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Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium (2022)

Chapter: 6 Community Interventions for Varied Applications in Housing, Health, and Safety

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Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
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6

Community Interventions for Varied Applications in Housing, Health, and Safety

The final panel of the first day, and the second panel of the second session, featured three presenters speaking about various forms and applications of community interventions. Jack Tsai (VA Homeless Programs Office and University of Texas) spoke about how housing and homelessness are related to suicide and the impact VA programs to alleviate homelessness have had on suicide risk. Holly Raffle (Ohio University) discussed the importance of collaboration, focusing on a range of ways that community-based coalitions might effectively address prevention of veteran suicide. Charles Branas (Columbia University) presented on the impact place can have on health, including the importance of place-based interventions in preventing suicide.

HOUSING AND HOMELESSNESS

Homeless populations—both veterans and other adults—have a high risk for suicide, Tsai noted, citing in particular a systematic review by Adam Hoffberg et al. (2018) that shows higher rates of both suicide attempts and

Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

suicide deaths among homeless veterans than veterans who are not homeless. Tsai also pointed to a study he led that found a “stronger association between homelessness and suicide among veterans” than non-veterans; while it is not clear why this is, he said, he noted that there are “upstream factors that are . . . common to both” and that these shared factors may be the reason for this stronger association in veterans (Tsai & Cao, 2019). These factors include being male; low socioeconomic status; mental illness; lack of social support; substance use disorders; chronic medical conditions; and adverse childhood events. Past experience of homelessness is also a predictor of homelessness, just as a family history of suicide and suicidal attempts are predictors of suicide, he said. One study looking at the timing around suicide risk and homelessness suggests that suicidal behavior often precedes homelessness (Culhane et al., 2019), Tsai reported. “This is important in terms of intervention and planning of services,” he noted.

Tsai then turned to an overview of VA homeless programs, particularly the Supportive Services for Veteran Families (SSVF) program, and their impact on suicide risk and mortality. The VA offers a range of homeless programs that serve more than 100,000 veterans a year. He referenced a study that compares homeless veterans who participated in a VA homeless program to homeless veterans who did not, and shows that “use of any VA homeless program was associated with 6 percent reduction in all-cause mortality and 21 percent reduction in suicide mortality” (Montgomery et al., 2021). The study also shows that use of additional homeless programs yields “an incremental benefit,” Tsai reported, with each additional program used reducing risk for all-cause mortality by a further 7 percent and suicide mortality by 19 percent. This study “really shows that homeless services do address social determinants of physical and mental health, and that [these services] reduce death overall” and especially suicide death, he summarized.

The SSVF program in the VA funds community grantees to provide services to homeless veterans. Tsai noted that this has the advantage of connecting veterans with providers who can, in turn, connect them to resources from the community as well as the VA. The program has two components: the Rapid Re-Housing Program, and the homeless prevention component, including temporary financial assistance (TFA). Both focus on “providing brief case management” and offer short-term assistant with rent and utilities; the former focuses on veterans who are homeless, with the goal of rehousing, while the latter focuses on veterans who are in imminent risk of homelessness. Program data on the return rate to homelessness show that, overall, one year out, more than 85 percent of veterans who use the SSVF have not returned to homeless programs, Tsai reported.

The TFA component of the SSVF has been shown to reduce health care service use and health care costs, mostly for inpatient costs, where there was a $372 reduction per quarter, Tsai said. He noted that the reduction in

Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

inpatient costs means that veterans reduced need for “intensive services” for mental health and medical needs, which provides evidence for temporary financial assistance as an effective intervention. Tsai pointed to a separate study that found that “temporary financial assistance increases housing stability as well.” However, a randomized controlled trial is needed to conclude effectiveness, he said.

“Studies have shown that participation in VA homeless program is associated with reduced risk of death, including suicide death,” said Tsai (Nelson et al., 2021). The SSVF program in particular is “exemplary in terms of a VA-community partnership model that can help address social determinants of health and health care costs,” which can in turn impact suicide risk, he concluded.

USING A COLLABORATIVE APPROACH IN SUICIDE PREVENTION

Suicide is a “wicked problem”—meaning a complex problem with more than one solution that are often “not solvable” in a simple way, Raffle said. “We solve and re-solve [wicked problems] again and again.” As such, the problem demands “multiple solution sets.” Raffle noted the effectiveness of a collaborative approach in suicide prevention work in producing multiple solution sets. She pointed to the Substance Abuse and Mental Health Services Administration’s 2016 declaration that “collaboration among prevention professionals across behavioral health fields has the potential to reduce suicide rates.”

There are many different ways of working together, Raffle noted. She illustrated this by way of a continuum showing stages of collaborative relationships, where participants are least to most enmeshed. These stages range from “immuring” (i.e., working primarily on one’s own) and “networking” to “collaboration” and “integration” (i.e., fully merging operations, structures, budgets) (Mashek, 2015). Organizations and individuals must “pick the best way to collaborate that works for your given situation,” she said. To this end, Raffle recommended a decision process based around three key questions: Can I do it? Will it work? Is it worth it? to support groups in deciding which type of collaborative relationship was appropriate or the

Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

best-fit scenario given the local circumstances. She compared this process, based on work by E. Scott Gellar, to the decision-making process involving the evaluation, selection, and implementation of specific interventions. Asking these questions can help participants in multiple situations: the critical work of evaluating strategies and selecting those that fit the capacity of those involved and that are “culturally responsive and sustainable” within the community as well as determining the level of collaboration that is required for any individual project, she said.

Raffle emphasized that collaborations evolve as the work continues (though she noted that it is not necessarily a goal for partnerships to move from less integrated to more integrated). Collaboration is a learned skill, she stressed, and as such, requires supports that facilitate this learning. Key areas where this takes place are capacity, inter-institutional supports, and a practice mindset, Raffle said. The latter describes approaching collaboration as “something that you constantly have to practice in order to get better,” she said. Raffle explained that as organizations work together, they can more fully develop an understanding of what collaboration involves and how to do it more successfully.

The first of these three key areas, capacity, describes developing organizational ability to connect, share, or coordinate efforts in a collaborative relationship, Raffle said. The question “Can I do it” becomes, “Do we have the capacity to work together at this time?” Organizational capacity can change over time, whether due to external factors or growth through accumulated internal experience, she noted. Illustrating the former, Raffle pointed to the example of two organizations who were at the cooperation stage on the collaboration continuum when the COVID-19 pandemic disrupted normal operations and forced them to pull back from cooperation to the “immuring” stage as they devoted time and resources to basic functioning within their own organization. She noted that once the two organizations figured out those changes to some degree, they had the capacity to resume their cooperative work. As to the latter, Raffle noted that collaborations might start with small—with a networking meeting, for example, or the establishment of a clear communication channel—and evolve slowly, as specific capacities are developed.

Raffle’s model connects inter-institutional supports, the second key area, with the evaluative question “Will it work?” Collaboration will work only if there is “support from our authorizing environment.” The more integrated the partnership, the more institutional support is needed, explained Raffle. Sometimes, she said, collaborations fail not because people do not have the capacity or lack the desire, “but because they do not have the support structures or do not honor [the idea that] support structures are necessary.”

The third key area, approaching collaboration through a growth mindset, links with the evaluative question “Is it worth it?” in Raffle’s model. She

Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

emphasized the emotional aspect of collaboration; referencing a model by Pat Collarbone that charts a typical up-and-down emotional trajectory that moves from initial interest through frustration and despair, to optimism and hope, to commitment (2009). Raffle notes that often when people begin collaborating, they make collective impact their goal when they might be more successful starting with a less intensive collaborative relationship (e.g., networking), with the aim of building from there. Collective impact is an important strategy in our toolkits, she noted, but, “It takes time to get to the degree of collaboration on the continuum that is necessary for collective impact.”

Raffle then outlined four tips for practitioners looking to collaborate. The first is to observe what organizations, programs, and coalitions already exist in the community, and look for ways of joining. “Do not start something new if you do not have to.” The second is to have a sense of collaborating partners’ agendas and capacities, which are likely different than one’s own. “Know your space but be willing to listen and learn from others.” This includes, for example, being aware of the different knowledge, skills, and attitudes that might be required for population prevention versus those required for treatment and recovery, Raffle said.

The third tip Raffle offered is to recognize that collaboration is a learned skill whose practitioners require supports. “Embed training opportunities about how to collaborate and how to lead collaborations into your funding opportunities,” she recommends. The fourth tip is to keep in mind that “collaboration is an intentional practice” that takes time—often years—to see collaborative efforts come to fruition, she says, and financial investments should be planned accordingly.

PLACE-BASED INTERVENTIONS

Branas discussed the importance of place—the “surroundings and environments that we experience every day”—in determining health, and reviewed several studies showing of impact of place-based interventions. He focused on the connection between vacancy and abandonment in urban

Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

areas, and gun violence. Branas explained that the everyday context people experience “all the time” (i.e., place) plays a role in determining poor health on par with genetics and “certainly more than the medical care you receive,” and is also “a major predictor of good health” alongside other social determinants like access to medical care and education. Places can sometimes be “underlying reasons that the poor health is occurring in the first place.” If environmental factors are not addressed, poor health will continue, he said.

Branas focused on the impact of vacancy and abandonment, illustrating this first by showing the effects of redlining in 1940s Chicago, which resulted—decades later—in neighborhoods with large numbers of vacant and abandoned properties that are caught up in the “spiral of structural racism, disinvestment, and abandonment.” These properties are “really toxic to [the] health and safety” of people who live in those neighborhoods today, he said. This is true of many other cities, Branas said, and noted that the area of vacant and abandoned spaces in U.S. cities equals that of Switzerland.

Branas pointed to groups that are implementing “in situ place-based changes” that introduce inexpensive structural changes designed to help people stay in their home neighborhoods and to bring amenities to those areas. These amenities might include greening; fewer abandoned buildings; community gardens; and business improvement districts, he said. “They are very scalable and . . . also quite sustainable.” Branas noted that while approaches differed between organizations, all began as “community-initiated ideas” and were co-designed based on input from the community, including concerns surrounding “environmental challenges that they could see on a daily basis . . . things like, you have to watch for yourself walking past vacant lots.” He reported, “many community members came back to this thing: that if they could change something . . . it would be the vacant lots and the abandoned buildings.” These places were often mentioned as the sources of fear and danger, whether because someone “might step out” or because the building was in a state of imminent collapse, Branas said. He noted that such places presented both challenges and opportunities.

Branas reviewed several studies he and his team have conducted. The first (2016) looked at what effects changing a place might have on the community around it. This study treated more than 10,000 vacant lots and abandoned buildings in Philadelphia, turning the vacant lots into green spaces as well as cleaning abandoned buildings and turning them into sites “do not detract” from the neighborhood as well as potentially livable places. Branas reported that there was significantly less gun violence and stress—as much as 39 percent less—around newly green spaces and newly fixed-up buildings. He stressed the cost effectiveness of this treatment, with every dollar spent yielding a return of as much as $300 through the

Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

reduction of gun violence, which is (a very costly event for a city . . . costly in many ways,” including not just the immediate response but “the ripple effect of that violence” in neighborhoods.

A randomized trial (Branas et al., 2018; Moyer et al., 2019), also in Philadelphia, compared about 200 spaces that were “cleaned, greened, and maintained” with 200 spaces that were only cleaned and maintained, and with another 200 spaces that did not receive any treatment (until the end of the study, when all spaces were fully greened). Branas reported that gun violence around the cleaned and greened spaces went down by 29 percent in some areas. Two more ongoing studies, with treatments again in Philadelphia and also in New Orleans, are starting to show “similar reductions in gun violence—about 23 percent in and around these spaces,” he said.

Branas pointed to good outcomes associated with these studies, or what he calls “win-win science” that results from the introduction of outside resources into communities. Treatments of the kind Branas described were shown to result in the reduction in gun violence and the reduction of nuisances (e.g., public drunkenness and noise complaints), he reported. These also yielded “co-benefits” that feed the reduction of gun violence, including the reduction of depression, fear, anxiety, and other mental health challenges; a higher willingness to go outside more; and a greater willingness to connect “not just . . . with the spaces but also to connect with each other.”

These positive outcomes are the result in part of a “biologic response, with less stress, fear, and aggression” associated with these newly-renovated spaces, Branas reported. This also comes of the place functioning as a site where community members can connect with one another: the creation of a “positive, ‘busy streets’ environment”—a “visual cue” that communicates care about the space. And finally, changing vacant and abandoned places can remove the opportunity to store illegal firearms, he said. Branas pointed to other cities that have undertaken some combination of place-based research and programming—“in situ, inexpensive, scalable structural and sustainable place-based interventions.” Across this group of cities, evidence shows between 6 percent and 66 percent less “violence, stress, fear, depression, sedentary behavior, and cardiovascular risks.”

In his conclusion, Branas stressed three points. First, that programs that focus on place have upstream influence that can impact “the lives of more people and for longer periods of time than programs that simply focus on individuals.” Second, that the everyday environment can play a role in the success of medical treatments for individuals. A “chaotic and unhealthy environment” can compromise the efficacy of such treatments. Third, that place-based changes might be thought of as treatments in and of themselves.

Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

DISCUSSION

Timothy Strauman, moderator for this panel, posed two general questions to the three presenters. The first focused on the fact that, despite conventional wisdom and popular reporting that frames problems like homelessness, infrastructure deterioration, and despair as intractable, there are “some very clear indications” that progress can be made in addressing these “seemingly intractable problems.” Strauman asked, “How do we get the word out that we can make this kind of significant progress and get the policy makers and the funders on board with these kinds of sustainable, economically viable programs that clearly are working?”

Branas identified the importance of simply “doing some really good science” that provides evidence for the impact of successful programs. This evidence might be used to raise awareness of success framed not just in terms of scientific outcomes but in terms that show these programs to have “a real return on the investment.” Raffle added that her organization is working to help community groups craft “social determinants of health impact statements” as part of their work around suicide prevention, the reduction of gun violence, etc. These statements serve as guideposts as the groups make funding decisions, write requests for proposals and design programs, she said. Like a diversity impact statement, and ideally together with it, this social determinants of health impact statement can help organizations to “make decisions with those things at the forefront of mind,” she said. Tsai added that getting the word out about success of programs addressing social determinants of health can help stakeholders with different priorities to understand that there are also common factors and mutual goals everyone is working toward.

Strauman then asked the panelists about their “most pleasant surprise in finding [that] community members, stakeholders, people who you thought would not be on board . . . actually were and [that] they were part of the solution?” Branas answered that his team was surprised with how many of the interventions, “at least in the research, turned out to be impactful.” He reiterated the importance of involving “community voices early, because they will . . . contribute very much to the sustainability of these programs.” With this kind of buy-in, Branas said, community members will be the ones “who will step forward to policy makers and leaders, and really elevate the program.”

Raffle noted the need to highlight both prevention and promotion within a program. She pointed to Branas’s discussion of how green spaces both promote health and have “a corresponding decrease,” in this case, gun violence. She argues that rather than an “either/or” mindset, organizers adopt a “both/and” approach that allows for “exponential growth in your community-based process.”

Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 51
Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 52
Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 53
Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 54
Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 55
Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 56
Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 57
Suggested Citation:"6 Community Interventions for Varied Applications in Housing, Health, and Safety." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 58
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On March 28 and 29, 2022, the Board on Behavioral, Cognitive, and Sensory Sciences at the National Academies of Sciences, Engineering, and Medicine held a virtual symposium entitled Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants to gain a better understanding of social determinants influencing the recent increase in suicide risk and how currently available practice guidelines can inform community-level preventive interventions, particularly those targeting veteran populations. Presenters and participants explored the relevant social, cultural, and economic factors driving changes in suicide risk among veterans and ways that current best practices for suicide prevention and treatment can be applied at the community level. This publication summarizes the presentations and discussion of the symposium.

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