OBJECTIVE:This study explored how rural communities can be involved in suicide prevention efforts for young people aged 12-25. It provides a focus on who is best placed to drive these efforts and what support these people need to implement initiatives in their communities. SETTING:The research was conducted across Australia, with a focus on rural areas, where suicide rates are higher due to unique challenges, including geographic isolation, stigma and limited access to health services. These areas require community-driven solutions tailored to local contexts. PARTICIPANTS:Thirty-seven participants aged 29-72 contributed insights, with diverse professional roles and lived experiences in rural youth suicide prevention, including service providers, programme leaders, researchers and policymakers. DESIGN:A qualitative approach was used, with semi-structured interviews and focus groups conducted between January and September 2021. Data were thematically analysed using a reflective approach to identify key factors supporting rural youth suicide prevention. RESULTS:Two key themes emerged: (1) Program planning and implementation: highlighting the need for adaptable, stigma-sensitive and culturally responsive approaches, and (2) Breaking down silos: emphasising collaboration between schools, families, health services and community leaders. Trusted local figures such as teachers, sports coaches and peers were identified as crucial for fostering engagement and early intervention. Lived experience voices were recognised as integral to co-designing and sustaining community-led efforts. CONCLUSION:Rural communities are central to youth suicide prevention. By leveraging local relationships, addressing stigma and fostering collaboration, communities can create supportive environments that save lives. Policy and practice must prioritise funding and resources for community-led, culturally sensitive approaches.

Rural communities are faced with unique social and geographical challenges which impact mental health and suicidality. Prevention efforts must support the essential resource in agricultural production: the people. Community-based suicide prevention is a social driver of change, enabling rural communities to leverage existing strengths and resources. This paper will reflect on the author's experiences evaluating recent suicide prevention programs implemented in Tasmania and research drawing on professional and lived experience perspectives across Australia. The discussion shows how community-based suicide prevention can be used to build the capacity of and re-purpose roles already in the community linked to agricultural extension. Community-based efforts are a means to align with, coordinate and empower extensionists to be involved with localised prevention efforts. This approach can support farmers and producers, communities, and industries to impact the complex factors contributing to increased suicide risk and the ripple effects widely felt across rural communities.

Rural communities have unique mental health needs and challenges which are often related to the uniqueness of the community itself. On a per-capita basis, the investment in rural mental health research is far less than that in urban communities. Added to this, rural communities are often at risk of researchers, based in large urban universities, visiting, conducting the research with minimal engagement with local stakeholders and limited understanding of the community's social-service-environmental context. Often this research leaves no visible benefit to the community with respect to increased knowledge, resources or community capacity. This commentary is based on the insights of a panel of authors from 9 countries, each with extensive experience of rural mental health research and work. And it seeks to stimulate the discourse on responsible rural mental health practice. The aim of this commentary is to provide a reference on research practice for novice and experienced researchers on rural mental health research and practice, to assist policymakers, government and funding bodies to establish appropriate standards and guidelines for rural mental health research, and support rural communities to advocate for equity of funding and sustainable research as they engage with researchers, funders and governments. The 10 standards in this declaration will help guide researchers toward research that is beneficial to rural communities and also help develop the local community's research capability, which ultimately will serve to enhance the mental health and well-being of rural communities.

BackgroundFor young living in rural areas around the world, suicide is a leading cause of death, stressing the need to understand characteristics of programs aiming to impact suicide and related behaviours.AimA systematic literature review aimed to synthesise the evidence and explore characteristics of programs seeking to impact suicidal behaviours (rates, attempts, ideation) for young people in rural areas.MethodData sources: Electronic databases EMBASE, Medline, PsycINFO and Scopus. Study eligibility criteria, participants, and interventions: Studies measuring suicide-related outcomes (rates, attempts, ideation) for youth (people aged 12-25 years) in rural areas worldwide, published 1 January 2000 to 6 June 2023. Study appraisal and synthesis: Data were thematically analysed, exploring intervention characteristics. Mixed Methods Appraisal Tool assessed study quality.ResultsEleven (11) studies met the selection criteria. Studies impacting suicides and attempts were often multiple strategies, multi-layered, combining universal, selective, and indicated programs, implemented across systems and settings, including public-health psychoeducation, referral mechanisms, crisis lines, postvention, peer support, outreach, means restriction, mindfulness, and gatekeeper training. Psychoeducation and mindfulness contributed to decreased suicidal ideation. Community-level partners were central to efforts, including working groups, networks, Indigenous people, people with lived experience, volunteers, and peers.ConclusionsVaried programs have capacity to reduce suicide rates and related behaviours among young people in rural areas, with communities and schools as crucial settings. Programs implemented across levels show promise at reducing the number of young people who end their lives by suicide or attempt to do so, demonstrating a need for program evaluations and continued, long-term outcome monitoring.

Suicide rates in rural communities are higher than in urban areas, and communities play a crucial role in suicide prevention. This study explores community-based suicide prevention using a qualitative research design. Semi-structured interviews and focus groups asked participants to explore community-based suicide prevention in the context of rural Australia. Participants recruited ((n = 37; ages 29–72, Mean = 46, SD = 9.56); female 62.2%; lived experience 48.6%) were self-identified experts, working in rural community-based suicide prevention (community services, program providers, research, and policy development) around Australia. Data were thematically analysed, identifying three themes relating to community-based suicide prevention: (i) Community led initiatives; (ii) Meeting community needs; and (iii) Programs to improve health and suicidality. Implementing community-based suicide prevention needs community-level engagement and partnerships, including with community leaders; gatekeepers; community members; people with lived experience; services; and professionals, to “get stuff done”. Available resources and social capital are utilised, with co-created interventions reflecting diverse lifestyles, beliefs, norms, and cultures. The definition of “community”, community needs, issues, and solutions need to be identified by communities themselves. Primarily non-clinical programs address determinants of health and suicidality and increase community awareness of suicide and its prevention, and the capacity to recognise and support people at risk. This study shows how community-based suicide prevention presents as a social innovation approach, seeing suicide as a social phenomenon, with community-based programs as the potential driver of social change, equipping communities with the “know how” to implement, monitor, and adjust community-based programs to fit community needs.

Abstract Purpose With emerging evidence indicating that systems-based approaches help optimise suicide prevention efforts, the National Suicide Prevention Trial sought to gather evidence on the appropriateness of these approaches to prevent suicide among at-risk populations, in regional and rural communities throughout Australia. The Tasmanian component of the Trial implemented the LifeSpan systems framework across three distinct rural areas with priority populations of men aged 40–64 and people 65 and over. The University of Tasmania’s Centre for Rural Health undertook a local-level evaluation of the Trial. Aims To explore key stakeholder perceptions of implementing a systems-based suicide prevention program in regional and rural communities in Tasmania, Australia. Method This study utilised qualitative methods to explore in depth, stakeholder perspectives. Focus groups and interviews were conducted with 46 participants, comprising Trial Site Working Group members (n = 25), Tasmania’s Primary Health Network employees (n = 7), and other key stakeholders (n = 14). Approximately half of participants had a lived experience of suicide. Data were thematically analysed using NVivo. Results Key themes centred on factors impacting implementation of the Trial. These included how the Trial was established in Tasmania; Working Group governance structures and processes; communication and engagement processes; reaching priority population groups; the LifeSpan model and activity development; and the effectiveness, reach and sustainability of activities. Discussion Communities were acutely aware of the need to address suicide in their communities, with the Trial providing resources and coordination needed for community engagement and action. Strict adherence to the Lifespan model was challenging at the community level, with planning and time needed to focus on strategies influencing whole or multiple systems, for example health system changes, means restriction. Perceived limitations around implementation concerned varied community buy-in and stakeholder engagement and involvement, with lack of role clarity cited as a barrier to implementation within Working Groups. Barriers delivering activities to priority population groups centred around socio-cultural and technological factors, literacy, and levels of public awareness. Working Groups preferred activities which build on available capital and resources and which meet the perceived needs within the whole community. Approaches sought to increase awareness of suicide and its prevention, relationships and partnerships, and the lived experience capacity in Working Groups and communities. Conclusion Stakeholder insights of implementing the National Suicide Prevention Trial in regional and rural Tasmanian from this study can help guide future community-based suicide prevention efforts, in similar geographic areas and with high-risk groups.

Participatory action research (PAR) is a novel approach to the design, conduct and evaluation of research that is increasingly favoured by public health researchers.1-4 It involves a cycle of critical reflection and action, centred on collaboration between researchers and participants in all aspects of the research process. Throughout this process, observation and reflection inform action, which then becomes the subject of later reflection and so on3 (Figure 1). Taking the historical, cultural and social nuances of a situation or environment into account, PAR is designed to shift the power differential from the researcher to the researched.1-4 Engaging community members in the design and conduct of research addressing relevant health concerns is seen to empower them to take ownership of these concerns and thereby play a direct role in promoting action and change.5, 6 Graphical Outline of the Participatory Action Research (PAR) Approach. In the past two decades, interest in the application of PAR to public health research and practice has grown, and the approach is increasingly viewed as being critical to the success of community-based health interventions.1, 2 PAR has been applied to research addressing, among other things, maternal and neonatal health, youth homelessness, mental health consumer engagement, and Indigenous health.1, 4 While in theory PAR might be applied to the implementation and evaluation of interventions for any given health problem, it has been suggested that the method may be particularly valuable for interventions seeking to improve the health and wellbeing of socially and economically disadvantaged communities.1, 5 That is, the increased empowerment and increased capacity to develop and deliver community programs that are inherent in the application of a PAR approach may be particularly beneficial for disadvantaged communities.1, 5, 6 One increasingly important public health concern to which PAR might usefully be applied is that of suicide prevention.7-9 It is well known that rates of suicide are elevated in disadvantaged communities and PAR approaches to suicide prevention program implementation and evaluation have been trialled with several populations in recent years, most notably Indigenous populations.5, 7-9 By engaging community members in all stages of the research process, the PAR approach allows suicide prevention efforts to capitalise on community strengths, such as local knowledge, experience and cohesion, to effect social change9. Individuals living in rural and remote communities experience elevated levels of social and economic disadvantage and evidence continues to show higher rates of suicidal behaviour – and poorer access to mental health services – for people living in these areas, relative to their urban counterparts.10 Information concerning the application of a PAR approach to suicide prevention efforts in rural and remote areas of Australia is, however, lacking. Hence, the utility and feasibility of the approach, when applied in these areas, remains unclear. In the current contribution, we reflect on our experience of applying a PAR approach to the evaluation of a community-based, suicide prevention trial conducted in several regional areas of Tasmania, Australia. An overview of the background and design of the trial is first provided, followed by an outline of the nature and scope of the evaluation. We highlight the key opportunities and challenges identified from our efforts to apply a PAR approach to the evaluation, and conclude by providing recommendations to assist in conducting similar evaluations in future. Findings from the evaluation per se will be reported in due course.11 In 2016, the Australian Government initiated a National Suicide Prevention Trial (NSPT).11, 12 The goal of the trial was to test the implementation of a systems-based approach to suicide prevention in local communities deemed to be diverse in terms of their need for, and capacity to implement, suicide prevention efforts. Twelve sites across Australia were selected to participate, with Primary Health Networks (PHNs) receiving funding over four years to coordinate the trial. The island state of Tasmania, home to just over half a million people, was selected as one of the 12 trial sites.11, 13 Its capital city, Hobart, is classified as ‘inner regional’, while areas in the remainder of the state range from ‘outer regional’ in the north-west and north-east coasts to ‘remote’ in the west.14 In 2018, Primary Health Tasmania (PHT) commissioned researchers at the University of Tasmania's (UTAS) Centre for Rural Health (CRH) to conduct a local-level evaluation of the Tasmanian trial site. The aim was to conduct a process-oriented evaluation that would inform future, local-level suicide prevention program implementation and supplement a more outcome-oriented, national-level evaluation being conducted by researchers at the University of Melbourne.11 The Tasmanian site encompassed the Local Government Areas of Launceston in Northern Tasmania, Break O'Day on the north-east coast, and the north-west Coast municipal areas of Burnie, Central Coast and Devonport.13 These locations were chosen by the Tasmanian Suicide Prevention Trial Advisory Group (TSPTAG), a group of members representing peak bodies, services, government and other key stakeholders, who were primarily responsible for key decisions in the early planning stages11. The local evaluation team and Working Group (WG) Coordinators joined the TSPTAG once they were engaged. The locations were chosen based on factors such as existing suicide prevention activities, suicide risk factor profiles and community readiness/capacity to be involved. WGs comprised local community members, service providers, a consultant from PHT who helped support and guide WGs, and a funded trial Coordinator, who had primary responsibility for the design and delivery of activities at each site.11, 13 The priority population groups for the Tasmanian site, selected by the TSPTAG, were men aged 40 to 64 years and people over 65 years, and trial activities were guided by the Black Dog Institute's LifeSpan framework.15 LifeSpan seeks to combine a broad range of suicide prevention strategies (e.g. improving public ability to recognise and respond to suicidality, improving emergency and follow-up care for suicidal crisis), with the aim of building community capacity to better support people facing suicidal crisis.15 The evaluation focused on the processes and governance structures affecting the ability and capacity of the local trial sites to develop and implement suicide prevention activities within the LifeSpan framework.11 Methods were approved by the UTAS Social Sciences Human Research Ethics Committee. The contract between PHT and the evaluation team stipulated using an action research approach and incorporating a range of activities consistent with such an approach. In particular, the evaluation team was required to convene regular gatherings – ‘Action Learning Circles’ (ALCs) – the venues for which were rotated among trial sites. The primary goal of the ALCs was to give WG members the opportunity to share learnings and discuss challenges and opportunities with the evaluation team. The ALCs also provided an opportunity for the evaluation team to update WG members on the evaluation, to elicit WG members’ feedback in this regard and to work with WG members in addressing practical challenges inherent in designing, implementing and evaluating suicide prevention activities11. In these, and all other forms of interaction with WG members, care was taken to ensure a collaborative approach in which WG members were encouraged to contribute to the design and conduct of the evaluation. WGs were asked to provide feedback at WG meetings, ALCs and via email. Providing various feedback channels helped to ensure that all WG members had a method of communication with which they felt comfortable. As evaluation team members received feedback, this feedback was considered, as a team, before being communicated back to the WG members and to the funding body along with any feedback from the team. Figure 1 provides a graphical outline of the PAR cycle of reflection and action, as described by Baum and colleagues.1 It highlights the unique opportunities and challenges that a PAR approach can bring to the evaluation of a suicide prevention initiative as identified by the evaluation team. WG members welcomed the opportunity to be involved in the evaluation process and to build their capacity to develop, implement and conduct their own evaluation of suicide prevention activities. Sustainability of these activities was seen to be augmented through this increased capacity (e.g. knowledge and experience of which strategies of the Lifespan framework were most likely to be feasible and effective in which environments). Program sustainability was also seen to be enhanced through relationships developed and consolidated within and between WG members from the different sites, local service providers, local government and non-government agencies. Including people with lived experience in evaluation activities aligned to the aims of the local-level evaluation and employment of a PAR approach. Knowledge of what was effective in terms of program planning and evaluation for people with a lived experience was driven by members of the WGs with lived experience. The evaluation activities in turn provided an open forum for those people with lived experience involved in the WGs and trial processes to provide feedback to the evaluation team on what they felt worked well and where there was room for improvement. The quality of the (primarily qualitative) data collected has, we believe, been enhanced by the active engagement and buy-in of WG members in the evaluation process. Whether such outcomes would have been possible with a more traditional, ‘top-down’ approach to evaluation, in which the focus is on independent assessment of processes and outcomes among study participants, rather than building the capacity of the local communities in which these participants exist, is debatable.3, 4 As is also apparent from Figure 1, the opportunities afforded by a PAR approach to program evaluation come with a number of challenges each of which, in our experience, has also been inherent in the application of a PAR approach to suicide prevention program evaluation. A key challenge for the current evaluation was that strict adherence to PAR approach was not possible because certain key decisions were made prior to engagement of the evaluation team. These included the choice of trial site locations, the demographic subgroups targeted in each location, the choice of LifeSpan as the suicide prevention framework guiding activity development and the WG structure and governance processes. These decisions were in turn influenced by factors such as the funding available to the PHN and delays in the timing and development of WGs. This is at odds with a strict PAR approach, in which such decisions are made in consultation with both the evaluation team and community members. In the current evaluation, the degree to which community members were effectively engaged by TSPTAG in these decision-making processes is unclear.6, 16 Nonetheless, the detailed, local-level information collected will, we believe, be invaluable in informing future, local-level suicide prevention initiatives. A second challenge, following from the pre-determined structure of the WGs, was that representatives from the funding body were present as ‘consultants’ at all WG meetings and ALCs, alongside members of the evaluation team. This might have limited the expression of valuable personal views on the part of WG members, opinions about funding structures, for example. This is an important consideration, given that freedom of disclosure is considered a fundamental element of the PAR approach.17, 18 The evaluation highlighted the potential challenges inherent in the ‘dual role’ of an evaluation team when using a PAR approach, namely, seeking to act as an independent party working with WG members to undertake an evaluation of existing processes and structures, while simultaneously feeding evaluation learnings back to WGs and thereby influencing these processes and structures.18, 19 This dual role could also be seen to present opportunities, however, the opportunity to provide assistance to WG members with the evaluation of activities if requested, for example. An additional challenge related to uncertainty regarding the nature and scope of the evaluation team's role when applying a PAR approach. Understanding of PAR and of research methodology more generally was limited among WG members and the evaluation team was required to work with WG members and the funding body to develop and communicate the best possible approach given the circumstances. Even so, a degree of confusion surrounding the nature and scope of the evaluation team's role remained and at various times all three parties – the evaluation team, WG members and the funding body – found themselves straddling the line between reflection (e.g. the evaluation team assisting WG members to reflect on practical challenges inherent in developing action plans) and action (e.g. the evaluation team suggesting solutions to such challenges). Perhaps not surprisingly, the application of a more inclusive, ‘bottom-up’ approach to the evaluation was welcomed by WG members. Whether and to what extent the use of PAR proves beneficial in future, when it comes to dissemination of the findings, for example, remains to be seen. We believe that the findings will, in due course, be seen to provide preliminary support for the utility of a PAR approach to the evaluation of suicide prevention initiatives in rural and remote areas of Australia. Also of note, the evaluation team found the experience of working with differing levels of community literacy and capacity to be generally positive. Community awareness and understanding of the challenges inherent in designing and implementing suicide prevention activities were seen to improve in the course of evaluation, as did awareness of potential barriers to implementing the Lifespan framework in regional/rural settings. WG members’ capacity to plan for and conduct their own evaluations of suicide prevention activities was variable, largely due to time and resource constraints impacting both the evaluation team and WG members. Several recommendations follow from these reflections, two of which we believe are key for any future application of a PAR approach in comparable contexts. First, the application of a PAR approach to suicide prevention program evaluation demands involvement of both participants and the evaluation team in the early stages of program planning, to ensure that community members are involved in the initial decision-making processes and that this involvement can be evaluated from the start. This will, in turn, maximise both the potential for capacity-building and the integrity of the evaluation. Early engagement of the evaluation team is also helpful in anticipating delays inherent in gaining ethics approval for ‘high-risk’ aspects of the evaluation, such as the recruitment and collection of data from individuals with lived experience. In our view, including individuals with lived experience in evaluation activities is key to local-level evaluations employing a PAR approach, and this early engagement should, where possible, be prioritised. In addition, early engagement between the evaluation team and other key stakeholders is needed to ensure a clear understanding of the role of the evaluator and the importance of the evaluation for program sustainability. This should, in turn, contribute to increased rates of participation in evaluation activities. Second, based on the evaluation team's experience, it needs to be assumed that there is no prior knowledge of PAR among community members and that time will need to be taken for the evaluation team to work with both community members and the funding body to ensure mutual understanding of the key principles of, and challenges and opportunities inherent in, the use of such an approach. This should be communicated to all key stakeholders involved, to enable critical reflection and the continuous improvement of planning decisions and processes. Consideration of the complexities associated with the nature and scope of the evaluation team's role within a PAR approach, including time and/or resource constraints, should also be identified and communicated early on. Ideally, this process would include practical examples of challenges likely to be faced by both participants and evaluation team members and how these challenges might be addressed. Practical examples of opportunities presented by a PAR approach would also be welcome, as this can help maximise participant buy-in and the likelihood of opportunities being realised. At least two limitations of the current contribution should be noted. First, whether and to what extent this contribution might be helpful in informing the evaluation of suicide prevention programs in other settings (e.g. rural/regional areas in others Australian states/territories and/or in other countries; across urban/rural boundaries) is unclear. Second, the authors recognise the potential for bias inherent in a commentary/perspective piece. Further insights, from the perspectives of WG members and other key stakeholders, will emerge from analysis of the qualitative data collected through the course of the evaluation. Findings from this analysis will be published in due course. The application of a PAR approach to program evaluation entails both opportunities and challenges, particularly in regional and rural areas, where close-knit communities turn their experiences and understanding of factors contributing to suicide into preventative action. Our experience is that these communities are eager to work together to undertake initiative and to engage with stakeholders, including evaluators, to build capacity and ensure program ownership and sustainability within their communities1, 5, 6. On balance, in our application of a PAR approach to the evaluation of a suicide prevention initiative in regional/rural areas of Tasmania, the opportunities outweighed the challenges. Hence we recommend the use of this approach in future work of this kind.