Building Resilience to Reduce Suicide in Arctic Indigenous Communities

Transcript

Webinar Operator:  Good day everyone, and welcome to today's mental health disparities conference call. At this time, all participants are in listen only mode. Later, you may ask a question or ask a question anytime in the Q & A box at the bottom-right of your screen. It's now my pleasure to turn the converse over to Roberto Delgado. Please go ahead.

Roberto Delgado:  All right, thank you everyone for joining us today. My name is Roberto Delgado, and I work at the Office for Researching Disparities in Global Mental Health at the National Institute of Mental Health, the US National Institutes of Health. I will be your master of ceremonies today. We are very excited to feature Dr. Allison Crawford and her work on the National Inuit Suicide Prevention Strategy.

Before we get to our presentation, I want to give some brief highlights of RISING SUN. An initiative undertaken during the recent US chairmanship of the Arctic Council. Our theme for today's webinar is building resilience to reduce suicide in our communities, and the work that we conducted over the past two years definitely aims to achieve those goals.

For those of you unfamiliar with the Arctic Council, it is an intergovernmental forum comprised of the Arctic States conditions people's organization and observers that are focused on collaborations and coordination on environmental conservation in sustainable development across the Arctic.

The slide you're seeing now illustrates our landing page or website that we created for initiative, and this site has a lot of information on the context of suicide prevention in the Arctic. It also describes our aims, which was to develop a series of community-based prioritized outcomes to evaluate suicide prevention intervention across the Arctic. There's also listings of our reference to our scientific advisory group, a diverse set of practitioners, researchers, and Native youth who participated in our initiative over the course of two years. There is reference to our US government and international partners including Denmark, Norway, Canada, and the Inuit Circumpolar Council. There also the summer reports of the workshop that we convene as part of our initiative.

The next slide shows ... It's a schematic illustrating the processes that which we undertook to achieve the goals of the RISING SUN initiative. First, there's a line of arrows at the top of the slide indicate three workshops that we convened over the course of approximately an 18-month period starting September of 2015. We launched our initiative in Anchorage, Alaska. Also, dedicated a part of a meeting to learning about the concerns and issues with Alaskan Native communities as well as providing an overview of our methodologies and the timelines for the initiative.

In May of 2016, we convene our second meeting in Tromso, Norway. We're, again, we split time between listening and dedicating activities towards the development of a national strategy for the local Indigenous communities or the Sami. We also continue with our efforts to develop the outcome under the RISING SUN initiative. I'll describe that process a little bit more in a few minutes.

Our third and final meeting was held earlier this year in March 2017 in Iqaluit, Nunavut in Canada. Here was an opportunity to really reflect and present on the initial findings of our initiative as well as to address the work that had been ongoing within Canada. We'll hear much more about that with the future presentation by Dr. Allison Crawford.

I'll skip down to the third series of arrows, which was a mechanism for supplementing inputs and feedbacks from Native communities, particularly because not everyone was able to attend the regional workshops we held in September, May, and March of the previous three years respectively. There were efforts to reach out and to hold focus group discussions within remote areas of Canada and Alaska. Although in Alaska, we actually took advantage of the annual conference of the Alaska Federation of Natives. Virtually the entire state tribe organizations were represented there. That was to supplement our data collection.

The meat of the initiative, however, focused on the Delphi process, which again is consensus building and priority setting activity. One that we at the National Institute of Mental Health had used previously a number of years ago for the grand challenges of mental health. Using this model essentially allows us to recruit hundreds of individuals from across the Circumpolar Arctic and reach out to them via email to ask and receive responses to a series of questions. Again, that will help us achieve our goals of developing outcomes to evaluate suicide prevention intervention in the Arctic.

We held three rounds over the course of the initiative. The first one had an open question asking all the participants, that included clinicians and researchers and policy makers, Native community members, elders, youth, to answer the question of: What outcomes do we hope to achieve in Arctic communities through suicide interventions in addition to reducing suicide rates? We received over 600 individual responses, which we synthesize and consolidated with the assistance of our scientific advisory group and our US government working group, which eventually distill down to about 135 outcomes for further review which we did during the second meeting in Tromso, Norway. Then following additional inputs, we were able to reduce the list to about 100 potential outcomes.

During the second round, we basically returned to our participants of the Delphi process and asked them to select their top 25. Everyone had 25 votes to choose to distribute among the 100 or so outcomes. At the end of this round, we had our top 25 and returned for a third and final round where we asked the participants to rank those top 25 based on three dimensions that included the relevance to their specific communities. We also asked about the feasibility of implementation, and lastly, we also asked them to rank based on the impact of those outcomes if they were to be implemented in the communities.

At the end of these three rounds, we had prioritized community-based outcomes that we are working with now to further disseminate and develop specific measures and indicators for evaluation purposes. I won't get into specific details about those outcomes right now because, first, we are in the process of submitting a manuscript for publication. So, can't publicly disseminate all these outcomes at this point. We are also in the final stages of developing and launching an online toolkit which will not only proved these outcomes but give background on the context of suicide prevention interventions across the Arctic. Also, highlight several effective interventions that are working well. And also provide a series of guidelines, you might say, for different stakeholders, whether you're a decision maker, whether you're a community member, or clinician, or a researcher, how best to utilize these outcomes that we developed through the process. That will be forthcoming later this year as well as the publication. I'll also highlight that later this year in the fall as we approach the launch of the toolkit at the request of the US State Department and US Interagency Arctic Research Policy Committee will be doing a more detailed webinar to disseminate those specific outcomes and the utility of that toolkit.

For our purposes now, we did submit an activities report to the State Department for the Arctic Council Ministerial Meeting that was held in Fairbanks, Alaska earlier this year. We're in the process of disseminating and ideally implementing these outcomes in the sense that working with a Finish government who now chairs the Arctic Council for the next two years, and doing informational webinars like this one and the ones that we'll do later for IARPC and the State Department, and writing small articles and briefings to relevant stakeholders. That's the key aspect of RISING SUN initiative.

I will also say a little bit about the levels of interventions of these outcomes we talked about and developed. This slide shows that interventions can come at many different scales from policy to the health systems or communities and individuals. I can't say that generally speaking the outcomes that were prioritized across the Arctic included those that were family and community level, those that really rely on the importance of relationships and cultural traditions to strengthen the protective factors in community. There was nice consistency across the Arctic in those elements.

One of our challenges going forward, however, is actually developing and vetting measures that are culturally appropriate for the different outcomes that we emerge. The current slide shows examples of types of measures that have been used for other aspects like adverse childhood experiences, child exposure domestic violence, protective factors, post-traumatic stress disorders, and even include measures to address physical, emotional and sexual abuse, physical and emotional neglect, or examples of household dysfunction like mental illness, having an incarcerated relative, or substance abuse, or divorce in the family, or observing a mother being treated violently. It's nice that there's a starting point in a sense, but these really need to be evaluated and vetted for Indigenous communities to make sure that they are in fact appropriate for those contexts.

I will say just to remind folks the RISING SUN products, again, will include the technical report that's coming forward. The web-based toolkit, which I mentioned earlier will include an introduction to suicide prevention efforts in Arctic Indigenous communities and we'll hear a little bit about that from Allison's presentation. Our website will also include case studies from communities that have successfully implemented interventions. Of course, the prioritized outcomes with what measures we have to date or the ones we hope to develop that are consistent with the outcomes and goals of the RISING SUN initiative as well as the strategies for using the toolkit, which I think will be most, most important going forward.

Speaking on going forward, given that this is an international issue, a concern, a real health crisis, we are working with Finland, as I mentioned, to develop follow-on activities around mental health and suicide prevention. We are awaiting forthcoming proposal ideas and ways that the US National Institute of Mental Health can contribute and support those activities. Some of these, we imagine that will be focused among the Sami communities, they recently released a strategy for suicide prevention among Sami, Norway, Finland, and Sweden. We're definitely going to support those activities. We'll hear much more about the National Inuit Suicide Prevention Strategy in Allison's presentation. From the US domestic-side, we are also working with the Arctic Mental Health Working Group, which is stood up by the United States Arctic Research Commission, which is a small independent agency tasked with advising and making recommendations to US Congress and president around Arctic research and policy. And so, this contributes to the Interagency Committee and their research plan. I serve on the Health and Well-being Collaboration Team pushing forward mental health and suicide prevention initiatives.

This slide just shows ... It's an excerpt from a fact sheet that the US Arctic Mental Health Working Group has put forward. Basically, their primary aim is to strengthen systems of care to prevent suicide and improve mental health in the Circumpolar North. They have various sub-aims. There's a website with a full fact sheet for your reference.

I will just close out here because I want to really dedicate the rest of the time to Allison's presentation and discussion session by saying that from NIMH perspective and our focus on our mission around conducting and supporting research, we are very excited to have recently awarded three new collaborative research hubs around ... a funding announcement that was put out last year ... focusing on reducing the burden of suicide among American Indian/Alaskan Native youth. The primary aims of this program was to increase the reach and research space for effective culturally relevant preventive interventions that would increase resilience and reduce suicide in tribal or urban Inuit communities. And I'm happy to announce that one of these new hubs will be based in Alaska at the University of Alaska, Fairbanks, focusing on resilience research.

For those of you interested in learning more about those, our next mental health disparities research webinar on Thursday, August 29, 3:00 Eastern Time, will focus on these different hubs. One in Alaska, the other two on the lower 48, but I think there are some very good applications and models that can be applied across Indigenous communities in the Arctic as well based on the research that is being proposed and will be conducted under these hubs.

That's all I have to say about RISING SUN and our efforts. Again, there will be further dissemination of information in the coming weeks and months as we publish our paper and also launch our online toolkit. With that, I want to turn now to Allison. Give her a very brief introduction and allow her to take the floor. Her bio was available on the registration website, so I won't repeat that. I just want to share my experience with Allison whom I first met a little bit less than two years ago in Anchorage during the RISING SUN launch meeting. She's one of our scientific advisory group members. A champion really for mental health and suicide prevention who very energetic, always engaged and responding in a timely manner, just a real pleasure to work with and I look forward to continuing that collaboration going forward. I will now let her join us.

In Pop-Up, I don't know. Allison, if you're camera is working, you can join us on video to discuss the work that you did around suicide prevention policy and community engagement in the development of the National Inuit Suicide Prevention Strategy in Canada.

Allison C.:  Thank you so much.

Roberto Delgado:  Allison?

Allison C.:   Hi there. I'm here. Can you hear me?

Roberto Delgado:  Yes.

Allison C.:  Great, and I should've popped up on the screen. Thank you for that introduction, it's so personal. Just very happy to know you don't consider me a procrastinator. I'm timely.

My bio is there, but I think as a way of introducing how I entered into this work I'll just tell you a little bit about how I came to work in Nunavut. I'm a psychiatrist. I work at the Centre for Addiction and Mental Health, which is in Toronto, Canada. For about 30 years, we've provided fly-in psychiatric care to the territory of Nunavut. I lived in Nunavut for a number of years, and then took over that role when I moved back to Toronto. We're a team of about 12 psychiatrists that provides care year-round to one of three regions in Nunavut, to the Baffin region. As part engaging in psychiatric work, I just became very dissatisfied with the limitations of a biomedical model. Our group started to do more community engagement, which we turned into some research. I was very fortunate about two years ago, the national Inuit organization, Inuit Tapiriit Kanatami, decided to create a national Inuit suicide prevention strategy, and I've been fortunate enough to work with them as a consultant as they led those efforts. I've really had the chance to see both the gaps but also hopefully increasing connections between community work and working at a policy level.

Thank you, Roberto, for inviting me to do this, and I thought what I'd like to talk about ... It's always a tough choice between do you go for breath and talk about a number of different things or do something in real depth. I decided I did want to put this within the context of the National Inuit Suicide Prevention Strategy, but I also want to make clear that the interventions I'm about to talk about or the community-based initiatives are not formally part of that strategy. First, I thought because Roberto introduced the RISING SUN initiative, and I think the National Inuit Suicide Prevention Strategy had an impact on that initiative and arose around the same time. I think it's good to put the interventions in the context of the strategy, but I did want to be clear, these aren't part of the strategy.

I should describe the image. On my first slide, there's an image ... It's actually a photograph of a soapstone carving by [Jamesee Pitsiulak 00:19:15] who's an artist Cape Dorset, Nunavut. I just love this ... Oh, I love the carving and the image of it because it's a reminder to me about innovation. Inuit knowledge as innovative, but also the way that Inuit knowledge is not static. That is always like any knowledge of any group, is always adapting and changing, and that when we talk about Inuit knowledge, Inuit approaches, Inuit values that's not a static ancient thing. It includes those elements but it's always evolving. As we have tried from ... I'm going to focus again on healthcare and how healthcare can engage with Inuit knowledge and with community. I like this image because it reminds of the beauty and complexity of knowledge.

All right. Let me ... Oh, all right. There we go. I'm just learning the technology too, which is quite cool except that this work has been so much about conservation and engagement it feels a little strange to me to know that you're all out there and I'm hoping we have a conversation in the chat box a bit later.

For today, I've already touched on this, but I'll talk about the National Inuit Suicide Prevention Strategy but I'll start off more broadly with: What is a suicide prevention strategy at a national level? I know in Canada, we don't have a national suicide prevention strategy. There's often a lot of dialogue about what good does a strategy do. I'm going to talk about what the intent of a strategy is. I'll talk about the National Inuit Suicide Prevention Strategy and some of its key features, and in particular what it means to create a strategy in an Indigenous context. In this case, by Intuits. This was really Inuit Leadership Initiative, but what it means to take best practices in creating a national strategy and then apply them and adapt them to that context. That movement I talked about, between strategy and then what's actually happening in the community. I think the RISING SUN really grappled with that. Everyone understands the need for policy and to be strategic and for vision, but how do you incorporate what's happening at the community level and all the knowledge that actually exists at the community level. How do you bring that forward towards a strategy? And then how do you move back and forth between the two levels? I'm not promising I have any answers to that in a 45-minute presentation, but that's really the crux of what I think about.

A national suicide prevention strategy ... I mean it's not ... it's a bit intuitive. It's not magic, but just so that we have these features in mind. A strategy is purposeful, so it sets out the objectives in a really purposeful way and there's thought given to what priorities are. There's integration of a kinds of initiative, so if it's around suicide prevention, the initiatives that are suggested by the strategy are meant to be integrated. It coordinates multi-faceted activities and most importantly ... It says government here, and I think in this case or in the case of the ... I'm going to say the NISPS, so that's ... I'll be NISPing them, but that's the National Inuit Suicide Prevention Strategy. In that case, it's the Inuit national body that is the coordinating body. A strategy aims to promote and support the links between different sectors, and also to account for what's happening at local levels, at regional, and national levels, which is obviously quite different from what a program of prevention is which can be very specific and very focused on few targeted activities or interventions. This actually looks at the links between those interventions.

These are the countries with a national suicide prevention strategy at least as of 2011, and also, glaringly, those that don't have a national suicide prevention strategy. The World Health Organization, when they came out with their policy statement on suicide prevention in 2014 recommends the creation of a national strategy as a suicide prevention effort in and of itself. That there is value to having a strategy and that that should be part of suicide prevention.

The Canadian Centre for Suicide Prevention developed an evaluation framework for national strategies in 2003, and these are some of the things that they ... which you can see on the slide. I'll go over them briefly. These are the gold standard characteristics of the ideal national strategy for suicide prevention. That there is coordination integration amongst activities. That there's political support for what the strategy outlines as its aims or that there's at least a process in place to gain that political support. That there's a coherent conceptual framework, and I think this is very important. This is one of the things I'm going to focus on. The strategy should layout why it think that suicide happens, what the risks are, what the processes are, and the aims of the strategy should be linked to that conceptual framework so that there's a rationale for it. I'm going to come back to that. That there's been community involvement and engagement. I'm also going to come back to that, so a national strategy really has to have all of these components to be a gold standard strategy. Also important that the objectives of the strategy are stated in such a way that they're achievable, so there feasible and can happen, and also measurable. We'll come back to this also.

You have to think of that implementation and then you have to think about how can you measure whether you've been successful in a strategy. We've all seen lots of papers with great ideas in them, lots of effort goes into them, but if they can't be implemented and evaluated, then they're very limited in their effectiveness. So the strategy has to have monitoring and evaluation as one of its aims. With those in mind, I'm going to turn to the conceptual framework because I think this is one of the challenges in creating a suicide prevention strategy for Indigenous communities who are creating a suicide prevention strategy.

A lot of the global evidence in suicide prevention focuses on this model here. This is one of the most well-known suicide-ologists or researchers Keith Hawton, and this is the conceptual model, so what he thinks based on the global evidence leads to suicidal behavior whether it's completed suicide or self-harm. What you see here is a lot of emphasis on the individual with most of the emphasis ... I'll describe this diagram a little bit; although, it is quite messy. The pathway to suicidal behavior starts with genetic and biological factors, personality factors, but really is precipitated in the present by pain, psychological distress, feelings of hopelessness, think about suicide, and then the person is exposed to suicide. So maybe there's been suicide in their community or they've seen a TV show about it, and at the same time they also have available to them means of suicide, and depending on how likely those means are to be lethal, and there's a stressful event that can precipitate the whole cycle and it leads to an outcome of suicidal behavior or self-harm. So, you see that the emphases in this conceptual model for why suicide happens really focuses on the individual and on risk factors that have to do with mental illness and that have to do with current stress, the precipitating factors that are in the present or what we may call, proximal risk factors. Risk factors proximal to the event.

Down in the lower-left corner of this diagram, you see it does say negative life events or social problems, but that relegated to a very small corner and not really ... If it's relegated to a small corner of the diagram, then it's not really deemed to be something that would be a focus of suicide prevention. This diagram dictates the focus. Somebody who took this diagram at face value would say, "Okay, we've got to get rid of lethal means." That is a very effective suicide prevention intervention. They might say, "We should focus on mental illness." But down at the bottom of the list would be focusing on negative life events and the social circumstance.

I'm seeing some traffic in the chat, just give me one sec. Can everybody hear me? I don't know if-

Roberto Delgado:  Yes.

Allison C.: Okay, thank you Roberto. Fabulous. Because it's really hard to look at the slide, monitor what I'm thinking, and read the chat, so jump in if at any point I'm not loud or clear enough. Okay.

Roberto Delgado:  I'm keeping track of that, the Q & A box. Don't you worry.

Allison C.: Okay, fabulous. I'm just going to go back because this is the real point that I want to make. The things that are missing, because this is the cornerstone of the conceptual frameworks for how we think about suicidal behavior. Certainly, in a biomedical context, which really translates into most of the national suicide prevention strategies. The three things that I think are missing or de-emphasized here: One is, again, that focus on the individual with almost no reference to family, community, and larger socioeconomic circumstance. This is an individual out there on their own. So yes, maybe it is a stressor that the person doesn't have meaningful work, but it's not really in the foreground of this model. The second thing, which I also mentioned, is that this focuses on proximal risk factors. Risk factors around the time of the suicide attempt or behavior, and not on early life events or on more distal or downstream impacts. And third that if this is a model for why suicide behavior occurs and this is meant to capture why that behavior occurs everywhere, including in Indigenous communities and contexts, we can immediately see that there's a lot lacking. I'm going to focus on Indigenous knowledge. In my context that, Inuit knowledge, but I think that equally applicable. There's nothing about cultural strengths, cultural knowledge, et cetera.

I'm not really going to go over this diagram. What this diagram shows is from the World Health Organization report in 2014. If you haven't seen it, it's a very useful document. It synthesizes the evidence available around suicide prevention, and what it does here ... The schematic on the left looks at risk factors, and here they do take a very broad perspective from the health system all the way down to the individual. It connects those up on the right-hand side with the evidence base for interventions at the universal level, so meaning interventions that everyone in a society or nation should get. Selective interventions, so subpopulations like youth. There's an intervention all youth should get. And then indicated, so that would be things like where there's a specific risk of suicide. People who suffer from depression or who have had a previous suicide attempt. The World Health Organization has made an effort to think at that whole systems level, and they do say that a national suicide prevention strategy has to be adapted to the local context. They talk briefly about cultural knowledge. They're trying to provide a synthesis, so they don't get into that.

Then I thought what I would do for the next couple of slides is just talk about, briefly, contexts where there has been the creation of specifically a national suicide prevention strategy that has an Indigenous focus, recognizing that these Indigenous groups are all very different, and how that's been done. In Australia, in Canada, the NISPS is the preeminent example in Canada, in Greenland, New Zealand, and the US has done some work in this as well. Just look at what they did to take those ... If you think about that conceptual model, how that's been addressed in these contexts that purport to be Indigenous suicide prevention strategies or strategies for Indigenous communities.

So, this is the end. Don't try to read this. This is a diagram of the Australian strategy for National Aboriginal and Torres Strait Islander Peoples. What you see here is some attention paid, it's still very ... There are more arrows and there still very focused on the individual. There is mention of ... You won't be able to read the text I don't think, but there is mention of community and family. There is mention of some distal risk factors or points of intervention like enhancing parenting skills, reducing exposure to family and community violence, but there really is no reference and nor in the document either to the knowledge of Aboriginal and Torres Strait Islander Peoples. That doesn't inform the document in a really explicit way. They did have stakeholders. They did have community engagement, but it's essentially very similar model to Keith Hawton.

This is actually, let me come ... I'm going to come back to that last slide. This is equally hard to read, but this is from the New Zealand national strategy. There is a lot more attention to cultural factors. Now, I have a bit of a bias, because when I look at this I think, cultural factors are listed, but they're listed as risk factors. They're not listed as protective factors, but they do mention exposure to trauma, the family context. They mention the socioeconomic context, which is really missing the Australian strategy. And as I said, cultural factors. What New Zealand has done, is they created, which you can see on the side, a group called The Waka Hourua, and that's Pasifika and Maori Peoples who are working together around suicide prevention and they've become very involved at that national strategy level. They do, I think in a way, that was very inspirational to me anyway when I was working on the National Inuit Suicide Prevention Strategy. They really include things like what you can see here.

This one in particular. The negative impact of colonization. They name it. They talk about that as a context, and then many other issues. As a risk for suicide behavior, so they go way downstream and really talk about that social and historical context in a way that none of the other strategies do. I'm not going to go into the whole thing. They also have list a lot of protective factors that come from Maori and Pasifika knowledge, and that's really their emphasis in suicide prevention.

This diagram here is by Lawrence Kirmayer at McGill and his group from 2009, and they attempted to ... This isn't from a suicide prevention strategy, per se, but they really attempted to think about the community factors, historical contexts, as well as the individual factors. People are aware of this, and that was very ... I'm going to switch now to National Inuit Suicide Prevention Strategy, and on the screen, you'll see the front cover of that. The reference to that is actually easily available online if you haven't seen it. That was really the basis for this strategy was thinking about the global evidence but also thinking about all of those other social, historical contexts including socioeconomic context, historical trauma, colonization. Thinking about all that can be drawn from the global evidence on suicide prevention, but then how to take Inuit knowledge and culture not only into consideration but how to use that to guide suicide prevention.

Here, you'll see is in essence a conceptual model, so risk factors that include historical trauma stemming from colonization and the multiple aspects of that were named from residential schools to relocation and other factors. Community distress that continues into the present based on some of those historical factors. Injury to families as a result of history and also present living conditions and socioeconomic distress. Traumatic stress, especially stress that children may grow up with. And then not ignoring those proximal more immediate factors of mental distress including mental illness like depression and substance misuse. And then acute stress and loss like what can precipitate suicide behavior. Those proximal factors are not given more weight than the distal factors, they're all seen as playing a role. It also, side by side, draws attention to some of the protective factors within Inuit society and communities that might be used to address some of those risk factors, so cultural continuity and knowledge, community cohesion, and family strengths, providing children with optimal development, and then focusing on mental wellness and coping with acute stress to address some of those more proximal factors. You can see immediately some of the differences in that.

This is a diagram, the graphics are ... ITK put a lot of time into developing the graphics for this strategy, which I think are so helpful because this strategy is read not just by professionals working in mental health or government but it's read by a whole range of people. I think the graphics really say a lot and this illustrates much of what I talked about, that risk is not just right at the end of when somebody actually attempts suicide but really is varied, it grows and multiplies from in utero and from early development all the way up to the present.

Focusing, I mentioned this a few times, but on the socioeconomic factors and the inequities that exist for Inuit in Canada compared to all Canadians. It's quite dramatic some of the differences. Things like educational attainment, household income, medical wellness, those things are vastly different on average for Inuit than they are for Canadians on average. The strategy really advocates for taking that seriously. You wouldn't normally see something like that as part of a suicide prevention strategy, at least not in other national strategies.

These are the priority areas that's also hard to read, so I would encourage you to seek out the document. I'm just going to briefly name the strategic priorities and you'll hear echoes of what I said already. That the strategy aims to create social equity. To create cultural continuity, so continuity in knowledge and approaches. To nurture healthy Inuit children, so to start early in development. To ensure access to a continuum of mental wellness services for Inuit. It doesn't leave out some of the more medical or healthcare focused initiatives but it includes much more. To heal unresolved trauma and grief. Lastly, which I think actually is more of an overarching priority, to mobilize Inuit knowledge for resilience and suicide prevention. To take suicide prevention head on, but also to emphasize strengths and resilience. That this isn't initiative being led from the outside, it's very much under Inuit Leadership and interested in Inuit knowledge to mobilize some of that change.

I'm happy to answer questions at the end about the National Inuit Suicide Prevention Strategy, but I'll just, in the remaining time, move on to some of the initiatives that I've worked with other people and with communities in Nunavut. I think-

Roberto Delgado:  Allison?

Allison C.:  Yeah.

Roberto Delgado:  Allison, this is Roberto. Just a quick clarification question from one of our participants. The question is: Do any of the protective factors vary based on age group?

Allison C.:  Oh, great question. I'm going to go back to that list just to think about that for a second. Do the protective factors ... I mean, let me tell you I didn't talk very much about how this strategy was derived. I did mention it was led by ITK. There was an executive group, and as part of that group we reviewed all of the global literature, and then we also reviewed all of the literature in Indigenous communities, and then for Inuit specifically. This was not found in that literature in what we would normally think of as scientific evidence. We also went to each of the four regions in Canada and spoke with people at the community level. So, between the literature and those conversations, that's how this model was created. There's lots about this model that could be further tested and aspects of it.

I'll give you an example, the wounded family as a risk factor. We know that children who group up in adverse circumstances with a lot of trauma or stress in the family can later go on to have greater rates of suicide. That's one example, and that is supported by the scientific literature. However, we don't yet know, to the same degree, what family strengths can prevent that because that's not usually been a focus of suicide prevention work. Strengthening families and improving the development of children is not usually connected all the way up to suicide prevention, but we know it's important and think it's important to invest and then measure as we go. I hope that makes sense. I just gave the really long answer.

The shorter answer is, I couldn't break this down by age category. The only way I could break it down by age category is to talk about the fact that the elevated rates of suicide, which actually I should've put a slide in, for Inuits in Canada are 11 times the national average, but that is much higher in specific groups. It's higher in groups of young males. Young adolescent males up until mid-20s have up to a 60 times the rate of suicidal behavior compared to the rest of the Canadian population. I think we could extrapolate from that and say that those risk factors are probably highest in that group. We shouldn't exclude female youths from that either, because although the rates aren't quite as high as with males, we see a lot of attempts in female youths as well.

I don't know, Roberto do you want me to answer that anymore or do you want to move on?

Roberto Delgado:  I think that's good for now. We could maybe return to it afterwards. Thank you.

Allison C.: That question I just saw, thank you. Thanks, [inaudible 00:45:57]. It's almost like a conversation. Okay. I will move on just to talk about how Inuit knowledge ...

For healthcare providers, healthcare can be, at least in Nunavut, very siloed off from communities. We have health centers in each community and then we have healthcare is delivered by the government in the territory or is administered by government in the territory. There's a move to change this, but there hasn't always been a lot of connection, communication, collaboration between community level and how healthcare is delivered and organized. I really felt that at the community level. I was interested in specifically for healthcare. Within primary care, we have some Inuit nurses and that number is growing. We have, I know of at least two, Inuit young people who are in medical school in Canada, but those numbers are just growing. I think ultimately that's how Inuit knowledge will become part of healthcare. It will be delivered by Inuit.

In the meantime, and as we engage with communities, what are the different ways that we could inform healthcare? I'm just going to tell you about three different ways. This won't by news to most of you. Anyone who's interested in this area, these are very common methodologies. I'm going to tell you about three of our initiatives. Again, I brought this up at the beginning, how do you get that traction between working at the community level and working with Inuit knowledge all the up to health policy and then how can you balance that with the biomedical framework? Which I was trained in.

The first one that I'd like to talk about, and it was a huge learning curve for me, is cultural adaptation of research supported interventions. When you have ... just for shorthand I'll call it, biomedical. When you have a biomedical intervention that has a research base, how do you bring that and make that meaningful into a different culture or a different community context? There's quite a growing literature on this because there are two ways to do this, two broad ways. One is to work with the community and develop an initiative; the other is to take an initiative and start to try to adapt it to make it more meaningful and get feedback from the participants in the initiative or the recipients of the initiative as you go along. That was my first attempt to do this work was to take Trauma-Focused Cognitive Behavioral Therapy, which is a really mainstream intervention, and to see if and how it could be made to work in Inuit community. I knew it had to be adapted, but you can hear that's a bit of a top-down approach. It's saying, "We know this intervention works and we're going to see how we can make it work with you." It's less than ideal, but that was the first thing that we did.

We took Trauma-Focused CBT and we adapted it for Inuit men who had experienced childhood sexual abuse. There were 82 people we identified could be part of this initiative in three communities. 67 of them agreed to participate and we did the intervention over four years. We took a staged trauma treatment, which I'm trained in, and we adapted it. The mean age of the participants was 41 years of age. TF-CBT works in multiple stages, but it culminates in the creation of a trauma narrative that's meant for exposure to the traumatic incident. Participants really engaged with this. We created these narratives using ... The adaptions were very basic. We did it orally instead of written. We used caribou sinew as the timeline. We used rocks and flowers as traumatic moments and moments of strengths and resilience. The men individually dictated to us or narrated to us their life history.

What we found ... Actually, I'm going to go to the next slide first. Another adaptation was we worked with cultural mentors to ... because it was over a period of a long time. It was over four years. We also did cultural programming that the participants had input into and we worked with cultural mentors who led this programming. We did a lot of the skills parts of the cognitive behavioral therapy embedded within these activities, so on the land, tool making, drum making. That was a pretty incredible part of the program. In fact, what we found is everyone loved to participate and no one liked to do evaluation the way we envisioned evaluation, and I'm going to come back to that. We only had 19 people complete both the pre-measures and the post-measures. We had measures of post-traumatic stress disorder, which is the PCL, quality of life, and also an instrument and this opened up a lot for me. It's called the multi-ethnic identity measure. We used those three measures pre-and post, among other measures, but these are the ones I'll tell you about.

We found that symptoms of PTSD significantly decreased over the course of the intervention and quality of life improved, so things that we would want to see. Even though we only had 19 people complete the evaluation, the effects were pretty strong to get those significant values. We used the MEIM, the multi-ethnic identity measure because we thought, "Well, perhaps this early abuse prevented people from engaging with their culture in ways they otherwise might have and could we, with our on the land programming et cetera, improve that." That was a bit of the hubris of our original evaluation plan, because everyone scored extremely high in the beginning and extremely high in the end. Meaning people had a very strong sense of cultural identity. That didn't end up being an outcome measure. I'm going to move on from that, but I can answer questions about that study later on.

The other thing that we tried to do is use what's also called community-based participatory action research. A lot of qualitative engagement with people to understand the things that they wanted to see changed about either their healthcare or suicide prevention more specifically. Two projects, we've done digital storytelling with Inuit youth and that's ongoing. That's really to get youth voice about what their experiences are and what's important to their wellness, so it has a very positive framing to build on strength and resilience of youth and communities. Again, my lens is often, what can we do in primary care to bring that in? I'm going to come back to the videos in a second because I'll show you two of those stories.

We also worked with elders to ask them, and this was specifically ... This is a publication that just came out this year, and it was done by a nurse that I worked with in Cape Dorset ... talking to elders, what do they think would contribute to a well community? A lot of the focus was on suicide prevention, and also on how to address some of those colonial influences. I won't go into that in too much detail, but it's really just, albeit harder to convey, but you have the reference to the paper. They had a lot of very important things to say that are in line with what I've been talking about especially around working together and decreasing some of the silos between what happens in community and what happens in healthcare, paying attention to family connection, utilizing elders more, and including Inuit knowledge within interventions. They confirmed some of those things.

The youth, I'm going to show you two stories done by youth, and I think it gives a flavor of what youth have to say, so much richer and so different to otherwise what we might come up with on our own. Is someone going to ... Oh, here we go. The magic of the ... These youths have given permission for their videos to be shown. Oh, and I'm going to press ... Sorry, I'm going to press play. Oh, no. There we go.

Youth Video: To be an Urban Inuk is to endure a conflicting ideas of being. There's a common need for both the urban citizen and the traditional Inuk, both are fully dependent on the land which we occupy. Despite this shared dependency this man often yearns for some missing element. So, where does such an individual find his identity? No practice of sustenance, sharing of stories, or way of being was left behind. While new stories were shared and experienced, the old ones reverberated gently as to never be forgotten. To connect with these experiences, the Urban Inuk must return to the community where his family is from. The homecoming for the Urban Inuk is the most important part of his experience and marks the discovery of his true identity. What he will bring home is a thirst for knowledge. This homecoming is a celebration. A celebration with family, a celebration with the land, and a celebration of community. The homecoming is a turning point. The homecoming is where an Inuk man finds himself.

Allison C.: I think ... Oh, sorry. I just created an audio loop. Sorry about that. I will talk a bit more about both videos together. But I should've set up that this ... We're doing digital storytelling in a number of places, and these two examples are from Inuit who live in urban environments, so Montreal, Ottawa, and Toronto or communities around those and don't live in Inuit Nunangat.

Okay, and we'll just show the second video and then I'll talk a little bit about the contrast between the two.

Youth Video:  I wake up with an aching head in a numb body. Slept for 13 hours last night. My phone says it's two o'clock in the afternoon and I missed four calls. My stomach's empty, but I have desire to eat. Find comfort in the feeling of being drained. My blanket guards me like a prison warden. I ignore my texts in the same manner as I do the rest of the world. I want nothing more than to lie here passively and allow the subtle pain to devour me. The color of my skin is not what it's supposed to be. My name betrays my face, and the words that I speak don't belong to me. My shame is the only thing that's acceptable. They tell me who I am and who I can't be. They've taken everything, and they won't stop until there's nothing left. I fought against these voices for a long time. Trying to fill the void with shallow novelties. My strength has been exhausted. My resolve has been extinguished. The only choice that remains is to expend the little bit of strength I have left and relinquish. My heart strikes with every beat like I'm a worn-out drum. Boom, boom, boom, boom. Cracks in the ice. Boom, boom, boom, boom. Silent screams. Boom, boom, boom, boom. And I'm drowning.

Then I realize that I'm wrong. The rhythm in my heart isn't trying to beat me down, it's spurring me forward, driving me, pushing me in the direction that I need to go. I'm alive. I can feel the blood flowing through me. I focus on my breathing. And I reflect on things in this life that I can't choose. There are things that are beyond my control, but I alone choose how they affect me. That's my responsibility. Now I can see I'm not the only one. We're all hurting. We all suffer. We have different roots, but the feeling of pain is the same. I want to heal. I want to help others heal. I can see the monsters inside now stabbing us with fear, protecting themselves with our regret. I will fight back with hope. I'll protect myself with joy. There's a home I can see on the horizon where we live together as a family. It's not there yet, but I know it's warm and I know that it's safe. And I know that if I pick up a tool to build it, I can rely on your hands to help me.

Allison C.: I think ... Whoops, here we go. I love seeing those videos because it reminds me of just what these youths have to offer. I should also say that work was done in collaboration with REDLAB, which is a group at the University of Guelph, and it's part of mobilizing Inuit knowledge projects. What comes out for me, anyway, in those videos, and they're still being made and we're still understanding the different things that youth have to say, but the importance of land really comes out in the first video. The importance of reconnecting with that in a cultural continuity for wellness. And that you can't think about wellness in a clinic room without thinking about that larger meaning and that meaning system and that sense of connectiveness.

In the second video, we see the same thing, but we also see how that can be an internal process that that can be reconstructed internally and can still happen in an urban setting. People carry that within them as a source of strength, and that can be utilized. I mean there's so much to say about those videos, but that's one thing. We're trying to advocate for interventions that take that larger context into consideration, that occur on the land, that use Inuit knowledge, including youth, and that's one of the things that doing that community engagement can bring. Again, with my focus on healthcare, but it has lots of other applications.

I'm just going to, because I want to close in a couple of minutes and save time for questions, talk as a last intervention specifically about primary care and how some of these more exploratory things can be brought within primary care. This is an initiative and many of you in the US will know about Project ECHO, which originated at the University of New Mexico. We had worked with them to bring that model to Ontario generally. I've been involved with that in ECHO Ontario. It's now being applied to multiple medical specialties and conditions, and we have started at CAMH a First Nations, Inuit, and Metis Wellness ECHO. For people who aren't familiar with ECHO. I'm going to describe what that is, and what you see here on this slide is our logo, which we developed. One of the challenges in working in Ontario is working with multiple Indigenous communities that each have their own knowledge, values, and perspectives and really finding that we can meaningfully work together while respecting that diversity. The medicine wheel is often used to orient some of that work and some of our Inuit participants very rightly pointed out that the medicine wheel is not based on Inuit knowledge. We tried to work out this approach that looks at sacred plants and how each community, and even communities within each group, use different sacred plants as a touchstone.

I'm going to say a little bit more about ECHO. I'll show you this last video, and then describe our program. This is just the general ECHO model.

ECHO Video: Project ECHO is a performance optimizer. Think of it as a high-speed internet connection for the healthcare system. It spreads new medical knowledge throughout the healthcare system from university medical centers and other specialty care sites to the front lines of community care. Rather than information flowing in one direction, community providers learn from specialists, they learn from each other, and specialists learn from community providers as new best practices emerge. Under ECHO, community providers use video technology to participate in guided practice with specialist mentors. They acquire new skills that allow them to treat patients they otherwise would've referred out. Patients with complex chronic conditions get high-quality care where they live from providers they know. No waiting months to see a specialist. No long drives back and forth to get critical care. ECHO exponentially increases access to specialty care by moving knowledge instead of moving patients. Suffering and pain are reduced and lives are improved and even saved. Project ECHO changing the world fast. Join us at ECHO.UNM.edu. Are you part of the ECHO?

Allison C.: That's a really great introduction to what ECHO is. I think it captures many of the important elements of ECHO. I love the part at the end where it says, "Even saving lives." It sounds very heroic. It's really a method of using televideo to connect communities, and what we've done ... Oh, I'll just wait till we get rid of that video. Oh, that's actually my slide. Sorry. There we go. What we've done in using ECHO in the First Nations, Inuit, and Metis ECHO is we bring together, every week, providers who work in those communities, in First Nations, Inuit, and Metis communities, together via televideo and we do didactic presentations on topics that they have chosen as a group and we review cases. What's unique about this ECHO, we really incorporate Indigenous knowledges and providers.

On our team, it's called the hub team or the central team, we have elders from the different communities. We have Indigenous social workers. Then along with addiction medicine specialists, psychiatrists, myself, and we all meet with these different communities every week. Rather than relying on the biomedical model, we really try to integrate even in the way that we talk about cases and our approach to cases to the clients that we're working with. We try to think about how we can bring those practices and knowledges together, so best practices in psychiatry, in addiction medicine, along with Indigenous approaches that are relevant to that community and thinking about the individual in the context of their family and community. We really try to ... I brought this example forward because it's a way that, we still deliver healthcare, we're tasked to deliver healthcare, but we try to do it in a way that brings that community knowledge forward and where we can learn from each other. That's also a key part of it. All of our participants who join us each week, they bring forward a lot of knowledge that we don't have at the community level. We have Inuit groups participating on that, and we're also hoping to start this ECHO model in Nunavut as well.

I'll say one last word about evaluation because I think that's a huge need right now to develop evaluation methods that's, and Roberto mentioned this as well, we have lots of validated and standardized evaluation tools but they haven't necessarily been used in these communities. And my example of the multi-ethnic identity measure was a very good example of that. It wasn't meaningful in the context that I brought it into. I think developing evaluation is very important because it is what's going to help us to get continued funding and for initiatives to be ongoing, supported in an ongoing way. We need to create and co-create evaluation methods. It's a blank slide for now, but aspirational I think.

I just want to say one more word. This other very messy diagram is work that the Inuit Circumpolar Council is doing. I noticed Selma Ford's name on the list of participants, so that's awesome. She's at ICC, and I've been really lucky enough to work with that group. This is ... trying to think of how to summarize it. I think to move back to the policy level is also very important. How can all of this work be correlated in a meaningful way? This was the attempt that ICC was making to put the World Health Organization framework, the RISING SUN outcomes, there are other slides I won't show you them all, but where each national suicide prevention strategy. Greenland's strategy, the National Inuit Suicide Prevention Strategy in Canada, the new Sami strategy, so to put all of those alongside each other so that we can continue to create that network and share that knowledge. I think that's been a real strength of RISING SUN, and what's happening at the community level will hopefully continue to influence that work at the policy level. I will leave it there for questions.

Roberto Delgado:  Great. Thank you very much Allison. Very, very informative. Just shows the tremendous amount of work that you been putting in the last few years. Let's see. I'll start with one question. Well, there's the prep slide saying, "Those of you interested in asking Allison questions can type it in the Q & A box," and I'll manage them as best as I can. We already have one in place. I'll also make time for others to add there's. Allison, one of the participants asks: If there are no resources in my hometown and I'm not getting help for my daughter from her school, what can I do?

Allison C.: That is such an important question and so pressing for people because it can be hard to access locally. I, of course, can answer about the Canadian context and the Ontario and Nunavut context most easily. Roberto, I don't know if you have any input in the US. Like how you would normally advise at the community level.

Roberto Delgado:  Why don't you give us the examples or efforts for your communities?

Allison C.: Absolutely. We have different points of contact, and that's one of the things about creating a strategy is creating those pathways for people. I think without a strategy what happens is people go 10 different places for help and don't necessarily get referred on where they need to get referred on. That would be part of my pitch for a strategy, but on a practical level at the community I think going to a primary care provider would be one point of entry that for me would be very common, like a family doctor, a nurse practitioner, a nurse.

Roberto Delgado:  Okay. Thank you, Allison. I'll just say quickly for US-based individuals. I think it really depends on the state and the county in which you reside. My suggestion would probably also be to go to the primary care provider as an initial start.

A second question we have from a participant is asking about equal partners with the tribal community and developing enhancement in who owns the curriculum afterwards?

Allison C.: I think that's a critical question also, and one of the things I was trying to get at. In the first intervention I did, the Trauma-Focused Cognitive Behavioral Therapy, that was a real learning experience for me. I would say there's been a range of collaboration and co-collaboration, and in that instance, we did work with individuals from the community. We had cultural mentors, we had a stakeholder group that was all Inuit who were helping to shape the initiative, but it did have a bit of a top-down approach. Because I was bringing that as a best practice from a very academic context to the community level. It was multiple communities. I think that's not necessarily the best way to do it, there were some positive outcomes from that, but one of the challenges is trauma-focused CBT is owned by the group that started it in, I think, Boston. The resources don't go back to the community. [inaudible 01:15:27] providers, however, so that knowledge stays. That's one end of the spectrum.

On the other end of the spectrum, the community participatory action research that we did interviewing elders was extremely collaborative and the information is owned by the community. They were involved at all stages including analysis of the data, determining the questions we were going to ask. They really co-guided that process. I think that approach is more of an ideal. In terms of the [inaudible 01:16:03] work, that was all Inuit organizations. The Inuit Circumpolar Council and Inuit Tapiriit Kanatami, they led those processes. I just participated in those as a ... I contributed with the expertise that I have towards their effort, but it was their effort and they own it. I think there's always a continuum that when we need to-

Roberto Delgado:  Right.

Allison C.: Yeah.

Roberto Delgado:  Okay, thank you Allison. The next question asks about distinction between emotional and mental health. Could you clarify the difference? I think this was in reference to one of the last slides of the ECHO program.

Allison C.:  Yes, great question. We're still trying to figure it out. That came from our group based on an integrated care model with Indigenous communities that already existed and we adapted. I don't think there's a hard and fast distinction. What we've tended do is think of things in the more mental health and psychiatric realm under mental, and then emotional has a bit of a broader connotation. It's a good question and different people interpret those dimensions differently. What we really try to do at the end is to synthesize all of those, so to treat all of those variables as important and as interacting with each other, that you can't separate out spiritual from emotional from mental from physical. That's really the most important thing. Yeah.

Roberto Delgado:  Thank you. Next question asks you Allison: With the four-year study, you had been a part of, did you find that the activities were more helpful with the participants overcoming PTSD more than those that did not complete the project?

Allison C.:  Well, and that, unfortunately, we can't say because only 19 completed the pre and post. All of them completed the project. Now having said that, all of those 19 did not make a trauma narrative, which this was a ... I didn't really go into the intervention. There were four stages to the intervention. The first ... There were cultural components in all of them, and land-based activities in all of them, but from the TF-CBT perspective, the first three of the four all done in groups and they had to do a psychoeducation and safety was first. Then breath management and affect regulation was second. There were some cognitive approaches in the third, all of that was done in groups. Then the fourth component was to make a trauma narrative, and not all of the people, of those 19, made the trauma narrative. The cell size that were the groups were too small to really compare one with the other in terms of outcome. I think it was more of a feasibility study, not a great randomized control trial.

Roberto Delgado:  Okay. Thank you. Somewhat related question from one of my colleagues here at the NIMH asks: Have the interventions resulted in reduced rates of suicide ideation and suicide events?

Allison C.:  We didn't measure that formally. That is one of the challenges as you guys will know Roberto.

Roberto Delgado:  Sure.

Allison C.:  Even those are so high compared to the general population, they're still rare enough in a statistical sense that it's hard to track that forward. I think that's why we need evaluation over the long term with larger scale interventions happening earlier in life and really followed in the longitudinal way to assess those outcomes. What I could tell you would just be anecdotal.

Roberto Delgado:  Okay.

Allison C.:  We do know that we lost, of those men ... They had all been impacted by the same perpetrator in the communities and many were lost to suicide before the intervention even started. Throughout the years, we lost one additional person to suicide.

Roberto Delgado:  Okay. We have just a few minutes left. I want to get at least one or two more questions in. I hope we have time. Another participant thanks you for your presentation Allison, and indicates that they understand how specific the examples on suicide prevention are to the community environment; however, do you think lessons learned can be adapted to work in low and middle-income countries? Specifically, did you notice ethnic pattern in data you analyzed especially in relation to immigrants?

Allison C.:   That's a tough question.

Roberto Delgado:  Yeah.

Allison C.:  I mean I think the process is important in any group. That really without that community collaboration and without involving the communities where the interventions are happening or needed that it's not going to be meaningful and not going to get at those larger issues. When I think of those videos by those youth, if we didn't ask them that's not at all what we would be thinking about in terms of their sense of futurity and meaning. I think that applies in any context, but we didn't do analysis by ... All of the interventions I've talked about or all of the collaborations I've talked about have to do with Inuit except the ECHO. We're actually just starting to measure outcomes, but they're more outcomes of the providers who participate in the ECHO.

Roberto Delgado:  Okay, thank you. I'll just add a comment from the NIMH perspective in reference to the American Indian/Alaskan Native Hub to reduce suicide in American Indian and Alaskan Native youth. That model is actually based on collaborative hubs for mental health interventions in low and middle-income countries that our office had supported previously. And so, engaging local communities in those working with local practitioners in the communities to develop and test interventions were relatively successful and effective and allowed us to expand and bring it to the United States and Indian country. I don't see why there wouldn't be the opportunity to do the reverse exchange, whatever we learn, whatever we determine as effective with our new collaborative hubs could also inform the work that is ongoing with low and middle-income countries and mental health and suicide prevention intervention.

Okay, so with that ... Let me see. Having a little bit of slow down with my questions here. They're mostly thank yous from many of our participants, and unless you have any other closing remarks Allison. I, again, want to thank you for your presentation. I thank all the participants for joining us and I would also again remind everyone that on August 29 we will have a second mental health disparities webinar focusing on those American Indian/Alaskan Native hubs to reduce burden of suicide in American Indian and Alaskan Native youth. I see that our organizers have provided our contact for anyone interested in following up with Allison on her work with the National Inuit Suicide Prevention Strategy or with me with respect to either RISING SUN as well as information on those collaborative hubs with American Indian/Alaskan Natives youth. Thank you everyone, we look [inaudible 01:24:18] to seeing many of you again on August 29.

Allison C.:  Thank you so much everyone. Thanks Roberto for inviting me.

Roberto Delgado:  My pleasure.

Webinar Operator:  This will conclude today's program. Thanks for your participation. You may now disconnect. Have a great day.

Male:  Thank you.

NIMH Mental Health Disparities
Q&A Log
8-3-2017

Answered Questions (6)
--------------------------
1. Janet Lindow: Will the U19 for establishing research hubs be reissued, and if so, when?
* Roberto Delgado(privately): Hi, Janet: A determination has not yet been made about reissuing

2. (Deleted) Katie Cueva: Now fixed!
* Kayla Baker(privately): Hello Katie - Great!  If you have any other issues, please let us know.

3. Patricia hill: Are there any recent studies, since that is from 2012?
* Roberto Delgado(privately): Hi, Patricia - I do not believe that there have been more recent studies proposing other conceptual frameworks

4. (Deleted) Jennifer Shaw: there is no sound
* Kayla Baker(privately): Hello Jennifer - The sound will play through your computer speakers.

5. (Deleted) Jennifer Shaw: okay. I don't have computer speaker. Dialed in through the phone
* Kayla Baker(privately): Hello Jennifer - unfortunately the video audio only comes through computer speakers.  The rest of the presentation can be heard through the phone line. 

6. Marguerite Pariani: if there are no resources in my hometown and I’m not getting help for my daughter from her school what can I do
* Roberto Delgado(privately): Hi, Margurite - I'll ask this question once Allison concludes her presentation

7. * Kayla Baker(privately): Hello Tamara - I noticed your hand was raised.  Can I help in any way?

8. SRINIVASA 2: This is from the last ECHO slide
* Roberto Delgado(privately): Thanks for clarifying

9. MARIA DEL PILAR: It’s a pleasure to meet you. We´re a group of Peruvian specialists interested in Mental Healthcare
* Roberto Delgado(privately): Yo soy del Ecuador!

Open Questions (19)
--------------------------
10. Janet Lindow: Thank you. We have been looking for it.
11. (Deleted) Katie Cueva: Perhaps it's just me, but I can't see a model - I just have a blank white screen.
12. (Deleted) teers Peterson: yes
13. (Deleted) Claudia Montoya: yes
14. Janet Lindow: Do any protective factors vary based on age group?
15. Janet Lindow: Thank you
16. (Deleted) Jennifer Shaw: okay thanks.
17. Margurite Pariani: thank you
18. Stan: Are you equal partners with the Tribal community in developing cultural enhancements and who owns the curriculum after?

19. SRINIVASA 2: You have made a distinction between emotional health and mental health-could you clarify the difference? Thank you

20. AmandaW.: With the four-year study you had been a part of, did you find that the activities were more helpful with the participants overcoming PTSD more than those that did not complete the project?

21. Tamara Lewis Johnson: Have the interventions resulted in reduced rates of suicide ideation and suicide events?

22. SRINIVASA 2: It is mental wellness and emotional wellness. Thank you.

23. Ikenna: Thank you Allison for the presentation. I understand how specific the examples on suicide prevention are to the Canadian environment. However, do you think lessons learnt can be adapted to work in LMICS? Did you notice any ethnic pattern in the data you analyzed (especially in relation to immigrants?)

24. Margurite Pariani: my daughter has an IEP but the team isn't listening to what is wrong

25. SRINIVASA 2: Thank you for the clarification.

27. Margurite Pariani: my daughter has ADHD with a learning disability she may be 12 but her brain is at age 5 I tried everything she isn’t able to follow along or read or do regular stuff like a normal 12 can and they are putting her in 7th grade with regular kids how can I put her in a special school? I am tired of my daughter getting bullied and I’m afraid it is going to be worse and I want her to be ok and get the help she needs

28. Stan: Thanks. I am trying to partner with Washington state Tribes and develop cultural enhancements to the CBT program Aggression Replacement Training

29. ANDREA HORVATH MARQUES: Roberto I sent you the NIMH website call too free National suicide prevention lifeline NSPL at 1800-273 -8255 24 hs 30. Catherine Roca: Thanks for this interesting presentation!

31. Margurite Pariani: the IEP team isn't listening or seeing the whole big picture and there are no advocates here what can I do

32. Tamara Lewis Johnson: Thank you. It was a thought provoking presentation.