Suicide is a significant public health concern, with rural communities experiencing disproportionately higher rates than urban areas. This disparity is linked to factors such as social and geographic isolation, socioeconomic disadvantage, and limited access to mental health services. In Australia, suicide rates increase with remoteness, affecting men in rural areas particularly severely. Existing suicide prevention programs often struggle to effectively address these unique challenges. Community-based approaches are recognized as cost-effective, but their operational definitions and implementation processes require further investigation. This study aims to address the gap in understanding community-based suicide prevention in rural Australia by exploring the key considerations when implementing such programs to best meet community needs. The study focuses on the perspectives of individuals with extensive experience in this field, considering how these approaches can be tailored to local contexts and realities while leveraging existing social capital and resources. This research seeks to clarify the meaning of 'community-based' suicide prevention, identify essential components for successful implementation, and offer guidance for future policy and program development.

The literature highlights the increased suicide risk in rural areas, influenced by social isolation, economic factors, and limited access to mental health services. Stigma and stoic ideals further hinder help-seeking behavior, especially among men. Community-based programs are recognized as cost-effective and crucial for strengthening community ownership and sustainability of suicide prevention efforts. Existing guidelines and toolkits, like the Suicide Prevention Australia's 'Communities Matter' toolkit, offer guidance on community-driven approaches. However, these resources often lack a precise definition of 'community-based' prevention, leading to varying interpretations and challenges in implementation. Evaluations of national programs like the National Suicide Prevention Trial have identified inconsistencies in the understanding of community-based programs and implementation barriers. The lack of studies specifically examining community-based prevention in rural Australia and its adaptation to local needs motivated this study.

This qualitative study employed a positivistic approach using semi-structured interviews and focus groups. Participants (n=37) were purposively recruited from across Australia based on their expertise in rural suicide prevention, encompassing roles in community services, program provision, research, and policy development. Inclusion criteria required participants to have experience working in paid positions in the field, be over 18 years of age, and able to communicate fluently in English. A snowball sampling technique was used to expand participant diversity and reach individuals at the community level. Data collection occurred between January and September 2021, utilizing Zoom for most interviews and one face-to-face interview, adhering to COVID-19 restrictions. A 32-item COREQ checklist guided the process. Thematic analysis was employed to identify patterns and themes within the transcribed data. Two researchers independently coded the data, ensuring accuracy and consensus on emerging themes. Data collection continued until data saturation was reached, indicating no emergence of new themes with additional data.

The analysis yielded three overarching themes: 1. **Community-Led Initiatives:** Participants emphasized grassroots approaches with community involvement at all stages. Non-clinical efforts, led by community members (including those with lived experience), were highlighted. Co-designing programs with community members ensured relevance and effectiveness. Partnerships between diverse groups—community members, local services, and professionals—were deemed essential for successful implementation. Identifying and empowering natural leaders and gatekeepers within the community to deliver practical interventions were considered crucial for achieving widespread impact. 2. **Meeting Community Needs:** A core element involved understanding the definition of ‘community’. The study found different perspectives on what constitutes a community. Some defined it geographically, while others emphasized shared interests and values. Understanding community needs and locally identified issues is crucial for effective intervention. Adapting programs to accommodate diverse cultural and social contexts is also essential for program success and acceptance. Inclusive engagement strategies that incorporate both formal and informal channels for communication were emphasized as critical for success. The research highlighted successful programs' ability to weave in community healing elements. 3. **Programs to Improve Health and Suicidality:** Community-based suicide prevention addresses the root causes and conditions contributing to suicidal behaviors. The emphasis is on improving overall health and well-being, addressing social determinants of health in non-medical settings. Universal programs that build community resilience, raise mental health awareness, and reduce stigma were highlighted. The interventions addressed the broader social environment, aiming to improve quality of life. A range of approaches were acknowledged, from awareness-raising activities and informal support networks to more formal programs, adapting to the availability of resources and the needs of the target population.

This study provides valuable insights into the nature of community-based suicide prevention in rural Australia. The findings reinforce the importance of community engagement, empowerment, and the utilization of existing social capital. The study supports a social innovation approach, framing suicide as a social issue that necessitates community-led solutions. The key themes highlight the need for non-clinical initiatives that address the social determinants of health, engage natural community leaders, and utilize the existing social networks. Furthermore, the findings emphasize the importance of flexible, culturally sensitive programs tailored to specific community needs and characteristics. The results suggest that effective suicide prevention requires a multi-faceted approach that involves various stakeholders, from community members and service providers to researchers and policymakers, working collaboratively. This study's findings can inform the development of more effective and relevant suicide prevention strategies.

This research underscores the vital role of rural communities in suicide prevention. Successfully transitioning suicide prevention from national to regional levels hinges on empowering these communities with the resources and knowledge to implement effective, locally relevant programs. The study’s findings recommend supporting community organizations and members, including those with lived experience, in program design and implementation. Future initiatives should prioritize community engagement, partnership building, and culturally sensitive program development to address the unique challenges and needs of rural populations. Further research is warranted to rigorously evaluate the effectiveness of various community-based interventions and to explore strategies for scaling up successful initiatives.

The study's limitations include potential sampling bias due to variations in participant numbers across states and demographic groups. The perspectives presented may reflect the experiences of specific participant groups and not necessarily generalize to the entire population. The influence of power dynamics between research/policy and service/program provider roles is also acknowledged as a possible influence. While participants shared experiences from various locations across Australia, the sample may not represent all communities or rural areas completely.