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Objective To develop and use planning maps to prioritize and facilitate county‐level recruitment for Together With Veterans (TWV), community‐based rural Veteran suicide prevention program. Method Choropleth maps were created for 49 U.S. states, with four mutually exclusive categories indicating eligibility for the TWV program and increasing levels of need assigned to each county based on (a) percent Veterans Health Administration enrollees residing in rural communities, (b) percent population that are Veterans, and (c) crude suicide mortality rate. Results Of 3113 counties, 78.2% were eligible for TWV and 25.8% met our highest priority definition. A national map and state map were provided to demonstrate final products used to engage stakeholders. A table of recommendations for creating and using planning maps was provided for future projects to reference. Conclusions Geographic information system (GIS) is useful for identifying and prioritizing counties that may benefit most from a rural Veteran suicide prevention program. Choropleth maps allow for dissemination of information about county suicide risk and need for suicide prevention to community members, researchers, and others with a vested interest in suicide reduction. The maps are one tool among many which can support decision‐makers in focusing available resources on populations with the most need.

Suicide is a significant public health concern for veterans residing in rural communities. Although various initiatives have been implemented to prevent suicide among veterans, efforts specific to rural veterans remain limited. To aid such efforts, we examined stigma as a potential barrier to community readiness in the implementation of a community-based suicide prevention program for rural veterans. In this qualitative study, community readiness interviews were conducted with 13 participants in a rural community. Themes included lack of awareness regarding veteran suicide, rare discussions of veteran suicide, and suicide-related stigma within the community. Results suggest that prioritizing destigmatization may be particularly important to implementing community-based suicide prevention programming in rural communities. In particular, addressing community misconceptions regarding veteran suicide, while increasing knowledge of the extent to which veteran suicide occurs locally may facilitate increased awareness and thus community readiness to prevent suicide among rural veterans.

Suicide is a major public health problem that disproportionately impacts veterans in the general U.S. population. Recent analyses indicate that American Indian and Alaska Native (AI/AN) veterans may be two to three times as likely as non-Hispanic White veterans to experience suicidal ideation. Although suicide prevention programs have been successfully implemented for many at-risk populations, to our knowledge, none have been designed or implemented for AI/AN veterans. To address this gap, we conducted a scoping review of suicide prevention programs with the objective of identifying promising strategies and lessons learned to identify promising practices for preventing suicide among AI/AN veterans. We conducted two parallel literature searches-a review of suicide prevention programs for the general U.S. adult population and AI/AN communities. We rated programs on 16 criteria, covering five domains-best practices in suicide prevention, U.S. Department of Veterans Affairs (VA) Office of Rural Health Promising Practice criteria, cultural fit, care coordination, and outcomes. Our findings indicate that many of the VA evidence-based or best practice programs are available system-wide, but none have been tailored for AI/AN veterans or the communities in which they live. Conversely, we found that many culturally specific programs implemented in AI/AN communities were rarely disseminated beyond tribal land and none were specifically developed for veterans. Based upon these findings, and to advance suicide prevention programs for AI/AN veterans, we propose a suicide prevention model that builds upon existing VA infrastructure to disseminate best practices to AI/AN communities and integrate tribal-specific cultural approaches to suicide prevention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

American Indian and Alaska Natives (AI/ANs) veterans may be at elevated risk for suicide, but little is known about suicide among this population.We conducted a retrospective cohort analysis of AI/AN veterans who received health care services provided or paid for by the Veterans Health Administration (VHA) between October 1, 2002, and September 30, 2014, and who were alive as of September 30, 2003. Age-specific and age-adjusted suicide rates through 2018, per 100,000 person-years (PY) at risk and 95% confidence intervals were computed.Age-adjusted suicide rates among AI/AN veterans in this cohort more than doubled (19.1-47.0/100,000 PY) over the 15-year observation period. In the most recent observation period (2014-2018), the age-adjusted suicide rate was 47.0 per 100,000 PY, with the youngest age group (18-39) exhibiting the highest suicide rate (66.0/100,000 PY). The most frequently used lethal means was firearms (58.8%), followed by suffocation (19.3%), poisoning (17.2%), and other (4.7%).Results suggest that: (1) suicide is an increasing problem among AI/AN VHA veterans; and (2) younger AI/AN VHA veterans are at particularly high risk and warrant focused prevention efforts. Findings are similar to those observed in general AI/AN population. There is a compelling need to review and strengthen VHA suicide prevention efforts directed towards AI/AN veterans.

Objective The purpose of this study was to develop a conceptual model of community‐based veteran peer suicide prevention. Method We conducted a qualitative study in which semi‐structured interviews were followed by three focus groups. Participants (n = 17) were chosen from community‐based organizations who had peers working on veteran suicide prevention; the sample included veteran peers, non‐peers, program managers, and community stakeholders. Interview data were analyzed thematically and inductively to identify key components and subcomponents of veteran peer suicide prevention. A draft model was shared with each focus group to elicit feedback and refine key concepts. Results A conceptual model containing nine components and twenty‐six subcomponents was developed. Participants emphasized key organizational, relational, and practical elements needed to achieve positive outcomes. In addition, they described critical contextual and cultural factors that impacted veteran peers’ ability to prevent suicide and promote overall wellness. Conclusions Community‐based veteran peer efforts are a promising public health approach to preventing veteran suicide. Provided veteran peers are supported and fully allowed to contribute, these efforts can complement existing clinic‐based efforts. Future research on community‐based veteran peer suicide prevention should document a range of outcomes (e.g., clinical, wellness, financial) and allow for considerable flexibility in peer approaches.

American Indian and Alaska Native (AI/AN) Veterans are at elevated risk for suicide, but currently, no population-based research exists on precursors, including ideation, plans, or attempts. We employed two large national surveys to investigate the occurrence of suicide-related behaviors among AI/AN Veterans. Using cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS, 2010–2012) and National Survey on Drug Use and Health (NSDUH, 2010–2015), we compared weighted frequencies of suicide ideation in AI/AN Veterans and non-Hispanic White (NHW) Veterans. Suicide ideation among AI/AN Veterans was 9.1% (95%CI = 3.6%, 21.5%) and 8.9% (95%CI = 1.9%, 15.9%) in BRFSS and NSDUH, respectively, compared to 3.5% (95%CI = 3.0%, 4.1%) and 3.7% (95%CI = 3.0%, 4.4%) for NHW Veterans. Logit analysis suggested higher odds of ideation among AI/AN Veterans in both samples (NDSUH: OR = 2.68, 95%CI = 1.14–6.31; BRFSS: OR = 2.66, 95% CI 0.96–7.38), although sample sizes were small and confidence intervals were wide. Consistent findings from two national samples suggest AI/AN Veterans have more than twice the risk of suicide ideation relative to NHW Veterans. Ongoing efforts include weighing these results together with data on suicide deaths from medical and death records to develop effective suicide prevention approaches in collaboration with AI/AN Veterans and their communities.

PURPOSE Suicide rates continue to be significantly higher in rural compared to urban communities in the United States, with the suicide rate disparity continuing to grow since 1999. This systematic review synthesizes rural-specific factors related to increased suicide risk. METHODS OVID Medline, EMBASE, OVID PsycINFO, Web of Science, SocINDEX, Cochrane Library, and Google Scholar were searched for articles published after 2003 investigating rural adult suicide in the United States. Selection criteria were: (1) study participants > 18 years old; (2) included rural participants or communities; (3) included suicidal self-directed violence outcomes; (4) within the United States; (5) published after 2003; (6) presented peer-reviewed original data; (7) identified rural-specific risk or protective factors for suicide or barriers to treatment. FINDINGS Of the 1,058 records screened, 34 studies were included. The strength of evidence was relatively stronger for individual level factors including lethal means, alcohol and substance use. CONCLUSIONS Access to firearms is strongly related to elevated rural US suicide rates, with substance use, economic stress, and behavioral health care utilization as additional individual level factors that may contribute to the disparity. At the community level, economic distress and access to care were commonly identified factors. Future research should better quantify how risk factors contribute to rural suicide and examine interdependence across social-ecological levels. Suicide prevention efforts for the rural United States must address access to lethal means, in particular the use of firearms, and navigate limited access to quality behavioral health care.

Background While the US Department of Veterans Affairs has made significant strides to prevent veteran suicide, efforts have largely targeted veterans actively engaged in and eligible for Veterans Health Administration (VHA) care, which is consistent with the VHA mission. The majority of veterans are not enrolled in VHA care, and many are ineligible for services. Veterans not connected to VHA have experienced an increase in suicides in recent years. Observations Since 2018, VHA National Center for Patient Safety has funded the Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), which has worked to develop, implement, and evaluate practical solutions aimed at curbing the rising suicide rate among veterans not receiving VHA care. PSCI-SPC has 3 guiding objectives: (1) Develop and test a collaborative, organizational structure to connect VHA and community organizations, such as national, local, public, private, nonprofit, and academic partners who provide high-quality and timely health care; (2) Build and test a learning collaborative to facilitate sharing of VHA suicide prevention best practices with community partners to increase availability, consistency, and quality of mental health services for all veterans; and (3) Implement, test, and refine a novel program to provide affordable suicide prevention interventions to veterans with mental health needs, regardless of their use of, or eligibility for, VHA services. This paper details the current progress for this demonstration project. As these objectives are met, PSCI-SPC will create and disseminate products to support broad implementation of these practices to other VA medical centers and the communities they are embedded in. Conclusions PSCI-SPC seeks to fill an important gap in veteran health care by serving as a national clinical innovation and dissemination center for best practices in suicide prevention for veterans who receive care in their communities.

Rural communities account for somewhere between 72% and 97% of the land mass in the United States and approximately 15–20% of the country’s population (United States Census Bureau. New census data show differences between urban and rural populations [Press release]. Retrieved from https://www.census.gov/newsroom/press-releases/2016/cb16-210.html, 2016; United States Department of Agriculture. Rural America at a glance 2016 Edition. Retrieved from https://www.ers.usda.gov/webdocs/publications/80894/eib-162.pdf?v=42684, 2017). Furthermore, rural communities are an important part of the American mythos, representing a population and lifestyle that features heavily in the identity of America (Stamm. Rural behavioral health care: An interdisciplinary guide. American Psychological Association, Washington, DC, 2003). As such, rural communities and people occupy both a large and socially important piece of the United States. Likewise, being only 20% of the population, rural residents are also an often overlooked and underserved minority. The dominant urban culture often portrays rural people in negative stereotypes that can both exacerbate behavioral health problems and impact the quality of care received by rural residents. Further, prejudice against rural people and communities is manifested in the lived realities of rural disadvantage and policy marginalization, which lead to challenges for the delivery of quality behavioral health care in rural communities. Taking a public narrative model for understanding community health outcomes (N. V. Mohatt et al. Soc Sci Med 106, 128–36, 2014; Rappaport. Am J Community Psychol 28(1), 1–24, 2000), we review how stigma and prejudices manifest in rural community life and relate to persistent rural health disparities. The objective of this chapter is to provide rural mental health practitioners with a deeper understanding of the ways in which stigma and prejudice toward rural communities shape the landscape of mental health in rural America. In conclusion, we provide a series of recommendations to reshape the structural and cultural biases and provide effective rural behavioral health treatment and community action.

Suicide rates are higher in rural communities than in their urban counterparts. Of particular concern are veterans residing in rural communities, who have a 20% higher risk of dying by suicide than veterans who live in urban areas. The objective of this manuscript is to assess the availability of evidence-based and promising practices to support a community-based suicide prevention effort for rural veterans. We compiled a compendium of evidence-based and promising practices-the "menu of options"-with resources across 4 levels: increasing access to crisis services, enhancing primary care suicide prevention, training community members, and raising public awareness. We compiled resources from multiple sources, then reviewed and rated each one to arrive at consensus on the final selections. The final menu includes 70 resources. However, only 20 are tailored for veterans, only one for rural communities, and none for rural veterans. More research is needed to identify effective strategies and develop rural-tailored resources for preventing suicide among this unique and often underserved population. The menu of options represents a first step toward developing an approach to rural veteran-suicide prevention that aligns with evidence-based practice, theory, and a public health model for suicide prevention. (PsycINFO Database Record

Persistent stigma, lack of knowledge about mental health, and negative attitudes toward treatment are among the most significant barriers to military service members and veterans seeking behavioral health care. With the high rates of untreated behavioral health needs among service members and veterans, identifying effective programs for reducing barriers to care is a national priority. This study adapted Mental Health First Aid (MHFA), an evidence-based program for increasing mental health knowledge, decreasing stigma, and increasing laypeople's confidence in helping and frequency of referring people in need, for military and veteran populations and pilot tested the adapted training program with 4 Army National Guard armories.A total of 176 community first responders (CFRs) participated in a comparative outcomes study, with 69 receiving the training and 107 participating in the control group. CFRs were individuals in natural positions within the Armory or home communities of Guard members to identify and help service members in mental health crisis. Surveys assessing confidence in helping, attitudes toward help seeking, knowledge of resources, use of MHFA practices, and stigma were completed before the training, immediately post-training, at 4 months post-training, and at 8 months post-training. Analyses included repeated measures analysis of variances on data from CFRs who received the training and mixed between-within subjects analysis of variances comparing the intervention and control group longitudinally at three time points. Institutional review board approval for this study was received from Montana State University and the U.S. Army Medical Department, Medical Research and Materiel Command, Human Research Protection Office.Significant and meaningful improvements in confidence (p0.05, ηResults from the comparative outcomes pilot study of military and veterans MHFA indicate that the intervention is acceptable and feasible to implement in National Guard Armories and among non-Guard community-based first responders. There was a significant intervention effect detected for the likelihood that a CFR would use appropriate engagement, support, and referral practices when identifying someone in need of mental health support. In addition, there were positive growth trends in the data for improvements in confidence, knowledge of mental health resources, attitudes toward help seeking, and stigma, which indicate that with a larger number of participants and armories we would expect to see significant intervention effects. Study weaknesses included insufficient power and demographic data for more robust analyses of intervention effects. A larger randomized controlled trial is recommended for better establishing efficacy; however, these results indicate that Military and Veterans MHFA is a promising intervention for reducing critical barriers to care.

Background Rural veterans are at increased risk for dying by suicide compared with urban veterans, yet interventions for preventing suicide among rural veterans have been limited. Objectives (1) Describe how Together With Veterans (TWV), a community-based intervention to prevent suicide among veterans in rural communities, aligns with the VA National Strategy for Preventing Veteran Suicide; (2) share lessons learned while beginning to implement TWV in rural communities. Methods Together With Veterans is being implemented in four rural communities and comprises six suicide prevention best practices: (1) reducing stigma and promoting help-seeking; (2) lethal means safety, with an emphasis on firearms; (3) gatekeeper training; (4) training primary care providers; (5) improving access to crisis services; and (6) enhancing support for high-risk veterans. Results Together With Veterans best practices align with most, but not all, of the strategies in the VA National Strategy for Preventing Veteran Suicide. Community veteran partners have shown a willingness to collaborate and provide local leadership, enthusiasm, and a sense of duty. Conclusions By supporting and facilitating local veteran leaders and their community partners in increasing suicide prevention knowledge, public awareness, and resources, we propose that TWV offers an acceptable and feasible approach that builds on the strengths of rural communities. Systematic evaluation is warranted.

The stigma associated with mental illness or addiction is significantly and positively related to psychiatric symptoms. According to Modified Labeling Theory, several processes should mediate this relationship, including rejection experiences, stigma management (secrecy coping), and social support. In the first comprehensive test of this theory, we examined a serial mediation model on three waves of data from 138 adults receiving outpatient behavioral health treatment. Participants were recruited from outpatient behavioral health clinics in a large northeastern city in the United States and completed interviews that assessed stigma, rejection experiences, stigma management, social support, and psychiatric symptoms. There was a direct effect between stigma and psychiatric symptoms and an indirect effect in which perceived rejection, secrecy coping and social support sequentially and longitudinally intervened in the stigma and psychiatric symptom relationship. Higher perceptions of stigma predicted more rejection experiences, which marginally increased secrecy coping and decreased social support. In turn, decreased social support increased psychiatric symptoms. We provide support for Modified Labeling Theory and the clinical utility of specific mediators in the relationship between stigma and psychiatric symptoms among adults in behavioral health treatment living in urban settings.

Suicide is a significant issue in the United States and worldwide, and its prevention is a public health imperative. The Suicide Prevention Toolkit for Rural Primary Care was developed to address gaps in education and tools to assist primary care providers and other clinic staff in identifying and managing patients at risk for suicide. Given the high suicide rates in rural areas, coupled with the evidence that many people who die by suicide visit their primary care provider in the month prior to their death, primary care health settings offer an important prevention and intervention opportunity for patients at varying levels of risk for suicide. This article details (a) the evolution of a project that began with identifying a need for tools and training in suicide prevention and brief intervention by rural primary care providers, (b) the development of the Suicide Prevention Toolkit for Rural Primary Care, (c) the effectiveness of a training based the toolkit to improve suicide prevention knowledge and skills of primary care providers and other employees in health care settings, and (d) recommendations for future research and dissemination strategies of suicide prevention and intervention in primary care and other health settings. Language: en

Research with Native Americans has identified connectedness as a culturally based protective factor against substance abuse and suicide. Connectedness refers to the interrelated welfare of the individual, one's family, one's community, and the natural environment. We developed an 18-item quantitative assessment of awareness of connectedness and tested it with 284 Alaska Native youth. Evaluation with confirmatory factor analysis and item response theory identified a 12-item subset that functions satisfactorily in a second-order four-factor model. The proposed Awareness of Connectedness Scale (ACS) displays good convergent and discriminant validity, and correlates positively with hypothesized protective factors such as reasons for living and communal mastery. The measure has utility in the study of culture-specific protective factors and as an outcomes measure for behavioral health programs with Native American youth.

The objective of this study is to identify individual mechanisms of change that result from engaging in an innovative participatory public art project for persons with significant behavioral health challenges. We present two case studies that examine how participatory public art promotes recovery and wellness. This research is part of a larger, multilevel comparative outcome trial on the impact of participatory public art on the health and well-being of adults in recovery from mental illness and addiction and on the distressed city neighborhoods in which they live. The case studies describe the unique ways in which participatory public art contributed to key recovery domains of growth in friendship, self-discovery, giving back, and hope. The two cases indicate that the development of a strengths-based sense of self through art was accompanied by a growth in personal social responsibility. The two cases also indicate that participatory public art may have a profound impact on the internalization of stigma. The findings support the value of participatory public art as a strategy for blending recovery and public health perspectives to promote both individual and community wellness.

Qualitative methods potentially add depth to prevention research but can produce large amounts of complex data even with small samples. Studies conducted with culturally distinct samples often produce voluminous qualitative data but may lack sufficient sample sizes for sophisticated quantitative analysis. Currently lacking in mixed-methods research are methods allowing for more fully integrating qualitative and quantitative analysis techniques. Cluster analysis can be applied to coded qualitative data to clarify the findings of prevention studies by aiding efforts to reveal such things as the motives of participants for their actions and the reasons behind counterintuitive findings. By clustering groups of participants with similar profiles of codes in a quantitative analysis, cluster analysis can serve as a key component in mixed-methods research. This article reports two studies. In the first study, we conduct simulations to test the accuracy of cluster assignment using three different clustering methods with binary data as produced when coding qualitative interviews. Results indicated that hierarchical clustering, K-means clustering, and latent class analysis produced similar levels of accuracy with binary data and that the accuracy of these methods did not decrease with samples as small as 50. Whereas the first study explores the feasibility of using common clustering methods with binary data, the second study provides a “real-world” example using data from a qualitative study of community leadership connected with a drug abuse prevention project. We discuss the implications of this approach for conducting prevention research, especially with small samples and culturally distinct communities.

Theories of historical trauma increasingly appear in the literature on individual and community health, especially in relation to racial and ethnic minority populations and groups that experience significant health disparities. As a consequence of this rapid growth, the literature on historical trauma comprises disparate terminology and research approaches. This critical review integrates this literature in order to specify theoretical mechanisms that explain how historical trauma influences the health of individuals and communities. We argue that historical trauma functions as a public narrative for particular groups or communities that connects present-day experiences and circumstances to the trauma so as to influence health. Treating historical trauma as a public narrative shifts the research discourse away from an exclusive search for past causal variables that influence health to identifying how present-day experiences, their corresponding narratives, and their health impacts are connected to public narratives of historical trauma for a particular group or community. We discuss how the connection between historical trauma and present-day experiences, related narratives, and health impacts may function as a source of present-day distress as well as resilience.

Suicide is a preventable public health problem and a leading cause of death in the United States. Despite recognized need for community-based strategies for suicide prevention, most suicide prevention programs focus on individual-level change. This article presents seven first person accounts of Finding the Light Within, a community mobilization initiative to reduce the stigma associated with suicide through public arts participation that took place in Philadelphia, Pennsylvania from 2011 through 2012. The stigma associated with suicide is a major challenge to suicide prevention, erecting social barriers to effective prevention and treatment and enhancing risk factors for people struggling with suicidal ideation and recovery after losing a loved one to suicide. This project engaged a large and diverse audience and built a new community around suicide prevention through participatory public art, including community design and production of a large public mural about suicide, storytelling and art workshops, and a storytelling website. We present this project as a model for how arts participation can address suicide on multiple fronts—from raising awareness and reducing stigma, to promoting community recovery, to providing healing for people and communities in need.