Introduction

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

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.

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Table 1. Initial and revised text message series.

https://doi.org/10.1371/journal.pone.0306801.t001

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).

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

Acknowledgments

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.