In Laudato Si', Pope Francis calls on us to pay attention to our social fabric, the community and social structures that sustain us. To combat social anonymity, antisocial behavior and violence, the Holy Father invites us to "weave bonds of belonging and togetherness … into an experience of community," calling on us to promote ways to "increase our sense of belonging, of rootedness, of 'feeling at home' within a city which includes us and brings us together."1
Simply stated, social cohesion matters. The relationship between social cohesion and population health long has intrigued researchers. Sociologists Regina Berger-Schmitt and Heinz-Herbert Noll propose that social cohesion is composed of two dimensions. The first is the reduction of disparities, inequalities and social exclusion such as government efforts to provide equal employment opportunities for minorities. The second concerns strengthening social relations, interactions and ties. Berger-Schmitt and Noll stress that the availability and the quality of relationships are both important.2
The health care field is recognizing that societal and nonmedical factors play a much larger role in population health than once envisioned. In 2002, the Canadian Institute for Advanced Research, Health Canada, and the Public Health Agency of Canada's Population and Public Health Branch estimated the impact of the social, economic and physical environment on health status of the population to be 60 percent. The estimated impact of the health care system on population health was 25 percent, and biology/genetics was 15 percent.
In the United States, Healthy People 2020 — the Department of Health and Human Services' 10-year objectives for health promotions and disease prevention — highlights the importance of addressing the social determinants of health. "Create social and physical environments that promote good health for all" is one of the four overarching goals for the decade. "Social and community context," namely social cohesion and civic participation, is specified as a social determinant of health category.
An important development emerging from health care reform is the evolution of traditional community benefit programs into comprehensive strategies to improve population health by addressing the social determinants of health. In coalition with public agencies and community partners across sectors, our community benefit programs can take an across-the-board approach to changing community norms and behaviors and addressing the social determinants of health, including our social fabric.
SUICIDE AND PUBLIC HEALTH
Suicide is a serious but preventable public health problem that can have lasting harmful effects on the families, friends and communities of the person who took his or her own life. Although its causes are complex, a combination of individual, relational, community and societal factors contribute to the risk of suicide. Psychological theories emphasize personality and emotional factors. Sociological theories stress the influence of social and cultural pressures on the individual, such as widowhood, childlessness and residence in metropolitan areas. Since the publication of French sociologist and philosopher Emile Durkheim's classic text, Suicide, in 1897, sociologists have known that low levels of community involvement contribute to suicide.
In April 2016, the Centers for Disease Control and Prevention released a report that highlighted a 24 percent increase in the U.S. suicide rate from 1999 through 2014, after nearly consistent decline from 1986 through 1999. The percent increase in suicide rates for females was greatest for those ages 10 to 14, and for males ages 45 to 64.
Suicide is currently the 10th leading cause of death for Americans. In 2014, more than 42,000 Americans completed suicide, and almost half a million Americans received medical care at emergency departments for self-inflicted injuries. More than 1 million adults self-reported a suicide attempt, and 9.4 million adults self-reported serious thoughts of suicide. Suicide costs society more than $44.6 billion a year in combined medical and work-loss costs.3
As a society, we rarely communicate openly about suicide, which hinders education, prevention, assessment and intervention. Research shows that the great majority of persons who attempt suicide give warning signs, verbal or behavioral, of their intent to kill themselves. Too often, those in a position to recognize the warning signs of a suicidal crisis fail to see the signs, deny their meaning or don't believe the individual is serious. Failure to recognize and acknowledge the warning signs of a pending suicide attempt may reflect a lack of basic knowledge on how to help — or it may suggest we are reluctant to get involved.4
Suicide is the most complex and difficult to understand of all human behavior. Most people who end their own lives do so for ordinary reasons, not extraordinary ones. In its simplest terms, suicide seems to be a solution to a problem. Thoughts of suicide occur during times of personal crisis, unrelenting stress, depression or when confronted with a fear of failure or the possibility of an unacceptable loss. Too frequently, what seemed worth dying for could have been treated with appropriate biological or psychological interventions or counseling, support and the passage of time.5
PROMOTE BELONGING AND ROOTEDNESS
In fiscal year 2012, mental health surfaced as a top community health need for two Wisconsin hospitals, HSHS St. Joseph's Hospital in Chippewa Falls and HSHS Sacred Heart Hospital in Eau Claire, according to their community health needs assessments. In response, both hospitals developed and implemented a wide range of strategies to address gaps of service in or understanding of mental health. To address stress and burnout, for example, nurses from both hospitals and community members participated in The Elijah Project, which provides biblically based tools to help move participants from burnout to re-engagement, based on Elijah's story found in 1 Kings:17-19.6
The hospitals, along with other community partners, also focused on infant mental health education — educating health care professionals and community members about the impact of the social and physical environment on the developing infant brain. The health care field is recognizing that adverse childhood experiences influence a person's health and well-being throughout life and can disrupt neurodevelopment, precede social, emotional and cognitive impairment, lead to the adoption of health-risk behaviors and contribute to disease, disability and early death. As part of their implementation plan, the hospitals also launched mental health awareness campaigns to increase understanding and decrease stigma, including the "You Matter" campaign and, for children, a feeling-identification campaign featuring Pixar's "Inside Out," the 2015 animated movie about emotions.
In 2014, Chippewa Falls joined the ranks of the International Compassionate Action Network, becoming one of 54 cities around the world designated as a City of Compassion. According to Rhonda Brown, CSW, director of the Chippewa Health Improvement Partnership, "The basic premise for being a City of Compassion is to live by the Golden Rule, to make decisions based on residents' well-being and not just economics."
Facilitated by HSHS St. Joseph's Hospital, the Chippewa Health Improvement Partnership is a multisector community health collaborative designed to enhance community health and quality of life through education and prevention. One of the partnership's major projects with Chippewa County leaders is creation of the Legacy Community Center to promote compassion, connection and self-sufficiency for Chippewa County residents and their vision of a county free from poverty of body, mind and spirit.
In fiscal year 2015, mental health surfaced again as a top community health need, specifically suicide. The suicide rates in Chippewa and Eau Claire counties are the highest in Wisconsin and eclipse national averages. In 2015, there were 40 suicides in Chippewa and Eau Claire counties, the highest suicide rates in at least five years for both. Between January and October 2016, 29 persons completed suicide in Chippewa and Eau Claire counties.
Building on their portfolio of mental health implementation strategies, HSHS St. Joseph's and Sacred Heart hospitals' 3D Community Health: Body.Mind.Spirit. program began to implement suicide education, prevention, assessment and intervention initiatives with multiple partners across sectors. In fiscal year 2015, the 3D Community Health team trained 40 people to be trainers in QPR, a system called Question, Persuade, Refer. QPR is an emergency mental health intervention for suicidal persons that identifies and interrupts the crisis and directs the person to the proper care. In fiscal year 2016, community-based trainers provided 47 90-minute classes to 2,399 adults and high school teachers, staff and students in the Chippewa Valley. QPR teaches participants to recognize the warning signs of people contemplating suicide and to act vigorously to prevent a possible tragedy.
In response to requests from the community for more mental health training, 3D Community Health launched adult and youth Mental Health First Aid in 2016. An eight-hour course, Mental Health First Aid teaches participants how to identify, understand and respond to signs of mental illnesses and substance abuse disorders. Mental Health First Aid is on the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-Based Programs and Practices.
Laura Baalrud, community health educator at HSHS St. Joseph's and Sacred Heart hospitals, is certified by the Mental Health First Aid USA educational program to teach the adult and youth courses. Plans are underway for staff to be certified to teach the older adults and veterans modules. In addition to training, HSHS St. Joseph's and Sacred Heart hospitals host The Human Connection Series — an opportunity for people to connect to enhance overall well-being. By hosting expert speakers who enlighten, educate and entertain, the hospitals create avenues to develop and deepen relationships and increase social cohesion. In 2015, the hospitals invited actress and author Mariel Hemingway to share her family history of alcohol and drug abuse and mental illness. As part of the 2016 series, award-winning youth speaker and former at-risk foster kid Josh Shipp presented "Decoding Your Teenager: The Power of One Caring Adult" at two area high schools, as well as at the State Theater in Eau Claire.
3D Community Health has created a unique memorial that is set up at many of their community events, such as the Out of the Darkness Walk, hosted by the American Foundation for Suicide Prevention, the Mariel Hemingway speaking event, and the Teen Mental Health Summit. In total, 154 pairs of shoes are displayed, each representing a life lost to suicide in Eau Claire and Chippewa counties between 2011 and 2015, each with a tag highlighting the age, gender and county of residence of the person who completed suicide.
In 2015, Prevent Suicide Chippewa County united with Eau Claire County to become Prevent Suicide Chippewa Valley. Comprising 17 member agencies, including the hospitals' 3D Community Health, state and county departments of human services, county health departments, the Department of Corrections, county school districts, Mayo Clinic Health System and several faith-based and social service agencies, the coalition increases awareness of the impact of suicide in the community.
Suicide death review teams were established in Chippewa and Eau Claire counties in 2016 to gather data and details to inform suicide education, prevention, assessment and intervention efforts. On the teams are the Chippewa County coroner, Eau Claire County medical examiner and members of the department of human services, members of law enforcement, representatives from the L.E. Phillips-Libertas Treatment Center, and HSHS St. Joseph's and Sacred Heart hospitals. The teams look for commonalities and trends including methods, time of year and geographic area.
Led by the Chippewa Falls Area Unified School District, a suicide "post-vention" community response team was established in fall 2016 to develop a respectful community response to suicide by funeral homes, local media, area schools and law enforcement. The team produced talking points and tools to help the surviving families, friends and communities speak openly and heal without denying or sensationalizing the suicide.
Most recently, HSHS St. Joseph's and Sacred Heart hospitals and other area health and behavioral health providers attended the Zero Suicide Academy,7 two days of training plus tools and support for health and behavioral health care systems to reduce suicide among patients in their care. The program helped attendees develop organization-specific action plans, which are currently being implemented at the hospitals.
In these ways, HSHS St. Joseph's and Sacred Heart hospitals promote social cohesion and encourage civic participation to address suicide in their communities. As a Franciscan health care ministry, Hospital Sisters Health System and its ministries are called to be in relationship, just as St. Francis of Assisi was called to be in relationship with the leper and was transformed by the experience: "When I was in sins, it seemed extremely bitter to me to look at lepers, and the Lord himself led me among them and I practiced mercy with them."8
We, too, in health care must be transformed by the experience of suicide. We must embrace Pope Francis' invitation to actively tend to the social fabric and weave bonds of belonging in the communities we are privileged to serve.
ANGELA D. HALL is system director, mission integration/Franciscan formation and community benefit, with Hospital Sisters Health System, Springfield, Illinois.
- Francis, Laudato Si', paragraphs 149 and 151.
- Regina Berger-Schmitt and Heinz-Herbert Noll, "Conceptual Framework and Structure of a European System of Social Indicators," EuReporting Working Paper No. 9 (Mannheim, Germany: Centre for Survey Research and Methodology, Social Indicators Department, 2000), 13–15. www.gesis.org/fileadmin/upload/dienstleistung/daten/soz_indikatoren/eusi/paper9.pdf.
- Sally C. Curtin, Margaret Warner and Holly Hedegaard, "Increase in Suicide in the United States, 1999-2014," National Center for Health Statistics Data Brief No. 241 (Hyattsville, Maryland: National Center for Health Statistics, 2016). www.cdc.gov/nchs/products/databriefs/db241.htm.
- Paul Quinnett, Question. Persuade. Refer. training manual (2013): 6.
- Quinnett, 7-8.
- The Elijah Project, http://livingtheelijahproject.com/.
- Zero Suicide in Health and Behavioral Health Care, http://zerosuicide.sprc.org/about.
- Thomas of Celano, First Life of Saint Francis, 17. www.vatican.va/spirit/documents/spirit_20001103_om-da-celano_en.html.
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