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Cultivating Protective Environments: Suicide and the Need for Interdisciplinary Health Equity Planning

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CULTIVATING PROTECTIVE ENVIRONMENTS: SUICIDE AND THE NEED FOR INTERDISCIPLINARY HEALTH EQUITY PLANNING by Kelli M. Peterman ©2021 Kelli M. Peterman A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in City and Regional Planning School of Architecture Pratt Institute January 2021 CULTIVATING PROTECTIVE ENVIRONMENTS: SUICIDE AND THE NEED FOR INTERDISCIPLINARY HEALTH EQUITY PLANNING by Kelli M. Peterman Received and approved: _______________________________________________________ Date: January 11, 2020 Thesis Advisor Signature Courtney Knapp Thesis Advisor Name _________________________________________________ Date: January 11, 2020 Thesis Advisor Signature John Shapiro Thesis Advisor Name _______________________________________________________ Date_______________ Chairperson Signature _______________________________________________________ Chairperson Name Acknowledgments: Many people contributed to this thesis. First, thank you to my academic advisors, Courtney Knapp and John Shapiro, for your keen eyes and encouragement. Your expert guidance and steadfast interest in a challenging topic kept me going. To the entire GCPE staff and faculty, but especially Sadra Shahab, learning from you has been a privilege. Thank you for your patience, accessibility, dedication, and good humor. To my fellow students: my time with you has been well spent. Your passion and knowledge made graduate school worthwhile. What a challenge it has been to write a thesis in the midst of a global pandemic, in isolation from one another. But we did it. I am looking forward to continuing our journey together as planning professionals. I am humbled by the many individuals who generously donated their time to informing and editing this thesis. Every conversation, interview, and draft review mattered. To my primary interviewees - Catherine, Elizabeth, Jerry, and Scott – I can only hope my words do your expertise justice. Thank you to Pablo Sadler, my public service moral barometer, and Alison Peterman, my wise and thoughtful sister, for providing feedback, and to Gary Belkin for your mentorship. I am grateful to my employer, the New York City Department of Health and Mental Hygiene, for giving me an on-the-job public health education. Thank you to my boss, Shirley Berger, who has unquestionably supported my academic studies and given me the freedom to innovate and excel. To the members of the Health Equity in Planning Workgroup and the Suicide Prevention Workgroup: I am lucky to be a sponge absorbing your brilliance. While I may critique the very real structures that impede our work, it is because of you that I know anything at all about public mental health. I would be remiss to not acknowledge The Trevor Project, for providing me with the foundation for a lifetime of suicide prevention work. Phoenix Schneider, Michael Vacha Jr., and Brock Dumville: you will forever hold a special place in my heart. I could not have completed this thesis without the support of my friends and family. Thanks especially to my parents, Corinne, Duane, Emily, Glo, Keith, Laurel, Steve, Talia, Timna, Verna, and the Monday Movie crew (Cecy, Janessa, Lindsay, and Steph). Your friendship, generosity, and motivation this year lifted my spirits and gave me much needed reprieve from my research. Finally, this thesis stands on the shoulders of scholars in the Critical Suicide Studies Network (Ian Marsh, Jennifer White, Mark E. Button, et al.). Many of the themes presented herein draw from your ideas. Thank you for your disruptive work. Dedication: This thesis was written in memory of Tony and is dedicated to anyone who has thought about suicide. You deserve an abundant and just life. 2 Table of Contents Glossary…………………………………………………………………………………………...5 List of Figures…………………………………………………………………………………..…6 Organization of the Study…………………………………………………………………….…...7 Chapter 1: Introduction…………………………………………………………………………8 Statement of the Issue……………………………………………………………………………..8 Goals and Objectives of the Study……………………………………………………………….11 Methodology……………………………………………………………………………………..11 Study Limitations………………………………………………………………………………...13 Chapter 2: Background………………………………………………………………………...15 The Relationship between Urban Planning, Public Health, and Suicide………………………...15 Interdisciplinary Alignment through Health Equity……………………………………………..17 Brief History of Western, Mainstream Thought on Suicide……………………………………..18 The Production of Knowledge and Racial Bias in Research…………………………………….22 Chapter 3: Literature Review………………………………………………………………….28 The Planned and Built Environment………………………………………………………….….29 Trends in urbanization…………………………………………………………………...29 Spatial patterning………………………………………………………………………...32 Quality of the built environment…………………………………………………………34 Means accessibility………………………………………………………………………36 The Natural and Geographic Environment………………………………………………………38 Climate……………………………………………………….…………………………..38 Altitude…………………………………………………………………………………..39 Air quality………………………………………………………………………………..41 Green and blue space…………………………………………………………………….42 The Social and Economic Environment…………………………………………………………43 Economic insecurity………………….…………………………………………………………..43 Connectedness……………………………………………………………………………………44 Chapter 4: Existing Conditions………………………………………………………………..47 Global and National Suicide Trends……………………………………………………………..47 New York City Suicide Trends…………………………………………………………….…….51 The Evolution and Current State of Suicide Research and Prevention Efforts………………….55 Chapter 5: Qualitative Research Analysis…………………………………………………….60 Description of Qualitative Analysis…….………………………………………………………..60 Presentation of Qualitative Analysis……………………………………………………………..61 Chapter 6: Recommended Future Directions………………………………….……………..88 Conclusion……………………………………………………………………………………….93 3 Bibliography……………………………………………………………………………………..94 Appendix A. Timeline of the Urban Planning and Public Health Relationship………………..115 Appendix B. Interviewee Biographies………………………………………………………….116 4 Glossary:1 A group of suicides or suicide attempts that occurs closer together in time and space Cluster than would normally be expected in a given community. A phenomenon whereby susceptible persons are influenced towards suicide-related Contagion behavior through knowledge of another person’s suicide. The instrument or object whereby suicide or self-harm is carried out (e.g., firearm, Means medication). Actions or techniques whereby suicide or self-harm is carried out (e.g., overdose, Methods jumping). Protective Factors (attributes, characteristics, or environmental exposures) that make it less likely factor that an individual will attempt suicide. Factors (attributes, characteristics, or environmental exposures) that make it more Risk factor likely that an individual will attempt suicide. Suicide Death intentionally caused by self-directed injurious behavior. An organized response in the aftermath of a suicide to facilitate the healing of Suicide individuals involved, mitigate negative effects of exposure, and prevent suicides of postvention affected community members. Suicide A collection of efforts to reduce the risk of suicide at the individual, interpersonal, and prevention societal level. Suicide rate* The number of deaths by suicide per 100,000 people in a given geographic area. Suicide-related A spectrum of activities related to thoughts and behaviors that include thinking about behavior suicide, self-harm, and suicide attempts. Suicidology The scientific study of suicide and suicide-related behavior. *Author’s note: Suicide rate, or the number of deaths by suicide per 100,000 people in a given geographic area, is generally associated with decedents’ residences. Suicide location refers to the place where a suicide occurred. A decedent’s residence and their suicide death location are two different data points, though they may overlap. 1 Terms and definitions informed by the Suicide Prevention Resource Center and the Center for Disease Control. 5 List of Figures Figure 1. Age-adjusted suicide rates, by county urbanization level: United States, 1999 and 2017. Source: Center for Disease Control, Morbidity and Mortality Weekly Report (2017)…………………………………………………………………………………….30 Figure 2. Age-adjusted suicide death rates by state, 2018. Source: Center for Disease Control, National Center for Health Statistics…………………………………………………….40 Figure 3. Annual age-adjusted suicide rates and deaths in the world, the United States, and New York City based on the most recent data available for each geographic region. Sources: World Health Organization (2018), Center for Disease Control (2018), NYC Department of Health and Mental Hygiene (2017)…………………………………………………...47 Figure 4. Age-adjusted suicide rates for U.S. females and males, by race and ethnicity, 1999 and 2017. Source: Center for Disease Control, National Center for Health Statistics, National Vital Statistics System…………………………………………………………...………49 Figure 5. NYC total reported suicide deaths, 2000-2017. Source: New York City Department of Health and Mental Hygiene, EpiQuery Mortality Data, Intentional Self-Harm (Suicide), 2017………………………………………………………………………………………52 Figure 6. NYC age-adjusted suicide rates by borough, sex, race/ethnicity, and age group, 2017. Source: New York City Department of Health and Mental Hygiene, EpiQuery Mortality Data, Intentional Self-Harm (Suicide)………………………………….………………..53 Figure 7. NYC age-adjusted suicide rates by community district of residence, multiple years. Source: New York City Department of Health and Mental Hygiene, EpiQuery
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