Culturally Appropriate Evaluation of Tribally Based Suicide Prevention Programs: A Review of Current Approaches

Suicide is a major health challenge in American Indian/Alaska Native (AI/AN) communities, particularly among youth. In 2004, suicide was the second leading cause of death for AI/ANs of all age groups, and the rate was higher than that for the general population. Among 10-14 year olds, 13.5 percent of deaths were from suicide, which is nearly twice the national rate of 7.2 percent.¹ Rates of suicide attempt are highest for AI/AN young women, while young men are the most likely to complete suicide. In 2004, among 15-19 year old AI/ AN males, 32.2 percent of deaths were from suicide, which was 2.5 times the rate for males of all races in this age range (12.6 percent).² Many factors contribute to the high prevalence of suicide in AI/AN communities, including mental illness, substance abuse, feelings of hopelessness or isolation, impulsive behavior, and a history of violence, substance abuse, or mental illness in their families. AI/ANs as a group also have specific risk factors for suicide, including historical trauma, such as boarding school experiences, high rates of poverty, unemployment, and geographic isolation.³ To assist tribes in preventing youth suicide, the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (DHHS) published a detailed resource guide in 2010.⁴ The guide is titled To Live to See the Great Day That Dawns: Preventing Suicide by American Indian and Alaska Native Youth and Young Adults, and provides a comprehensive review of research studies and programs related to suicide prevention in AI/AN communities. For a good overview of the current state of suicide prevention efforts in Indian Country, we recommend consulting this resource guide.

Rates of suicide and contextual factors underlying suicide risk are different in each AI/AN community. For this reason, many tribes have developed their own strategies and programs for suicide prevention. This essay reviews current approaches for evaluating tribally based suicide prevention efforts in AI/AN communities and highlights particularly promising evaluation strategies. By "tribally based," we mean efforts that are tailored to the local context of individual tribes and Native communities. In some cases, communities might design their own suicide prevention programs (often based on their traditional spiritual/cultural beliefs and healing practices), while other communities adapt existing tools developed for the mainstream U.S. population. This essay aims to review the spectrum of approaches being used in the evaluation of tribally based suicide prevention programs, and to make recommendations about how tribal communities, health care providers, and researchers might be better supported in evaluating locally tailored efforts to prevent suicide. As we describe in the next section, our goal was not to capture an exhaustive list of strategies being used to evaluate tribally based suicide prevention programs. Rather, we reviewed existing literature and consulted a select group of key informants in order to broadly describe the landscape—the contours and gaps in these evaluation strategies—at a level of detail necessary to identify future research needs and policy change recommendations for a tribal leader and program staff audience.

Below, we first describe the process of developing the essay and our research methods. The sections that follow highlight key areas that emerged from our literature review and consultation with key informants. We first examine what constitutes "evidence" of program efficacy and ways to broaden the definition to be more inclusive of tribal programs. We then present specific strategies and approaches currently being used to evaluate tribally based suicide prevention programs. Finally, based on our literature review and comments from key informants, we offer policy-change recommendations for facilitating effective evaluation of tribal suicide prevention programs. We hope that these recommendations will assist tribal, federal, and state policy makers in better supporting tribally based suicide prevention programs.

Essay Development and Research Methods

We developed this essay in collaboration with all the individuals and organizations that we consulted about tribally based suicide prevention programs. For a list of the organizations and...