Empowering Youth to Build BRIDGES: Youth Leadership in Suicide Prevention

Suicide is a prevalent health issue for youth and understanding youth experiences is critical for the development of effective prevention strategies. Although youth perceptions regarding suicide are relatively well studied, there is a paucity of youth voices in the planning, design, facilitation, and implementation of suicide prevention research. This study examines youth perceptions of suicide prevention through a community-academic partnership with the Youth Council for Suicide Prevention (YCSP). Working together as co-researchers, the YCSP conducted a modified Group Level Assessment with over 200 youth to understand youth perspectives on suicide prevention. The findings were used by the council to inform outreach and prevention activities that directly affect YCSP members and their peers.

Suicide is a serious public health issue impacting communities and is now the second leading cause of death for children aged 12-17 in the United States (Centers for Disease Control [CDC], 2015). While researchers and practitioners continue to examine the reasons for the rise in adolescent suicide and to address them through evidence-based practices, the CDC has advocated for youth and communities to be included as essential drivers of suicide prevention (2015). The evidence for a number of suicide prevention strategies are mixed (Miller et al., 2009;Robinson et al., 2013), however, those which employ peer-to-peer approaches seem to reap the most positive outcomes (Bunney et al., 2002;Randell et al., 2001;Stuart et al., 2003;Wyman et al., 2010). Though the aforementioned peer frameworks have been effective in decreasing suicidal ideation and enhancing healthier coping behaviors, youth were not involved in the planning, design, or implementation of the strategies as recommended by the CDC (2015) and World Health Organization (WHO, 1993). The mixed evidence of strategies and exclusion of youth from research and intervention development warrants the exploration of youth participation in suicide prevention. This study describes the involvement of youth in the planning, design, facilitation, and implementation of suicide prevention research for contextualized findings on youth perceptions of suicide prevention that inform outreach.

Youth Perceptions of Suicide Prevention
Despite lack of youth voices in suicide prevention efforts, researchers have investigated youth perceptions regarding barriers to suicide prevention. The scholarship reiterates the role of stigma, trust, and confidentiality as major obstacles to help-seeking (Curtis, 2010;Gilchrist & Sullivan, 2006;Thapa et al., 2015). When asked why young people may not seek help, 60% of youth in one study believed suicidal youth lack someone they can confide in (Gilchrist & Sullivan, 2006). While parents believed their children can confide in them regarding suicidality, most youth were concerned with parents not being able to cope. Other studies have found that youth are more willing to seek help for another person but less willing to seek help for themselves due to stigma and a perceived need for self-reliance (Curtis, 2010). In response to these barriers, much of the literature proposes a need for comprehensive mental health education that teaches healthy coping behaviors and targets youth willingness to seek help through mental health services, peers, and resourceful adults (Curtis, 2010;Del Mauro & Jackson Williams, 2013;Gilchrist & Sullivan, 2006).

Youth Participatory Action Research
Though youth-led, health-related initiatives are recommended, there is still a scarcity of youth voices in suicide prevention research. Youth Participatory Action Research (YPAR) may help fill this gap by offering a unique action-oriented approach that engages youth as equitable co-researchers to investigate health and social problems that matter to them (Rodriquez & Brown, 2009). YPAR is considered an approach to research rooted in critical theoretical frameworks that encourages young people to critically analyze their social contexts and identify and challenge the social injustices that impede their development (Cammarota & Fine, 2008;Foster-Fishman et al., 2010;Rodriguez & Brown, 2009). While research is one component of YPAR, youth who participate in YPAR are also involved in a pedagogical process where they acquire knowledge about their social contexts and become empowered to take action to change their lives (Cammarota & Fine, 2008). This philosophical stance can be traced to Paulo Freire, a philosopher-practitioner who emphasized the role of critical reflection in social change (Maguire, 1987;McIntyre, 2002;Selener, 1997) and was concerned with empowering marginalized members of society to challenge their social injustices through critical consciousness (Freire, 1970). In the context of suicide prevention, YPAR can be employed to engage young people in an iterative cycle of critical reflection and action around adolescent suicide in their communities, among other health issues germane to youth. In fact, as YPAR becomes more widespread in different disciplines, it is touted for translating research on complex health issues into actionable plans for the reduction of health disparities (Minkler & Wallerstein, 2008). YPAR posits that youth are experts on issues affecting them and should be involved as equitable co-researchers throughout each phase of the research process (Israel et al., 2010). YPAR has been shown to contribute to health programs that better meet the needs of youth while building knowledge and skills that youth apply to their own lives, making more healthful decisions of their own (Suleiman et al., 2006). As an additional benefit, youth who become engaged in YPAR create a ripple effect and encourage their own peers, parents, teachers, and medical practitioners to become involved in health and social issues like suicide prevention (Israel et al., 2010) -a strategy that is vital to reducing the rates of teen suicide (CDC, 2015;Suleiman et al., 2006; U.S. Department of Health and Human Services, Office of the Surgeon General, and National Action Alliance for Suicide Prevention [UDHHS], 2012;WHO, 1993).

Youth Council for Suicide Prevention
The YPAR approach of involving young people as co-researchers may prove useful for the construction of tailored health interventions that are more relevant to youth (Lindquist-Grantz & Abraczinskas, 2018), thus potentially reducing adolescent suicide attempts. To address this need in the Greater Cincinnati region, Cincinnati Children's Hospital Medical Center (CCHMC) developed the Youth Council for Suicide Prevention (YCSP) in 2013. Since 2013, the YCSP has employed YPAR to engage young people in critical reflection and action around the issue of adolescent suicide in Cincinnati. While CCHMC initially developed the council to inform suicide prevention in the emergency department, the YCSP has traditionally followed the principles of YPAR where young people are involved in all decision-making matters as equitable partners of the council. The adults on the YCSP (two doctoral students) act as facilitators of the group, who embed activities, discussions, and trainings within council meetings to help YCSP members make decisions and execute project plans. YCSP members are continuously engaged in a critical reflection of their schools and communities, where they identify priorities, people, and areas of importance and develop action plans to address adolescent suicide in Cincinnati. YCSP members repeat this iterative cycle of reflection and action each year to make a more profound impact on their schools and communities. Over time, council members demonstrate leadership by taking more responsibility of YCSP projects and sometimes bringing YCSP projects into their own schools, which may be evidence of positive youth development (Lerner, 2005) and critical consciousness (Freire, 1970).
The YCSP is comprised of 28 youth from 11 different schools who design and participate in various research and action projects centered on suicide prevention through the YPAR process described above. All youth participate in council activities on a voluntary basis; many were motivated by their own personal experiences with suicide. Past projects have included: advising researchers on suicide screening in the emergency department through questionnaires and concept mapping; interviewing peers about effective suicide prevention communication strategies; surveying peers and parents about effective strategies for encouraging communication about suicide prevention; and presenting research and workshops at five regional high school conferences. The council accepts applications for new members twice a year with rolling membership to ensure a wide variety of youth voices. Applications are sent to guidance counselors across the Greater Cincinnati region who are asked to share the application with two to three students. Current council members also share the application with their friends. To date, no applicants have been denied membership on the council, as the YCSP values young people with a variety of life experiences. However, the council seeks high schoolers with a passion for mental health, a commitment to attend meetings, and a strong letter of recommendation. Most applicants are Caucasian females who are high achieving students -perhaps due to a number of factors, such as guidance counselor recommendations, interest in mental health, and our network of schools and stakeholders.
The purpose of this study is to describe how the YPAR approach was used to involve young people as equitable co-researchers in the planning, design, facilitation, and implementation of suicide prevention research and how the findings informed outreach activities pursued by the YCSP. YCSP was granted a Non-Human Subjects Determination by the Cincinnati Children's Hospital Medical Center Institutional Review Board for research conducted by YCSP or with YCSP members. In addition, all YCSP members have assented to the publication of this manuscript and the disclosure of the YCSP name for publication. YCSP members encourage dissemination of our work and actively present themselves as leaders in suicide prevention, with their primary goal being to normalize the issue of mental illness and suicide through transparency and open conversations. The YCSP believes this transparency is beneficial for the advancement of youth leadership in suicide prevention and other youth councils working to address social and health issues such as teenage suicide.

Method Participants
The study participants included over 200 students who attended an annual local high school student leadership conference. Due to the YCSP workshop being the most attended session at past conferences, the council has been invited to facilitate workshops for the past five consecutive years. The students in the current study participated in a modified Group Level Assessment (GLA) (Vaughn & Lohmueller, 1998, 2014) facilitated by the YCSP as part of the conference workshop. While there is no demographic data available about students who attended our particular workshop, 570 high school students from 66 different schools and from a range of backgrounds (race, socio-economic status, ethnicity, gender, etc.) in the Greater Cincinnati area attended the conference to learn how to engage in service-learning. The workshop was well-received by attendees who then voted for YCSP as one of two organizations to win a grant to conduct additional outreach activities throughout the region.

Data Collection and Analysis
The council co-designed a modified GLA in which over 200 high school students generated ideas about strategies for suicide prevention and ways to empower youth to take action in their own communities and schools. GLA is a validated qualitative and participatory method developed by Lohmeuller (1998, 2014). Unlike traditional focus groups which require more time for completion and are expert-driven, GLA is a method where "timely and valid data are collaboratively generated and interactively evaluated with relevant stakeholders leading to the development of participant-driven data and relevant action plans" (Vaughn & Lohmeuller, 2014, p. 336).
The full GLA process involves seven steps. First, prompts probing about suicide prevention were designed by the YCSP and written on adhesive flip charts which were placed around the room on the walls (See Table 1). The council decided on these prompts through a brainstorming session where questions about 5. Teens would not attempt suicide if… 6. One way I can prevent suicide in my school or community is… suicide prevention were written in a shared Google document by all council members. Through a democratic discussion, the YCSP weighed the pros and cons of each prompt and discarded or modified them to suit the purposes of the workshop. Council members prioritized six questions about suicide prevention that would lend action-oriented information to help the YCSP form action plans. YCSP members guided the participants through an overview of the GLA and a short, warm-up activity (Step 1: Climate Setting). YCSP members then instructed participants to respond to all 6 prompts using markers (Step 2: Generating), then after all responses were written, invited them to participate in a gallery walk to read the responses of their peers (Step 3: Appreciating).
The council completed the remaining GLA steps by co-analyzing and prioritizing the data, then generating youth-driven themes that emerged from the workshop attendee's responses. The adult facilitators of the council asked each YCSP member to first reflect on the data individually in terms of what it meant to them and their peers (Step 4: Reflecting). After this, the facilitators split the council into 4 small groups of 5-6 youth and assigned them 1-2 flip charts. The facilitators asked the small groups to discuss the responses on their assigned flip charts and identify themes, which were described as patterns, similarities, differences, or anything that 'pops out' in the responses. The small groups then reported their themes to the larger group (Step 5: Understanding). One of the facilitators recorded these themes on flip chart paper for the larger group to see. The analysis process concluded with the large group prioritizing and consolidating the themes into similar categories through democratic discussion (Step 6: Selecting). Through discussion, the council decided ways in which themes were related to one another and should be consolidated, discarded, or developed into new themes. The council used the resulting themes to develop action plans and outreach activities (Step 7: Action). Through YPAR and through the GLA methodology, council members were involved in the project design, data collection, data analysis, interpretation, and dissemination of findings through action plans that took place in the community. YCSP members reviewed this manuscript, which was written by the facilitators of the council, in order to enhance the validity of the study findings.

Findings and Discussion
YCSP council members analyzed the responses from the conference using the GLA methodology. Their thematic analysis revealed 6 major themes: (1) Belonging; (2) Red-Light, (3) Isolation; (4) Dedication; (5) Guidance and Education; and (6) Stigma. The council strategically assembled these themes into an acronym -BRIDGES -which they believe represents what youth think about suicide prevention. While each letter of the acronym represents its own theme, together, BRIDGES means involving multiple groups of people, resources, and systems to combat suicide -a strategy that aligns with recommendations for suicide prevention (CDC, 2015;USDHHS, 2012;WHO, 1993). Each theme was developed through discussions that unfolded during the analysis and interpretation phases of this study. This section is organized by first discussing how each theme emerged during analysis with quotes from the conference as support. Then, each theme is discussed in the context of the literature on suicide prevention.

Belonging
The belonging theme emerged from a series of conversations about the responses the YCSP had collected from the original six prompts. Using the GLA analysis process, council members reported frequent and noteworthy responses from the flip charts. The prompt "teens would not commit suicide if…," in particular, sparked many conversations that led to the belonging theme. In response to this prompt, students wrote things like "people were accepting of all," "they felt loved," "they weren't called names," "they had a safe environment," and "they had a strong network of people for help." These quotes are just some of many that capture the desire for connectedness in the students' responses. The YCSP discussed the frequency of these responses and supported them with their own experiences as young people who desire feelings of belongingness in their schools and social circles. The YCSP then brainstormed words that would capture the essence of these responses and agreed that belongingness was appropriate.
Like the conference participants indicated through their responses to the GLA prompts, many teens feel like they do not "fit in" with peers within their schools and communities. Studies have that found that teens are hesitant to seek help because they lack someone they can confide in (Gilchrist & Sullivan, 2006) or hold a perceived need to rely on themselves (Curtis, 2010). Using the BRIDGES concept, individuals, communities, and institutions can foster feelings of belongingness in teens. At the individual level, peers, parents, teachers, and others can make teens feel like they belong by making themselves available as supportive, unbiased resources. Although this is a difficult task, education may be one of the ways to achieve these goals. Mental health education in schools may help young people feel more comfortable discussing personal-emotional issues (Randell et al., 2001;Robinson et al., 2013;Tang et al., 2009). In addition, more consistent and comprehensive curriculum on mental health in schools may help adolescents better understand suicide and develop empathy for peers who may be struggling with mental health issues (Curtis, 2010;Del Mauro & Jackson Williams, 2013, Gilchrist & Sullivan, 2006. Some interventions have successfully targeted perceived burdensomeness and failed belongingness among students (Joiner, 2009). One program specifically described as a belongingness intervention involved mailing letters expressing concern to high-risk individuals after they refused ongoing treatment (Motto & Bostrom, 2001). When matched with another control group that did not receive letters, there was a demonstrable difference in suicide rate between the two groups after five years -specifically, those that received the letters experienced fewer deaths by suicide. Another study compared treatment without follow-up to a follow-up intervention that included continued communication between at-risk patients and clinical staff (Fleischmann et al., 2008). In this study, too, the interpersonal component resulted in more feelings of belongingness and fewer deaths from suicide. Schools can help promote belongingness and connection among students by utilizing these programs and by following up with at-risk students. When consistent in their actions, schools have the ability to develop a culture which makes students feel like they belong and are supported in their particular school communities. Cultivating this culture is one of the ways in which students may feel more comfortable confiding in someone about their suicidal thoughts, whether that be peers, teachers, guidance counselors, or other school personnel.

Red-Light
The red-light theme was formed by the council due to a large number of responses about warning signs, causes, outcomes, or means of suicide. For instance, in response to the prompt "____ is often ignored in suicide prevention for youth," students wrote things like "the obvious signs of suicidal thoughts," "the cause of these thoughts," "statements made by suicidal teens," "cries for help," "the gravity of the situation," and "warning signs." Further, in response to the prompt "The most important health/social/community issues for Cincinnati youth are…," students wrote responses such as "depression," "sadness," "drugs," "violence," "coping," "bullying," and "stress." Students at the conference also referenced "guns," "pills," and "cutting" in response to the prompt that asked what comes to mind when they hear the word 'suicide.' The YCSP discussed the commonalities between these responses and identified them as warning signs, causes, outcomes, or means of suicide. The YCSP chose the word "Red-Light" to represent these responses as one theme.
As mentioned previously, suicide is the second leading cause of death for children aged 12-17 in the United States (CDC, 2015). The responses from the youth in this study augment these statistics, drawing attention to the influence of existing mental health issues on suicide outcomes. These findings remind school and health practitioners to be aware of the signs and take action to intervene when adolescents display behavioral changes, such as drug use, fighting, and behaviors associated with depression and sadness (Bae et al., 2005;Kann et al., 2016). Being knowledgeable about resources is another way of supporting teens who may be experiencing suicidal thoughts and mental health concerns. Within the BRIDGES framework, this means being responsible for teaching and learning the warning signs and most effective ways to intervene, but also ensuring that educational, medical, and governmental institutions provide the provisions for this to be possible. With over ten million primary and secondary school students in the United States requiring mental health intervention, it is becoming increasingly important for schools to connect students to mental health services (National Center for Health Statistics, 2011). Since students spend most of their young lives in school, schools should strive to offer more comprehensive strategies for suicide prevention that involve multiple approaches, including accessible mental health care, curriculum-based programing, and professional development for school personnel.

Isolation
Isolation was another theme that emerged through discussions about the flip chart responses. Across a number of flip charts, youth wrote responses such as "sadness," "loneliness," "suicidal feelings," and "feeling as if there is nobody to confide in." There were also comments that said teens would not commit suicide if "they had a friend to turn to," and "had someone that listened to them." The council noted the frequency of these comments and connected them to their own experiences with feeling alone or knowing friends or family who isolated themselves. It is through these conversations that the council developed the "Isolation" theme.
Social isolation is a major correlate of suicide alongside depression and loss of friends (Greydanus et al., 2010). Research finds that teens are less willing to seek help for themselves due to stigma (Curtis, 2010). Isolation may be reduced by utilizing programs that focus on building protective behaviors and engaging youth through peer models (Bunney et al., 2002;Randell et al., 2001;Stuart et al., 2003;Wyman et al., 2010). These include curriculum-based programs in schools, skill training programs, and research frameworks like YPAR which engage youth as more than passive participants. Following the tenants of BRIDGES may be another helpful model for reducing isolation -fostering environments which encourage belongingness, making more opportunities for education, and providing and being knowledgeable about resources which support students in time of need. Changing the ways in which we respond to mental illness and suicide may break down stigma and encourage youth to reach out to friends, family, and other adults with personalemotional issues.

Dedication
The Dedication theme emerged due to the number of names that were listed in response to prompt "When I hear the word suicide, I think of…" Many students at the conference wrote down actual names of people who died by suicide. Aside from names, students wrote about people they knew such as friends, sisters, uncles, and cousins had attempted or died by suicide. The council discussed the weight of these responses and the commonality of suicide. As such, the council decided to create a "Dedication" theme to represent the importance of remembering those who have suffered from mental illness, as a way to raise awareness and showcase the impact of suicide on surrounding family and friends.
According to the council, reading these responses was an emotional experience. The Dedication theme is an especially rich aspect of the data, because it shows that suicide is a personal issue to youth -with suicide being the second leading cause of death for adolescents (CDC, 2015), many teens know peers who have committed suicide. While there seems to be no literature on the impact of dedications in suicide prevention, the council discussed the power of making dedications to raise awareness about suicide. Rather than hearing about a teen from across the country who committed suicide, they believed it is much more poignant to learn that someone you knew was struggling with suicidal thoughts. Dedications may also be an opportunity for schools to raise awareness about suicide and offer support to students who may be experiencing similar difficulties. The youth on the council mentioned that some of their schools could have provided more support in the way of helping students grieve their peers after a suicide. Therefore, this can be viewed as an important moment for school personnel to target at-risk students who may be especially vulnerable after the loss of a friend.

Guidance and Education
This theme is comprised of resources that would help prevent suicide, such as people, places, and sources of education. For example, in response to the prompts "I would turn to ___ if I were feeling suicidal," and "Teens would not commit suicide if…," students wrote responses such as "if they had support," and "if there was better mental health education." The students also identified people or places who they would turn to, such as "teachers," "church," "god," "doctors," "parents," and "friends." Students also wrote about the need for a "safe environment" and "a strong network of people for help." Thus, the council developed the theme "Guidance and Education" to represent all of the resources necessary for suicide prevention.
The essence of the Guidance and Education theme is consistent with the messages reiterated from the CDC (2015), USDHHS (2012), and WHO (1993), who recommend multiple groups and strategies to be utilized in suicide prevention efforts. These findings validate the BRIDGES philosophy which emphasizes engaging multiple stakeholders, systems, and approaches to construct comprehensive prevention strategies. With youth spending most of their time at school in particular, school personnel are in a unique position to provide evidence-based methods for teaching about mental health and suicide. Evidence-based programs involving multiple approaches will help students better understand mental illness and suicidal thoughts in themselves, as well as how to intervene when their peers are experiencing the same issues. In addition, acquiring more knowledge about suicide will reduce the stigma and encourage more conversation about the topic.
As stated earlier, over ten million students require mental health services (National Center for Health Statistics, 2011). This makes it paramount for schools to focus on better integration with mental health care through school-community collaborations (Adelman & Taylor, 2000). Such collaborations make services more accessible for underserved, hard to reach students while building capacity for diverse psychosocial contexts seen in schools. For example, one study redesigned mental health services in a school to "support children's learning within communities of concentrated urban poverty," finding that the communitytailored services led to improved behavior compared to the usual mental health services (Atkins et al., 2015, p. 848). The responsibility of schools as sources of mental health education and care is an essential aspect of the BRIDGES framework. Research shows that when communities become involved with school-based services, they provide support networks, learn and teach coping skills, and participate in governance around services (Adelman & Taylor, 2000;Ballard et al., 2013). Whether or not schools are capable of providing services within their own institutions, they should move toward a "nexus point" model in which they connect their unique communities to mental health services (Haddad et al., 2017). More collaboration between the community and school may be an avenue for constructing tailored interventions that are relevant to student experiences.

Stigma
The stigma theme was created from a number of responses alluding to the stigma associated with speaking about mental health. For instance, some students wrote that teens would not commit suicide if "people didn't judge you for who you are," and if "[people would] listen more [and] judge less." Some people also wrote that "if people were more open minded," and "if they didn't feel that they weren't accepted," teens would not commit suicide. The council discussed these themes and agreed that they were associated with the stigma around speaking about emotional difficulties and mental health issues. As such, the council grouped these responses into the "Stigma" theme.
The literature repeatedly identifies stigma, trust, and confidentiality as barriers to suicide prevention (Curtis, 2010;Gilchrist & Sullivan, 2006;Thapa et al., 2015). Peer-to-peer mental health education may be useful in reducing stigma or negative stereotypes while increasing knowledge about suicide among youth (Curtis, 2010;Del Mauro & Jackson Williams, 2013;Gilchrist & Sullivan, 2006). The YCSP members discussed the importance of interventions and activities that target small groups of students on issues related to mental health. Future interventions should focus on targeting small groups of peers who may relate to the experiences of other youth, opening up conversations that are more comfortable and normalized. In addition, the YCSP has recommended social media as a prevention tool. Although cyber bullying plays a part in mental health issues for teens, youth believe that social media can still be used to raise awareness and reduce isolation in teens.

Local Implementation of BRIDGES
As the final step in analysis, students on the council were engaged in a conversation about action plans based on the data gathered from the workshop. The youth discussed the overall meaning of BRIDGES and how the characteristics of the acronym should apply to their future outreach activities. With the importance of schools and conversations occurring in small groups, they discussed developing presentations, workshops, a video series, and other outreach events modeled after their BRIDGES philosophy. Social media was also discussed as an avenue to raise awareness and promote their outreach activities, particularly during National Children's Mental Health Awareness Month. One idea that was actually executed, for instance, was to use each letter of the acronym BRIDGES for each day of posts on their social media profiles (Twitter, Instagram, and Snapchat) while engaging youth in contests and raffle drawings that led up to a fundraising and awareness gala. The gala was organized by the YCSP in spring 2017 and invited teens, parents, school personnel, researchers, and physicians to learn about the research projects of the YCSP, hear talks from youth and local experts in mental health, participate and vote in a youth art gallery, and network with other stakeholders passionate about ending suicide. The components of this event and future outreach activities reflect the BRIDGES philosophy of involving multiple groups of stakeholders and strategies to combat suicide.

Limitations and Future Directions
Although this study presents a host of strengths for researchers interested in partnering with youth to enhance the relevance, rigor, and reach of their scholarship (Balazs & Morello-Frosch, 2013), there are some limitations worth noting. First, the majority of youth on the YCSP are Caucasian females who are high achieving students. Ensuring equal representation of youth from a wide spectrum of demographic backgrounds is imperative to constructing generalizable knowledge and relevant interventions for all adolescents. The research team is currently engaging in discussions with community stakeholders to understand how to best market council membership to marginalized populations of students. Another potential limitation is that council members did not determine the focus of the council, which was developed by the hospital in response to the growing need for suicide prevention in Cincinnati. Traditionally, in YPAR, young people determine the problem of focus at the beginning stages of the partnership (Cammarota & Fine, 2008). Without involving young people in defining the problem, we can only rely on the assumption that young people volunteered for this cause because they truly see teen suicide as a problem worth addressing. Additionally, participants engaging in the analysis phase of the project could enhance the effect of the present study. While participants in this study were involved in data generation, the time constraints of the workshop did not allow for participants to become involved in analysis, which is typically a component of the GLA method. As a result, themes produced by the YCSP may not necessarily represent the views of the participants. Still, by presenting at the workshop, the research team elicited the responses from a large number of youth. The data was also analyzed by youth from the YCSP, generating themes that are youth-driven rather than researcherdriven. Additionally, students who attended this conference may have different perspectives on suicide prevention than other young people in area schools and in the community. These biases in our sample should be considered when developing suicide prevention strategies.
Engaging youth as co-researchers allows for the co-construction of tailored, contextualized prevention strategies that are relevant to youth perspectives. This study demonstrates YPAR as a potentially effective strategy for suicide prevention because it (1) involves peers working together toward solving a common health issue; (2) involves the community in implementing social change; (3) requires that youth lead the efforts; (4) has been used before to improve health programs to better meet the needs of youth; (5) increases knowledge and skill in youth; and (6) provides relevancy and context to suicide prevention strategies. Future research should aim to test the effectiveness of suicide prevention strategies which are designed and implemented using a YPAR approach.

Conclusion
The themes identified by the council are consistent with much of the literature, which proposes a need for multiple groups to become involved in suicide prevention efforts. Furthermore, prevention strategies which demonstrate the most success use multiple approaches that do not just target youth, but also their peers and the systems that affect their lives. YPAR is an effective way to accomplish these goals because it engages youth as active participants of their own change, making YPAR particularly useful for suicide prevention. Through conducting research in this particular study, the students on the council were able to make meaning of what other youth think about suicide prevention. They not only identified salient themes but combined each theme together to tell a story -a story about building BRIDGES between all of the stakeholders that are essential for suicide prevention. BRIDGES provides a framework to make youth feel like they belong, to learn about the warning signs, to combat isolation, to incorporate personal dedications when possible, to offer evidence-based guidance and education, and to work to reduce the stigma that surrounds the topic of suicide. Finally, it is a useful guiding framework for organizing suicide prevention activities that respond to contextualized youth needs.