Guam is an island of 209 square miles located in the Western Pacific; nearly 3,700 miles southwest of Hawaii, the closest United States (US) land mass (1). Most residents of Guam identify as Asian and/or Pacific Islander [AAPI; (2)]; specifically, Chamorro or CHamoru, who are indigenous to the Mariana Islands (3), Chuukese, from Chuuk State in Micronesia (4), Filipino, or from other Micronesian communities. Like in other AAPI communities across the US, suicide rates are elevated and rising in Guam (5–7).

Following more than 300 years of Spanish rule, including integration of Catholicism, Guam came under American control in 1898. Guam was governed by the US until 1941, when it was seized by Japan during World War II, and occupied until Allied forces retook the island in 1944. The island served as a vital air and naval base for the US until the end of World War II, and remains an important strategic location for the US military (8).

Guam has a population of 153,836 (9) and is home to a growing number of US military members and Veterans, due to its strategic military location (8, 10). There are approximately 9,700 service members stationed across several bases (11), with an additional 5,000 Marines expected to arrive following the recent reactivation of a Marine Corps base on the island (12). Guamanians have high rates of military service, with 10.5% of the adult population being Veterans (11,927 people), compared to 6.8% at the national level (13).

While most Guamanians identify as AAPI, the US Veteran population is comprised of a relatively small percentage of AAPI individuals [i.e., approximately 2%; (14)]. The age- and sex- adjusted suicide rate among Veterans in 2020 was 57% higher than among non-Veteran adults (15). When disaggregated by race, the unadjusted suicide rate among AAPI Veterans was the second highest rate across all racial groups (15), at 30.2 per 100,000 in 2020 (15). Of further concern, the suicide rate among AAPI Veterans increased 167% between 2001 and 2020, a larger increase than among any other racial and ethnic group (15). Another recent analysis of suicide rates among AAPI Veterans also noted high and increasing suicide rates in this population, with suicide rates among those ages 18–34 exceeding those of similarly aged Veterans (16). In addition to elevated and increasing suicide rates among AAPI Veterans, regional differences have been noted (17).

Suicide rates among members of the general population on Guam are also high, with age-adjusted suicide rates of 30.0 and 21.2 per 100,000 in 2020 and 2021 (5). Suicide rates in Guam are further elevated among those who identify as Pacific Islanders, specifically Chuukese or Chamorro, with suicide rates of 50.4 and 23.8, per 100,000, respectively (5). While the overall rate of suicide across the general US has decreased (6), Guam’s rate increased from 2010 to 2020 (5); highlighting the need for increased understanding of factors influencing risk among those living on the island (7).

Suicide prevention is a priority area for the VA, as reflected in the VA National Strategy for Preventing Veteran Suicide, which outlines a public health approach (18). Community-based interventions play a pivotal role in reaching Veterans where they live (18), and implementation often requires leveraging multiple partners and methods. For example, current VA community-based efforts include the Governors’ and Mayor’s Challenges, which engage local and state government and community partners to facilitate interagency suicide prevention planning. VA has also prioritized hiring Community Engagement and Partnership Coordinators, who expand on the work of Suicide Prevention Coordinators by partnering with communities to implement evidence-based suicide prevention strategies (19).

Initially funded in 2015, TWV is a community-based suicide prevention approach for individuals residing in rural settings. Communities receive funding, technical assistance, and coaching support for 36 months to implement evidence-based suicide prevention strategies [i.e., provide suicide prevention training; enhance primary care suicide prevention; promote connectedness and help seeking; improve communication across Veteran-serving programs; enhance behavioral health suicide prevention; promote lethal means safety; (20)] in a manner consistent with the needs of their communities. Thirty-eight communities across 26 US states and territories have implemented TWV. For more information regarding TWV, see Kreisel et al. (21) and Monteith et al. (22).

As Guam is unique in many ways, the decision was made to analyze qualitative and quantitative data from this community separately from other TWV communities. Specifically, the present study aimed to increase understanding regarding the community context, and factors associated with suicide risk among those living in Guam, as well as initial considerations regarding barriers and facilitators to implementing TWV. Qualitative themes were organized by socio-ecological model (SEM) framework domains, in which health behaviors are viewed within the context of multiple levels of influence (23, 24). This model has been used to evaluate a wide range of health promotion efforts (24, 25).

Data collection was approved by local review boards. Three members of the study team traveled to Guam in September 2022. All are women, and had previous experience conducting qualitative interviews. None are part of the Guamanian community or identified as AAPI or Veterans. One-on-one semi-structured interviews were conducted with a purposive sample of 12 individuals, which included members of the Guam TWV team and other community members who were selected by the TWV community’s leadership team and who were colleagues and peers from various community agencies/groups and were familiar with both the community and the work of TWV, and who agreed to be contacted by our interview team. All participants had indirect or direct community roles related to suicide prevention or associated topics (see demographic details in Table 1). Interviews were conducted in private rooms at a public-serving facility. Members of the study team had been professionally introduced to a few interviewees prior to the visit, and additional interviewees were identified via these contacts, or through the TWV coach.

Interviewers employed an interview guide, which included questions about the experience of living in Guam and community members’ perceptions regarding mental health and suicide prevention. Questions were open-ended, and probes were used as needed to clarify responses (see Supplementary material A1). Interviews (durations ranged from 30 to 90 min) were recorded with permission, and transcribed by a professional transcription service. Informants also completed a demographics questionnaire and three quantitative scales collected using REDCap (26). The Communal Mastery Scale assessed individuals’ beliefs in their ability to attain goals secondary to being interconnected with others (27). Possible total scores ranged from 10 to 40, with higher scores indicating higher communal mastery. The Collective Efficacy Scale (adapted) was administered to obtain information regarding individual beliefs about the capacity of their community to achieve specific goals (28). The possible total score range is 5 to 25, with higher scores indicating belief in the capacity of the community to achieve goals. The TWV Implementation Questionnaire (TWV-IQ) includes questions covering five domains [Planning and Implementation (3 questions); Leadership (5 questions); Community Involvement in the Coalition (6 questions); Progress and Outcome (4 questions)], and Overall Approval (1 question); with two additional binary questions regarding TWV impact on the community and sustainment (see Supplementary Table A2).

Consistent with best practices for convergent mixed-methods analyses, quantitative and qualitative data were analyzed separately, then synthesized into meta-inferences in a joint display table. Meta-inferences were identified as congruent when inferences were drawn from qualitative and quantitative data that aligned and discrepant when inferences were drawn from data that were not aligned. Following the analysis, qualitative themes, quantitative results, and congruent and discrepant findings are reported (Table 2). For more information regarding mixed-methods employed, see pages 68–77, Creswell and Clark (29). For quantitative data, mean, standard deviation, range, median, and 25th and 75th percentile values were calculated. Frequencies were tabulated for the two binary questions.

Qualitative interviews were analyzed using an approach developed for health services efforts to obtain actionable, targeted data over a shorter period of time than usually required to process such information (30, 31). All four female analysts, none of whom were Guamanian or identified as AAPI or Veterans, had attained a master’s level education or higher and underwent training in qualitative methods. Each interview was analyzed independently by two individuals. Analysts first organized interview content by questions from the interview guide, extracting quotes and summarizing information into a summary template using neutral domain names and a designated section for additional observations. Each analyst independently reviewed a set of transcripts and associated audio recordings as primary or secondary reviewers and summarized information using the template. The team regularly met during analysis to review emergent themes, ensuring investigator triangulation (32). Themes were derived consensually from interview summaries, and emblematic quotes were selected across interviews. A matrix (33) was then used to further organize themes by SEM framework domains (25, 51) including: intrapersonal; social-interpersonal; social-community; social organizational; social-public policy and federal systems; and chronosystem (see Table 2; Figure 1). More specifically, within the SEM, health behaviors are viewed within the context of multiple levels of influence (24) [e.g., individual behaviors, characteristics of the environment (23). The model has been used to evaluate a wide range of health promotion efforts (24, 25)].

Demographic characteristics for the 12 interviewees are presented in Table 1. Two-thirds (66.7%) of interviewees were male. The majority identified as Pacific Islander (83.3%), and most (66.7%) had served in the US military.

Results [mean (standard deviation)] from surveys were as follows: Communal Mastery Scale, 32.3 [3.6], and Collective Efficacy Scale 21.3 [4.8] (Table 2). TWV-IQ Planning and Implementation, Leadership, and Progress and Outcome domain scores each exceeded 4 on a 5-point scale. Items regarding satisfaction with community involvement were rated the lowest, with a mean of 3.8 [0.8] points (see Table 2; Supplementary Table A2).

Meta-inferences drawn from the synthesis of quantitative and qualitative results revealed areas of congruence (inferences drawn from the qualitative and quantitative data are aligned) and discrepancy (inferences drawn from the qualitative and quantitative data are not aligned). Information regarding specific data (qualitative, quantitative) by SEM domains used to make such inferences are presented in Table 2 (Joint Display Table for Mixed-Methods Findings). Overall, results indicated that despite significant challenges, the 12 TWV community members who were interviewed reported the ability to make positive changes within their community, which are expected to help prevent suicide.