Youth-Led Suicide Prevention in an Indigenous Rural Community

Figure. HCCI youth leadership model

Although Hawaii is often advertised as an idyllic paradise, suicide is a pervasive public health issue for adolescents. In Hawaii, suicide is the second leading cause of injury-related death among youths aged 15 to 14 years.¹ In the US, Hawaii has one of the highest percentages of young people that report suicide ideation, make a suicide plan, and attempt suicide.² Native Hawaiian youths are disproportionately affected with higher rates of suicidality compared with the other major ethnic groups,³ reflecting the effects of historical trauma endured by other indigenous communities across the globe.⁴

In addition, Hawaiian youths living in rural communities are at greatest risk, with the highest rates of suicide and suicide attempts.^5,6 All 5 inhabited islands outside of the metropolitan center of Honolulu on the island of Oahu are considered rural and are federally designated as health professional shortage areas and medically underserved populations/areas.⁷

In response to these needs, Hawaii’s Caring Communities Initiative (HCCI) on Youth Suicide Prevention was initiated. Using a youth leadership model to prevent youth suicides (Figure), HCCI partnered with 6 youth-serving organizations in rural communities across the State of Hawaii.

This model focuses on developing and empowering young leaders in suicide prevention through evidence-based training, relationship building, and promoting community awareness. Rather than being passive targets of the intervention, these youths are active partners in suicide prevention and they have many skills and insights to offer. This model provides a foundation for each organization to develop its own unique plan that not only addresses the needs of its community but also uses its strengths.⁸

One of the community organizations that HCCI has partnered with is Molokai Community Health Center (MCHC). The island of Molokai is 38 miles long and 10 miles wide and has a population of approximately 7300. It is home to one of the highest populations of Native Hawaiians, with over 60% of residents identifying as part or full Native Hawaiian.⁹

MCHC is the only federally qualified health center on Molokai. It emphasizes holistic, preventative, and patient-driven health care through the provision of comprehensive and culturally appropriate services, including community outreach and mental and behavioral health services. Given the small size and close-knit nature of the Molokai community, the rippling effect of a suicide death is much more pronounced.

Understanding that any type of change is more successful when created internally and with respect to the local culture and people has been essential to the partnership between MCHC and HCCI. At the beginning of the partnership, MCHC and HCCI staff members were trained and certified as trainers in an evidence-based suicide prevention initiative called the Connect Program.¹⁰

The trainers from MCHC included mental health professionals and those who are involved in community and youth outreach. Following the training, MCHC trainers began to recruit young leaders by sending personalized formal invitations to youths from various social circles on the island, asking them to join a youth leadership and advocacy group that focuses on suicide prevention. These invitations offered them an opportunity to meet with other youths in their community, to become trained in the Connect Program in order to recognize warning signs of suicide and promote help-seeking behaviors, to apply their training to organize community awareness campaigns using safe messaging-guidelines,¹¹ and to gain valuable leadership skills.

Sixteen trainees joined the leadership group, and after several months of purposeful relationship-building activities, they developed a group identity known as Suicide Preventers Around Molokai (SPAM). Each youth leader had a unique role in the group that used his or her strengths and interests. This foundation has been critical for their success in implementing 10 community awareness events and community trainings that have reached over 500 people on the island thus far and have involved collaborations with at least 5 other community agencies in Molokai.

For example, they coordinated a family-friendly event called the Mixed Plate Festival for Mental Wellness, where they invited cultural practitioners from the island to host workshops on lei making, basket weaving, fishing, and traditional and modern crafts. The purpose of this event was to promote mental wellness by recognizing and promoting the strengths and gifts that reside in the community. In addition, SPAM youth leaders have coordinated multiple sign-waving events and have written articles in the local newspaper about the importance of suicide prevention.

These efforts have led to an increase in help-seeking behaviors with at least 15 youth and community members being identified to be at risk for suicide and being connected to mental health professionals, including Behavioral Health Services at MCHC. The SPAM community awareness activities have allowed them to get to know and developed a sense of trust with health care providers from MCHC and the rest of the island.

By focusing on relationship-building opportunities, both among youth leaders in SPAM and out in the community, preliminary evaluation efforts show the SPAM youth leaders’ sense of community connectedness is being enhanced, which is a protective factor for suicidality.¹² These findings build on the strong sense of connection Native Hawaiian youths have with their ‘ohana, or family, including extended family and community members.¹³

Interventions developed with a strengths-based model for positive youth development can systematically promote healing and decrease stigma by facilitating a positive sense of belonging to a valued community.^14,15 Peer-led suicide prevention projects enhance protective factors by increasing knowledge, validating a young person’s role in the community, and fostering social and community connectedness.¹⁶ Youths provide valuable cultural insight into and creativity to suicide prevention initiatives that, if acknowledged, can become powerful modes of prevention in the community.^17,18

Partnering with a youth leadership group, such as SPAM, may be a promising way to connect mental health providers to the community, especially with sensitive and stigmatized issues, such as suicide prevention. If implemented, mental health professionals should play an active role in supporting such groups to promote self-care among young people and enhance community outreach efforts. The partnership between MCHC and HCCI embraces a holistic, culturally relevant approach that focuses on relationship building and community connectedness to build a comprehensive, sustainable, and effective safety net for community mental wellness.

Acknowledgments
We would like to thank the youth leaders of SPAM, and the staff and community partners of Molokai Community Health Center, Molokai General Hospital, and Hawaii’s Caring Communities Initiative for their dedication in suicide prevention and mental wellness. This manuscript was developed, in part, under grant number 1U79SM060394 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The views, opinions, and content of this publication are those of the authors and contributors, and do not necessarily reflect the views, opinions, or policies of CMHS, SAMHSA, U.S. Department of Health and Human Services, or Molokai Community Health Center and should not be construed as such.

Disclosures:

Dr Chung-Do is an Assistant Professor with the Department of Public Health Sciences at the University of Hawaii at Manoa in Honolulu, Hawaii. She was the Director of the Youth and Community Project (Mobilizing Communities At Risk) for the Hawaii's Caring Communities Initiative. Dr Napoli was a psychologist who worked with Molokai Community Health Center and assisted with the SPAM (Suicide Preventers Around Molokai) youth leadership group. She is currently in private practice.

Mr Hooper is a community coordinator for Hawaii’s Caring Communities Initiative. He leads the SPAM (Suicide Preventers Around Molokai) youth leadership group on the island of Molokai. He also works as a community outreach worker for Consuelo Foundation. Ms Tydingco received her MPH in Health Policy and Management from the University of Hawaii at Manoa. She was a graduate assistant for Hawaii’s Caring Communities Initiative. Her research interests include Indigenous health, youth development, and mental health. Ms Bifulco is Project Coordinator for Hawaii’s Caring Communities Initiative for Youth Suicide Prevention in the department of psychiatry at the University of Hawaii John A. Burns School of Medicine.

Dr Goebert is Professor in the department of psychiatry at the University of Hawaii John A. Burns School of Medicine. She is Director of National Center for Indigenous Hawaiian Behavioral Health and Hawaii’s Caring Communities Initiative for Youth Suicide Prevention. Dr Goebert receives funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) through the Garrett Lee Smith Memorial Act for Youth Suicide Prevention (U79SM060394). The authors report no conflicts of interest regarding the subject matter of this article.

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