Table 3.

SAFETY-A implementation determinants: Interview and focus group themes and exemplar quotes

Themes	Exemplar Quotes
Facilitators
1. Legislation/policy (AB 2246) driving districtwide action	“We are a preschool through transition school district, so when we did our board policy and all that, we were not specific to just 7th to 12th. It was district wide. So, I know they’ve now passed the other one for elementary, while we were already doing it with the whole school district with AB 2246.” [I-13]
2. Collaborative and supportive risk assessment teams	“That collaboration and team effort, it’s definitely very, you know, all of us collaborating that means, we are, we donť feel we are alone in the risk assessment, which is definitely very comforting.” [FG-4]
3. Staff dedication to student mental health	“The strengths are the caring adults and whatever it takes attitude, right? It’s the people. The strengths are the people and the care.” [I-14]
4. Perceived benefits of SAFETY-A	“So this plan, or this program, has in place that opportunity for the parent and the school counselor or the school personnel to really start building that relationship so that hopefully that comfort level then increases and then hopefully there’s more opportunity then for follow through on the parents’ part because they’re building that trust, that trusting relationship. So, I really like that part of the program.” [FG-1]
Barriers
5. Lack of funding	“Again can we improve? Yeah, if we had more funding that would help, but you know. So you have to be able to do everything, even though you don’t have funding right?” [I-14]
6. School and individual liability	“I just can’t help but worry about the liability of saying okay, I’m working with the student, I’m working with the parent, we have a plan, everything seems to be going great, and then they go home, and then something happens. And then I have to go back to my plan, thinking where did I go wrong?” [FG-1]
7. Challenges with getting everyone “on the same page”	“Well we do, but we are also reviewing to make sure, because you know it’s, it’s a constant, the constant challenge to have everyone on the same page, you know?” [I-7]
Subtheme: Variability in provider confidence with risk assessment	“I think that some of our academic counselors are more comfortable with the suicide assessment than others. And so, I think there are some that would not be comfortable doing this, as we are already not comfortable of necessarily even with training, doing a suicide risk assessment.” [FG-5]
Subtheme: “Different hats”: Competing staff priorities	“I would say the most difficult part about all of this is the fact that school psychologists are in charge and they also wear different hats in special education and are in charge of assessments and timelines and holding [Individualized Education Program] meetings.” [I-10]
8. Long wait times to access community-based MHS	“It’s whether or not there’s anybody on the other side who has space in their calendar to take them on and there can be a delay that turns the families off because they get tired of trying to work within the system.” [FG-5]
Tailoring Variables
9. School district culture valuation of student mental health	Facilitator: “Because the district is forward thinking, they’re very collaborative and open to new ideas, and it’s a district that really value the mental health of their kids.” [I-9] Barrier: “But there really isn’t more of a universal approach to really help the entire school community know that mental health is important. It is a need. Our kids are crying out for help...We need to shift our mindset and really put this as a priority.” [I-6]
10. Leadership support for mental health initiatives	Facilitator: “We have a new Superintendent who is very, very much invested in our schools’ safety and students’ mental health. And so it’s very easy for me to bring in, you know, a program forward and to say that it’s going to benefit our students.” [I-3] Barrier: “And so there has to be approval from the district-level in order for changes to truly happen and because there isn’t really much advocacy for mental health at that level, it makes it challenging for the change to happen across the board.” [I-6]
11. Reliance on external agencies for risk assessment and deploying emergency transport	Facilitator: “We hardly ever use PMRT. We do everything locally. We train our staff, we train our psychs, our interns…the intern academy, and we do it as a team. And we would like to keep it that way, internally, because we know the students and their families.” [FG-4] Barrier: “We provide social and emotional support and we do safety assessments. But for hospitalization purposes, PMRT would assess the students. So, we’re not the final determiners of whether a student goes to the hospital or not.” [FG-1]
12. Workforce capacity and provider burden	Facilitator: “When there is something like this particular protocol or program or training, it is put throughout the school and we can tap into different individuals because you don’t need to be necessarily, have particular credentials to offer this.” [FG-1] Barrier: “I'm wondering about the capacity. At the high school we’ve got four counselors and they have a caseload of about 400 each, and it seems like their days are just chock full of academic careers and social-emotional learning, not any deeper extended therapy.” [FG-4]
Subtheme: Presence of licensed mental health clinicians at school sites	Facilitator: “Right now is fortunate that in the past five years we’ve had some mental health therapists within our department…we also have a very strong intern Academy.” [FG-4] Barrier: “We don’t have clinical therapists at our schools. Our school counselors do safety assessments for suicide intervention. And we do rely on PMRT when it’s a high risk.” [FG-1]
13. Provider attitudes towards adopting new practices	Facilitator: “I’m so excited about this program that you’re talking about because we absolutely want to have the most up-to-date, evidence-based, cutting-edge practices and procedures and protocols in place to be able to support our programs and families.” [I-7] Barrier: “Absolutely. And you're always going to have a few people that, been there done that, ‘Wait, another new program?’ You have some of those.” [I-7]
14. Interpretation support for school community threshold languages	Facilitator: “And we provide everything in Spanish and English, and now we’re also starting to do it in Mandarin.” [FG-3] Barrier: “The one concern with some populations might be, as one of our staff mentioned, we think, was the language, right? So, we needed translators and all of that.” [FG-5]
15. Perceptions of stigma and knowledge about mental health in families	Facilitator: “Last year we had a foundation, it’s called the With Hope Foundation, that came out from Orange County and did a suicide, a suicide awareness workshop for our parents, and it was well attended, and the parents, they want the information.” [FG-1] Barrier: “There is, you know, much more stigma in certain populations with mental health and having somebody else be involved and how much you’ll share with outsiders.” [FG-5]
Subtheme: Perceptions of caregiver engagement in risk assessment	Facilitator: “I think when I have made calls, they have been supportive. They have been able to kind of follow, kind of, the recommendations that we as a team have provided.” [FG-4] Barrier: “There are often times where students and parents can’t be in the same room and can’t get to that strengths-based place. And it’s really difficult when you have a student and a parent in the room and the parent is not listening to that student or not validating.” [FG-1]
16. Resources to mitigate cost and insurance barriers	Facilitator: “…‘We don’t have the $100,’ and that’s the reason why a child is not being able to service, then we pick up the tab. So, I have a therapist in our department, that we will serve the family and the student at no charge for the family.” [FG-4] Barrier: “I think everybody else’s concern is when we have this student who’s super high risk, who has frequent suicidality, but they have insurance. They can’t do full-service partnership or come into an agency that’s going to meet them where they’re at. They are kind of stuck.” [FG-4]
17. Relationship-building and outreach efforts to engage families	Facilitator: “I think one of the things that will be key to this is developing that level of trust with the school and the families beforehand…So, I think in addition to our counseling services, and I think the fact that we started with the foundation of [Positive Behavioral Interventions and Supports] at all our school sites will help to make this a little more successful.” [FG-5] Barrier: “And so the resistance I could see from our newly immigrated families, who are really kind of scared of the whole mental health talk and understanding it, their knowledge is very limited. There is trust issues there with the majority culture.” [FG-4] “We have families who are living, you know, in our school district who live in fear every day because of immigration statuses and blended family statuses when it comes to immigration, and so there is a resistance, and fear to seek services.” [FG-3]

Note: “I” indicates that the quote was stated in one of the 15 interviews; “FG” indicates that the quote was stated in one of the five focus groups.