Ines Gonzalez Casanova, Indiana University, United States
This is an open-access article distributed under the terms of the
Currently, seventeen veterans die by suicide daily in the United States (U.S.). There are disparities in suicide behavior and access to preventative treatment. One disparity is the suicide rate in rural areas, including the state of Arkansas—suicide deaths among rural veterans increased 48% in the last 2 decades, double that of urban veterans. One major challenge for veterans in rural areas is the lack of healthcare providers to provide Safety Planning Intervention, which is an effective intervention to reduce suicide attempts in the general adult population and among veterans. One solution is more broadly implementing Safety Planning Intervention, by using peers to deliver the intervention in rural communities. Before implementation, the intervention needs to be adapted for peer-to-peer delivery, and barriers and facilitators identified.
Since January 2021, using community-based participatory research, we collaboratively developed and executed a 1 year study to adapt Safety Planning Intervention for peer-to-peer delivery in rural communities and identified implementation barriers and facilitators prior to spread. From July 2022 to February 2023, we conducted group interviews with 12 participants: rural veterans with prior suicidal thoughts or attempts in one U.S. state, their support persons, and healthcare professionals with expertise in veteran suicide prevention, Safety Planning Intervention, and/or peer delivery. We collected qualitative data through interviews during nine, 2 h meetings, and quantitative data from one anonymous survey and real-time anonymous voting—all on the topic of core and adaptable components of Safety Planning Intervention and implementation barriers and facilitators for peer delivery in rural communities. Questions about adaptation were designed according to processes in the ENGAGED for CHANGE community-engaged intervention framework and questions about facilitators and barriers were designed according to the Health Equity Implementation Framework. Participants categorized which Safety Planning Intervention components were core or adaptable, and how freely they could be adapted, using the metaphor of a traffic light in red (do not change), yellow (change with caution), and green (change freely) categories.
Participants made few actual adaptations (categorized according to the FRAME modification system), but strongly recommended robust training for peers. Participants identified 27 implementation facilitators and 47 barriers, organized using the Health Equity Implementation Framework. Two example facilitators were (1) peer-to-peer safety planning intervention was highly acceptable to rural veterans; and (2) some state counties already had veteran crisis programs that could embed this intervention for spread. Two example barriers were (1) some community organizations that might spread the intervention have been motivated initially, wanting to help right away, yet not able to sustain interventions; and (2) uncertainty about how to reach veterans at moderate suicide risk, as many crisis programs identified them when suicide risk was higher.
Our results provide one of the more comprehensive pre-implementation assessments to date for Safety Planning Intervention in any setting, especially for peer delivery (also referred to as task shifting) outside healthcare or clinical settings. One important next step will be mapping these barriers and facilitators to implementation strategies for peer-to-peer delivery. One finding surprised our research team—despite worse societal context in rural communities leading to disproportionate suicide deaths—participants identified several positive facilitators specifically about rural communities that can be leveraged during implementation.
Currently, 17 veterans die by suicide daily in the United States (U.S.) (
Although there are evidence-based interventions to prevent suicides, such as Safety Planning Intervention (which includes lethal means safety counseling, they are primarily delivered in healthcare settings that can be hard to access for rural veterans due to long drives or limited internet access to use telehealth (
Veterans’ preference is to first have discussion about securing lethal means—items a veteran might use to harm themselves, such as firearms or pain medication—with family members or peers (
In the current study, we used scientific methods for community engaged adaptations of interventions, community based participatory research (CBPR), and implementation science, relying on data generated by veterans with lived experience with suicidal thoughts or attempts (community) and healthcare professionals with expertise in suicide prevention. Since January 2021, our community-academic research team has met every 2 weeks to collaboratively develop research questions, study design, and execute the study. From January to September 2021, we collectively participated in a local university course on community-based participatory research designed for community-academic research teams. This course included online modules, live video courses, textbook readings, and team mentoring with an experienced community engagement researcher to assist us in preparing a grant application for this study. To ensure every team member provided input, accommodations were made for amputee veterans, limited internet services, and team members who were not comfortable speaking in a group. By making accommodations to receive input from every team member, we were able to thoroughly understand others’ needs for our research and what study modifications were needed after the study commenced. This study was co-led by an academic principal investigator and a community principal investigator. Our first aim was to determine core and adaptable components of Safety Planning Intervention that could be used in implementation of the intervention peer-to-peer in community organizations. Our second aim was to identify anticipated implementation barriers and facilitators if deploying this in real world settings, to prepare for spread and scale through community organizations.
To guide adaptation, we use the ENGAGED for CHANGE framework (
We used mixed methods research, QUAL + QUAN design, in which qualitative and quantitative data were collected concurrently throughout the study and priority was equally shared between both data types (more detail in Analysis section) (
We convened research study participants known as the “Arkansas Safety Planning Intervention Workgroup” at nine monthly meetings. Participants included: rural Arkansas veterans with prior experience with suicidal thoughts and/or attempts, support persons of those veterans, rural Arkansas veterans who worked in community organizations to prevent veteran suicide but did not necessarily experience suicide thoughts or attempts themselves, mental health and internal medicine professionals with expertise in suicide prevention and/or peer support interventions (some working in VA). The goal of the participant workgroup was to decide on core and adaptable components of Safety Planning Intervention, determine adaptations to Safety Planning Intervention for peer-to-peer delivery, and identify preliminary implementation barriers and facilitators. The Arkansas Safety Planning Intervention Workgroup followed the ENGAGED for CHANGE steps, digesting data from different sources of knowledge, including veterans’ lived experience, government reports, existing training manuals and tools for Safety Planning Intervention, and published peer-reviewed research. This group was distinct from our research team, the latter of which oversaw and coordinated the study with community partners embedded as a co-principal investigator and significant contributors. Both groups had members from the community with lived experience.
Regarding eligibility criteria, we recruited veterans from rural communities to become participants and members of our Arkansas Safety Planning Intervention Workgroup. To be eligible to participate, veterans had to meet these inclusion criteria: they must have formerly served in the U.S. military, had suicidal thoughts or attempts before but not within 6 months, and live in a rural community with a Rural Urban Commuting Area code of four or higher (higher codes equal more rural places) (
To recruit veterans and their support persons participants, each community-academic research team member sent an initial outreach to potential participants via text message, e-mail, and social media pages of their own and of the community organization partner using scripted text with a flyer about the purpose of the study, roles for participants, risks, benefits, compensation, and contact information. Forty-one people were interested. From this initial pool, 19 people were not responsive to follow-up for screening, and 22 potential participants agreed to complete eligibility screening questions by any member of the community-academic research team. During eligibility calls, two individuals’ phone numbers were not working, 5 were not eligible due to not living in a rural area, three declined to participate [did not want to commit to monthly meetings (
Demographic characteristics of veteran and support person participants.
| Demographic characteristic | |
|---|---|
| Age | Mean = 49.78 years, Range = 33–62 years |
| Veteran status | |
| Veteran | 6 (66.67%) |
| Not a veteran (support person) | 3 (33.33%) |
| Gender identity | |
| Man | 4 (44.44%) |
| Woman | 5 (55.56%) |
| Racial identity | |
| American Indian or Alaska Native | 1 (11.11%) |
| White | 7 (77.78%) |
| Declined to report | 1 (11.11%) |
| Ethnicity | |
| Hispanic or Latino | 1 (11.11%) |
| Not Hispanic or Latino | 8 (88.89%) |
| Sexual identity | |
| Straight or heterosexual | 7 (77.78%) |
| Lesbian, gay, or queer | 2 (22.22%) |
We assembled the Arkansas Safety Planning Intervention Workgroup for nine, 2 h meetings from July 2022 to February 2023, approximately every 3–4 weeks. The first and last meeting were hosted in-person in the public library, rather than our hospital clinics, in a convenient central city agreed upon by all participants. The purpose of in-person meetings was relationship building and had a hybrid video conference option for those who could not attend in person. The remaining seven meetings were hosted via video/telephone conference as this was preferred by participants and the research team due to participants being geographically dispersed and ongoing COVID-19 infection concerns.
To enhance equitable participation and minimize power imbalances, we started with only community member participants at the first three meetings and met with the healthcare professional participants in one meeting separately, so all could become oriented to the topic and process with people more like themselves (
Meeting numbers, topics, and participants aligned to ENGAGED for CHANGE framework steps to adapt an existing intervention and identify preliminary implementation barriers and facilitators.
| Meeting topic and data collection by ENGAGED for CHANGE step | # of meetings on topic and participants |
|---|---|
| Prior to study | |
| i |
Prior to study |
| Bonus: created community agreements about ground rules for discussion Community: review written summaries of safety planning intervention and data on suicide risk factors for rural veterans; bring their expertise from other sources to blend with research expertise (interview) Professionals: review safety planning intervention steps and determine what they perceive as core/adaptable functions and forms of the intervention (interview) |
1 (community); |
Open-ended questions about anticipated implementation barriers and facilitators for future spread (interview) |
1 (community) |
Create draft of core functions and forms of the intervention to begin to focus intervention goals on community needs and priorities (interview + survey + real-time voting) |
2 (combined) |
Identify and incorporate any theories that may provide systematic knowledge check of existing perspectives (interview) Refine list of red/yellow/green light adaptations (interview + survey + real-time voting) |
1 (combined) |
Draft and finalize a visual logic model to depict links between suicide risk factors, intervention functions and forms, and hopeful outcomes (interview) |
1 (combined) |
Determine which materials and activities need to be adapted (interview + real-time voting) Generate list of important measures of acceptability, feasibility, and fidelity for future pilot (interview + real-time voting) |
|
| 1 (combined) | |
| Bonus topic: “member checking” results including (1) Red/Yellow/Green light adaptations, (2) implementation barriers and facilitators, (3) logic model with measures for future pilot to finalize analysis and interpretation (interview + real-time voting) | 1 (combined) |
One academic member
The process used for each workgroup meeting followed a general agenda of greeting each other, reviewing community agreements made collaboratively as ground rules for discussion, presenting information needed to discuss the topic, open-ended or “fill-in-the-blank and elaborate” questions about the topic, and if related to making decisions about adaptations, anonymous real-time voting on adaptations. Tasks varied each meeting depending on the step from the ENGAGED for CHANGE framework that allowed us to meet research aims; see
The primary data collection method was group qualitative interviews, documented through audio recording and intensive notetaking during meetings to identify: (1) adaptations; (2) potential barriers and facilitators to eventual implementation and spread of the adapted intervention; and (3) creating a community-academic logic model of how peer-to-peer Safety Planning Intervention might reduce suicide risk (not the focus of this manuscript). Qualitative questions about adaptations were broader in initial meetings and became more focused closer to making decisions. Questions were designed before each meeting by the two meeting co-facilitators. Before participants completed the anonymous survey about adaptation preferences and their priority (i.e., red/yellow/green light), broad question examples were “What parts could remain the same and would work if a peer were doing this with a veteran?,” What parts do you think should be changed and why?” and “What do you think is the least/most important aspect? Why?” After reviewing the survey (below), co-facilitators created narrow qualitative questions about each step for discussion, asking specifically for thoughts on each step of the safety planning process in which there was not consensus.
After three meetings using qualitative interviews with workgroup participants, our research team realized we might not be hearing every participant's voice when it came to making decisions about adaptations to Safety Planning Intervention peer-to-peer. Suggested by community members on our research team, we modified our protocol and created a one-time anonymous survey about each step in the Safety Planning Intervention process as traditionally used in healthcare settings. We sent participants the survey through a web-based survey platform, RedCAP, and ensured it was anonymous by not tracking their IP address nor asking for identifiable information. Questions asked about comfort sharing during group meetings and also asked participants to review each step of safety planning and whether they wanted to retain that step, change it, or were unsure about adaptation (see
If there was clear consensus with >70% of participants reporting the same preference for the adaptation on the survey, the researcher team recorded this as a decision, still presenting it at the next meeting to workgroup participants as a decision on which they predominantly agreed. When there was not clear consensus on an adaptation in survey results, data were used to formulate qualitative questions at the next two meetings to clarify perspectives, elaborate on differing viewpoints, generate possible adaptations, and eventually, narrow options for voting (see below).
For each adaptation decision made, after discussion and some verbal indication of consensus in workgroup meetings (not anonymous), group interviewers created a voting poll using Zoom videoconference software in real-time to assess whether participants agreed or disagreed with a proposed decision for adaptation. All participants were requested to vote anonymously on the poll during the meeting whether they (1) “mostly agreed” or “strongly agreed,” (2) were “ unsure,” or (3) “mostly disagreed” or “strongly disagreed” about the adaptation. Decisions were considered final when all participants anonymously voted they “mostly agreed” or “strongly agreed.” If anyone voted for other responses, discussion continued until a decision was made.
Data were integrated after each data collection point in an ongoing, iterative template analysis and interpretation process (
For all analysis, we sorted qualitative and quantitative data into templates, reflecting data gathered at one point in data collection. The templates were organized into three categories aligned to research aims: (1) adaptation suggestions or decisions, (2) implementation barriers and facilitators, or (3) other (which over time, became training for peers in Safety Planning Intervention, informed by qualitative data) (see FRAME system to track adaptations made to Safety Planning Intervention ( Red/yellow/green traffic light categories for categorizing how freely a peer could adapt each step of Safety Planning Intervention ( Barriers and facilitators to implementation of peer-to-peer Safety Planning Intervention organized using domains of the Health Equity Implementation Framework (
The FRAME coding system enables teams to note multiple facets of adaptations to an intervention, including but not limited to when it was made, why, type of modification, and who prompted the adaptation. Red/yellow/green traffic light categories have been used as a dissemination tool in training people learning an intervention on what should be modified and what should remain intact. Using the metaphor of a traffic light in the U.S., each color of the traffic light signifies what intervention components are core and should be retained in their original state (red light), could be adapted but should occur with caution or under certain conditions (yellow light), and can be adapted freely (green light). The Health Equity Implementation Framework is an implementation science framework documenting factors of successful and
Because the coders had analyzed data in between each meeting, they were prepared to present preliminary results to workgroup participants at the last meeting for member checking (see
One major finding from this study was that participants declined to significantly change the intervention, but strongly recommended robust training for peers and had suggestions about content for the training (the latter not the focus of this manuscript). Although there appeared to be diverse opinions initially on quantitative survey ratings, once those topics were discussed with participants, they asked questions, heard others’ viewpoints, and learned more about Safety Planning Intervention, and ended with unanimous real-time voting results on every decision to adapt (or not) Safety Planning Intervention peer-to-peer. They made few actual adaptations.
The adaptations to Safety Planning Intervention from professionals delivering it in healthcare settings to peers delivering it in community settings included: (1) the intervention can be delivered by peers in the community; (2) coping strategies and social settings for distraction must fit the veteran's life situation including housing, social connections, physical ability, interests, transportation, and income; (3) peers providing safety planning can have written or pictorial information such as visual aids showing the efficacy of safety planning and the suicide risk curve; (4) when peers are learning about the veteran's suicidal crisis, this information may be in the form of written thoughts from the veteran, a text message, received face-to-face, or via telephone; and (5) an optional follow up contact line can be added to the bottom of the safety plan copy if there is a safe and clear choice for follow up. See more modification details in FRAME coding log as a
Participants also categorized each step in the process of conducting a safety plan as core or adaptable using the red/yellow/green traffic light categories (see
Core and adaptable parts of safety planning intervention for peer-to-peer delivery by red, yellow, and green traffic light categories.
| Red light—must not change (core) |
|
The first three steps of safety planning should happen if veteran is willing and can do the safety plan: |
|
Get the veteran's story of most recent suicidal crisis |
|
Show veteran the suicide risk curve |
|
Explain suicidal thoughts come and go |
|
Safety planning should not be done with people who are intoxicated, high, or cannot problem solve to complete safety planning |
|
When understanding veteran's most recent suicidal crisis, the peer needs to understand what got the veteran to that point, so the peer may need to ask follow-up questions. |
|
The peer must tell veterans the safety planning process is a team effort. |
|
Listing warning signs should remain as first formal written step before working on other steps of the plan |
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Peer must ask veterans if their personal warning signs listed would signal a crisis is coming or remind them to use the safety plan |
|
For the following steps, they must fit the veteran's life situation including housing, social connections, physical ability, interests, transportation, and income: |
|
List |
|
List people to call or places to go for |
|
List at least one person to call for help with |
|
The peer must explain how to follow the safety plan (e.g., as soon as they feel better, they can stop, also can skip to whatever step they want) |
|
The peer must ask about the chances of veteran actually using safety plan. Examples include: How likely are you to use this? How comfortable are you in using this properly? Do you see any barriers to using the safety plan? |
|
Veterans must get a copy of their safety plan |
| Yellow light—can make changes with caution (adaptable) |
|
Peers can also have written handouts on some facts about need for safety planning and other pictures like the risk curve, but do not need this. |
|
The following steps are very important and ideally should be done in order, but if veteran is having difficulty, these steps could be skipped and come back to later, or left empty if unable to brainstorm good ideas for safety plan: |
|
List |
|
List people to call or places to go for |
|
Lethal means safety counseling should happen at the end of safety planning where it is listed but could happen at any step before conversation ends if there is limited time, an interruption, or needs to end before the entire plan is completed. |
|
When discussing lethal means, another support person can be discussed or brought in the conversation but does not have to be. |
|
It is important to make sure veterans have a clear place they will access the safety plan, but the peer should be aware it may be redundant depending on format. |
|
Peer can ask veteran who they would like to share the safety plan with depending on whether the person had social contacts listed on the plan or not. Do not ask if they could not identify anyone to call for distraction or crisis. |
|
Adding a line on the safety plan for follow up contact can happen if there is a safe and clear choice, but is not required. |
| Green light—changes can be freely made (adaptable) |
|
How the peer explains the suicide risk curve to veterans can be in any format—draw out it, show a written handout, or use hands to show, while explaining verbally |
|
Veteran's recent suicidal crisis story can be received in any format including written, text message, verbal in person, or verbal via telephone call. |
|
Safety plan can be in any format such as photo, screenshot, smartphone app, wallet size card, or full-size paper. |
Regarding implementation barriers and facilitators, participants identified 27 facilitators, or strengths to harness, and 47 barriers, or challenges to overcome or plan to work around, should peer-to-peer Safety Planning Intervention be deployed in community settings. All were categorized into domains of the Health Equity Implementation Framework (see
Implementation barriers and facilitators to spreading peer-to-peer safety planning intervention in rural Arkansas community organizations.
| About safety planning intervention veteran-to-veteran in rural Arkansas |
| Facilitators |
|
Easier for veterans to relate to other veterans—peer delivery is very acceptable. |
|
Peers can share their experiences with the veteran in crisis, which may lead to trust and a greater connection. |
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Veterans feel safety planning is important and has potential to be impactful. |
|
Safety planning is something to learn with skills to use—a relative advantage over current management of higher suicide risk (e.g., medications). |
|
Peer-to-peer safety planning is important because most providers are not trained in safety planning and a veteran peer can make a bond with another veteran that some providers cannot make. |
| Barriers |
|
Some veterans will not tell the whole truth to questions that are sensitive or personal. |
|
The safety planning process may take a while and the veteran may walk away or disengage. |
| Recipients: about veterans considering suicide—at moderate risk in rural areas |
| Facilitators |
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For people who are religious, trusting in a higher power and having faith is a resource (culturally relevant belief). |
|
Safety planning, especially steps about connections with others, plant a seed that others value them and enhance the veteran's self-worth. |
|
Safety planning is a good start to find out what works and what does not, possibly bridge to treatment, and is flexible for the veteran. |
| Barriers |
|
People who are actively using drugs or alcohol might not be able to engage in a safety plan. |
|
Some veterans have distrust in the government, although this is lessened by peer outreach (culturally relevant belief). |
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Some veterans are programmed from military training not to discuss problems, to keep secrets (culturally relevant belief). |
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Veterans do not discuss mental health enough. |
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Veterans trained to be combative in military, and if frustrated, might be combative with a peer trying to help (culturally relevant belief). |
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Veterans with personal suicide experiences are a minority even though it is a huge problem. It may be hard to find these Veterans in crisis. |
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Veterans are fearful they will be “locked up” and cannot get out, so delay seeking mental healthcare (culturally relevant belief). |
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Veterans may not be able to think of a list of contacts or healthy distractions, it may take a while to come up with answers. |
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Veterans may fear others will take away their firearms or important medications. |
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Feeling of being a burden to others prevents calling on others during times of crisis. |
| Recipients: about peers offering safety planning (not trained professionals) |
| Facilitators |
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Peers are unrelated to any institution—not medical, not police, not government—and so might be more acceptable. |
|
Peers have “ |
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Peers with suicide experience are very motivated to help. “ |
|
People in the military work with people across difference—race, state of origin, sexual identity, and can stay focused on “ |
| Barriers |
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May not be enough peers to match veterans based on lived experience (e.g., women sexual assault survivors, suicide survivors). |
|
Peers will be exposed to scenarios that are triggering to them based on their lived experience (e.g., active drug use). |
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Safety concerns for peers: veterans or their families could be potentially dangerous to peers. |
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Peers will need scripts, checklists, and a lot of training and debriefing to feel comfortable doing safety planning. |
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It will be hard to figure out how to assign a certain number of veterans per peer so not overloading one peer. |
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Unclear how peer support will be different from clinicians. |
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Without written notes documented and stored by peers, it would be hard for one peer to pick up where another peer left off. |
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Where would peers store safety plan with veteran's information securely if they use it for follow up? |
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Peers fearful to call veterans to follow-up in the event the veteran is in immediate crisis and peer does not know what to do. |
| Interaction: the moment when a peer tries to connect with a veteran considering suicide |
| Facilitators |
|
Timely—being able to offer it when they need it, rather than wait for a healthcare appointment. |
| Barrier |
|
Peers need to establish trust quickly with veterans they do not know. “ |
| Inner context: state-level community and professional settings where safety planning intervention might be delivered, including organizations in Arkansas (e.g., VFW, American legion, churches) |
| Facilitators |
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Multiple veteran groups are available to spread safety planning as many have established networks statewide. They can also train peers. |
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Some gun manufacturers and VA give gun locks and medication storage as a resource. |
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One good entry into each community is the county Veteran Service Officer through state-level veteran affairs office. |
| Barriers |
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Peers could get calls about someone who is not a veteran (e.g., a veteran's child). |
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Training peers in safety planning would need to be regular, with ongoing support so they can deliver it well. |
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Some organizations are motivated the moment you talk with them and want to help right away. When actual work is ready, there can be low or no response. |
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Professional resources like counselors or doctors are not always available immediately because of other patients and not usually free during evening hours, so peers and veterans would need to have some resources like this available 24/7. |
| Outer context: state-level settings relevant to peer-to-peer delivery of safety planning intervention in community organizations (including rural areas and healthcare settings in Arkansas) |
| Facilitators |
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Some counties already have veteran crisis programs that we can collaborate with. |
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There exist multiple generations of veterans here in Arkansas to help each other. |
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We have a state suicide hotline that is not VA (∼5% of veterans who call suicide crisis line choose the state version). |
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There are already places who have trained peers and we can learn from them. |
| Barriers |
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May not be enough providers to include as professional contacts on safety plan in rural areas. |
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May not be enough police force for safety/wellness checks in rural areas. |
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Sometimes in healthcare, providers and staff are rotating so frequently that it is hard to get the same provider twice. |
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If emergency department is needed in rural areas, they are often not equipped to assist with suicide prevention. |
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Non-VA emergency services or mental health providers need to understand military culture working with veterans (e.g., screening for common problems like post-traumatic stress disorder or traumatic brain injury). |
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Current emergency department way of doing things can be further alienating, isolating, and cause anxiety. |
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Ambulances take people to the closest emergency department, so they are not guaranteed to go to the VA. |
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Not sure where we will find moderate risk veterans, as existing veteran crisis programs tend to serve people at imminent risk. |
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Moving through healthcare systems is hard, and can be a taxing job for caregivers or families to help veteran. |
| Broader VA-related contexts |
| Facilitators |
|
VA mental healthcare is available to any veteran who presents or calls. They can see a provider in person or via video that day in primary care or the mental health clinic and the veteran does not have to be enrolled at the VA. |
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There are different types of suicide prevention treatments available in VA and all of them are evidence-based. |
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There is an entire psychotherapy program for suicide prevention available at the regional level. |
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Providers have experience dealing with veterans and veterans have different issues than the civilian population. |
| Barriers |
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Rides to VA healthcare offered by Disabled American Veterans are not accessible—too early, run only once daily in the morning. |
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There is a belief that some veterans aggravated the VA healthcare system and got banned so are unable to use those services. |
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Some veterans have bad feelings towards VA based on negative experiences such as “ |
| Economic or financial factors |
| Facilitators |
| There are a lot of free, trustworthy online resources for managing mental health distress to apply at home (e.g., apps, youtube channels, websites such as Urban Valor, PTSD Coach, Virtual Hope toolbox). |
| Barriers |
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If veteran is not connected to VA, do not have easy or affordable services to refer to (on the safety plan). |
|
Poverty and economic distress in rural Arkansas led to veterans not having insurance or funds to get care that would be part of a safety plan. |
| Physical environment in which peers will be conducting safety plans with veterans |
| Facilitators |
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Being outside and away from people can be soothing, calming, and private for sensitive conversations about suicide. |
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Many veterans are overwhelmed by crowded places, so fewer people in rural areas is comforting. |
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Peer-to-peer delivery is flexible and can go to where the veteran is located. It can even take place on private chats or via telephone in the format the veteran in crisis prefers. |
| Barriers |
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Hard to find veterans in rural areas who are considering suicide, especially those living in secluded environments. |
| Sociopolitical forces: social norms of our culture, state or county politics, policies, laws or legal factors |
| Facilitators |
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Arkansas has a perceived culture of support for veterans. |
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Veterans want to help and support each other, and it lends itself to peer-to-peer safety planning. |
| Barriers |
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Participants heard of situations where police departments took firearms or veterans gave them to police, but firearms were not returned. |
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Some stigmas about mental health and drug use problems—e.g., even going to VA community based outpatient clinics in rural areas evokes a belief if you are there, you are there because of drug use or mental health treatment. |
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Peer concern about legal liability in making suggestions about suicide prevention, firearm, or medication safety. |
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Strong culture of hunting and owning firearms in Arkansas, so if peers are going to bring up gun safety, they need to be careful on wording. |
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Structure of the military is not present in veteran status, so the transition from military to veteran status can make it such that veterans are unsure how and when to get help for others. |
Regarding implementation barriers, majority of barriers were identified among similar domains in which majority of facilitators were identified: veterans considering suicide at moderate risk in rural areas, peers offering safety planning, state-level contexts including our healthcare systems and rural communities, and sociopolitical forces including social norms, state or county policies, laws and legal factors. Among veterans who might need safety planning, participants reported multiple barriers that would result in a veteran declining or prematurely dropping out of the intervention, even if a one-time interaction, including culturally relevant beliefs that veterans are programmed from military training not to discuss problems, especially mental health problems. Among peers offering the intervention, participants reported several implementation barriers related to logistics and workflow, such as being unsure if or how peers should document Safety Planning Intervention like healthcare professionals do and where they would store that information. In the state-level context domain, one barrier reported was that they reported if a peer should need to help a veteran access an emergency department in a rural area, emergency departments were not perceived as equipped to assist adequately with suicide prevention. Among the sociopolitical domain, one barrier for implementing this intervention, which involves discussion of safe firearm and medicine storage when in suicidal crisis, is that there was a strong culture of hunting and owning firearms in Arkansas, so if peers are going to bring up gun safety, they need to be careful on wording so as not to cause defensiveness among veterans. See
In this study, we assembled a workgroup of participants in one U.S. state, Arkansas, to adapt Safety Planning Intervention from being delivered by healthcare professionals in clinical settings to being delivered by peers without medical or mental health training in community settings. Through multiple group interviews, a one-time anonymous survey, and anonymous real-time voting during workgroup meetings, participants suggested few changes to adapt Safety Planning Intervention delivered peer-to-peer. Initially, in survey results, there appeared to be much difference in opinion on whether intervention components were core or adaptable, and after discussing these items with open-ended questions and role plays of what safety planning looks like traditionally delivered by a healthcare professional, participants formed consensus on adaptations with few changes to the intervention delivery or format. One concern might have been that the consensus resulted from social desirability bias or perceived pressure to conform, however, we used several strategies to offset this and believe research participants genuinely agreed on adaptations over time. One strategy we used was to closely review and record each participants’ anonymous survey results because the quantitative ratings made it appear their views were quite divergent from one another, yet their qualitative responses in the open-text boxes showcased more of a cohesive viewpoint. Another strategy we used was to ensure anonymous ways of decision making with a range of response options (rather than only agree/disagree)—the survey was anonymous, and at the end of discussing each possible adaptation, we created anonymous polls in real-time to ask how much participants agreed or disagreed with the proposed change. Our final strategy was to ensure the group interviewers were not espousing any position on each component of the intervention, rather, they made efforts to clarify participants’ viewpoints and roleplay examples to showcase an intervention step.
One concern could be whether having community members suggest core and adaptable components is recommended. Similar to other work to merge community and professional knowledge on adaptation (
Overall, community members reported Safety Planning Intervention was acceptable and desirable (see
Our findings of barriers and facilitators to the implementation of peer-to-peer Safety Planning Intervention showcase a wide range of promising factors to be harnessed and key challenges to plan for in future deployment of the intervention, notably in rural community settings where suicide deaths are higher. One finding surprised our research team—despite societal challenges in rural communities leading to disproportionate suicide deaths in the U.S (
Aside from our study, there are few published reports on assessing implementation context or preparing implementation strategies for spread of Safety Planning Intervention. There is one study suggesting that, in pediatric healthcare settings, collaboration with multiple personnel and brief provider training would be two suggested implementation strategies (
There are some items which could limit the generalizability of these results. Since data were collected from participants that live in rural areas of Arkansas, these results may not be generalizable to urban or other rural areas across the U.S. The Arkansas Safety Planning Intervention Workgroup included 12 participants, with a predominantly white sample, limiting validity of results for racially and ethnically minoritized individuals. The homogenous racial identity of our sample was despite conscious attempts to recruit more Black and African American veterans living in rural Arkansas, including reaching out to Arkansas chapter members of the National Association for Black Veterans and working with established, informal liaisons in Black, rural communities in Arkansas. It is possible that adaptation results or implementation barriers and facilitators might be different among Black and African American, Hispanic and Latinx, and veterans of other racial/ethnic backgrounds. Since workgroup participants were being observed (by the research team and other participants) while conducting interviews, it is possible they may not have given their true thoughts and feedback. This was why it was important to orient the group before interviews, review the community agreements, and conduct anonymous surveys and voting during data collection.
Safety Planning Intervention via peer-to-peer delivery, especially in rural community settings where suicide disparities exist, was seen as very acceptable and advantageous given existing contextual barriers to spreading this effective intervention to all who need it. We identified adaptations needed for peer-to-peer delivery for this intervention and produced a document for future dissemination and training efforts for other rural states that may wish to adopt peer-to-peer Safety Planning Intervention for veterans in their communities. We also identified copious barriers and facilitators to real-world implementation of this intervention in rural communities, which can be used to inform implementation strategies and planning efforts in a thoughtful way, centering the community voice from the beginning. This study is an example of community-engaged implementation science in pre-implementation stages to promote future equitable spread and scale of an effective intervention.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The studies involving humans were approved by University of Arkansas for Medical Sciences Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The Ethics Committee/institutional review board waived the requirement of written informed consent for participation from the participants or the participants’ legal guardians/next of kin because It was deemed not feasible to obtain written signatures on a consent form from participants dispersed many miles from the study site. Also, the study was low risk to participants. Researchers engaged participants in a verbal consent process and mailed them a paper copy of study information.
EW conceptualized the study, design and executed all data collection and analyses, and contributed to this manuscript. AL recruited participants, executed data collection and analyses, and contributed to this manuscript. RB conceptualized the study and study design, recruited participants, interpreted results, and contributed to this manuscript. DD executed data collection, interpreted results, and contributed to this manuscript. IB helped design the study, assisted with participant recruitment, interpreted results, and contributed results to this manuscript. JG-K conceptualized the study, design data collection, interpreted results, and contributed to this manuscript. AS conceptualized the study, helped design the study methods in this manuscript, and assisted with participant recruitment. OA recruited participants, helped lead some data collection, and interpreted results in this manuscript. TG recruited participants and assisted in writing sections of this manuscript. All authors contributed to the article and approved the submitted version.
This work was supported by Career Development Award Number IK2 HX003065 through the United States Health Services and Research Development Service (Woodward) and a Community Based Participatory Research Pilot Grant (Woodward and Brown) through the University of Arkansas for Medical Sciences Translational Research Institute Award Number UL1 TR003107 through the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH nor the U.S. Department of Veterans Affairs.
Thank you to the research participants in our workgroup, who must remain unnamed to protect your privacy in this research. Your knowledge and expertise are the foundation of these findings, and your lived and professional experiences are irreplaceable. Thank you to the UAMS Center for Health Literacy for reviewing and editing participant and community facing materials, which was supported by the University of Arkansas for Medical Sciences Translational Research Institute.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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