Developing self-efficacy and ‘communities of practice’ between community and institutional partners to prevent suicide and increase mental health in under-resourced communities: expanding the research constructs for upstream prevention

Abstract

Background
Suicide is a serious and growing health inequity for Alaska Native (AN) youth (ages 15–24), who experience suicide rates significantly higher than the general U.S. youth population. In under-served, remote AN communities, building on existing local and cultural resources can increase uptake of prevention behaviors like lethal means reduction, interpersonal support, and postvention by family members, workers and community members, which can be important for preventing suicide in places where mental health services are sparce. This study expands the variables we hypothesize as important for reducing suicide risk and supporting mental wellness. These variables are: (1) perceived suicide prevention self-efficacy, (2) perceived wellness self-efficacy, and (3) developing a ‘community of practice’ (CoP) for prevention/wellness work.

Method
With a convenience sample (N = 398) of participants (ages 15+) in five remote AN communities, this study characterizes respondents’ social roles: institutional role if they have a job that includes suicide prevention (e.g. teachers, community health workers) and community role if their primary role is based on family or community positioning (e.g. Elder, parent). The cross-sectional analysis then explores the relationship between respondents’ wellness and prevention self-efficacy and CoP as predictors of their self-reported suicide prevention and wellness promotion behaviors: (1) working together with others (e.g. community initiatives), (2) offering interpersonal support to someone (3), reducing access to lethal means, and (4) reducing suicide risk for others after a suicide death in the community.

Results
Community and institutional roles are vital, and analyses detected distinct patterns linking our dependent variables to different preventative behaviors. Findings associated wellness self-efficacy and CoP (but not prevention self-efficacy) with “working together” behaviors, wellness and prevention self-efficacy (but not CoP) with interpersonal supportive behaviors; both prevention self-efficacy and CoP with higher postvention behaviors. Only prevention self-efficacy was associated with lethal means reduction.

Conclusions
The study widens the scope of suicide prevention. Promising approaches to suicide prevention in rural low-resourced communities include: (1) engaging people in community and institutional roles (2), developing communities of practice for suicide prevention among different sectors of a community, and (3) broadening the scope of suicide prevention to include wellness promotion as well as suicide prevention.

Full text

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Wexler et al. BMC Public Health (2025) 25:1323
https://doi.org/10.1186/s12889-025-22465-1 BMC Public Health
*Correspondence:
Lisa Wexler
lwexler@umich.edu
Full list of author information is available at the end of the article
Abstract
Background Suicide is a serious and growing health inequity for Alaska Native (AN) youth (ages 15–24), who
experience suicide rates signicantly higher than the general U.S. youth population. In under-served, remote AN
communities, building on existing local and cultural resources can increase uptake of prevention behaviors like lethal
means reduction, interpersonal support, and postvention by family members, workers and community members,
which can be important for preventing suicide in places where mental health services are sparce. This study expands
the variables we hypothesize as important for reducing suicide risk and supporting mental wellness. These variables
are: (1) perceived suicide prevention self-ecacy, (2) perceived wellness self-ecacy, and (3) developing a ‘community
of practice’ (CoP) for prevention/wellness work.
Method With a convenience sample (N = 398) of participants (ages 15+) in ve remote AN communities, this study
characterizes respondents’ social roles: institutional role if they have a job that includes suicide prevention (e.g.
teachers, community health workers) and community role if their primary role is based on family or community
positioning (e.g. Elder, parent). The cross-sectional analysis then explores the relationship between respondents’
wellness and prevention self-ecacy and CoP as predictors of their self-reported suicide prevention and wellness
promotion behaviors: (1) working together with others (e.g. community initiatives), (2) oering interpersonal support
to someone (3), reducing access to lethal means, and (4) reducing suicide risk for others after a suicide death in the
community.
Developing self-ecacy and ‘communities
of practice’ between community
and institutional partners to prevent suicide
and increase mental health in under-
resourced communities: expanding the
research constructs for upstream prevention
LisaWexler1*, LaurenWhite2, JoelGinn3, TaraSchmidt1, SuzanneRataj4, Caroline C.Wells5, KatieSchultz1, Eleni
A.Kapoulea6, DianeMcEachern7, PatrickHabecker8 and HollyLaws6
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Wexler et al. BMC Public Health (2025) 25:1323
Suicide is a leading cause of death for young people ages
10 through 24 in the United States [1, 2]. Preventive
eorts are especially urgent for American Indian and
Alaska Native (AIAN) youth whose elevated rates [1, 3]
have increased signicantly in recent years [4]. Similarly,
rates of suicide in rural areas have increased 1.5 times
faster than in urban areas in the United States from 1981
to 2018 [1]. Although the denition of rurality has been
critiqued for being overbroad [5], generally, the associa-
tion between suicide and rural America has been linked to
economic distress and access to care [6]. More specically,
suicide in rural areas is linked to limited access to mental
healthcare generally, mental health provider shortages,
and stigma around mental health help-seeking [7, 8]. For
AIAN young people, these factors are likely exacerbated
by culturally incongruous care [9]. e cultural dier-
ences between therapists and the communities they serve
can reduce the acceptability and impact of mental health
services particularly to prevent suicide for AIAN people
[10, 11]. For communities with histories of systemic injus-
tice, oppressive practices such as involuntary inpatient
treatment that is linked to suicide interventions, con-
tribute to many not seeking mental health services [12].
ese issues are particularly relevant in rural locations
and in racially and ethnically marginalized communities
[13–16], and in the remote, roadless predominately AN
region of this study, particularly acute [11].
With suicide rates highest in rural areas and fast-
est growing among younger people of color [17–19]
where culturally-responsive mental health services are
sparce, there is an urgent need to understand the fac-
tors that can contribute to the success of a broad public
health approach to suicide prevention. Such an approach
includes more than professional mental health services,
and builds on the more readily-available community,
cultural and social resources in rural and diverse com-
munities (e.g., Elders, parents, family members, mentors)
to address suicide [20–23]. A public health approach to
suicide prevention engages diverse collaborators within
dierent community sectors (e.g., law enforcement,
schools, religious organizations) and within young peo-
ple’s existing social support networks [24–26]. Such mul-
tilevel eorts can include oering interpersonal support
to young people, bolstering family support systems, and
developing community-level opportunities that pro-
mote youth wellbeing and reduce suicide risk. Previous
research suggests that such initiatives can be leveraged to
create community-based, culturally- and locally-appro-
priate strategies [21, 23, 27].
A public health approach to suicide prevention targets
multiple levels of inuence on health and mental health
across societal, community, family and individual lev-
els [28]. ese strategies include universal, selective and
indicated spheres of prevention [28] and require multi-
sector cooperation to support people– especially young
people with intersecting marginalized identities– in the
settings they frequent such as schools, religious and
sport organizations, homes (parents and extended fam-
ily members) [29]. Indigenous theories of holistic health
align well with this framework; for example [30], found
that cultural continuity—maintaining community values,
practices, and social support systems—serves as a pro-
tective factor against youth suicide. Further, Indigenous
resilience emphasizes that wellness arises from social
relationships, collective identities, and traditional prac-
tices [31, 32] and community-engaged research across
many dierent AIAN populations has often yielded
strengths-based, multi-level, and upstream suicide pre-
vention initiatives [33]. Building from the intersecting
lenses of public health and AIAN research and theory,
this study highlights two signicant, often overlooked,
aspects of universal suicide prevention: building Com-
munities of Practice (CoP) that include people in both
community and institutional support roles, and self-
ecacy to take upstream action for suicide prevention,
including actions for mental health wellness promotion
as well as prevention or reduction of suicide risk.
Results Community and institutional roles are vital, and analyses detected distinct patterns linking our dependent
variables to dierent preventative behaviors. Findings associated wellness self-ecacy and CoP (but not prevention
self-ecacy) with “working together” behaviors, wellness and prevention self-ecacy (but not CoP) with interpersonal
supportive behaviors; both prevention self-ecacy and CoP with higher postvention behaviors. Only prevention self-
ecacy was associated with lethal means reduction.
Conclusions The study widens the scope of suicide prevention. Promising approaches to suicide prevention in
rural low-resourced communities include: (1) engaging people in community and institutional roles (2), developing
communities of practice for suicide prevention among dierent sectors of a community, and (3) broadening the
scope of suicide prevention to include wellness promotion as well as suicide prevention.
Keywords Suicide prevention, Health promotion, Communities of practice, American Indian/Alaska native, Rural,
Wellness
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Wexler et al. BMC Public Health (2025) 25:1323
Communities of practice
Developing collaborative relationships for suicide pre-
vention and wellness, also described as “communities of
practice” (CoP) [34] can be important for locally-driven
and adaptive prevention strategies [35] as well as sus-
tainment of suicide prevention strategies, particularly in
under-resourced communities. Rooted in social learn-
ing theory, CoP are groups of people that cultivate three
inter-related elements: shared interest, common com-
munity, and practice [34]. Separate from institutional
or organizationally based groups, CoPs are dened by a
collective process of engaging, sharing information, and
doing [36]. Often, people within a CoP represent dierent
perspectives and areas of expertise and therefore learn
about and address complex issues from multiple angles
[37]. Since the eects of colonization have unfolded at
multiple levels, eroding the agency of AIAN commu-
nities by disrupting traditional governance and social
support structures [38, 39], leveraging CoPs to build
community practice across community and institution-
ally oriented social groups is tting. CoP can strengthen
AN community helping networks by linking across com-
munity structures and institutional services and systems.
is can help demystify and destigmatize mental health
and wellness, and foster increased interactions between
local helpers (e.g., parents, Elders) and institutional help-
ers., (service providers, teachers), making it easier for
integrated and coordinated care to occur when a young
person is struggling but not yet actively suicidal [40].
rough engagements in CoP, institutional helpers can
connect with communities and families they serve, and
get feedback for practicing cultural humility, making
their services more locally responsive [41]. Social net-
works of support are an important and often overlooked
resource to engage in suicide prevention, particularly in
under-resourced communities where institutional ser-
vices are limited [42]. Building CoP [34, 37] that include
AN community and family resources (i.e. community
leaders, parents, etc.) as well as people in institutional or
professional roles (i.e. community health workers, teach-
ers, social workers) is an innovative way to address the
complex and culturally-specic issue of youth suicide
prevention.
Wellness and prevention self-ecacy Our measured
behavioral suicide prevention constructs test whether
respondents in institutional or community/family roles
endorsed participation in “promotion behaviors” (actions
done to attain a positive outcome, for example: “I talked
with someone about how culture can promote youth well-
ness”) and/or in “prevention behaviors” (actions done to
avoid a negative outcome, for example: “I helped someone
who was down get help”). is distinction between “pre-
vention” and “promotion”-oriented behaviors aligns with
Regulatory Focus eory, which posits that people are
motivated to pursue goals from these two dierent ori-
entations, depending on personality and circumstances
of an action [43, 44]. Promotion behaviors for health can
generally be done regularly, regardless of circumstances
within family and community life. Emergent opportuni-
ties to do “prevention” behaviors occur less frequently in
daily life because they are predicated on risk detection or
observed struggles. us, for people in community and
family roles such as parents, teachers, coaches, Elders,
these behaviors are more challenging to capture over a
period of a few months. It is important to include both
prevention and promotion in suicide prevention eorts.
Our study assesses how wellness self-ecacy and
suicide prevention self-ecacy relate to self-reported
preventative behaviors of community members and con-
siders participants’ collaborative relationships or CoP. Put
dierently, our theoretical model includes those in com-
munity and institutional roles and asks about their social
relationships (i.e. CoP) that both enable supportive inter-
actions with people who are suering and oer resources
and support to enhance and sustain culturally-responsive
and culturally-based practices to enhance mental wellbe-
ing and to intervene when someone is struggling to pre-
vent suicidal behavior (see Fig.1).
Our cross-sectional survey research from ve Alaska
Native (AN) rural and remote communities oer a
snapshot of community members’ self-perceptions and
self-reported behaviors–including suicide prevention
Fig. 1 Theoretical model of study constructs
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Wexler et al. BMC Public Health (2025) 25:1323
and health promotion hereafter referred to as “preven-
tative behaviors”—to assess the relationships between
these key factors. Our analysis considers the preventa-
tive behaviors of people in dierent kinds of roles within
community (family, friends, and Elders) and institutional
(behavioral health and mental health counselors, teach-
ers, community health workers) support networks of
young people. We have updated our use of the terms
“community” instead of “informal” and “institutional” in
lieu of “formal” to acknowledge the important ways in
which cultural and local protocols structure social rela-
tionships, and to reect language that does not margin-
alize these social structures of engagement. Our study
highlights how survey respondents’ self-perceptions and
current collaborations support a variety of preventative
behaviors. Our measures of prevention behaviors include
a broad range of activities done with others (“Working
together to prevent suicide and promote health”), oering
interpersonal support, reducing access to lethal means
(i.e. rearms) and reducing risk for others after a suicide
death in the community (i.e. postvention). Suicide pre-
vention requires a breadth of activities [18–24, 28] as well
as collaboration across and among these social networks
may be important for sustaining suicide prevention and
wellness promotion activities, particularly in tight-knit
communities. To date, little research considers the role
of collaborative relationships in diversifying approaches
to suicide prevention to include broad prevention strate-
gies, including wellness promotion, that can be put into
practice across multiple community sectors [25, 45].
Methods
Participatory approach
is analysis grows from over 25 years of partnership
with AN communities focused on participatory research
for suicide prevention. is study was conducted in col-
laboration with regional tribal health and social services
organizations and local tribes where the research took
place. In keeping with the principles and practices of
community-based participatory research methods, the
study design and measures were informed by a Local
Steering Committee and the research was done under
their guidance to benet local communities as well as to
advance the science. e PC CARES steering commit-
tee meets on a monthly basis, and members are paid for
contributing their guidance and oversight at each meet-
ing. More details about our participatory practice can be
found in other PC CARES papers [46–51].
Key constructs
We describe the connections between the self-percep-
tions of people in community (family, friends, and Elders)
and institutional (counselors, teachers, community health
workers) roles, which includes their self-ecacy related
to both wellness (“ere are things I can do to promote
wellness here.”) and suicide prevention (“I feel condent
that I can do things to prevent suicide.”). Our analyses
describe the relationship of these self-perceptions and
CoP constructs (i.e., “I have many people to work with in
my community to prevent suicide.”) to participants’ self-
reported preventative behaviors, which includes a wide
range of health and mental health promotive behaviors as
well as those aimed at suicide prevention.
ese preventative behaviors reect actions at the com-
munity, family and interpersonal levels. ese include
community-level actions such as “working together” to
support youth wellness and prevention suicide (e.g.,
working with a group of people in the community to edu-
cate others, such as “I spoke up about what community
organizations can do to reduce the risk of youth suicide.”);
oering “interpersonal support” (e.g. encouraging help-
seeking for someone who is down, such as “I reached
out to someone who was hurting (alone, sad, angry).”);
“reducing access to lethal means” (e.g., “I discussed how
to make a home safer (no alcohol, gun safes).”); and “post-
vention” which involves precautions to reduce the risk of
contagion if a suicide should occur (e.g., “I shared that it
can be harmful to honor someone who died by suicide
more than is done for other deaths.”) ese categories of
behaviors include a range of prevention strategies and are
intentionally broad so can be enacted by a variety of peo-
ple within a young person’s institutional and community
social network. Notably, our dependent variables include
actions taken within families and communities for both
universal health promotion (i.e., to support wellbeing) as
well as suicide prevention (i.e., done in response to risk)
as important behavioral outcomes.
Recruitment procedures and sample
We used baseline survey data collected as part of the Pro-
moting Community Conversations About Research to
End Suicide (PC CARES) initiative [see Wexler [40, 47] or
www.pc-cares.org for more information on PC CARES].
ese data were collected in fall 2019 from residents in
ve communities in rural, remote Alaska. e 20-min-
ute electronic survey was completed on electronic tablet
(iPads) and included questions about self-perceptions of
suicide prevention and wellness self-ecacy, CoP, and
preventative actions taken “within the past few months”
both for promoting general wellbeing and buering risk
at times of struggle (suicide prevention via lethal means
reduction and postvention, wellness, and supportive
interpersonal interactions).
Participants were recruited by posting informational
yers in high trac areas around each community,
and by word of mouth. Participants were compensated
twenty dollars in cash for completing the survey. Surveys
were administered over a period of 1–2 days at central
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Wexler et al. BMC Public Health (2025) 25:1323
locations in each village (e.g., churches, schools, tribal
buildings) by a PC CARES coordinator (BLINDED) who
grew up in the participating region. Across the ve com-
munities (population ranging from 193 to 975 inhabit-
ants), 430 people lled out surveys (about 15% of the
pooled population across participating villages) with
more people recruited in bigger villages.
Steps to prevention survey development
We worked closely with the PC CARES Local Steer-
ing Committee (LSC), made up of people who live and
work in the rural communities where data collection
took place, to develop and adapt our survey. Starting with
survey items that showed positive change in the pilot
research for PC CARES pilot project between 2014 and
2016 [47], we worked with our LSC to collaboratively
develop new questions and adjust survey items to ensure
they t with changes in curriculum, were clear and com-
municated the intended meaning [49]. e adapted
“Steps toward Prevention Survey” (StP) was piloted with
100 people in the region to assess understandability, ease
of use and preliminary psychometrics. See Table1 for all
items and associated reliability of each subscale.
Our independent variables are self-reported behav-
iors: wellness self-ecacy, prevention self-ecacy,
and CoP, and were rated on a Likert scale ranging from
Strongly Disagree = 1 to Strongly Agree = 7. Each fac-
tor composite was calculated as an item average. e
StP Survey dependent variables focus on dierent kinds
of suicide preventative activities and are characterized
as: [1] Working together to prevent suicide and promote
health (8 items which includes 2 wellness and 3 suicide
prevention actions, and 3 actions encompassing both)
[2], Interpersonal support (7 items, of which 4 focused on
wellness promotion, and 3 on suicide prevention actions)
[3], Lethal means reduction (3 items, all of which focus
on prevention actions), and [4] Postvention (8 items, all
of which focus on prevention actions). ere are more
promotion items overall, especially for working together
and community of practice constructs. We ask respon-
dents to report their behaviors as they relate to the above
constructs “in the last few months.” Actions were rated
as binary endorsements (1 = Yes, 0 = No) of a list of sui-
cide prevention and promotion behaviors and summed
to form behavior scales in each domain. is process
resulted in our nal survey (see Table1 for items and
Cronbach’s alpha for each subscale) [41].
Given our focus on developing a community of prac-
tice, our study explores the roles held by our participants
and how people in various positions in the community
perceive their own knowledge and condence related to
prevention and how they interact to do prevention activi-
ties. e role distinction was self-selected without excep-
tion. “High School student” was a role participants could
choose on the survey, but for analysis purposes this cat-
egory was included in the “no role” category.
Data analysis
All analyses were conducted using IBM SPSS Statistics
(version 28) software [52] for our nal sample of N = 398.
Analyses Our analysis considers the associations
between self-perceptions, community of practice and par-
ticipants’ preventative behaviors. We applied familywise
test corrections using the Holm-Bonferroni sequential
method to determine the relationship between our inde-
pendent variables of wellness self-ecacy, suicide preven-
tion self-ecacy and CoP and our dependent behavioral
variables: working together, interpersonal support, lethal
means reduction and postvention. To estimate the rela-
tionship between the self-perceptions and behaviors, each
type of behavior was regressed on each self-perception
construct to examine independent eects of each self-
perception on behavior, while accounting for the eects
of other self-perceptions. Using the role categories of par-
ticipants, we conducted one-way ANOVAs and pairwise
post-hoc tests to examine if there were dierences in each
of our measures of self-perceptions and actions between
participants who held dierent types of roles in the com-
munity. e Holm-Bonferroni sequential method was
used to correct for family-wise error for each association
tested on the four behavioral outcomes, as behavior con-
struct outcomes were correlated measures [53].
Results
Descriptive and exploratory analysis results
An analytic subset of N = 398 participants with complete
data on all independent (predictor) and dependent (out-
come) variables was used for all analyses. Of these 398
respondents, 182 were aged 15–29. We over-sampled
young people since they represent the highest risk age
group in Alaska [54, 55]. Our sample had the follow-
ing role groupings: those with undened roles and high
school students (n = 120, 30%), community role only
(n = 211, 53%), institutional role only (n = 25, 6%), or both
institutional and community roles (n = 42, 11%). Descrip-
tive statistics and bivariate Pearson correlations among
study variables for each of the composites are provided
in Table2. Note that all variables were signicantly and
positively correlated with one another. For example, par-
ticipants who rated their wellness self-ecacy higher also
tended to endorse higher ratings of perceived self-e-
cacy around suicide prevention.
We examined dierences in all study variables by par-
ticipants’ social roles: institutional role (e.g. behavioral
health and mental health counselors, teachers, commu-
nity health workers) (n = 25, 6%), community role (e.g.,
parent, Elder) (n = 211, 53%), those who endorsed both
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Wexler et al. BMC Public Health (2025) 25:1323
institutional and community roles (e.g., both parent and
community health worker, n = 42, 11%), and those who
reported holding neither institutional or community
roles (e.g. not currently employed, high school students,
younger people not yet parents) (n = 120, 30%). Groups
were compared using one-way ANOVAs, with follow-
up pairwise comparisons performed with no familywise
correction to explore potential role dierences in our
study variables.
For the self-perception independent variables, a signi-
cant group dierence was found for wellness self-ecacy.
ose endorsing institutional or community roles (or
both) had signicantly higher ratings of wellness self-e-
cacy than those not endorsing these roles. For the behav-
ior composites, those endorsing a community and/or
Table 1 PC CARES steps to prevention (StP) measure
Construct Name Item Text Cronbach’s α
PREDICTORS
Suicide Prevention Self Ecacy
I know how to talk safely about suicide, in ways that help with prevention α = 0.779
I know how to decrease suicide risk for others by the way I talk about suicide
I know how to support someone who is at risk, whether or not I am close to them
I feel condent that I can do things to prevent suicide
Wellness Self Ecacy
There are things I can do to promote wellness here α = 0.842
I know how to create a healthy environment for youth as they grow up
I know how I can make positive changes for community wellness
Community of Practice
Many people in this community work together for suicide prevention/wellness α = 0.727
I have regular opportunities to work with others to increase wellness
I have many people to work with in my community to prevent suicide
BEHAVIORS
Work Together to Prevent Suicide and Promote Health
I asked someone for help doing prevention/wellness work when I needed it
I spoke up about what community organizations can do to reduce the risk of youth suicide α = 0.841
I suggested ways community organizations could work together to increase wellness
I talked with community members about wellness
I talked with others about wellness and/or suicide prevention
I worked with others to prevent suicide or promote wellness
I let people know what resources are available for prevention
I worked with a group of people in the community to share suicide prevention information
Interpersonal Support
I spent time listening to someone who just wanted to talk about their experience
I trusted others in the community to hear what I have to say α = 0.689
I reached out to someone who was hurting (alone, sad, angry)
I helped someone who was down get help (Behavioral Health Services, Alaska Careline, etc.)
I reminded someone that just listening to someone can be more supportive than giving advice
I quietly listened to someone who had a problem, reecting back to them what I heard.
I encouraged others to oer small acts of kindness when someone was having a hard time
Lethal Means Reduction
I tried to make a home safer (such as no alcohol, locked guns) when worried about someone living
there.
α = 0.498
I worked on a community-wide project to make homes safer
I discussed how to make a home safer (no alcohol, gun safes)
Postvention
I shared only the basic facts of a suicide (avoiding details)
I spoke to someone about how to talk safely after a suicide α = 0.742
I talked about how suicide is no one’s fault
I shared that it can be harmful to honor someone who died by suicide more than is done for other
deaths
I talked about how we can help prevent further harm after a suicide happens.
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Wexler et al. BMC Public Health (2025) 25:1323
institutional role were more likely to work together with
others to prevent suicide and promote health and to oer
interpersonal support to others. ose with an undened
role (did not select one) were less likely to take action to
reduce someone’s access to lethal means as compared
with those with who selected a community and/or insti-
tutional role. Pairwise follow-up comparisons indicated
that those endorsing no institutional or community roles
reported engaging in signicantly fewer prevention and
wellness behaviors compared with other groups. e
analysis found no other signicant dierences between
roles, including tests to control for age and gender.
Table3 provides means on each subscale by role group
and includes relevant statistics from the ANOVAs.
To test our hypotheses linking self-perceptions to self-
reported behavior, we conducted a separate multiple
linear regression for each behavioral outcome construct
(Working Together, Interpersonal Support, Lethal Means
Reduction, and Postvention) with self-perceptions (Well-
ness Self-Ecacy, Suicide Prevention Self-Ecacy, and
CoP) as simultaneous predictors. Results indicated dis-
tinct patterns of association of self-perceptions to behav-
ior for each behavioral outcome. Higher self-ratings of
wellness self-ecacy, as well as having collaborative
relationships for suicide prevention or a CoP each were
signicantly and positively associated with the Working
Together behavioral construct. Both self-ecacy rat-
ings (prevention and wellness self-ecacy) were signi-
cantly associated with Interpersonal Support behaviors.
e only statistically signicant association with Lethal
Means Reduction behaviors was suicide prevention self-
ecacy. Finally, both suicide prevention self-ecacy
and CoP were signicantly associated with Postvention
behaviors. Taken together, self-perceptions of wellness
self-ecacy, prevention self-ecacy and CoP explained
a substantial proportion of the variability in suicide pre-
vention and health promotion behaviors, with R2 values
ranging from 0.17 to 0.32. Importantly, follow-up analy-
ses controlling for role dierences found no signicant
eects for role type on the outcomes after controlling
for self-perceptions, and the pattern and strength of
results for these associations was consistent with models
reported here (results for models controlling for Role
available upon request). See Table4 for statistical results
from all multiple regressions.
Discussion
Our study clearly emphasizes the importance of commu-
nity adult supporters in both institutional and commu-
nity roles (i.e., people within families and communities
outside of institutional roles as well as professionals) as
a vital source for enacting suicide prevention and well-
ness promotion activities within under-resourced Alaska
Native communities. is nding is supported by a previ-
ous social network analysis describing young AN people’s
social support networks in remote Alaskan communities
where they rely predominantly on family members and
peers for support [20]. Developing a community of prac-
tice (CoP) to enact a variety of community and family-
based suicide prevention and wellness initiatives is novel,
and this study provides evidence for this approach. Adult
family and community members as well as social service
providers (including community health workers, teach-
ers, coaches) are oering a variety of preventative inter-
actions and social support to young people. Additionally,
our study supports an expanded conception of self-e-
cacy that includes health promotion as well as suicide
risk reduction behaviors (i.e., lethal means reduction,
postvention). ese points push the eld toward a more
expansive approach to suicide prevention and oers clear
ways to measure these variables, which have important
implications. Each will be discussed here.
Often, suicide prevention interventions in the United
States ignore the community, cultural, and family assets
that our data show as vital (i.e., those adult support-
ers endorsing community roles) and relegates people
occupying supportive family and community roles (i.e.,
Elders, parents, aunts, etc.) to positions of ‘gatekeepers’
who identify and refer vulnerable young persons to men-
tal health care [56, 57] rather than active partners in this
work [28]. e youth suicide prevention eld has devoted
much time and attention to this gatekeeper model [26,
56] even though evidence of this strategy’s mitigating
impact on youth suicidal events is sparce, mixed, and
Table 2 Descriptive statistics and correlations for study independent and dependent variables
Variable M SD 1 2 3 4 5 6 7
1. Wellness self-ecacy 5.67 1.05 -
2. Suicide Prevention self-ecacy 5.68 1.12 0.72 -
3. Community of Practice 5.24 1.26 0.61 0.58 -
4. Working Together to Prevent Suicide and
Promote Health
3.14 2.62 0.53 0.43 0.50 -
5. Interpersonal Support 5.20 1.69 0.43 0.41 0.34 0.54 -
6. Lethal Means Reduction 1.75 0.91 0.35 0.40 0.31 0.50 0.40 -
7. Postvention 2.86 1.92 0.46 0.54 0.43 0.70 0.61 0.51 -
All correlati ons were statisticall y signicant, p <.0 01
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 8 of 12
Wexler et al. BMC Public Health (2025) 25:1323
ultimately inconclusive [57–59]. Most importantly, the
aim of gatekeeper approaches is to assess individual risk
and refer to clinical services, which are not often avail-
able in under-resourced communities [7, 8] nor are they
typically culturally-responsive for marginalized young
people [9]. erefore, while the popular use of gatekeeper
training may contribute to suicide prevention, it is not
enough on its own; particularly in marginalized, under-
resourced, and rural communities where youth suicide
is a growing concern. is study provides an expanded
perspective and identies measures for tracking com-
munity-based eorts and interactions with preventative
potential.
Our data underscores the importance of systems-based
approaches that strengthens the cultural, community,
and family resources which are often more plentiful in
rural settings than clinical mental health services or insti-
tutional resources. Such approaches empower rural com-
munities to leverage their existing resources and local
expertise to reach the people in their communities who
need help the most [60]. People who identied as occupy-
ing both community and institutional roles were likely to
work together with others to prevent suicide and promote
health (Table2), supporting the notion that both com-
munity and institutional systems are important vectors
for multidimensional and collaborative suicide preven-
tion actions [61]. is nding highlights the important,
often ignored, cultural and community strengths within
communities that can be important assets for promoting
wellness and preventing suicide before a crisis. Partner-
ing with community and family members–those who
are already engaged in the lives of youth–oers a way to
strengthen the social safety net that is currently in place
in communities. Indeed, such collective eorts may
support more sustainable and larger-scale outreach for
suicide prevention and health promotion in rural, under-
served communities, like the remote AN communities in
this study.
Likewise, in our analysis, people who indicated hav-
ing an existing CoP to work with (i.e., “I have regular
opportunities to work with others to increase wellness”)
were more likely to report taking actions in collabora-
tion with others to address suicide (Table3). ese mul-
tidimensional activities included collaborative eorts
to educate others about protective factors, do wellness
activities, participate in postvention planning, and share
suicide prevention resources. is nding is consistent
with the literature about CoP [34], and illuminates the
importance of developing a CoP to facilitate collabora-
tive initiatives (i.e. “Working Together”) in many dierent
locally-directed ways to reduce suicide risk and promote
overall health. is clear nding suggests that creating a
CoP that supports collaborative preventative activities
is a promising and under-utilized avenue for a variety
Table 3 Role dierences in study variables
Participant Role Omnibus Test of
Group Dierences
Pairwise
Dierences
Other Role
n = 120
Community
Role
n = 211
Institutional Role
n = 25
Institutional & Community
n = 42
M SD M SD M SD M SD F (df = 3,394) p
IV: Self-Perceptions Wellness Self Ecacy 5.43 1.06 5.70 1.02 6.00 0.94 6.01 1.12 4.43 0.004 a, b,c
Suicide Prev. Self-Ecacy 5.52 1.14 5.72 1.12 6.07 1.12 5.68 1.07 1.96 0.308 −−
Community of Practice 5.17 1.22 5.21 1.28 5.66 1.12 5.33 1.37 1.17 0.321 −−
DV: Wellness/ Prevention Behaviors Working Together 2.69 2.48 3.17 2.63 4.08 2.90 3.71 2.65 2.96 0.032 b, c
Interpersonal Support 4.93 1.83 5.23 1.60 5.92 1.68 5.38 1.65 2.78 0.041 c
Lethal Means Reduction 1.54 0.93 1.85 0.84 1.84 1.11 1.76 0.96 3.15 0.025 a
Postvention 2.64 2.01 2.96 1.87 3.32 1.81 2.69 1.92 1.32 0.266 −−
Note: ANOVA Signic ant pairwise diere nces reported only w here F test was signican t, and are indicated as:
a Participants endorsing no role dier from those endorsing community roles only
b Participants endorsing no role dier from those endorsing institutional roles only
c Participants endorsing no role dier from those endorsing both institutional & community roles.
No signica nt pairwise dieren ces were found for any other ro le comparison aside fr om the three outlined ab ove.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 9 of 12
Wexler et al. BMC Public Health (2025) 25:1323
of strategies at multiple levels and across the prevention
spectrum, especially for rural communities and those
with limited institutional resources.
Shifting focus from an individual’s perceived self-e-
cacy to execute narrowly prescribed actions to consider-
ing their perceptions about their ability to problem solve
and collaborate with others to execute locally directed
actions [62] oers an expanded orientation from which
to approach suicide prevention. is collective orienta-
tion is measured through our CoP independent variable
and is associated with both Working Together and Post-
vention behaviors (see Table4). e distinct associations
include the social support systems for both those show-
ing signs of suicide risk and for those who are supporting
them. In small, tight-knit and under-resourced commu-
nities with limited professional helpers and too common
suicidal events [55], this social support system for those
providing support is clearly important for sustainable
action.
Our ndings also elucidate some important distinc-
tions within the idea of self-ecacy for suicide preven-
tion. Self-ecacy is a central component to many social
science theories of individual behavior change. It has
been incorporated into foundational implementation sci-
ence frameworks, and is typically dened as “…an indi-
vidual’s belief in their own abilities to execute [specic]
courses of action…” [57, p. 9], is study includes two
dimensions of self-ecacy: wellness and suicide preven-
tion, signifying one’s perceived knowledge and skills to
do these two types of actions. As discrete yet inter-related
concepts, our Wellness Self-Ecacy and Prevention Self-
Ecacy constructs are a novel way to conceptualize these
two self-perceptions. Our ndings corroborate previous
research that self-ecacy is important, but for dierent
kinds of behavioral outcomes. Both wellness and pre-
vention self-ecacy are associated with oering Inter-
personal Support, whereas only wellness self-ecacy is
associated with Working Together. Distinctly, prevention
self-ecacy is associated with Lethal Means Reduction
and Postvention behaviors (see Table4). Including both
wellness promotion and suicide prevention orientations
expands our understanding of the kinds of perceptions
and resources needed for comprehensive prevention
eorts.
ese ndings suggest that Regulatory Focus eory
may be an important consideration for suicide preven-
tion, specically the implications of promotion versus
prevention framing. A wellness promotion orientation
expands measurement to include commonplace events
(not predicated on crisis or risk), such as listening to or
oering opportunities to young people, that can promote
wellbeing in an on-going way. A prevention orientation
may be more aligned with stopping a rare event. While
these Regulatory Focus eory framings have been
Table 4 Associations between Self-Perceptions and suicide prevention and promotion behaviors
Working Together Interpersonal Support Lethal Means Reduction Postvention
B
[95%CI]
SE β B
[95%CI]
SE β B
[95%CI]
SE β B
[95%CI]
SE β
Wellness Self Ecacy 0.86***
[0.55, 1.17]
0.16 0.34 0.40***
[0.18, 0.62]
0.11 0.25 0.09
[-0.03, 0.21]
0.06 0.10 0.16
[-0.07, 0.39]
0.12 0.09
Suicide Prevention Self-Ecacy 0.05
[-0.23, 0.34]
0.15 0.02 0.28**
[0.08, 0.48]
0.10 0.18 0.22***
[0.11, 0.33]
0.06 0.27 0.66***
[0.45, 0.87]
0.11 0.38
Community of Practice 0.57***
[0.35, 0.79]
0.11 0.28 0.12
[-0.04, 0.27]
0.08 0.09 0.06
[-0.03, 0.14]
0.04 0.08 0.23**
[0.06, 0.39]
0.08 0.15
Model R2R2= 0.33
F(3,394) = 64.34*** R2= 0.21
F(3,394) = 35.05*** R2= 0.17
F(3,394) = 26.98*** R2= 0.31
F(3,394) = 58.74*** R2= 0.21
F(4,393) = 26.09***
*p <.05, **p <.01, ***p <.001. Bold coecient s indicate ndings which h eld after applyin g familywise test co rrections using the H olm-Bonferro ni sequential method . The pattern of thes e results remains the sam e even after
controlling for role dierences
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Page 10 of 12
Wexler et al. BMC Public Health (2025) 25:1323
shown to impact outcomes in health communication [63,
64], and across many other domains including leadership
styles [65, 66], social support [67], consumer purchasing
behaviors [68], and even athletic performance [69], to our
knowledge, no work has been done to investigate how
Regulatory Focus constructs of prevention and promo-
tion may be important for suicide prevention programs.
Further research might explore how and for whom these
dimensions—promotion and prevention—may be dif-
ferently important for uptake of suicide prevention
programs.
Limitations
e study reports on cross-sectional data from remote
and rural AN communities that was collected over sev-
eral days in the Fall in 2019. ese data were originally
intended as baseline measures prior to testing the PC
CARES intervention, which ultimately did not proceed
in person as planned due to COVID restrictions. Under
the direction of our community partners, we conducted
secondary analysis of what we collected to deepen our
understanding of suicide prevention processes in AN
communities and to honor the eort and contributions
of the AN individuals who completed the baseline sur-
veys. Because data collection was cut short by COVID
and represents a single point in time, this study cannot
establish causal relationships, determine the directional-
ity, or elucidate the temporal sequence of the associations
found. Future research should be done to conrm our
ndings and better elucidate the causal pathways under-
lying the observed associations.
Although the data represents approximately 15% of
the population of participating villages, the sample is not
representative. We strategically recruited those in the
main institutions within communities as well as people
employed by institutions like the school or tribal health
corporation and oversampled youth. Our survey cat-
egorized individuals according to self-reported “com-
munity” or “institutional” roles, which may not capture
the nuances of how Alaska Native participants see their
connections in the social environment. Indeed, 120 (30%)
of our participants selected neither institutional nor
community roles. is may impact our ndings on role
dierences across our study constructs (Table2). Addi-
tionally, the survey analysis relies on self-reported behav-
iors done over the last few months. us, our results oer
just a snapshot of community members’ self-perceptions
and reported suicide prevention and health promotion
behaviors. It is likely that the StP survey items neglected
more subtle and culturally-based forms of local sup-
port as it was limited to the survey’s prescribed behav-
iors. Importantly, the StP Survey measure is a work in
process. Our conrmatory factor analysis (posted on
Psych Archives) shows limitations of our binary (Yes/
No) behavior outcomes, specically related to our three
item Lethal Means Reduction subscale. is scale has
Cronbach’s alpha lower than desired. However imper-
fect our measure, this evidence-based construct of lethal
means reduction [70–72] is a vital way to prevent suicide
in communities with household rearms. We continue to
work with our community partners to develop a precise
and understandable subscale for this critical construct,
and because of its importance, include lethal means
reduction as a key behavior subscale in our analysis.
Conclusion
Our ndings overall provide foundational information
for multidimensional intervention practices that sup-
port local people working collaboratively across exist-
ing institutional and community systems of care. e
cross-sectional study investigates how self-perceptions
related to suicide prevention, wellness and collabora-
tive relationships are associated with suicide prevention
and health promotion activities, which include behaviors
across the prevention spectrum. Our study found that
general support for young people (wellness or health pro-
motion) is important to include alongside targeted sui-
cide prevention outreach. Research suggests both types
of approaches contribute to lowering youth suicide risk
[73]. Given our ndings, we suggest an expansion beyond
focusing solely on intervening according to individual
risk to include collaborations across sectors through a
community of practice to encourage and support suicide
prevention and wellness promotion. Moving beyond indi-
vidual-level approaches to suicide prevention, this study
highlights key factors in the social environment that
encourage people’s engagement in activities to reduce
risk and promote wellness. is expanded approach to
suicide prevention is especially important for under-
resourced, culturally distinct communities.
Acknowledgements
These data would not exist without the community-based support provided
by the village-based counselors and schools in the Bering Strait region. Thank
you, Yuka Ungwiluk, Edna Apatiki, Joseph Kingeekuk , Emma Olanna, Donna
Barr, and Josie Garnie, for hosting research activities in your communities.
Thank you to the school principals in the region who accommodated us in
school buildings. Thank you, Promoting Community Conversations about
Research to End suicide (PC CARES) Local Steering Committee members, who
have helped shape and guide the project since the beginning.
Author contributions
LW: Conceptualization, investigation, writing– original draft and review
and editing, supervision of project overall, funding acquisition LAW:
Conceptualization, investigation, writing– original draft, review & editing
JG: Formal analysis, writing– original draft, visualization (rst drafts of tables)
TS: Project administration, investigation, writing– original draft, review &
editing SR: Project administration, data curation, writing– original draft,
review & editing CW: Writing - review & editingKS: Writing - review & editing
EK: Validation, created nal tablesDM: Conceptualization, writing - Review
& Editing PH: Methodology HL: Validation, formal analysis, methodology,
writing– original draft, review & editing, supervision of JG and EK.
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Page 11 of 12
Wexler et al. BMC Public Health (2025) 25:1323
Funding
This study was funded by National Institute of Mental Health of the National
Institutes for Health award numbers R34MH096884, R01MH112458,
R01136768, R61 MH 125757, U19 MH113138.
Data availability
The datasets generated and analyzed in the current study are not publicly
available due tribal shared ownership. If interested, data can be made
available from the corresponding author after going through tribal review by
the Research Ethics Review Board of Norton Sound Health Corporation and
Kawerak, Inc.
Declarations
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in
accordance with the ethical standards of the institutional and/or national
research committee and with the 1964 Helsinki Declaration and its later
amendments or comparable ethical standards. This study was reviewed and
approved by the University of Michigan Institutional Review Board (IRB),
University of Massachusetts IRB, the Alaska Area IRB, and the Norton Sound
Health Corporation (tribal health organization) Research Ethics Review Board.
Consent to participate
Research participants indicated their consent to participate by reviewing and
signing an electronic consent document informing them about the details
of the study, including its risks and benets. Informed consent was required
before participating in the Steps toward Prevention (StP) Survey.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1Department of Social Work and Research Center for Group Dynamics,
Institute for Social Research, University of Michigan, Ann Arbor, MI
48104, USA
2School of Social Work, University of Washington, 4101 15th Ave NE,
Seattle, WA 98105, USA
3Department of Psychology and Neuroscience, Boston College, McGuinn
300, 140 Commonwealth Ave, Chestnut Hill, MA 02467, USA
4Department of Health Promotion and Policy, University of
Massachusetts, Amherst 01003, USA
5Division of Social and Transcultural Psychiatry, McGill University,
Montreal H3A 0G4, Canada
6Center for Research on Families and Psychological and Brain Sciences,
University of Massachusetts, Amherst 01003, USA
7Rural Drug Addiction Research Center, University of Nebraska-Lincoln,
Lincoln, NE 68588, USA
8University of Alaska Fairbanks, Kuskokwim Campus, Bethel, AK
99559, USA
Received: 21 February 2024 / Accepted: 24 March 2025
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