Culturally informed gatekeeper training for youth suicide prevention in Guyana: A pilot examination

Abstract

Adolescent suicide is a pressing concern in Guyana, a low-to middle-income country in South America with the highest adolescent suicide rate globally. Gatekeeper trainings for suicide prevention conducted in high-income countries have been found to increase knowledge of suicide prevention, increase referrals of at-risk youth, and reduce stigma toward help-seeking for suicidality. The current study sought to engage in a pilot examination of the effectiveness, acceptability, and feasibility of a culturally informed gatekeeper training suicide prevention program for Guyanese youth. Secondary school teachers and staff (N = 16) were trained in a culturally informed, evidence-based gatekeeper suicide prevention program. Mixed methods analyses revealed significant increases in knowledge of suicide prevention, as well as decreases in rigid or judgmental attitudes toward suicide post-training among secondary school teachers and staff. Further, results indicated that participants deemed the program culturally acceptable and feasible for use in the school setting. Findings have implications for the delivery and implementation of culturally informed gatekeeper training programs for suicide prevention in low-to middle-income countries.

Keywords

adolescent Guyana prevention schools suicide

Introduction

Adolescent suicide is a problem worldwide (Wasserman, Cheng, & Jiang, 2005). Globally, suicide is the second leading cause of death for people aged 15–29 (Wasserman et al., 2005; World Health Organization (WHO), 2018). Guyana, a low- to middle-income country (LMIC) in South America considered to be part of the Caribbean, leads the world in suicide rates among adolescents, with suicide being the leading cause of death for individuals ages 15–24 (WHO, 2014). Rates of completed suicides are particularly high among Guyanese adolescents of East Indian descent (Guyana Ministry of Health, 2006) and youth in rural areas (Graafsma, Kerkhof, Gibson, Badloe, & van de Beek, 2006).

Youth in LMICs often have limited access to mental health services (Bachmann, 2018). High financial burden related to low family income, higher incidence of bankruptcy, and lower value of family assets further contribute to the inaccessibility of mental health services in LMICs even when available (Bantjes et al., 2016). Within Guyana, mental health services have been determined to be inaccessible and insufficient in number to meet the population’s needs (WHO, 2014). Specifically, no inpatient or outpatient psychiatric services reserved for children or adolescents exist, and only 4% of individuals treated in psychiatric facilities are children or adolescents (WHO, 2014). Therefore, non-health professionals, such as teachers, community/religious leaders, traditional healers, and nongovernment organizations, have been underscored as critical in the delivery of sustainable mental health services for children and adolescents in Guyana (Arora & Persaud, 2019). Thus, mental health services that address adolescent suicide among Guyanese youth are urgently needed.

School-based suicide prevention

Schools have been found to be viable settings for increasing children’s and adolescents’ access to mental health services globally (Arora, Nastasi, & Leff, 2017). Children and adolescents spend most of their time during the day in school, allowing interventions to be interwoven into their schedule (Catron, Harris, & Weiss, 1998). Furthermore, school-based interventions have been found to be effective in reducing symptomology of psychopathology, including depression (Arora et al., 2019) and suicide (Singer, Erbacher, & Rosen, 2019).

School-based suicide prevention programs fall into five categories: screenings, awareness and education, skills trainings, peer leadership trainings, and gatekeeper trainings (Katz et al., 2013). Gatekeeper trainings in suicide prevention, which aim to equip stakeholders (e.g., teachers, students, school staff) with skills in recognizing signs of suicide and how to respond effectively to at-risk youth (Katz et al., 2013), may be particularly promising for use in Guyana. Among parents and youth, the school system is an established trustworthy system (Arora & Persaud, 2019). Further, as such programs may serve to reinforce existing social support systems in communities thus leading to more permanent institutional change (Isaac et al., 2009), they present an appealing and potentially sustainable solution in Guyana, where long-term and permanent systems-based outreach is needed to address adolescent suicide.

Research on gatekeeper training programs has primarily been in high-income countries (i.e., U.S. and Europe; Katz et al., 2013; Mann et al., 2005). These studies have supported the use of such programs, particularly the Question Persuade Refer program (QPR; Quinnett, 2011), demonstrating positive effects of QPR on gatekeeper attitudes and knowledge of suicide prevention (Cross, Matthieu, Cerel, & Knox, 2007), referrals of at-risk youth (Condron, Susanne et al., 2015), and crisis intervention skills (Romeo, 2015) among school stakeholders. One examination of QPR conducted with adults in a Polynesian Maori community in New Zealand demonstrated effectiveness in increasing knowledge about suicide, mental health referral, and suicide crisis intervention skills (McClintock et al., 2017). However, no studies to date have examined QPR in a school-based setting in a LMIC, nor in a school-based setting outside of the U.S. and Europe.

Culturally informed mental health interventions

It is unclear how effective suicide prevention programs developed in the U.S. and Europe may be at preventing suicide among diverse youth in international settings, as it has been found that risk and protective factors for suicidality differ across sociocultural contexts (O’Connor & Pirkis, 2016). Cultural adaptations to mental health interventions, which increase their cultural acceptability, may improve utilization, retention, and outcomes among individuals from historically disadvantaged and/or non-European backgrounds (Arora et al., 2017).

Although research on culturally informed, school-based interventions for suicide prevention in LMICs is lacking, research does support gatekeeper trainings, and more broadly, school-based mental health services. Culturally informed gatekeeper trainings in mental health programming in LMICs similar to Guyana have shown effectiveness in increasing teachers’ knowledge of common child mental health issues, increasing teacher awareness of signs of symptoms of mental illness, improving teacher skills in behavioral management, and reducing teachers’ stigma towards mental health help-seeking (Hussein & Vostanis, 2013; Pereira et al., 2012; Vieira, Gadelha, Moriyama, Bressan, & Bordin, 2014).

Studies on culturally informed interventions specifically targeting suicide prevention for youth are limited. In the Aboriginal community of Victoria, Australia, researchers in collaboration with community healthcare workers developed a culturally informed skills training suicide prevention program for at-risk Aboriginal youth that demonstrated effectiveness in increasing early identification and referral of suicidal individuals, as well as in increasing mental health support for the community after a suicide (Isaacs & Sutton, 2016). However, this study took place in a community healthcare setting, not in a school. Further, the program was specifically designed for use with Aboriginal people in Australia, and the cultural practices integrated may not be relevant for those outside of this specific cultural context.

Similarly, in the QPR trial within the Polynesian Maori community, cultural adaptations included changing the language related to healing after suicide to include cultural concepts, which demonstrated effectiveness in helping participants to recognize cues to suicidality, improve effective listening and communication with people at risk for committing suicide, increase referral to healthcare workers, and establish community-based suicide prevention groups (McClintock et al., 2017). However, this study did not specifically target school stakeholders or youth specifically.

Current study

With the broader goal of addressing suicide prevention among Guyanese adolescents, the current study aimed to examine effectiveness, acceptability, and feasibility of a school-based, culturally informed suicide prevention program for Guyanese youth. Based on cultural adaptations made to the program, we anticipated that the program would increase stakeholders’ knowledge of suicide prevention and positive attitudes toward suicidal individuals and suicide prevention post-treatment. Further, we predicted that participants would rate the content of the intervention to be acceptable and that the intervention would be feasible to implement.

Methods

Setting

Guyana is a Caribbean country located on the northern coast of South America. Guyana’s population is made up of people of East Indian (n = 39.8%), African (n = 29.3%), multiracial (n = 19.9%), and Amerindian (n = 10.5%) descent, with a small population of people of other ethnicities (e.g., Chinese, European; n = 0.5%) (Guyana Bureau of Statistics, 2019). Specifically, East Indian people, the descendants of indentured laborers from the Indian subcontinent, make up the largest ethnic group in Guyana, followed by Afro-Guyanese people, the descendants of enslaved people from Africa. Amerindian (precolonial indigenous) communities include Arawaks and Caribs, amongst other groups (Guyana Bureau of Statistics, 2019). While Guyana has had a history of a number of European colonial conquests, the British Empire had the most pervasive rule across the country, with deep cultural and systemic impacts up to today in terms of racial tensions between Afro-Guyanese and Indo-Guyanese groups, parliamentary structure, cultural norms, and education systems (Hinds, 2011).

This study took place at a private secondary school in a rural area of Guyana with which the researchers had developed a partnership. The school attracts youth from various socioeconomic strata in Guyana, including many adolescents who reside in local orphanages. The student body of 459 students is largely of East Indian descent (i.e., ethnically from the Indian subcontinent), though there are also students of African, Amerindian (i.e., Indigenous), and multiethnic/racial descent. For the purposes of this study, the research team decided to include only stakeholders (i.e., teachers, staff) and not students. Specifically, due to the pressing nature of the concerns of youth suicide in Guyana, it was determined that training teachers would provide a more sustainable option in terms of increasing the school’s capacity to meet the students’ needs.

Participants

Participants included stakeholders (i.e., teachers, staff) affiliated with the secondary school. All stakeholders (N = 16; 68.8% female, 31.2% male) identified as East Indian and endorsed English as their first language. The 25–34 age range was the most common (n = 7, 43.8%; see Table 1). A subset of participants (n = 7; 18–34 years old; 71.5% female, 28.5% male) were interviewed individually after completion of each training session. All interviewed participants were teachers (n = 7, 100%).

Table 1.

Stakeholder demographics (n = 16).

	n	%
Gender
Male	5	31.2
Female	11	68.8
Age
18–21	4	25
21–24	5	31.2
25–34	7	43.8
Ethnicity
East Indian	16	100
First language
English	16	100
Role in school
Teachers	12	75
Administrators	3	19
Other school staff	1	6.3
Years employed in school
1 year or less	1	6.3
1–2 years	4	25
3–5 years	5	31.2
5–10 years	5	31.2
10 years or more	1	6.3

Procedures

Needs assessment

Prior to the beginning of the current study, a needs assessment was conducted at the partner school in Guyana to determine ways to support school-based suicide prevention efforts (Arora & Persaud, 2019; Arora, Persaud, & Parr, 2019). Participants of the needs assessment included adult stakeholders in the school community (i.e., teachers, administrative staff, school-allied community workers such as afterschool activities instructors), and secondary school students. Specifically, three (n = 3) focus groups were conducted with seventeen (n = 17) total adult stakeholders in groups of five to eight adult stakeholders per focus group. Individual interviews were conducted with forty (n = 40) students 12–17 years in age. Focus groups and interviews were audio recorded with parental consent (and assent of students).

Focus group and interviews queried participants’ views on whether or not suicide is a problem in their community; risk and protective factors for suicidality; help-seeking behaviors; the school’s role in suicide prevention; and, the school’s needs in terms of suicide prevention. Interviews and focus groups were audio recorded and recordings were transcribed by members of the research team. Data were analyzed via a grounded theory approach (Charmaz, 2006). Several themes were uncovered, including perceived risk factors and protective factors of suicidality among Guyanese youth (Arora, Persaud, & Parr, 2019); perceptions of barriers to mental health help-seeking; and recommendations for adolescent suicide prevention in Guyana (Arora & Persaud, 2019). Overall, the input from stakeholders and students highlighted the need for suicide prevention interventions targeted at Guyanese youth, and the ways in which these needs could be met by school-based services.

Current study

Following written confirmation of the secondary school principal’s support for the study, approval was obtained from the first author’s university IRB. Research team members were both American nationals of Indo-Guyanese descent, and included one psychology doctoral student and one research scientist. To recruit participants, first the principal introduced the study to stakeholders at a faculty and staff meeting. A study flyer developed by the researchers, which contained a brief description of the gatekeeper training, participation criteria (i.e., must be teacher, administrative staff, or school-allied community worker at school; must be willing to participate in group suicide prevention training during dates and times provided), information on whom they could speak to about the study, and the researchers’ contact information, was then disseminated. Once researchers arrived in Guyana, they provided stakeholders with additional details and allowed for potential participants to ask questions at a faculty and staff meeting. At the meeting with researchers, participants signed up for their preferred time during common nonteaching hours.

Subsequent to providing consent, each participant engaged in the suicide prevention training, which consisted of one approximately 2-h session. Five training groups (n = 5) were conducted over the course of one week, ranging in size from two to four participants and from 93 to 135 minutes (M = 120 min). Groups ranged in length based on questions from participants and discussions elicited by topics during the training sessions; however, standardized training content remained the same across all sessions. Participants were grouped based on scheduling preferences. One research team member, who received certification from the QPR Institute prior to conducting research in Guyana, acted as instructor of the suicide prevention trainings, while the other researcher completed treatment adherence checklists and assisted participants as the trainings were in session.

Immediately prior to beginning the training session, demographic information and pretreatment measures were collected. During the sessions, researchers recorded fidelity, assessing the instructor’s adherence to the content and session attendance. Immediately after the session, participants completed posttreatment measures. Six participants (n = 6) were selected via convenience sampling based on their availability at the end of the session(s) to participate in semi-structured interviews. Individual interviews provided an opportunity for these participants to thoroughly share their thoughts in a more private manner.

Intervention

Participants were trained in the QPR suicide prevention program (Quinnett, 2011). QPR is characterized as a gatekeeper training, which teaches community stakeholders such as teachers, parents, and other community workers how to recognize the signs of suicide, deliver mental health interventions, and refer people at-risk for dying by suicide to a mental health worker (Quinnett, 2011). QPR has demonstrated effectiveness in increasing participants’ knowledge about suicide prevention and self-efficacy in referral and prevention skills in school-based settings (Katz et al., 2013). Further, cultural adaptations of QPR have shown effectiveness with gatekeepers in LMICs (McClintock et al., 2017). The Suicide Prevention Resource Center (SPRC) lists QPR in their Best Practices Registry as a “program with evidence of effectiveness” (2017). QPR is also listed in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP) (Substance Abuse and Mental Health Services Administration (SAMHSA), 2018).

The QPR training consists of a basic orientation to suicide prevention and the role of gatekeepers and different community groups in suicide prevention (Quinnett, 2011). The QPR acronym refers to the central intervention technique of the training, namely: how to ask the suicide question with examples of specific phraseology and anticipated results; how to persuade a suicidal person to accept help (active listening skills, focus on problem(s), requests for life-saving action); and, how to refer a suicidal person to local/national resources (accompanied referral, names, numbers, addresses).

The training is delivered by a certified QPR instructor, and includes didactic/lecture-based, discussion, and role play/pragmatic components (Quinnett, 2011). The basic learning module is 90 min long, and instructors have the option to integrate additional modules that place more emphasis on certain aspects of suicide prevention (e.g., risk assessment for emergency medical personnel), which may extend the training duration up to 8 hours. Trainers are instructed to emphasize ways to question at-risk individuals about a desire to commit suicide in culturally relevant ways, and to be mindful of taboos around speaking about suicide.

QPR encourages cultural adaptation to increase its relevancy to the target population, as long as the basic modules remain intact (Quinnett, 2011). Based on the pilot study needs assessment (Arora & Persaud, 2019; Arora et al., 2019) and previous cultural adaptations made to QPR (McClintock et al., 2017), several adaptations were made to the content of the QPR curriculum to meet specific cultural needs of stakeholder groups in Guyana. Specifically, additional content on culture-specific risk factors for, behavioral cues of, and myths about suicide (e.g., that suicide may allow individuals to reincarnate and seek revenge on others) was added to the training. Further, as the pilot study emphasized the need to teach emotion validation skills, especially as they relate to parent–child communication, modules on emotional validation skills and interpersonal effectiveness were added (Arora & Persaud, 2019). This included content on how to speak to students in emotionally validating (i.e., encouraging, friendly, trustworthy) ways, thereby reducing judgmental and admonishing behavior. For example, participants were taught ways to build rapport, such as by speaking in language that may be more accessible to students (i.e., colloquialisms), while still respecting cultural views on appropriate communication styles between adults and youth (e.g., not divulging too many personal details from adults to youth, retaining use of honorifics and titles such as the respectful “-ji” suffix). Finally, considering the relevance of religion and spirituality as both a risk and protective factor for youth suicidality (Arora et al., 2019), a guided discussion on the topic with participants was included (e.g., how people may feel judged for not being religious enough, which may contribute to suicide risk; the role of social support in faith institutions as protective against suicide).

Measures

Demographics

Participants reported their age, race, gender, number of years working in the school, language(s) spoken, and, position (teacher, administration, other school staff).

Attitudes toward suicide (ATTS)

The ATTS (Renberg & Jacobsson, 2003) was used to measure ATTS. The second and most recent version includes 37 items that assess respondent attitudes toward 10 different factors, rated on a five-point scale from 0 (“strongly disagree”) to 4 (“strongly agree”). Responses are summed to reveal a total score, with higher scores (112–185) indicating more rigid attitudes toward suicide and lower scores (37–111) indicating more permissive and understanding attitudes toward suicide. Internal reliability estimate for this study was α = .56 after removing one item that was negatively impacting internal reliability (i.e., the first item on the measure). This is similar to the internal reliability found in past studies (α = .60) (Renberg & Jacobsson, 2003). For this study, language was revised in this measure for cultural relevancy (i.e., American idiom, “feeling blue,” changed to “feeling sad”).

QPR Gatekeeper Knowledge of Suicide Questionnaire

The QPR Gatekeeper Knowledge of Suicide Questionnaire (Quinnett, 2011) was used to measure knowledge of suicide/suicide prevention. The measure includes 14 items that assess participant knowledge of suicide prevention, including the definition of suicide; risk factors for suicide; causes of suicide; signs of suicide; basic counseling skills; and other intervention methods for working with youth who are at-risk for suicide. Items are either multiple choice (n = 11) or true and false (n = 3). Correct responses are summed, with higher scores indicating greater knowledge. One item was removed for this study, as it pertained to U.S. suicide statistics and was not relevant to the study population. Additionally, language was revised to make the measure more culturally relevant for participants. For example, in one item that asks respondents to choose the best response to someone expressing suicidality, the multiple choice answer, “Warn the person that they will go to Hell” was changed to, “Warn the person that their soul will suffer” to reflect theological beliefs of the majority of participants. Given the nature of this measure (i.e., an assessment of different aspects of suicide-related knowledge, with only one right answer out of four possible choices), the authors of this study have not calculated the internal reliability of this measure. This measure performs similarly to an index which sums the amount of knowledge that one has; therefore, it is not necessarily expected that if a respondent knows one topic about suicide prevention, that they must necessarily know the others. For this reason, past studies have not reported internal reliability of this measure (Mitchell, Kader, Darrow, Haggerty, & Keating, 2013; Quinnett, 2011).

Suicide Prevention Program Rating Profile (SPPRP)

The SPPRP was used to measure acceptability of suicide prevention programs (Eckert, Miller, DuPaul, & Riley-Tillman, 2003; Miller, Eckert, DuPaul, & White, 1999). The scale includes 11-items. For this study, three items (i.e., 9, 10, 12) were removed, as they were not applicable to the current study (i.e., they were for student participants, which there were none of in this study). Responses to statements about the acceptability of the intervention (e.g., “Most teachers and school staff would find this suicide prevention program appropriate”) are rated on a 6-point scale from 1 (“Strongly Disagree”) to 6 (“Strongly Agree”). Responses are summed, with higher scores indicating greater acceptability. The SPPRP has demonstrated excellent internal reliability (α = .95–.97), and demonstrated internal reliability of α = .88 in the current study.

Semi-structured interviews

Semi-structured interviews probed participants’ views on the training acceptability. Specifically, participants were asked which aspects of the training they found most and least helpful.

Fidelity

Treatment adherence checklists were used to assess whether the intervention content was delivered as intended. Checklists of every intervention topic or activity (e.g., “Discuss how to persuade someone to seek help for suicidal ideation,” “Active behavioral rehearsal of QPR skills in role-play situation”), with a total of 22 items (n = 22), were completed by a researcher, who observed each training session and rated the content delivery of each topic on a scale from 0 (“Not covered at all”) to 3 (“Group leaders covered the topic thoroughly, integrating it into the larger context of the intervention and in an interactive style”).

Attendance and recruitment capability

Participants’ expected attendance was recorded during an initial recruitment meeting during which participants signed up for the study. Participants’ actual attendance was recorded by researchers. Recruitment capability was calculated by dividing actual number of participants in attendance by the anticipated number of participants (as per the sign-up sheet in the initial informational meeting) (Orsmond & Cohn, 2015).

Data analysis

To assess program effectiveness, the QPR Gatekeeper Knowledge of Suicide questionnaire and the ATTS were completed immediately before and after the training session. These data were analyzed with a one-way repeated measures analysis of variance (ANOVA) to test if there were significant increases in knowledge and decreases in rigidity of attitudes toward suicide from pre- to posttest.

To assess program acceptability, a one sample T-test compares the mean acceptability score from the SPPRP to those from existing trials of school-based suicide prevention programs (Eckert et al., 2003; Miller et al., 1999). Acceptability was also assessed qualitatively via individual interviews with a subgroup of participants. Participants’ responses to interview prompts (i.e., which parts of the training participants found most and least helpful) were transcribed verbatim by researchers during interview sessions. All transcripts were de-identified to protect participant confidentiality. Interview data were analyzed using inductive content analysis (Elo & Kyngäs, 2008). This consisted of an initial open coding phase, followed by higher order categorical grouping, and finally, abstracting further upon these categories to form general thematic descriptions.

Program feasibility was measured by descriptive statistics with respect to fidelity (as recorded by research assistants on treatment adherence checklists) and recruitment capability. Treatment content delivery between sessions of 72–92% has been found to indicate acceptable treatment fidelity (e.g., Leff et al., 2009; Lyon et al., 2015). Recruitment capability was evaluated by comparing actual versus anticipated attendance (Orsmond & Cohn, 2015). Recruitment capability of 50% or higher has been found to indicate feasibility (Hagen, Biondo, Brasher, & Stiles, 2011; Orsmond & Cohn, 2015).

Results

Effectiveness

Two one-way repeated measures ANOVAs were conducted to test the effect of time (pre- versus posttest) on knowledge of suicide prevention and on ATTS separately. There was a significant effect of time on knowledge, Wilks’ λ = .342, F(1, 15), p < .001, partial η²= .66, with increases in knowledge of suicide prevention from pretest (M = 8.06, standard deviation [SD] = 1.53) and to posttest (M = 10.56, SD = 1.90). The effect of time on attitudes was also significant, Wilks’ λ = .748, F(1, 15), p = .040, partial η²= .252, with decreases in rigid and judgmental attitudes toward suicide from pretest (M = 63.50, SD = 6.14) to posttest (M = 58.69, SD = 9.79).

Acceptability

A one-sample T-test compared the mean acceptability score on the SPPRP in the current study to the mean acceptability score on the SPPRP in comparison studies (Eckert et al., 2003; Miller et al., 1999). Stakeholders in the current study had significantly higher acceptability scores (M = 63.38, SD = 4.16) than those in the Eckert et al. (2003) study (M = 38.11, SD = 9.84), t(21) = 3.00, p < .001, as well as those in the Miller et al. (1999) study (M = 46.69, SD = 7.83), t(61) = 1.20, p < .001.

Content analysis of participant interviews regarding acceptability of the training revealed content that participants found to be the most helpful. Themes are presented in descending order of frequency of participant endorsement. With regards to content, information on how to recognize signs of depression and other adolescent mental health concerns (n = 4), how to approach at-risk students about suicidality (n = 4), and how to communicate in emotionally validating ways (n = 4) were noted to be the most helpful. Other helpful aspects of the content endorsed by at least one participant were information on how to retain confidentiality, how to discuss the role of religion as a risk or protective factor for suicide, and how to speak to administration and parents about students’ mental health concerns. In terms of approach to the training and delivery, participants indicated that language used in materials, the easy-to-use QPR acronym, and role-playing exercises were the most helpful. Although participants were also asked which parts of the training they found to be least helpful, no feedback was provided in this regard.

Feasibility

The content delivery for the present study ranged from 92% to 100% across sessions, with a mean treatment content delivery of 96.75%, providing support for intervention feasibility. Training feasibility was also examined by recruitment capability. Twenty-one participants signed up for and were expected to attend the training sessions. Of those, 16 attended (76%), which falls within the range of attendance rates that indicate feasibility in comparison studies (i.e., above 50%) (Hagen et al., 2011; Orsmond & Cohn, 2015).

Discussion

This study assessed effectiveness, acceptability, and feasibility of a culturally informed school-based suicide prevention gatekeeper training at a secondary school in Guyana. This is the first study to our knowledge to investigate use of a suicide prevention gatekeeper training in a school setting in Guyana, as well as in any LMIC in general. Study results are consistent with previous studies finding changes in participants’ suicide prevention knowledge (e.g., Reis & Cornell, 2008; Wyman et al., 2008) and attitudes following suicide prevention training (e.g., Aseltine & DeMartino, 2004). Further, current findings underscore the potential benefits of culturally-adapted gatekeeper suicide prevention trainings in LMICs in particular.

Although there was an increase in positive, flexible, nonjudgmental attitudes toward suicide, this difference was not as great as the increase in suicide prevention knowledge. This is likely because participants already started with more flexible beliefs about suicide (i.e., scoring lower on the ATTS), suggesting a group with more rigid beliefs may have been more influenced in this area. While the low internal reliability of the ATTS in this study (α = .56) suggests limited generalizability of these results, past research with similar low internal reliability estimates (Adjaottor & Ahorsu, 2015; Renberg & Jacobsson, 2003) has suggested that this may be related to the wide variety of attitudes towards suicide that this instrument measures. Future studies may consider the use of alternate measures to assess changes in ATTSs.

Findings supported acceptability and feasibility of this training in this setting. As hypothesized, participants rated the intervention to be more acceptable than in comparison studies (Eckert et al., 2003; Miller et al., 1999). However, the suicide prevention gatekeeper trainings used in these studies did not employ additional cultural adaptations (as in the current study), as their trainings were already culturally appropriate for their setting. Therefore, our findings reflect comparable acceptability in relation to the comparison studies. These findings may reflect that this study integrated feedback from community members in developing a culturally informed gatekeeper training program. Findings support the use of cultural adaptations to suicide prevention training programs by integrating stakeholder input during development (Arora et al., 2017). Mean content delivery was 96.75%, which supports the feasibility of implementing this intervention in one session for this population. Further, feasibility was supported by the attendance retention rate of 76%, which provides support for the methods designed to retain participant attendance in this study; namely, recruiting participants during a faculty meeting, collaborating with teachers and staff to fit the training into natural gaps in teaching schedules, providing multiple sessions that teachers could sign up for over a week, and providing the training within one session.

Limitations and future directions

Participants were recruited from only one school, which was private and in a rural region. Additionally, participants in the study were primarily school teachers and staff with fewer years of experience (i.e., less than 10 years at the school), young (i.e., under 34 years of age), and of East Indian descent. Thus, results may not be generalizable to the larger Guyanese educational community. Future studies should examine the training among a larger group of more diverse teachers and school staff in various regions of Guyana, as well as with extracurricular activity leaders, other individuals who may have regular contact with youth, and with students themselves. Further, no control group was included, and posttest measures were administered directly after the training. Future research should include a control group and assess the impact of the intervention on other variables besides knowledge and attitudes (e.g., behavior) at later intervals (e.g., one month, three months).

Finally, the researchers who conducted this study were American nationals of Indo-Guyanese descent, which may have made them more relatable and comfortable with meeting cultural etiquette of the community. The researchers conducted this study after having built positive relationships with school stakeholders in the U.S. and Guyana, as well as leveraging family ties in the region to connect and network with local community members. However, as noted above, participants did not provide feedback on least helpful parts of the intervention, which could be related to cultural values that dissuade individuals from giving negative feedback to visitors (e.g., the researchers, who were guests from outside of the country). Future efforts might include an anonymous measure of acceptability or have another individual outside of the researchers delivering the intervention conduct the interviews (e.g., local community member with whom the participants are comfortable).

Implications

The current study provides initial evidence for nascent efforts toward school-based suicide prevention in Guyana. Findings suggest that training teachers and other school staff who regularly interface with youth at-risk for suicide in Guyana may be a beneficial way to engage in suicide prevention efforts. Globally, this study also provides evidence for use of school-based suicide prevention interventions to meet needs of at-risk youth in under-resourced settings, including in LMICs. This study builds on existing efforts involving nonmental health workers, such as community leaders and laypeople concerned with youth mental health, in suicide prevention in places where mental health resources are limited. However, future research is needed to test the generalizability of results as well as to create appropriate cultural adaptations in other places around the world.

Findings also underscore the prospective importance of considering cultural context when implementing interventions. Incorporating needs expressed by stakeholders into intervention design provided additional support for the culturally informed adaptation of mental health programming (Arora et al., 2017). Future suicide prevention programming implemented in Guyana and LMICs generally should seek to integrate stakeholder feedback in the intervention development and implementation process. More broadly, the role of school stakeholders in promoting youth mental health may be improved through reform in teacher education (i.e., at the university level) and by extending the goals of national education curriculum to include student socioemotional development (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011).

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Sarika Persaud, PsyD, is a Psychologist and Coordinator of Diversity, Inclusion, and Social Justice Initiatives Counseling and Psychological Services at Fordham University, New York City. Her research interests include the development of culturally-responsive and accessible mental health services for Indo-Caribbean and South Asian youth.

Lisa Rosenthal, PhD, is an Assistant Professor in the Psychology Department at Pace University, New York City. Her research focuses on intersectional stigma and social justice, including seeking to understand how experiences with different forms of prejudice, discrimination, stereotyping, marginalization, and inequality contribute to gender, racial/ethnic, and other health disparities.

Prerna G. Arora, PhD, is an Assistant Professor of Psychology and Education in the School Psychology program at Teachers College, Columbia University. Dr. Arora's research focuses on issues of access to school-based, culturally-informed, mental health services for ethnic minority and immigrant-origin youth and families.

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