Suicide ideation - experiences of adversely racialised people: research

3 Methodology

The research was shaped and guided by TREEM as outlined in Figure 1 below. TREEM is composed of community engaged researchers and community activists with wide experience of working with racialised communities in Scotland.

In line with the specifications from SAMH, TREEM set out to recruit participants, collect the data and generate a report from the findings. The work began in January 2021 and the report was to be submitted by 31 May 2021. Due to this short time scale, it was important that all activities happened almost simultaneously, and critical that the people involved had the right skill-set and experience.

Using TREEM's networks, a core research team was set up. The team included a mental health professional and an interviewer who had successfully completed Applied Suicide Intervention Skills Training (ASIST).

Figure 1: Outline of Approach Taken in the Research

Structure

• TREEM Consultancy
• Research Team
• Focus Groups and Interviews

People

• Community engaged Researchers and community activists
• Racialised communities
• Community organisations
• Researchers
• Mental health specialist
• ASIST Interviewer
• Young People
• Older People
• Organisations
• Individuals

Activities

• Collating data
• Outreach
• Report generation
• Literature review
• Recruiting participants
• Interviewing/facilitating
• Transcribing
• Thematic analysis
• Documenting first-hand experiences

3.1 Literature review

A literature review was undertaken to inform implementation of the study (see Appendix 1). As stated previously, we are not mental health experts. The expertise of our work is with engagement with racialised communities. The literature review was to support our learning of the mental health landscape in Scotland as we undertook this piece of work.

A rapid review was also requested from the Scottish Government's National Suicide Prevention Leadership Group Academic Advisory Group, a specification of which is in Appendix 2. The request was for a literature search on suicide ideation in 'BAME' communities in Scotland and the UK in the last 10 years.

We approached the AAG to include the terminology - racism and racialisation, individual, institutional and systemic - in the search criteria in order to explore what has been evidenced in relation to risk and protective factors associated with suicidal thoughts and behaviours among the target group. However, as indicated by the AAG doing this was inconsequential as including these terms returned only the three publications outlined in Box 1 below and none of them in the context of the UK. As indicated by our literature review in Appendix 1, prevalent literature largely focuses on ethnicity and not racism as an analytical concept.

Given these results, it was agreed that the review keep its broad focus on risk and protective factors for suicide, suicidal thoughts and behaviours within BAME communities.

The rapid review had not been received by the time of writing this report.

Box 1

Publications on suicide ideation with racism and racialisation, individual, institutional and systemic included in search criteria

Bowden, M., McCoy, A., & Reavley, N. (2020). Suicidality and suicide prevention in culturally and linguistically diverse (CALD) communities: A systematic review. International Journal of Mental Health, 49(4), 293-320.

Hamilton, S. M., & Rolf, K. A. (2010). Suicide in adolescent American Indians: Preventative social work programs. Child and Adolescent Social Work Journal, 27(4), 283-290.

Christson Adedoyin, A., & Nicole Salter, S. (2013). Mainstreaming black churches into suicide prevention among adolescents: a literature review. Ethnicity and Inequalities in Health and Social Care, 6(2/3), 43–53. doi:10.1108/eihsc-10-2013-002.

(Scottish Government's National Suicide Prevention Leadership Group Academic Advisory Group, 2021)

3.2 Using Participatory Ethnographic Evaluation and Research (PEER)

From a methodological perspective this research was informed by Black feminist thought (Hill Collins, 2009), with Participatory Ethnographic Evaluation and Research (PEER) (Hawkins, et al., 2009; Heslop & Banda, 2013; O'Brien, et al., 2016; Elmusharaf, et al., 2017) methodology used for data collection and intersectional analysis for interpreting the data (Cho, et al., 2013; Hill Collins & Bilge, 2020). This orientation made both the research process and the research outcomes equally important in assessing the contribution of this work.

PEER is based on members of a community (PEER researchers) being trained to carry out in-depth conversational interviews with friends in their social networks. Building on the established relationships of trust between people who are socially networked, PEER is acknowledged to generate rich insights into the lived experiences in relation to the issues being researched. Thus, it is recognised to be highly effective in generating insights into sensitive issues in communities where stigma and marginalisation often makes traditional research methods difficult to implement. For example, it has been demonstrated to be effective in obtaining young people's perspectives on transitions from care to adulthood (Lushey & Munro, 2015). PEER has also been used successfully in Scotland to engage with communities potentially affected by Female Genital Mutilation (FGM) to inform the development of policy and the design of services (O'Brien, et al., 2016).

In this research, however, because the target participants were expected to have lived experiences related to suicide, it was a prerequisite for the interviewer to have successfully completed ASIST. Thus, the PEER approach was altered slightly; the interviews were carried out by an ASIST trained interviewer, with the support of someone socially connected with the interviewee.

TREEM also considered the ethical and process issues that might arise from this work. As SAMH had already made an exploration of these issues in the first phase and a framework agreed, we build on it by incorporating PEER ethics guidelines (Options, 2007) throughout the research process.

3.3 Multi-sited research sites capture intersecting issues

The literature review undertaken by TREEM (Appendix 1) emphasises that exploring the experiences of suicide ideation and attempts in racialised groups is incomplete without exploring the full diversity of the mental health experiences of racialised groups in Scotland. Furthermore, it suggests that effective suicide prevention in racialised groups cannot be addressed in isolation, but rather in conjunction with addressing the prevailing systemic issues that perpetuate unequal access to mental health services for racialised communities.

This research therefore acknowledged that ethnic minorities in Scotland experience multiple intersecting challenges, of which vulnerability to suicide ideation is potentially one of the outcomes. Hence, a multi-sited approach to data collection was sought in attempt to capture the interrelated and intergenerational issues impacting on the lives of people with experience of suicide ideation in these communities.

Intersectional analysis is founded on Black feminist thought which emphasises centring participants lived experiences in making sense of the interlocking systems of power that impact on those who are most marginalised in our society.

In this regard, data was collected from four sites: five one-to-one interviews were carried out, and focus group meetings held with young people and older people. The fourth site involved a group discussion with representatives from organisations that support people from ethnic minorities with mental health.

3.4 Participants

The study recognised the term 'ethnic minority' encompassed a wide range of communities with multiple diverse experiences. However, due to the short timescale, it was agreed that for effective capture of the rich data, participants be drawn from TREEM's embeddedness in communities hence participants are largely from the African diaspora. The organisational focus group had representation which encompassed more diverse minority ethnic variation.

In addition, Appendix 1 signposts existing literature of research carried out in some 'ethnic minority communities' living in Scotland which can be used towards meeting Action 7's research objectives. For example, several studies on suicide ideation in Polish communities living in Scotland already exist (Gorman, et al., 2018; McArdle, 2018; Kopeć & Czarnecka, 2020).

Critically however, intersectional analysis emphasises that the day to day experiences of racialised communities are largely shaped by societal structures. Hence, irrespective of the diverse racialisations that the diverse ethnic minority communities might be subjected to, the experiences at personal level are largely similar. For example, this study's focus is an exploration of the risk of 'experiences of suicide'.

As defined by the Action 7 research framework, 'experience of suicide' in this research designates someone who has had thoughts of suicide; past suicide attempts; supported someone with thoughts of suicide; and/or bereavement by suicide. Due to the stigma surrounding mental health, careful consideration was made in framing the issue when approaching potential participants. It was agreed that interviewees had to be emotionally stable enough to participate in the research. This information was shared with all our contacts.

The study recognised that interview and focus group discussions were may cause upset and/or to "trigger" participants and arrangements were put in place to mitigate this. The participant information sheet shared contained information about support organisations to contact should this happen and useful activities/ techniques to help in the moment. For each interview and focus group a trusted person was on standby to "reach out" for support.

Initial exploration of how to get access to potential participants for this sensitive research was made through telephone conversations with TREEM's trusted networks – this was the most effective approach as the research took place during lockdown. Once links had been made with a potential participant, a researcher with experience of managing difficult conversations reached out to provide more information about the study and explore the possibilities for engagement. The best leads were made from community organisations already working with people from the African diaspora, especially those tackling mental health issues.

The participants involved in the research at the four sites were as follow.

3.4.1 Site 1 – One-to-one interviews (1-1)

Specifications from SAMH indicated that up to five individual interviews be held. The five interviews were carried over a two-week period, from 19 – 26 February 2021. Participants were mainly from second-generation migrant families who had schooled, gone to university in Scotland, and were in employment. Two of them had set up mental health community organisations to address the lack to access to information and culturally sensitive services. One was a parent of refugee background whose child had completed suicide and was keen to raise awareness about the issue.

3.4.2 Site 2 – Young Peoples' Focus Group (YPFG)

There was an overwhelming interest in the Young People's Focus Group (YPFG). Despite a request for up to 6 people aged 18 – 30 years to attend, fourteen turned up. Children and young people under the age of 18 years were excluded from the study due to the short time scale and the need to seek more rigorous ethical approval required for this group. The participants were generally second and third-generation immigrants from diverse backgrounds including refugees.

3.4.3 Site 3 – Organisations' Focus Group (OFG)

Representatives from ten organisations The Organisation Focus Group (OFG) included organisations that delivered mental health advocacy, education and awareness workshops for racialised communities, and one-to-one and group counselling. All organisations played a signposting/referral role, in which they referred clients to specialised mental health services.

The mental health support services were often combined with other key support services, including housing and employment support. The organisations emphasised that due to the intersecting challenges experienced by racialised communities, it was difficult to prioritise their mental health when there were key areas of day to day life that often required more urgent attention.

The organisations involved in the research were:

African Caribbean Society Scotland

African Caribbean Women's Association

Afro Caribbean Elders' Society

Baba Yangu Foundation

Jones&us

Hwupenyu African Health and Wellbeing Project

Information and Learning for All Project (ILFA Project)

Mental Health Foundation

Pachedu Health and Wellbeing

Waverley Care African Health Project

3.4.4 Site 4 – Elders' Focus Group (EFG)

The six participants in the Elders' Focus Group (EFG) generally ranged from forty years onwards with some having worked in Scotland for more than thirty years and retired. Most elders had experienced suicide ideation and completion through engagement with their grandchildren and teenage nieces and nephews who struggled to communicate their challenges and feelings.

3.5 Documenting first hand evidence

As the research happened during a lockdown period, the focus groups and interviews were an online video discussion using a Zoom platform. The framework for the conversations was set in phase 1 of the study, and focused on the following topics.

1. Participants' experience of suicide

2. Participants' experience of interventions/services that helped when they experienced suicide

3. Participants' experience of interventions/services that did not help when they experienced suicide

4. Things that participants believed would help people experiencing thoughts of suicide

The 1 -to-1 interviews were carried out by an ASIST interviewer with the support of a TREEM researcher socially linked with the interviewee. The interviews lasted about an hour each. The focus group discussion took up to 2 hours and were facilitated by a mental health professional. Both the interviewer and facilitator were of African descent, and the meetings were recorded.

3.5.1 Safe spaces

PEER ethical guidelines^[1] and Black feminist thought (Hill Collins, 2009) both emphasise the need for safe spaces during research with marginalised groups, especially when the research focuses on sensitive issues like suicide ideation.

An important first step of PEER is to ensure a comfortable informal environment. An online video platform offered the informality of the venue in terms of participants being in their home environment.

Like with all research with vulnerable groups, it was recognised that participation may carry risks for participants and arrangements put in place to mitigate them. Firstly, it was identified that involvement in the research might trigger negative memories for participants. Provisions were made for access to support before, during and after the research - see Appendix 3 for the details. In addition, a mental health professional facilitated the focus groups and an ASIST interviewer the interviews. This was to ensure potential triggers were picked up and support sought timeously.

In addition, the literature review highlighted the stigma around mental health in racialised communities. This highlighted the potential risk of participants being inadvertently labelled and further marginalised in their communities because of participating in the research.

In depth knowledge by researchers of the community being researched was helpful in making the relevant arrangements to mitigate this risk. In particular, working with community organisations already working with the target group was helpful in both identifying participants who felt able to speak out, building their confidence regarding their personal information being safe with us.

In this regard, the potential risk of participants being identified for participating in the study was also identified, Participants were reassured that all data shared in the research would be anonymised such that it would not be traced to participants. This point is addressed in the data analysis below.

Issues of cultural sensitivity were highlighted by our literature review. Thus, the benefits for participants speaking to someone who looked like them were acknowledged. Hence, both the facilitator and interviewer were people of African descent, just like the participants themselves.

3.5.2 Managing expectations

Racialised communities are often bombarded with research requests, but often, the research results are not shared with the communities nor do they see much change as a result of the research. It is therefore important for the research objectives to be shared with the research target group upfront.

Most participants were happy that this research was bound to directly influence the Scottish Government's Every Life Matters Action Plan and keen to see change in policy for their communities.

3.5.3 Compensation for time and contribution

Participants in this research were offered a small honorarium.

3.6 Data analysis

The interviews were transcribed and thematic analysis carried out by different research team members. Transcribing the two-hour long focus group discussions was particularly challenging due to the multiple voices involved. All the data was anonymised during transcribing and data from each site conflated, such that all submissions made in the 1-to-1, YPFG, OFG and EFG, are treated as one entry, respectively.

The findings from the research are presented in the next section.