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Social, Cultural, and Economic Determinants Related to Suicide, Panel 2

Evelyn Lewis moderated the second panel of the virtual first session, which focused on special populations within the veteran population. Nathanial Mohatt (Department of Veterans Affairs) reviewed some of the evidence on rural social determinants of health and risk factors that are related to suicide both in the general population and among veterans in particular. Pamela End of Horn (Indian Health Service [IHS] Headquarters) discussed morbidity and mortality of American Indian and Alaska Native (Native) populations and how that is correlated to native veterans. Claire Hoffmire (Department of Veterans Affairs, University of Colorado School of Medicine) addressed social determinants of health and risk factors as related to suicide rates among women veterans.

VETERANS IN RURAL AREAS

Rates of suicide are much higher in rural communities of the United States than in urban ones, Nathaniel Mohatt told the group. As a rule, the rural classification includes a range from any town with 50,000 people or fewer to open, empty spaces. He explained that rural in the United States

includes 97 percent of U.S. land, 18 percent of the population, and 24 percent of veterans specifically. There is also a great deal of diversity to be found in these rural areas, Mohatt said. Rural communities are not only diverse in terms of population density, but areas with economic, cultural, and educational diversity. While rural economies were historically primarily agricultural, with 40 percent of jobs in that sector 100 years ago, at present less than 1 percent of rural jobs are in agriculture and rural economies are more reliant on other sectors like “retail, tourism and outdoor recreation, health care, and education,” said Mohatt. Culturally, rural areas are often thought of as being primarily White; while there is a higher proportion of White people living in rural communities than in urban ones, he noted, cultural diversity is growing, particularly in the Hispanic/Latinx community. Mohatt also noted a general assumption that people in rural communities have less education than their urban counterparts; while people in rural areas do “on the whole have lower educational attainment,” this does not mean that “rural people are uneducated or unaware of what’s going on in the world, or unable to think deeply about life.”

Mohatt then discussed three factors within the social determinants of health in rural areas that account for at least some of the disparity between rural and urban suicide rates: poverty, poor access to health care, and geographic isolation. Of poverty, he noted that not only do rural areas have relatively high poverty rates, but also, a higher proportion of rural counties are at the worst level of deprivation compared with urban counties. Access to health care is another challenging area; 65 percent of rural counties are designated as health care workforce shortage areas, with very few specialty providers. This means that people living in rural areas are less likely to receive needed treatment for mental health and substance use. As such, rural residents “have a higher disease burden,” explained Mohatt, “so the mental illness that they’re experiencing . . . lead[s] to greater burden or greater problems from the same levels of diagnoses that exist in urban areas.” Finally, he noted, geographic isolation in rural communities can lead to greater social isolation, which disproportionately impacts vulnerable populations. One such population is older adults who can no longer drive; similarly, people with disabilities and people with mental illness challenges can “become increasingly more socially isolated.”

Suicide rates are increasing more quickly in rural areas than urban communities, Mohatt said, and “this disparity has been widening over the past 30 years.” Rural veterans have a 14 percent to 20 percent increased risk of death by suicide compared with urban veterans, he said. Mohatt noted that breaking this number down by race and ethnicity reveals several reasons for the disparity between rural and urban rates of suicide. The first is that “growth in suicide among Hispanic Americans in rural communities has grown faster” than rates of suicide for Hispanic Americans in urban

areas. This disparity between urban and rural areas is not evident in data on rates of suicide among Black and White populations, Mohatt observed. The second reason for the higher rates of suicide in rural areas seen when breaking data down by race and ethnicity is that there are more rural White veterans than urban White veterans, proportional to other races. Non-Hispanic Whites and non-Hispanic Natives had the “highest suicide rates across all three urbanization levels, with both groups experiencing greater increases compared with non-Hispanic blacks, non-Hispanic Asian/Pacific Islanders, and Hispanics across the study period” (Ivey-Stephenson et al., 2017). The third is that a much higher proportion of Native American veterans live in rural areas than urban communities, compared with other races, and this population is the highest risk racial group with the highest suicide rates. These trends all contribute to the disparity between rural and urban rates of suicide among veterans: higher proportions of White and Native American veterans, and a faster rate among rural Hispanic veterans.

Mohatt noted that while understanding risks for suicide among rural White populations is an important part of “understanding rural suicide in the United States,” attributing higher suicide rates in rural America to a proportionately higher White population in those areas is oversimplifying the problem and “doesn’t help us understand why there are higher suicide rates in rural places where there aren’t White Americans with guns.” Rates of suicide are higher in rural communities not just in the United States but internationally; international literature can help identify factors beyond race that contribute to this disparity between rural and urban suicide rates, he said. Factors cited by international literature on rural rates of suicide include geographic isolation and lack of access to services—in themselves factors as discussed above—which can contribute to cultural factors like stigma toward mental illness, stoicism, and self-reliance. Economic factors include the impact of natural disasters on agricultural areas and the impacts of economic downturn on the farming sector. Environmental factors include lethal means, said Mohatt; while firearms are used more frequently in rural communities than in urban areas in the United States, international data show high rates of suicide by poisoning from pesticides. Social isolation is an interpersonal factor, while chronic health disparities and mental health disease burden also are shown in international literature to play a significant role, he said.

A systematic review conducted by Mohatt et al. (2020) of data show several factors for the rural/urban disparity within the United States that particularly impact Native American communities, he said. First, the disparity in suicide rates “among rural adults is largely driven by lethal means,” he said; “if you control for firearms, that rural/urban disparity either goes completely away or mostly goes away.” Second, data point to substance use, particularly alcohol, as a comorbidity with suicide attempts and suicide

deaths in rural communities, with higher prevalence among men and in Native American populations. Third, Mohatt noted that there are not a lot of data linking poor access to health care and higher rates of suicide, but that the literature does show a “persistent disparity” between urban and rural communities in this area, particularly mental health care. This will “continue to be a barrier to our ability to do suicide prevention if you don’t figure out either creative ways around [this lack] or new ways to get better access to mental health care in rural communities,” said Mohatt. Fourth, he noted that the review found that financial and economic factors do not contribute more to suicide risk in rural communities than in urban ones, and so do not explain the disparity between the two; but they do contribute to rural suicide.

In addition to these factors that increase risk of suicide, Mohatt noted, rural areas also possess strengths that can possibly be leveraged to decrease risk of suicide. These include the land itself as a source of peace and quiet as well as recreation and shared pursuits; a culture of resilience; social capital (i.e., “people are fewer degrees separated from decision makers in rural communities in general”); and, a culture of self-reliance which, at the community level, is a culture of collective agency—coming together to overcome adversity.

Mohatt et al. (2020) found a lack of studies around the impact of “community-level factors like access to care and financial risk” on suicide rates in rural communities, Mohatt said. “There are fewer studies, and lower evidence quality.” He continued, “in terms of suicide prevention, most best practices haven’t been examined relative to rural needs.” He emphasized the need for further research and work into questions of “how do we design our services and our programs to better meet the needs of rural areas.”

As one example of how community-based suicide prevention efforts might be used for rural veterans in particular, Mohatt pointed to the VA’s Together With Veterans (TWV) program. This program is veteran-driven, collaborative, evidence-based, and community-centered; in collaboration with rural communities, this becomes about collaborating with rural communities to draw on their strengths—particularly in the area of social capital—to establish more effective prevention interventions, he said. This includes “training rural veterans to become public health leaders in their communities.” Such training can serve as a “force extender to the health care community that is resource-strapped,” Mohatt said. Training laypeople to be public health planners has been shown to be effective in this program, he noted.

NATIVE AMERICAN/ALASKA NATIVE VETERANS

End of Horn’s presentation focused on the social determinants of health, and suicide as alongside other health outcomes, among Native populations. She began by describing social determinants that affect the population as a whole and then turned to how these factors particularly impact the Native veteran population.

Native people comprise about 1.7 percent of the U.S. population, with 574 tribes recognized by the federal government as sovereign nations, and more than 300 different languages, End of Horn said. She described several features of this population: they are a “mobile population,” with many moving between reservations and urban areas, sometimes with two homes and sometimes without a fixed home and living with family. This group is also multicultural—different nations, bands, and families comprise this group, End of Horn noted.

Natives serve at the highest rate of any minority in the military, with members from all tribes, End of Horn said. This makes for about 150,000 currently serving, with women making up 10 percent of that number. Native service members are “very different from their compatriots in other races,” she continued. These differences include a tendency to live in the west; a lower median age (59 years as opposed to 64 years of other races); lower personal income; more likely to lack health insurance; and more likely to have a service-related disability.

Native service members are also impacted by factors that affect the entire population, End of Horn continued. These include a lower life expectancy (78 years compared with 80 years for the non-Hispanic White population); high disease burden; inadequate education; disproportionate rates of poverty and economic adversity; difficulty starting and maintaining a business under federal jurisdiction (i.e., on a reservation); discrimination and racism; and poor social conditions, including gang violence and other crime. End of Horn also noted that Native veterans also face a lack of access to local, county, and state services. Because of living on a federal

reservation or trust land, they may only have access to tribal services or the IHS, she said.

End of Horn observed that because of these challenges, Natives are often thought about or approached by others via a “perspective of deficiency.” This perception of deficiency contrasts with the high esteem and respect afforded to veterans within the community, and, together, these conflicting elements can prompt Natives to join the military, End of Horn suggested. Natives leave the reservation and community to better themselves—to overcome this perceived deficiency—and to emulate family members who may be veterans highly respected within the community. She noted that often veterans then return to their home communities and that “often [these veterans are] one of the more core groups on the reservation that are willing to do a lot more for specifically elderly and for children.”

The mortality rates among Natives are an important factor in understanding the situation for Native veterans in particular, End of Horn said. The average age of death is 78 years old, which is lower than the non-Hispanic White population; additionally, “they are suffering from a high rate of morbidity,” she noted. Pointing to data from the IHS, she noted that heart disease, cancer, diabetes, and unintentional injuries/accidents are more prevalent among the Native population than the general U.S. population. The first three can result from “historic inadequacies” of food, with a lack of access to “green leafy vegetables” and a diet heavy in processed carbohydrates a contributing factor to the particularly high rates of diabetes. The high mortality rate associated with accidents is associated with living and working in rural areas, often on a farm or ranch with livestock, End of Horn noted. She also pointed to the especially high rate of mortality due to of alcohol abuse and related health conditions, as well as the high rates of infectious disease such as influenza, pneumonia, and now, COVID-19 (see Figure 3-1).

Suicide was the eighth leading cause of death across all ages among Native populations in 2017, making up 18 percent of total deaths (640 of 3,447). End of Horn reported. This is a higher rate of suicide than other races and ethnic groups, she noted. Of these suicide deaths, 46.6 percent were by suffocation/hanging and 38.6 percent were by firearms; End of Horn said that “depending on what dataset you look at,” firearms are sometimes shown to be more prevalent than suffocation, “but the reality is, it’s both.”

One of the most difficult parts of suicide prevention in Native communities is stigma, End of Horn said. “Suicide as a word is very taboo in a lot of our tribal communities,” who believe that in saying the word, “we’re bringing it into awareness.” This results in a stigma around suicide that can be a barrier for struggling individuals who might not seek needed mental health services because of this cultural pressure.

Not a lot is known about Native veterans as a group, because most of the data come from two health care systems—the VA and the IHS—that approach care and data tracking from two different perspectives, said End of Horn. The VA attends to individuals as veterans, while the IHS data reflect individuals’ identity within the Native population, she said. In addition to this difference in perspective, the two systems also have different ways of taking in data, which makes it difficult to identify and begin to understand this population, End of Horn observed.

Among Native veterans, the suicide rate has more than doubled, with ages 18–39 having the highest rate, End of Horn reported (Mohatt et al., 2022). She noted that this highest risk for suicide among younger veterans reflects the higher risk of young people within the larger Native population. Additionally, risk of suicidal ideation is twice as high for Native veterans as for non-Hispanic White veterans, she said.

End of Horn concluded her presentation with a discussion of some strategies for meeting the needs of Native veterans. She advocated for community-based outreach done via building relationships through net-

working, “meaning finding an individual, getting them connected, and then having them make connections for you,” rather than cold calling or other non-relationship-based forms of outreach. This would involve getting to know individuals and finding out what their specific needs are, she noted.

Another effective strategy was the inclusion of traditional healers and traditional practices, End of Horn said. She cited the inclusion of a traditional healer in the Veterans Integrated Service Networks (VISN23) of the VA at the St. Paul VA Medical Center in St. Paul, Minnesota, as a contributor to good outcomes at that institution. “The traditional healer within the community often bridged the gap for Native veterans to get into services and result in actually coming and getting care.” End of Horn emphasized that in this situation, participation in traditional practices often served to connect Native veterans with the VA. She noted that the IHS often includes traditional practices as an element of care and includes healers on the care team, if desired by the patient.

Finally, End of Horn pointed to the complex interplay of two health care systems—the VA and the IHS—and noted that many Native veterans get care through IHS but eschew the VA. Bridging this gap and helping Native veterans take advantage of available services in the VA is an important area of inquiry, she suggested. She noted the importance of having VA staff, including social workers, who are able to help resolve issues that come up when learning a new system. Having “peer support providers who are Native veterans who can help other Native veterans . . . would be the most beneficial to Native veterans overall.” This is because Native peer support providers might be able to bridge cultural barriers, she said. Additionally, “chances are, they’re going to trust that [peer] more so than anybody else simply because that Native person may understand the system a lot better, is working in the system, and able to provide information in a way that would really connect them” to these services in a way that will truly help not just achieve a specific goal and get relevant services but, ultimately, “help [Native veterans] increase their quality of life.” Native veterans are so important to traditional communities and beliefs, End of Horn said, that “serving Native veterans is one of the highest things we can do.”

WOMEN VETERANS

Hoffmire’s presentation focused on how social determinants of health impact women veterans in particular. She began by reminding listeners that gender itself is a social determinant of health; additionally, “we should expect that other social determinants of health impact outcomes differentially by gender as well.” She sketched an overview of women in the military, women veterans, and suicide rates compared with male veterans. Following this, Hoffmire discussed three studies that showed fluctuations in the risk for suicide and instances of suicidal ideation over the life course. She then reviewed some of the factors that impact rates of suicidal morbidity in women veterans. And finally, Hoffmire considered the close connection between wellbeing and social determinants in light of separation from the military for women veterans and suicide risk in that population.

About 10 percent of veterans are women; this is one of the fastest growing subgroups of veterans, and projected to reach approximately 16–17 percent around 2043, said Hoffmire. As in the general population, the rate of suicide for female veterans is lower than for male veterans. Hoffmire pointed to data showing that, for Western cultures, “across the vast majority of populations, females have higher rates of suicidal ideation and non-fatal suicidal behavior, but lower rates of suicide” when compared to males. The comparative rates of suicide among female and male veterans reflect this, Hoffmire noted. She continued, 2001 to 2017 saw a “substantial” increase in rates among women veterans. From 2017–2019, there was “a pretty notable decline in suicide rates among our female veterans;” while this decline is “promising,” it is not clear if it is a long-term trend, she said.

Data show that the risk of suicide differs at different points within the life course of the female veteran, Hoffmire said. “The relationship between suicide rates and time since leaving military service appears to differ for men and women, but considering overall rates when evaluating such trends may mask variable trajectories of risk over the period of reintegration into civilian life. Understanding drivers of high-risk trajectories is critical.” Hoffmire pointed to one study on veteran suicide rates by sex and time

since separation that showed that for male veterans, the suicide rate is highest at the point of separation and then decreases over the next seven years (Bullman et al., 2015). This same study showed that for women, there did not seem to be a decrease in risk for suicide. Data on suicidal ideation after separation from the military over a three-year integration period, gathered by Hoffmire and colleagues, does not show meaningful gender differences, she reported (Hoffmire et al., 2022). There may, however, be differences in predictors of suicidal ideation trajectories post-separation from military service, she said.

Hoffmire pointed to a third study, this one focused on women veterans, that showed “a high lifetime rate of suicidal ideation, attempt, and non-suicidal self-injury, with prevalence of both ideation and attempt higher following separation from service than the women experienced prior to and during military service” (Monteith et al., 2020). However the onset of suicidal morbidity (i.e., “the time that women veterans indicate they first experienced ideation and attempt”) among this group was most often premilitary, Hoffmire reported. Thus many women veterans have some prior ideation or attempt that already puts them at risk, she said.

Another study by Hoffmire and colleagues compares women veterans to non-veteran women, non-veteran men, and to male veterans, she said. “In comparison to non-veteran women, we found that women veterans experienced a higher prevalence of ideation and attempt in adulthood but not in childhood and adolescence,” she reported (Hoffmire et al., 2021). Additionally, for women veterans, the odds of ideation and attempt onset were increased in adulthood relative to childhood, while for non-veteran women, the odds were decreased in adulthood.

Turning to a consideration of the social determinants of suicide risk for women veterans, Hoffmire summarized, “We know that gender is clearly a determinate of suicide risk among our veterans.” For women in particular, she noted that data are scarce but “increasingly available.” Hoffmire stated, “delineating specific factors, including social determinants of health, driving suicide risk for women veterans, overall and at specific times across the life course, is essential.” She said that one growing area of research is psychosocial stressors and differences of their impact by gender. Hoffmire briefly reviewed such stressors, including the following:

• Housing and financial concerns. Hoffmire noted that, in one study, housing and financial concerns associated with suicidal ideation among female veterans but not male veterans, “whereas concerns about other recent stressful life events were associated with ideation only among males.”
• Justice involvement. Hoffmire reported that another study found that female justice-involved veterans were three times more likely

• to report a lifetime suicide attempt than women veterans without a history of justice involvement. She also noted that most research in this area has been focused on male veterans, but recent data show this as an important social determinant for women veterans.
• Homelessness and housing instability. Women veterans who have experienced homelessness and housing instability have been shown to be at “even greater risk for suicide attempts,” Hoffmire explained.
• Access as a barrier to health care. In 2017 and 2018, the age-adjusted suicide rate for non–Veterans Health Administration (VHA) female veterans exceeded that of VHA female Veterans. However, the majority of women veterans do not use VHA services and women encounter unique barriers to health care access, she continued. For example, 25 percent of women veterans report experiencing harassment at VHA health care centers, which “may result in delayed or missed care,” Hoffmire reported. Challenges around childcare also disproportionately affects women veterans seeking care. Finally, a historic lack of gender-sensitive care within VHA has also presented challenges for women as well as any veteran seeking care related to gender identity; though substantial efforts have and continue to be to provide more care of this kind, she noted.
• Military sexual trauma (MST) and interpersonal violence. Hoffmire reported that women who have a history of MST often have a lower willingness to use VHA if they’re suicidal or experiencing mental health challenges. This aversion might be the result of many factors, Hoffmire noted, citing “institutional betrayal” as one possibility.

“Certainly we can address suicide risk for our women veterans by looking at and addressing social determinants of health” including these psychosocial stressors as they particularly impact women, Hoffmire summarized.

One growing area of research around the mitigation of these psychosocial stressors and the decrease of suicide risk is through a framework of the concept of wellbeing, Hoffmire said. Wellbeing includes an individual’s health (physical and mental) as well as vocational, financial, and social circumstances, with the latter three considered aspects of psychosocial wellbeing, she noted. Hoffmire said that these aspects of psychosocial wellbeing overlap greatly with social determinants of health—and that social determinants of health greatly contribute to psychosocial wellbeing; but, she explained, the two are distinct in that social determinants of health “typically focus on status” while psychosocial wellbeing is concerned with “functioning and satisfaction” in addition to status. For example, in the

area of finances, income is a social determinant of health whereas financial wellbeing also includes a person’s sense of satisfaction and how they are functioning within various financial domains.

Hoffmire pointed to the Wellbeing Inventory (WBI) (Vogt et al., 2019), a multidimensional assessment tool developed with veteran populations to measure status, functioning, and satisfaction within four life domains: health, vocation (work and education), finances, and social relationships (intimate, community, parenting). She reported that data gathered as part of the Veterans Metrics Initiative Study (in progress) on overall wellbeing show an association of higher levels of wellbeing with a lower likelihood of “high-risk trajectories of ideation” among both male and female veterans. A second study using the WBI focused on women veterans using VHA reproductive health care services shows that in the domain of parenting, there is “a threefold increase in the prevalence of current [suicidal] ideation among women who reported low versus high satisfaction in their parenting,” reported Hoffmire (in progress). Status (whether or not someone is a parent) and functioning, however, were not associated with suicidal ideation. These findings point to “the importance of continuing to study the intersection between parenting and suicide risk among women veterans,” she noted. Hoffmire concluded her presentation by gesturing to several ongoing studies that will expand knowledge regarding social determinants of suicide risk for women veterans, including consideration of the impact that COVID-19 might have on the risk for suicide among this population.

DISCUSSION

Discussion for this panel was moderated by Lewis and began with a consideration of the impact of an increase in rural populations due to relocation from urban centers spurred by the COVID-19 pandemic. Mohatt expressed worry that the health system in rural areas is “already overextended, overtaxed.” This is the result of “negative trends in access to care over the last five years plus,” including difficulty attracting providers to rural areas and hospital closures “because the economics of rural health care are just really challenging.” He did note that one thing to hope for is that an increase in population will bring with it an increase in money within the local economy and so help mitigate some of the deficits.

Hoffmire addressed the need for intersectional research that attends to the experiences of women veterans of color, and the question of why current studies are not designed to include subpopulations from the start. She noted that while this is an important area of research, feasibility is a problem in that women veterans are already a small minority subgroup, and getting a big enough sample can be difficult; “most studies don’t have enough women veterans to make meaningful informative conclusions about

women veterans as a whole,” let alone subgroups. Two ways of correcting this limitation in future studies would be to design studies that address specific subpopulation questions or to design large-scale studies that oversample women and veterans of color to yield enough data to analyze different subgroups and do comparative analysis, Hoffmire said. She noted the present importance of the second type of study as a way of identifying factors that are particularly important for certain subgroups that might then receive more focused study.

End of Horn discussed why some of the strategies for reducing suicide risk mentioned in her presentation have not been implemented in a robust way within the VA and the IHS health care systems. She reiterated the importance of having representation within the VA system, not just for Native populations but for other religious affiliations. She also noted that Native veterans come to the IHS over the VA in part because “we’re right there” on the reservation, making access easier. End of Horn suggested the importance of “getting outside of the medical center . . . and going to the community,” leveraging connections and presence within a community to slowly connect and built trust with Native veteran representatives, not just tribal leaders.

Discussing the problems of racism and discrimination as they appear in rural areas, Mohatt pointed to an in-progress survey of all veterans participating in TWV, a rural suicide prevention program. Preliminary findings show the training topic of most interest to study participants is “diversity, equity, and inclusion,” he reported. There is “a very strong interest in learning more about diversity and culture as it relates to suicide, and how to be more engaged across cultures and communities in rural areas.”

The final part of the discussion concerned the further development of connections between large agencies such as the VA and veteran-owned, veteran-run small organizations around prevention of veteran suicide. Mohatt pointed to the TWV program as one example of the VA doing this: “it’s completely built and predicated on the idea of engaging with rural veterans and rural veterans’ service organizations to ensure that veterans are the leaders of community-based suicide prevention.” Hoffmire spoke to the importance of involving veteran partners from various subgroups in order to make sure that studies include their perspective throughout the process, from design to data gathering to the dissemination of results.

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