential and may also change structural-level determinants, a young, rural wife experiences multiple social and structural constraints to perform handwashing with soap, even if she has high handwashing intentions.

Conclusion

This study provides a holistic analytical framework for the identification of determinants on multiple levels and accumulating intersections of socially produced inequalities for handwashing and is applicable to other health topics. As the exploration of handwashing was approached from a solution-focused instead of a problem-focused perspective, the analysis can guide multi-level intervention approaches (e.g., using low-cost, participatory activities at the community level to make use of the available social capital).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11923-1.

Intersectionality, social support, and youth suicidality: A socioecological approach to prevention

OBJECTIVE

This study examined the relationship between social support and suicidality among youth from a public health perspective by using (1) a socioecological framework and (2) an intersectional approach to social identity.

METHODS

Secondary analysis of cross-sectional survey data (N = 5058) involved means comparisons and a series of standard and hierarchical regression analyses.

RESULTS

Youth with intersecting marginalized identities (i.e., females and racial and sexual minority youth) were significantly more likely to report higher suicidality scores. Social support at the family, school, and community levels was significantly associated with lower suicidality scores, and the combination of family and school support was associated with the lowest suicidality scores. Finally, family support significantly reduced the relationship between intersecting marginalized identities and suicidality.

CONCLUSIONS

Findings highlight the importance of protective factors in every context in which youth live, learn, and play. Measuring and reporting social identities as well as their intersections add to our understanding of both risk and prevention.

The Social Roots of Suicide: Theorizing How the External Social World Matters to Suicide and Suicide Prevention

The past 20 years have seen dramatic rises in suicide rates in the United States and other countries around the world. These trends have been identified as a public health crisis in urgent need of new solutions and have spurred significant research efforts to improve our understanding of suicide and strategies to prevent it. Unfortunately, despite making significant contributions to the founding of suicidology - through Emile Durkheim's classic Suicide (1897/1951) - sociology's role has been less prominent in contemporary efforts to address these tragic trends, though as we will show, sociological theories offer great promise for advancing our understanding of suicide and improving the efficacy of suicide prevention. Here, we review sociological theory and empirical research on suicide. We begin where all sociologists must: with Durkheim. However, we offer a more comprehensive understanding of Durkheim's insights into suicide than the prior reviews provided by those in other disciplines. In so doing, we reveal the nuance and richness of Durkheim's insights that have been largely lost in modern suicidology, despite being foundational to all sociological theories of suicide - even those that have moved beyond his model. We proceed to discuss broadly acknowledged limitations to Durkheim's theory of suicide and review how more recent theoretical efforts have not only addressed those concerns, but have done so by bringing a larger swatch of sociology's theoretical and empirical toolkit to bare on suicide. Specifically, we review how recent sociological theories of suicide have incorporated insights from social network theories, cultural sociology, sociology of emotions, and sociological social psychology to better theorize how the external social world matters to individual psychological pain and suffering. We conclude by making explicit bridges between sociological and psychological theories of suicide; by noting important limitations in knowledge about suicide - particularly regarding the roles of organizations, inequality, and intersectionality in suicide - that sociology is well situated to help address.

The Role of Technology and the Continuum of Care for Youth Suicidality: Systematic Review

Background

Youth suicide is a global public health issue, and using technology is one strategy to increase participation in preventive interventions. However, there is minimal knowledge on how technology-enhanced interventions for youth correspond to the stages of care, from illness or risk recognition to treatment follow-up.

Objective

This systematic review aims to examine the efficacy of technology-enhanced youth suicide prevention and interventions across the continuum of care.

Methods

Four electronic databases were searched up to spring 2019 for youth suicide preventive interventions that used technology. The review was not restricted by study design and eligible studies could report outcomes on suicidality or related behaviors, such as formal treatment initiation. An adapted version of the Methodological Quality Ratings Scale was used to assess study quality.

Results

A total of 26 studies were identified. The findings support the emerging efficacy of technology-enhanced interventions, including a decline in suicidality and an increase in proactive behaviors. However, evidence suggests that there are gaps in the continuum of care and recent study samples do not represent the diverse identities of vulnerable youth.

Conclusions

The majority of identified studies were conducted in school settings and were universal interventions that aligned with the illness and risk recognition and help-seeking stages of the continuum of care. This field could be strengthened by having future studies target the stages of assessment and treatment initiation, include diverse youth demographics, and examine the varying roles of providers and technological components in emerging interventions.

Suicide among Black Children: An Integrated Model of the Interpersonal-Psychological Theory of Suicide and Intersectionality Theory for Researchers and Clinicians

Recently, research has reported that the rates of suicide among Black children between the ages of 5 to 12-years-old are increasing as they are now more likely to commit suicide than White children. Yet, there are very few, if any, frameworks being used by researchers to explain the risks of suicide among Black children. Suicide research has overwhelmingly been focused on White youth thus leaving a critical gap in suicide research. This conceptual paper provides an integrated framework using the Interpersonal-Psychological Theory of Suicide and Intersectionality theory, as a guide for researchers, clinicians, and practitioners to incorporate culturally appropriate techniques in their work as a way to prevent suicide among Black children. This framework highlights racial discrimination, mental health, socioeconomic status, and sexual/gender minority status to be the most preeminent, yet understudied factors leading to suicide risk among Black children in the United States.

Preferences in Information Processing, Marginalized Identity, and Non-Monogamy: Understanding Factors in Suicide-Related Behavior among Members of the Alternative Sexuality Community

Suicide-related behavior (SRB) is a mental health disparity experienced by the alternative sexuality community. We assessed mental health, relationship orientation, marginalized identities (i.e., sexual orientation minority, gender minority, racial minority, ethnic minority, and lower education), and preferences in information processing (PIP) as factors differentiating lifetime SRB groups. An online cross-sectional survey study was conducted in 2018. Members of the National Coalition for Sexual Freedom (NCSF; n = 334) took part. Bivariate analyses identified the following SRB risk factors: female and transgender/gender non-binary identity, sexual orientation minority identity, lower education, suicide attempt/death exposure, Need for Affect (NFA) Avoidance, depression, and anxiety. Monogamous relationship orientation was a protective factor. Multi-nomial regression revealed the following: (1) monogamous relationship orientation was a protective factor for suicidal ideation and attempt; (2) lower education was a risk factor for suicide attempt; (3) anxiety was a risk factor for suicide attempt; and (4) depression was a risk factor for suicidal ideation. A two-way interaction showed that elevated NFA Approach buffered the negative impacts of depression. Relationship orientation, several marginalized identities (i.e., based on gender, sexual orientation, and educational level), and PIP all contributed uniquely to SRB. Further study is necessary to understand the role of relationship orientation with suicide. Health education and suicide prevention efforts with NCSF should be tailored to account for marginalized identity, mental health, and NFA factors.