Care Packages to Promote Universal Suicide Prevention for Remote Alaska Native Communities: What Worked?

Abstract

Purpose:

Alaska Native (AN) youth living in remote Alaska suffer disproportionately from suicide when compared to all other American youth. Promoting Community Conversations About Research to End Suicide (PC CARES) is an intervention led by trained community facilitators, which shares scientific best practices to prevent youth suicide with community adults to spark feasible, culturally-tailored personal and collective action. After training 34 AN facilitators to implement PC CARES in their home communities in late 2019, COVID-19 precluded in-person PC CARES activities, but the need to help adults support youth mental health during this period of quarantine and social distancing remained.

Method:

The resulting adapted ‘PC CARES at Home’ intervention delivered mail-based mental wellness and suicide prevention information and resources to adult community members from June 2020 to July 2022. The project sent 1,527 care packages to 492 participants.

Finding:

According to short surveys (n=199) and interviews done with randomly selected recipients (n=24), adults who received the PC CARES care packages were very satisfied with the contents and found them useful.

Conclusion:

Both acceptance and utility of mental health and safety promotion care packages has implications for offering information and resources to adults in remote communities to support them in promoting youth mental wellness.

Introduction

American Indian and Alaska Native (AIAN) communities have cultural and healing practices that support (and have supported) collective well-being for generations.^1–3 With colonization, AIAN communities and the young people within them face unique challenges that contribute to mental health inequities.^4–6 These issues are linked to imposed historical and on-going cultural violence.⁷ Because Alaska Native (AN) communities are also some of the most remote in the United States, their experience of colonization was particularly recent and rapid.^8–10 Currently, most AN communities are located far from any major metropolitan area and typically disconnected from the National Highway System.¹¹ The lack of accessibility poses distinct challenges to education, health care, employment, and housing, which combined with intersectional marginalization, can reduce opportunities and contribute to AN youth mental health struggles.^12–13 These experiences in conjunction with Western expectations and pressures can contribute to young people’s sense of ‘no way out’ in remote communities.¹⁴

At the beginning of the COVID-19 pandemic, AN communities’ remoteness was an asset since tribal governments exercised their local control by issuing stay-home orders and travel restrictions to keep the disease out of the villages.¹⁵ However, as the pandemic wore on, AN individuals had significantly higher rates of COVID-19 infection, hospitalization, and death when compared to non-Hispanic white residents of Alaska.¹⁶ Factors such as overcrowded housing, inadequate sanitation, and difficulties associated with rural medical care all exacerbated the spread of COVID-19 in remote Alaska.¹⁷ Due to limited resources and health infrastructure, remote AN communities were especially susceptible to long-term injury and mortality from COVID-19.¹⁸

This paper describes how a participatory research project designed to test an in-person suicide prevention intervention (PC CARES) shifted to remote delivery via virtual sessions to schools. Care-packages with suicide prevention information and resources were mailed to adults in remote AN communities who wanted to support youth mental wellbeing during the COVID-19 Pandemic.¹⁹ Promoting Community Conversations About Research to End Suicide (PC CARES) is a community health intervention designed, supported, and implemented for and by AN communities. PC CARES reflects the shared belief that research information can be strategically used by community members that are experts in local community dynamics, practices, traditions, and culture. Developing a ‘community of practice,’ the intervention enables community members to come together to find the best, most appropriate and impactful solutions to reduce suicide risk and promote youth mental wellness.²⁰

The original plan for 2019–2022 was to train local facilitators to host a series of five “learning circles” in their home community. PC CARES learning circles (LCs) equip participants (e.g. parents, teachers, community health workers, counselors, pastors) from the community with actions and ideas for working together to prevent suicide and promote health. The first cycle of in-person PC CARES implementation began with a Training of Facilitators (ToF) in November 2019 which trained 41 community health workers from 15 remote communities to host PC CARES learning circles. After this training, local Facilitators hosted meetings in seven different communities, with 134 learning circle attendees participating before pandemic precautions limited in-person gatherings.

PC CARES At Home

As the COVID-19 pandemic continued, it became clear that in-person PC CARES sessions would not be possible, but community members suggested finding alternative ways to support youth mental wellness during a difficult and unprecedented time.²¹ To do this, the project team worked with community partners to figure out ways to engage with community health workers who were trained as facilitators, as well as with people who had participated in meetings in their community. The remoteness of the participating communities posed some challenges to virtual distance-delivery because of limited internet access, bandwidth, and expensive data plans. The team wanted to continue offering helpful support for youth wellness in an accessible way that was affordable for the project.

The eventual solution was a two-pronged approach: 1) Virtual PC CARES¹⁹ and 2) PC CARES at Home. Virtual PC CARES was an online model that delivered LCs via Zoom mainly to school staff and some clinic-based community health workers, both of which have consistent, reliable internet access through their workplaces. The second component, PC CARES at Home, expanded the program to include information and resource-sharing to support youth mental wellness through care packages (CPs) mailed every few months. CPs typically included information to support adults in connecting with young people in their lives, supporting mental wellness, and increasing safety. Vetted by local experts, CP contents represented some of the content of the PC CARES intervention. These were originally sent to community members in remote communities who attended the in-person meetings at the start of the intervention; however, over time, were sent to a wider population. In this manner, the reach of PC CARES programming spread over the course of the pandemic. In this manuscript, we describe the process of developing this distance-delivered universal prevention intervention, PC CARES at Home, and evaluate its acceptability and potential utility.

Methods

Rural Definition

All Alaska Native communities in this study are defined as “rural” per the guidelines set forth by the Economic Research Service (ERS) of the USDA. In particular, rural-urban continuum codes distinguish these communities as distinct from Alaska’s metropolitan regions.

Local Steering Committee

The original PC CARES study established a Local Steering Committee (LSC) made up of Elders, school personnel, community health workers, and wellness advocates who live in the study regions. The LSC consisted of 8–10 members who met remotely every 1–2 months and gathered in-person annually (pre-pandemic). Membership included leadership with a long history collaborating on the PC CARES project, and newer members representing the school districts involved with virtual LCs.¹⁹ For ‘PC CARES At Home’, the LSC discussed regional priorities related to universal suicide prevention, progress with CPs, and future CP development to ensure that lessons and CP contents were respectful of and aligned with cultural and community norms.

Recruitment

Care packages were originally mailed to PC CARES Facilitators who had attended the ToF, and they distributed the care packages to people in their community who attended the in person learning circles they had hosted. Over time, recipients included people who attended virtual PC CARES sessions, LSC members, and those nominated by existing recipients.

Care Package Development

The specific contents of each CP were organized based on three key factors: 1) research-based information aligned with the original PC CARES curriculum, 2) the ability for these ideas and practices to be translated into material items that could be included in a mailed package, and 3) guidance from the LSC about preferences and usefulness of information and material items. The packages were crafted with intention: planning out useful information for adults, resources to send, and considerations of what recipients could do after getting each package. The number of recipients changed over time as the team required people to ‘opt in’ to continue receiving the care packages, and others chose to receive them after participating in Virtual PC CARES.

When PC CARES at Home began, several PC CARES learning circles had already taken place, providing a starting point for CP materials to remind participants of prevention activities and reinforce the PC CARES information they had already discussed in their community. For example, a handful of communities paused learning circles after attending a learning circle that discusses how “non-demanding” small acts of kindness increase help-seeking for individuals going through a tough time. Small cards to remind the recipient “You Matter” were included in one of the care packages. These popped open with affirming messages inside, and participants were encouraged to distribute to those around them along with a gift box of sweets (Figure 2).

Figure 2.

Example of Care Package Contents

PC CARES solicited input from LSC members about possible topics and in the monthly meetings these ideas were shared, discussed, and workshopped to develop each care package theme and materials. Rather than focus on sending as many packages to as many people as possible, the LSC helped us think strategically about how the packages could be used and what actions or changes might result. LSC members shared their extensive experience with, and knowledge of, the Alaska communities involved in the project. This is well demonstrated through the inclusion of a locking medication bag, to help limit access to pills as a potential means of suicide. LSC members assured PC CARES that the resource was explained in a respectful and culturally acceptable way. More information about the items included in each of the care packages can be found at www.pc-cares.org/care-packages.

Care Package Measures

Evaluation involved participant surveys and phone interviews with five randomly selected recipients for each CP. Paper surveys assessed broad indicators across all CPs using a 7-point Likert scale of agreement for satisfaction ratings, such as “I am happy the PC CARES team sent this package to me.” A 1 indicates total agreement whereas a 7 indicates total disagreement. These surveys also accounted for measured actions, like “I joined (or will join) the PC CARES Facebook group.”, by using frequency counts; the higher the percent on a measure, the higher the number of respondents saying “yes” to a (yes/no) indicator. The survey also included open-ended questions: “What was the best part about getting this package?” and “What do you think could make future packages better/more useful to you?” Several unique questions also reflected the focus of each CP to gauge knowledge and compatibility of the information, such as “Spending time with youth can help with wellness.” from CP 2: Talk with Youth. Participants could send their surveys back to the research team with a self-addressed, stamped envelope, and be entered into a raffle for a $50 gift card.

To collect qualitative information from participants about their experience and satisfaction with the CPs, the research team randomly selected 15 CP recipient phone numbers for each distinct theme and attempted to reach them by phone for an interview. Interview data collection stopped after five recipients per CP participated in brief, 15-minute interviews for each respective CP. Individuals received a $20 gift card for participating in the phone interview. During the phone interview, participants were asked specific questions pertaining to the most recent CP they received like “How, if at all, did you or the young people in your life use the most recent PC CARES care package contents?”, as well as those about suicide prevention broadly such as “Are you interested in learning more about what you can do for wellness in your community?” Questions assessed recipients’ perceptions ranging from lessons learned to feelings generated. All questions were open-ended, and the interviewers followed a semi-structured interview guide (Appendix C). Typically nine questions were asked per interview. The interviews were not audio-recorded, but interviewers took detailed notes, including verbatim quotes.

Analysis

Descriptive statistics of Likert scale questions were analyzed in Excel, while open-ended survey questions were analyzed using Dedoose, a digital software used for mixed-methods research. This was carried out by members of the research team with experience in qualitative coding and analysis. To evaluate open-ended responses, a deductive codebook was developed, reflecting themes that were likely to occur based on the prompts; for example, questions like “What, if anything, didn’t make sense about the PC CARES care package?” were likely to prompt a response expressing confusion.

Thematic and content analysis were used to analyze survey responses.^22–23 Study team members analyzed the interview notes individually, identifying prevailing themes during their review. Once all interviews were read, the noted topics were grouped and labeled thematically. The coding process was adaptive; if one theme was discovered during the reading of the tenth interview, for example, the first nine interviews would be re-read to ensure this theme was not initially missed.

Results

Care Package Construction

Once the focus and contents of each CP were established, the construction and shipment phase began. Items were typically purchased from bulk retailers and delivered to an on-campus site for assembly. There, team members packaged the CPs identically, so that each recipient received the same contents and information. Depending on the theme for a given CP, it typically included: snacks, educational materials, an activity designed to foster connections with others, and a survey. The educational materials were provided in the form of informational cards that integrated easy-to-understand evidence-based suicide prevention and wellness information. Once assembled, CPs were mailed to recipients in remote Alaska.

Excluding postage and labor, the average cost per package was $19.88, with the most expensive package costing $49.66 (with a custom cut and printed deck of conversation starter cards) and the least expensive being $10.02. The information and contents of each CP are described in Appendix A.

Care Package Recipients

The first two CPs were mailed to each community’s PC CARES facilitator who then distributed each package to individuals who participated in the initial in-person LCs (n=140). The next package (CP3) expanded to also include LSC members and village-based counselors due to their interest in receiving CPs (n=170). For CP4, we added recipients nominated by LSC members for being active role models to youth in their respective communities (n=192). Anyone who received CP3 or 4 had the option to opt-in to future deliveries, with a lack of response resulting in a discontinuation from the program, reducing recipients for CP5 and CP6 to 74 and 75. This was both a cost-saving measure and a way to ensure the packages were sent to recipients who wanted them and wanted to make use of them. After this, virtual LC participants had the option to sign up to receive CPs when they registered for the virtual sessions (n=95). There were 2 waves of virtual PC CARES with CP recruitment increasing participation in PC CARES At Home to 201 for CPs 7 through 10. Lastly, sign ups occurred via social media (n=4).

Demographic data were not collected as part of care package evaluation, however LC participants who participated in a baseline survey (n=232) did indicate both their gender and race/ethnicity. Most respondents were women (75%), and the most represented racial group of respondents were Alaska Native individuals (42%).

Care Package Reach

Overall, ten distinct CPs (CP1 - CP10) were sent over the course of approximately two years. Table 1 summarizes theme, shipment date, and the number of CP recipients per package. In total, 492 individuals from a variety of recruitment methods received care packages (Figure 1). It is important to note that recipients had to opt-in to receive future packages after CP4; this accounts for the significant decrease in participants from 192 (CP4) to 74 (CP5). Additionally, CP10 represents a decrease after list maintenance such as eliminating repeat addresses. In total, 492 people in Alaska, mostly rural-remote, received at least one PC CARES care package. A total of 1,527 packages were sent to 34 communities across the state of Alaska.

Table 1.

Care Package Information

Number	Theme	Date Mailed	New Recipients	Packages
1	Small Acts of Kindness	June 2020	132	132
2	Talking with Youth	August 2020	0	132
3	Listening Well	March 2021	38	170
4	Nominated Small Acts of Kindness	March 2021	192	192
5	Restful Sleep	May 2021	0	74
6	Healthy Living	August 2021	0	74
7	Reach out to Youth to Show you Care	October 2021	95	170
8	Safe Homes	January 2022	31	201
9	Building Connections	May 2022	4	205
10	Finding Balance	July 2022	0	177
Total			492	1527

Figure 1.

Number of Distinct Recipients by Recruitment Methods

Surveys

Surveys were included in each of the 1,527 CPs sent between June 2020 – July 2022. Response rates were generally low since participants needed to fill out surveys and mail them back. Response rates were as low as 8% for CP10, and as high as 30% for CP5. Out of 1,527 total surveys sent to participants, 208 were returned, giving an overall response rate of 14%.

Returning to the scale of 1–7 in which 1 represents total agreement, most recipients agreed that they were glad to receive the shipment (1.24), and that it was well put together (1.11). Similarly high agreement was seen for measures of finding contents useful (76–82%) and planning to use the contents in the future (76–80%). Respondents overwhelmingly felt that CP contents made sense, namely the theme and enclosed letter (1.37) and information card (1.33). Individuals described an overall sense of understanding of the different aspects of CPs, including the purpose of the mailings (1.56), recommendations for promoting wellness (1.46), and applications for preventing youth suicide (1.34). Beyond simply understanding what they received, most people said they could envision themselves doing the suggested activities (1.38), and most were comfortable enough to take action to engage with youth (1.44). Participants broadly agreed that they already have or plan to partake in various actions after receiving the package (e.g., sharing food items, 82%). Participants widely agreed that they already or planned to participate in the activities suggested by the care package (e.g., sharing food items, 82%) which varied according to its theme (Table 2). Tables 3 and 4 shows complete survey results.

Table 2.

Survey Suggested Activities

CP Number	Example of Suggested Activity
1, 4- Small Acts of Kindness	I gave some treats to someone I don’t know well.
2- Talking with Youth	I used the question cards to start a conversation with a young person in my life.
3- Listening Well	I created opportunities for youth to talk about their emotions.
5- Restful Sleep	I put up the magnet showing how much sleep we really need.
6- Healthy Living	I put up the CDC exercise recommendations magnet or shared it with someone.
7- Reach out to Youth to Show you Care	I shared or used the stickers or the “You Matter”/”Happy Day” cards.
8- Safe Homes	I put pills in the locking medication bag.
9- Building Connections	I read or shared the deck of cards with questions and prompts with youth.
10- Finding Balance	I put up the “My Balanced Plate” magnet about eating traditional, local foods as part of a balanced diet.

Table 3.

Survey Summary- Likert Average

Package	Number of respondents	I know what the PC CARES team is trying to do with this package	This package gave me ways that I can promote wellness	I am happy that the PC CARES team sent this package to me	I see how the information in the package can help with youth and prevent suicide	I can imagine myself doing the suggested activities	I feel comfortable following the tips in the package to engage with youth	The theme and letter made sense to me	The information card sense to me	This care package was well done
CP 2	12	1.92	1.36	1.00	1.00	-	1.43	1.00	1.07	1.00
CP 3	23	1.21	1.29	1.43	1.43	-	1.53	1.82	1.07	1.00
CP 1 + CP 4	39	1.70	1.56	1.30	1.21	-	1.42	1.47	1.44	-
CP 5	22	1.41	1.36	1.05	1.36	-	1.36	1.36	1.09	1.00
CP 6	18	-	1.39	1.11	1.06	1.22	1.67	1.11	1.11	1.00
CP 7	29	-	1.41	1.10	1.41	1.34	-	1.35	1.32	1.00
CP 8	29	-	1.53	1.38	1.44	1.38	-	1.47	1.31	1.21
CP 9	21	-	1.62	1.38	1.57	1.48	1.33	1.38	1.76	1.35
CP 10	15	-	1.62	1.38	1.57	1.48	1.33	1.38	1.76	1.35
Mean:	-	1.56	1.46	1.24	1.34	1.38	1.44	1.37	1.33	1.11

“-” represent data that was not available for a given CP (e.g., question was not applicable, sample size was too small)

Values represent the average score on a Likert scale of 1–7, with 1 being total agreement and 7 being total disagreement

Table 4.

Survey Summary- Percent Agreement

Package	Number of respondents	I read* the letter or information card	I talked* to youth about the information	I participated* in the suggested activities	I used* the shareable food items	I used* the activity guides	I spent* time with youth through the activities
CP 2	12	86%	71%	79%	71%	79%	79%
CP 3	23	92%	76%	52%	-	72%	64%
CP 1+CP 4	39	91%	-	-	79%	40%	60%
CP 5	22	100%	-	91%	82%	91%	86%
CP 6	18	95%	100%	83%	95%	100%	95%
CP 7	29	90%	-	83%	87%	57%	83%
CP 8	29	97%	-	88%	56%	88%	81%
CP 9	21	95%	-	67%	95%	81%	95%
CP 10	15	100%	-	47%	87%	80%	-
Mean:	-	94%	82%	74%	82%	76%	80%

^*Despite being listed in the past tense, these actions also encompass the future tense (e.g., I will read)

“-” represents data that was not available for a given CP (e.g., question was not applicable, sample size was too small)

Percentages represent the percent of respondents providing a 1, 2, or 3 on a given question, indicating agreement with the respective statement

Interviews

Despite attempting to contact and interview 25 individuals, only 24 participated in 20-minute interviews. In total, there were 14 broad themes identified throughout the interviews (Table 5).

Table 5.

Codebook Descriptions

Theme	Example Response
Learned something	“1 think since there was only 1 fidget spinner and 5 kids in the house, they learned how to share.”
Provided reccomendation	“Include maybe artwork unique to the region, photos.”
Engaged with youth	“My grandkids who live with me they love the fidget spinners. They said ‘ana, you play with fidget spinners?’ I said no, you got to show me.”
Redistributed contents	“Magnet went directly to a teacher [for classroom use].”
Found useful	“I like the lock bag. I feel that’s very useful.”
Satisfied	“I like the graphics, bullet points… the fact that it’s not too long.”
Surprised	“I was surprised to see the lock bag in there because in previous care packages it was more inexpensive items.”
Confused	“[Figuring out] how to reset the lock [was unclear]. No instructions that I could find. I guess I can Google it.”
Forgot about PC CARES	“I’m not sure what PC CARES is, I don’t know if it’s an icebreaker approach or what.”
Future interest	“Do I you have to ask to join [the Facebook group]? I’ll googe [it] now… I just requested.”
Future actions	“We are just adding a few more things to our daily routines… less screen time and more outdoor time.”
Connection to suicide or violence	“Here we’ve seen suicide in a village that’s quite close to us.”
Age appropriate	“I just have younger students who are 4th grade or younger, so I have not shared [CP contents] with them.”
Alaska or Native culture	“[I recommend] stuff towards more of the native culture; native coloring books… magnet with 4–5 phrases in Inupiaq… berry buckets.”

Overall, interview participants overwhelmingly were satisfied with CPs and found them useful. Frequency of each codebook theme varied greatly with the most common sentiment reflecting interest in care packages continuing (21 interviewees; 88%). People who opted out of the interview usually said it was because they were too busy. Most respondents (20 interviewees, 83%) expressed satisfaction with the care package contents and found the packages useful. When explaining how they used one or more of the items; the snacks were often used immediately whereas less tangible components, such as the magnet in CP5 “Restful Sleep”, were described in terms of their planned future use. Seventeen people (71%) gave specific recommendations for improving future mailings, such as items they would like to see in the future, including regional artwork. Of those interviewed, 16 individuals (67%) used the CP contents to engage with youth in their life, and this was often done with the included games or activities:

“I brought up [depression] while [my son] was eating the gummies. I reflected on how I went through depression before in the past… and I just told him you can tell me anything”.

- Care package recipient

Fifteen interviewees (63%) mentioned redistributing the contents of CPs, typically sharing items with youth in their life, neighbors, and co-workers. One interviewee described giving the lockable medication pouch from CP8 “Safe Homes” to another person who had a sibling that could benefit from it. There were 10 individuals (43%) who described some form of a planned future use, such as going berry picking. Ten people (43%) also expressed feeling surprised about the CPs; in some instances, surprise originated from forgetting that they signed up or not knowing when the next one would show up, nor what it would include. Nine interviewees (38%) reported that they had learned something from the CPs, most often attributing this to the information on the included card. There were 6 individuals (25%) who told a story about some personal connection to suicide”

“In the last week one of my friends attempted suicide, and it was through conversation that it was figured out what was going on”.

- Care package recipient

Six interviewees (25%) also brought up some aspect of Alaska Native culture as either a future suggestion or key value to their communities:

“We like simplicity. Iñupiaq people, like me, just say it straight. Just the easiest words you can use. That way, we’ll remember and apply it to our thinking”.

- Care package recipient

In a few instances, people we interviewed expressed questions or concerns about age-appropriateness of CP contents (n=2), wondering about the target age range of care package recipients.

Discussion

Across both surveys and interviews, evaluation findings show that recipients 1) were satisfied with the included materials and 2) saw utility in them. By building the LSC with individuals who live in remote Alaska and know it best, this intervention was guided from the beginning by local experts. Creating culture- and region-specific programming is optimal for maximizing the experience of participants,²⁴ and this was reflected in PC CARES at Home. This intervention was a “light-touch” in comparison to the pre-existing PC CARES model; through similar structures of community involvement and promoting social connectedness (i.e. including “You Matter” cards to be shared with others to show that they are appreciated). PC CARES at Home built on what was already working in communities, meaning the care packages offered ideas and resources for adults to support the young people in their lives.^25–29 Both survey and interview results demonstrated high levels of satisfaction with CPs, as well as perceptions of CP utility. Interviews brought up new topics around prevention that had not yet been seen in the surveys: personal connections to suicide or violence, and Alaska Native-specific references.

In surveys, individuals’ participation in suggested activities were relatively low, with 40% being the lowest in one specific suggestion—using the activity guide. This may be because of the difficulty of facilitating broad behavior change after one-time receipt of information. This was however the activity guide for CP4, a package that otherwise was highly accepted by recipients. Regardless, in discussion of these results, members of the Local Steering Committee emphasized that even 40–50% rates of engagement represent progress that has been made over time, even compared to 25 years ago.

A greater proportion of people reported they can imagine themselves doing the suggested activities than said they did them. Making the leap from intention to enacting behavior change involves several factors, including opportunity, self-efficacy, and beliefs about the benefits and barriers to action.³⁰ Bridging this gap can be done in a variety of ways such as reducing perceived barriers and increasing self-efficacy. It is also beneficial to ensure that practices remain culturally-informed in order to have even greater success.³¹

There is strong evidence to suggest that the care packages augmented the remote PC CARES learning circles that occurred during the COVID-19 pandemic, specifically by increasing at-home access to tools for practical health promotion. According to the Health Belief Model, reducing barriers and influencing participants’ self-efficacy are key moderators affecting uptake of health behaviors.³⁰ The packages were intentionally designed with the audience—and their potential barriers—in mind. For example, in development of a care package about restricting access to lethal means of suicide, we discussed how to address the topic when households rely on firearms for protection and hunting. Further discussion involved the curation of items small enough to be shipped to 200 households, but useful enough to be worth including. The package eventually became CP8, Safe Homes, which included a lockable medication pouch— a practical solution for addressing one specific means of suicide. The care packages represent a shift to community empowerment by showing that suicide prevention is something in which everyone can participate.

Strengths

Our novel mail-based youth mental wellness promotion program was highly acceptable, feasible, and brought the information and material resources directly to the adults who were encouraged to offer support and safety to young people in their lives. This offers a potential supplement to previous findings that promote support from adults to reduce youth suicide risk.^20,32–33 Additionally, the simplicity of the intervention-sending mental health promotion information and resources to hard-to-reach recipients- makes it replicatable. Mental health counselors in two communities who received care packages were inspired by the program to replicate it: in at least two villages, village-based counselors made some of their own care packages to give out in their own villages after receiving some of the PC CARES packages.

Related to this, the successful ongoing recipient contact that occurred within PC CARES at Home offers insights towards strategies for rural health promotion. Caring contacts approaches using text messages for suicide prevention with AIAN peoples has been found similarly promising.^34–35 Our approach utilizes this non-demanding approach of “caring contacts”, in which affirmational messages are sent via various modes of communication (e.g., mailed letters, text messages), to increase help-seeking before a crisis.^36–38 The CP intervention is preventative in nature and, unlike existing ‘caring contact’ programs, does not focus on those in distress or receiving emergency care, however, it was highly acceptable and initiated support that was well-received by caregivers or adults interested in supporting youth mental health. Since recipients’ satisfaction did not diminish over time, the study offers support for the existing recommendations for continuing contact long-term.^36,39

PC CARES at Home maintained on-going connections with participants up to two years after initial contact. This approach was highly acceptable and engendered positive associations with PC CARES, which may support future engagement. Recipients’ high levels of satisfaction and utilization of promotion items offers an acceptable way to reach many under-served recipients and share resources to promote mental wellbeing.

Limitations

A limitation of the CP program was the low response rate (14%) from the surveys. It is possible that the participation incentive (a $50 gift card drawing) was not proportionate to the effort involved in responding. There is also often unreliable mail service in remote Alaska, where priority mail packages can sometimes take over a month to be delivered; participants may have felt that too much time had passed before they were able to return the survey, and so they discarded it. The remote communities who received the CPs require people to bring outgoing mail to their local post office, an extra step that may have impacted response rate. Additionally, selection bias may have been present in the evaluation process. Since most CP recipients were receiving shipments based on their attendance at LCs, these individuals were likely already interested in the topic of suicide and prevention. These individuals may also be more prone to taking positive initiatives to promote community wellness, so it is not clear if these results are generalizable to the greater AN population.

Conclusion

Effective suicide prevention requires sustained and multilevel efforts (Wexler et al., 2024). The CP mailings engaged remote community members during the COVID-19 pandemic, supplementing virtual PC CARES and reinforcing the attitudes and behaviors aimed at universal prevention: reducing suicide risk and promoting mental wellness.^19–20,40 Recipient satisfaction and utilization of materials and ideas in PC CARES at Home suggests the promise of mail-based programming for maintaining connection with and offering resources and information to underserved remote communities. The intervention offers a way to reinforce prevention messages and engender good will with community members who are important supporters for suicide prevention efforts, especially in remote regions with very limited formal services and opportunities. Offering culturally-responsive, mail-based universal prevention resources to remote AN community members is a promising way to maintain contact, support everyday risk reduction, and promote mental wellbeing, as well as encourage partnership with the sending organization. These outcomes can lay important groundwork for building collaborative and positive relationships with adult family members in under resourced, remote communities with mental health organizations. These connections can begin to bridge the gap between community and institutional supports, which together can work to prevent youth suicide.

Appendices

Appendix A.

CP Contents

	CP 1	CP 2	CP 3	CP 4	CP 5	CP 6	CP 7	CP 8	CP 9	CP 10
Health Promotion Items
Topic information card	x	x	x	x	x	x	x	x	x	x
Snacks	x	x	x	x	x	x	x	x	x	x
Tea/coffee	x			x	x	x		x
Words of affirmation	x			x			x
Card game		x							x
Sewing kit		x
Conversation starters		x				x			x
Berry-picking bucket		x				x				x
Tissues			x
Wellbeing magnets			x		x			x	x
Inspirational stickers				x			x
Earplugs					x					x
Lotion					x	x
Fishing lure						x
Fidget toy							x
Lockable medication bag								x
Wellbeing poster								x
Temporary tattoos									x
Sunscrees										x
Hygiene products										x
Satisfaction Assessment
Survey	x	x	x	x	x	x	x	x	x	x
Pre-addressed/stamped envelope	x	x	x	x	x	x	x	x	x	x
Price	$10.02	$49.66	$16.84	$11.88	$10.81	$13.95	$17.86	$19.26	$26.65	$25.33

Appendix B.

Survey from CP5

Appendix C.

Interview Questions

PC CARES AT HOME

INTERVIEW QUESTIONS

1. What, if anything, would make the most recent PC CARES care package better or more useful to you or to the young people in your life?

2. What, if anything, did you or the young people in your life learn from the most recent PC CARES care package?

3. What, if anything, was surprising about the most recent PC CARES care package?

4. What, if anything, didn’t make sense about the PC CARES care package?

5. How, if at all, did you or the young people in your life use the most recent PC CARES care package contents?

6. Have you joined the PC CARES at Home Facebook group? Have you “liked” our page on Facebook?

a. If so, what do you think about it?

b. If not, why have you not joined the group yet?

c. What, if anything, could we do to make the Facebook group better?

7. Are you interested in learning more about what you can do for wellness in your community?