摘要：Objectives. We evaluated the efficacy of 15 years of a public health–oriented suicidal-behavior prevention program among youths living on an American Indian reservation. Methods. All suicides, suicide attempts, and suicidal gestures were monitored. Age-specific analyses over time were used to assess outcomes. Results. Both descriptive and linear regression analyses indicated that a substantial drop occurred in suicidal gestures and attempts. Suicide deaths neither declined significantly nor increased, although the total number of self-destructive acts declined by 73% ( P =.001). Conclusions. Data from this community-based approach document a remarkable downward trend—measured by both magnitude and temporal trends in the specifically targeted age cohorts—in suicidal acts. The sequential decrease in age-specific rates of suicide attempts and gestures is indicative of the program’s success. Recently, a number of scholars and officials have called for population-based public health strategies for preventing suicide in entire communities and racial/ethnic groups. Noting that approaches to suicide prevention are often narrowly based on psychiatric and individual dynamics, the surgeon general, 1 the US Public Health Service, 2 and the Institute of Medicine 3 have voiced the need for a new, comprehensive understanding of suicidal behavior on which to base suicide prevention efforts. Three recent publications explain the rationale for a population-based approach to preventing suicidal behavior, 3 calling suicide prevention a national imperative 3 for public health intervention. 4 , 5 American Indian/Alaska Native (AIAN) suicide studies and prevention programs have frequently been approached from a public health perspective, 6 – 22 but detailed evaluation of such programs among American Indians/Alaska Natives has been quite rare in practice and in the literature. 18 We describe an outcome evaluation of a suicide prevention program among the Western Athabaskan Tribal Nation (a pseudonym used to protect the identity of this tribe—one of several Athabaskan tribes in the southwestern United States—and its reservation) of New Mexico. This program is part of an ongoing effort to evaluate AIAN suicide trends, potential causes of these trends, and the efficacy of prevention programs in New Mexico 19 , 23 , 24 (P. Serna, unpublished data, 1991; Western Athabaskan Tribal Nation, unpublished data, 2003). An increase in suicidal activity among AIAN adolescents and young adults on this reservation in 1988 prompted the tribal council and community and the Indian Health Service (IHS) to work together to establish an adolescent suicide prevention program on the reservation in 1990. 17 second and third leading causes of death, respectively, among American Indians/Alaska Natives aged 15–24 years, with unintentional injury and adverse effects of trauma combined being the leading cause of death. 25 , 26 In the same time period, suicide rates among American Indians/Alaska Natives aged 15–24 years were consistently 2 times higher than those among all American 15- to 24-year-olds. 3 , 25 However, suicide rates vary from tribe to tribe, 20 , 21 with higher rates in Western states. 25 They also vary over time in individual AIAN communities. 15 , 22 – 23 In 1988, the annual rate of suicide and suicide attempts combined for the Western Athabaskan Tribal Nation was 15 times higher than the US rate and 5 times higher than rates for other New Mexico American Indians/Alaska Natives. 23 From 1957 through 2000, suicide death rates on this reservation fluctuated in 6- to 8-year cycles. 20 – 23 The Western Athabaskan Tribal Nation is rural and isolated, with 90% of the population living on the reservation, primarily in a single town. In 1990 and 2000, the total population served by the IHS on this reservation numbered 2639 and 3047, respectively. In 1990 and 2000, respectively, the population targeted by the suicidal behavior prevention program comprised 284 and 291 youths aged 10 to 14 years, 261 and 293 aged 15 to 19 years, and 224 and 245 aged 20 to 24 years 23 (IHS Office of Program Planning and Evaluation, unpublished program data, July 23, 2003). Eighty percent of those aged 16 years or older were unemployed, with some seasonal employment from firefighting, hunting and fishing guiding, and agriculture (P. Serna, unpublished data, 1991). In 1989, the IHS provided initial funding for a small model Adolescent Suicide Prevention Project. The IHS designed and implemented the project in collaboration with tribal officials in 1990 and funded it through 1994. During that time, it was the only active project in a New Mexico community specifically designed for suicide intervention and prevention (P. Serna, unpublished data, 1991; Western Athabaskan Tribal Nation, unpublished data, 2003; IHS Office of Program Planning and Evaluation, unpublished program data, July 23, 2003; K. Gaylord, MA, injury prevention manager, Office of Injury Prevention, New Mexico State Department of Health, oral communication, July 8, 2003). With grants from various sources, the project developed into a more broadly focused program; it is now the Department of Behavioral Health of the Western Athabaskan Tribal Nation, with an annual budget of more than $1 million. The program focused primarily on 10- to 19-year-olds, the population in this community identified by prior research as most at risk for developing symptoms of self-destruction. 16 , 20 , 21 Five years into the project, specific re-education and awareness-raising activities for the 20- to 24-year-old age group were added. The goals of the program were to reduce the incidence of adolescent suicides and suicide attempts and to increase community education and awareness about suicide and related behavioral issues, such as child abuse and neglect, family violence, trauma, and alcohol and substance abuse (P. Serna, unpublished data, 1991). All levels of prevention (universal, selective, and indicated) 34 were targeted in program activities. Key components were based on the following program goals and objectives: (1) identifying suicide risk factors specific to the Western Athabaskan Tribal Nation that may be applicable to other AIAN communities; (2) identifying specific individuals and families at high risk for suicide, violence, and mental health problems; (3) identifying and implementing prevention activities to target high-risk individuals, families, and groups; (4) providing direct mental health services to high-risk individuals, families, and groups; and (5) implementing a communitywide systems approach to enhance community knowledge and awareness (P. Serna, unpublished data, 1991). A broad, community-wide systems suicide prevention model was developed 4 , 5 that solicited active involvement from key constituencies—tribal leadership, health care providers, parents, elders, youths, and clients—in its design and implementation. The community planning process 35 had a broad effect on other public institutions of the reservation, such as those involved with judicial, social service, and health program policies. More than 50 interactive community workgroup sessions were held to examine the following questions: What are the problems and issues in the community? What are the barriers to resolving these problems? What can be done to solve problems and overcome barriers? At each meeting, all statements and comments were recorded, and these transcribed notes were subsequently compiled into a single document and distributed throughout the community. This document formed the foundation for program components and the development and implementation of the Western Athabaskan Tribal Nation’s judicial and program policies, such as a domestic violence code and a domestic violence and child abuse prevention program. Interestingly, suicide itself was not one of the most important problems identified by the community. Instead, community members stated that, because many of the problems identified could lead to suicide, suicide could not be addressed in isolation. To prevent suicide, underlying issues of alcoholism, domestic violence, child abuse, and unemployment must also be confronted. Community meetings were held in conjunction with a community mobilization project, 35 sponsored by the IHS in collaboration with Rutgers University, and continued to be held on a regular basis long after the mobilization project was completed. The model Adolescent Suicide Prevention Project had the following integrated program components: surveillance through constant data and information gathering; screening/clinical interventions with extensive outreach in conventional institutions (health clinics, schools, and social welfare programs) and unconventional settings (outdoor venues where troubled youths and alcohol abusers frequently congregate, community functions such as traditional and modern dances); social services (child and adult welfare activities); school-based prevention programs on topics including general life skills development 14 ; and community education for adults and youths on general topics (e.g., parenting) and specific topics (e.g., the nature of self-destructive behaviors). Neighborhood volunteers of various ages were chosen as “natural helpers” to engage in peer training, personal and program advocacy, referral of clients for professional mental health services, and provision of counseling to people who preferred to seek help and assistance from knowledgeable and trusted laypersons in less formal settings. 27 – 29 Professional mental health staff worked as a team with the natural helpers, and these staff often provided services in unconventional settings in the community (e.g., in cars or outdoors) to avoid feelings of discomfort that might arise in visiting the mental health program offices. Staff growth was substantial and constant throughout the evaluation period. Before 1989, the IHS employed 1 full-time mental health technician and contracted for the services of 1 master’s-level counselor and 1 doctoral-level (PhD) psychologist 1 day per week. As part of the Adolescent Suicide Prevention Project, the tribe hired 1 full-time master’s-level social worker and increased the psychologist’s time to 3 days per week in 1989. In 1992, staff increased to 5 full-time positions (82% clinical). By 1996, funding for child abuse, fetal alcohol syndrome, and domestic violence prevention activities and a contract with the IHS for mental health services increased the full-time support staff to 12. In 1997, the tribe entered into another contract with the Bureau of Indian Affairs for additional clinical social workers for child and adult welfare and financial services. In 2000, the behavioral health program had a staff of 33, including support personnel. In 2001, the tribe merged the substance abuse program with the mental health and social services functions to form the Department of Behavioral Health Department of the Western Athabaskan Tribal Nation, and project staff increased to 57 positions, including the director, the clinical director, a psychiatrist 3 days per week, and 21 clinical positions. The department encompasses 19 positions for an inpatient social detoxification program; 5 positions for maintenance/transportation services; and 9 positions for support services such as accountants, medical records personnel, receptionists, and secretaries. Most of these people also assist in public education and other prevention activities.
