Introduction
Suicide claims nearly 1600 lives in North Carolina each year.1 Both the rate of suicides, from 13.8 per 100,000 in 2004 to 16.6 per 100,000 in 2023, and the total number of suicide deaths per year—from 1017 deaths to 1593 deaths over the same time span—have risen in the state over time.1 Available data on rates of suicide and suicidality may not capture the full extent of the issue. For each individual who dies by suicide, many more consider suicide, attempt it, or receive medical care for self-harm. Further, each death by suicide leaves a lasting impact on loved ones, friends, and community members. As many as 135 people may be affected by each individual suicide.2
Many of the most concerning trends in suicidality center on the state’s youth and young adults. Suicide is the second leading cause of death for youth aged 10 to 18 and the third leading cause of death for those aged 19 to 34. In 2023, nearly 10% of North Carolina high school students reported that they had attempted suicide within the past year.3 These figures were even higher for students identifying as female (12.2%), Asian (21%), Hispanic or Latino (11.7%), and gay, lesbian, or bisexual (18.9%).4
Research points to a number of factors contributing to youth suicide risk in recent years. These include increasing rates of isolation and loneliness among young people, negative impacts of the COVID-19 pandemic on youth mental health, impacts of rising technology and social media use, and young people’s concerns about the world and their futures.5 Barriers to treatment for youth mental health are also a significant issue in North Carolina. Sixty-seven counties in North Carolina have no practicing child or adolescent psychiatrists, and 29 counties have no practicing psychologists.6
Given the pervasiveness of mental health challenges and the structural barriers to care, community actors are increasingly called upon to identify complementary approaches to suicide prevention. This can be especially valuable for addressing youth suicide. Schools, faith communities, youth-serving nonprofits, health providers, and other local organizations often serve as trusted points of contact for young people and their families, positioning them to play a critical role in recognizing signs of distress, normalizing help-seeking behaviors, and connecting youth to appropriate supports.
This need for multi-sector community partnerships informed the development of “Our State, Our Wellbeing,” an initiative launched in 2023 by Carolina Across 100 in partnership with the University of North Carolina (UNC)'s Suicide Prevention Institute (SPI). The initiative sought to convene community teams with a shared interest in suicide prevention and to support them in developing coordinated, cross-sector strategies responsive to local needs.
Our State, Our Wellbeing: Program Design and Objectives
Carolina Across 100 launched at UNC Chapel Hill in 2021 with a mission to establish partnerships between UNC and communities in all 100 North Carolina counties to address challenges associated with the COVID-19 pandemic.7 Following a statewide listening phase to identify priority issues, Carolina Across 100 was determined to make mental health and suicide prevention one of its core efforts.
Carolina Across 100 engaged with SPI as a co-lead for this effort. Founded in 2022 through a major gift from William and Dana Starling, SPI seeks to offer cutting-edge care to patients in North Carolina while also supporting research to better understand the neurobiology of suicide and how it can be prevented.8 SPI includes more than 40 affiliated faculty and researchers across disciplines including medicine, psychiatry, social work, education, and psychology.
The program came to be known as “Our State, Our Wellbeing.” Carolina Across 100 selected 15 local teams representing 24 counties to participate in a year-long peer learning program through a competitive application. Each selected team was composed of varied local stakeholders, including health providers, government agencies, educational institutions, faith-based groups, and civic and nonprofit organizations. The program was intentionally designed around the premise that no single organization or sector is capable of comprehensively addressing this challenge, particularly in contexts where clinical capacity is limited. While teams were interested in suicide prevention across demographic subgroups, youth was a common focus among teams, often inspired by the loss of a young person or young people in the community.
Between August 2023 and August 2024, teams participated in four peer learning forums and monthly webinars to deepen their understanding of both principles for community collaboration and strategies for suicide prevention. Carolina Across 100 also provided financial support to each team for project management and to sponsor pilot implementation projects. Faculty and staff from SPI provided subject matter expertise and technical assistance on research about suicide, its contributing factors, and strategies for prevention, intervention, and postvention. Carolina Across 100 also sought to align program content and team activities with other frameworks for suicide prevention in the state and nationally, including the North Carolina Comprehensive Suicide Prevention Action Plan and the Centers for Disease Control (CDC) Suicide Prevention Resource for Action.9,10
The program began with the presentation of community-level data for teams to understand the prevalence of suicidality and associated risk factors. Teams then developed shared vision statements, goals, objectives, and action plans to support their work. Forum and webinar content highlighted potential case studies and strategies for engaging with different types of partners or stakeholders (e.g., schools, faith communities, demographic subgroups) and understanding contextual issues related to suicide prevention (e.g., state policy and investment in mental health, mental health workforce availability). With support from partners including SPI, the American Foundation for Suicide Prevention, and the North Carolina Department of Health and Human Services, teams were connected with resources (e.g., 988 Suicide and Crisis Lifeline materials, gun locks, gatekeeper training opportunities) to implement select strategies.
Core Strategies
Many of the initiatives teams pursued were based on the CDC’s Suicide Prevention Resource for Action, which highlights 7 broad strategies for suicide prevention: strengthen economic supports; create protective environments; improve access and delivery of suicide care; promote healthy connections; teach coping and problem-solving skills; identify and support people at risk; and lessen harms and prevent future risk.10
Within these strategies, teams tended to focus their efforts on reducing stigma toward mental health and increasing awareness of resources; expanding trainings in gatekeeper protocols including Question, Persuade, Refer (QPR), Mental Health First Aid (MHFA), and Applied Suicide Intervention Skills Training (ASIST); limiting access to lethal means of suicide; and promoting healthy connections through community events. Importantly, however, the local knowledge, resources, and partnerships that Our State, Our Wellbeing teams brought to their work shaped the ways in which these strategies were implemented on the ground.
For teams focused on youth, schools were a natural starting place to implement their priorities. The Ashe County Mental Health Forum integrated mental health screenings into annual sports physicals offered to student athletes in their school district, reaching approximately 400 students each year and allowing school counselors to efficiently identify students in need of additional support.11 Multiple teams created suicide prevention resource kits to share with students and their families, which included gun locks, medication disposal bags, 988 Suicide and Crisis Lifeline materials, and resource pamphlets, along with items like fidget toys and stress balls. A number of other teams made concerted efforts to train staff in Teen MHFA and implement evidence-based programs like Sources of Strength and Tealeaf through partnerships with SPI faculty.12,13
However, teams also looked more widely for potential partners to implement the work. For example, Village of C.A.R.E., a team based in Wake and Franklin Counties, developed an outreach strategy relying on local barbershops to expand mental health training and distribute suicide prevention resources. This approach was intended to overcome traditional barriers to mental health care in Black communities through the recognition that barbershops can provide a more comfortable setting to discuss mental health and related issues. Village of C.A.R.E. trained local barbers in gatekeeper protocols like Question, Persuade, Refer (QPR) and Mental Health First Aid and distributed gun locks and 988 Suicide and Crisis Lifeline materials in their shops.14 These types of creative approaches were common among participating teams and proved especially effective for trainings and resource dissemination. Churches, summer camps, YMCAs, Big Brothers Big Sisters, scout troops, and youth sports organizations were among numerous other partner teams engaged in the team work.
Teams also provided creative opportunities to engage young people directly in their work to promote mental health and suicide prevention. For example, in Transylvania County, TC Strong established chapters of the student-led organization Voice of the Students at the county’s middle and high schools.15 The organization, which offers a forum to discuss issues related to mental health, provides opportunities for youth in the community to develop leadership skills and strengthen connections with peers while simultaneously providing insight on youth needs to school personnel and community partners.
Program Successes
Carolina Across 100 partnered with SPI, Abacus Evaluation, and participating teams to develop a shared measurement system to track teams’ activities and accomplishments throughout Our State, Our Wellbeing. Teams reported data three times during the year-long program: at six months, nine months, and one year.
Over the course of the program, the participating community teams collectively delivered 1641 mental health services and distributed 5006 gun locks. They held 661 trainings and events, reaching a total of 19,005 attendees. They distributed 57,751 physical or virtual informational resources, including psychoeducational materials, referral information, and 988 Suicide and Crisis Lifeline promotional materials. While prevention outcomes are difficult to assess due to the complex and multi-causal nature of suicide, these metrics suggest progress. Participating communities now have more individuals trained to help others in need, broader awareness of available resources, and new approaches to overcoming stigma related to discussions of suicide and mental health.
Beyond these measures, teams also increased their capacity for collaboration, laying the foundation to build stronger, more aligned systems of care moving forward. The teams reported forming a total of 410 new organizational partnerships through the program, primarily community-based organizations, educational institutions, and faith-based organizations. Through qualitative survey responses, teams highlighted that the cross-sector approach allows them to expand their service reach, increase access to resources, and avoid duplicative efforts.
Future Directions
The cross-sector collaborative approach employed in Our State, Our Wellbeing provides one replicable model to involve a broad array of stakeholders in efforts to prevent suicide. Our State, Our Wellbeing and efforts like it can be an important complement to more comprehensive efforts to expand mental and behavioral health care. Policies and practices that expand the behavioral health workforce and increase access to crisis care and mental health services can address critical gaps, particularly for more intensive forms of care. North Carolina leaders have recently prioritized such systemic action, including an $835 million investment in the state’s behavioral health system using federal funds received following the expansion of Medicaid.16
Despite these limitations, the practical experiences of the Our State, Our Wellbeing cohort suggest that cross-sector community collaboration is a valuable tool for suicide prevention, both across populations and for youth in particular. By using local networks and engaging a variety of partners and community members, the Our State, Our Wellbeing teams demonstrate how community stakeholders can work together to spread awareness, promote connection, identify individuals at risk, and connect people to valuable resources and supports for suicide prevention.
Financial support
Financial support for the Our State, Our Wellbeing program was provided by the UNC Office of the Chancellor, UNC Suicide Prevention Institute, and Camber Foundation.
Declaration of interests
The author has no conflicts of interest to declare.
Correspondence
Address correspondence to Michael Welker, 400 South Road, Knapp-Sanders Building, CB 3330, Chapel Hill, NC 27599-3330 (mwelker@sog.unc.edu).