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 their 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
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.
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.
Age of respondents
32.7% of Port Augusta respondents have experienced suicidal thoughts.
67% of Port Augusta respondents identified as having a lived experience of suicide.
Clients with access: youths and adults were believed to have the highest level of access to suicide prevention services in Port Augusta. The lowest level of access was attributed to males, children, and families and people bereaved by suicide.
Barriers to access: waiting times and availability of suicide prevention services were the main perceived barriers to access for survey respondents in Port Augusta.
Needs and gaps: The three predominant needs and gaps highlighted in the Port Augusta community were:
• Follow-up care for attempted suicide
• Perceived stigma around mental health services
• Discharge planning and follow-up
The lowest need in the region was for access to digital mental health.
To further measure community perceptions of suicide prevention services in Port Augusta, a series of statements were listed, allowing respondents to answer with agree, unsure or disagree. The following was found:
Access to psychiatrists is generally poor
Services are available for youth experiencing suicidal...
Knowledge of where to go for help is low
Suicide Prevention promotion and education is provided
Support is available to carers and family
There are services for family and friends after an attempt
Early intervention is easily accessible
Access to social support is good
Support for someone feeling suicidal is easily accessible
GPs are appropriately equipped with suicide prevention...
Notably, access to psychiatrists was perceived as poor by the majority 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. Comparatively, youth services were believed to be readily available.
The top five factors contributing to suicide in Port Augusta were:
• Drug and alcohol use
• Family breakdown
• Unemployment
• Lack of support for families and carers
• Stigma associated with suicide
Access to suicide prevention services in Port Augusta
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/ gaps and 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 Sam Johnson had the following to say:
“Suicide prevention doesn’t sit neatly within the medical sector. It is important for our community to have the skills and confidence to recognise and support those at risk, and for community leaders to step up and lead the conversation.”
PORT AUGUSTA MAYOR SAM JOHNSON
Each forum highlighted ideas and issues unique to their specific region and key themes were deliberated. For Port Augusta, the key themes from the community forum were:
• Cultural awareness and improved cultural competencies for Aboriginal care
• Workforce development and upskilling
• Referral pathways and early intervention
• Follow-up and discharge planning following a suicide attempt.
Cultural awareness and improved cultural competencies for Aboriginal care
Cultural awareness and improved Aboriginal care was the predominant theme at the Port Augusta forum, with the need for upskilling, awareness, understanding and recognition of traditional Aboriginal approaches being
emphasised. Current services available were deemed by community members as not culturally appropriate for their target clientele and community elders were often not engaged with the services or their action plans in the design phase.
Suggestions to improve the current shortfalls included active engagement with Aboriginal Elders and community bodies throughout the service design, and for organisations to create a reconciliation plan to oversee all practices and increase awareness of Aboriginal needs.
Workforce
development and upskilling
Correspondingly, workforce development and upskilling of services around suicide prevention was another issue highlighted. The forum identified a need for further GP training targeting the assessment of mental health and suicidal tendencies. It was believed that currently, the skillset around recognising and reporting mental illness was limited and consumers were falling through the gaps, not receiving the help they required.
Mental health specialists, psychiatrists and qualified professionals were all thought to be lacking in the region, emphasising the need for upskilling available health professionals. There was also a consensus that workforce retention in regional centres was problematic and so exploration of options around telepsychiatry were strongly supported.
Upskilling was not exclusive to service providers and professionals but also for the general community. Access to training and upskilling opportunities for all community members was seen as important, and would increase not only knowledge in recognising the signs of suicide, but also on reducing the stigma around suicide and mental illness.
Community forum findings
Referral pathways and early intervention
Referral pathways and appropriate linkages between health services were not seen to be evident through the community. The community perceived a need for better linkages and collaboration between services in order to streamline referrals, reduce waiting times and create a ‘no wrong door’ approach. Furthermore, the creation of an online portal to direct individuals to available services in their region was suggested in accompaniment to information packs being available 24/7 at emergency departments.
The development of local multidisciplinary networks and a single information sharing network was another key topic discussed regarding service delineation. Such a network could ensure information is shared safely and confidentially to ensure individuals do not fall through the gaps.
Follow-up care and discharge planning following a suicide attempt
Information and support following a suicide attempt was raised repeatedly throughout the forums, specifically the need for the development of a regional suicide response plan. The regional suicide response plan would coordinate local response following an event and entail aftercare procedures for first responders and impacted individuals alike. The current system was seen to not support the families of an individual in crisis or provide support post the attempt and/ or suicide.
Ideas and suggestions to meet the current shortcomings in the community regarding suicide prevention included the development of an accessible information pack outlining services and support including cards, flyers, brochures, signs, pages and apps that communicate service options. Also suggested was the development of a locally based suicide prevention plan that is solution-focused.
Cultural competence, upskilling and appropriate engagement with the Aboriginal community to improve Aboriginal health outcomes was a major priority for Port Augusta.
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 Port Augusta. Generally, the key issues and trends for the community were prevalent in both the forum and survey with limited differences noted.
Cultural competency and awareness was a persistent theme for the community forums, whereby the need for more awareness, understanding and recognition of Aboriginal approaches was required. Comparatively, in the online survey, the Aboriginal population was believed to be among the highest target group with access to mental health and suicide prevention services. These findings suggest that while Aboriginal-specific services are available in Port Augusta, they are not being utilised and/ or are not seen as appropriate by their target population. Potential reasons for these shortcomings could be lack of cultural competency and awareness, as highlighted in the forums. The need for Aboriginal Elders to be involved in service design and planning was thoroughly discussed and, therefore, may be an answer to resolving some of the barriers faced by the Aboriginal community.
Access to services and awareness of services was an issue highlighted in both forms of data collection. The availability of services and waiting times associated were predominant barriers highlighted in the survey, which was further reinforced through the need for more streamlined referral pathways in the community forums. A well-developed referral pathway, with a ‘no wrong door’ approach would direct consumers to their appropriate level of care, ensuring high-risk individuals get the support they require, but that information is available to all levels of need. The lack of service availability identified in the survey could additionally be counteracted through the incorporation of information packs readily available in emergency departments. Such information could be accessed by families and carers, identifying alternative support mechanisms for varying levels of need.
Multidisciplinary networks and linkages between health providers was believed to have a significant role in the disjointed referral pathways. It seemed service providers were unaware of local service availability much like community members. This factor was reinforced through the online survey where 35% of respondents perceived no workforce collaboration taking place in the region. Of specific concern, frontline workers (paramedics and police officers) had little knowledge of where to refer individuals
The key gaps identified within suicide prevention for the Port Augusta community were:
Cultural awareness and improved cultural competencies for Aboriginal care
Workforce development and upskilling
Referral Pathways and early intervention
Follow up care
and discharge planning following a suicide attempt
who had suicidal thoughts and/ or behaviours that did not require immediate medical attention. The need for followup care and appropriate discharge planning corresponded with the overwhelming need for streamlined referral pathways that continue after support/ treatment for both the patient and family has been sought. Current services were perceived to end once initial treatment was received.
On reviewing the predominant needs and gaps identified through the forums and survey, an underlying need for upskilling was evident. Through training more providers and community members to recognise and respond to suicidality, in addition to understanding referral pathways and alternative support mechanisms, accessing help would be simplified.
Overall, the findings from the community forums aligned with the online survey’s 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.
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 latest 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 Port Augusta were:
Improving emergency and follow-up care for suicidal crisis
• Implement a dedicated aftercare service for those who have made a suicide attempt, including continuity of care, coordination across services and follow-up, whilst ensuring service is culturally appropriate.
• Provide locally developed resource packs to patients, family and carers who have been in contact with crisis care.
• Implement targeted ATSI focused strategies aligned with the ATSISPEP (Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project Report Recommendations).
Using evidence-based treatment for suicidality
• Improve meaningful information sharing between care providers.
• Encourage the use of Telehealth and e-Mental Health tools.
• Utilise Tele-psychiatry to support and build the capacity of nurses and general practitioners in regional areas.
• Develop a service level agreement to improve the local provision of emergency mental health care and assessment processes via GPs and accident and emergency staff.
• Recommend delivering Advanced Training in Suicide Prevention Training (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, including cultural competence training.
• Develop a streamlined referral process and referral map to assist GPs, frontline workers and communities, to ensure individuals can access the help they require.
• Support organisations to develop culturally appropriate environments through the creation of reconciliation plans reflective of local Aboriginal communities
• Equip practices with a ‘StepCare’ model that allows GPs to 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 health 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.
• 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 ‘Youth Aware of Mental Health’ (YAM) training in schools to upskill youth and reduce the stigma around suicide and mental illness.
• Provide Question. Persuade. Refer. (QPR) training to all levels of education staff.
• Review school referral pathways to ensure at-risk students are being connected to appropriate care.
• Create awareness of bullying through social media platforms and active strategies that reduce and/ or eliminate bullying from schools.
Training the community to recognise and respond to suicidality
• Provide Question. Persuade. Refer. (QPR) training free of charge to community members to raise awareness of what to do in a crisis, referral and access points.
• Encourage the delivery of ‘Youth Aware of Mental Health’ (YAM) training in schools to upskill youth and reduce the stigma around suicide.
• Develop an easy-to-access portal of available services and agencies.
• Distribution of an up-to-date referral map, highlighting pathways and services available.
Engaging the community and providing opportunities to be part of the change
• Support the development and expansion of programs that address intergenerational trauma experienced by Aboriginal people to reduce suicidality risk.
• 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.
• Encourage pro-active use of social media to engage and inform the community.
• Develop programs that enable local community members (particularly Aboriginal community members, staff and Elders) to be actively engaged in suicide prevention and expand the training options available including for those with lived experience.
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
• Remain vigilant about emerging trends in means of suicide.
• Facilitate real-time electronic data collection by these agencies to report and measure the level of suicidal crisis in the community.
