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10.1371/journal.pone.0306801
PONE-D-23-23584
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Text2whaiora after a suicide attempt: Text message design alongside people with lived experience
Text2whaiora after a suicide attempt
https://orcid.org/0000-0002-7189-1272
Ng Lillian Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing 1 2 *
Diamond Danielle Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Supervision Validation Visualization Writing – original draft Writing – review & editing 2
Ang Mike Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Supervision Validation Writing – original draft Writing – review & editing 2
1 Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
2 Department of Mental Health and Addictions, Health New Zealand Te Whatu Ora Counties Manukau, Auckland, New Zealand
Davison Karen M Editor
Kwantlen Polytechnic University Faculty of Science and Horticulture, CANADA
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: lillian.ng@auckland.ac.nz
6 9 2024
2024
19 9 e03068012 8 2023
24 6 2024
© 2024 Ng et al
2024
Ng et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background

People with lived experience have had limited opportunities to meaningfully contribute to the design of caring contacts interventions. The objective of this study was to co-design text messages with peer support specialist staff to determine optimal language and delivery, within a cultural context.

Methods

In this qualitative study, participants were professional peer support specialist staff with lived experience employed by specialist mental health services. They were asked to evaluate the initial series of text messages by taking part in a focus group using a semi-structured interview. This was audiotaped, transcribed and analysed using reflexive thematic analysis with specific coding of cultural themes.

Results

Three main themes were identified: upholding a person’s autonomy; establishing connection as a bridge to safety; and, words as healing rongoā (remedy). The last theme contained a cultural subtheme: Māori language providing entry to the Māori world.

Conclusion

People with lived experience breathe empowerment and hope into caring contacts interventions and should be considered vital partners in developing any suicide prevention initiative. Feeling genuinely cared for promotes connection and may enable an internal sense of safety. Tailoring of texts can be enhanced by culturally nuanced language.

http://dx.doi.org/10.13039/100012744 Oakley Mental Health Research Foundation 3725210 https://orcid.org/0000-0002-7189-1272
Ng Lillian Lillian received an Oakley Mental Health Foundation Grant 3725210 oakleymentalhealth.co.nz The funders did not play any role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data AvailabilityData cannot be shared publicly because the participants have been users of mental health services. Excerpts of the transcripts relevant to the study will be made available upon reasonable request from the corresponding author. Data requests may be sent to the New Zealand Health and Disability Ethics Committee by e-mail: hdecs@health.govt.nz or Professor Trecia Wouldes, Head of Department of Psychological Medicine, Faculty of Medical and Health Sciences: t.wouldes@auckland.ac.nz
Data Availability

Data cannot be shared publicly because the participants have been users of mental health services. Excerpts of the transcripts relevant to the study will be made available upon reasonable request from the corresponding author. Data requests may be sent to the New Zealand Health and Disability Ethics Committee by e-mail: hdecs@health.govt.nz or Professor Trecia Wouldes, Head of Department of Psychological Medicine, Faculty of Medical and Health Sciences: t.wouldes@auckland.ac.nz
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pmcIntroduction

SMS text messages are becoming a powerful tool to connect service users to mental healthcare services [1]. They can be sent to a person shortly after they attempt suicide and reach them over a sustained period of time [2]. Text messages are an example of caring contacts [3], an intervention for suicide prevention that is gathering research interest. The essential element of caring contacts is the use of brief, caring language to communicate the sender’s awareness of the patient and convey positive feelings towards them [4]. Caring contacts involve sending a person a series of personalised text-based communications that express interest and concern for their wellbeing. The person is not required to respond or act, and the contact may indirectly facilitate engagement with healthcare services [3]. In principle, caring contacts are an asynchronous, non-intrusive, inexpensive intervention with a potentially broad reach [5, 6]. In New Zealand, and globally, SMS text messages are a practical means to enhance help-seeking behaviour and engagement with treatment [7]. Caring contacts can be delivered to people when they are discharged from acute psychiatric settings, such as an Emergency Department (ED) [8].

The concept of caring contacts originated in the form of typewritten letters [3] but progressively evolved to include postcards [9], emails [10] and text messages [11]. The protective effect on preventing suicide may be the recipient of messages developing a sense of connection and relatedness. They may perceive this connection and social support as a buffer against stress and suicidal behaviour. Text messaging has advantages over other types of interventions in being able to reach people wherever they are located and addressing suicide risk during treatment gaps [10]. However, the evidence for efficacy of brief contact interventions is mixed [12]. Findings from a small Australian study show text messages provided comfort to service users in knowing that there was someone who cared [1]. Meta-analytic studies show caring contacts reduce some suicidal behaviours and there is limited evidence in reducing suicide mortality, hospitalisation or presentations to the emergency department [5]. A randomised controlled trial of caring text messages sent to military personnel in the United States had inconsistent results but recipients had less suicidal ideation and fewer attempts at suicide [11].

Caring contacts are culturally and ecologically relevant to indigenous peoples and collaboration with specific communities allows messages to be tailored to their needs [13]. In Aotearoa New Zealand, consideration of Māori health dimensions is essential in working with tangata whaiora, defined as ‘a person seeking wellness’ [14]. Māori models of health provide access to Māori world views, incorporating hinengaro (mental), cultural, wairuatanga (spiritual), environmental and whānau (family) dimensions [15, 16]. Increasing suicide rates among indigenous peoples have been linked to cultural alienation, not helped by western philosophies and traditions [17]. A multi-dimensional approach to suicide prevention is necessary, particularly research that affirms indigenous self-governance, culture and world views. Culturally nuanced findings may be transferable internationally, where there are indigenous or first nations peoples who are familiar with the Turamarama declaration [17], which affirms the agency and rights of these communities to find their own solutions for health, including suicide prevention.

The Lancet Commission recommends that people with lived experience of suicidal behaviour be involved in all stages of treatment development [18]. This is in keeping with the movement toward patient-oriented research, that aims to empower patients in the process of research, optimise research design, enhance validity and make knowledge exchange more effective [19]. The goal of patient-oriented research is achieved when research findings improve the health of the population under study [20, 21].Having lived experience of a condition, of navigating the healthcare system and being willing to share those experiences are important contributions.

So far, people with lived experience have had limited opportunities to meaningfully contribute to the design of caring contacts interventions. These studies typically involve small numbers [22, 23]. Larsen et al’s research co-designed a SMS brief contact intervention with lived experienced groups for delivery in an ED setting after a suicide attempt. People with suicidal ideation or suicidal behaviour had a preference for SMS, compared with other forms of follow up [22]. In this research, we aimed to co-design SMS text messages with peer support specialist staff working in mental health service to determine optimal language and delivery, tailored to our cultural context. We describe our peer specialist participants as “people with lived experiences,” and acknowledge that this term encapsulates a range of experiences such as distress and a range of social stressors [24]. We take “lived experience” to mean someone who has an experience of mental distress, and acknowledge their diverse experiences, and intersections with other identities. In this article, we use Māori terms that can be translated differently in other contexts.

Methods

Research context

The research team are located at Health New Zealand Te Whatu Ora Counties Manukau in Auckland, an ethnically diverse city (approximately 1.5 million) which includes New Zealand’s largest Māori and Pacific population. At our locality, there are approximately 2000 mental health-related presentations to the emergency department per year. Most who attempt suicide will be discharged to primary care or to a local community mental health team. There can be a significant delay in follow up after the person leaves the emergency department and some will receive minimal follow up, if at all. The researchers’ backgrounds include expertise in academic, clinical, quality improvement, policy and suicide prevention coordination. One of the authors (DD), is a psychologist of Māori (Kāi Tahu and Ngāpuhi) descent, and was instrumental in leading the research team in Māori and Pacific consultation to ensure the study incorporated culturally safe practice, equity and the needs of Māori participants in consideration of constitutional Te Tiriti o Waitangi (Treaty of Waitangi) principles. As such, an indigenous lens on the research process, which include specific analysis of cultural nodes and their interpretation in reporting the findings.

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the S1 File.

Study design and recruitment

This qualitative study was approved by the New Zealand Health and Disability Ethics Committee. We used interpretive description, a methodology that combines a clinical and research lens to study design, which has pragmatic utility in applying findings to clinical contexts [25], including psychiatric settings [26]. The first draft of a series of seven text messages were designed by a psychiatrist (MA) in consultation with a clinical psychologist (Table 1). Consultation was then obtained from the specialty Māori and Pacific cultural teams and the peer support professional lead based at Te Whatu Ora Counties Manukau. The participants were professional peer support specialist staff employed by specialist mental health services, with lived experience of mental health care. Most had direct experience of suicidal behaviour, such as suicidal ideation, a suicide attempt or the death of a family member from suicide. All had experience of supporting someone with suicidal behaviour. They were asked to evaluate the initial series of text messages by taking part in a focus group using a semi-structured interview. The coordinators of the peer support programme invited potential participants to the study who were sent a participant information sheet (PIS), including a copy of the proposed questions, prior to the focus group interview. Written consent was obtained from all participants. The recruitment period of the study was from 28 February 2023 to 28 March 2023.

10.1371/journal.pone.0306801.t001 Table 1 Initial and revised text message series.

TEXT SERIES	Original Text	Modified Text	
Text 1
(Within Week 1)	Kia ora [name],
It was good to meet you yesterday. If you need more support you can freephone 1737.
Arohanui [name]	Tēnā Koe [name],
It’s [name] here from [location]. I was just wondering how you were going after yesterday. Remember for support freephone or text 1737.
Arohanui (warm regards) [name]	
Text 2
(Week 1)	Kia ora [name],
Hope your day is going well. You can freephone 1737 if you want to kōrero about how things are going.
Take care [name]	Tēnā Koe [name],
[name] here from [location]. Just seeing how you are doing? You are most welcome to freephone or text 1737 if you want to korero(talk) about how things are going. Take care. [name]	
Text 3
(Week 2)	Tēnā Koe [name],
Hope you are feeling uplifted in your Mauri today. 1737 is available on text for support.
Ngā mihi [name]	Kia ora [name],
We were thinking of you. Hope you are feeling uplifted in your Mauri (energy) today.
If you like to you can contact 1737 by free phone or text.
Ngā mihi (Regards) [name]	
Text 4
(Week 4)	Kia ora [name],
Hope all is well with you and your whaanau. You can Freephone 1737 at any time if you want a chat.
Kia kaha. [name]	Kia ora [name],
Hope all is well with you and your whanau (family). You can Freephone or text 1737 at any time if you want a kōrero (chat).
Ngā mihi (regards) [name]	
Text 5
(Week 7)	Kia ora [name],
[name] here. Thinking of you and wishing you well.
For support or a kōrero Freephone 1737.	Kia ora [name],
[name] here. Thinking of you and wishing you well.
For support or a kōrero (talk) Freephone or text 1737.	
Text 6
(Week 11)	Tēnā Koe [name],
Hope you are feeling settled in your wairua.
Freephone 1737 for support.
Ngā mihi [name]	Tēnā Koe [name],
Hope you are feeling settled in your wairua (spirits). Freephone or text 1737 for support if you want.
Ngā mihi [name]	
Text 7
(Week 12)	Kia ora [name],
Hope all is going well for you. You can Freephone or text 1737 for support or a korero.
Arohanui. [name]	Kia ora [name],
Hope everything is going well for you. Support or a korero (chat) continues to be here for you. Freephone or text 1737.
Arohanui (warm regards) [name]	
Optional on birthday	Happy Birthday [name],
We hope it’s been ka pai and that this year brings you good things!
From [name]	No change	

Data collection

The researchers met with the participants for two sessions. In the first session (60 minutes), the study rationale and context were explained to participants at which time they had the opportunity to ask questions. In the second session (90 minutes), participants were asked to provide basic demographic information and the focus group interview was audio-recorded.

Analysis

The audiotaped recording from the focus group interview was professionally transcribed. The transcripts were de-identified and stored in NVivo version 14, a computer assisted qualitative database system. Participants were given the option to check their transcript for accuracy. Data was analysed using reflexive thematic analysis [27, 28]: first steps were familiarisation and engagement with transcripts, descriptive coding (defined as facets of meaning) and generating initial themes (defined as central organising concepts). To enhance analytic rigour, the research team discussed queries regarding context and initial themes with a researcher with expertise in qualitative methodology, who independently coded the transcript. Specific coding of Māori cultural themes was conducted to the analysis (DD) to ensure tino rangatiratanga (ownership) over matauranga Māori (Māori knowledge). In a recursive process, themes were refined in relation to the research question, returning to the original data for deeper interpretation. The process was documented in memoranda in keeping with an audit trail.

Results

There were seventeen participants, ranging in age from 26 to 57 years, including Māori, Samoan, Niuean, Cook Island, European, Indian and Chinese ethnicities with between 1 to 14 years of experience employed by publicly funded mental health services in peer specialist support roles. Three main themes were identified: 1) upholding a person’s autonomy; 2) establishing connection as a bridge to safety and 3) words as healing rongoā (remedy). A cultural subtheme was identified within the third theme: Te Reo Māori (Māori language) providing entry to te Ao Māori (the Māori world).

1) Upholding a person’s autonomy

This theme was focused on tangata whaiora (person seeking wellness) and their progression from being in an emergency department having just attempted suicide to recovering from the ordeal. Participants highlighted the concept of returning power to the person. They were cognisant of wider effects of suicide on other family members, with associated trauma, suffering and devastation:

“The family are the ones on the ground floor, ground zero, they’re the ones that have the initial impact. I found my older brother and the impact of seeing [him] do that is really destructive. Having some support for the whanau while they’re going through that difficult time”

The participants wanted the text messages to “create inclusion,” to include key supports but ensure permission was granted to let family know they were receiving text messages:

“Can we ask whānau if they would like them to receive them as well? ”

They were mindful of evoking memories of the suicide attempt and carefully holding the person in mind with “a statement you’re making in these texts.” They endorsed practical encouragement in SMS to “help them through challenges they’re experiencing.”

Participants spoke of having power in exercising choice, whether to discontinue texts or call a free phone for support services, not to feel pressured, and a conversational and friendly invitation to engage:

“We’re just checking in. You have the option if you want to kōrero [talk]… Not demanding to but implying it would be great to hear from you. Not saying, please do or you have to but we’d be happy if you did.”

The group emphasised “mana” [a definition used here is ‘personal power’] of tangata whaiora, so they controlled decision-making in their recovery:

”What if they don’t want to talk to you? We’re thinking about you and you’re most welcome to call freephone 1737 if you want to korero about anything. I think the mana must stay. The choice must stay.”

As part of maintaining autonomy, participants wanted details about the text message schedule to be clear: who they were from, where they were sent from, how often, what would happen if they replied back to a text message and the process of opting out of receiving them.

2) Establishing a process of connection as a bridge to safety

From the first contact, creating a caring connection was viewed as important. Participants liked the idea of being called beforehand, to impart a sense of there being a real person behind the messages. This promoted feelings of being connected to someone who was holding them in mind, “thinking about you,” in a personal way:

“It lets people know they haven’t been forgotten, that contact’s important. Yeah, and personalised. Being able to cater to someone who is from a certain age range who would respond a bit differently to different types of language use…If someone a lot younger talks a different way it might feel more personalised to their way of talking.”

The genuine and compassionate conveyance of hope resonated most with participants, feeling like someone cared:

“I’m wondering who’s this? Because I just had a really traumatic day…A bit on introduction to who is sending the text…Most government departments, they never write they care about you. I would love that, seeing that aroha nui [love] and thinking, oh they care…you’ve really hit that connection there.”

Participants recommended invitations to seek out support to be threaded in every text message. This consistency was a reminder that support was available to opt into and link to safety.

“We’re holding hope for you. This third text you can freephone text for support or kōrero ‐ that might be nice with the first text you send. I don’t know if they already know [freephone number]…this point needs to be in the first statement…That wasn’t offered in the first one or the second one, the freephone. It just came over here in text seven.”

The frequency of the SMS schedule (delivered the day after their suicidal attempt, then one week, two weeks, three weeks, four weeks, six weeks and three months) was “about right.” People would potentially be reminded of an event they wanted to move on from, evoking mixed feelings if it was untimely, if they were at work, or in a different headspace. No assumptions could be made about whether a text message would be interpreted positively or negatively:

“If you hang out with your friends and your phone’s on the bench and you get that, I mean, if you’ve got good enough mates they won’t care… oh that’s right, I tried to do that a few months ago…it’s just the timing of it, maybe a little bit awkward… Might make a day not the best or make a bad day potentially worse but also the chance to make it significantly better.”

Some participants commented on the emotional tone of messages, “that one felt warmer to me, got support and kōrero [talk] and she [the sender] wished me well. Thanks [name] for wishing me well, is probably what I would say after I read it, thanks.” They were receptive to this warmth, a sense of plugging into a human connection. They also highlighted that whaiora could opt out of receiving texts if they did not find them helpful.

3) Words as healing, rongoā

This theme emphasised i) the power of words and ii) Te Reo Māori (Māori language) as entry to te Ao Māori (the Māori world). Words were spoken of as having healing qualities like rongoā, a Māori term to describe healing through medicinal and other cultural treatments (one definition).

i) The power of words

One participant described how physical wounds could be seen but unseen wounds from a suicide attempt which required mending.

“If you have the opportunity to hear somebody else talking and breathing life into you, it helps you grow and improve…this can be very beneficial because the healing will continue even after the attempt.”

Participants were sensitive to people feeling raw, traumatised and having negative memories of the event. They proposed using words that would accurately reflect and convey understanding, potentially that all may not be well:

“If I’ve been in hospital because I’ve had a suicide attempt, someone a couple of days later saying, I hope your day’s going well, I will feel like, do you really get it? You know, I’m probably still transitional. It sounds a little too happy to me.”

Carefully choosing words to frame messages was highlighted as very important particularly in the texts that people would receive in the few days after their suicide attempt.

“It was good to meet you–just doesn’t sound right. I mean, they’ve been there for a suicide attempt… something more like, we wanted to check in after our meeting yesterday.”

Subtle changes to the wording in texts were suggested to neutralise the tone of messages. Different phrases were trialled, for example:

“I was just wondering how you are after yesterday, how are you going? I really like this one…because it’s not insinuating anything…it’s saying, hey I hope everything’s going well, not necessarily saying anything’s wrong. It’s just a reminder, I think that’s very middle ground… One word can change the perspective of the person completely.”

Participants were asked about visual images sitting alongside words in text messages, which they were cautiously receptive to:

“You’ve got to be careful what images trigger for people. I mean, if they just tried to drown themselves, that [image of the water] wouldn’t be it.”

They liked the idea of colours, seeing yellow as “vibrant and hopeful,” green as “peaceful and chilled” and purple as “spiritual.”

ii) Te Reo Māori (Māori language) providing entry to te Ao Māori (the Māori world)

Sending greetings in Te Reo Māori was seen as a gateway into te Ao Māori (the Māori world), which was also acknowledged as part of contemporary life in Aotearoa New Zealand:

“Start with Tēnā koe [formal greeting] then go onto Kia ora [less formal greeting].”

There were healing properties in introducing self as a means of whakawhanaungatanga, (a process of establishing relationships) to establish connection and rapport. Conveying “I wish that you are well, I care about you” in text messages epitomises connection. Participants advocated for translating key Māori words into English, to enhance access into Te Ao Māori (the Māori world) An example is the use of the word mauri, which one definition can mean vital essence or life force. This was translated further simply into energy.

“It might not be the same but it would be good. Energy is a nice word…[next to] mauri…I feel that would be in everyday use and more widely accessible.”

Taking care in saying goodbye, even briefly, was considered important:

“I think ngā mihi is great, that’s commonly known. It’s at the end of the message…you feel like okay, this is signing off. If I was feeling quite fragile and the message showed an understanding of how it was it might make me feel better.”

The use of Te Reo Māori was threaded throughout the messages, which further demonstrated the importance of language in connection for tangata whaiora Māori. Participants highlighted being mindful of a person’s background and tailoring messages according to context and preferences, for example translating mauri into equivalent language for Pacific people.

Discussion

The objective of this research was to design SMS text messages with peer support specialist staff working in mental health services, with attention to language, delivery and cultural context. We suggest three coherent principles to guide communication via texts: upholding a person’s autonomy; establishing connection as a bridge to safety and words as healing rongoā. The third theme guides the design of messages that are tailored to indigenous culture in Aotearoa New Zealand, incorporating Te Reo Māori (Māori language) and providing entry to te Ao Māori (the Māori world).

The participants’ experiential knowledge is central to this study. This research responds to a challenge of more closely examining the acceptability of interventions [12, 18], by working with people with a personal connection to suicide as vital partners in developing, testing and refining the text message series. This aligns with expressed expectations that health services will partner with service users and whānau [29]. The participants’ embodiment of empowerment and hope represent the ultimate connection to choice and collaboration with mental health services [30]. Their contributions emphasise aspects of personal agency, such as intentionality, self-regulation and motivation [31]. As a collective, their focus on caring for the person and capacity for reflectiveness undoubtably added value to the SMS series, promoting connection by use of caring language. The process of hearing the series of text messages spoken out loud was unifying and validating. The participants held in mind people receiving the texts, infusing compassion into the design process by the use of humanising language [32]. They heightened awareness of sensitive factors and contexts that surround people attempting suicide and returning to their lives thereafter. They endorsed self-efficacy [31], and the idea that even a simple message can have an important impact [5]. Establishing connection is the foundation of caring contacts, and the Māori concept of whakawhanaungatanga, which essentially focuses on relationships [33]. In this study, participants articulated the positive emotional impact of feeling genuinely cared for and not forgotten. This potentially enables an internal sense of safety and being in control, expressed in confidence to reach out for help, connecting to other support or opting out of the intervention.

The cultural context of this study is unique [34], in referring to words as healing rongoā, a solution that contributes to Māori health gains and reduces barriers to access and use of healthcare services [35]. This is exemplified by the discussion of mauri or life force that is evident in the vitality, integrity and energy within a person, and establishing positive relationships in the wider environment. Māori language is linked to the concept of mana, or dignity [36]. Participants from different cultural backgrounds connected with the expression of mauri as the essence of a person’s character. The concept of mauri is important in understanding suicide [17], acknowledging the anguish and perplexity associated with suicide and the impacts on families, friends and whole communities. There was specific mention of healing the wounds of suicide. There is need to heal both our own wounds and the wounds of our lineage [15]. The task in preventing suicide is rejuvenating mauri, to overcome grief. The text messages express expectations for wellness. In essence, when we greet one another with ‘Tēnā koe’ and ‘Kia ora’, we are equally saying ‘be well’ [37]. Cultural identity and language, as means of establishing connection, are precursors to living well [38, 39]. Language was revised with humanistic and cultural qualities there were not necessarily clinical or technical. The participants highlighted whānau, or families, as prime agents in strengthening mauri [15]. This illustrates agency as integral to personal context and their wider sociocultural milieu [31].

Strengths and limitations

A strength of this study is the unique sample, a large group of ethnically diverse people of different age ranges with lived experience who also work in publicly funded mental health services. The seventeen participants meet together on a regular basis. This familiarity enhanced rapport and open dialogue within the focus group. Members of the group had lived experience of mental health service involvement, and were familiar with navigating the mental health system but not all may have had lived experience of suicidal behaviour. Quotations are not individually attributed and the large size of the focus group may have privileged the voices of some group members, at the expense of those who were reticent, shy or least experienced. We do not consider these to be critical limitations in reporting the data. Their collective contributions are accepted as “taonga” (treasure) rather than “tokenistic [40]. We acknowledge the influence of our disciplinary origins and collective interpretations on the analytic narrative as a limitation. This was mitigated by independent co-coding by an experienced qualitative researcher and specific focus on cultural coding. The original text messages (Table 1) may reflect clinical psychiatry and psychology perspectives on the core components of caring contacts, being brief and non- demanding, whereas the final modified text highlights how the experiential knowledge of those with lived experience was elevated to convey a more humanistic tone, emphasising different modes of communication and nuances of Te Reo Māori. Peer specialist-researchers were not involved in designing the original draft of the SMS text series and analysing the data, which would have provided a different perspective on the findings.

Implications for practice and future research

This study illustrates the value of including people with lived experience of mental distress in planning and designing mental health interventions [18, 30]. Access to the voices of this important stakeholder group is facilitated by building trust in relationships with gatekeepers, who protect the welfare and interests of such groups. It would be helpful to involve peer support specialists in conducting research and implementing findings in healthcare services.

Text (SMS) messages can potentially overcome the limitations of other types of contact [6]. The optimal frequency and length of SMS contact may be up to 12 months, extending well beyond an acute crisis [1]. SMS can be considered an adjunct to formal follow up and service users can determine if it is conducive to their recovery by choosing to opt out of receiving messages. In terms of upscaling this type of caring contacts intervention, widespread use of mobile phone technology allows SMS to be readily deployed and may be more acceptable than alternative clinical therapeutic options, especially for young people [23, 41]. Text messages can be used as a brief intervention to identify emergency contacts during a suicide crisis [42] and promote engagement with treatment and safety planning. New Zealand census data indicates a high level of access to mobile phones with active internet connections [43]. Texts may be suitable for those who do not receive formal follow up from mental health services [44], although it cannot be assumed that all have access to, or funds to maintain mobile phones.

Emergency Departments are underutilised sites for suicide prevention for treating those who attempt suicide [8]. The ED can be a site to implement caring contacts as people discharged after a suicide attempt may not attend follow up. Obtaining perspectives of service users on engaging with caring contacts using technology would be a valuable focus for future qualitative research.

Conclusion

Words are healing and powerful when delivered in a way that uphold a person’s autonomy. People with lived experience breathe empowerment and hope into caring contacts interventions and should be considered vital partners in developing suicide prevention initiatives. The emotional impact of SMS text messages in feeling genuinely cared for promotes connection and may enable an internal sense of safety. There is benefit in designing this intervention with people who have lived experience. There is additional value in input from people from the same cultural background to tailor messages with more culturally nuanced language.

Supporting information

S1 File Inclusivity in global research.

(DOCX)

The authors gratefully acknowledge the contributions of the research participants. Thank you to Moko Kairua for contributing her expertise, and to Rapua Whaioranga, Faletoa and Kiri Prentice for leading and supporting the study design. Thanks to Olivia High for her advice on the initial SMS series and to Lyn Lavery for her assistance with the analysis.

10.1371/journal.pone.0306801.r001
Decision Letter 0
Davison Karen M Academic Editor
© 2024 Karen M Davison
2024
Karen M Davison
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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PONE-D-23-23584Text2whaiora after a suicide attempt: text message design alongside people with lived experiencePLOS ONE

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Thank you for your submissions and two reviews have been completed. I am hoping you can address their comments and resubmit your manuscript.

Kind Regards,

Karen Davison

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall this study is very important as a "method" SMS text messaging for structurally vulnerable people who experience mental health challenges and or mental illness. The value added of this qualitative study is in the inclusion of peers as evaluators for text messages.

1.The background shows a good understanding of the literature and need for the study. However, it would be good to situate the study within a global context. For example, the human rights of Indigenous people globally and the global movement toward "Patient Oriented Research" or the inclusion of patient involvement in research extends to public involvement, which means that research is carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them. There is another important concept of "peer" and this has not been defined interms of where this concept came from? this again might help contextualize the paper and its findings within a broader audience.

2. On Page p.4 can you clarify which sentence is requiring a page number reference? see: p2.” Meta-analytic studies show caring contacts reduce some suicidal behaviours and there is limited evidence in reducing suicide mortality, hospitalisation or presentations to the emergency department (Skopp et al., 2023).

3.On page p. 5 please elaborate on how this affected access and support see "…For example, a New Zealand qualitative study asked people with suicidal ideation or suicidal behaviour about their emotional responses to caring contacts and accessing supports (High, 2022). SMS text messages were preferred, compared with other forms of follow up".

4.Methods: If you are using reflexivity as a method of analysis vs a “ method” please elaborate. You could describe this method as a qualitative method incorporating critical reflexivity?- semi structured interviews peer involved research..is not as clear. You note that you adapt from Braun and Clarke to use thematic reflexive analysis, how critical is it that your peers had lived experience, when some research participants did not have lived experience of suicide? this leads to the rich texts and quotes which came from your participants, and it is difficult to see who said what.

The authors mention on p.7 "The analytic narrative of the research was influenced by the intersections of our disciplinary origins and collective interpretations". However as a reader it is hard to see the variation of your participant responses in relation to the themes. The collective meaning that was derived makes sense but we don't get a clear sense of who said what and why.

5. The recommendation under number 4 is to provide some distinctions amongst the data participants as later the authors go on to state on p. 17 " Culturally nuanced findings may be transferable internationally, where there are indigenous or first nations peoples who are familiar with the Turamarama declaration, which affirms the agency and rights of these communities to find their own solutions for health, including suicide prevention". It is recommended that these kinds of human rights and Indigenous rights policies be addressed in the backround section as well as this should not be written as a limitation- given you adopt Braun and Clarke's thematic and reflexive analysis which foreground the active role of the researcher in developing and reflecting on the findings. This idea might also be strengthened if the authors clarify the role of psychiatrist and clinical psychologist. If embedded in a culturally safe framework what is the role of these professionals?

6. More analysis could be provided related to frequency of text schedules as most participants noted that they would prefer to have messages stopped after 3 months, but connect and support should last longer? so there maybe a need to explain what this means in relation to acute mental health crisis and need for follow up support.

7. Not clear how NVivo data analysis software program was used in the analysis or storing the data, please use standard spelling. Limitations could include a mention of other methods that could be used in future to strengthen "peers" voices.

8. The discussion and conclusion provide good implications for policy recommendations. This section could be strengthened by highlighting key policy and practice recommendations for institutional settings, i.e. main stream or Maori mental health settings where mental health supports are provided for patients and families that have experienced a suicide attempt and/or lived experience of someone they know. Is there also a need to adopt an intersectional analysis for diversity of needs that attend to having hand held "devices" where affordibility might be an issue. This section could be strengthened with a discussion related to policy and practice recommendations keeping in mind the peer recommendations.

9. Finally, there is good attention to power but less attention to individual agency and the factors that promote agency. The authors might consider this to add to the nuanced discussion on power. Further, what do the findings mean globally related to issues about equity and virtual care technologies, again this could also be added in the background sections.

The paper could be strengthened with attention to these details.

Reviewer #2: This is an interesting and important study. It is well written and clearly presented.

At the same time, the manuscript can be enhanced through attention to the following:

1. How is 'lived experience' being conceptualized in this study?It would be good for the authors to elaborate on this and cite the literature that acknowledges the limitations of singular and static categorical identities, which do not fully recognize that people often occupy multiple identity categories, including clinician/service user/person with lived experience/suicide survivor/professional, etc. See for example J. Voronka's work on the politics of people with lived experience

2. It would be illuminating to see the original text messages prepared by the psychiatrist/psychologist, which were provided to the focus group for evaluation. Note that this relegates the persons with lived experience to the role of 'editors' more than co-designers of the text messages. I wonder if this might be considered as a potential limitation.

3. In the description of the analysis, the authors note that they were influenced by their 'disciplinary origins' but this is not made explicit. What is the theoretical orientation that is being brought to bear on these data?

4. How is the experiential knowledge of those with lived experience being elevated/mobilized to add value to what is already known about the content/form of caring contacts?

5. The qualitative data provided in support of the claims is often rather sparse and the analysis would be strengthened if there were more in-depth quotations provided across the participants

6. What was the length of time provided for the focus group? For 17 people to be able to share their views, there would need to be ample time given to listening to the diverse range of perspectives.

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Reviewer #2: No

**********

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10.1371/journal.pone.0306801.r002
Author response to Decision Letter 0
Submission Version1
5 Apr 2024

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

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The revised manuscript and title page are now formatted to meet the PLOS ONE style requirements.

2. Note from Emily Chenette, Editor in Chief of PLOS ONE, and Iain Hrynaszkiewicz, Director of Open Research Solutions at PLOS:

Did you know that depositing data in a repository is associated with up to a 25% citation advantage (https://doi.org/10.1371/journal.pone.0230416)? If you’ve not already done so, consider depositing your raw data in a repository to ensure your work is read, appreciated and cited by the largest possible audience. You’ll also earn an Accessible Data icon on your published paper if you deposit your data in any participating repository (https://plos.org/open-science/open-data/#accessible-data).

The authors have elected not to deposit the focus group data, as it contains some participants’ more sensitive and personal information.

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The PLOS questionnaire on inclusivity in global research has been completed and is attached as supporting information.

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The funding information and financial disclosure sections are completed.

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Before we proceed with your manuscript, please address the following prompts:

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b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible.

Please update your Data Availability statement in the submission form accordingly.

Excerpts of the transcripts relevant to the study will be made available upon reasonable request from the corresponding author.

7. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

The ethics statement is located in the Methods section, as per the online submission form.

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Additional Editor Comments:

Thank you for your submissions and two reviews have been completed. I am hoping you can address their comments and resubmit your manuscript.

Kind Regards,

Karen Davison

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall this study is very important as a "method" SMS text messaging for structurally vulnerable people who experience mental health challenges and or mental illness. The value added of this qualitative study is in the inclusion of peers as evaluators for text messages.

1.The background shows a good understanding of the literature and need for the study. However, it would be good to situate the study within a global context. For example, the human rights of Indigenous people globally and the global movement toward "Patient Oriented Research" or the inclusion of patient involvement in research extends to public involvement, which means that research is carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them. There is another important concept of "peer" and this has not been defined interms of where this concept came from? this again might help contextualize the paper and its findings within a broader audience.

We have added to the introduction:

“This is in keeping with the movement toward patient-oriented research, that aims to empower patients in the process of research, optimise research design, enhance validity and make knowledge exchange more effective. (19). The goal of patient-oriented research is achieved when research findings improve the health of the population under study (20,21).Having lived experience of a condition, of navigating the healthcare system and being willing to share those experiences are important contributions.”

“We describe our peer specialist participants as “people with lived experiences,” and acknowledge that this term encapsulates a range of experiences such as distress and a range of social stressors (24). We take “lived experience” to mean someone who has an experience of mental distress, and acknowledge their diverse experiences, and intersections with other identities.”

Further details are provided in the recruitment section: “All had lived experience of mental health care and most had direct experience of suicidal behaviour, such as suicidal ideation, a suicide attempt or the death of a family member from suicide. However, all had experience of supporting someone with suicidal behaviour.”

2. On Page p.4 can you clarify which sentence is requiring a page number reference? see: p2.” Meta-analytic studies show caring contacts reduce some suicidal behaviours and there is limited evidence in reducing suicide mortality, hospitalisation or presentations to the emergency department (Skopp et al., 2023).

The page number referred to the Josifovski, 2022 article in the sentence before. We have seen fit to condense the quote from the article and remove the page number, as it appears as a distraction.

3.On page p. 5 please elaborate on how this affected access and support see "…For example, a New Zealand qualitative study asked people with suicidal ideation or suicidal behaviour about their emotional responses to caring contacts and accessing supports (High, 2022). SMS text messages were preferred, compared with other forms of follow up".

This sentence is not clear as it makes two points. We now make one point and have modified the next two sentences, which briefly describe the two studies.

“These typically involve small numbers (22,23). Larsen et al’s research co-designed a SMS text message brief contact intervention with lived experienced groups for delivery in an ED setting after a suicide attempt. In another study, people with suicidal ideation or suicidal behaviour preferred SMS text messages, compared with other forms of follow up (22).”

4.Methods: If you are using reflexivity as a method of analysis vs a “ method” please elaborate. You could describe this method as a qualitative method incorporating critical reflexivity?- semi structured interviews peer involved research..is not as clear.

Reflexivity is part of the methods, and we acknowledge our backgrounds as influencing the research process. We have changed the heading to “Research context” which more accurately describes the earlier part of the section. While reflexivity is not explicit as a heading, we have integrated this lens into the manuscript; for example we note the reviewer’s comment re “analytic narrative" and have placed this in the limitations section.

You note that you adapt from Braun and Clarke to use thematic reflexive analysis, how critical is it that your peers had lived experience, when some research participants did not have lived experience of suicide? this leads to the rich texts and quotes which came from your participants, and it is difficult to see who said what. The authors mention on p.7 "The analytic narrative of the research was influenced by the intersections of our disciplinary origins and collective interpretations". However as a reader it is hard to see the variation of your participant responses in relation to the themes. The collective meaning that was derived makes sense but we don't get a clear sense of who said what and why.

We have modified this sentence slightly:

”All had lived experience of mental health care and most had direct experience of suicidal behaviour, such as suicidal ideation, a suicide attempt or the death of a family member from suicide. However, all had experience of supporting someone with suicidal behaviour.”

We have added that “quotations are not individually attributed” and the “collective contributions” of participants which “are accepted as “taonga” (treasure) as opposed to being “tokenistic.” (Ross et al, 2023).”

We have shifted the sentence: “The analytic narrative of the research was influenced by the intersections of our disciplinary origins and collective interpretations.” To the Strengths and Limitations section and modified it to:

“We acknowledge the influence of our disciplinary origins and collective interpretations on the analytic narrative as a limitation. This was mitigated by independent co-coding by an experienced qualitative researcher and specific focus on cultural coding. The original text messages (Table 1) may reflect a clinical psychiatry and psychology perspective on the core components of caring contacts, being brief and non- demanding, whereas the final modified text highlights how the experiential knowledge of those with lived experience was elevated to convey a more humanistic tone, emphasising different modes of communication and nuances of Te Reo. Peer specialist-researchers were not involved in designing the original draft of the SMS text series and analysing the data, which would have provided a different perspective on the findings.”

5. The recommendation under number 4 is to provide some distinctions amongst the data participants as later the authors go on to state on p. 17 " Culturally nuanced findings may be transferable internationally, where there are indigenous or first nations peoples who are familiar with the Turamarama declaration, which affirms the agency and rights of these communities to find their own solutions for health, including suicide prevention". It is recommended that these kinds of human rights and Indigenous rights policies be addressed in the backround section as well as this should not be written as a limitation- given you adopt Braun and Clarke's thematic and reflexive analysis which foreground the active role of the researcher in developing and reflecting on the findings. This idea might also be strengthened if the authors clarify the role of psychiatrist and clinical psychologist. If embedded in a culturally safe framework what is the role of these professionals?

The sentence " Culturally nuanced findings …suicide prevention” has been moved to section on cultural relevance to indigneous peoples in the introduction.

We have retained the general background of the research team but have added some more information:

One of the authors (DD), is a psychologist of Māori (Kāi Tahu and Ngāpuhi) descent, and was instrumental in leading the research team in Māori and Pacific consultation to ensure the study incorporated

Attachment Submitted filename: PONE-D-23-23584.Response to reviewers.docx

10.1371/journal.pone.0306801.r003
Decision Letter 1
Davison Karen M Academic Editor
© 2024 Karen M Davison
2024
Karen M Davison
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
25 Jun 2024

Text2whaiora after a suicide attempt: text message design alongside people with lived experience

PONE-D-23-23584R1

Dear Dr. Ng,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Karen M Davison, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Based on review of your responses to the reviewers and the revised manuscript I recommend acceptance. My only suggestion is to add to the quotations some reference to the participant to show if there was a diversity of quotes e.g., participant #1, participant #2.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: (No Response)

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

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10.1371/journal.pone.0306801.r004
Acceptance letter
Davison Karen M Academic Editor
© 2024 Karen M Davison
2024
Karen M Davison
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
1 Jul 2024

PONE-D-23-23584R1

PLOS ONE

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