Suicide is a leading cause of death for young people ages 10 through 24 in the United States (1,2). Preventive efforts are especially urgent for American Indian and Alaska Native (AIAN) youth whose elevated rates (1,3) have increased significantly in recent years (4). Similarly, rates of suicide in rural areas have increased 1.5 times faster than in urban areas in the United States from 1981 to 2018 (1). In rural America, mental health services are not available to many because of limited access to healthcare generally, mental health provider shortages, and stigma around mental health help-seeking (5,6). For AIAN young people, these factors are likely exacerbated by culturally incongruous care (7). The cultural differences between therapists and the communities they serve can reduce the acceptability and impact of mental health services particularly for suicide prevention for AIAN people (8,9). For communities with histories of systemic injustice, the oppressive practices, such as involuntary inpatient treatment that is linked to suicide interventions, contribute to many not seeking mental health services (10). These issues are particularly relevant in rural locations and in racially and ethnically marginalized communities (11–14).
With suicide rates highest in rural areas and fastest growing among younger people of color (15–17) where culturally-responsive mental health services are sparce, there is an urgent need to understand the factors that can contribute to the success of a broad public health approach to suicide prevention. Such an approach includes more than professional mental health services, and builds on the more readily available community, cultural and social resources in rural and diverse communities (e.g., Elders, parents, family members, mentors) to address suicide (18–21).
A public health approach to suicide prevention engages diverse stakeholders within different community sectors (e.g., law enforcement, schools, religious organizations) and within young people’s existing social support networks (22–24). Such multilevel efforts can include offering interpersonal support to young people, bolstering family support systems, and developing community-level opportunities that promote youth wellbeing and reduce suicide risk. Previous research suggests that such initiatives can be leveraged to create community-based, culturally- and locally- appropriate strategies (18,20,25).
We hypothesize that developing collaborative relationships for suicide prevention and wellness, also described as ‘communities of practice’ (CoP)(26) can be important for sustainment of suicide prevention strategies, particularly in under-resourced communities. Rooted in social learning theory, CoP are groups of people that cultivate three inter-related elements: shared interest, common community, and practice. Often, people within a CoP represent different perspectives and areas of expertise, and therefore learn about and address complex issues from multiple angles. Thus, CoP can strengthen community helping networks by linking them to institutional services and systems, demystifying or destigmatizing mental health or wellness, and increasing interactions so that connections and care may more easily occur when a young person is struggling but not yet actively suicidal (27). Through engagements in CoP, institutional helpers can connect with communities and families they serve, and get feedback for practicing cultural humility, making their services more locally responsive (28). Social networks of support are an important and often overlooked resource to engage in suicide prevention, particularly in under-resourced communities where institutional services are limited (29). Building CoPs (26,30) is an innovative way to address the complex and culturally-specific issue of youth suicide prevention.
Through this study, we highlight these two significant, often overlooked, aspects of suicide prevention: CoP and health promotion in addition to risk reduction or prevention. Our measured behavioral suicide prevention constructs test whether respondents endorsed participation in “promotion behaviors” (actions done to attain a positive outcome, for example “I talked with someone about how culture can promote youth wellness”) and/or in “prevention behaviors” (actions done to avoid a negative outcome, for example: “I helped someone who was down get help”).
This distinction between “prevention” and “promotion”-oriented behaviors aligns with Regulatory Focus Theory, which posits that people are motivated to pursue goals from these two different orientations, depending on personality and circumstances of an action (31,32). Promotion behaviors for health can generally be done regularly, regardless of circumstances within family and community life. Emergent opportunities to do “prevention” behaviors occur less frequently in daily life because they are predicated on risk detection or observed struggles. Thus, for people in community and family roles such as parents, teachers, coaches, Elders, these behaviors are more challenging to capture over a period of a few months. It is important to include both prevention and promotion in suicide prevention efforts.
Our study assesses how wellness self-efficacy and suicide prevention self-efficacy relate to self-reported preventative behaviors of community members and considers participants’ collaborative relationships or CoP. Put differently, our theoretical model includes the social relationships that both enable supportive interactions with people who are suffering, and offer resources and support to enhance and sustain culturally-responsive practices to enhance mental wellbeing and to intervene to prevent suicidal behavior.
Our cross-sectional survey research from five Alaska Native (AN) rural and remote communities offers a snapshot of community members’ self-perceptions and self-reported behaviors--including suicide prevention and health promotion hereafter referred to as ‘preventative behaviors’--to assess the relationships between these key factors. Our analysis also considers the preventative behaviors of people in different kinds of roles within community (family, friends, and Elders) and institutional (behavioral health and mental health counselors, teachers, community health workers) support networks of young people. We have updated our use of the terms “community” instead of “informal” and “institutional” in lieu of “formal” to acknowledge the important ways in which cultural and local protocols structure social relationships, and to reflect language that does not marginalize these social structures of engagement. Our study highlights how survey respondents’ self-perceptions and current collaborations support a variety of preventative behaviors. Collaboration across and among these social networks may be important for sustaining suicide prevention and wellness promotion activities, particularly in tight-knit communities. To date, little research considers the role of collaborative relationships in diversifying approaches to suicide prevention to include broad prevention strategies, including wellness promotion, that can be put into practice across multiple community sectors (23,33).