Rationale

Urgent need

There is an urgent need to act. According to the ABS, there were 996 Aboriginal and Torres Strait Islander suicide deaths registered across Australia between 2001 and 2010 - about 100 per year for that period. In 2012, the ABS reported 117 Aboriginal and Torres Strait Islander deaths by suicide, perhaps suggesting a worsening situation. The overall Aboriginal and Torres Strait Islander suicide rate was twice that of other Australians, with a rate ratio of 2.0 for males and 1.9 for females.

Importantly and of critical concern, suicide rates are higher among young Aboriginal and Torres Strait Islander people aged 15–19 (5.9 times higher for females and 4.4 times higher for males), and Aboriginal and Torres Strait Islander women experience poorer maternal and infant outcomes associated with perinatal mental health than other women, which can have devastating impacts along the causal pathway.

Suicide clusters

Suicide clusters are devastating some Aboriginal and Torres Strait Islander communities. In some regions the situation is particularly alarming. For instance, in 2007, 23 deaths by suicide occurred in the Kimberley region of WA: 13 in Fitzroy; five in Oombulgurri; and five in Balgo. In such small Aboriginal and Torres Strait Islander communities where many people are related, and where many people face similar histories and challenges, the impact of suicide clusters is widespread and severe. The Kimberley is the region of highest risk with suicides reaching more than 70 per 100,000 Aboriginal and Torres Strait Islanders.

Child and youth suicide has reached alarming levels Australia-wide but particularly so in Western Australian and the Northern Territory. The majority of Aboriginal and Torres Strait Islander suicides occur before the age of 35 and have a detrimental impact on families and communities. The overall national suicide trend is 11 deaths per 100,000 population, but for Aboriginal and Torres Strait Islander people aged 25-29 years the suicide rate is 91 per 100,000 population. For Aboriginal and Torres Strait Islanders aged 20-24 years the suicide rate is 75 per 100,000 and for children aged 15-19 years the rate is 44 per 100,000.

Appropriate responses

Aboriginal and Torres Strait Islander communities at risk of suicide must determine appropriate responses. Only by actively listening to these communities, in addition to those that appear to have more effectively addressed risk factors and reduced historical rates of suicide among their members, can the Australian Government (and service providers and practitioners) better understand what is required in the short, medium and long term to prevent suicide.

Short-term responses might include ensuring counsellors and support services are available 24/7. Such communities are also best placed to develop longer-term responses that address the deeper, underlying causes of suicide. In particular, self-determination, community ownership and the role of culture in suicide prevention must be explored with these communities.

Formal evaluation

There is a need to formally evaluate the many different suicide prevention programs already operating in Aboriginal and Torres Strait Islander communities. These programs are a resource for shaping suicide prevention activities into the future except for the lack of their formal evaluation. Such evaluations should be culturally appropriate and should be complemented by an international review of what works in suicide among Indigenous peoples in settler countries.

Systematic approach

There is a need for a systematic approach to building the Aboriginal and Torres Strait Islander wellbeing workforce and to improving specific skills in suicide prevention and supporting social and emotional wellbeing. The approach needs to be cross-sectoral, encompassing workforces in early childhood, education, health care, child protection therapeutic services, police, juvenile justice and other sectors. It requires culturally appropriate resources, tools and principles as well as access to training.

Evidence base

There is a need to develop an evidence base of what works to ensure funding is effectively targeted. The Australian Government should be confident that funding allocated to Aboriginal and Torres Strait Islander suicide prevention services and programs will build community resilience and reduce suicide. In particular, this applies to the $17.8m allocated in 2013 for the implementation of the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy over four years that is yet to be distributed.

Recommendations

Without an evidence-base of what works it will not be possible to make recommendations for systemic change to tackle suicide. Questions need to be asked about what is best, who should be involved, how and when. For example, what are the best service models in the health and mental health sector and for family and youth support services to prevent suicide? What are the workforce needs? What is the role of schools, family support services, and so on? How effective are existing clinical diagnostic models to assess suicide risk among Aboriginal and Torres Strait Islander peoples? Are existing post-vention referral strategies adequately supporting people who have presented in emergency departments and primary health care due to self-harm or attempted suicide?

'Third Conversation'

On 24 June 2014, the participants of the 'Third Conversation' Roundtable on Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention issued a Call to Action that reinforced many of the issues discussed above. Over 50 Aboriginal and Torres Strait Islander leaders and other experts met in Perth with Professor Michael Chandler, Canadian expert in trends and causes of suicide, for a third time to discuss suicide prevention and to identify the actions needed to turn this critical problem around. The resulting Call to Action established culture as central to all solutions aimed at improving social and emotional wellbeing, mental health and reducing suicide, with actions to be underpinned by culturally informed research, knowledge and evidence, and supported by Whole of Community and Whole of Government approaches.

Summary

There is a need to develop an evaluation framework that can measure the effectiveness and appropriateness of the range of suicide prevention programs and services needed to address the complex issues contributing to Aboriginal and Torres Strait Islander suicide at a number of levels. Importantly, this work must be underpinned by understandings of suicide and actions identified by communities and by national and international best practice, as necessary, and support community ownership and delivery of these programs wherever practical.

Methodology

The project will be conducted in three distinct phases as outlined below. While the methodology is described as being undertaken in a series of stages the project is actually quite iterative and there will be overlaps in timing and various refinements along the way. The various elements and key outcomes are shown in the flowchart below.

Phase 1

• Undertake a meta-analysis of systematic reviews of Suicide Prevention programs and services in Australia that have been evaluated and shown to be promising practice, and those that have not evaluated.
• Undertake a review of existing literature–including State and Territory reports data, and a statistical analysis of suicide and self-harm–on suicide prevention programs to identify what works and identify suicide trends and causes.
• Map the prevalence of Aboriginal and Torres Strait Islander suicide and self-harm.
• Compare to the availability of existing suicide prevention programs and services.
• Undertake a comprehensive review of existing evaluation frameworks and program and wellbeing indicators.
• Evaluate suicide prevention programs identified in the systematic review that have not previously been evaluated.

Phase 2

1. Identify all programs that have been evaluated and assess the type of evaluation conducted:

• the level of rigour involved
• whether the program was developed in response to the incidence of suicide, was community led, who developed and delivered it
• where the program has been implemented and whether any impact analysis has been undertaken
• gauge stakeholder and community perspectives, and follow up as necessary.

2. Develop a proposed culturally appropriate evaluation framework informed by these evaluations and the literature and data review ensuring that the framework:

• is principle based
• will support implementation of the recommendations of the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy, and
• is consistent with the Close the Gap Paper No.12 on ‘Effective Strategies in Aboriginal and Torres Strait Islander Mental Health and Wellbeing’ and key themes identified in the meta analysis of key national and state community consultations such as the Elders’ Report and various National Empowerment Program community site reports.

Phase 3

1. Undertake a minimum of three regional roundtable community consultations. These will include The Kimberley, WA (Broome), NT (Darwin) and VIC (Mildura) to identify what communities need to prevent suicide and to hear first-hand of community experiences with suicide prevention services and programs to help identify what works and why. 

2. Undertake additional consultations and/or targeted fora, subject to available funding. Targeted regions include Cairns (QLD), Adelaide (SA) and the Shoalhaven area (NSW), while the targeted national topical groups may include Aboriginal and Torres Strait Islander youth; those recently re-entering communities following incarceration; and those identifying as lesbian, gay, bisexual, transgender or queer.

3. These consultations will enable the project to:

• gain feedback and input to the Project work to date
• hear the different experiences with suicide prevention programs and services across Australia to further identify what works and why
• identify those programs that have previously been assessed as effective and seek community perspectives on whether they have access to these programs, whether they consider they may be relevant to their communities and, if so, what would be needed to support effective implementation
• determine where programs are already in use, what changes could be made to further improve their effectiveness.

4. Scope and map the available programs in at-risk and resilient communities.

5. Pilot the proposed culturally appropriate evaluation framework in selected communities and with target groups to seek feedback on it.

6. Consult with key stakeholders, including the following, to gain their insights and access to methodologies, trends, and the like:

• The Australian Institute for Suicide Prevention
• World Health Organisation Collaborating Centre for Research and Training in Suicide Prevention
• National Centre of Excellence in Suicide Prevention
• The Healing Foundation
• National Aboriginal Community Controlled Health Organisation
• National Mental Health Commission

7. Consult with the Queensland Government on the implementation and outcomes of the Queensland Government Suicide Prevention Action Plan 2010-2015.

National Conference

The project has sought additional funding through the Indigenous Advancement Strategy and, if successful, will conduct the additional roundtables and consultations noted above and will also convene a National Conference on Aboriginal and Torres Strait Islander Suicide Prevention.

This conference would play an important role in sharing the lessons learned in the project and in raising awareness about the incidence of Aboriginal and Torres Strait Islander suicide and self-harm and the services and programs that are available to help individuals, families and communities to address the high suicide rates.

National Advisory Committee

A National Advisory Committee will be formed to provide independent external advice to the project and it is hoped that this advisory committee will be a precursor to the formation of a National Alliance to combat the high Aboriginal and Torres Strait Islander suicide rate.