Centering Indigenous knowledge in suicide prevention: a critical scoping review

Suicide is a pressing health concern that continues to disproportionately impact Indigenous populations around the globe. Indigenous peoples of Canada, United States, Australia, and New Zealand experience rates of suicide approximately two to three times higher than the general population of their respective countries [1‐5]. At the individual-level, the primary risk factors for suicide are mental health disorders, traumatic/stressful life events, and substance abuse [6‐8]. All of these risk factors occur at disproportionately high rates in Indigenous populations as a result of the collective and shared trauma experienced with colonization and contemporary experiences of oppression and social exclusion including dispossession and disconnection from the land, loss of language and culture, grief and loss, and racism [9‐14].

The rate of suicide among First Nations, Métis, and Inuit peoples in Canada is at least two times that of Canada’s general population [1]. In the United States, the rate of suicide among the American Indian/Alaskan Native population is approximately 3.5 times higher than those among racial/ethnic groups with the lowest rates and about 1.7 times higher than the overall US rate [2, 3]. In Australia, suicide rates for Indigenous people ranged from 1.4 to 2.4 times that of non-Indigenous Australians in 2020 [4]. In New Zealand, suicide among Māori from 2010 to 2012 was 1.8 times greater than among non-Māori, with particularly high rates among Māori men [5].

Nevertheless, national-level data can obscure considerable variability in suicide rates and patterns between communities and wider regions [1, 4, 15‐17]. While there is evidence demonstrating the connection to broader protective factors like employment status, educational attainment, and social support networks at the individual-level [6] this paper focuses on the community-level risk and protective factors for Indigenous populations. Research has identified a number of community-level factors that have been demonstrated to create resiliency to suicide in Indigenous populations, and can explain much of the observed variability in suicide rates across different communities. These protective factors include advances towards self-determination, efforts to secure Indigenous title to traditional lands, and activities that promote and protect Indigenous culture and language [15, 16, 18]. Research has also demonstrated that integrating Indigenous knowledge into mental wellness promotion, prevention and intervention initiatives has been associated with positive outcomes, including in suicide rates [19‐21]. Calls continue to grow for upholding Indigenous peoples’ right to self-determination in defining effective and culturally-grounded means to address health and wellness needs in their respective communities [22, 23]. Moreover, a growing body of research contends that standard suicide prevention programs—primarily rooted in Western individual-level efforts for behavioural change via mental health professional intervention—are culturally misaligned with Indigenous paradigms of health, mental wellbeing, and relationality [24, 25]. For these reasons, many Indigenous communities, organizations and governments have been moving away from initiatives designed for the general population and moving towards more cultural and community-based approaches for mental health promotion [26].

Despite these advancements in knowledge and understanding of the unique factors impacting Indigenous peoples’ risk and resilience for suicide, suicide prevention initiatives continue to fall short of meeting the needs of Indigenous peoples who are at a higher risk of adverse mental health outcomes and experience limited access to appropriate care and resources. Overall, there is a notable gap in comprehensive community-based, culturally safe suicide prevention resources for Indigenous communities. In recent years, many suicide prevention programs targeting Indigenous populations and incorporating Indigenous approaches have been developed; however, a thorough review of these initiatives has yet to be conducted. While a number of reviews of Indigenous suicide prevention initiatives have been conducted, they have focused on specific Indigenous groups (e.g., Indigenous youth, Inuit, or American Indian/ Alaska Native populations), particular programs employed in Indigenous populations (e.g. Adolescent Suicide Prevention Project), or focused on specific types of evidence (e.g. case files or evaluated programs only). To the authors’ knowledge, no reviews to-date have broadly examined suicide prevention efforts employed in Indigenous populations nor explicitly the contribution of Indigenous knowledge. A comprehensive exploration of how Indigenous approaches have been incorporated into suicide prevention efforts to-date could be instrumental in informing and supporting further development of Indigenous-driven suicide prevention. Consequently, this review explores how Indigenous knowledge and approaches have been incorporated in suicide prevention for Indigenous populations.

A critical scoping review was conducted to conceptualize, map and identify gaps in the literature and to assess if Indigenous knowledge was the guiding principle in developing these programs and interventions. Scoping reviews aim to map ‘the key concepts underpinning a research area and the main sources and types of evidence available [27, 28]. As such they differ from systematic reviews in focusing on broader topics and a range of study designs with little emphasis on quality; nor are they designed to perform detailed assessments or synthesis of findings [29]. Our critical scoping review aligned with the processes and objectives of a scoping review as recommended by Arksey and O’Malley [29] and Levac, Colquhoun, and O’Brien [30]. Additionally, we applied a two-step process to better align with ethical standards of research involving Indigenous peoples, and to enable Indigenous knowledge to inform the evidence appraisal and interpretation: 1) Indigenous and non-Indigenous co-authors synthesized the evidence; and 2) input was sought from a reference group of Indigenous community leaders with expertise in Indigenous knowledge systems.

The review process resulted in the collection of 1,352 academic papers and grey literature documents, with 391 articles ultimately considered after duplicates were removed. Of these, 961 were excluded as, despite appearing in the search, upon interrogation of the article title and abstract, it was determined that the content of the article fell outside of the scope of the review objectives. 197 articles necessitated full text review as inclusion could not be determined from the title and abstract alone. Of these, 149 further papers were excluded because they did not align with our review objectives nor did not meet inclusion criteria. 8 articles were identified via a hand-search of the reference lists of relevant reviews. Sixteen articles from the grey literature were ultimately included as well. Thus, our final search process resulted in 72 articles—56 of which were academic papers and 16 grey literature documents—that were included for extraction (Fig. 1). The characteristics of the articles along with the overarching themes identified through thematic analysis are summarized in the following section.

This scoping review set out to identify and describe what is known about the types of Indigenous approaches to suicide prevention that are employed with Indigenous populations and their implications for program outcomes. All articles, from both the academic and grey literature, were from Canada, the United States, or Australia. Notably, no suicide prevention initiatives from New Zealand were identified in our search strategy. We hypothesize that this may be because a higher rate of suicide among Māori in comparison to non-Māori is a relatively newer phenomenon and no public-facing reports on prevention strategies have been published yet [101]. There was also a notable absence of inclusion of considerations for Indigenous sexual minorities and gender diverse persons in suicide prevention. While the suicide rates among these groups is not well-known, two-spirited, queer, gay, lesbian, bisexual, or transgendered Indigenous persons experience suicide-related risk factors at a much higher rate than cis-gendered, heterosexual Indigenous persons [102]. Indigenous sexual minorities and gender diverse persons’ experiences around suicide, risk and protective factors may also be unique—including compounded effects of discrimination, arguably necessitating special consideration in suicide prevention [103].

Another noteworthy gap was the absence of articles concerning Indigenous approaches to tertiary suicide prevention, namely suicide and crisis response and postvention. Conventional crisis response and acquiring care via the medical system for a suicide attempt or self-harm may be present problems for Indigenous peoples as these systems may be culturally unsafe and possibly less helpful than they could be. In order to respond to a lack of accessible and culturally safe crisis and suicide response services, many First Nations in Canada are establishing their own mobile crisis response teams (e.g., Manitoba Keewatinowi Okimakanak, n.d.; Southern Chiefs Organization, 2022; Thunderbird Partnership Foundation, 2018 [104‐106]). The activities of these teams commonly have culturally inclusive elements, but still follow mostly Western crisis response models. We are unaware of any Indigenous approaches to suicide postvention; however, given the issues many Indigenous communities face following the suicide of a fellow community member including trauma, grief and loss, and possibilities of suicide clusters [107], further exploration is warranted.

The grey literature articles included toolkits, guides, information resources, and strategies to support Indigenous communities and/or organizations in developing and implementing suicide prevention programs and increasing suicide knowledge and awareness. Both academic and grey literature articles emphasized the role of culture, community connectedness and Indigenous knowledge in the prevention of suicide. Whereas the grey literature articles provided practical “how to” resources, information and guidance for delivering suicide prevention programs, the academic literature provided knowledge of “what works” by reviewing the outcomes of different suicide prevention strategies and interventions in Indigenous communities, including effective approaches to community engagement, and identifying key components of culturally-appropriate, -sensitive, -tailored, or -safe interventions.

Outcomes of this critical scoping review align with much of the work being done within the context of the broader field of Indigenous mental wellness promotion and Indigenous health research in general, which is increasingly looking to approaches that are decolonizing; founded on community engagement and self-determination; and inclusive of Indigenous culture, language and knowledge [26, 108, 109]. Moreover, in Indigenous mental wellness promotion, there is also an increasing focus on intervening beyond the individual to the family- and community-level, with an emphasis on fostering strength and resiliency [110, 111]. Family and community are important resources for developing a sense of belonging, connectedness, meaning, and identity, all of which are well-established protective factors for overall mental wellness and suicide in Indigenous populations [112]. It is within the family and the community where Indigenous culture, knowledge and language is transmitted, positive cultural identity forms, and where one can seek out support in a crisis [112]. However, in many Indigenous contexts, family and community environments have been severely damaged with colonization [13, 113]. Hence why community engagement outcomes consistently point to a need to move beyond the individual to support family and community strengths [53]. This need was echoed in articles examined in this review; however, we found that few suicide prevention initiatives employed broader family and community approaches.

Many of the suicide prevention programs identified as “community prevention” still primarily focused on protective and risk factors among individual participants and not on broader familial and community elements. As noted by Cox et al., [62] family-level intervention activities could involve a wide variety of initiatives—but especially cultural or spiritual activities—to restore and strengthen connections within and between families. Community-level suicide prevention activities might focus on bolstering the fabric of community by creating places and reasons to gather, unite, and build connection. This could be achieved through a variety of community-driven activities, for example via sports, competitions, ceremony, celebrations, gardening, learning programs, traditional land use, medicine picking, community groups, advocacy, and self-determination efforts [62].

This gap was also observed within program evaluations examined for this review, the majority of which did not incorporate any type of community-level outcome measure. The rare few that did attempt to measure, for example, community connectedness via social network characteristics [93], changes in community readiness for suicide prevention [39], or community-level changes in suicide and self-harm behaviours [59]. No evaluations included family-level outcome measures. Overall, we found that efforts to include family- and community-level initiatives within suicide prevention and evaluation did not adequately meet the need or sufficiently answer the consistent calls for such considerations from Indigenous communities [53, 83, 85]. Future suicide prevention development and implementation must do more to address this need.

In this review, we examined the ways in which Indigenous approaches have been incorporated into suicide prevention targeting Indigenous populations and the resulting impacts. Incorporation of Indigenous culture and knowledge as well as decolonizing efforts into suicide prevention was consistently shown to have positive implications for suicide-related outcomes. The meaningful inclusion of these components into suicide prevention, however, is dependent on the extent to which community self-determination is respected and upheld. From the articles reviewed here, which primarily involved partnerships between Western institutions and Indigenous communities, self-determination was best upheld where community engagement efforts were employed from before the development of a prevention program began all the way through implementation and evaluation to the finish. These engagement processes—especially those utilizing community-based participatory research (CBPR) approaches—also had a particular focus on restructuring the relationships between power, knowledge production, and public health policy and practice [24, 55]. Suicide prevention strategies that employed such community-engaged approaches were transformative and privileged Indigenous knowledge, culture, language, and locally-driven strategies that were decolonizing in nature. Decades have come to pass with no alleviation of suicide rates within Indigenous populations in Canada, the United States, Australia, and New Zealand. Dominant Western approaches to suicide prevention by themselves have largely failed at addressing suicide in Indigenous populations [114]. Consequently, future suicide prevention development and implementation must endeavor to privilege self-determined Indigenous approaches that are developed via comprehensive community engagement processes. While our review examined protective factors for suicide prevention within Indigenous populations in Canada, the United States, Australia, and New Zealand, higher suicide rates among Indigenous peoples compared to non-Indigenous populations have also been reported in Latin American countries including Brazil, Peru, Colombia, and Chile [115]. However, there is limited research evidence on Indigenous suicide in Latin American countries. A possible explanation for this lack of research could be that suicide among Indigenous peoples in those countries is significantly underreported.

Many of the suicide prevention efforts incorporated an evaluation component to measure impacts on suicide-related outcomes and were able to demonstrate some level of evidence for effectiveness. However, few evaluations were scientifically and methodologically rigorous [83, 116, 117]. In a systematic review of evaluations of suicide prevention targeting Indigenous populations and critique of their methodological quality, authors point out that evaluations were vulnerable to bias; heavily focused on proximal outcomes versus intermediate or distal outcomes; measured proxy outcomes like hopelessness and depression while ignoring suicide and self-harm behaviours entirely; and failed to consider cost [117]. In addition, it has been noted that there are considerable challenges related to suicide surveillance, including that national health data systems often lack Indigenous identifiers, do not capture data from some regions, and do not routinely engage Indigenous communities in data governance [118]. While we recognize that evaluation methodologies are heavily grounded in Western ways of knowing and constructs of “value” [119], evaluation outcomes are often crucial for justifying to funders (most often Western/colonial institutions) for continued resources for programming [117]. Moreover, evaluation can provide valuable insight into program goals, activities, strengths, areas for improvement, and cost-effectiveness [120, 121] and do not have to rely purely on Western epistemologies.

Practices to uphold Indigenous self-determination in suicide prevention (i.e. community engaged, participatory approaches) should extend to the evaluation phase in order to ensure outcomes measured are also meaningful to community and reflect Indigenous worldviews and ways of knowing [119, 121]. Evaluation processes that are culturally inclusive and community-driven have a number of crucial benefits. For instance, community-engaged suicide prevention evaluation ensures the needs and knowledge of the community remain central and community ownership, control, access and possession of evaluation outcomes and surveillance data are safeguarded. This includes how outcomes and surveillance data are shared, mitigating potential for harm that Indigenous communities have faced with non-inclusive research and surveillance [119, 122]. Unfortunately, most of the suicide prevention initiatives examined for this scoping review did not extend community engagement processes to the evaluation phase and thus failed to develop measures and evaluation tools based in Indigenous knowledge, focused on community-level outcome measures, or inclusive of Indigenous culture. Future work involving suicide prevention evaluation should ensure processes of community engagement are incorporated.

This critical scoping review is limited in two ways. Firstly, scoping studies provide a narrative or descriptive account of research and do not seek to appraise their quality or effectiveness [29]. Thus, in the context of this paper, which seeks to describe how Indigenous approaches have been integrated into suicide prevention, we do not evaluate individual program content, approaches to establishing programs, their methods, or their impacts. Instead, in employing a critical lens to this review, we sought to examine underlying structures of power and meaning that organize relationships, institutions, and knowledge production in suicide prevention, how Indigenous peoples are challenging these structures, and the resultant impacts on suicide outcomes [86] Secondly, this study is limited to the review of public-facing, written Indigenous suicide prevention only. Further exploration into informal, oral, and/or non-publicly facing initiatives would be required to create a more comprehensive picture of how Indigenous peoples are intervening on suicide in their communities.

The urgent need to reduce the disproportionately high rates of suicide in Indigenous populations of Australia, New Zealand, Canada and the United States has been widely acknowledged. Conventional Western approaches to suicide prevention by themselves have largely failed at addressing this disproportionate burden. On the other hand, initiatives that are built upon comprehensive community engagement processes and which incorporate Indigenous culture, knowledge, and decolonizing methods have been shown to have substantial impact on suicide-related outcomes in the communities in which they are employed. Indigenous approaches to suicide prevention are diverse, drawing on local culture, knowledge, need and priorities. Nevertheless, substantial barriers persist to implementing such strategies. Existing funding and health service provision systems operate from a Western, biomedical model and may be unable or unwilling to provide the resources required to invest in Indigenous approaches, highlighting the importance of evaluation to establish efficacy. On a practical level, the findings from this critical scoping review may be useful to Indigenous communities and their partners to inform their own endeavours to develop and implement suicide prevention. We hope that the outcomes presented here encourage funders, health promotion experts, and government decision-makers to support community-driven, Indigenous-approaches to suicide prevention.