From the Magazine

REDUCING THE INCIDENCE OF SUICIDE IN INDIGENOUS GROUPS – STRENGTHS UNITED THROUGH NETWORKS (RISING SUN)

Photo credit: Alexandra Sawatzky

Political, scientific, and community leaders from across the Arctic have described mental health issues – especially suicide – as one of the region’s most pressing public health problems. Despite best efforts and considerable expenditures, the problem of suicide continues to be a barrier to health and development in the circumpolar North. High rates of suicide among youth exist across the Arctic due to complex reasons ranging from historical traumas as well as new and emerging environmental and social stressors in the face of limited mental services in remote and, often, rural areas. These pressures, and their impact on cultural integrity, access to resources, and the educational and economic prospects of young people, also contribute to Arctic Indigenous suicide.

Under the 2015-2017 US Arctic Council Chairmanship theme of Improving Economic and Living Conditions in Arctic Communities, the RISING SUN initiative used a consensus-building process to identify common outcomes for evaluating suicide prevention efforts across the circumpolar North. Whereas a mental wellness project under the preceding 2013-2015 Canadian Arctic Council Chairmanship focused on documenting best practices from the literature and community-based interventions, RISING SUN was designed to take the next step: to develop a web-based toolkit comprising the key outcomes associated with successful suicide prevention interventions across the Arctic.

The toolkit, under development at this time and projected to launch in spring 2018, is proposed to include information on the following: suicide risk factors across the Arctic, along with a general introduction to suicide prevention efforts in circumpolar Indigenous communities; what can be done to alleviate this public health threat and lessons learned from communities that have successfully implemented effective suicide prevention interventions; a collection of prioritized outcomes and existing measures to assess the impact and effectiveness of suicide prevention interventions being implemented across the circumpolar Arctic; and a strategy with best practices for using the toolkit.

In the context of RISING SUN, outcomes are the result of a health service, program, or intervention; and one way to determine if an outcome is achieved is by using measures. For example, the most common outcome of a suicide prevention intervention is a reduction of deaths by suicide, and a corresponding measure would be the number or the rate of suicides over a chosen time interval. Common outcomes and their measures, developed through engagement with Arctic Council Permanent Participants (i.e., Indigenous peoples’ organizations) and community leaders, as well as with mental health experts, are intended to be used for evaluating and improving suicide prevention interventions.

Thus, the principal goal of the RISING SUN initiative was to aid health and community workers in better serving their communities, and to help policy-makers measure progress, evaluate interventions, and identify regional and cultural approaches to suicide prevention. Arriving at common outcomes and having valid measures is important in the Arctic, where the vast geography, high number of remote communities, and breadth of cultural diversity pose challenges for standardized approaches to suicide prevention and the consistent delivery of high-quality mental health care services.

To develop its outcomes, RISING SUN employed diverse approaches that included an adaptation of a technique used for the US National Institute of Mental Health (NIMH) Grand Challenges in Global Mental Health initiative. Following selection of a Scientific Advisory Group, RISING SUN recruited and selected members for a stakeholder panel—from the eight Arctic States and five of the six Permanent Participants of the Arctic Council—to represent diverse advocacy, clinical, Indigenous, policy, research groups, and communities. To this approach was added face-to-face meetings across circumpolar regions to achieve a shared vision and inclusive priority-setting. The method’s structured, sequential questioning with feedback, complemented by regional face-to-face meetings for soliciting group consensus, was ideal for attaining the stated goals of this initiative: to distill knowledge and build reliable consensus to produce a web-based toolkit of outcomes for individual-, family-, community, clinical-, national/regional-, and policy-level interventions.

The RISING SUN initiative convened a series of regional meetings in September 2015 (Anchorage, USA), May 2016 (Tromsø, Norway), and March 2017 (Iqaluit, Canada). Collectively, participants at these meetings reviewed the international community’s understanding of suicide and acknowledged common elements of effective interventions that include agency (i.e., a sense of control over one’s life), self-determination, community engagement, cultural competencies, trained and committed community workers, and sustainable funding. Participants also learned about and assessed various local activities over the past five years pertaining to evidence gathering and intervention strategies. Some examples included building healthy relationships, improving coping skills and self-esteem, and celebrating Indigenous culture. During the final meeting, project co-leads reported on the findings from RISING SUN including the outcomes, a discussion of methodologies, the form and function of the proposed RISING SUN toolkit, the knowledge gaps that remain, and future opportunities for dissemination, implementation, and research.

Overall, the findings from RISING SUN revealed that panelists identified and prioritized outcomes resulting from family- and community-level interventions such as improved social and emotional coping skills among children and youth, an increased number of trained and educated community members who understand resources for care and who can provide support in a crisis, and increased community involvement in suicide prevention including an increased number of youth who are equipped to provide peer-to-peer support.

Several regional focus group discussions were also convened and designed to ensure that additional community and Indigenous participants (who did not otherwise attend the workshops or participate in the online consensus-building activity) could provide input and feedback to the RISING SUN initiative. These activities included interviews conducted with Indigenous leaders, elders, youth and other stakeholders. The purpose was to evaluate what local assets are already in place and that lead to the outcome of healthy communities, and to prioritize the RISING SUN outcomes. In an analysis of the interviews, one theme arose acknowledging the wide variety of relationships that are held sacred and kept in balance when it comes to the health and wellbeing of Indigenous communities.

Activities under the RISING SUN initiative reaffirmed that Arctic Indigenous communities continue to face in access to and quality of mental health care with respect to suicide prevention. However, a number of themes emerged that can offer focus to clinical services providers, community members, policymakers, and suicide prevention researchers. The prioritized outcomes generated from this initiative will form the basis for a web-based toolkit hosted by the Mental Health Innovation Network that provides resources to help Arctic stakeholders evaluate interventions intended to reduce the burden of suicide among Indigenous communities. Immediate areas of emphasis stemming from the RISING SUN initiative may include working more closely with federal, state, and tribal partners (e.g., Alaska Department of Health and Social Services, the Substance Abuse and Mental Health Services Administration (SAMHSA), and Tribal Health Organizations) in promoting opportunities for dissemination and implementation of the RISING SUN toolkit, and research to address remaining knowledge gaps. Given that accurate and reliable measures are essential for evaluating interventions, one likely area of activity could be research associated with the identification and assessment of measures in Arctic Indigenous communities for promising but underappreciated outcomes including increased trauma-informed support for survivors, increased access to relationships with elders, and increased number of youth that are engaged in traditional Indigenous activities.

Once the web-based RISING SUN toolkit is launched, it will be disseminated via webinars and through in-person presentations during circumpolar meetings addressing mental health and suicide prevention among Indigenous communities. Since the resulting outcomes represent different levels of interventions, the intended audience is diverse. For clinicians, the outcomes can be used to promote community engagement and cultural competency (including Indigenous ways of knowing and healing), to improve and evaluate interventions, as well as to reduce suicidal behavior and suicide ideation.

In turn, communities can use the outcomes to enhance their resilience, improve supportive trans-generational relationships, promote protective factors, strengthen social networks, and share effective strategies across the circumpolar Arctic. For policy-makers, the outcomes can be used to inform the design and implementation of policies, intervention programs, and investments in resources including infrastructure and health services workforce training for improving the mental health and wellbeing of Arctic residents. Researchers can use the outcomes to inform research questions, identify gaps in mental health services and intervention research, and promote measures development and validation for Arctic Indigenous communities.
In closing, the RISING SUN initiative made strides toward facilitating efforts to build resilience and reduce suicide among Arctic communities; used community-driven stakeholder engagement, consensus-building and priority-setting processes; and built a narrative around outcomes and measures that can be used to evaluate the effectiveness of suicide prevention programs that are being implemented among Arctic Indigenous communities. ◉

Dr. Roberto Delgado is a trained anthropologist and works in the Office for Research on Disparities and Global Mental Health of the US National Institute of Mental Health. His work focuses on supporting suicide prevention research among Indigenous communities and scaling up mental health interventions in rural and other low-resource settings. For any questions or further information, please email Roberto Delgado – roberto.delgado@nih.gov.

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