Participatory Implementation for Suicide Prevention with American Indian and Alaska Native Communities

Abstract

Suicide, the third leading cause of death among people aged 10-34, is an urgent health problem. Among American Indian and Alaska Native (AIAN) youth in particular, suicide remains one of the largest health disparities, where suicide rates of AIAN youth are among the highest levels globally, despite extensive prevention efforts. Research suggests that this increase is linked to forced social, cultural, and environmental changes, as well as historical trauma due to attempted genocide and ongoing colonization.

Predominant suicide prevention approaches have largely prioritized individual risk factors, early identification, and clinical treatment. This narrow focus has shaped the mainstream US suicide response, limiting efforts to understand and address root causes. As a result, progress in reducing suicide deaths—especially among marginalized groups—has stalled, contributing to worsening suicide rates overall. For Indigenous youth, clinical and expert-led types of interventions may unintentionally reproduce historical trauma and exacerbate stigma, further deterring clinical help seeking.

An emerging direction which has been especially promising in AIAN suicide prevention research is to develop community-based suicide interventions. Important features of these interventions are that they emphasize self-determination, are culturally responsive, designed to intervene at multiple points across the suicide prevention spectrum, and include intervention at multiple social-ecological levels. Several such interventions have been effectively developed in collaboration with Tribal communities, however, there has been limited research on how to implement, sustain, and scale such complex programs. Participatory implementation, a methodology that combines the participatory approaches used to develop these interventions with implementation science methods to clearly identify and delineate the determinants, strategies, and outcomes most important for their implementation may be useful.

This dissertation uses participatory implementation in a three-part analysis that examines the contextual factors, strategies, and outcomes most important for implementing suicide prevention interventions in AIAN communities. Studies one and two assess the determinants of implementation (e.g., barriers and enablers) when applying suicide prevention research evidence in rural Alaskan villages and in a rural Northern Plains reservation community, respectively. Study three is a systematic review of suicide prevention intervention trials with AIAN communities, analyzing the implementation strategies and outcomes measured and reported in existing literature. This review sheds light on how participatory approaches and implementation science have already been used together, and identifies gaps in our understanding of the implementation of AIAN suicide prevention interventions. The dissertation concludes with a model synthesizing the findings and lessons learned from all three studies, emphasizing the potential and challenges of using participatory implementation to advance our knowledge of implementation science for and with Indigenous communities.