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Volume 50 Number 4
Rural Interest Group
Edited by Cheryl Ramos and Suzanne Phillips
Written by Susana Helm, Rural.IG@scra27.org, University of Hawai`i at Mānoa
The Rural IG column of The Community Psychologist highlights rural resources as well as the work of community psychologist, students, and colleagues in their rural environments. Please email Susana if you would like to submit a brief rural report or if you have resources we may list here.
In this issue, we highlight the work of Dr. Nate Mohatt, who also serves as the SCRA Indigenous Interest Group co-chair. In addition to his brief report on a community development approach for preventing suicide and promoting wellbeing with rural veterans, Nate has provided a list of potential resources for Colorado where he currently is based, other US states, and beyond.
The community readiness handbook is available online at: http://triethniccenter.colostate.edu/communityReadiness_home.htm
Suicide media reporting guidelines are critical to supporting safe reporting and community discussions of suicide: http://reportingonsuicide.org/
Make the Connection is a campaign to reduce stigma toward mental illness among veterans: https://maketheconnection.net/
The Suicide Prevention Toolkit for Rural Primary Care Practices was developed with input from rural PCP to support effective and efficient suicide prevention in primary care. Over 80% of individual who die by suicide have seen their primary care physician in the prior month. Rural PCPs report having less knowledge, resources, and confidence to deal with suicide. http://www.wiche.edu/pub/12453
The Rocky Mountain MIRECC for Suicide Prevention provides a wide variety of suicide prevention educational tools (from crisis line products, to DVDs, brochures, videos, and podcasts) available free to the public on their website: https://www.mirecc.va.gov/visn19/education/
Stigma as a Barrier to Community Readiness for Suicide Prevention among Rural Veterans
Nathaniel Vincent Mohatt, PhD
Assistant Professor, Department Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus
Research Psychologist, U.S. Veterans Administration Rocky Mountain Mental Illness Research, Education, and Clinical Center
Lecturer, Division of Prevention and Community Research, Department of Psychiatry, Yale School of Medicine
Suicide is a major public health problem that disproportionately impacts rural communities. Suicide is the 10th leading cause of death in the United States, with over 41,000 Americans dying by suicide each year and with rising suicide rates nationally (Centers for Disease Control and Prevention, 2015). Suicide rates in rural areas have been consistently higher than they are in urban areas (Hirsch, 2006). Veterans are one group with elevated suicide rates (Office of Suicide Prevention, 2016) for whom rurality may serve as a compounding factor elevating suicide risk. Veterans living in rural areas are at 20% greater risk of dying by suicide than veterans who live in urban areas (McCarthy et al., 2012). The challenging nature of reducing veteran suicide rates requires collaboration and partnerships both within the VA, as well as with other federal agencies, state and local governments, organizations, families, and individuals within the communities (Bagalman, 2016).
Community psychology offers a variety of tools that can be helpful to supporting partnerships to address the challenges of veteran suicide prevention in rural communities. Over the last four years our research team from the VA’s Rocky Mountain Mental Illness Research, Education, and Clinical Center and the Western Interstate Commission for Higher Education has been collaborating with a rural community in Colorado to develop a comprehensive and community-partnered strategy for rural veteran suicide prevention. Our work seeks to align multi-level prevention practices with a community development as suicide prevention approach. Through coalition development and participatory action, we are supporting local leaders in preparing to implement a complex and multi-level initiative including increasing access to crisis services, enhancing primary care suicide prevention, training community gatekeepers, and raising awareness of the issue and reducing mental illness stigma.
To support the development of a coalition of community partners we began our work conducting a community readiness assessment (Stanley, Kelly, & Edwards, 2014). The community readiness model is a method for assessing a community across five dimensions and nine stages of change (see handbook, page 6: http://triethniccenter.colostate.edu/communityReadiness_home.htm). The nine stages are based on the trans-theoretical model of behavioral change. The community readiness model recommends strategies for effective change based on level of readiness. Although the majority of published studies evaluating community readiness look at an intervention’s ability to change community readiness (Kostadinov, Daniel, Stanley, Gancia, & Cargo, 2015), some studies have linked changes in community readiness to intervention outcomes (Jason, Pokorny, Kunz, & Adams, 2004; Millar et al., 2013; Allen, Mohatt, Fok, Henry, & Team, 2009).
In this brief report, I describe the community readiness assessment that we conducted with one rural community and preliminary results from analysis of the interview transcripts. The objective of this study was to identify planning needs and objectives for a comprehensive suicide prevention initiative for rural veterans, as well as to identify barriers to program implementation.
We conducted a community readiness assessment following the guidelines outlined in the community readiness handbook (Stanley et al., 2014). Through discussion with local partners, we defined the community to include six isolated and rural counties in Colorado, and identified the issue as suicide prevention for veterans and their families. We then modified the interview template to reflect the defined community and issue. The Colorado Multiple Institution Review Board and the Denver VA Medical Center’s Research and Development committee reviewed and approved this study for adherence to standards of research ethics.
We conducted 13 community readiness interviews with key informants. The research team initially identified sectors of the community representing critical perspectives for the implementation of suicide prevention and delivery of services to veterans. Our community partners then identified individuals from these sectors and recommended additional key informants. Participants included representatives from health and behavioral health care provider agencies, county public health offices, media, the business community, the faith community, emergency response, law enforcement, the judicial system, political leadership, and veteran service organizations.
All interviews were recorded and transcribed. Participants provided verbal consent prior to the interview. Following the guidelines from the community readiness handbook, each interview was scored independently by two reviewers who subsequently met to arrive at a consensus score for each interview. Interview scores were then aggregated to arrive at an overall community readiness score and domain specific scores.
The overall level of community readiness for veteran suicide prevention was stage two, resistance or denial. Similarly, the domains of knowledge of community efforts, knowledge of the issue, leadership, and community climate were at the denial/resistance level of readiness. The domain of community resources was at a vague awareness (stage 3) level of readiness.
The stage two level of readiness is characterized by little recognition that the problem exists locally. Study participants frequently expressed awareness that Veteran suicide is a problem nationally, but that there is no acknowledgement that it is an issue that impacts their community. One participant summed this up as, "It’s not that people don’t care, but at least from my perspective, it’s not anything I hear about. I am not very aware it is an issue in our community.” Another participant said, “In these small rural communities, unless you know the family or you have lived [here] a long time… no one else knows, and word is not out that this is a problem that needs to be fixed." A third, “I do try to keep up with what is going on. I pay attention, I read the paper, I talk to people. So if I’m any indication, then I would say people are not very knowledgeable.”
In addition to the domains, we identified stigma as a theme that emerged through the interview scoring process and significantly impacted the scoring. Multiple participants expressed a strong cultural stigma towards suicide in their community. This issue was summed up well by one participant who said, “You know, it's the 'S' word. And people are afraid. If I say 'suicide,' someone's going to kill themselves, you know? Of if we talk about it, it's going to bring that to people's minds, and if we just leave it alone, they won't think about it."
During our scoring process, the issue of stigma carried an inordinate amount of weight. The community readiness scoring procedure involves a consensus meeting where raters discuss the scores they arrived at and negotiate a final consensus score for the interview. Frequently one member of the scoring team would identify moments in the interview pointing towards vague awareness, pre-planning, or even planning stages of readiness. However, these possible higher scores were invariably reduced during the consensus meetings in the face of the statements regarding stigma. For example, in one breath an interviewee would state that the community is incredibly supportive of veterans and the climate is excellent for suicide prevention, but then later state that people will not discuss suicide due to the stigma. As a team we agreed that the statements regarding stigma limited our ability to score many of the interviews above a denial/resistance level at the very best.
The stigma towards mental illness is well established in the research literature as a barrier to help seeking (Corrigan, 2004), and internalized stigma is known to negatively impact mental health treatment outcomes (Livingston & Boyd, 2010). Similarly, the literature on rural suicide rates suggests that high levels of stigma may serve to limit help seeking and thereby indirectly lead to increased suicide rates (Hirsch, 2006). Our findings, however, suggest that public stigma toward suicide may impact communities on another level as well—that is, the public stigma may have a macro-level community effect in the form of a barrier to community readiness. By negatively impacting overall community readiness and domain specific readiness (e.g., knowledge of efforts, knowledge of the issue, leadership, climate, and resources), the public stigma towards suicide may have a negative impact on community systems critical to developing and implementing suicide prevention strategies? Combining this finding with the general guidelines from the Community Readiness model, we believe that, in this one rural community at least, addressing the stigma and teaching the community how to talk safely about suicide is a critical first step necessary to increase readiness and move toward implementation of other suicide prevention strategies.
Allen, J., Mohatt, G., Fok, C. C. T., Henry, D., & Team, P. A. (2009). Suicide prevention as a community development process: understanding circumpolar youth suicide prevention through community level outcomes. International Journal of Circumpolar Health, 68(3), 274.
Bagalman, E. (2016). Health Care for Veterans: Suicide Prevention. Retrieved from https://fas.org/sgp/crs/misc/R42340.pdf
Centers for Disease Control and Prevention. (2015). Suicide Facts at a Glance. Retrieved from https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf.
Corrigan, P. W. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614.
Hirsch, J. K. (2006). A review of the literature on rural suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 27(4), 189-199.
Jason, L. A., Pokorny, S. B., Kunz, C., & Adams, M. (2004). Maintenance of community change: Enforcing youth access to tobacco laws. Journal of Drug Education, 34(2), 105-119.
Kostadinov, I., Daniel, M., Stanley, L., Gancia, A., & Cargo, M. (2015). A systematic review of community readiness tool applications: implications for reporting. International journal of environmental research and public health, 12(4), 3453-3468.
Livingston, J. D., & Boyd, J. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Social Science & Medicine, 71(12), 2150-2161.
McCarthy, J. F., Blow, F. C., Ignacio, R. V., Ilgen, M. A., Austin, K. L., & Valenstein, M. (2012). Suicide among patients in the Veterans Affairs health system: Rural–urban differences in rates, risks, and methods. American Journal of Public Health, 102(S1), S111-S117.
Millar, L., Robertson, N., Allender, S., Nichols, M., Bennett, C., & Swinburn, B. (2013). Increasing community capacity and decreasing prevalence of overweight and obesity in a community based intervention among Australian adolescents. Preventive medicine, 56(6), 379-384.
Office of Suicide Prevention. (2016). Suicide Among Veterans and Other Americans: 2001-2014. Retrieved from http://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf.
Stanley, L. R., Kelly, K., & Edwards, R. (2014). Community readiness for community change. Tri-Ethnic Center Community Readiness Handbook. 2nd edition. Tri-Ethnic Center for Prevention Research, Colorado State University.