The review process resulted in the collection of 1,352 academic papers and grey literature documents, with 391 articles ultimately considered after duplicates were removed. Of these, 961 were excluded as, despite appearing in the search, upon interrogation of the article title and abstract, it was determined that the content of the article fell outside of the scope of the review objectives. 197 articles necessitated full text review as inclusion could not be determined from the title and abstract alone. Of these, 149 further papers were excluded because they did not align with our review objectives nor did not meet inclusion criteria. 8 articles were identified via a hand-search of the reference lists of relevant reviews. Sixteen articles from the grey literature were ultimately included as well. Thus, our final search process resulted in 72 articles—56 of which were academic papers and 16 grey literature documents—that were included for extraction (Fig. 1). The characteristics of the articles along with the overarching themes identified through thematic analysis are summarized in the following section.
Article characteristics
This section presents an overview of the suicide prevention strategies targeting Indigenous populations examined in this review, namely describing the Indigenous communities involved, target demographics, and the types of strategies employed.
Indigenous population and sample
Thirteen articles focused on Indigenous Australians; thirty-two on Indigenous peoples living in the United States (US) (specifically fourteen with Alaska Natives, four Alaska Natives and/or American Indians; eleven American Indians/Native Americans, and three Native Hawaiians); nine on Indigenous peoples in Canada; one on Indigenous peoples in North America; and one on Indigenous peoples in Canada, the US, Australia and New Zealand. No articles involved the Māori of New Zealand. The sample populations reported by studies included Indigenous youth, general community members, or specific subpopulations (such as Indigenous prisoners, students, or males). Notably, no papers incorporated considerations for lesbian, gay, bisexual, transgender, queer, and two-spirited (LGBTQ2+) or gender diverse Indigenous persons.
Types of Articles
The main prevention strategies employed in articles examined in this scoping review comprised: culture as treatment; community prevention activities; gatekeeper training; and education/awareness initiatives. The remaining articles were different types of academic reviews. See Supplementary File 2 for a table detailing key information extracted from academic literature. Articles obtained from the grey literature concerned: guides, strategies, toolkits for suicide prevention in Indigenous populations, outcomes of community engagement on suicide prevention; curriculum documents; brochures, magazine or news articles describing suicide prevention projects; and literature reviews (see Supplementary File 3).
Culture as treatment specifically involved engaging Indigenous culture to mitigate suicide risk or “treating” suicidality among individuals, usually on a one-on-one basis. Community prevention initiatives typically involved empowerment programs, multi-level approaches, broader resiliency strategies targeting Indigenous groups and communities at high risk of suicide, or community-based participatory research to inform program development. Gatekeeper training strategies featured prominently. Gatekeeper training involved teaching specific groups of people in the community how to identify and support individuals at high risk of suicide. Education/awareness initiatives involved activities that explicitly aimed to improve suicide knowledge, attitudes, and/or awareness to develop knowledge/skills that are known to be protective against suicide via, for example, school-based programs for youth, multi-media education sessions to interested community members, or culturally-tailored life skills training for youth. 25 articles involved community prevention, 13 concerned educational/awareness initiatives, 7 featured gatekeeper trainings, 3 involved culture as treatment, 1 featured both community prevention and gatekeeper training components, and 1 involved community prevention, gatekeeper, and education/awareness approaches. The remaining 6 were scoping or systematic reviews of Indigenous suicide prevention projects/programs. Community prevention and education/awareness initiatives involved primary prevention that address upstream root causes and aim to prevent suicide ideation or attempts from even happening by reducing risk and promoting protective factors. Gatekeeper training and culture as treatment involved secondary prevention which endeavour to provide support to persons at immediate risk for suicide/self-harm. No articles involved tertiary prevention efforts which might involve postvention to reduce the risk of further suicides or clusters. Levels of suicide prevention and corresponding articles are detailed in Fig. 2.
Themes
The findings are presented through four overarching and intertwining thematic areas that emerged out of analysis of the academic and grey literature. These thematic areas focus on (1) engaging culture and strengthening connectedness; (2) integrating Indigenous knowledge; (3) Indigenous self-determination; and (4) employing decolonial approaches. We also highlight components of strategies that exemplify each theme. Table 1 summarizes themes, subthemes and corresponding articles.
Table 1
Themes, subthemes, and corresponding articles
Theme
|
Subtheme
|
Articles
|
Engaging culture & strengthening connectedness
|
Culture as treatment
|
[32–40]
|
Engaging cultural connections
|
[32, 37, 41–54, 64]
|
Intergenerational relationships (youth & Elders)
|
[34, 45, 55–65, 67]
|
Strengthening connectedness in families & communities
|
[57, 65, 68–70]
|
Cultural continuity
|
[60, 68, 71, 72]
|
Cultural intervention vs. Culturally-appropriate, -sensitive, or -safe intervention
|
[34, 35, 46, 49, 51, 63, 65, 70, 73–75]
|
Integrating Indigenous knowledge
|
Indigenous understandings of suicide defined by authors
|
[32, 37, 39, 40, 42–44, 46, 47, 52–54, 56, 57, 63, 66, 67, 76, 78, 86, 89, 90, 105, 115–118]
|
Indigenous understandings of suicide defined via community engagement
|
[49, 50, 51, 55, 41, 62, 65, 70, 73, 77, 79–85]
|
Indigenous self-determination
|
Community-based participatory research
|
[41, 49, 55, 70, 34, 35, 46, 63, 65, 73]
|
Other community-engaged approach
|
[33, 36–38, 40, 42–45, 47, 48, 50, 52–54, 56, 57, 62, 64, 66, 75–77, 79, 80, 82, 83, 86, 90, 91, 105, 115–117]
|
Indigenous ownership
|
[41, 53, 55, 60, 85, 88, 89]
|
Employing decolonial approaches
|
Cautioning against pan-Indigenous approaches
|
[52, 62, 68, 77]
|
Integrating contextual considerations
|
[44, 51, 63, 73, 81, 91]
|
Other decolonial approaches
|
[40, 41, 44, 45, 50, 63, 64, 79, 80, 85, 86, 91]
|
Engaging culture and strengthening connectedness
Engaging culture and strengthening connectedness to prevent suicide emerged as an important theme across the articles examined in this critical scoping review. All articles highlighted connection to culture as a crucial component to meaningful and effective suicide prevention in Indigenous populations. Within this theme, we focused on analyzing the ways in which culture and efforts to strengthen connectedness are integrated into suicide prevention content and the resulting impacts.
Generally, engaging culture took on several different forms. First, some initiatives were built around the notion of “culture as intervention” or “culture as treatment,” where engaging Indigenous culture was seen as an important means for mitigating suicide risk or “treating” suicidality among individuals. Culture as intervention or treatment could be the main strategy, or a component of a broader strategy, and took on several forms including resilience retreats/culture camps, cultural teachings/values, ceremony, sharing circles, storytelling, creative arts, narrative approaches to psychotherapy, art therapy, other locally-relevant healing/coping strategies and more [32–40].
In these initiatives, individual-level effects on suicide risk via cultural connections included increases in the number of protective behaviours which authors argue were fostered by culture-specific beliefs and experiences that make life enjoyable, worthwhile, and meaningful [34]. Individual-level impacts among participants included reductions in distress, bolstering of protective factors, and reduction in suicide/self-harm behaviours [34, 36, 40]. Activities that involved local Indigenous culture as suicide prevention were observed to have a measurable impact on suicide-related outcomes such as increased positive mood, feelings of belongingness, and perceived coping of participants, even in programs where the specific topic of suicide was not breached [32, 33].
Second, engaging cultural connections arose as an important means to create new or adapt existing suicide prevention strategies to increase effectiveness and appropriateness in Indigenous contexts. Initiatives often took the form of gatekeeper trainings or educational/awareness initiatives and were typically created or adapted from the ground up either in partnership with or, less frequently, under the leadership of the respective Indigenous community [41–47]. Cultural inclusion in the design of programs or adaptation involved a multitude of factors including: acknowledgement of the impacts of colonization and ongoing marginalization on suicide in Indigenous contexts, integration of Indigenous pedagogies (i.e. team-teaching, land-based learning, experiential/hands-on activities, etc.), emphasis on the holistic aspects of wellbeing, focus on strengths-based approaches, incorporating art, and inclusion of Indigenous languages and cultural values [32, 41–44, 47–51].
Authors underlined the positive impacts of integrating local Indigenous culture at both the individual- and community-level. For instance, individual-level impacts for gatekeeper trainings included improved attitudes toward suicide, increases in participants’ knowledge and confidence in how to identify individuals at-risk of suicide, increases in intended and actual assisting behaviours, and significant improvements in understanding the links between cultural strengths, social and emotional wellbeing and suicide prevention [43, 44, 47, 48]. Moreover, participants in culturally-grounded suicide education and awareness initiatives were shown to have less suicidal ideation and “negative thinking”, expressed fewer feelings of hopelessness, could come to terms with the ‘cycle of grief,’ demonstrated reduced stigma towards suicide and increased willingness to seek help, and had an increase in psychological service utilization [45, 52–54]. Participants in community suicide prevention programs which integrated culture had significant increases in positive mood, feelings of belongingness, perceived coping, reasons for living, and overall resiliency [32, 34, 37].
Strengthening connectedness was consistently identified by articles as an important element for effective suicide prevention in Indigenous populations. We included it along with the theme of engaging culture as it was typically discussed as a key Indigenous cultural value which contrasted conventional Western approaches to suicide prevention. While there is much diversity in Indigenous ways of being and knowing, the ontologies of interconnectedness and relationality are shared across many of the Indigenous populations involved in articles reviewed. Strengthening connectedness comprised emphasis on encouraging intergenerational relationships, particularly between youth and Elders, strengthening connectedness within families and whole communities, and bolstering cultural continuity.
Fostering relationships between youth and Elders was a frequent community-identified means of prevention to support protective factors and promote healing among youth via opportunities to learn cultural teachings, language, and connect with the land and spirit with Elders who are the holders of a community’s traditional knowledge. Three strategies featured approaches that brought together youth and Elders as part of suicide prevention, which were noted to have implications for protective factors against suicide among youth such as strengthening youth reasons for living and combating “discontinuity” [34, 55, 56]. Furthermore, a participatory action research project that sought to explore community-identified risk factors as well as strategies to strengthen protective factors found connection between youth and Elders to be an important community-level strategy to suicide prevention [57].
This importance of bringing together youth and Elders was also echoed across the grey literature, typically as outcomes of community engagement on suicide prevention. Reports emphasized how Indigenous culture, knowledge, and language—which impart protection against suicide—are transferred from Elders to youth and suicide prevention thus needs to foster these relationships [58–61]. This sentiment is embodied in a quote from an Elder from an Australian Indigenous community experiencing high rates of youth suicide and self-harm: “The only way to stop suicide is to fulfill our cultural obligation to teach our young ….strength of character through strength of culture.” [59]. Other suicide prevention initiatives did not necessarily bring together youth and Elders as an intervention component, but still created opportunities for connecting them as part of community engagement processes [41, 61–67].
Notably, articles also spoke to the importance of strengthening connectedness within families and across community as part of suicide prevention [57, 65, 68–70]. For families, this could include restoring and strengthening connections within and between families through shared activities (especially cultural or spiritual activities); offering life skills programs; and providing access to education and/or training [57, 68]. For communities, fostering connections might involve a focus on youth (i.e. drop-in centres, camps, connect to Elders, health promotion and education sessions, parenting programs, restore sporting competitions); restoring and strengthening a sense of community through shared activities (i.e. community events, fun days, competitions, projects); upholding self-determination; men’s and women’s groups; and providing access to employment, education, housing and transport [57, 69].
Several articles noted the importance of efforts to bolster cultural continuity as part of suicide prevention. Authors stressed how strengthening “cultural continuity,” or the degree to which a community participates in actions symbolic of their sense of community as a cultural group, has positive implications for mental wellness, resilience, and thus suicide in Indigenous contexts [60, 68, 71, 72]. Many cite the research of Chandler and Lalonde [16, 17] to underline that a community’s effort to preserve the continuity of their collective culture can impact continuity at the individual-level and act as a hedge against suicide by facilitating individuals’ endurance through life’s routine hardships and build a connection to a sense of self and identity.
Despite the expressed importance of including cultural continuity in suicide prevention, no initiatives involved explicit efforts to support continuity of collective culture at the community-level to impact suicide. When culture was integrated into suicide prevention, it was primarily done so to impact the wellbeing, knowledge and/or behaviours of individuals, not the community as a whole. This was also reflected in the outcome measures captured in program evaluations.
A final subtheme around the definition of cultural intervention emerged from the literature reviewed in this scoping study. Many articles made the distinction between cultural intervention and culturally appropriate or culturally safe intervention. In the former, Indigenous culture is both a central focus of the intervention activities and underlies the theory guiding the intervention. In this sense, a cultural intervention is more likely to be transformative; underpinned by Indigenous ontologies, epistemologies, and/or worldviews; incorporate Indigenous notions of suicide; and be rooted in community defined and prioritized health issues [34, 35, 63, 65, 70].
Culturally-appropriate, -sensitive, -tailored, or -safe interventions, on the other hand, may incorporate Indigenous cultural activities, teachings, language and more but can still be dominated by and reproduce conventional Western/colonial understandings of mental wellness and perpetuate colonial power dynamics [34, 35, 51, 65, 70, 73–75]. As one author notes, the focus on culture by outsiders in health intervention has “too often been a shallow or surface translation describing more macro-level, formulaic, and ahistorical aspects of [Indigenous] life.” [49]. Cultural adaptations of conventional suicide prevention strategies may be more susceptible to reliance on the underlying Western/colonial assumptions of the original intervention and typically involve modifying “non-active” treatment components of the intervention for cultural acceptability such as language or style of the intervention, who delivers it, or the treatment setting [46]. Many adaptations also place importance on finding a balance between meeting community/cultural needs and preserving fidelity/standardization [50, 52, 68, 76].
Integrating Indigenous knowledge
Integrating Indigenous knowledge into suicide prevention arose as a prominent theme across articles included in this scoping review. In this section, we specifically focus on how Indigenous knowledge impacts the conceptualizing of the issue of suicide and subsequently shapes how programs are designed and implemented. The majority of articles attempted to define the issue of suicide from an Indigenous perspective as a foundational step to developing an appropriately community-driven initiative. This was achieved through two methods: via author-driven definitions or via definitions acquired through community engagement processes. In cases where definitions were proposed by authors, suicide was commonly defined in connection to assumed Indigenous notions of wellness in general. For example, one study’s authors characterized suicide in alignment with Indigenous perspectives which “[focus] more on understanding and addressing what is going on around the individual than addressing what is going on inside.” [73]. Focusing on what is going on around the individual meant consideration of the “complex socio-cultural, political, biological and psychological phenomenon that needs to be understood in the context of colonization, loss of land and culture, transgenerational trauma, grief and loss, and racism and discrimination." [42].
Some strategies informed by this notion employed multi-level approaches (community-wide events, policy efforts, educational programs for youth, and traditional ceremonies) that involved multiple sectors of the community simultaneously (individuals, families, wider community) [34, 65, 70, 73, 77]. Others took aim at intervening on one or more of these broader determinants like, for example, seeking to support knowledge transfer via intergenerational relationships or just generally integrating Indigenous culture into curriculum content [55]. Other initiatives incorporated locally-relevant content, information about Indigenous culture or colonization and ongoing marginalization and how they contribute to the issue of suicide in Indigenous contexts [42, 45, 78].
On the other hand, articles that sought community-based understandings of suicide via engagement processes tended to emphasize a focus on strengths and resilience in opposition to the typical focus on deficits and problems [41, 49–51, 55, 62, 65, 70, 73, 77, 79–85]. This is illustrated in a statement from an Elder who co-led the development of a youth resiliency project and co-authored the resulting paper: “Why do we talk about suicide all the time!? Let’s talk about love!” [41]. Thus, strategies informed from Indigenous notions of suicide intentionally shifted from a focus on deficit—which is more typical of conventional Western suicide prevention—to a focus on life promotion with attention to existing community strengths and assets, while upholding community control and sovereignty and supporting local empowerment [41, 63, 73, 79, 77, 81]. This connects with the subsequent section in which we discuss the theme of Indigenous self-determination in suicide prevention.
Indigenous self-determination
Self-determination in suicide prevention was frequently identified as an essential requirement for success. The majority of articles employed some means to ensure some level of self-determination was achieved via community engagement in the design and/or implementation of suicide prevention. This was commonly achieved by employing community-based participatory research (CBPR) or participatory action research approaches. CBPR was utilized “to address power differentials through shared learning ….[it] is a move toward reconciliation, reciprocity, and production of culturally relevant prevention measures” [63]. Community engagement was seen by authors as a key requirement for success, as it increases community relevance, appropriateness, and in particular, ownership of suicide prevention [34, 35, 41, 53, 63, 73, 81, 85–88].
The emergent subtheme of ownership referred not to the legal sense of the word (i.e., the right to possess and control the initiative) [87] but more to the community stepping up to take on responsibility in executing an initiative while being invested in seeing out its success [41, 53, 60, 85, 88, 89]. In this sense, community ownership in a strategy has implications for acceptability, uptake, participation, and dedication to investing necessary resources. Another reason why community ownership was expressed as crucial to suicide prevention success is because it is correlated with longevity and sustainability [41, 53, 89].
Indigenous authorship also emerged as a notable subtheme of Indigenous self-determination in suicide prevention. Many of the articles reviewed here highlighted that they were co-authored by members of the specific target Indigenous communities or members of broader Indigenous communities [32, 35, 37, 39, 41–43, 46, 47, 49, 52, 55, 62, 63, 65, 76, 82, 85, 90]. Indigenous authorship was important to ensure materials represent content as intended by community stakeholders, particularly when it comes to native language expertise [55].
Employing decolonial approaches
Lastly, employing decolonial approaches in suicide prevention creation and implementation was a prominent theme in the literature. Decoloniality—or the creation of “locally-governed, community-based, and culturally-responsive systems of care” [51]—has been touched upon in many of the themes already discussed above (i.e., incorporating Indigenous knowledge and culture, upholding self-determination, community-engaged approaches). In this section, we hence focus on other attributes of decolonial approaches highlighted in the literature, namely avoidance of pan-Indigenous approaches, integrating contextual considerations, and more generally, approaches that might diverge from features of conventional Western suicide prevention.
Use of pan-Indigenous approaches was cautioned in the literature and authors advised against application of Indigenous-driven suicide prevention in contexts that they were not designed for [52, 62, 68, 77]. This is because pan-Indigenous strategies may not be reflective of diverse cultural practices, values, sociohistorical context, and geographic considerations unique to each group. Authors stress that programs need to be adaptable to the local community context. This is especially pertinent in the issue of suicide, which can vary significantly from community to community [52, 63].
In line with this, integrating contextual considerations into suicide prevention was also expressed as an important decolonial component. This subtheme was most prominent in recommendations for suicide prevention in Indigenous populations outlined in the grey literature. Contextual considerations included gaining the knowledge of a community’s unique risk and protective factors, incorporating local examples where possible, respect for and adherence to local protocol, involvement of local experts/Elders, developing culture-centered understanding of suicide, assessing community readiness, building and maintaining relationships, contemplating the impact of recent incidents of suicide, considering existing level of trauma and unresolved grief, and incorporating healing components [44, 51, 63, 73, 81, 91].
Other decolonial approaches detailed in the literature specifically took aim at breaking down some of the features common in conventional, Western programs that tend to persist in Indigenous programs (especially cultural adaptions) despite communities finding them unhelpful. This includes allowing for flexibility, especially in contrast to rigid, standardized procedures employed by some interventions like, for example, in Applied Suicide Intervention Skills Training (ASIST). Flexibility could include encouraging use of Indigenous language, carrying out sessions in outdoor settings, allowing for adjusting of required time commitment, creating space for ceremony/spirituality, and more [50, 63, 64, 66, 80, 86].
Articles also discussed avoidance of clinical language or jargon which can create barriers to understanding content. Finally, articles discussed efforts to break down power imbalances between Western and Indigenous approaches by, for example, focusing on local empowerment and capacity by training Indigenous facilitators, involving locally-recognized experts/leaders/healers, and employing Indigenous ways of learning versus a focus on employing clinical experts or utilizing the typical didactic educational models [40, 44, 50, 66, 79, 91]. According to authors, breaking down power imbalances could also involve creating a practice of reflexivity as part of the strategy, where researchers and developers actively reflect on their relationships, position, and privilege and how they are fulfilling their obligations to community [41, 50, 79, 85, 86].