Meeting Summary

Pragmatic Considerations of Culture in Preventing Suicide

September 9, 2004 – September 10, 2004
Philadelphia, Pennsylvania

U.S. suicide rate patterns associated with age, gender and ethnicity provide profound evidence that culture is associated with suicide risk and protective factors. On September 9-10, 2004, the NIH Office of Rare Diseases, National Institute of Mental Health, Indian Health Service, Annenberg Foundation Trust at Sunnylands, and Emerging Scholars Interdisciplinary Network co-sponsored a workshop entitled “Pragmatic Considerations of Culture in Preventing Suicide.” The purpose of the meeting was to examine how culture pertaining to ethnicity can be considered in the development and implementation of suicide preventive interventions. Three fielded studies were considered as examples in reducing suicide risk and included studies focused on African American, Hispanic/Latino, and American Indian communities. For this workshop, culture was defined as self- and community- identity, community norms, and behavioral practices that can affect how an individual engages in behavior linked to life or death outcomes. Recognizing that this field is in an early stage of development, approaches to theory, measurement and intervention development for each of the three studies was discussed with regard to their strengths and opportunities for further development. Experts knowledgeable about suicide risk for other understudied minority groups (e.g., Pacific Islanders) were asked to attend and provide feedback on the content and process of the workshop, and recommend approaches for future meetings.

On the first day, the epidemiology of suicide among selected U.S. racial and ethnic groups was reviewed and the challenges of using national or weighted data to understand community-specific patterns were discussed. Next, the group considered three fielded studies by investigators who are using culturally based models to refine theories of risk and protective factors for suicidality and/or test interventions. Each of the models is being developed and/or implemented in collaboration with the community. Following each presentation, designated discussants moderated breakout groups where the model was again reviewed, ways of further testing the model were considered, and additional research questions were posed. Following the breakout sessions, attendees reconvened for a brief overview and discussion. Day two of the meeting focused on pragmatic suggestions and technical needs for advancing the testing of models that incorporate culture in suicide prevention.

Examples of Suicide Prevention Models that Incorporate Culture: Research Approaches and Considerations

The Role of African American Churches in Suicide Prevention

Dr. Sherry Molock and Reverend Joseph Lyles, one of her community collaborators, presented their plan to improve mental health services help-seeking within an urban African American church as a step toward improving protective factors against suicide. The theoretical model includes the specification of the cultural and structural characteristics of the particular church, family norms, and peer norms; attitudes and perceived norms; problem recognitions and help-seeking behavior. The intervention model focuses on reducing risk factors and enhancing protective factors through community alliances, sermons, workshops and annual conferences; as well as increasing appropriate referrals by church staff and accepting referrals from congregants. The group discussed strengths and further considerations for this research, including:

Dr. Molock is a clinical psychologist, ordained minister, and member of the community she is collaborating with. The group viewed her clinical experience and insider perspective as a strength that could facilitate the collaboration and the research process.
The level of collaboration with the African American churches of interest to the study and involvement of key stakeholders is high, potentially increasing buy-in among the target population.
Due to time constraints for presenting the logic model for the study, there were numerous questions of clarification around model specification. Among these were the ways and degrees to which changes in help-seeking and awareness by the congregation as a whole will later affect rates of youth suicidality, one of several aims of their program of research. Defining increased and appropriate help-seeking among congregants was seen as a key intermediate and more measurable outcome for the model as currently construed.

Integrative Models of Suicide Attempts by Adolescent Latinas

Dr. Luis Zayas and one of his community collaborators, Ms. Eva Morales, presented their culturally-based research model to better understand Latina teen suicidality. The study examines the sociocultural elements that are hypothesized to explain the phenomenology of suicide attempts by adolescent Latinas and identifies culturally specific risk and protective factors of suicidal behavior among Latinas in New York City, many of whom are children of immigrant parents. The conceptual model is based on ideas drawn from theory and clinical practice relating to the family sociocultural environment, psychosocial functioning and subjective experiences of family crises. The group identified several strengths and research considerations, including:

The research model operationalizes cultural constructs of family and individual level outcomes; specifically assesses family values and behaviors in context of social norms; and measures the acceptability of suicidal behavior messages.
Additional considerations for this research effort include identifying ways to disentangle adverse stress reactions and normal adolescent behaviors and clarifying what aspects of adolescent development are most affected; and determining what aspects of involvement in U.S. culture increase risk and protective factors for these Latina youth.

American Indian Life Skills Development: Community-based Suicide Prevention

Dr. Teresa Lafromboise presented on her curriculum, American Indian Life Skills Development Curriculum, a theoretically and empirically based intervention that she developed and evaluated in collaboration with the Zuni Pueblo in New Mexico. The intervention targets specific skills to reduce risk for suicide (increasing knowledge about suicide prevention, managing depression, stress and anger, improving communication, increasing goal setting, and increasing ability to refer a friend for help when she or he is suicidal). An initial test of this intervention using a quasi-experimental design found that the intervention was effective for reducing several risk factors for depression and increased peer helping skills. The model is being further developed to increase cultural identity, resilience and competence, and community empowerment. Several strengths and research considerations were noted by the group:

This research model served as a good example of how research based on white youth could be culturally tailored for ethnic minority youth through community-based participatory research. Dr. Lafromboise worked collaboratively with American Indian school administration and teachers to garner their input and incorporate important Zuni values into the curriculum. The group viewed the collaboration as a strength because it may ultimately increase the recruitment, retention, and sustainability of the intervention.
Additional considerations for this research effort include identifying ways to integrate family influences in the model; determine additional aspects of various American Indian cultures that may reduce and/or enhance risk and protective factors; identify valid measurement and fidelity methods for culturally-adapted interventions.

At the end of the first day, the group reviewed similarities in approaches and challenges across the three models, how developmental/age and gender issues were considered within the models, and how other risk behaviors could be expected to change or could be co-morbid target outcomes.

Similarities in Approach

Each model had strong cultural relevance (e.g., familism among Hispanics; religious beliefs and traditions of the African American church; inclusion of tribal values and rituals in the American Indian community) in the development of the conceptual model and in the intervention model.
Each study drew on community-based participatory research to increase its validity, acceptance, and sustainability with the communities being studied.

Similarities in Challenges

Noting the diversity within ethnic and racial groups even within specified communities, a common challenge across the models was developing a culturally-informed model broad enough to capture the heterogeneity within the community.
Culturally-informed research models may increase the internal validity of the research, but it also may limit the generalizability of the research findings, and limit the applicability of interventions to other groups. The process of culturally tailoring interventions and research may be a generalizable process or method, and researchers should be encouraged to document this process.
Suicide research requires particular safeguards. Monitoring for potential iatrogenic effects and being sensitive to possible stigma associated with suicidality is an ongoing challenge. For example, understanding how cultures use various terms to describe suicidality (which are not likely to be consistent with medical terminology) can also pose challenges in navigating a study that will provide more benefit than risk with regard to stigma and providing crisis services.

Considerations of Age, Development, and Gender

Each of the models focused on youth, and another consideration would be development of models for older individuals, especially among cultures where suicide risk for adults is also high.
Various forms of media are significant socialization influences for youth, and these influences should be considered in models of risk and protection for suicidality.
Youth development is dynamic and many of the constructs under study may need to be adapted to remain valid across developmental stages.

Implications for Other Risk and Protective Factors

While the ultimate outcome is reduction/prevention of suicide morbidity and mortality, substance use, violence, depression and other related mental disorders are important intermediate targets of interventions.
The role of the family as a conveyor of one source of cultural influences, in contrast to peer or other community contexts (e.g. school), could be further elaborated with regard to various effects on suicide risk and protective factors for youth.
Overall, research on prevention of youth suicide should include more attention to identifying and increasing culturally consistent protective factors.

Pragmatic Considerations, Technical Needs, and Research Issues

On day two of the meeting, the group considered pragmatic issues in the development of culturally-informed suicide prevention strategies, and the research implications for suicide prevention more broadly.

Measurement of suicidality; risk and protective factors

Currently, no standard definitions exist for suicidal behavior. One of the challenges in developing standard definitions is difficulty in assessing intent. The Centers for Disease Control and Prevention is taking the lead on developing standard definitions for suicidal behavior that may aid surveillance and research efforts. However, valid measurement of suicidality for many understudied cultures remains a critical need.
Research with culturally and linguistically diverse populations raises a number of measurement issues including measurement equivalence, variation across cultures in concepts and language for suicide, communication of internal processes related to suicide research constructs (e.g., “communicating deep emotional and cognitive states in native language”), and contextual variations in use of language even among English speaking populations.

Research Design

Study designs that incorporate both quantitative and qualitative methods may further elucidate research constructs and increase engagement with the study population. Qualitative methods such as focus groups may increase understanding of the intervention experience and increase understanding of the phenomenon of suicide.
Study designs that utilize telemedicine technologies may increase inclusion of underserved populations, such as rural populations.

A strength of telemedicine is that it allows for real-time access to intervention expertise that is not normally available.
Research considerations for telemedicine include a need to know the local service ecology and how the program will affect it; plans for addressing technical problems; implementing safeguards to address urgent and emergency safety issues that may arise during and between sessions.

Ethical and Safety Concerns

Throughout the meeting, ethical issues and considerations for adequate safeguards were discussed.

The group discussed the need to establish an ethics framework to guide the research process and collaborations with the community. Key features of the ethics framework were having respect for the community and establishing trust with the community. The ethics framework should be as important as other aspects of the research — e.g., the methodological framework.
The consent process should be transparent, clearly outlining the research and what is required of the participant; and the process should include a system for ensuring that participants understand what they are consenting to.
With diverse cultures, there may be other issues to consider in the consent process beyond the typical issues such as reading level:

Concepts may need to be explained with examples that facilitate participants’ understanding of the process and its importance to their full participation.
There may be a power differential between the researcher and participant—perhaps due to “services” that may be available in the research, or because participants may not understand that they have a choice to say no to a “doctor.”

Researchers should consider what additional issues around the consent form and consent process need to be addressed prior to engaging in the research. This may involve developing the consent procedures with the community, and piloting them prior to conducting the research.
Community consent may be necessary in addition to individual consent and assent (for minors). Researchers and communities may need to jointly consider potential risks and benefits to communities associated with the research, and develop safeguards to protect communities.
Researchers and communities may need to reach a mutual understanding of confidentiality and its limits. A goal for the researcher may include gaining a clear understanding of how the community views their responsibilities to the individuals in their community to balance issues of autonomy versus safety. For instance, the community/setting leaders may not feel it is acceptable to not share information about a child’s suicidal thoughts with the parent.
When conducting research in a community setting, it is important for researchers to understand the procedures/guidelines and safeguards for handling crises that are in place within that setting. Current procedures may need to be modified and additional procedures and safeguards may need to be developed.
A challenge for mental health research is stigma, and a collaborative or participatory research approach to the consent process—an early point of engaging participants—may increase acceptance and involvement in the research.

Lessons learned in developing community collaboration

During the meeting, the group heard about collaborative research projects with a Latino community in the Pacific Northwest and Inuit communities in Canada. Common themes and broader research considerations associated with collaborative and participatory research were discussed.

Engagement of the community may involve multiple levels: working with community stakeholders and key leaders to develop a common agenda and build alliances with the broader community.
Researchers and communities should consider ways to address potential power differentials within the relationship, such as a having a community member as a co-principal investigator on the project.
Community collaboration/participatory research involves a long-term relationship with the community and an extended engagement process. Initially, researchers and community representatives may spend much of their time acknowledging, listening to and negotiating their common and competing interests, prior to beginning the research.

Next Meeting Ideas/ Lessons Learned

This workshop addressed only three example studies that were informed by culture. Given the early stage of research on the role of culture in suicide risk and protection, much more consideration of research needs for other underserved racial and ethnic groups is desired. The participants made the following recommendations for future meetings.

Meeting Framework

Participants desired to have more time allocated to each fielded approach in order to assess it more thoroughly, have the researcher and community partners discuss their collaborative process, and keep the small group format because it enhanced the discussion and networking opportunities. Other suggestions included structuring the format of the meeting around a particular theoretical framework for suicide and/or culture; tailoring each meeting to one particular ethnic group; providing written feedback from small group to each participant; inviting those ethnic/cultural groups not present at current meeting; engaging the collaborators in the planning process.

Career Development

The participants thought that it would be beneficial to find ways to incorporate activities that would enhance the professional development of early career and junior investigators, particularly those of underrepresented racial and ethnic groups. Some examples of the activities included developing and disseminating a repository of best practices to junior investigators so that they will not have to re-invent the wheel; linking junior investigators with senior investigators to develop concept papers on issues identified at this meeting; provide opportunities for junior investigators to present research ideas at future meetings; conduct mock reviews at future workshops as a learning opportunity; include presentations on how qualitative researchers can be successful NIH grantees.