Respect Life Culture Formation and Suicide Prevention Project

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
■ Korea’s suicide rate is the highest among OECD members! Is suicide preventable? In 2009, the suicide rate in Korea was 31 per 100,000, the highest among OECD countries. In fact, the suicide rate in Korea has been the highest for nine straight years since 2003, a cause of great concern for the nation. That’s before the Nowon-gu district implemented a respect life and suicide prevention project. The suicide rate, which began to rise in the early 1990s, accelerated due to massive layoffs and the collapse of families amid the IMF foreign currency crisis in Korea in 1998. Later on, the rate continued to rise because of complex social problems, such as the continuing economic recession, the collapse of family, and social polarization. The situation in the Nowon-gu district is not much different. The suicide rate continued to rise, registering 29.3 in 2009, a rise of 6.7 over the previous year. This amounts to 180 out of 610,000 (two per day), the total population of the district in 2009. In 2009, 180 suicides of the Nowon-gu included 64.5 elderly people with an age of over 65, which is 9.6 times as high as that of the youth in their teens. The rate of suicide among the elderly is 2.9 times higher than the youth in their 20s to 40s, the group with the second highest suicide rate. These statistics show that the elderly group is particularly vulnerable to suicide. Suicide among the elderly can be attributed to low income, poor health, lack of leisure and inadequate social activities. A low level of social recognition is regarded as another factor. Thus, a combination of negative views about their own future and high depression leads to their desperate choice of suicide. This suggests that comprehensive measures, such as social protection and support for the elderly who may have not prepared adequate retirement plans, are called for. Although the suicide rate continued to rise, the Korean government continued to regard suicide purely as ‘individual mental problems’, and thus failed to produce any solutions from the multi-sector perspectives of health, medical services, and social integration. The Act on Suicide Prevention and Respect Life Culture by the central government was created in 2012, two year after the Nowon-gu district made its own Ordinance on Respect Life and Suicide Prevention.

B. Strategic Approach

 2. What was the solution?
■ A Small movement in Nowon changes the world! Kim Seong-hwan, the incumbent mayor of Nowon-gu, was formerly an officer of the Blue House since 2003. He was at that time keen on suicide affairs, but he was frustrated to see the central government unable to establish an effective suicide prevention measure even as the suicide rate was accelerating. In 2010, when he was inaugurated as mayor of Nowon-gu, he realized that Nowon-gu was suffering from a serious suicide problem as well. Through discussions with experts from various sectors, it was concluded that suicide can be prevented and he embarked on a respect life and suicide prevention project with strong commitment and ambition. Mayor Kim thought if Nowon-gu succeeded in the prevention of suicide as the first district in Korea and spread the project to other districts and the central government, the overall suicide rate would fall nationwide. First, to obtain practical results for this project, he set the goal of reducing the rate below the OECD average of 11.2 by 2017. People who committed suicide and their immediate family members who are the most vulnerable, were designated as the first target group, with the elderly who live alone and basic livelihood support program (for the socially underprivileged) recipients designated as the second target, and all residents of Nowon-gu as the third target group. First, with regard to people who committed suicide, and their family members, sustained monitoring activities, such as counselling, monitoring, and treatment were made available by the Nowon Mental Health Center, a professional mental health institute which the Nowon-gu contracted to join the suicide prevention project. The second target group, the socially disadvantaged group was tested for their mental health (depression test). In accordance with the level of depression, they were cared for by the Nowon Mental Health Center and Gatekeeper volunteers of Nowon-gu. Besides medical measures for mental health for the first and second target groups, their ‘desires’ were investigated to give them ‘welfare service’, together with the welfare departments in the district office. This is an effort to combine medical treatment with non-medical social services. In addition, with respect to the third target group, promotions, campaigns, gatekeeper education, and suicide prevention theatrical performance have been conducted to increase the awareness of the need to respect life.

 3. How did the initiative solve the problem and improve people’s lives?
■ Suicide is a problem of social structure, and thus suicide prevention needs an integrated, sustained approach. Nowon-gu established the Respect Life Team and Suicide Prevention Team and created related ordinances for the first time in the nation for effective implementation. Nowon-gu views suicide as a complex problem of social structure and public health, and thus prepared and implemented integrated practical solutions which include the establishment of a community network, the promotion of respect life culture, mental health evaluations, gatekeeping activities, mental health counselling, and a case study of people at risk. Moreover, in order to make a systemic framework to carry out the project, the Respect Life Committee is run by doctors and specialists. In addition, the suicide prevention management system was launched by collaborating with 20 private organizations, such as emergency medical centers and police stations, ■ Restoration of the local community to prevent suicide The ultimate goal of the project is to restore a local community. Examples include the Gatekeeper Volunteer Group (private and public cooperation) and Life Love Sharing Center. The Gatekeeper Volunteer Group provides the emotional support of talking and strolling with the elderly who live alone, and utilize welfare resources. Life Love Sharing Centers in each of 19 dongs (or villages) collect volunteers and provide various services.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
■ Organization and System Nowon-gu created systems and organization in order to implement the project more effectively. As the first such project in the nation, in October 2010, the Respect Life Team in a community health center and the Suicide Prevention Team within the Nowon Mental Health Center were organized. These two structures are the core of the Nowon suicide prevention efforts and they ensure the smooth operations of various programs under the project. In addition, in December 2010, the Ordinance on Respect Life Culture and Suicide Prevention was created as the first district office in the nation. The ordinance gives responsibility and rights to the mayor of the district and residents, the installation of the Respect Life Committee, the establishment of a suicide prevention system, and preventive education to ensure the systematic and sustained implementation of the project. ■ Private-Public Cooperation Governance In October 2010, Nowon-gu signed an MOU with police stations, fire stations, and emergency medical centers within the district to establish a public private cooperation system. The MOU aims at sharing information about people who committed or attempted suicide, their families and monitoring activities. By 2013, about 20 MOUs were signed with the Association of Doctors in Nowon-gu, the Association of Pharmacists, and universities to establish a crisis management system to prevent suicide. ■ Intensive Preventive Measure As an intensive preventive measure, in order to share information on people who committed or attempted suicide and monitoring, and to coordinate responses to an emergency situation, an MOU was signed with three emergency medical centers, Nowon police station, and Nowon fire stations. . In addition, in 2012, a cooperative system with mental health treatment centers was built to reduce treatment costs and reduce the rate of suicide repeat. ■ Optional Preventive Measure The optional prevention measure targeted socially disadvantaged groups vulnerable to suicide, such as the elderly, basic livelihood support program beneficiaries, the unemployed and day laborers. In order to collect the targets, mental health evaluations – a depression test – have been conducted since 2011, and as of 2013, a total 102,147 people were tested. From the test, 16,216 people were diagnosed as being at a high risk of committing suicide. To help them, gatekeeper volunteers and the mental health center have provided counselling, treatment, and welfare service resources. ■ General Preventive Measure In order to increase awareness about respecting life and strengthening suicide prevention for the whole population of Nowon-gu, publicity towards religious organizations began in 2011. In June 2012, a joint workshop with the Association of Doctors in Nowon-gu was conducted to increase doctors’ awareness of suicide prevention. In September 2013, on the occasion of the Suicide Prevention Month, the ‘Nowon Community Mental Health Walking’ event was held to raise awareness of the need to respect life among the youth and to promote dialogues and communication among family members. . In September 2013, residents and the district office staff conducted Ribbon-wearing for the Respect Life campaign, and held various promotional activities, including theatrical performances. In addition, education for religious leaders, teachers, welfare program personnel, students, civil employees, and residents of Nowon-gu has been established.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
■ Nowon-gu suicide prevention team On Oct 1, 2010, a respect life team was created to cultivate a respect life culture and supervise the suicide prevention project of Nowon-gu with one team leader and two team members from the public health department of the community health center. The team reviews the achievements of the previous year and sets a new business plan for the following year. Based on the basic plan, the team is responsible for stronger public and private cooperation, the early detection of people at risk through mental health assessments, education and reviews, the operation of gatekeeper volunteers, suicide prevention education and promotions for residents. ■ Nowon mental health center supplied mental health professionals The Suicide Prevention Team under the Nowon Mental Health Center has a team leader and five working-level members. They are mental health specialists, such as mental health workers and mental health nurses. The team takes care of the ‘high suicide risk group’ such as those who attempted suicide and family members of those who committed suicide, and the ‘suicide risk group’ diagnosed as having a high level of depression. The team offers mental health counselling, tailored case management, a self-healing program for the family of people who committed suicide. ■ MOU collaborators Nowon police stations, fire stations, and three emergency medical centers supply information on those who committed suicide and attempted suicide in accordance with MOU with Nowon-gu to jointly cope with crisis. Based on this information, the family members of those who committed suicide and attempted suicide are guided on the suicide prevention efforts of Nowon-gu and are advised to agree to receive counselling from the Nowon Mental Health Center. In addition, the Bukbu Employment Center, the Nowon branch of Korea Senior Citizens Association, and the Bukbu Women Development Center are conducting mental health evaluations for the elderly, jobless, day laborers and women who visit them.
 6. How was the strategy implemented and what resources were mobilized?
■ Bold investment to save lives despite unfavorable financial conditions As of 2013, the fiscal self-reliance ratio of Nowon-gu is 22.3%, the lowest among the 25 districts of Seoul. The cause of the poor fiscal condition is a huge expenditure on health and welfare due to the highest number of socially disadvantaged groups, such as the basic livelihood support program recipients, the handicapped, and the elderly residents in Nowon-gu. Mayor Kim, despite such adversity, invested courageously in this suicide prevention project by saving in other sectors, in order to rescue people before it was too late. In 2011, as the project intensified, 403 million won was spent, with a total 1.38 billion won spent over a three year period. This represents a 24.8% increase over 2011, with 15 million won allocated to private sector cooperation, 83 million won for public-relations efforts and education, and 1.29 billion won for the management of resources to care for the high-risk suicide group and case management. ■ Suicide Prevention Project needs ‘humanism’ Besides a fiscal injection, the other important factor in suicide prevention efforts is human resources. Human resources are needed to identify people with suicidal tendencies and to prevent those with suicide intentions from making a fatal decision. Civil employees in charge of social welfare, 458 heads of village (welfare assistants) and 772 gatekeeper volunteers were trained at Nowon-gu district office, and currently participate in activities to detect the high-risk suicide group and to care for them. Christians, Buddhists, and Catholics actively joined the gatekeeper volunteer activities to care for those at risk. Furthermore, the Nowon police station, the Nowon fire station, and Sangye Paik Hospital are parties of the MOU working to build community suicide prevention & a crisis management system by actively participating in suicide prevention activities..

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
■ Reduction of the suicide rate in Nowon-gu The most important result is the reduction of the suicide rate in Nowon-gu. According to the data provided by the Office of Statistics Korea, the number of suicides in 2009 was 180 with a suicide rate of 29.3. This continued to fall gradually to 150 suicides and a suicide rate of 24.1. The outcome of Nowon-gu toward suicide prevention efforts has been recognized by awards from the Minister of Health and Welfare, Excellent Community Welfare Award by Hangyeore Social Policy Research Institute, and the top prize from Korea Manifesto Center. ■ Expanding awareness of suicide prevention in the community In Korea, having a mental problem is considered as a serious personal defect. So even patients with mental problems are not eager to see psychiatrists. Experts see this as one of the leading causes for the rising suicide rate. From 2008 to 2010, just before the suicide prevention project was implemented in Nowon-gu, the number of suicide counselling at the Nowon Mental Health Center was a mere 118, but after the project, the number skyrocketed to 11,408 by September 2013, a 96-fold increase. And project collaborators, such as the police station, the fire station, and emergency medical centers, actively cooperated to convey information regarding 1,430 suicides and attempted suicides. These results are evidence which suggest there is public awareness of the need to respect life and have suicide prevention among the residents of Nowon-gu and related institutions are on the rise. ■ Significant contributions to local community formation About 20 institutions, such as the police stations and emergency hospitals are cooperating to push for suicide prevention. In addition, Life Love Sharing Centers were established in 19 dong (village) offices, and gatekeeper care volunteers and heads of the centers place phone calls and visit high-risk to commit suicide groups in the community to help them with talking and strolling, and to provide various welfare and medical support according to their needs. Public and private cooperation and gatekeeper volunteer activities towards suicide prevention project have greatly contributed to the formation of a happy community through sustained activities toward a goal.

 8. What were the most successful outputs and why was the initiative effective?
■ Academic research to evaluate the long term effect of the suicide prevention project in Nowon-gu The relationship between the steadily declining suicide rate and the suicide prevention project needed to be analyzed. And it was necessary to generalize the project results to establish a scientific business model. Nowon-gu requested the Academia-Industry Center of Hallym University to perform academic research, and to prepare a study on the long-term effects of the Nowon-gu suicide prevention project and expansion strategies. Research was done from June 2012 to January 2013, and in February, 2013, the academic research results were presented and discussed. The academic research was presented to 327 participants, including suicide prevention specialists, mental health center personnel, suicide specialists, and residents. According to the research, rates of suicide and attempted suicides were reduced but they were only short-term results. So it should not be interpreted as a lasting effect. Still, the reduced rates were positive and significant. In addition, it was concluded that, for the sustainable performance of the project, it was important to ensure that the project is implemented properly and to identify problems in individual programs and find solutions. Moreover, opinions were collected on the future directions of core projects, such as the local community network, the respect life culture project, mental health evaluations, and gatekeeper volunteer activity. Experts were unanimous in saying that sustainability was essential for the success of the project. So Nowon-gu holds an event to evaluate the achievements of annual gatekeeper volunteer activities at the end of every year. Volunteers are asked to present excellent cases to share and review among all members. That has enhanced the sustainability of the service. Besides, based on the suicide statistics released by Statistics Korea every October and suicide information from the Nowon Police Station, annual results are reviewed and solutions are found and planning for the following year is made.

 9. What were the main obstacles encountered and how were they overcome?
■ Early detection of the high-risk to commit suicide group using chiefs of tong (welfare assistants) Nowon-gu has the biggest number of high-risk to commit suicide group, such as the elderly who live alone and the handicapped in Seoul, and thus in the early phase of the project, the availability of suicide prevention specialists was urgent. In 2010, the high-risk to commit suicide group was estimated at 150,000, but it was not easy to obtain the personnel and budget to conduct mental health tests for the group, given the fiscal status of the Nowon-gu district. As an alternative, chiefs of tong who were already acting as welfare assistants were asked to conduct the mental health tests, without use of a budget. Chiefs of tong are usually very familiar with the things and people of their villages since they have lived there for a long time, and thus they are the best human resources to conduct mental health tests. They were trained about the mental health test and gatekeeping and since 2011, they have acted as volunteers for early detection of the high-risk to commit suicide group. ■ Suicide prevention volunteers, Gatekeepers In addition to manpower for mental health tests, Gatekeepers are another essential part of suicide prevention efforts. The major role of gatekeepers is to visit the high-risk to commit suicide group, and provide emotional support like talking and strolling with them, and to utilize welfare resources. However, given the unfavorable fiscal condition of Nowon-gu district, the paid system of Gatekeepers was not possible. Nowon-gu decided to run the Gatekeeper system as a volunteer group, and made several presentations to religious groups among Christians, Buddhists, and Catholics because they are more willing to help others. After the presentation, applications were received. Currently 727 Gatekeepers are now working.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
■ Public service through public-private governance, not publicly driven. Conventionally, public services were provided from the public sector to the private sector (top-down method). But we came to realize that our project (the respect life culture formation and suicide prevention) needed to be implemented through a public private partnership, not just by the Nowon-gu office alone, given the nature of the project and the limited financial resources. Accordingly, all efforts were made to establish a public private cooperation. The Respect Life Team of the Nowon-gu Community Health Center supervises all administrative affairs of the project, while the Nowon Mental Health Center was responsible for overall mental health matters. In addition, the Respect Life Committee, which consists of specialists in welfare, health, and mental health, continued to receive advice on the project, so that professionals in the private sector can help the project. Also, police stations and emergency medical centers informed those who attempted suicide as well as the family members of suicides about Nowon-gu’s suicide prevention program and guided them to the Nowon Mental Health Center. Bukbu Women Development Center, the Nowon branch of the Korea Senior Citizen Association, and the Bukbu Employment Center signed an MOU with the Nowon-gu office so that each institution conducted mental health tests to detect the high-risk to commit suicide group early. By cooperating with private organizations, such as the resident welfare council and religious organizations, applications for Gatekeeper volunteers were received and gatekeepers are now providing emotional support to the elderly who live alone, a high-risk of suicide group. Furthermore, in order to help residents who are not entitled to health and welfare benefits due to legal requirements, we referred them to resident welfare councils and the Nowon Education Welfare Foundation. These are good examples of public private collaboration in terms of public health and welfare. ■ Improved awareness of residents, and increased mental health results According to the research on the long-term effects of the Nowon-gu suicide prevention project released in 2013, when residents of Nowon-gu and residents of other districts in Seoul were asked about whether they heard any advertisements about the suicide prevention program. 31% of residents in other districts answered yes while 37.4% of the residents of Nowon-gu responded yes. And to the question of whether they regard suicide as a public health issue that can been prevented, 67% of other districts said yes while 68.9% of Nowon-gu responded positively. According to the survey on the attempted suicides rate in 2008 and 2012, in 2008, the rates of Nowon-gu and other districts were the same with 1.1%, but in 2012, the rates of other districts were down 0.2% to 0.9% while the rate of Nowon-gu fell 0.7% to 0.4%. As Nowon-gu’s suicide prevention project is not long-establised, it has not produced a substantial positive change and any definitive, objective correlation between factors has not been established. Nevertheless, it is still meaningful that the program is widely accepted by many institutions as the leading suicide prevention project in Korea and the project is carried out with warm hearts and sincerity to save more people at risk.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
■ Efforts toward ‘sustainable’ suicide prevention Nowon-gu created an ordinance on respect life culture and suicide prevention at the initial stage of its suicide prevention project. This legal framework was prepared to ensure the project continues to run even after change of command at the Nowon-gu office. In addition, the Respect Life Team was created within the community health center to supervise the project, and the Nowon Mental Health Center created a suicide prevention team to ensure the project continues to run. Significantly, various community restoration projects are implemented in several departments within the Nowon-gu district office. Since Nowon-gu’s project ultimately aims at restoring communities, circumstances surrounding the project get developed. The establishment of a public private cooperation system by signing MOUs with 20 private organizations is another effort to make sure the project trickles down to every part of every community. In 2013, an MOU signed with the Nowon branch of KT, the largest private telecommunication company in the nation reflects Nowon-gu’s efforts to expand the project into more private organizations. ■ Dissemination of the Respect Life and Suicide Prevention Project to the outside The Ordinance on Respect Life Culture and Suicide Prevention of Nowon-gu has prompted the central government and other local governments to create similar laws. The Ministry of Health and Welfare introduced the Nowon-gu project as an excellent model during a discussion session with the Prime Minister to have this included in the national policy. The comprehensive suicide prevention measures announced by the Seoul Metropolitan Government in April 2013 are based on the project in Nowon-gu, and the National Assembly Budget Office visited the Nowon-gu office in July 2013 to file a report. Moreover, 33 institutions, including the district offices of Seoul City, public institutions and private organizations in Gyeonggi-do Province, Busan Metropolitan City, and Gangwon-do Province have visited to benchmark the Nowon-gu project. And at the forums hosted by 8 institutions, including Seoul City, Gangwon Province’s mental health center, and Hallym University, the Nowon-gu project was introduced as an excellent example. The press has recognized the project with 140 articles covering the Nowon-gu project in major newspapers and television channels, including Kyoto News KBS, SBS, Hangyeore, and Dong-A Ilbo. ■ Seoul Metropolitan Government supports budget, recognizing the necessity of the suicide prevention project Seoul Metropolitan City began to support the budget for suicide prevention programs in 25 district offices from 2013. Seoul City prepared its own suicide prevention program based on Nowon-gu’s suicide prevention project. Also, Seoul City collected ideas for a suicide prevention project for the elderly from district offices in Seoul, and gave support of 200 million won to three districts, including the Nowon-gu district.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
■ Even a small local district office can cause a ripple effect as the central government does, when it is innovative. In the early phase of the project, some viewed it as a waste of administrative and financial resources because the project was pursued by a district office with poor fiscal condition and even the central government was not involved in a similar project. Nowon-gu, despite having an adverse fiscal situation, concluded that through discussions with specialists, suicide can be prevented and it embarked on the project to save people. The suicide rate in Nowon-gu from 2009 to 2012 actually fell, but there is a long way to go since the rate is still above the OECD average. But, above all, it is encouraging that the project is now disseminated into other institutions as an exemplary case. The Nowon-gu project has made an impact on policies in the central government and the Seoul Metropolitan Government as well as other districts of Seoul. In particular, Park Won-sun, the mayor of Seoul City mentioned the Nowon-gu project as an example when the Seoul City’s comprehensive suicide prevention measure was announced in April 2013. ■ Innovative change in policy making from the bottom to the top Generally, large public projects are planned by the central government and local governments just implement them, a kind of top-down policy-making process. Hence, should the central government fail to produce solutions to important problems with a national dimension, local governments are not able to deal with the problems properly. But in these situations, it is the citizens and residents that suffer most. Even as the central government does not respond quickly, if local governments manage with innovative solutions, it can have a positive impact on the central government, generating bottom-up changes. This is the lesson we can learn from the Nowon-gu project. ■ The ultimate goals of the project are the restoration of the Nowon-gu community and improved life quality. The ultimate objective of the Nowon-gu suicide prevention project is to restore the local community. Public and private institutions and organizations should cooperate to dissuade residents from choosing to commit suicide by providing love and care to them and to help to improve the quality of the lives of Nowon-gu citizens. Helping people under a difficult situation due to health, economic problems or living alone, and talking with them on the phone, visiting them, and providing medical treatment and life necessities, will ultimately promote community solidarity and a sharing culture among all citizens. The Gatekeeper volunteer activity, part of the Nowon-gu suicide prevention project, shares humanitarian love and care for others. It is hoped that this benevolent activity can spread to every corner of every community and allow each citizen to build a happy and prosperous Nowon-gu community, beyond suicide prevention.

Contact Information

Institution Name:   Nowon-Gu
Institution Type:   Government Department  
Contact Person:   Myungjae Yong
Title:   Person in charge  
Telephone/ Fax:   82-2-2116-4327
Institution's / Project's Website:  
Address:   437 Noheagil, Nowon-gu
Postal Code:   139-703
City:   Seoul

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