Acknowledgements
We acknowledge those people with a lived experience of mental health issues and suicide, their families, friends and supporters who provided input into the process and shared stories, along with the many people from different organisations and the general public who hold an interest in mental health and suicide prevention.
We also acknowledge Aboriginal and Torres Strait Islander people as the traditional owners of this country throughout Australia and their connection to land, waters and community. We pay respect to them and their cultures, and to the Elders both past and present. We thank the contribution of local Aboriginal communities to help shape our knowledge of their country and identity. We benefit from the generosity in sharing their country and their culture as part of these consultations.
We acknowledge and thank the more than 500 people who contributed to the National Suicide Prevention Trial community consultations; your voice and feedback has formed this report.
Background
While suicide is an infrequent occurrence in Australia, the effects and aftermath can be both traumatic and longlasting for families and communities alike. Across Australia, people residing in rural and remote communities have a higher risk of suicide than those living in metropolitan cities. Particular rural communities across the state experience significantly higher rates of attempts and deaths. Compared to the national average, South Australia’s suicide rate is slightly higher at 13.4 deaths per 100,000 compared to 12.61
Suicide can affect any person at any time, however there are sub groups of individuals that remain at higher risk than others. The reasons for suicide are complex and multifaceted, influenced by the vulnerabilities, risk factors and events in a person’s life and their interactions with other social, cultural, economic and environmental factors2
For people aged 15-44 years, suicide remains a major cause of death. Furthermore, across all age groups Aboriginal people are more than twice as likely to die by suicide compared to their non-Aboriginal counterparts1 In terms of gender, males account for the majority of deaths by suicide, while females often attempt at a higher rate. Males aged 25-44 years are dying at a higher rate than all other age groups in regional SA 1
The key aims of the trial are to respond to local needs and identify new learnings in relation to suicide prevention strategies. To achieve this aim, an established evidencebased suicide prevention model was selected, the LifeSpan model.
LifeSpan is an innovative, evidence-based, world-class approach to suicide prevention developed by the Black Dog Institute. Based on scientific modelling, LifeSpan is predicted to prevent 20% of suicide deaths and 30% of suicide attempts. The model involves the implementation of nine strategies simultaneously within a localised area. Active strategies that form part of the trial will include:
• Training for frontline workers, community members, young people and leaders;
• Coordination of referral networks and multidisciplinary teams; and
• The development of systems that can reduce suicide attempts and deaths in communities.
1 Government of South Australia (2018) South Australian Suicide Prevention Plan 2017-2021, SA Health. 2 World Health Organisation. (2014) Preventing Suicide: A Global Imperative. Geneva. WHO
About the National Suicide Prevention Trial
Country SA PHN is one of twelve sites nationally taking part in the trial which aims to reduce suicide at a local level.
The Federal Government is providing $4 million which will enable Country SA PHN to implement evidence-based integrated approaches to suicide prevention.
The three-year trial will adopt a systems-based approach to the delivery of suicide prevention services, targeting populations identified as ‘at-risk’.
The trial brings significant resources, activity and funding to areas of established need across the country. The selected area in South Australia is the Country North region, including Port Augusta, Whyalla, Port Lincoln, Port Pirie and the Yorke Peninsula.
The population targets within these regions were selected based on the Country SA PHN Needs Assessment in addition to state and national data sets in relation to death and/or suicide attempts due to intentional self-harm. The three populations are:
• Youth (15-24 years)
• Adult Males (25-54 years)
• Aboriginal and Torres Strait Islanders
The trial will work closely with local suicide prevention networks, state government and the Office of the Chief Psychiatrist to implement effective strategies and programs across the region. The consultation that forms the basis of this report will support the design of localised action plans that will continue after the trial end date in June 2020. All research, programs and strategies used within the trial will be evaluated upon completion to help inform policy and programs nationally.
Aims
The aims of the community consultations were to gauge the current community knowledge of suicide prevention, services available and areas of need within the Country North region as a prelude to the development of a community action plan.
To meet the aim, the following objectives were addressed in each of the consultations:
• Determine the level of need and service availability in the local regions
• Identify key barriers and obstacles to help-seeking and service access
• Brainstorm solutions to create multidisciplinary links between service providers, and
• Create achievable recommendations in conjunction with the LifeSpan model.
Methodology
Design
The project adopted a two-stage approach involving:
• Paper-based and online self-administered surveys; and
• Face-to-face community consultations in six regional centres in country South Australia.
Paper-based and online survey
The purpose of the survey was to assess the perceived needs and barriers in relation to suicide prevention in the regional hubs of South Australia.
Between late November 2017 and early February 2018, the CSAPHN conducted a survey, available online and as a paper-based version. The survey was promoted through social media and distributed in a paper-based form at community consultations throughout the region. The targeted catchment locations for the survey were Port Lincoln, Whyalla, Port Augusta, Port Pirie and the Yorke Peninsula in line with the targeted region for the National Suicide Prevention Trial (NSPT).
Community consultation
During the same period, face-to-face consultations were facilitated across the Country North region. To complete this process in a timely manner, Sevenseas Creative Australia was contracted to work with the Country SA PHN
Suicide Prevention Project Officer to conduct six Regional Suicide Prevention Forums. The aim of the forums was to gather community members who could contribute to the development of an effective regional approach to suicide prevention, with a focus on building the capacity of organisations and the community to better support individuals.
For the Aboriginal component of the consultation, interviews and group yarning sessions were utilised in addition to the six forums. The results of these are incorporated below.
The forums included leaders and influencers from the community, including Suicide Prevention Networks (SPNs), community groups, sporting clubs, government and non-government agencies, business, health, education, hospital, emergency responders, GPs, researchers, industry stakeholders, people with lived experience, consumers and carers who collectively identified the needs and actions required for the region in relation to suicide prevention.
Promotion of the community forums was through advertisements in local newspapers, formal invitations, Cash Classifieds and media campaigns via Facebook and the Country SA PHN website.
Results
Online survey findings
The survey was the first stage of the consultation process and was opened for a three-month period in line with the face-to-face community forums. During this period, 337 responses were collected from both community representatives and forum participants.
Age of respondents Demographics
The survey in its entirety consisted of 26 questions identifying demographics, workforce capacity, level of need for suicide prevention and alignment with the nine LifeSpan strategies. The key findings are summarised below.
32% of Whyalla respondents were bereaved by suicide.
79% of Whyalla respondents identified as having a lived experience of suicide.
Clients with access: Youth and adults were believed to have the highest level of access to suicide prevention services in Whyalla. Additionally, males and people bereaved by suicide were perceived to have the lowest level of access to services.
Barriers to access: Availability of suicide prevention services and waiting times were the main perceived barriers to access for survey respondents in Whyalla.
Needs and gaps: The three predominant needs and gaps highlighted in the Whyalla community were:
• Follow-up care for attempted suicide
• Perceived stigma around mental health services
• Suicide prevention training opportunities
The lowest need in the region was for access to digital mental health.
To further measure community perceptions of suicide prevention services, a series of statements were listed allowing respondents to answer with agree, unsure or disagree. The following was found:
Knowledge of where to go for help is low
There are services for family and friends after a suicide ...
Support for someone feeling suicidal is easily accessible
Services are available for youth experiencing suicidal...
Support is available to carers and family
Access to social support is good
Access to psychiatrists is generally poor
GP’s are appropriately equipped with Suicide...
Suicide Prevention promotion and education is provided
Early intervention is easily accessible
Notably, access to psychiatrists was perceived as poor by a high percentage of respondents as well as knowing where to go for help in a suicidal crisis. Furthermore, a lack in GP knowledge and skills in suicide prevention was highlighted, as well as a need for more support for individuals and their families during a crisis.
The top five factors contributing to suicide in Whyalla were:
• Drug and Alcohol Use
• Poor understanding of suicide and mental health
• Unemployment
• Family Breakdown
• Lack of community coordination regarding mental health services
Access to suicide prevention services in Whyalla
Community forum findings
In the second stage of the methodology, six community forums were conducted across major regional centres.
An estimated total of 500 people engaged in the forums and provided their feedback on the current state of suicide prevention in their region, key needs and gaps as well as future plans to reduce suicidality.
In addition to community and service providers, local mayors were also engaged to form partnerships and strengthen the community focus. Local Mayor Lyn Breuer had the following to say on suicide in their region:
“Suicide in a smaller community affects everyone. The community mourns with the family, and everyone asks why, and how could we have
helped. As a community leader, through council and through our networks,
it is important to ensure we have in place the preventative
measures
and support necessary for our community and our people.”
WHYALLA MAYOR LYN BREUER
Each forum highlighted ideas and issues unique to their specific region and key themes were deliberated. For Whyalla, the key themes from the community forum were:
• Workforce development and upskilling
• Youth education and resilience building
• Referral pathways and early intervention
• Follow-up care and dischaning following a suicide attempt.
Workforce development and upskilling
Workforce development and upskilling was identified as a priority for both the community and service providers in the region. Emphasis was placed on training for frontline workers and first responders, as well as general practitioners (GPs) in assessment skills and appropriate referral pathways. There was participant acknowledgement surrounding the high demand for GP services in regional
areas and the need to explore e-mental health options to accompany locally available services and facilitate training.
Youth education and resilience building
Youth mental health was also a priority area raised for the Whyalla region, particularly regarding education and resilience training. The incorporation of suicide prevention and mental health education into school curricula was suggested to reduce stigma and build resilience and was strongly supported within the community forums. Upskilling for school counsellors and teachers alike to recognise the signs of suicide and to respond accordingly was thought to also complement this process.
Referral pathways and early intervention
The community perceived a need for better collaboration between services to streamline referrals, reduce waiting times and create a ‘no wrong door’ approach. The creation of an online portal to direct individuals to available services in their region was discussed to meet this requirement in accompaniment to information packs being available 24/7 at emergency departments.
Furthermore, the implementation of a stepped care model with a person-centred approach, aiming to increase early intervention and prevention of mental health issues, was suggested to improve the current referral issues.
Follow-up care and discharge planning following a suicide attempt
Information and support following a suicide attempt was raised repeatedly throughout the forum, specifically the need for the development of appropriate discharge planning in the region. The current system was seen to not support the families of an individual in crisis or provide support post the attempt and/or suicide. Creating a local multidisciplinary network with adequate information sharing to provide such follow up was therefore strongly supported in Whyalla. These formalised networks could ensure information is safely and confidentially shared in order to provide the most effective aftercare services for individuals and their families.
Discussion
Upon the completion of the community forums and the closure of the online survey, data was analysed and compared to highlight consistent themes in the needs and gaps identified within Whyalla. Generally, the key issues and trends were highlighted and reflected in both methods, and no obvious disparities were found in the Whyalla data.
Workforce collaboration and a need for structured multidisciplinary networks was identified in both methodologies. Fifty-three percent of survey respondents perceived no workforce collaboration taking place in the region, while the forums highlighted a lack of linkages between organisations, particularly for follow-up care. A lack of support avenues was additionally highlighted in the forums and the survey once more in the followup/ discharge planning phase, suggesting collaboration between primary care providers and community support services is not being effectively utilised. This presents an opportunity for improvement within the region by establishing ties between the various levels of care.
On reviewing the predominant needs and gaps identified through the forums and survey, an underlying need for upskilling and service coordination was evident. Overall, the findings from the community forums aligned with the online survey findings from the Country North region as a whole with the key gaps highlighted being follow-up care, stigma around suicide, suicide prevention training opportunities and workforce collaboration.
The key gaps identified within suicide prevention for the Whyalla community were:
Workforce development and upskilling
Youth education and resilience building
Referral Pathways
and early intervention
Follow up care and discharge planning following a suicide attempt
Upskilling of frontline workers and GPs alike in assessment skills and referral pathways was a key priority for Whyalla.
Key recommendations
The themes and priorities identified through the consultation process were used to form recommendations to improve suicide prevention within each community and the region as a whole. The interventions and/or programs recommended were in turn aligned with the LifeSpan
model and the nine evidence-based strategies. These strategies are based on the most up-to-date evidence drawn from large scale suicide prevention programs overseas that have shown positive results. The LifeSpan wheel and strategies are shown below.
Improving emergency and follow-up care for suicidal crisis
Improving safety and reducing access to means of suicide
Encouraging safe and purposeful media reporting
Using evidence-based treatment for suicidality
Engaging the community and providing opportunities to be part of the change
Training the community to recognise and respond to suicidality
Equipping primary care to identify and support people in distress
Improving the competency and confidence of frontline workers to deal with suicidal crisis
Promoting help-seeking, mental health and resilience in schools
The recommendations for Whyalla were:
Improving emergency and follow-up care for suicidal crisis
• Implement a dedicated aftercare service to provide follow-up care for those who have made a suicide attempt. This includes providing continuity of care, coordination across services and strong follow-up.
• Develop comprehensive safety plans which can prevent suicide or assist people in crisis.
• Create a ‘no wrong door’ approach.
• Provide locally developed resource packs to patients, family and carers who have been in contact with crisis care.
• Implement best practice care guidelines within the emergency departments and deliver training to emergency department personnel and hospital staff.
• Implement workforce development strategies that can attract, train and retain frontline workers and emergency responders.
• Establish specialised mental health trained nurse practitioners, to be based in Emergency Departments.
Using evidence-based treatment for suicidality
• Improve information sharing between services, families and carers.
• Increase specialist support and training for GPs.
• Encourage the use of Telehealth and e-Mental Health tools.
• Implement improved consent tools to enable better sharing of information between health services.
• Deliver Advanced Training in Suicide Prevention (ATSP) to clinicians including doctors, psychologists and psychiatrists.
Equipping primary care to identify and support people in distress
• Provide further training opportunities for GPs and practice staff.
• Encourage the development of local multidisciplinary networks.
• Establish clear referral mechanisms in the community.
• Create linkages and collaboration between services to ensure streamlined referrals and aftercare support.
• Equip practices with the ‘StepCare’ platform allowing GPs to easily identify patients in need of support and tailor a treatment plan that is right for them.
Improving the competency and confidence of frontline workers to deal with suicidal crisis
• Develop a common appropriate language across agencies and sectors.
• Provide targeted education and training for Accident and Emergency staff to refresh or upskill and build their capacity to support the community.
• Build awareness across first responders of local referral pathways.
• Facilitate real-time electronic data collection by agencies to report and measure the level of suicidal crisis in the community.
• Encourage participation of frontline workers in multidisciplinary events such as Expert Insight forums.
Promoting help-seeking, mental health and resilience in schools
• Encourage the delivery of evidence-based programs, promoting help-seeking behaviours and building resilience.
• Provide suicide prevention training to all education staff.
• Review school referral pathways to ensure students at risk are being connected to appropriate care.
• Work with young people to develop awareness and tools to prevent bullying.
Training the community to recognise and respond to suicidality
• Provide training opportunities for the community to help recognise and respond to suicidality.
• Develop a local resource that provides people and agencies with a greater level of knowledge and information about who to contact when people are in crisis.
• Develop an online portal of services and agencies that is easily accessible.
• Implement Question Persuade Refer (QPR) strategies, targeting community members and health professionals alike.
• Engage with local government to provide community support through venues, events and staff resources.
Engaging the community and providing opportunities to be part of the change
• Establish suicide prevention representatives within organisations to promote help-seeking and suicide prevention awareness.
• Provide targeted engagement for key stakeholders through training and information that activates positive change and builds the capacity for people to support each other and respond in a crisis.
• Proactive use of social media to engage and inform the community.
• Engage with community and sporting groups to build capacity and promote help-seeking behaviours.
• Ensure information about support services and programs are accessible and visible in the local community 24/7.
• Develop posters on local service options that are visible and accessible across the community.
Encouraging safe and purposeful media reporting
• Facilitate Mindframe training for media and key spokespeople, including mayors, politicians, and others.
• Provide training opportunities for people with a lived experience of suicide to share their story to create understanding and awareness.
Improving safety and reducing access to means of suicide
• Review data processes for the State Ambulance Service to ensure adequate reporting of suicide attempts and deaths by suicide.
• Facilitate real-time electronic data collection by agencies to report and measure the level of suicidal crisis in the community.
