Using a Service Sector Segmented Approach to Identify (suicide prevention article)

MILITARY MEDICINE, 179, 4:388, 2014

Using a Service Sector Segmented Approach to IdentifyCommunity Stakeholders Who Can Improve Access

to Suicide Prevention Services for Veterans

Monica M. Matthieu, PhD, LCSW*†; Giovanina Gardiner, MSW*; Ellen Ziegemeier, MA*;Miranda Buxton, MSW‡

ABSTRACT Veterans in need of social services may access many different community agencies within the publicand private sectors. Each of these settings has the potential to be a pipeline for attaining needed health, mental health,and benefits services; however, many service providers lack information on how to conceptualize where Veterans go forservices within their local community. This article describes a conceptual framework for outreach that uses a servicesector segmented approach. This framework was developed to aid recruitment of a provider-based sample of stake-holders (N = 70) for a study on improving access to the Department of Veterans Affairs and community-based suicideprevention services. Results indicate that although there are statistically significant differences in the percent ofVeterans served by the different service sectors (F(9,55) = 2.71, p = 0.04), exposure to suicidal Veterans and providers’referral behavior is consistent across the sectors. Challenges to using this framework include isolating the appropriatesectors for targeted outreach efforts. The service sector segmented approach holds promise for identifying and referringat-risk Veterans in need of services.

INTRODUCTIONThe release of the 2012 suicide data report from the Depart-

ment of Veterans Affairs (VA) highlights the vital role of

outreach for ongoing suicide prevention efforts.1 As clinical

and public health efforts continue to target Veteran suicide,

the VA is striving for innovative and new ways to reach

Veterans in their communities who are at increased risk for

suicide. This article presents a framework for outreach to

service providers in the public and private sectors who may

have access to the Veteran population and who could poten-

tially serve as a gateway to needed VA and community-based

suicide prevention services.

Background

The research literature defines the public sector as any public

agency, to include federal, state, or local government agen-

cies, which provides benefits or services for the public use.

This sector is differentiated from the private sector in that

services are provided by nongovernmental and privately

owned entities such as nonprofit community-based agencies

and for-profit organizations.2,3 In addition, the term “health

care sector” in the economic literature has been used to

describe the delivery of health care services and products for

humans.4 However, to our knowledge these various sectors

have not been used as the foundation for recruiting providers

within these types of organizations to participate in mental

health services research focused on the particular population

of former members of the U.S. Armed Forces. Implemen-

tation science suggests that one of the most efficient means

of disseminating evidence-based interventions and quality

improvement research findings involves identifying clusters

or sectors that may first adopt the innovation or program.5–7

These “early adopters” are typically defined as key stake-

holders with vast knowledge of issues facing the community,

are considered hubs within communication channels, and

may possess a vast professional and social network.8 With

respect to the Veteran population, a critical component of

ascertaining a sample by sector is to first ask a variety of key

stakeholders where Veterans typically seek services in their

community. Yet in so doing, one must take into consideration

the entire community, to include the federal and state health

care and benefits systems for Veterans as well as all other

social services available in the community.

In addition to stakeholder perspectives, research has con-

sistently indicated that traditional mental health settings are

used as the primary information and referral gateway to a

variety of community-based agencies and social services.9

Although these settings and clinical providers are one

model that determines the need for mental health services

based on individual characteristics of the client and their

referrals to services, which are typically based on their

existing professional networks,10 they may also fail to con-

sider the full range of help-seeking behaviors Veterans

exhibit within their community. Veterans may seek mental

health services in traditional medical settings such as the

VA health care system, community health centers or clinics,

*Department of Veterans Affairs, VA St. Louis Health Care System,

Mental Health Service, 915 North Grand Blvd, Saint Louis, MO 63106.

†School of Social Work, Saint Louis University, Tegeler Hall, Suite 300,

3550 Lindell Blvd, Saint Louis, MO 63103.

‡George Warren Brown School of Social Work and Public Health,

Washington University in St. Louis, 700 Rosedale Avenue, Campus Box

1009, St. Louis, MO 63112.

The views expressed in this article are those of the authors and do not

necessarily represent the views of the Department of Veterans Affairs.

doi: 10.7205/MILMED-D-13-00306

MILITARY MEDICINE, Vol. 179, April 2014388

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and yet they can also seek these same or allied services

from local community-based organizations, such as employ-

ment agencies, faith-based organizations, schools, the justice

system, and state and federal agencies that assist with a range

of military and Veteran benefits. By first considering stake-

holder opinions and then assessing the typical access points

to mental health care for Veterans, identifying a range of

community services organized by sectors can significantly

broaden outreach efforts. The ability to look beyond the

health care sector to identify where Veterans may present

in their community for services offers great promise for

VA’s suicide prevention efforts.

Study Aims

Evidence-based suicide prevention strategies to identify vulner-

able and hard-to-reach Veteran populations (e.g., nonenrolled

Operation Enduring Freedom/Operation Iraqi Freedom and

rural veterans) are underdeveloped.11 Research, federal

reports, and the VA strategic plan all point to the impor-

tance of including stakeholders in design, implementation,

and use of services locally.11,12 With an eye to furthering

these strategies, this study sought to elicit stakeholder per-

spectives on the organization- and provider-level barriers

to Veterans accessing suicide prevention services in their

local communities.

Although other research in cancer communications uses

a social ecological framework to aid recruitment efforts for

diverse and hard-to-reach populations,13 to our knowledge,

there is a paucity of information on how sectors can be used

to inform a recruitment strategy for mental health services

research focusing on Veterans at risk for suicide. There-

fore, for this article, there are two primary aims. First, we

will describe a conceptual framework that uses a service

sector segmented approach to identify agency-based clinical

and community providers who may come into contact with

Veterans in need of suicide prevention services. Second, we

will describe the methods used for ascertaining the sample,

and in particular, the success of segmenting recruitment

efforts by service sector to find agencies that serve Veterans.

METHODS

Study Design

This mixed-methods study consisted of a qualitative, semi-

structured interview and a quantitative, self-report survey

that was administered to VA and community-based providers

(N = 70) serving rural and urban communities in the Midwest.

This design was selected to enable the use of both within-case

and across-case analytic strategies. The primary objective

was to attain in-depth information from diverse stakeholders

affiliated with the VA and community agencies within

10 different service sectors. The total proposed sample size

(N = 70) avoided groups with less than 5 individuals per

service sector. Ethical approval was obtained before data

collection from the local VA and the academic affiliate’s

institutional review boards and informed consent was obtained

from each participant.

Ascertainment and Sample Characteristics

The ascertainment of the sample for this study used a service

sector segmented approach. Considering the need to obtain

data from providers serving rural-living Veterans, as well as

to maintain representativeness of population dispersion, we

chose both an urban and a rural segment of a Midwestern

state as our sampling areas. We limited our sampling frame

to agencies within the state given (1) our focus on returning

Veterans, (2) the number of programs and services for Veteran

and military service members offered by the public sector, and

(3) the high density of private agencies in each region.

For this study, the sample comprised 70 providers. The

goal was to recruit at least 6 different VA and community-

based providers from the 10 different service sectors we

identified (n = 60). In addition, the study oversampled pro-

viders (n = 10) from the aging sector to increase the focus on

life transitions encountered as part of aging and on male

Veterans over 50 years of age, because of their increased risk

for suicide.1

Characteristics of the sample included adults aged 18

and older who were employed in the public or private

sector providing health, psychosocial, employment, benefits

assistance, or other social services within organizations

that may serve Veterans in one Midwestern state. The exclu-

sion criteria, informed by our theoretical frameworks,10,14

included individuals who did not have sufficient experience

with Veterans to provide a perspective on the topic of suicide

prevention services.

Sampling Strategy

The providers were identified using a two-step, purposive,

snowball sampling process. First, the research team proposed

10 different Veteran-focused service sectors based on the

principal investigator’s nearly 15 years of experience as a

VA social worker, her position as the community outreach

codirector for a federally funded academic research center

affiliated with a school of social work, and her professional

networks within the Veteran community across the state.

After defining each service sector, team members developed

an initial contact list of agencies using the Internet to match

the agency mission to each sector. Specific attention was paid

to national agencies with local chapters such as the American

Red Cross, the Alliance on Mental Illness, state agencies

such as the state Department of Mental Health, and local

nonprofit agencies that focused on Veteran’s issues such as

Welcome Home. From this initial list of service sectors,

descriptions, and matching agencies (Table I), the research

team identified at least 3 providers within each of the 10 ser-

vice sectors (n = 30).

MILITARY MEDICINE, Vol. 179, April 2014 389

Improve Access to Suicide Prevention Services for Veterans



TABLE I. Service Sectors, Descriptions, and Examples of Agencies

Service Sector Description Agencies

Mental Health Public (federal, state, and local) and private sector

community agencies that provide general and

specialty mental health services to include

suicide prevention, health and wellness, family

psychoeducation, and military- and Veteran-

specific information and referrals to mental

health care

VA mental health clinics in the state, local crisis

and suicide prevention centers, Alliance on

Mental Illness, the state Department of Mental

Health, state and local university counseling

and student health centers, counseling services

for the National Guard and the Reserves, and

providers in private practice, etc.

Substance Abuse Public (federal, state, and local) and private sector

community agencies that provide specialty

substance use services to include prevention

of substance use, detoxification, inpatient

or outpatient substance abuse treatment,

and peer support/recovery services

VA’s substance abuse clinics in the state, state

Department of Mental Health substance

abuse treatment facilities, substance abuse

prevention agencies, detoxification facilities,

Alcoholics Anonymous, and providers in

private practice, etc.

Aging Public (federal, state, and local) and private sector


specialty services for older adults, defined as

agencies that serve the primary populations

of individuals 60 years and older, experiencing

life transitions and in need of skilled nursing,

caregiving, or other aging-related support services

VA’s Domiciliary, geriatric extended care, and

community living centers, state Department

of Health and Senior Services, state VA homes,

assisted living and rehabilitation facilities,

Alzheimer’s Association, community hospice

services, home health agencies, care giver and

respite services, Area Agencies on Aging, etc.

Homeless Public (federal, state, and local) and private sector


specialty services for the homeless, defined

as agencies that serve the primary population

of adults who are currently homeless or at risk

of homelessness

VA’s Homeless Program including the grants and

per diem programs, local Housing and Urban

Development, community homeless programs,

emergency shelters, food banks, homeless

prevention programs, housing and financial

literacy programs, etc.

Employment Public (federal, state, and local) and private sector

community agencies that provide employment and

career services to address issues of (un)employment,

self-employment, entrepreneurship, and business

development

VA’s Vocational Rehabilitation and Employment

programs, Vet Success, Compensated Work

Therapy, state Department of Economic

Development and Career Centers, U.S. Small

Business Administration, Veterans Business

Resource Centers, etc.

Justice System Public (federal, state, and local) and private sector


specialty legal services for individuals,

(particularly Veterans) who are engaged in

some aspect of the criminal justice system

VA’s Veterans Justice Outreach program, U.S.

and state Department of Corrections, probation

and parole offices, law enforcement agencies,

Crisis Intervention Teams, Court systems

including mental health treatment and Veterans

courts, etc.

Education Public (federal, state, and local) and private sector

community agencies that provide education and

training to include postsecondary education,

community education, outreach, life skills and

lifelong learning

VA representatives on college campuses, state and

local universities, community colleges, university-

affiliated outreach and education programs, Area

Health Education Centers, university-based Student

Veteran Centers, etc.

Military Public (federal, state, and local) and private sector

community agencies that provide information,

referral and morale, wellness, and recreation

services for current military service members on

active duty, in the Reserves and National Guard

U.S. Departments of Defense and Veterans Affairs,

state National Guard, state VA, The USO,

American Red Cross, etc.

Benefits Public (federal, state, and local) and private sector

community agencies that provide information,

referral, benefits assistance, and civic

engagement services to former members

of the U.S. Armed Forces

Veterans Service Organizations, state VA,

The Mission Continues, etc.

Policy Public (federal, state, and local) and private sector

community agencies that that provide advocacy

and policy related services for at-risk and

vulnerable populations

Academic research centers, policy centers, House

and Senate Committees on Veterans Affairs,

Congressional offices, The White House’s

Joining Forces program





As a parallel process to developing the sampling strategy,

this initial list included employees of a small group of agencies

(n = 7) who were purposively selected to participate in the

pilot phase of the study, because of their access to and

knowledge of the target population, and who were consid-

ered key stakeholders in the Veteran community. These

individuals, because of their participation in the pilot, were

excluded from the formal study. This pilot phase included

testing the interview guide and survey, recruitment and

data management procedures, and finally, as a stimulus to

initial recruitment, participant nominations. Every partici-

pant recruited for the study, including the pilot group, was

asked to nominate 3 other practitioners within any of the

10 service sectors who they thought would be appropriate

for the study. This nomination procedure sought to mini-

mize potential bias in using the initial contact list devel-

oped by the research team.

The second phase of sampling then focused on this

resulting group of nominated providers (N = 149). The

research team, using the Internet searches to confirm agency

mission, staffing profiles and duties, geographic service areas,

organizations with satellite locations serving rural areas (e.g.,

community mental health centers, hospitals, homeless shelters)

then classified each participant and their agency into 1 of the

10 service sectors. Weekly meetings to review agency infor-

mation guided team decision-making on the assignment of

sectors. Initial recruitment goals within each sector, which

was also stratified by the geographic area of service delivery

for the agency (i.e., agency primarily serves rural or urban

areas) and participant job type (e.g., administrator or clinician),

were used to monitor recruitment efforts.

Data Collection Procedures

The research team was composed of a doctoral-level

research social worker with experience in the design and

conduct of mixed methods and suicide prevention research,

a master’s level cultural anthropologist, a master’s level

quantitative analyst, and a graduate-level social work stu-

dent project coordinator. An initial recruiting e-mail was

sent to prospective participants with study information and

informed consent materials attached. Follow-up telephone

calls reviewed the materials, discussed the survey, and

scheduled the interview.

After attaining informed consent, all interviews were

administered individually in person by the anthropologist,

who has extensive experience conducting interviews on mental

health topics and with adult social service providers. The

interviewer trained all staff who participated as members of

the coding team on qualitative data analysis procedures.

Surveys were e-mailed to participants in advance of the

interview, with additional copies brought to the session,

completed by participants, and subsequently collected by

the interviewer. The total survey response rate was 99%

(n = 69).

Theoretical Frameworks Guiding Measurement

The semistructured interview guide and self-report surveys

were developed by the research team based on constructs and

items from the Behavioral Model of Health Services Use14

and the Gateway Provider Model.10 The Anderson model is a

framework that depicts service use as a function of “client

needs, predisposing factors” that influence clients to want to

use services, and “factors enabling” access to services. How-

ever, from the perspective of the provider, as in the Gateway

Provider Model, the elements that influence use of services

by the individual in need of care can also be elements that

influence provider decision-making as to the need for ser-

vices and referrals to attain those services.

At the interface of the provider and the organization is the

Gateway Provider Model. This model outlines the “enabling

factors” for health care use, the view providers have of their

“client’s need for services,” “predisposing factors,” and the

“provider’s perceptions and knowledge of services to meet

the client’s need.” Then the organizational context is applied

to the model. This context, referred to as “structural charac-

teristics,” influences the provider and their decision-making

process regarding making a referral to services to address a

client’s need. As such, these models have applicability to all

Veterans at high risk for suicide who may be identified and

referred to care by providers, some of whom are VA staff,

but also for community-based providers who may encounter

Veterans within their own agencies in local communities.

Measures

Data collected for the interview focused on three main topics

from the providers’ perspective: (1) Veterans’ overall need

for mental health and suicide prevention services, (2) the

referral process to attain these services, and (3) the barriers

encountered in accessing mental health services, particu-

larly when Veterans are at heightened risk for suicide. The

interview guide divided these topics into five sections

(predisposing and enabling factors, provider perspective on

client service needs, provider knowledge of services to meet

client needs, multilevel barriers to care, and the structural

characteristics of the employing organization), with addi-

tional questions pertaining to older Veterans asked of pro-

viders in the aging sector. Several close-ended questions

were also included in the interview guide, particularly when

asking for clarification on survey answers (i.e., military

service is assessed on intake, percent of current client popu-

lation with a history of military service) and in regard to

Veteran mental health care needs (perceived need for sui-

cide prevention services for Veterans).

Four of the five sections of the self-report survey instru-

ment have been used previously.15,16 The sections were

(1) organizational assessment (developed for use in this

study), (2) provider demographics, (3) individual-level fac-

tors, (4) exposure to suicide, and (5) awareness of suicide

prevention resources. The organizational assessment collected





data with regard to the type of organization, annual budget,

number of clinical/medical and all employees, annual number

of clients served, age range of clientele, type of services

provided, and if services were military- or Veteran-focused.

Demographics data on the provider’s age, gender, race, eth-

nicity, education, job role, and years of clinical experience

were collected. The individual-level factors data included

an assessment of the participant’s lifetime history of general

and clinical interviewing experience and trainings attended

related to suicide and crisis. The provider exposure to suicide

included a series of questions related to lifetime exposure to

suicide, such as previous contact with potentially suicidal

individuals, suicide attempters, and suicide decedents. Also

included were a series of questions about provider referral

behavior, including the lifetime number of referrals offered

for suicidal individuals and the relationship to the person

referred. For this study, the number of referrals was recoded

into a dichotomous variable using a range previously used

in literature,15 where 1 = referred greater than 11 individuals

and 0 = referred 11 or fewer individuals, as nearly everyone

in our study had referred someone for suicide prevention

services over their lifetime. Finally, awareness of suicide

resources was assessed using four items with dichotomous

(e.g., scored “yes” or “no”) response options. These items

asked participants whether they had any awareness of efforts

regarding suicide prevention specific to their (1) workplace,

(2) local community, (3) state, and (4) nation.

Data Analysis

For this study, we only report on a subset of survey data. Data

on service sector assignment were obtained from the research

team’s recruitment tracking database and combined with the

participants’ survey data. All data were entered by the

research team into Microsoft Access then transferred to SPSS

19.0 (IBM Corporation, Armonk, New York) for univariate

and bivariate analysis. Missing data on some survey items led

to differences in sample sizes for some items.

To assess the aims of this study related to success of

segmenting recruitment efforts by service sector to identify

agencies that serve Veterans, rates of success in scheduling

and completing interviews were calculated by service sector

using a c2 analysis. Rates of success in terms of finding

agencies that served Veteran populations were also calcu-

lated and compared across service sector using a one-way

analysis of variance to detect differences between rates of

Veterans served by service sector. Referral behavior and con-

tact with suicidal individuals were compared across service

sector using a c2 analysis.

RESULTS

Recruiting by Service Sectors

Table I outlines 10 different service sectors, descriptions, and

typical examples of agencies who’s clinical and community

providers may come into contact with Veterans in need of

suicide prevention services. First, the “mental health service

sector” was defined by VA and non-VA mental health clinics,

inpatient and outpatient psychiatric treatment facilities, and

TABLE II. Demographics and Organizational Characteristics

Provider Variables N %

Mean Age = 46.4 (SD = 9.5) 65

Gender 69

Male 37 53.6

Female 32 46.4

Race 68

Caucasian 60 87.0

African American 6 10.1

Native American 1 1.4

Ethnicity 67

Hispanic/Latino 7 10.4

Education 69

Master’s or Above 51 73.9

Bachelor’s or Below 18 26.1

Degree 49

Social Worker 30 61.2

Counselor—General 8 16.3

Psychologist 3 6.1

Chemical Dependency Counselor 2 4.1

Nurse 1 2.0

Veteran Status 70

Yes, History of Service in U.S. Armed Forces 21 30.0

Job Role 63

Administrator 39 61.9

Clinician 24 38.1

VA Provider 70

Yes, VA Employee 17 24.3

Organization Variables N %

Type of Organization 69

Not-for-Profit Agency 25 36.2

For-Profit Agency 3 4.3

Governmental Agency 32 46.4

College/University 6 8.7

Public/Private Hospital 2 2.9

Other 1 1.4

Budget 56

Under $1 Million 28 50.0

Over $1 Million 28 50.0

Total Number of Employees 67

Less Than 100 38 56.7

100 or More 29 43.3

Total Number of Clinical/Medical Staff 65

Less Than 25 41 63.1

25 or More 24 36.9

Number of Clients 65

Less Than 1,000 22 33.8

1,000 or More 43 66.2

Age Range of Clients 69

Birth to 17 Years 22 31.4

18–24 Years 58 89.2

25–64 Years 64 91.4

65 Years and Older 54 77.7

Provides Veteran-Focused Services 67

Yes 50 74.6

Provides Services to Rural Areas

Yes 30 42.9





community mental health centers, such as those run by the

state department of mental health and by private providers.

The “substance abuse sector” consisted of inpatient and out-

patient substance abuse prevention and treatment settings.

The “aging sector” comprised agencies whose primary

populations include those over 60 years of age with services

focusing on older adults. The “homeless sector” included

agencies whose primary population included those who were

homeless or at risk of homelessness. The “employment sector”

consisted of those organizations whose primary concern is

assisting with (un)employment, self-employment, and/or busi-

ness development. The “justice system sector” comprised law

enforcement, courts, and other legal agencies whose primary

population includes those involved in the criminal justice

system. The “education sector” consisted of organizations

whose primary mission is adult postsecondary education.

The “military sector” consisted of agencies whose primary

population includes current military service members. The

“benefits sector” consists of agencies that provide informa-

tion, referral, benefits assistance, and/or civic engagement

opportunities for Veterans. Finally, the “policy sector”

included agencies whose primary mission is advocacy and/

or specific policy, research, or allied services targeting ser-

vice delivery for vulnerable and at-risk populations.

Success Rates Using the Service SectorSegmented Approach

A total of 149 potential participants were contacted with 70

participating in the study, for a response rate of 47%. Overall,

the sample was composed of middle-aged, Caucasian, Master’s

level-educated social workers. As shown in Table II, the sam-

ple was almost half women and half men, nearly two-thirds

were administrators, and about 30% had previously served

in the military. Organizationally, the majority of providers

worked in medium to large governmental settings, with 75%

of the sample reporting to provide Veteran-focused services.

In terms of success rates, there were no statistically sig-

nificant differences between recruitment by service sector

( c2 = 13.35, p = 0.20); all had rates around 50% per sector.

Results (Fig. 1) indicate statistically significant differences

in the mean percentage of Veterans served by the agency in

each service sector, meaning that not all agencies in our

study served a similar percentage of Veterans (F(9,55) =2.71, p = 0.04). Agencies that provided Veteran-specific

services, such as those in the benefits sector, had the highest

percentage of Veteran clients, as may be expected. Seven of

the ten sectors indicated more than 50% of their population

served includes Veterans.

Finally, there were no statistically significant differences

by service sector in terms of contact with suicidal individuals

(c2 = 11.62, p = 0.24), nor were there differences by referral

rate (c2 = 9.19, p = 0.42). Similar results were found when

comparing referral of a Veteran across service sectors (c2 =8.21, p = 0.51). See Table III for more detail.

DISCUSSIONThis article describes a conceptual framework for identify-

ing community and clinical providers employed in organi-

zations that may come into contact with Veterans, some of

whom may be in need of mental health, suicide prevention,

or other service needs. Although the service sector seg-

mented approach was used in this study with some success

in guiding recruitment efforts, the framework may also

be useful to inform outreach strategies to engage the public

and private sectors in identifying and referring Veterans to

needed and appropriate services.

As reiterated by the VA’s recent release of 2012 suicide

data,1 the issue of Veteran suicide is of great concern in all

FIGURE 1. Percent of Veterans served by service sector.





of our communities. Thus, one specific goal of this study

was to develop a framework to improve methods of locat-

ing Veterans within their community. As one example, this

approach can specifically aid clinical and community pro-

viders in proactive decision-making and thoughtful alloca-

tion of scarce resources when competing demands on their

time necessitate a more focused outreach plan. By consid-

ering different sectors, clinical and community providers

can potentially expand their professional networks to iden-

tify and refer Veterans in crisis when in need of care. For

private sector program planners, this framework can also be

used to align the program objectives with targeted outreach

activities in specific community locations with a greater

density of high-risk individuals or to specifically address a

service sector with high-priority clinical need. And finally,

the framework can inform strategic planning and policy

making when drafting calls to action and national agenda

setting to address long-term, public health, and complex

prevention issues.

The second aim of this article was to highlight the specific

benefit of this approach in terms of outreach to Veterans

within their community. Our findings indicate that all of the

providers in each service sector have had experience with

suicidal individuals with the highest percentages found in

the mental health, military, homeless, justice, education, and

aging sectors. Results also indicate that there are some ser-

vice sectors, such as the employment sector, that may not

seem specifically targeted toward Veterans, yet actually have

a significant amount of Veteran clients. In addition, there are

service sectors that are known to provide benefits services

specifically for Veterans, but that are not focused on provid-

ing mental health services. These agencies are encountering

Veterans with mental health issues and are referring Veterans

for services, including suicide prevention services. Interest-

ingly, nearly the entire sample (96.4%, n = 65) had referred

someone to mental health services. Although mental health

providers may have referred more individuals for services,

they are by no means the only ones encountering Veterans at

risk for suicide.

Contact with suicidal individuals was prevalent not only in

the mental health sector, but also within the employment and

justice system sectors. Nearly the entire sample had contact

with someone who was suicidal at some point in their life.

Contact with a suicidal Veteran was similarly not limited

solely to those who typically work with Veterans—there

were no statistically significant differences within our sample

among those who had contact with and even referred a Veteran

for suicide prevention services. However, this highlights a

need to expand outreach efforts beyond the traditional loca-

tions and for providers to think more broadly about how and

where to locate Veterans within the community. This service

sector segmented approach offers a novel way of approaching

this outreach issue.

Study Limitations

Although using the conceptual framework divided by ser-

vice sectors was beneficial to aid recruitment, there were

limitations to its use that should be considered when apply-

ing the framework. First, segmenting sample ascertainment

by service sectors can be somewhat of a moving target—

i.e., there are many ways to describe various sectors (e.g.,

type of services, primary client population) and those defi-

nitions are inherently unstable in a constantly changing

public–private sector service delivery environment. Pro-

viders may also define their membership in a particular

sector differently than researchers or define the services

they provide in more than one sector or crossing sectors

(e.g., the education sector provides health services for enrolled

TABLE III. Suicide Exposure by Service Sector

Contact With

Someone Suicidal p

Service Sector N % 0.24

Mental Health (n = 12) 12 100

Substance Abuse (n = 3) 2 66.7

Aging (n = 9) 9 100

Homelessness (n = 10) 10 100

Employment (n = 6) 5 83.3

Justice System (n = 10) 10 100

Benefits (n = 5) 4 80.0

Military (n = 5) 5 100

Education (n = 3) 3 100

Policy (n = 6) 5 83.3

Total (n = 69) 65 94.2

Referred >11 People p


Mental Health (n = 12) 9 75.0


Aging (n = 9) 2 22.2

Homelessness (n = 10) 5 50.0


Justice System (n = 10) 5 50.0

Benefits (n = 4) 1 25.0

Military (n = 5) 2 40.0

Education (n = 3) 2 66.7

Policy (n = 5) 1 20.0

Total (n = 65) 31 47.7

Referred a Veteran

for Suicide Prevention

Services p


Mental Health (n = 12) 8 66.7


Aging (n = 9) 3 33.3

Homelessness (n = 10) 5 50.0


Justice System (n = 10) 5 50.0

Benefits (n = 4) 4 100

Military (n = 5) 2 40.0

Education (n = 3) 2 66.7

Policy (n = 5) 2 40.0

Total (n = 65) 36 55.4





students Veterans, faith-based organizations provide many

homeless sector services). Second, the response rate (47%)

to our study was moderate, which may have been partially

or fully driven by our exclusion criteria and nominating

procedure that asked providers to recommend others with

sufficient experience with Veterans. Given this variability

and the potential omission of other relevant sectors and

providers, the framework is presented here as merely an

additional tool to augment other established strategic plan-

ning and outreach efforts.

Implications for Future Research, Clinical Practice,or Policy

Clinical and community providers in the public and private

sectors may use this approach as a means of identifying new

portals to better align and target their outreach efforts. With

regard to suicide prevention, it remains critically important to

consider all sectors, not just the mental health sector, in

communities where Veterans may seek services. However,

future research is needed to determine the use and feasibility

of using this approach to improve access to care for Veterans

at risk of suicide. Finally, although this study focused on

the providers’ perspective of Veterans’ need for services,

Veterans themselves may have an entirely different outlook

on desired services in their community that would add to

the relevance and importance of this framework. Future stud-

ies to examine the Veteran perspective on seeking services

are needed.

CONCLUSIONSEarly identification of Veterans at risk for suicide can be

lifesaving. This study offers a framework to identify pro-

viders within the public and private sector who may come

into contact with Veterans in hopes of expanding the network

of people who can help to prevent suicide. Although some

results confirm what was expected (i.e., mental health care

providers refer more suicidal individuals, more Veterans

are served by the benefits service sector), these results also

indicate that consideration of nontraditional service sectors,

such as education, justice, and employment services, is a useful

means of locating potentially suicidal Veterans. Segmenting

outreach efforts by service sector allows providers to concep-

tualize the various ways in which Veterans interact with the

community to increase their success at locating at-risk Vet-

erans and providing them with potentially lifesaving assistance.

ACKNOWLEDGMENTS

The authors thank Lu Han, Tara Sabharwal, and Rachel Perkins, the Center

for Violence and Injury Prevention, and all our community stakeholders

for their assistance and support of this project. This project is funded by

the Department of Veterans Affairs (VA), Health Services Research and

Development (HSRD), Quality Enrichment Research Initiative (QUERI

RRP 11-002), and the Center for Violence and Injury Prevention (grant

number 1620-94692). This study was also supported with resources and the

use of facilities at the VA St. Louis Health Care System.

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Using a Service Sector Segmented Approach to Identify (suicide prevention article)

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