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20: Multi-Component Community Interventions

Risk Management and Treatment » Community-Based Interventions
20: Multi-Component Community Interventions

We suggest multi-component community interventions to reduce the risk of suicide. Common components include but are not limited to:

  • Training on mental/behavioral health topics and/or suicide risk factors;
  • Local networking and/or community facilitation;
  • Providing mental/behavioral health and/or suicide prevention materials.
Strength:

Weak for

Category:

ReviewedNew-replaced

Grades and Definitions

Strong for
or "We recommend offering this option …"
Weak for
or "We suggest offering this option …"
No recommendation
or "There is insufficient evidence …"
Weak against
or "We suggest not offering this option …"
Strong against
or "We recommend against offering this option …"

Categories and Definitions

Evidence Reviewed* Recommendation Category* Definition*
Reviewed New-added New recommendation following review of the evidence
New-replaced Recommendation from previous CPG that has been carried over to the updated CPG that has been changed following review of the evidence
Not changed Recommendation from previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed but the recommendation is not changed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed based on review of the evidence
Not reviewed Not changed Recommendation from previous CPG that has been carried forward to the updated CPG, but for which the evidence has not been reviewed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has not been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed because it was deemed out of scope for the updated CPG
*Adapted from the NICE guideline manual (2012): The guidelines manual. London: National Institute for Health and Care Excellence;2012. and Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated recommendations: An assessment of NICE clinical guidelines. Implement Sci. 2014;9:72.

Recommendation Resources

A public health approach to suicide prevention includes community-based interventions (CBI), in addition to clinical interventions. As such, CBI were included in the CPG literature review. Evidence from six studies suggested that multicomponent community-focused interventions reduced suicide death rates. There were elements that were common to many of the interventions tested in these studies (see the Table below). It is unknown how the effect on suicide would be impacted if any individual component were to be removed.

Table 7. Interventional Strategies
Component Székely et al. (2013) (194) Oyama et al. (2005) (193) Collings et al. (2018) (190) Hegerl et al. (2006) (191) Knox et al. (2003) (192)
Training on Suicide Risk Factors X
(To general practitioners, somewhat focused on depression)		 X
(Elderly – depression and suicide risks)		 X
(Lay and professionals)		 X
(PCP)		 X
(Leadership)
Workshops on Mental Health Topics/Training X
(To general practitioners)		 X
(Elderly)		 X X
(12 session PCP)		 X
(Leadership, briefings to commanders)
Local Networking and Advocacy/ Community Facilitators X   X X X
(Community Preventive Services)
Distribution of Materials on Web-Based Resources/ Public Relations Campaign X   X X
(Health professional, lay public)		 X
(Community education)
Emergency Cards to High-Risk Individuals X        
Group Activity Programs/ Self-Help Groups   X
(Elderly)		   X
(Depressed persons, history of SA, relatives)		  
Self-Assessment   X
(Elderly)		      
Screening X
(Encouraged use of BDI – general practitioners)		        
Investigative Interview Policy         X
Critical Incident Stress Management         X
Integrated Delivery System (Increase protective factors)         X
Limit Patient Privilege         X
Behavioral Health Survey         X
Suicide and Surveillance System         X
Abbreviations: BDI: Beck Depression Inventory; PCP: primary care provider; SA: sexual assault

CBIs generally aim to reach Veterans through multiple touch points and target universal, selective, and indicated prevention strategies. According to the National Strategy for Preventing Veteran Suicide:

  • Universal strategies aim to reach all Veterans in the U.S. These include public awareness and education campaigns about the availability of suicide prevention resources for Veterans, promoting responsible coverage of suicide by the news media, and creating barriers or limiting access to hot spots for suicide, such as bridges and train tracks.
  • Selective strategies are intended for some Veterans who fall into subgroups that may be at increased risk for suicidal behaviors. These include outreach targeted to women Veterans or Veterans with substance use challenges, gatekeeper training for intermediaries who may be able to identify Veterans at high risk, and programs for Veterans who have recently transitioned from military service.
  • Indicated strategies are designed for the relatively few individual Veterans identified as being at high risk for suicidal behaviors, including someone who has made a suicide attempt. These include referring Veterans in crisis to the Veterans Crisis Line, putting time and space between a Veteran who has expressed thoughts of suicide and a firearm or prescription medication, and providing a Veteran survivor of a suicide attempt or loss with enhanced support and expedited access to care.

In VA, our foundational approach to CBI centers on coalition building and sustainment at the state and local level. Community coalitions are often used to promote and improve community health and health service systems (Granner & Sharpe, 2004) and is often characterized as an "organization of individuals representing diverse organizations, factions or constituencies who agree to work together in order to achieve a common goal" (Butterfoss et al., 1993).

VA's CBI work aligns state Governor's Challenge initiatives, the Together With Veterans rural peer-to-peer initiative and Community Engagement and Partnership Coordinators to help local communities adapt an evidence-informed public health model to local needs and resources. This model builds on VA's focus on high-risk individuals in health care settings while embracing cross-agency collaborations and community partnerships working to end Veteran suicide. Further, our program evaluation efforts are looking at the impact of the work and assessing quality, accountability, and effectiveness of this model and approach with an aim to further share outcomes with the broader Suicide Prevention community.

Across all components of VA's CBI work, we have three priority areas where we work with state and local coalitions to focus their action plans and activities on when working to address Veteran suicide:

  1. Identify Service Members, Veterans and their Families and Screen for Suicide
  2. Promote Connectedness and Improve Care Transitions
  3. Increase Lethal Means Safety and Safety Planning
Priority Areas Across CBI-SP Unifying Model
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CBI Priority Areas
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Priority Areas Across CBI-SP Unifying Model

Identify Service Members, Veterans, and their Families and Screen for Suicide Risk

  • Identifying Veterans — "Ask the Question" — enables culturally competent care and access to resources; allows community members, families, and community service providers to connect individuals to appropriate care
  • Suicide risk screening in healthcare settings allows providers to recognize and prevent self-harm

Promote Connectedness and Improve Care Transitions

  • Connectedness to others (including family members, co-workers, community organizations, and social institutions) is an important factor
  • Providing caring contacts upon discharge from one setting to another can reduce suicide attempts and increase compliance with treatment recommendations

Increase Lethal Means Safety and Safety Planning

  • Limiting access to lethal means during periods of crisis can make it more likely that ht person will delay or survive a suicide
  • Completing a personal safety plan is a clinical intervention that can help individuals manage and decrease suicidal feelings and help them stay safe when these feelings reoccur

Training and Clinical Resources

This section includes recommended trainings and/or clinical resources about multi-component community interventions.

Coalition Building
Society of Public Health Education (SOPHE) Learning: Coalition Building Resources
Toolkits | Community Tool Box (ku.edu)
Priority Area #1: Identify Service Members, Veterans and their Families and Screen for Suicide
VA Suicide Prevention — Community Outreach Toolkit
Ask the Question Toolkit
Priority Area #2: Promote Connectedness and Improve Care Transitions
VA Community Provider Toolkit
Coaching Into Care | When a Veteran you know needs help — MIRECC / CoE (va.gov)
Community Toolkit | VA Suicide Prevention Resources (veteranscrisisline.net)
Social Media Safety Toolkit for Veterans, Their Families, and Friends (va.gov)
Priority Area #3: Increase Lethal Means Safety and Safety Planning
What Is a Safety Plan? | VA Suicide Prevention Resources (veteranscrisisline.net)
Start the Conversation Template to create a Safety Planning (veteranscrisisline.net)
Suicide Prevention is Everyone's Business: A Toolkit for Safe Firearm Storage in Your Community (va.gov)
Gun Shop Project | Means Matter | Harvard T.H. Chan School of Public Health
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Manuals

This section includes recommended implementation manuals about multi-component community interventions.

Rand Suicide Prevention Program Evaluation Toolkit
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Videos

This section includes recommended videos about multi-component community interventions.

Public Health Approach to Suicide Prevention
VA's Public Health Approach to Suicide Prevention
Connecting with and Understanding Veterans
Make the Connection | Videos & Info for Military Veterans
Lethal Means Safety
Keep It Secure
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Books

This section includes recommended books about multi-component community interventions.

Butterfoss, F.D. (2007). Coalitions and Partnerships in Community Health. Wiley.
Butterfoss, F.D. (2013). Ignite!: Getting Your Community Coalition Fired up for Change. AuthorHouse.
Keyes, K.M., & Galea, S. (2016). Population health science. Oxford University Press.
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Webinars

This section includes recommended webinars about multi-component community interventions.

Coalition Building
CPG Webinar iconCommunity-Based Interventions for Veteran Suicide Prevention (CBI-SP)
Webinar iconSMVF Webinar: Leadership—An Essential Element: Implementing Interagency Suicide Prevention Action Plans for Service Members, Veterans, and their Families in States and Communities
Priority Area #1: Identify Service Members, Veterans and their Families and Screen for Suicide
CPG Webinar iconEvidence-Based Practice in Suicide Risk Screening and Evaluation: Why, What, How, and When?
Webinar iconAsking the Critical Question Can Make a Difference: "Have you or a loved one ever served in the military"
Priority Area #2: Promote Connectedness and Improve Care Transitions
CPG Webinar iconIt is That Simple: Nondemanding Caring Contacts for Suicide Prevention: Webinar Series — MIRECC / CoE (va.gov)
Priority Area #3: Increase Lethal Means Safety and Safety Planning
CPG Webinar iconPartnering with Firearm Retailers to Promote Temporary Out-of-Home Firearm Storage
CPG Webinar iconCommunity Prevention Progress: A Look at Governor's Challenge Efforts to Educate Communities on Lethal Means Safety
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Podcasts

This section includes recommended podcast episodes about multi-component community interventions.

Rocky Mountain MIRECC Short Takes on Suicide Prevention
Icon for Short Takes podcast Community Partnerships for Preventing Veteran Suicide with Dr. Bryann DeBeer
Icon for Short Takes podcast Caring Contacts — Simple and Meaningful with Dr. Kate Comtois
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Articles

This section includes recommended articles about multi-component community interventions.

Bandel, S. L., Bond, A. E., & Anestis, M. D. (2023). Interactions at the point of firearm purchase and subsequent use of locking devices. Injury epidemiology, 10(1), 11. https://doi.org/10.1186/s40621-023-00421-0
Caine, E. D. (2013, May). Forging an agenda for suicide prevention in the United States. American Journal of Public Health, 103(5), 822-9. https://doi.org/10.2105/AJPH.2012.301078
Carroll, D., Kearney, L. K., & Miller, M. A. (2020). Addressing Suicide in the Veteran Population: Engaging a Public Health Approach. Frontiers in Psychiatry, 11:569069. https://doi.org/10.3389/fpsyt.2020.569069
Collings, S., Jenkin, G., Stanley, J., McKenzie, S., & Hatcher, S. (2018). Preventing suicidal behaviours with a multilevel intervention: a cluster randomised controlled trial. BMC public health, 18(1). 140. https://doi.org/10.1186/s12889-018-5032-6
Constans, J. I., Houtsma, C., Bailey, M., & True, G. (2023). The armory project: Partnering with firearm retailers to promote and provide voluntary out-of-home firearm storage. Suicide & life-threatening behavior, 10.1111/sltb.12977. Advance online publication. https://doi.org/10.1111/sltb.12977
Frieden, T. R. (2014). Six components necessary for effective public health program implementation. American Journal of Public Health, 104(1), 17-22. https://doi.org/10.2105/AJPH.2013.301608
Granner, M. L., & Sharpe, P. A. (2004). Evaluating community coalition characteristics and functioning: a summary of measurement tools. Health Education Research, 19(5), 514-532. https://doi.org/10.1093/her/cyg056
Hegerl, U., Althaus, D., Schmidtke, A., & Niklewski, G. (2006). The alliance against depression: 2-year evaluation of a community-based intervention to reduce suicidality. Psychological Medicine, 36(9), 1225-1233. https://doi.org/10.1017/S003329170600780X
Isaac, M., Elias, B., Katz, L. Y., Belik, S. L., Deane, F.P., Enns, M.W., & Sareen, J. (2009). Gatekeeper training as a preventative intervention for suicide: A systematic review. The Canadian Journal of Psychiatry, 54(4), 260-268. https://doi.org/10.1177/070674370905400407
Kania, J., & Kramer, M. (2011). Collective impact. Stanford Social Innovation Review, 9(1), 36-41. https://doi.org/10.48558/5900-KN19
Knox, K. L., Litts, D. A., Talcott, G. W., Feig, J. C., & Caine, E. D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. BMJ (Clinical research ed.), 327(7428). 1376. https://doi.org/10.1136/bmj.327.7428.1376
Knox, K. L., Pflanz, S., Talcott, G. W., Campise, R. L., Lavigne, J. E., Bajorska, A., Tu, X., & Caine, E. D. (2010). The US Air Force suicide prevention program: Implications for public health policy. American Journal of Public Health, 100(12), 2457-2463. https://doi.org/10.2105/AJPH.2009.159871
Lai, C., Law, Y. W., Shum, A. K., Ip, F. W., & Yip, P.S. (2019). A community-based response to a suicide cluster: A Hong Kong experience. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 41(3), 163-171. https://doi.org/10.2105/AJPH.2009.159871
Oyama, H., Watanabe, N., Ono, Y., Sakashita, T., Takenoshita, Y., Taguchi, M., Takizawa, T., Miura, R., & Kumagai, K. (2005). Community-based suicide prevention through group activity for the elderly successfully reduced the high suicide rate for females. Psychiatry and Clinical Neurosciences, 59(3), 337-44. https://doi.org/10.1111/j.1440-1819.2005.01379.x
Sarchiapone, M., Mandelli, L., Iosue, M., Andrisano, C., & Roy, A. (2011). Controlling access to suicide means. International Journal of Environmental Research and Public Health, 8(12), 4550-4562. https://doi.org/10.3390/ijerph8124550
Székely, A., Konkolÿ Thege, B., Mergl, R., Birkás, E., Rózsa, S., Purebl, G., & Hegerl, U. (2013). How to decrease suicide rates in both genders? An effectiveness study of a community-based intervention (EAAD). PloS one, 8(9). e75081. https://doi.org/10.1371/journal.pone.0075081
Vriniotis, M., Barber, C., Frank, E., Demicco, R., & New Hampshire Firearm Safety Coalition (2015). A suicide prevention campaign for firearm dealers in New Hampshire. Suicide and Life-Threatening Behavior, 45(2), 157-163. https://doi.org/10.1111/sltb.12123
Walters, H., Kulkarni, M., Forman, J., Roeder, K., Travis, J., & Valenstein, M. (2012). Feasibility and acceptability of interventions to delay gun access in VA mental health settings. General Hospital Psychiatry, 34(6), 692-698. https://doi.org/10.1016/j.genhosppsych.2012.07.012
Wandersman, A., Imm, P., Chinman, M., & Kaftarian, S. (2000). Getting to outcomes: A results-based approach to accountability. Evaluation and Program Planning, 23(3), 389-95. https://doi.org/10.1016/s0149-7189(00)00028-8
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