The Zuni Life Skills Development Program: a school/community-based suicide prevention intervention

Examining global Indigenous community wellness worker models: a rapid review

BACKGROUND

There is a growing interest in employing community wellness worker models in Indigenous populations to address inequities in healthcare access and outcomes, concerns about shortage in health and mental health human resources, and escalating burden of chronic and complex diseases driving significant increase in health services demand and costs. A thorough review of Indigenous community wellness worker models has yet to be conducted. This rapid review sought to outline the characteristics of a community wellness worker model in Indigenous contexts across the globe, detailing factors shaping implementation challenges and success.

METHODS

A rapid review of the international peer-reviewed and grey literature of OVID Medline, Global Index Medicus, Google, and Google Scholar was conducted from January to June 2022 for Indigenous community wellness/mental health worker models and comparative models. Articles were screened and assessed for eligibility. From eligible articles, data pertaining to study design and sample; description of the program, service, or intervention; model development and implementation; terminology used to describe workers; training features; job roles; funding considerations; facilitators and barriers to success; key findings; outcomes measured; and models or frameworks utilized were extracted. Data were synthesized by descriptive and pattern coding.

RESULTS

Twenty academic and eight grey literature articles were examined. Our findings resulted in four overarching and interconnected themes: (1) worker roles and responsibilities; (2) worker training, education, and experience; (3) decolonized approaches; and (4) structural supports.

CONCLUSION

Community wellness worker models present a promising means to begin to address the disproportionately elevated demand for mental wellness support in Indigenous communities worldwide. This model of care acts as a critical link between Indigenous communities and mainstream health and social service providers and workers fulfill distinctive roles in delivering heightened mental wellness supports to community members by leveraging strong ties to community and knowledge of Indigenous culture. They employ innovative structural solutions to bolster their efficacy and cultivate positive outcomes for service delivery and mental wellness. Barriers to the success of community wellness worker models endure, including power imbalances, lack of role clarity, lack of recognition, mental wellness needs of workers and Indigenous communities, and more.

Adolescent suicide risk factors and the integration of social-emotional skills in school-based prevention programs

Adolescents are considered one of the most vulnerable groups affected by suicide. Rapid changes in adolescents' physical and mental states, as well as in their lives, significantly and undeniably increase the risk of suicide. Psychological, social, family, individual, and environmental factors are important risk factors for suicidal behavior among teenagers and may contribute to suicide risk through various direct, indirect, or combined pathways. Social-emotional learning is considered a powerful intervention measure for addressing the crisis of adolescent suicide. When deliberately cultivated, fostered, and enhanced, self-awareness, self-management, social awareness, interpersonal skills, and responsible decision-making, as the five core competencies of social-emotional learning, can be used to effectively target various risk factors for adolescent suicide and provide necessary mental and interpersonal support. Among numerous suicide intervention methods, school-based interventions based on social-emotional competence have shown great potential in preventing and addressing suicide risk factors in adolescents. The characteristics of school-based interventions based on social-emotional competence, including their appropriateness, necessity, cost-effectiveness, comprehensiveness, and effectiveness, make these interventions an important means of addressing the crisis of adolescent suicide. To further determine the potential of school-based interventions based on social-emotional competence and better address the issue of adolescent suicide, additional financial support should be provided, the combination of social-emotional learning and other suicide prevention programs within schools should be fully leveraged, and cooperation between schools and families, society, and other environments should be maximized. These efforts should be considered future research directions.

Educational agents and institutions called into action in suicide prevention, intervention, and postvention

Introduction

Suicide is the second leading cause of death in the 15 to 29 age group worldwide, and is a severe public health problem. Adolescent and young adult individuals attend educational institutions which can play an essential role in detecting and preventing suicide. For this reason, the purpose of this research is to identify what educational institutions and agents are called into action in suicide prevention, intervention, and postvention.

Methods

The method of systematic review of the literature based on the PRISMA protocol was used. The review protocol was registered in PROSPERO (PROSPERO 2020 CRD42020189127). The systematic review yielded 66 articles published between 1990 and February 2023.

Results

The results show that a wide variety of educational stakeholders are required to intervene for suicide prevention, interventions and postvention between primary education and college. The study describes the different programs that have been provided, the countries in which they have been implemented and the agents who have been targeted. It also identifies gaps in the research on suicide in the educational field.

Discussion

Overall, educational suicide initiatives report positive effects on participants' understanding, attitudes, and beliefs regarding suicide and suicide prevention, although some studies have expressed some caution.

Psychological, Structural, Social and Economic Determinants of Suicide Attempt: Risk Assessment and Decision Making Strategies

The aim of this research was to conduct a risk assessment and management of psychological, structural, social and economic determinants (PSSED) in a suicide attempt. The sample consisted of 353 individuals who had a recorded history of suicidal attempt; and 20 professional individuals by purposive sampling method within a descriptive cross-sectional design. Worksheets for RAM and AHP were used for data collection in this study. The rate of suicide attempt was 7.21 per 100,000 population in this study. Analysis showed that depression and mental disorders; personality disorders; family problems; socio-cultural and economic problems; lack of awareness; and low level of education have a high level of risk for suicide attempts. Psychiatric and psychological services; awareness and knowledge of life skills; medical services to dysfunctional families; development of community-based planning for PSSED of suicide; and employment and entrepreneurship services may lower suicide attempt risk.

Centering Indigenous knowledge in suicide prevention: a critical scoping review

BACKGROUND

Indigenous peoples of Canada, United States, Australia, and New Zealand experience disproportionately high rates of suicide as a result of the collective and shared trauma experienced with colonization and ongoing marginalization. Dominant, Western approaches to suicide prevention-typically involving individual-level efforts for behavioural change via mental health professional intervention-by themselves have largely failed at addressing suicide in Indigenous populations, possibly due to cultural misalignment with Indigenous paradigms. Consequently, many Indigenous communities, organizations and governments have been undertaking more cultural and community-based approaches to suicide prevention. To provide a foundation for future research and inform prevention efforts in this context, this critical scoping review summarizes how Indigenous approaches have been integrated in suicide prevention initiatives targeting Indigenous populations.

METHODS

A systematic search guided by a community-based participatory research (CBPR) approach was conducted in twelve electronic bibliographic databases for academic literature and six databases for grey literature to identify relevant articles. the reference lists of articles that were selected via the search strategy were hand-searched in order to include any further articles that may have been missed. Articles were screened and assessed for eligibility. From eligible articles, data including authors, year of publication, type of publication, objectives of the study, country, target population, type of suicide prevention strategy, description of suicide prevention strategy, and main outcomes of the study were extracted. A thematic analysis approach guided by Métis knowledge and practices was also applied to synthesize and summarize the findings.

RESULTS

Fifty-six academic articles and 16 articles from the grey literature were examined. Four overarching and intersecting thematic areas emerged out of analysis of the academic and grey literature: (1) engaging culture and strengthening connectedness; (2) integrating Indigenous knowledge; (3) Indigenous self-determination; and (4) employing decolonial approaches.

CONCLUSIONS

Findings demonstrate how centering Indigenous knowledge and approaches within suicide prevention positively contribute to suicide-related outcomes. Initiatives built upon comprehensive community engagement processes and which incorporate Indigenous culture, knowledge, and decolonizing methods have been shown to have substantial impact on suicide-related outcomes at the individual- and community-level. Indigenous approaches to suicide prevention are diverse, drawing on local culture, knowledge, need and priorities.

Saving Lives: A Systematic Review on the Efficacy of Theory-Informed Suicide Prevention Programs

Suicide is a global epidemic. This review assessed the scope and effectiveness of suicide prevention programs. Systematic literature searches were conducted using PsycINFO, ERIC and MEDLINE to retrieve articles published between January 2007 and March 2017 and fulfilled inclusion criteria (studies evaluating the efficacy of theory/model-informed suicide prevention programs in increasing participant knowledge or skills when presented with a peer at risk of suicide). The review is informed by PRISMA guidelines. Of 1398 studies identified, 25 were reviewed and most: targeted professionals; were 1-4-day workshops; were underpinned by 21 different theories; taught less detail to the community than professionals; and improved target outcomes. Current programs, although effective, are limited by their inaccessibility, narrow content for the community and substantial variability in theory base. Future suicide prevention programs will benefit from being informed by a more specific theory, delivered through technology, targeting more of the community and improving methodological rigour.

Are American Indian/Alaska Native Adolescent Health Behaviors Different? A Review of AI/AN Youth Involved in Native STAND Curriculum, 2014-2017 United States

OBJECTIVES

To explore health behavior profiles of AI/AN youth involved in native students together against negative decisions (STAND), a national culture-based curriculum.

METHODS

We analyzed data from 1236 surveys conducted among AI/AN youth at 40 native STAND implementation sites located in 16 states throughout the US from 2014 to 2017. Health profiles included demographics, sexual orientation, sexual activity, STI testing, cigarette use, and suicide attempts in the past 12-months. We used t-tests and chi square tests of independence to compare risk behavior prevalence among the sample.

RESULTS

Health behavior profiles of AI/AN youth indicate that 45.6% of youth did not use condoms the last time they had sex, and 82.7% have never been tested for STIs. Differences in cigarette smoking were observed in questioning youth (questioning: 80.3%, straight/heterosexual: 63.8%, LGBTQ2S + : 49.9%, p = 0.03).

CONCLUSIONS FOR PRACTICE

Health behaviors related to sex, substance, violence and self-harm, are at least as common for AI/AN youth as those observed in other US teens. Future research should consider similarities and differences in health profiles of AI/AN youth when designing interventions that affect them. Further, our findings underscore the need for culturally-relevant curricula like native STAND, not because their health behavior is different, but because their socio-ecologic environment is different.

Sustaining suicide prevention programs in American Indian and Alaska Native communities and Tribal health centers

Background

Research on sustaining community-based interventions is limited. This is particularly true for suicide prevention programs and in American Indian and Alaska Native (AIAN) settings. Aiming to inform research in this area, this paper sought to identify factors and strategies that are key to sustain suicide prevention efforts in AIAN communities.

Methods

We used a modified Nominal Group Technique with a purposeful sample of N = 35 suicide prevention research experts, program implementors and AIAN community leaders to develop a list of prioritized factors and sustainability strategies. We then compared this list with the Public Health Program Capacity for Sustainability Framework (PHPCSF) to examine the extent the factors identified aligned with the existing literature.

Results

Major factors identified included cultural fit of intervention approaches, buy in from local communities, importance of leadership and policy making, and demonstrated program success. Strategies to promote these factors included partnership building, continuous growth of leadership, policy development, and ongoing strategic planning and advocacy. All domains of the PHPCF were representative, but additional factors and strategies were identified that emerged as important in AIAN settings.

Conclusions

Sustaining effective and culturally informed suicide prevention efforts is of paramount importance to prevent suicide and save lives. Future research will focus on generating empirical evidence of these strategies and their effectiveness at promoting program sustainability in AIAN communities.

Reservation-Urban Comparison of Suicidal Ideation/Planning and Attempts in American Indian Youth

BACKGROUND

Our aim was to identify sex- and location-specific risk factors for suicide ideation/planning and attempts among American Indian youth.

METHODS

Biennial data for 6417 American Indian high school students attending reservation and urban schools were extracted from the Montana volunteer sample Youth Risk Behavior Survey data for pooled years 2003 to 2011. Logistic regression was used to identify sex- and school location-specific risk behaviors and psychosocial factors for past 12-month ideation/planning and past 12-month attempts.

RESULTS

Contrary to our hypothesis, the prevalence of ideation/planning and attempts did not significantly differ between reservation/urban location; however, risk factors associated with suicidality did. Sadness/hopelessness was associated with both outcomes for all groups. However, violent victimization was associated with both outcomes only among girls. Lack of school safety was associated with attempts but not ideation/planning among all students. There were distinct differences in risk factors associated with both outcomes among boys.

CONCLUSIONS

The results indicate differences and similarities in risk behaviors and psychosocial factors associated with suicidality by sex and reservation/urban setting. Implications include screening potentially at-risk students for depression, violent victimization, substance use, and school safety and use of the findings by tribal and school programs in designing prevention and intervention programs.

Evidence Mapping: Interventions for American Indian and Alaska Native Youth Mental Health

Background: Suicide is the second leading cause of death for Native youth aged 15-24. Similarly, Native youth have a suicide rate 1.5 times higher than the general population and are at higher risk for depression and substance use. A persistent need remains for culturally specific mental health interventions for American Indian youth.Methods: In response to the push for research-supported interventions, evidence mapping has emerged as systematic, rigorous, and replicable analysis of evidence. The overall goal of this study is to utilize evidence mapping for mental health interventions for American Indian youth.Results: A total of 9 interventions were mapped as research-supported interventions for American Indian mental health. The interventions fell into one or more of four main categories: school-based services, cultural adaptations, culture as treatment, and community involvement.Discussion: Results of this study demonstrate the strength of culturally specific mental health interventions for American Indian youth. Future research should seek to evaluate promising practices for American Indian youth in order to increase available research-supported interventions. Additionally, future endeavors should seek to combine both Indigenous and Western approaches to practice with a particular focus on holistic wellness.

A Community-Based Response to a Suicide Cluster

Background: A 45-month community-based suicide prevention program was launched in response to the emergence of a suicide cluster in 2010 in Hong Kong. Aims: This study aimed to evaluate the effectiveness of the program, document the implementation and outcomes of the project, and identify factors that contribute to the outcomes. Method: The program was delivered following the five key components of the public health approach: (a) community consensus building; (b) surveillance and monitoring; (c) development of coordinated action strategies; (d) interventions development and implementation at the universal, selective, and indicated levels; and (d) program evaluation. Results: A significant decreasing trend of suicide was found in the study site during the intervention period, whereas no changes were found in the three control sites. Spatial analysis also showed that the suicide cluster subsided after the intervention. Three impacts and one challenge of the program were identified from the qualitative feedback of the program stakeholders. Limitations: More investigations should be made to assess the sustainability of this community-based suicide prevention effort in the long run. Conclusion: A community-based suicide prevention program was successfully implemented to address the suicide cluster. A reduction in the suicide rate was observed after the intervention.

LET's CONNECT community mentorship program for youths with peer social problems: Preliminary findings from a randomized effectiveness trial

This study examined the effectiveness of LET's CONNECT (LC), a community mentorship program for youths who report peer social problems, which is based on a positive youth development framework. Participants were 218 youths (66.5% girls), aged 12 to 15 years, who were recruited from an urban medical emergency department and screened positive for bullying victimization, bullying perpetration, and/or low social connectedness. Youths were randomized to LC (n = 106) or the control condition (n = 112). Six-month outcomes were assessed with self-report measures of youth social connectedness, community connectedness, thwarted belongingness, depression, self-esteem, and suicidal ideation. LC was associated with a significant increase in only one of these outcomes, social connectedness (effect size = 0.4). It was associated consistently with trend-level positive changes for thwarted belongingness (decreased), depression (decreased), community connectedness, and self-esteem (effect sizes = 0.2). There was no effect on suicidal ideation (effect size = 0.0), and although not a primary outcome, eight youths in the LC condition and seven youths in the control condition engaged in suicidal behavior between baseline and follow-up. Although LC effect sizes are consistent with those from previous studies of community mentorship, there were multiple challenges to LC implementation that affected dosage and intervention fidelity, and that may account for the lack of stronger positive effects.

Barriers and Strategies for Healthy Food Choices among American Indian Tribal College Students: A Qualitative Analysis

BACKGROUND

American Indian and Alaskan Native individuals experience disproportionate levels of chronic health conditions such as type 2 diabetes and overweight and obesity that are influenced by dietary patterns and food choices. Understanding factors that influence healthy food choices among tribal college students can enrich education and programs that target dietary intake.

OBJECTIVE

To build an understanding of factors that influence healthy food choices among tribal college students at increased risk for college attrition.

DESIGN

A nonexperimental cohort design was used for qualitative descriptive analysis.

PARTICIPANTS/SETTING

Participants (N=20) were purposively sampled, newly enrolled, academically underprepared tribal college students enrolled in a culturally relevant life skills course at an upper Midwest tribal college between September 2013 and May 2015. Participant demographic characteristics included various tribal affiliations, ages, and number of dependents.

MAIN OUTCOME MEASURES

Participant responses to qualitative research questions about dietary intake, food choices, self-efficacy for healthy food choices, psychosocial determinants, and barriers to healthy food choices during telephone interviews were used as measures.

ANALYSIS

Qualitative analysis included prestudy identification of researcher bias/assumptions, audiorecording and transcription, initial analysis (coding), secondary analysis (sorting and identifying meaning), and verification (comparative pattern analysis).

RESULTS

Qualitative analysis revealed a variety of themes and subthemes about healthy food choices. Main themes related to barriers included taste, food gathering and preparation, and difficulty clarifying healthy food choices. Main themes related to strategies included taste, cultural traditions and practices, and personal motivation factors.

CONCLUSIONS

Qualitative analysis identified barrier and strategy themes that may assist nutrition and dietetics practitioners working with tribal/indigenous communities, tribal college educators and health specialists, and tribal community health workers who target health and dietary intake of American Indian and Alaskan Native students.

Insights from Cowichan: A Hybrid Approach to Understanding Suicide in One First Nations' Collective

Explanations for suicide are theorized primarily in terms of the individual, seldom considering the interdependent orientation of Indigenous communities. Drawing on the interpersonal theory of suicide and settler colonial theory, this study addresses Indigenous suicide on two levels: the individual and the collective. Twenty-one interviews were conducted with members of the Cowichan Tribes to understand reasons for suicide in one community. Qualitative analysis identified explanatory constructs proposed by the interpersonal theory as well as negative conditions stemming from colonialism, as proposed by settler colonial theory. These results argue that Indigenous suicidal behavior is best understood from an interdependent standpoint.

Suicide in Brazilian indigenous communities: clustering of cases in children and adolescents by household

OBJECTIVE To estimate age and sex-specific suicide rates, compare suicide rates between indigenous communities, and quantify the frequency of intrafamilial suicide clustering. METHODS We performed a retrospective cohort study involving 14,666 indigenous individuals in reservations in Dourados, state of Mato Grosso do Sul, Brazil, from 2003 through 2013 using national and local census. RESULTS The overall suicide rate was 73.4 per 100,000 person-years. Adolescent males aged 15-19 and girls aged 10-14 had the highest rates for each sex at 289.3 (95%CI 187.5-391.2) and 85.3 (95%CI 34.9-135.7), respectively. Comparing the largest reservations, Bororo had a higher suicide rate than Jaguapiru (RR = 4.83, 95%CI 2.85-8.16) and had significantly lower socioeconomic indicators including income and access to electricity. Nine of 19 suicides among children under 15 occurred in household clusters. Compared with adult suicides, a greater proportion of child (OR = 5.12, 95%CI 1.89-13.86, p = 0.001) and adolescent (OR = 3.48, 95%CI 1.29-9.44, p = 0.017) suicides occurred within household clusters. CONCLUSIONS High rates of suicide occur among children and adolescents in these indigenous reservations, particularly in poor communities. Nearly half of child suicides occur within household clusters. These findings underscore the need for broad public health interventions and focused mental health interventions in households following a suicide.

Cyberbullying and Internalizing Difficulties among Indigenous Adolescents in Canada: Beyond the Effect of Traditional Bullying

Most research on bullying and cyberbullying has focused on dominant populations. In particular, inquiries into Indigenous adolescents' involvement in bullying and cyberbullying are scarce. The present study examines the relationship between bullying and cyberbullying involvement and self-reported depression, anxiety, and stress among a sample of 170 Indigenous adolescents (54% female; M age = 15.2 years). Controlling for age and gender, the results of a series of hierarchical multiple regression models indicate that cyberbullying victimization uniquely contributes to self-reported anxiety and stress among Indigenous adolescents, beyond the contribution of traditional bullying victimization. The implications of these findings are discussed.

Longitudinal Prediction of Suicide Attempts for a Diverse Adolescent Sample of Native Hawaiians, Pacific Peoples, and Asian Americans

The objective of this study was to determine the longitudinal predictors of past-6-month suicide attempts for a diverse adolescent sample of Native Hawaiians, Pacific peoples, and Asian Americans. The study used longitudinal data from the Hawaiian High Schools Health Survey (N = 2,083, 9th to 11th graders, 1992-1993 and 1993-1994 school years). A stepwise multiple logistic regression was conducted. The final model consisted of three statistically significant predictors: (1) Time 1 suicide attempt, odds ratio = 30.6; (2) state anxiety, odds ratio = 4.9; and (3) parent expectations, odds ratio = 1.9. Past suicide attempt was by far the strongest predictor of future suicide attempts. Implications are discussed, including the need for screening of prior suicide attempts and focused interventions after suicide attempts.

An Australian Indigenous community-led suicide intervention skills training program: community consultation findings

BACKGROUND

Little is known of the appropriateness of existing gatekeeper suicide prevention programs for Indigenous communities. Despite the high rates of Indigenous suicide in Australia, especially among Indigenous youth, it is unclear how effective existing suicide prevention programs are in providing appropriate management of Indigenous people at risk of suicide.

METHODS

In-depth, semi-structured interviews and focus groups were conducted with Indigenous communities in rural and regional areas of Southern Queensland. Thematic analysis was performed on the gathered information.

RESULTS

Existing programs were time-intensive and included content irrelevant to Indigenous people. There was inconsistency in the content and delivery of gatekeeper training. Programs were also not sustainable for rural and regional Indigenous communities.

CONCLUSIONS

Appropriate programs should be practical, relevant, and sustainable across all Indigenous communities, with a focus on the social, emotional, cultural and spiritual underpinnings of community wellbeing. Programs need to be developed in thorough consultation with Indigenous communities. Indigenous-led suicide intervention training programs are needed to mitigate the increasing rates of suicide experienced by Indigenous peoples living in rural and remote locations.

The need for a culturally-tailored gatekeeper training intervention program in preventing suicide among Indigenous peoples: a systematic review

BACKGROUND

Suicide is a leading cause of death among Indigenous youth worldwide. The aim of this literature review was to determine the cultural appropriateness and identify evidence for the effectiveness of current gatekeeper suicide prevention training programs within the international Indigenous community.

METHOD

Using a systematic strategy, relevant databases and targeted resources were searched using the following terms: 'suicide', 'gatekeeper', 'training', 'suicide prevention training', 'suicide intervention training' and 'Indigenous'. Other internationally relevant descriptors for the keyword "Indigenous" (e.g. "Maori", "First Nations", "Native American", "Inuit", "Metis" and "Aboriginal") were also used.

RESULTS

Six articles, comprising five studies, met criteria for inclusion; two Australian, two from USA and one Canadian. While pre and post follow up studies reported positive outcomes, this was not confirmed in the single randomised controlled trial identified. However, the randomised controlled trial may have been underpowered and contained participants who were at higher risk of suicide pre-training.

CONCLUSION

Uncontrolled evidence suggests that gatekeeper training may be a promising suicide intervention in Indigenous communities but needs to be culturally tailored to the target population. Further RCT evidence is required.

A systematic review of evaluated suicide prevention programs targeting indigenous youth

BACKGROUND

Indigenous young people have significantly higher suicide rates than their non-indigenous counterparts. There is a need for culturally appropriate and effective suicide prevention programs for this demographic.

AIMS

This review assesses suicide prevention programs that have been evaluated for indigenous youth in Australia, Canada, New Zealand, and the United States.

METHOD

The databases MEDLINE and PsycINFO were searched for publications on suicide prevention programs targeting indigenous youth that include reports on evaluations and outcomes. Program content, indigenous involvement, evaluation design, program implementation, and outcomes were assessed for each article.

RESULTS

The search yielded 229 articles; 90 abstracts were assessed, and 11 articles describing nine programs were reviewed. Two Australian programs and seven American programs were included. Programs were culturally tailored, flexible, and incorporated multiple-levels of prevention. No randomized controlled trials were found, and many programs employed ad hoc evaluations, poor program description, and no process evaluation.

CONCLUSION

Despite culturally appropriate content, the results of the review indicate that more controlled study designs using planned evaluations and valid outcome measures are needed in research on indigenous youth suicide prevention. Such changes may positively influence the future of research on indigenous youth suicide prevention as the outcomes and efficacy will be more reliable.

Developing a school-based preventive life skills program for youth in a remote Indigenous community in North Australia

Purpose

– The purpose of this paper is to describe the process of development and the pilot implementation of a preventive life skills curriculum for Indigenous middle school students in a very remote community college in the West Arnhem region of North Australia. The curriculum integrates proven educational and psychological techniques with culturally informed notions of relatedness and was developed as a contribution to efforts to prevent alarming rates of suicide among remote Indigenous youth. In this paper, the term, Indigenous refers to Australians of Aboriginal or Torres Strait Islander descent.

Design/methodology/approach

– Based on reviews of research literature on school-based suicide prevention and social and emotional learning in both general and Indigenous populations, and following detailed community consultations, a 12 week curriculum was drafted and implemented in two middle school classes (combined years 7-9). Lessons were videotaped and later analyzed and detailed commentary was sought from participating school staff.

Findings

– The pilot program has yielded important insights into requirements of a curriculum for young people with low English literacy levels and with variable school attendance patterns. It confirmed the need to adjust both pedagogical approach and curriculum content for the program to have resonance with students from this linguistic and cultural background and with varying levels of exposure to multiple stressors in disadvantaged community settings.

Practical implications

– The project has identified and resolved key questions for sustainable implementation of a preventive curriculum in challenging community circumstances.

Originality/value

– There are to date no examples of the systematic adaptation and design of a universal preventive intervention specifically for remote Australian Indigenous youth. The project is the first step toward the formal evaluation of the efficacy of a classroom-based approach to suicide prevention in remote community schools.

Suicide Prevention Strategies for Improving Population Health

Suicide is a public health problem that accounts for more than 1 million deaths annually worldwide. This article addresses evidence-based and promising youth suicide prevention approaches at the primary, secondary, and tertiary levels. Coordinated, developmentally timed, evidence-based suicide prevention approaches at all intervention levels are likely to reduce youth suicide. For most youth who die by suicide, there are opportunities for intervention before imminent risk develops. Current research in suicide prevention points to the value of investing in "upstream" universal interventions that build skills and resilience as well as policies that enable access to care and protection from lethal means.

Advancing suicide prevention research with rural American Indian and Alaska Native populations

As part of the National Action Alliance for Suicide Prevention's American Indian and Alaska Native (AI/AN) Task Force, a multidisciplinary group of AI/AN suicide research experts convened to outline pressing issues related to this subfield of suicidology. Suicide disproportionately affects Indigenous peoples, and remote Indigenous communities can offer vital and unique insights with relevance to other rural and marginalized groups. Outcomes from this meeting include identifying the central challenges impeding progress in this subfield and a description of promising research directions to yield practical results. These proposed directions expand the alliance's prioritized research agenda and offer pathways to advance the field of suicide research in Indigenous communities and beyond.

A continuum of approaches toward developing culturally focused prevention interventions: from adaptation to grounding

The purpose of this article is to describe a conceptual model of methods used to develop culturally focused interventions. We describe a continuum of approaches ranging from non-adapted/surface-structure adapted programs to culturally grounded programs, and present recent examples of interventions resulting from the application of each of these approaches. The model has implications for categorizing culturally focused prevention efforts more accurately, and for gauging the time, resources, and level of community engagement necessary to develop programs using each of the different methods. The model also has implications for funding decisions related to the development and evaluation of programs, and for planning of participatory research approaches with community members.

People awakening: collaborative research to develop cultural strategies for prevention in community intervention

The consequences of alcohol use disorder (AUD) and suicide create immense health disparities among Alaska Native people. The People Awakening project is a long-term collaboration between Alaska Native (AN) communities and university researchers seeking to foster health equity through development of positive solutions to these disparities. These efforts initiated a research relationship that identified individual, family, and community protective factors from AUD and suicide. AN co-researchers next expressed interest in translating these findings into intervention. This led to development of a strengths-based community intervention that is the focus of the special issue. The intervention builds these protective factors to prevent AUD and suicide risk within AN youth, and their families and communities. This review provides a critical examination of existing literature and a brief history of work leading to the intervention research. These work efforts portray a shared commitment of university researchers and community members to function as co-researchers, and to conduct research in accord with local Yup'ik cultural values. This imperative allowed the team to navigate several tensions we locate in a convergence of historical and contemporary ecological contextual factors inherent in AN tribal communities with countervailing constraints imposed by Western science.

Outcome of a school-based intervention to promote life-skills among young people in Cambodia

BACKGROUND

Most of the school-based interventions to prevent suicide are from high income countries and there is a need for evidence based interventions in resource-poor settings. The aim of this study is to evaluate the outcome of a school based intervention to reduce risk factors for suicide among young people in Cambodia by promoting life skills.

METHOD

Six classes were randomly selected from two schools each, one designated as experimental and the other as control school, respectively. In experimental school 168 young people (M=92, F=76) received 6 sessions of life skills education and in the control school 131 students (M=53, F=78) received three general sessions on health. We looked at the pre-post differences on Life-Skills Development Scale Adolescent Form (LSDS-AF)- and Youth Self-Report (YSR) questionnaire to measure the effect size (ES) from the intervention after 6 months. We analyzed the data by stratifying for gender and for those who reported more severe suicidal expressions at baseline (high-risk group).

RESULTS

The girls showed improvement in Human Relationship (ES=0.57), Health Maintenance (ES=0.20) and the Total Life Skills Dimensions (ES=0.24), whereas boys with high-risk behavior improved on Human Relationship (ES=0.48), Purpose in Life (ES=0.26) and Total Life Skills Dimensions (ES=0.22). Effect size for YSR-syndrome scores among all individuals showed no improvement for either gender. Among high-risk individuals boys had a small to moderate effect size from intervention on Withdrawn/Depressed (ES=0.40), Attention problems (ES=0.46), Rule breaking behavior (ES=0.36), Aggressive behavior (ES=0.48) and Externalizing syndrome (ES=0.64).

CONCLUSION

Promoting life skills in schools may enhance the overall mental health of young people, indirectly influencing suicide, particularly among boys with high-risk behavior in Cambodia.

Improving care for depression and suicide risk in adolescents: innovative strategies for bringing treatments to community settings

This article reviews the literature on interventions and services for depression and suicide prevention among adolescents, with the goals of placing this science within the context of currently changing health care environments and highlighting innovative models for improving health and mental health. We examine the challenges and opportunities offered by new initiatives and legislation designed to transform the US health and mental health care systems; summarize knowledge regarding the treatment of depression and suicidality/self-harm in adolescents; and describe innovative models for partnering with health systems and communities. This review demonstrates that treatment models and service delivery strategies are currently available for increasing evidence-based care, particularly for depression, and concludes with recommendations for future research and quality improvement initiatives aimed at inspiring additional efforts to put science to work, bridge science and community practice, and develop strategies for partnering with communities to improve care, mental health, and well-being among adolescents.

A systematic review of school-based suicide prevention programs

OBJECTIVE

Suicide is one of the leading causes of death among youth today. Schools are a cost-effective way to reach youth, yet there is no conclusive evidence regarding the most effective prevention strategy. We conducted a systematic review of the empirical literature on school-based suicide prevention programs.

METHOD

Studies were identified through MEDLINE and Scopus searches, using keywords such as "suicide, education, prevention and program evaluation." Additional studies were identified with a manual search of relevant reference lists. Individual studies were rated for level of evidence, and the programs were given a grade of recommendation. Five reviewers rated all studies independently and disagreements were resolved through discussion.

RESULTS

Sixteen programs were identified. Few programs have been evaluated for their effectiveness in reducing suicide attempts. Most studies evaluated the programs' abilities to improve students' and school staffs' knowledge and attitudes toward suicide. Signs of Suicide and the Good Behavior Game were the only programs found to reduce suicide attempts. Several other programs were found to reduce suicidal ideation, improve general life skills, and change gatekeeper behaviors.

CONCLUSIONS

There are few evidence-based, school-based suicide prevention programs, a combination of which may be effective. It would be useful to evaluate the effectiveness of general mental health promotion programs on the outcome of suicide. The grades assigned in this review are reflective of the available literature, demonstrating a lack of randomized controlled trials. Further evaluation of programs examining suicidal behavior outcomes in randomized controlled trials is warranted.

Understanding the effectiveness of school-based interventions to prevent suicide: a realist review

BACKGROUND

Schools appear an obvious place to deliver suicide prevention interventions for children and adolescents. The complexity of suicide interventions lead to a paucity of good quality evidence. An alternate approach of information gathering is needed to identify and collate evidence from existing interventions.

SCOPE

We completed a realist review of school-based suicide interventions. This is a novel method of understanding complex interventions that uses an iterative approach. In this review, we attempt to clarify and lay out what type of suicide intervention programme might be useful in schools, based on the local needs and context.

CONCLUSION

It is possible to develop and implement an evidence-based suicide intervention in schools by understanding the different processes that can contribute to success or failure of these interventions in a real-world setting.

A systematic review of suicide prevention interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand

BACKGROUND

Indigenous peoples of Australia, Canada, United States and New Zealand experience disproportionately high rates of suicide. As such, the methodological quality of evaluations of suicide prevention interventions targeting these Indigenous populations should be rigorously examined, in order to determine the extent to which they are effective for reducing rates of Indigenous suicide and suicidal behaviours. This systematic review aims to: 1) identify published evaluations of suicide prevention interventions targeting Indigenous peoples in Australia, Canada, United States and New Zealand; 2) critique their methodological quality; and 3) describe their main characteristics.

METHODS

A systematic search of 17 electronic databases and 13 websites for the period 1981-2012 (inclusive) was undertaken. The reference lists of reviews of suicide prevention interventions were hand-searched for additional relevant studies not identified by the electronic and web search. The methodological quality of evaluations of suicide prevention interventions was assessed using a standardised assessment tool.

RESULTS

Nine evaluations of suicide prevention interventions were identified: five targeting Native Americans; three targeting Aboriginal Australians; and one First Nation Canadians. The main intervention strategies employed included: Community Prevention, Gatekeeper Training, and Education. Only three of the nine evaluations measured changes in rates of suicide or suicidal behaviour, all of which reported significant improvements. The methodological quality of evaluations was variable. Particular problems included weak study designs, reliance on self-report measures, highly variable consent and follow-up rates, and the absence of economic or cost analyses.

CONCLUSIONS

There is an urgent need for an increase in the number of evaluations of preventive interventions targeting reductions in Indigenous suicide using methodologically rigorous study designs across geographically and culturally diverse Indigenous populations. Combining and tailoring best evidence and culturally-specific individual strategies into one coherent suicide prevention program for delivery to whole Indigenous communities and/or population groups at high risk of suicide offers considerable promise.

The Racial-Cultural Framework

Suicide-related outcomes are a major public health challenge in communities of color in the United States. To address these challenges, this Major Contribution makes theoretical, empirical, and practice-related contributions to scholarship on suicide-related outcomes among people of color. In this article, the authors present a new framework to conceptualize previous suicidology scholarship, address existing literature gaps, and inform counseling psychologists’ future work on suicide-related outcomes in U.S. communities of color. The framework consists of three components and nine principles that highlight the types of constructs, populations, and preventive interventions that should be emphasized in theory, research, and practice addressing suicide-related outcomes in communities of color. The authors explain why suicide-related outcomes in communities of color deserve attention, describe the framework, and discuss implications of the framework for future practice and training. It is hoped that this framework can serve as a resource and impetus for new paradigms of suicidology work in communities of color.

Suicide mortality in São Gabriel da Cachoeira, a predominantly indigenous Brazilian municipality

OBJECTIVE

To describe the characteristics and the raw suicide mortality rates (RSMR) during the period 2000-2007 in the municipality with the largest proportion of self-reported indigenous people in Brazil, São Gabriel da Cachoeira (SGC), State of Amazonas.

METHOD

A retrospective descriptive study was carried out using data from the Information Department of the Brazilian Unified Health System (DATASUS). We considered suicide the cause of death coded in the records as voluntary self-Inflicted injuries according to the International Classification of Diseases and Related Health Problems, 10th revision.

RESULTS

Forty-four suicide cases were registered in this period. The average RSMR was 16.8 per 100,000 inhabitants (male, 26.6; female, 6.3). The highest rates were observed in the age groups 15-24 years and 25-34 years, with RSMR of 43.1 and 30.2 per 100,000 inhabitants, respectively. Most suicides occurred among indigenous people (97.7%), males (81.8%), and unmarried people (70.5%). In most cases, deaths occurred at home (86.4%), during weekends (59.1%) and mainly by hanging (97.7%).

CONCLUSION

Suicide is a significant health and social problem in SGC. The suicide profile observed in this municipality was, as a whole, more similar to that observed in certain indigenous communities than that found in most urban and non-indigenous environments, demonstrating the sociocultural specificity of these events in Brazil.

Feasibility, Acceptability, and Initial Findings from a Community-Based Cultural Mental Health Intervention for American Indian Youth and Their Families

Through a CBPR partnership, university and American Indian (AI) tribal members developed and tested Our Life intervention to promote mental health of AI youth and their families by addressing root causes of violence, trauma, and substance abuse. Based on premises that well-being is built on a foundation of traditional cultural beliefs and practices, and that it requires a process of healing and understanding, the 6-month intervention had four components: 1) recognizing/healing historical trauma; 2) reconnecting to traditional culture; 3) parenting/social skill-building; and 4) strengthening family relationships through equine-assisted activities. Feasibility, acceptability, appropriateness, and preliminary outcomes were examined in a mixed-method within-group design. Engagement and retention were challenging, suggesting that families faced numerous barriers to participation. Youth who completed the program experienced significant increases in cultural identity, self-esteem, positive coping strategies, quality of life, and social adjustment. Qualitative data supported these findings and suggested additional positive effects.

Understanding and preventing military suicide

The continual rise in the U.S. military's suicide rate since 2004 is one of the most vexing issues currently facing military leaders, mental health professionals, and suicide experts. Despite considerable efforts to address this problem, however, suicide rates have not decreased. The authors consider possible reasons for this frustrating reality, and question common assumptions and approaches to military suicide prevention. They further argue that suicide prevention efforts that more explicitly embrace the military culture and implement evidence-based strategies across the full spectrum of prevention and treatment could improve success. Several recommendations for augmenting current efforts to prevent military suicide are proposed.

American Indian and Alaska Native mental health: diverse perspectives on enduring disparities

As descendants of the indigenous peoples of the United States, American Indians and Alaska Natives (AI/ANs) have experienced a resurgence in population and prospects since the beginning of the twentieth century. Today, tribally affiliated individuals number over two million, distributed across 565 federally recognized tribal communities and countless metropolitan and nonreservation rural areas. Although relatively little evidence is available, the existing data suggest that AI/AN adults and youth suffer a disproportionate burden of mental health problems compared with other Americans. Specifically, clear disparities have emerged for AI/AN substance abuse, posttraumatic stress, violence, and suicide. The rapid expansion of mental health services to AI/AN communities has, however, frequently preceded careful consideration of a variety of questions about critical components of such care, such as the service delivery structure itself, clinical treatment processes, and preventive and rehabilitative program evaluation. As a consequence, the mental health needs of these communities have easily outpaced and overwhelmed the federally funded agency designed to serve these populations, with the Indian Health Service remaining chronically understaffed and underfunded such that elimination of AI/AN mental health disparities is only a distant dream. Although research published during the past decade has substantially improved knowledge about AI/AN mental health problems, far fewer investigations have explored treatment efficacy and outcomes among these culturally diverse peoples. In addition to routine calls for greater clinical and research resources, however, AI/AN community members themselves are increasingly advocating for culturally alternative approaches and opportunities to address their mental health needs on their own terms.

Developing preventive mental health interventions for refugee families in resettlement

In refugee resettlement, positive psychosocial outcomes for youth and adults depend to a great extent on their families. Yet refugee families find few empirically based services geared toward them. Preventive mental health interventions that aim to stop, lessen, or delay possible negative individual mental health and behavioral sequelae through improving family and community protective resources in resettled refugee families are needed. This paper describes 8 characteristics that preventive mental health interventions should address to meet the needs of refugee families, including: Feasibility, Acceptability, Culturally Tailored, Multilevel, Time Focused, Prosaicness, Effectiveness, and Adaptability. To address these 8 characteristics in the complex environment of refugee resettlement requires modifying the process of developmental research through incorporating innovative mental health services research strategies, including: resilience framework, community collaboration, mixed methods with focused ethnography, and the comprehensive dynamic trial. A preventive intervention development cycle for refugee families is proposed based on a program of research on refugees and migrants using these services research strategies. Furthering preventive mental health for refugee families also requires new policy directives, multisystemic partnerships, and research training.

Suicide prevention programs through community intervention

Broad general community campaigns were developed to reduce suicide rates. The aim of the current paper was to review such studies in the literature. The MEDLINE search using a combination of the keywords 'suicide', 'education'/'psychoeducation' and 'community' updated through January 10th 2010, returned 424 references and relevant for the current review were 48 with 14 papers reporting results. Although suicide prevention programs through community education are widespread, the reporting of their efficacy is limited. It seems that only long term programs that utilize a commitment of the society at multiple levels and succeed in establishing a community support network that can effectively reduce suicidal rates. The success of most interventions in changing the attitudes and improving the knowledge of the public concerning suicide is restricted at the theoretical-intellectual level; when it comes to action there seems to be no change. Very short duration interventions don't seem to have even this slight effect.

Circle of strength: a case description of culturally integrated suicide prevention

This article presents a case description of an American Indian female at high risk for suicide in effort to document the potential effectiveness of a college student suicide prevention program designed for Northern Plains American Indian students. The program is integrative and culturally grounded within the Medicine Wheel, stressing continuity of care through programming and ongoing communication across support systems. The composite case description presented illustrates the secondary prevention aspects of the model, and how utilizing the model within the framework of continuous care was helpful for a suicidal person and produced a successful outcome over the course of 6 months.

Behavioral and mental health challenges for indigenous youth: research and clinical perspectives for primary care

After first discussing historical, community and epidemiologic perspectives pertaining to mental health problems of Indigenous youth and families, this article reviews available research data on behavioral and mental health interventions and the roles that Native and Indigenous research programs are serving. Given the legacy of transgenerational trauma experienced by Indigenous peoples, community-based research and treatment methods are essential for solving these problems. The primary care provider stands in a unique position within the community to offer a "coinvestigator spirit" to youth and families in the pursuit of improving behavioral health. Strategies are presented for using the research literature, and collaborating with communities and families to help solve behavioral and mental health problems.